In the last decades, there is a shif in the provision of health services from the formal facilities to home care. The delivery of care at home is considered a sustainable approach that not only results in substantial cost savings but is also a key step towards achieving optimal outcomes in the delivery of high-quality health services. Moreover, the adoption of this approach is facilitated by the prompt development of medical and non-medical technologies that can simplify care coordination and enable distant monitoring of the patient. However, home care requires the integration and coordination of health and social stakeholders in a continuity of care perspective. This requires the adoption of standards to defi ne a common shared conceptual model that improves the interoperability among information systems and organizations. In this paper to accomplish this task we combine the ContSys standard and the HL7 FHIR (Fast Healthcare Interoperability Resources) framework to identify concepts to be exchanged between systems, organizations and providers involved in the health and social context. This model has been developed to improve the integration and coordination of social and health care services within the Italian H@H project.