National Fund for vulnerable people needing long-term care

Why was this example implemented?

Over the last decade, a wide discussion on a national reform about vulnerable people needing LTC has been advanced through consultation. In Italy, which counts one of the oldest populations in Europe, 18.3% of citizens above the age of 65 (2.1 million people) are in need of full or part-time assistance (ISTAT, 2008). The bulk of care is provided by the family or other informal helpers, while the network of private and public services is not equally developed all over the country.

Actually in Italy there are huge differences among Regions concerning health expenses, equal access and effectiveness of health and social care services.

Through this National Fund, the Italian government aims to support frail people with multiple needs by combining services, in order to sustain home family care as well as informal care. Dependant allowance and family allowances absorb almost half of public expense for long-term assistance. The National Fund would like to change the system of services and money supply (for older people needing LTC) by giving a strong role to social and health professionals involved in initial assessment and in outlining an individual action plan. In addition, the Italian government would like to introduce formal control on the use of financial resources by ensuring that part of it is used for purchase of services. This initiative would mean a better use of public resources and more equity. Nowadays beneficiaries of financial help and their families are mostly left alone, without receiving suggestions on the best way to use benefits and no help in their relationship with local health and social services. It is clear then that families with higher cultural, relational and economic resources can manage the benefits with some advantage on others.

The Fund aims at ensuring the same system of social protection and care for older people all over the country. Discussion is still open about the definition of guaranteed ‘essential levels’ and out-of pocket contributions for users and citizens.

Description

With the Financial Law 2007 the Italian government set up a National Fund for vulnerable people needing LTC (governed by the Ministry of Labour and Welfare). This fund provides resources for health and social services and interventions for frail people with the following aims:

• To strengthen local networks of outreach hospital services, in order to promote home services and integration of social and health services;
• To increase the amount of time for ‘essential care’ services and/or the number of people cared for in each region. Informal carers can provide home care and assistance following a monitored intervention programme (focused on older people with care needs) that is planned and shared together with health and social services’ staff. Some Regions allocate financial resources to be distributed monthly among informal carers, and schedule periodic monitoring of care provided. There is no specific training programme to attend, but informal carers are intended to follow encounters with staff and peer groups aimed to face difficulties and problems related to diseases and home care.

The fund grew from €100 million (2007) to €400 million in 2009. In 2010, a 2-year budget of €400 million was provided until the end of 2011. The budget has been distributed to the Regions that had to present a plan of interventions to the Ministry of Labour and Welfare. Many Regions have integrated the government contribution from the National Fund with own resources, thus setting up Regional Funds for vulnerable people or simply assigning additional resources to interventions in this area. Services are provided depending on a multi-professional needs assessment and on family income calculated on the basis of a specified income indicator (ISEE – Indicator of equivalent economic situation).

In 2010, 5% of total resources are reserved to the Ministry of Labour and Welfare to promote innovative regional interventions for older and vulnerable people, particularly actions aiming at:

• Defining instruments to assess individual needs according to principles of the UN Convention on people with disabilities and according to WHO indications (e.g. protocols, unique points of access that are linked to multi-dimensional evaluation units, multi-dimensional evaluation sheets);
• Organising interventions for severely disabled people whose relatives have died (e.g. rehabilitation residential services, protected residential services and court appointed custodians);
• Strengthening interventions for people affected by Alzheimer’s disease (e.g. temporary residential care, day centres); and
• Improving support to families caring for severely disabled people or patients in a vegetative state (e.g. respite services, self-advocacy, Alzheimer counselling centres, self-help groups).

With the 2011 “Stability Law” the Fund has been set to zero (the resources that will be distributed during 2011 were financed during 2010 for the next two years.

What are/were the effects?

In Italy there are huge differences among Regions in relation to health expenses, equal access and effectiveness of health and social care services. Assistance to frail older people, particularly in Central and Southern Regions, lies almost completely with the families and, within families, as a responsibility of women. The Fund has been set up in order to improve home and residential care services and to support families.

The Fund is accessible to all vulnerable people in need of LTC living in Italy. According to ISTAT (National Institute of Statistics), in Italy there are 2,615,000 older people needing LTC who could benefit from the Fund (about 4.3% of the Italian population). Considering also people who need help to carry out essential basic activities, such as getting up, washing or dressing, this number rises to nearly seven million (about 12% of the Italian population). Older people above the age of 80 with a disability constitute about 45% of the entire vulnerable population. Theoretically, the Fund could have a high impact on this group of potential users. However, considering access regulations (request, needs assessment, means-test) chances to use services financed by the Fund (e.g. incentives to employ qualified migrant care workers) can easily decrease, as income is calculated on the basis of an ‘Indicator of the Economic Situation’ (ISEE) that takes into account the individual income and family members’ incomes (including husband/wife, sons/daughters, sisters/brothers) who are legally obliged to take the burden of care of the older family member.

Unfortunately, as stated by the annual National Report on Long-Term Care, there are data on the amount of each regional budget from the Fund, but there are no data provided on the number of users and access to services.

What are the strengths and limitations?

The introduction of the National Fund for vulnerable people was highly relevant since it acknowledged long-term care needs as a social risk that calls for public support. The Fund’s suspension for the period 2012-2013 with the Stability Law in 2010 was thus a very negative step backwards in a country with 2.6 million of vulnerable people.

The strengths of the Fund were that it aimed at developing health and social services for older people in need of LTC to promote:

• information and access to health and social services
• prevention and maintenance of autonomy
• care at home, rather than in residential facilities
• full integration of social and health care and of formal and informal care (e.g. unique point of access) for all SHD (Social Health District).  Services linked to multi-dimensional evaluation units, integration of services provided by migrant care workers who can be part of care services’ network when attending dedicated training programmes and when they are subjected to supervision and tutoring of formal services.

However, its implementation revealed significant weaknesses:

• The total amount of resources is not enough to fulfil the population’s needs. Indeed, even when calculating only the 2.6 million older people with assessed LTC needs, the Fund stipulates no more than about €150 per year per older person with care needs.
• The budget is defined from year to year, thus suffering from political and economic trends.
• There are no rules defined by the national government for managing the resources at regional and local levels. The ample autonomy of Regions resulted in furthering inequalities and a lack of homogeneity.
• There are huge regional differences in assigning resources to users:  i.e. from €450 per month in Sicily (Southern Italy) to €1.800 per month in Bolzano Autonomous Province (Northern Italy). Regions can use the Fund to provide further subsidies for frail older people or as a contribution to sustain costs of migrant carers.
• The distribution of funds between Regions is not based on actual needs: 60% of the resources are distributed according to the amount of older people, not considering the incidence of disabled or frail people; 40% are distributed according to rules from the ‘National Fund for Social Policies’ which consider a mix of indicators, not only referred to vulnerable people.
• Resources are distributed without specific objectives, because at central national level there are no instruments to verify their actual destination.

Credits

External Links and References

• Legge 27 dicembre 2006, n. 296, “Disposizioni per la formazione del bilancio annuale e pluriennale dello Stato” (legge finanziaria 2007) 
• Decreto Ministeriale 6 agosto 2008 Fondo non autosufficienze anni 2008 e 2009.  
• Decreto Ministeriale 4 ottobre 2010 Fondo non autosufficienza anno 2010
• Ministero del Lavoro e delle Politiche Sociali “Il sistema di protezione e cura delle persone non autosufficienti. Prospettive, risorse e gradualità degli interventi”, July 2010 (National Report)
• NNA, IRCCS-INRCA “L’assistenza agli anziani non autosufficienti in Italia. 2° Rapporto”, 2010 (National Report)