Italy

Demographic information (ISTAT, 2010)

• Inhabitants: 60,340,328
• No. of citizens 65+: 12,206,470 (20%)
• No. of citizens 75+: 6,008,000 (10%)
• No. of people with long-term care needs (according to national eligibility criteria): about 2,240,000 (4%)

Characteristics of health, social and long-term care delivery

In Italy, health and social systems are financed, regulated and organized separately. In order to understand the difficulties of integrated health and social service provision it is necessary to keep in mind that, when the public health system was born in 1978, Italy still lack a complete system of social protection on the national level. In particular, social services had not been regulated universally and homogeneously until 2000, when the legal framework and the financial basis for a national development of social services was developed (l.328/2000). Although the integration between the two systems has been one of the main themes of the Italian welfare policy of the last ten years, the two systems are still rather separated. Health System is still hospital centred even though the economic and financial crisis that is involving national and regional health system is placing investments in territorial network of health service. The decrease of financial resources for social services is another factor that influence LTC services. The  non-self-sufficient fund’s reform was recently approved, but it is not bringing particular innovations.  

In Italy differences and gaps between different areas of the country (Regions) are raising. National legislation only define guidelines for the development of health and social care, it describes some basic services that should be present in every region. It also delegate the detailed plans to regional institutions. There are variation between regions in term of economics resource, local culture, and attitudes of public administration towards innovation. North and central areas have more health and social services, whereas in the south there is a lack of services and less capability in investments. According to the reform of title V of the Constitution, it’s up to the Region to plan the services and regulate their functioning; Local Health Authorities (LHAs)  and Municipalities, on the other side, have the function to supply services. In both the sectors, services can be either directly supplied or bought from other public or private supplying bodies accredited by the Region. Long-term care includes all types of health and social care as well as family care, which are by their nature long-term actions. In Italy, the long-term care system includes three types of care aimed at satisfying the welfare need deriving from the older population who is in need of LTC: in-home assistance, residential care and money support. The first two forms of assistance can have a prevailing health or social character, depending on the subject’s condition, the aim and nature of services and the source of funding. Health care targeted to the older people includes medical, nursing, therapeutic and rehabilitation services, while social care is oriented to personal care and to preserve the person’s living environment. Among the actions to financially support the older people there are dependant allowances, care cheques and vouchers supplied by LHAs and Municipalities.

To summarise, long term-care can include:

• Nursing care if medical treatment have been required
• Medical care: rehabilitation and continuous care
• Home help and personal care regarding home help, meals and personal care  
• a period in a Rehabilitation hospital before coming back home  (if necessary)
• combined care: remaining at home and spending the day (9.00-17.00) in a day care integrated care
• residential service where is delivered medical and rehabilitation care and aids for daily activities
• cash benefits to buy private care services and to eliminate architectural feature that denies accesses to the disease people
• tele-assistance (in some areas Municipality granted this kind of service to older people 

Local Authorities Agency and Municipality would divide the costs of service according to DPCM 14/02/2001.  Local Health Agency is in charge of the sanitary services (100%). Municipalities are in charge of the social services (100%), but people can pay a quota. LHA and Municipalities are in charge of the integrate services (50% each one) in Integrated Home Care program. NHS Local Health Authorities and Municipalities pay all or only part of the costs of home care services, it depends on the amount of financial resources of the person. If she or he is over ISEE  limit,  she or he has to cover part of it by her own or family resources.

In order to take care of their own person and environment, most of the older people who are in need of LTC ask for informal care that can be provided by relatives, friends, people who they are acquainted with, and volunteers. Besides, in the last decade, together with the assistance given by public services and informal networks, in-home care has been developing as a service provided by private operators, mostly immigrant women.

Background information on key-issues

Quality assurance and quality management in LTC

(...) The quality system in Italy is basically made up of five key actors:

• The Ministry (Health and Social Policy)
• The Region
• The Local Health Authorities and Local Authorities
• The service suppliers
• The citizens

The Ministry of Health and Social Policy guarantees comprehensive quality criteria, which are valid all over the country, in order to ensure equal dignity and equal opportunities to all the Italian citizens. The Reform of the State towards federalism has limeted the responsibility of central State.  The Region is the body that regulates the quality and plays a primary role in:

• ensuring the network variety and suitability
• assuring the quality of the different local services, either those adopting well-established organizational models or those implementing new approaches
• managing the mix of public and private services, thus regulating the quality of services provided for free or completely or partially paid by the citizens.

The Region defines the rules to allow functioning and accreditation, identifies the agencies in charge of quality control, and the most suitable tools and methodologies. The Local Health Authority and the Town Council are respectively the holders of health and social services supply and the referees of quality towards the citizens. As referees, they answer for the quality of the services provided. According to regional directives, local authorities must authorize and accredit services.

Services suppliers must conform to the regional laws for authorization and, if they want to be entrusted with services by the public subject, they have to obtain accreditation and adopt the Service Chart.In the last years, public organizations have progressively replaced directly managed services with services delivered in private-public partnership. Within this scheme, quality is regulated by the supply contract on the one hand, and on the other hand by a system of  supervision and control on contract fulfillments. In addition, suppliers can choose to certificate themselves on the basis of voluntary rules and adopt those advices believed to be the most suitable to improve the service operators’ skills as well as their business capacity (ISO 9000).

Citizens are those who testify the service quality and the quality of the network as a whole. Even if user organisations must be involved in serviceplanning and quality assessment, the individual citizen as a final user of the service does not take part in the game, unless later, when an individual action plan is defined (more ...)

The role of informal care in LTC

(...) In Italy, most of the care provided to old people in need of LTC is by the family, as informal help, and only as second resort comes the network of private and public services. Besides, it is crucial the role played by private assistants at home, usually coming from other countries and women, privately hired by the old people’s family in order to face the needs of support and care of older people. The contribution provided by the migrant care workers overcomes, and sometimes by far, the contribution of “formal” care supplied by public or private organizations, in all the fields of action except the field of healthcare.

In Italy as well as in other countries, professional care and family care are not considered as alternatives any longer, they are instead complementary activities to be connected and integrated through measures of support to family care. So, in many regional and local areas (the most advanced) family care is explicitly taken as an important element to assess care cases and suitable measures to put into action. However, the continuum between formal and informal care is usually very difficult to implement because it’s hard to make formal and informal carers cooperate together, especially for two reasons (more ...)