Cancer patients often require ongoing treatment and frequent follow-ups, making proximity to care essential. However, those living in remote areas face major obstacles, particularly long travel times to hospitals, which is especially taxing for elderly or frail individuals. This can lead to delayed treatment, lower adherence and poorer outcomes. To address this inequity, the Local Health Authority (AUSL) of Piacenza introduced a decentralized onco-hematologic care model. By delivering services through the local Community Health Centers (Casa della Salute – CDS), care is brought closer to patients, improving accessibility, continuity and equity.
In 2016, the Local Health Authority of Piacenza (in Emilia-Romagna Region) initiated a pilot project in Bettola, a remote mountainous town lacking hospital facility where 34% of the population is aged over 65. The objective was to decentralize oncological and hematological care and bring it closer to patients through the local CDS. The action focused on reducing the need for patients to travel over 80 kilometres to the main hospital in Piacenza by equipping the CDS to deliver cancer treatments. The CDS, which already offered a variety of outpatient services, was enhanced to support the administration of chemotherapy and oral therapies by trained nurses under the supervision of onco-hematologists. To ensure consistent quality of care across settings, all patients treated at the CDS were regularly discussed with the medical and nursing staff of the Oncology Unit in Piacenza, enabling shared decision-making and the potential inclusion of eligible patients in clinical research protocols. The initiative was led by the Department of Oncohematology in partnership with the Departments of Internal Medicine and Primary Care. Key stakeholders included local and hospital leadership, political representatives, hospital and CDS’s healthcare and administrative staff, general practitioners, transport services, and patients and caregivers. This coordinated “micro-network” was designed to enhance access, continuity of care and treatment adherence, and to reduce both environmental and socio-economic burdens. The action supports the Emilia-Romagna region’s broader strategy of strengthening community-based healthcare delivery.
Oncological care was decentralized through a weekly outreach clinic led by a mobile team – composed of an oncologist or hematologist and an oncology nurse – who provided services directly at the CDS in Bettola. The CDS was equipped to deliver key cancer services including clinical assessments, chemotherapy and oral/injectable drug administration, blood testing, ECGs, ultrasounds, and minor procedures such as biopsies and paracentesis. Patients were selected primarily based on geographic proximity, with treatment protocols shared electronically with the central hospital in Piacenza. The hospital continued to handle diagnostics and manage complex or high-risk cases. Chemotherapy medications were centrally prepared at Piacenza’s antiblastic unit (UFA) and safely transported to Bettola. Due to the absence of a nearby emergency department, emergency readiness was ensured with trained personnel and appropriate equipment. Results from 2016 to 2021 show 2,292 clinical interventions, saving over 218,000 km in travel, preventing 32.37 tons of CO₂ emissions, and yielding a net socio-economic gain of €110,976, with only €26,152 in additional healthcare system costs (Fattore et al., 2025). The initiative strengthened hospital-territorial coordination, reduced the care burden for rural patients, and proved replicable in other underserved areas, though full decentralization remains limited by the need for centralized diagnostics and the exclusion of complex cases.
Several enablers supported successful implementation. Notably, integrated ICT infrastructure facilitated seamless data exchange and real-time sharing of treatment protocols between the CDS and the main hospital, ensuring safe and continuous care. The dedication of healthcare professionals – many of whom volunteered – was instrumental, driven by professional motivation and community commitment. The centralized preparation of chemotherapy drugs at the UFA in Piacenza ensured both high safety standards and logistical efficiency. The initiative also benefited from the longstanding policy environment of the Emilia-Romagna region that supports decentralized, community-based healthcare. Political and institutional alignment between local authorities and health departments provided essential governance and logistical backing. The initiative was seen as a shared effort between sectors and levels of care.
Challenges included diagnostic imaging services that are not available locally, requiring patients to still travel to Piacenza for assessments. Emergency care is limited in Bettola, necessitating tailored safety protocols. Additionally, patient referrals to the CDS often relied on informal networks among clinicians, highlighting the lack of standardized, institutional referral pathways. These barriers suggest the need for more structured integration, institutional support and broader formalization of decentralized access pathways to scale the model sustainably.
The Bettola initiative has significantly advanced broader health system objectives by promoting equity, access, efficiency and person-centred care. It has reduced the logistical and financial burdens faced by rural cancer patients, leading to more timely treatment and improved adherence. This was particularly impactful for elderly populations who are disproportionately affected by distance-related barriers. The model optimized the use of resources by minimizing hospital visits, reallocating manageable cases to the territorial level, and reducing travel and related emissions. It also promoted integration between hospital and community services, creating a coherent care continuum. This not only improved care coordination and follow-up but also helped reduce pressure on central hospital services. In environmental terms, the model demonstrated measurable reductions in CO₂ emissions and transport use, contributing to health system sustainability. The experience in Bettola illustrates the potential for decentralized models to be scaled and adapted in other rural areas across Italy and Europe, particularly as part of ongoing health reforms supported by the Next Generation EU funding and Ministerial Decree (DM) 77/2022.
Key lessons from Bettola include the value of strong collaboration between hospital and territorial health services and the essential role of digital infrastructure for care continuity and safety. Voluntary participation by experienced staff helped maintain high standards of care and fostered patient trust. The experience shows that decentralized oncology care is feasible and beneficial when supported by integrated teams, dedicated logistics, and policy alignment. The initiative’s success has encouraged replication in other settings, tailored to local contexts. Its alignment with Italy’s strategy for territorial healthcare under Next Generation EU funding and Ministerial Decree 77/2022 is accelerating its expansion. For other countries, the main takeaway is that decentralization can work – even for complex care – if supported by proper governance, workforce capacity and digital solutions.
