Background and Objectives: The process of population ageing leads to greater needs for local welfare services. This projects main Objective is to strengthen the hospital-territory integration by establishing Hospital - Territory Agencies of Continuity and Integration (AgICOT) in the Local Health Unit (ASL) of Teramo. The specific target of the project is frail elderly people aged 65 years or more. Methods: A multidisciplinary working group (health professionals from the Local Health Unit of Teramo and academics from the University of Florence) has set up an organizational plan and a training course for all the health professionals working in AgICOT. The innovative tools used by AgICOT are the Life Project (LP), a document that collects clinical, social, psychological, and linguistic-communicative assessments of the followed person, and the Healthcare Budget (HB), which is the sum of all healthcare, social and relational resources and services used for this person. Individuals followed by AgICOT are monitored and/or re-evaluated continuously, and LP and HB are updated in each of these situations. Results: Between April and October 2022, the working group defined the organization of AgICOT and its kick-off, and at the same time prepared and implemented a training course on the topics of primary care and transition care management. The first AgICOT was inaugurated in October 2022 and started working on 20 cases, which represent the first group of patients served by the new Agency. Conclusions: AgICOT takes care of the frail elderly by defining a care pathway that is comprehensive of both social- and health-related aspects. The re-evaluations and continuous monitoring guarantee that every need is better assessed and can find a proper answer outside the hospital. AgICOT will not only improve the integration between the hospital and the territorial services, but it will also improve an effective and efficient use of the latter.