The public system of LTC in Italy is underdeveloped and characterised by a high degree of institutional fragmentation, as sources of funding, governance and managerial responsibilities of public services are spread over local (municipal), regional and national authorities, with different methods according to the institutional models of each region (Gabriele et al., 2014). This fragmentation relates to the fact that the LTC sector originates from multiple legislative interventions over a period of more than 30 years.  Unpaid carers as well as care assistants privately hired by households,  represent the bulk of LTC provision (Fosti et al., 2021). There is no official data on the number of unpaid family carers, but estimates from 2018 suggest that about 2.8 million people aged 18-64 were involved in caregiving for their older or disabled relatives (ISTAT, 2019). Also the total number of home care assistants (privately employed, primarily migrant care workers) is unknown, but it has been estimated that this involves over 1 million people (Fosti et al., 2021).

References:

Barbarella F, Casanova G, Chiatti C and Laura G (2018), ‘Italy: emerging policy developments in the long-term care sector’.  Retrieved from: CEQUA LTC network report. Fosti G, Notarnicola, E. and Perobelli, E. (2021), Le prospettive per il settore socio-sanitario oltre la pandemia. Rapporto Osservatorio Long Term Care 3. CERGAS, Università Bocconi. Retrieved from: il+welfare+e+la+long+term+care+in+europa+cover.pdf (unibocconi.it) Gabriele S and Tediosi F (2014), Intergovernmental relations and Long Term Care reforms: Lessons from the Italian case. Health Policy 116 (1) 61-70. https://doi.org/10.1016/j.healthpol.2014.01.005 ISTAT (2019): CONCILIAZIONE TRA LAVORO E FAMIGLIA. Retrieved from: https://www.istat.it/it/files//2019/11/Report-Conciliazione-lavoro-e-famiglia.pdf Rotolo, A. 2014. ‘Italia.’ In Fosti, G and Notarnicola, E, (eds). Il Welfare e la Long Term Care in Europa. Modelli istituzionali e percorsi degli utenti, 93–114. Egea, Milano. Retrieved from: il+welfare+e+la+long+term+care+in+europa+cover.pdf (unibocconi.it)

In 2020, 23.2 % of the total population in Italy was 65 years and older, the share of older people in the Italian society has been growing constantly in recent years. According to 2019 data, the country was considered to have the largest percentage of elderly population in Europe. This share is projected to rise up to 34% by 2045.

In 2019, 32.5% of people aged 65 and above reported living with chronic diseases, rising up to 47.7% among those abed 85 and over. 1 million persons aged 65+ require care or support devices.

As with the National Health System, LTC sector is a regional competence. The Ministry of Labour and Social Policy and the Ministry of Health are responsible for defining the national framework, the issue general guidelines, and fund specific interventions to secure regional equity. At the central level, the National Social Insurance Agency is in charge of monetary contributions and cash allowances which are paid directly to citizens. The regions are the key actors and they regulate and fund in-kind services. Local health authorities (LHAs) and municipalities are responsible for interventions that are delivered through care providers. The system is highly reliant on publicly funded services, which account for around 85% of service providers’ revenues.

Coordination between different LTC responses is poor or left to local best practices. There are different need assessment systems (LHAs, municipalities, and INPS) which individuals can go through to access the in-kind and cash services they are eligible for, there is no guidance or coordination between the different interventions (Notarnicola et al., 2021).

References:

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

In 2020 public Long-Term Care (LTC) expenditure in Italy was estimated to represent 1.9% of Gross Domestic Product; 74.1% of this expenditure is devoted to over 65 people (Fost et al., 2021).  Public expenditure on LTC includes three components: 1) LTC  services to dependent people provided by the public health 2) the social component of LTC  provided by municipalities and  3) attendance allowances. The social component of LTC are generally means-tested, access to services are based on needs-assessment but also on income levels (European Commission, 2016).

The bulk of LTC is provided by unpaid, family carers. Also, a large share of home care is provided by privately employed, primarily migrant care workers. The annual estimated expenditure in this type of household-based care is €17.000 per family. Almost 60% of these care workers are employed totally or partially irregularly, with an annual average estimated expenditure of €11.000 (Fosti, at al., 2021).

Access criteria to LTC services are determined at the regional level (with a high level of heterogeneity) and Local Health Authorities (LHA) can established further criteria. Hence, it is very difficult to establish an overreaching picture of access and affordability for these services. The only major intervention that is subject to nationally established criteria is the companion allowance (CA), a cash transfer given to all those with a very severe disability regardless income or other personal features.

Practically all LTC services are based on co-payments and, given the fact that the coverage rate is relatively low, waiting lists are common, although there are no official data on the size of the phenomenon (European Commission, 2021).

References:

Barbarella F, Casanova G, Chiatti C and Lamura G (2018), ‘Italy: emerging policy developments in the long-term care sector’. CEQUA LTC network report. Retrieved from Italy Country Report

European Commission (2016), ‘Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability’. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee. Retrieved from update_joint-report_it_en.pdf (europa.eu)

European Commission (2021). ‘2021 Long Term Care in the EU’ Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG Empl). Retrieved from: Publications catalogue – Employment, Social Affairs & Inclusion

Fosti G, Notarnicola E, Perobelli E (2021) Le prospettive per il settore socio-sanitario oltre la pandemia. Rapporto Osservatorio Long Term Care 3. Egea. CERGAS. Università Bocconi. Retrieved from: 2019-2020 report Le prospettive per il sistema socio-sanitario oltre la pandemia.

Ministero dell’Economica e delle Finanze (2021) Le tendenze di medio-lungo periodo del sistema pensionistico e socio sanitario. Rapporto n.22.

Municipalities, local health authorities and the National Institute of Social Security (INPS) are directly involved in the organisation of LTC services, but others are involved in planning and funding these services, including the central state, regions and provinces.

The table below classifies the Italian LTC system according to initiative and actor involved:

Typology	Service/Intervention	Actors involved
Cash transfer	Companion Allowance (CA – Indennità di Accompagnamento)	National Social Insurance Agency
	Monetary vouchers to finance informal caregiving or care services	Municipalities Regions Local Health Authorities
In-kind services	Home care Nursing homes Day care Informal caregiving	Local Health Authorities and Municipalities Municipalities and regions; providers (public, private, or not for profit) Relatives or migrant care workers

(source: Notarnocola et al., 2021).

Informal care and migrant care workers, often with irregular contracts, play an important role in the organisation and provision of home care (European Commission, 2016).

References:

European Commission (2016), Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee. Retrieved from update_joint-report_it_en.pdf (europa.eu)

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

There is no overall definition of LTC quality either at national or regional/local level. The national government is responsible for quality control at system level, this responsibility is shared with the regions. The latter adopt slightly different solutions and, to varying degrees, have been able to implement quality-assurance measures. Given the absence of a quality framework, LTC quality is assured through the following tools: authorisation and accreditation; the ratio between beneficiaries and different kinds of professional staff; legislation addressing abuses and mistreatment of LTC recipients; and professional requirements for workers employed in the sector. The use of these tools varies according to whether the services are residential/home-based, or whether they are related to healthcare or social care (European Commission, 2021).

References:

European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

 

The Italian care system remains fragmented, which relates to the fact that the essential functions (e.g. health and social care as well as care training) are decentralized and managed at regional level. There is an increasing trend to reorganize the LTC system via ‘decentralisation’ of the health and social care, from the national to the regional and local level. In the social care sector, this development has led local administrations to develop their own LTC policies. The State-Regions Conference is the only body in charge of ensuring inter-institutional coordination (Barbarella et al. 2018).

References:

Barbarella F, Casanova G, Chiatti C and Lamura G (2018), ‘Italy: emerging policy developments in the long-term care sector’. CEQUA LTC network report. Retrieved from Italy Country Report

For healthcare, Italy has a comprehensive information and monitoring system (National Healthcare Information System) covering population health status, budgetary and economic efficiency, organisation climate and staff satisfaction, patient satisfaction, performance indicators (appropriateness, quality) and effectiveness in reaching regional targets (European Commission, 2016).

Out of the 33 indicators that monitor and assess regions’ health and LTC systems’ quality, there are only three LTC-related measures: number of care home beds and residents, number of hours of home care delivered and day care centres (Ministerio della Salute, 2021). The status of LTC information system is poor (particularly compared to heathcare), which led to negative consequences during the Covid-19 outbreak. As of November, 2021 there was no  official data on the pandemic outbreak in LTC services (Notarnicola et al., 2021).

References: 

European Commission (2016), Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee. Retrieved from:  update_joint-report_it_en.pdf (europa.eu)

Ministerio della Salute (2021) Monitoraggio di LEA attraverso la cd. Grillia LEA. Metodologia e Risultati dell’anno 2019. Direzione Generale della Programmazione Sanitaria – Ufficio VI. Retrieved from: C_17_pubblicazioni_3111_allegato.pdf (salute.gov.it)

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

The actual number of nursing homes in Italy is unknown: different institutional sources indicate distinct values. In particular, the Interior Ministry estimated that there were 4,629 nursing homes for dependent older people in 2019 (data confirmed also by the National Committee for the guarantee of people deprived of their freedom – Garante Nazionale dei diritti delle persone private della libertà personale). The National Health Institute provides data on 3,417 nursing homes for people living with dementia. The Ministry of Health considers 3.475 residential centers, which include nursing homes, care homes, hospice and a blurry “other type”. Such inconsistency between numbers makes it difficult to build up a comprehensive picture of the service supply.

Also the number of service providers is uncertain, estimates talk about 1.927 companies. As concerns nursing homes’ features, the Observatory on nursing homes from one of Italy’s largest trade unions pointed out that:

• 10,3% NHs count less that 20 beds;
• 33,1% NHs have 21 to 50 beds;
• 38,9% NHs have between 52 and 100 beds
• only 17.7% of NHs dispose of over 100 beds.

The average nursing home counts 67,5 beds. Moreover, the large majority (70%) of NHs is managed by private providers – generally in accreditation regime -, 38,2% are for profit companies, 6% are public owned foundations, 15% are NGOs. 14% of NHs are directly managed by municipalities or Local Health Authorities. On average, each provider manages 2,07 nursing homes and 140 beds. Hence, the typical nursing home is quite small and managed by a private provider which received an accreditation from the public sector.

The distribution of nursing homes is diversified and heterogeneous throughout the national territory, with strong consequences for equity in access. The table below shows the take up rate of care home beds with respect to the number of people with functional dependency aged 75 and over in each region, representing the population most likely to consider nursing home care.  the most vulnerable and likely target for such service

The distribution of the rate follows the Italian geography: Southern regions have the lowest rates; regions from the Centre reach middle values and the Northern regions have the highest take-up values. For example in Trento, there are 25 beds for each person aged 75 with dependency, compared to 0.65 in Basilicata, signalling the almost total absence of care home services in some areas of the country.

Region	Take up rate of nursing homes’ beds with respect to dependent over75 residents in the region (2016)
Molise	0,26%
Basilicata	0,65%
Sicily	0,69%
Puglia	2,57%
Calabria	2,78%
Abruzzo	2,73%
Campania	0,73%
Marche	5,89%
Valle d’Aosta	0,25%
Tuscany	6,28%
Umbria	5,12%
Friuli – Venezia Giulia	15,36%
Liguria	9,73%
Emilia – Romagna	9,61%
Veneto	17,88%
Trento	25,66%
Lazio	2,85%
Sardinia	1,03%
Bolzano/Bozen	24,21%
Piedmont	18,15%
Lombardy	18,97%

References:

Berloto, S., Fosti, G., Longo, F., Notarnicola, E., Perobelli, E., Rotolo, A. (2019). La rete dei servizi di LTC e le connessioni con l’ospedale: quali soluzioni per la presa in carico degli anziani non autosufficienti? In Cergas (Eds.), Rapporto OASI 2019. Retrieved from: Cap5OASI_2019.pdf (unibocconi.eu)

Fosti G, Notarnicola, E. and Perobelli, E. (2021), Le prospettive per il settore socio-sanitario oltre la pandemia. Rapporto Osservatorio Long Term Care 3. CERGAS, Università Bocconi. Retrieved from: il+welfare+e+la+long+term+care+in+europa+cover.pdf (unibocconi.it)

Garante Nazionale dei diritti delle persone private della libertà personale (2020). Atto di sindacato ispettivo n° 3-01482.

Istituto Superiore di Sanità (2020). Mappa dei servizi.

Ministero della Salute (2021). Annuario Statistico del SSN. Anno 2019.

Ministero dell’Interno (2019). Le statistiche ufficiali del Ministero dell’Interno. Strutture per anziani. Ed. 2019.

A recent report from Amnesty International (2021) on health and care workers in Italy found that:

• 85% of care workers are women, 12% are migrant;
• Wages in LTC services are lower than those of the NHS
• The care worker/person aged 65+ ratio is among the lowest in the OECD area: 2 care workers per 100 persons 65+ vs 5 care workers per 100 persons 65+

Moreover, as other countries, Italy is experiencing a shortage of nurses: trade unions claim that healthcare and LTC services are lacking 60.000 FTE nurses. The pandemic experience showed that LTC services are seen as a transitory moment of one’s own career, since many professionals apply to move to the NHS at the first opportunity.

The estimated 1 million informal and migrant care workers are important in providing private home care, but it is estimated that only 40% are employed under a regular employment contracts. The trend to rely on home-based migrant carers has been supported by different policy measures (at local, regional and national level), including training and accreditation programmes for informal and migrant carers, regular contracts for the latter have also been promoted by policy makers  (Barbarella et al. 2018).

References:

Amnesty International (2021) Muzzled and unheard in the pandemic: Urgent need to address concerns of care and health care workers in Italy. Retrieved from EUR30/4875/202

Barbarella F, Casanova G, Chiatti C and Lamura G (2018), ‘Italy: emerging policy developments in the long-term care sector’. CEQUA LTC network report. Retrieved from Italy Country Report

Federazione Nazionale Ordini delle Professioni Infermieristiche. (2021) Vaccinazioni, FNOPI: “oltre 60mila infermieri liberi professionisti sono pronti, ma per loro sono indispensabili maggiori tutele”.

Italy has a strong family-based approach to LTC and unpaid carers represent the bulk of  provision. No precise figures are available, however, the number of family carers among the population in working age (15–64) who care for an adult, has been estimated at over 3.3 million. Carers have access to a number of provisions, including: help in performing care tasks (e.g. training); provision for carers but also for people with needs (e.g. respite care); ‘indirect specific’ services which aim to improve conditions for unpaid carers (e.g. measures to help carers combine caring with paid work); ‘indirect non-specific’ provisions:  directed at care
recipients however carers may also benefit from them. Migrant domestic carers constitute an important part of care provision in the country (Barbabella et al. 2017).

References:

Barbabella, F., Casanova, G., Chiatti, C., Lamura, G. (2017). ‘Italy: emerging policy developments in the long-term care sector’ CEQUA Report 

During the pandemic, the right of care home residents to emotional support and social interaction was recognised in a legal document for the first time (Bolcato et al., 2021).

With regards choice, for people whose application for access to services to the Local Health Authority is successful, there is the possibility to choose the provider that they prefer (if the providers have capacity). Social services are normally activated directly by the family. There is no national mechanism to measure satisfaction with care services (European Commission, 2021).

References: 

Bolcato M, Trabucco Aurilio M, Di Mizio G, Piccioni A, Feola A, Bonsignore A, Tettamanti C, Ciliberti R, Rodriguez D, Aprile A. (2021) The Difficult Balance between Ensuring the Right of Nursing Home Residents to Communication and Their Safety. International Journal of Environmental Research and Public Health. 2021; 18(5):2484. https://doi.org/10.3390/ijerph18052484

European Commission (2021). ‘2021 Long Term Care in the EU’ Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG Empl). Retrieved from: Publications catalogue – Employment, Social Affairs & Inclusion

Italy had formally updated the 2006 National Pandemic Plan for Influenza, only in late February 2020; leading to major shortcomings in the overall management of the COVID-19 outbreak.  The LTC sector was poorly prepared for the pandemic and it was not prioritised after the outbreak (in terms of Personal Protection Equipment and personnel), giving rise to multiple issues within services (high mortality rate, lack of coordination with hospitals, etc.).

The pandemic exacerbated pre-existing weaknesses within the Italian LTC sector, such as lack of coordination between and within care sectors; national and regional investments focused on acute care, neglecting LTC services; the poor management of care personnel and a lack of dedicated workforce; poor connection with other care settings and the functioning of nursing homes as acute care settings, that are neither recognised nor funded as that (Notarnicola et al., 2021).

There are indications of a large number of deaths that occurred in nursing homes during the first wave of the pandemic, and the weak capacity of public policy to provide adequate protection. The Lombardy Region had the highest mortality rate due to COVID-19 in nursing homes in Europe. Researchers argued that the negative impact of COVID-19 results from the poor development of LTC policy and from the marginality of residential institutions within the healthcare system (Arlotti et al., 2021).

References:

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

Arlotti, M., & Ranci, C. (2021). The Impact of COVID-19 on Nursing Homes in Italy: The Case of Lombardy. Journal of Aging and Social Policy, 33(4–5), 431–443. https://doi.org/10.1080/08959420.2021.1924344

As of November 3rd, 2021 4.785.867 Italians tested positive for Covid-19 since the beginning of the pandemic, 131.560 people died from the virus, and 95.1% of deaths concerned people aged 60 or more (source: Ministry of Health).

The share of people fully vaccinated against Covid-19 is higher than the average of the European Union: 72% vs 66% respectively.

Sources:

Istituto Superiore de Sanità. Epidemia COVID-19. Aggiornamento Nazionale 3 novembre 2021.

Our World in Data. Coronavirus (COVID-19 Vaccinations), accessed 5th November 2021.

For the first wave of the pandemic in Italy, the only data available on the virus outbreak in LTC services are for nursing homes, thanks to the results from a survey carried out by the National Health Institute (Istituto Superiore di Sanità), which was sent to 3,292 nursing homes out of the 3,417 NHs for people living with dementia. These data cover the period between February 1^st and May 5^th and were published on June 17, 2020. By May 5, 2020, 1,356 nursing homes had responded. The total mortality rate during that time was 9,1% (considering all deaths). The COVID-19 related mortality rate (tests and suspected) was 3,1%.

In September, 2021 the National Health Institute published a new report on the results of the surveillance of COVID–19 cases from October 5^th 2020 to September 19^th 2021 for a sample of Long-Term Care Facilities (LTCFs) representing 31,178 beds. Overall, 341 out of the 852 facilities were nursing homes for older adults, counting 15,031 beds. Indicators show an increase in both COVID-19 cases and deaths in the months of October and November 2020, in line with the second epidemic wave in Italy. However, in contrast with the national data, there was a progressive reduction of COVID-19 cases, hospitalizations of SARS-CoV-2 positive residents and deaths in LTCFs in the period from February to April 2021. This trend is associated with the start of the vaccination campaign, which prioritised nursing home residents and severely vulnerable people, as well as LTCFs staff.

In the months of July, August and September 2021, there was slight increase in COVID-19 cases, both in residents and among the staff. This relates to the increase in the number of new cases in the general population in the same period. However, despite the increase in new cases and outbreaks in the monitored facilities, the number of deaths from COVID-19 occurring in LTCFs remained very low (< 0.01% per week), and this is probably due to the protective effect of the SARS-CoV-2 vaccination against the most severe forms of COVID-19.

Although the surveillance showed a significant decrease in new SARS-CoV-2 positive cases in LTCFs during the period May-June 2021, a slight increase of positive cases has been observed during summer, in the period July-September 2021. Yet, the Institute claims that this trend shall not be overlooked: rather, it suggests the opportunity to strengthen the immune protection through an additional dose of vaccine, as already provided for by the Ministry of Health. 

At present, these reports are the only official data on deaths related to the pandemic in LTCFs, urging for a comprehensive revision of monitoring systems in the LTC sector.

Sources:

Berloto, S., Notarnicola, E., Perobelli, E., Rotolo, A. (2020) Italy: Estimates of mortality of nursing home residents linked to the COVID-19 pandemic. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 25 June 2020.

National Health Institute (2021). Surveillance of COVID–19 at Long–Term Care Facilities. Italian National Report. Time course of the COVID–19 epidemic. October 5th 2020 – September 19th 2021

Ministry of Health (2021). Circular no. 43604 of September 27th

At present, there is no specific data on the impact of long Covid among people who use Long-Term Care. In July, 2021 the National Health Institute published the national guidelines to assess and manage patients affected by long Covid. The National Government established that people who recovered from severe forms of Covid-19 will have free access to follow up exams for two years (without paying the so-called “ticket” for highly specialized exams).

References:

Istituto Superiore di Sanità (2021). Indicazioni ad interim sui principi di gestione del Long-COVID

Quotidiano Sanità. Long Covid. Il Governo chiarisce in Parlamento modalità di monitoraggio pazienti ed esenzione dal ticket per le visite specialistiche. Published on June, 25th 2021. 

Impact of the pandemic on health and long-term care system

More generally in the health system, non-urgent annual health checks, appointments, and elective surgeries have been suspended from March 2020. In 2020, clinic and specialised interventions decreased by 20,3%, with respect to 2019, and non-deferrable exams decreased by 7%.

Impact on access to health care for care home residents

During the initial spread of Coronavirus COVID-19 in Italy, care homes were isolated from the rest of the healthcare system. Hospitals in many of the regions that were under pressure during the peak of COVID-19 (such as Lombardy, Veneto, Emilia-Romagna, Marche and Piemonte), started to reject and deny admission to care homes residents who might have problems related with COVID-19 (since testing was not available for all, the evaluation was based on symptoms). As a result, many of them were cared for in facilities not equipped for high-severity conditions and lacking the specialized health care workers that you can find in other settings such as hospitals. Moreover, access to palliative care has been critical, not only for care homes residents. The associations representing palliative care and intensive care unit doctors (SICP, SIAARTI and FCP) issued a press statement in April 2020 urging for specific protocols for COVID-19 patients.  

In 2021 new rules have been implemented including testing and isolation procedures. The guidelines have been issued by the Ministry of Health through the Italian Institute for Health (ISS).

Impact on availability of care and support for people living in the community

Italian data from a survey on the Impact of the Covid-19 outbreak on informal carers across Europe show that 44% of carers experienced a decrease in health and/or social care services during the outbreak (Eurocarers/IRCCs, 2021).

A qualitative study found that although alternative forms of support and interaction with services were introduced, they did not compenssate for the loss of in person support experienced by people with dementia and their family carers (Chirico et al., 2022).

References:

Chirico, I., Ottoboni, G., Giebel, C., Pappadà, A., Valente, M., Degli Esposti, V., Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in Italy. Health & Social Care in the Community, 00, 1– 10. https://doi.org/10.1111/hsc.13758

Eurocarers/IRCCS-INRCA (2021). Impact of the COVID-19 outbreak on informal carers across Europe – Final report. Brussels/Ancona.

Istat (2021). Rapporto Annuale, anno 2020.

Rapporto ISS COVID-19, n. 6/2021, Assistenza sociosanitaria residenziale agli anziani non autosufficienti: profili bioetici e biogiuridici

There is no information available that systematically measures the impact of COVID-19 on the health and wellbeing of people who use Long-Term Care.

A qualitative study asked family carers of people living with dementia in the community about the impacts they perceived on their relatives with dementia. The carers reported acceleration decline of both cognitive and physical abilities, increased behavioural and psychological symptoms and difficulties meeting care needs due to reduction in formal care and support (Chirico et all, 2022).

References:

Chirico, I., Ottoboni, G., Giebel, C., Pappadà, A., Valente, M., Degli Esposti, V., Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in Italy. Health & Social Care in the Community, 00, 1– 10. https://doi.org/10.1111/hsc.13758

Unpaid carers of people with dementia reported that caring was more challenging, experienced high stress levels, and other negative implications. This was atttirbuted to the impact of restrictive measures, fear of contagion and feeling abandoned by the usual services and other forms of support that were disrupte by the pandemic (Cagnin et al., 2020 and Chirico et al. 2022).

References:

Cagnin A., Di Lorenzo R., Marra C., et al. (2020) Behavioral and Psychological Effects of Coronavirus Disease-19 Quarantine in Patients with Dementia. Frontiers in Psychiatry 11. https://doi.org/10.3389/fpsyt.2020.578015

Chirico, I., Ottoboni, G., Giebel, C., Pappadà, A., Valente, M., Degli Esposti, V., Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in Italy. Health & Social Care in the Community, 00, 1– 10. https://doi.org/10.1111/hsc.13758

A study of the self-rated mental wellbeing (depression, trauma, quality of life at work, etc) of over 300 employees (91 clinicians, nurses and physiotherapists; 99 care workers and 110 administrative personnel) in multiple nursing homes in Northern Italy found that 1 in four employees reported symptoms consistent with severe post-traumatic stress disorder, 16% reported moderate to severe depression symptoms and 11% severe anxiety. 40% of the sample declared that their mental health status had a negative impact on their social and professional life.

During the first wave of the pandemic, a large share of nurses and doctors left long-term care (LTC) settings to enter the national health service, which was recruiting professionals to cope with the outbreaks in hospitals. Since then, the shortage of LTC personnel keeps growing, and as of December 2021 there were no plans to increase the LTC workforce (source: LTC system and the pandemic December 2021; Amnesty International Report 2021).  Conversely, an OECD paper indicated that in several Italian regions (e.g. Apulia, Lombardy, Piedmont, Veneto), an important hiring effort was implemented during the first wave of pandemic attracting many professional care workers thanks to public sector contractual conditions (generally better contracts applied in private nursing homes).

According to a recent report (February 2022) by The Federation of European Social Employers, Italy has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

After the first two Covid-related cases in Italy were registered and confirmed in Rome on the 21st of January 2020, the Italian government suspended flights to China and declared a six-months state of emergency throughout the national territory with immediate effect on 31st of January 2020. At the same time, the Italian Council of Ministers appointed the head of the Civil Protection as Special Commissioner for the Covid-19 emergency. In the following days and weeks, additional regulations opened the possibility for the central government as well as other administrative levels (regions, cities etc.), in case of absolute need and urgency, to adopt stricter containment measures in order to manage the epidemiological emergency. At the end of February the first cases and deceased were registered in small towns in Northern Italy (Codogno, Vo’) that were placed under stricter quarantine(schools closed, public events cancelled, commercial activities closed etc.); on February 22rd carnival celebrations and some soccer matches were cancelled. On 1st of March, a Ministerial Decree established that the Italian national territory was divided in three areas: (i) Red zones (composed of Northern Italy municipalities that registered a certain level of COVID-19 cases where the population was in lockdown); (ii) Yellow zones (composed of regions of Lombardy, Veneto and Emilia-Romagna where certain activities were closed – schools, theatres – but people still had the liberty of limited movements); (iii) the rest of the nation where both safety and prevention measures were advertised but no further limitations were put in practice. On March 8th the government approved a decree to lockdown the entire region of Lombardy (and 14 other neighbouring provinces) establishing “the impossibility to move into and out of these areas” – with only few exceptions. Just a day later, on the evening of 9th of March, the government extended the Lombardy quarantine measures to the entire country. This national lockdown was expended several times until the 3rd May (Galeazzi et al., 2020).

If containment measures and lockdown were enforced by the central government, the same cannot be said for provisions detailing how the health sector and the LTC should respond to the COVID-19 crisis. In Italy, in fact, the health sector management and legislation fall within the competence of the Regional level; hence, especially during March and April all Italian Regions have adopted, at different times, plans, norms and decrees for managing the crisis.

Sources:

Galeazzi, A., Cinelli, M., Bonaccorsi, G., Pierri, F., Schmidt, A. L., Scala, A., … & Quattrociocchi, W. (2021). Human mobility in response to COVID-19 in France, Italy and UK. Scientific Reports, 11(1), 1-10

In Italy, as in other countries, measures to mitigate the impact of COVID-19 in care homes were adopted later than in the national health services. A detailed study attributes this delay (as well as the lack of timely resources to support the implementation of measures) to policy legacies resulting in nursing homes lacking recognition and visibility and being seen as a marginal part of the Long-Term Care system.

This is also connected with the governance of LTC sector, allocating to Regions the responsibility of regulating elderly sector. This led to differences in the regional approaches, also following the spread of Covid-19 across the country.

However, the national level kept a significant role in allocating resources (such as PPE and personnel) during the first phases of the pandemic. I.e. in early April, 2020, The Ministry of Health published the operational guidelines for a “rational”  use of Personal Protection Equipment (PPE) in healthcare and LTC settings. The guidelines list the basic principle to ensure personal protection and recommends that regional authorities guarantee adequate provision of PPE and engage in training activities for care workers. Also, Ministry of Health published the first guidelines for COVID-19 management in nursing homes, requiring providers to ensure training of care workers and suggesting extensive testing.

Much of the legislation was then promoted from the Regions, since they represent the institutional level in charge of defining the operating rules and guidelines for the LTC sector. During the pandemic, Regions (and local health authorities) gave directions, regulations and instructions to the health institutions for older people, for the management of COVID-19 cases and their containment and prevention. The spread of the virus in the sector was very vast as witnessed by previously exposed data: it had a significant impact on all settings providing care to a population particularly at risk. The combination of these two factors has led to the need to define emergency and risk management plans which had to be differentiated between the LTC sector and the “rest of the world”, precisely to take into account these specificities and, in some cases, guarantee additional protection to the older population. The healthcare sector managers, for their part, have activated internal risk management strategies, aimed at protecting their structures and ensuring the maximum quality of assistance. At the same time, however, common regional instructions were also needed to coordinate action in the LTC domain, also guaranteeing homogeneous treatment consistent with the simultaneous “pure health” policies that were implemented. (Berloto et al. 2020)

Sources:

León, M., Arlotti, M., Palomera, D., & Ranci, C. (2021). Trapped in a Blind Spot: The Covid-19 Crisis in Nursing Homes in Italy and Spain. Social Policy and Society, 1-20. doi:10.1017/S147474642100066X

Berloto, Longo, Notarnicola, Perobelli, Rotolo (2020), Il settore sociosanitario per gli anziani a un bivio dopo l’emergenza Covid-19: criticità consolidate e prospettive di cambiamento, Rapporto OASI 2020, Egea Milano

At the end of 2020, three different national «commissions» on the future of nursing homes have been established by the central government. These are: one parliamentary investigation commission on Covid-19 death in nursing homes (Commissione Parlamentare di Inchiesta) that has the aim of assessing mortality during the first and second wave and establishing potential responsibilities of managers and public officials with this respect; one specialized commission promoted by the Ministry of Health (Commissione Monsignor Paglia) with the aim to reform nursing homes sector mainly involving geriatricians and medical experts; one specialized commission promoted by the National Agency for Excellence in Health Care Services (AGENAS) with the aim of defining effective tools for integrated care. These different commissions have a specific focus on residential care, with a medical perspective (social care experts are missing).

Sources:

AAVV, 2021, PIANO NAZIONALE DI RIPRESA E RESILIENZA MISSIONE SALUTE, Monitor, Anno II, Numero 45

One of the major problems with Italy’s management of the COVID-19 crisis, was the absence of care coordination between care settings. The efforts have been focused on acute hospitals, trying to preserve their safety and resilience. This implied that, in many Regions, transfers from Long Term Care services (nursing or care homes) to Hospital has been blocked, providing guidelines to treat even the most severe case without access to the NHS. The same applied for emergency care. No specific national measures have been promoted on this. In some territories (such as Lombardy and Sardinia) nursing homes were formally asked to accept patients transferred from hospitals, becoming COVID-19 centres. Nursing homes representatives refused to accept this proposal, considering that they did not have neither appropriate staff nor equipment. Concerning staff, transfer from settings happened on voluntary basis and following local necessity. We have records of situations were trained staff were moved from acute care setting to nursing homes to provide training and expertise. This happened following specific agreement between providers. At the same time, many providers reported that they have been losing nurses and care personnel following the massive campaign of recruitment from the NHS. In March an extraordinary enrolment of health staff was implemented in Lombardy, Piedmont, Veneto, Apulia and other regions, so that many professional care workers applied, attracted by public sector contractual conditions (generally better than contracts applied in private nursing homes).

With respect to the coordination measures between the health and socio-healthcare sector, an analysis (Berloto et al, 2020)  was made of whether and how integration methods were established between the hospital, regional and social-health network in the context of the COVID-19 emergency. On this, no Region among those analyzed has adopted measures specifically aimed at this objective. Even in the cases mentioned above, Liguria and Tuscany, the operational units responsible for coordination between settings had the primary objective of evaluating and managing individual cases and not the organizational supervision of the network as a whole. The topic was delegated to the local level, in the direct relationship between healthcare institutions and care homes which, on the basis of highly differentiated indications, also the result of historical relationships and dynamics, gave themselves operating methods and rules. The management of the patient/user relationships and professionals flows between the network nodes has in some cases been hampered if not blocked, for example with the prohibition of transfer to the emergency room or hospitals. The objective pursued was therefore opposite: instead of reinforcing coordination between settings, the aim was to isolate them and make them independent.

Apart from the Lazio experience, no specific guidelines or indications were identified in Phase 2 with respect to the coordination between the health and social and health sector. Also, in this Phase 2 the theme was not put on the “legislative” agenda of the Regions and indications supported by structured initiatives and regulations were not produced. Rather, nursing homes have been kept separated without regulating common elements with other services.

Source:

Perobelli, Berloto, Notarnicola, Rotolo, 2021, L’impatto di Covid-19 sul settore LTC e il ruolo delle policy: evidenze dall’Italia e dall’estero, in Le prospettive per il settore socio-sanitario oltre la pandemia. Egea: Milano

During the first and second waves of the pandemic access to long term care was deeply impacted. Initially, new admission have been stopped. Generally speaking, Regions were oriented to order the closure of the services (both in terms of cessation of activities and of physical limitation of access) by regulating the methods of access. The focus was on the “physical” containment of existing situations and on the prevention of new outbreaks, giving indications on the obligations of use of personal protective equipment (PPE) and on the safety procedures to follow. With respect to home care, there were opposite attitudes with Regions that blocked the services and the access to people’s homes, and others that instead incentivized them. This led to negative impact on equal accesso to care (Cipriani and Fiorino, 2020).

From Autumn 2020 access to care was re-established but this was not sufficient to restore previous levels of take up rates, with a double effect on wellbeing and health outcomes of elderlies and on economic performances of care provider. Concerning the latter, national and regional measures have been enacted to provide extra funding so to mitigate the losses of activities consequences of the first waves of the pandemic. One example is Piedmont region.

Sources:

Cipriani, G., & Di Fiorino, M. (2020). Access to care for dementia patients suffering from COVID-19. The American Journal of Geriatric Psychiatry, 28(7), 796-797.

Absence of data and figures of what happened during Covid-19 in LTC sector has been acknowledged as one of the main critical issues for the sector and for the impact of the pandemic by the newly established commissions on the post-covid reforms that have been enacted in the last months (2021). At the national level, the Istituto Superiore di Sanità was the only actor collecting comparable and robust figures on what was happening in nursing homes. This was done through a voluntary national survey submitted to nursing homes providers in three rounds: April 2020, June 2020 (for an international report on this data see Lombardo et al.). Regions enacted some ex-post data collection with limited relevance and poor continuity of data. During 2021 the same institute promoted a new survey on the surveillance of vaccination and spread of Covid-19 in nursing homes, covering the period October 2020-September 2021.

Sources:

Lombardo, F. L., Salvi, E., Lacorte, E., Piscopo, P., Mayer, F., Ancidoni, A., … & Nursing Home Study Group. (2020). Adverse events in Italian nursing homes during the COVID-19 epidemic: a national survey. Frontiers in psychiatry, 11.

LTC oversight and regulation is part of regional functions and did not changed during the pandemic. No specific intervention has been implemented during 2020 or 2021 and the governance model remained unchanged.

During the first and second waves of the pandemic Long Term Care Facilities experienced a severe shortage of nurses due to both the effect of Covid-19 on the overall population and specific dynamics of LTC sector (high level of burnout, low commitment, preference to work in other care settings when possible). No support was provided in this respect to care providers from public authorities, and single institutions implemented corporate actions to try to guarantee care standards (i.e. transfer of care workers from one unit to another, transfer from different regions, collaboration with other care providers, relocation from care settings closed during lockdown).

With respect to measures addressed to staff in the LTC sector, it is noted that Regions have mainly focused on giving very operational and peremptory indications on the use of PPE, without giving space to training and emergency management preparation practices. There is variability between more general indications provided to the staff of the organisation (e.g. Piedmont) and cases in which the indications have been provided in detail for the individual professional figures (e.g. Tuscany). Once again, the issue of training of care workers and not of care homes has been delegated to the local level and managed by each structure or in conjunction with the healthcare companies. Also in this case, most attention was on the issues of isolation and containment of cases both by limiting movement and through the use of devices, without due attention to what the staff of the facilities could and should have done during the emergency or to any greater or different need for staff.

Generally speaking, this situation negatively impacted the wellbeing and job satisfaction of care workers. Moreover, in 2021, the Italian NHS and LTC sector in facing a massive shortage of care workers due to lack of vocational training and the absence of professionals (source: Amnesty International Italy, 2021).

Sources:

Amnesty International Italy (2021), Italy: Muzzled and unheard in the pandemic: Urgent need to address concerns of care and health workers in Italy

There were no no national or regional strategies to provide “squads” or rapid response teams to support care homes with outbreaks or staff shortages. When these teams were deployed, this was through local partnership and supported by private care providers.

At the beginning of the pandemic there was lack of ability to monitor and control the spread of the COVID-19 in nursing homes, and no testing of suspected cases among residents and care personnel. For several months (until Autumn 2020) procedures did not foresee testing residents in nursing homes, not even those presenting symptoms. This compromised data gathering on the actual number of COVID-19 related deaths among people living in nursing homes. From Autumn 2020, guidelines have been promoted by representative associations of care providers and the Istituto Superiore di Sanità concerning nursing homes internal procedures on Covid-19 management.

In relation to training, each region have then promoted specific measures on training on prevention and control measures. Moreover, guidelines published by the Ministry of Health required providers to ensure the COVID-related training of care workers.

Source:

Rapporto ISS COVID-19, n. 6/2021, Assistenza sociosanitaria residenziale agli anziani non autosufficienti: profili bioetici e biogiuridici

During the initial spread of Coronavirus COVID-19 in Italy, care homes were isolated from the rest of the healthcare system. Hospitals in many of the regions that were under pressure during the peak of COVID-19 (such as Lombardy, Veneto, Emilia-Romagna, Marche and Piemonte), started to reject and deny admission for care homes residents who might have problems related with COVID-19 (since testing was not available for all, the evaluation was based on symptoms). As a result, many of them were cared for in facilities not equipped for high-severity conditions and lacking the specialized health care workers that you can find in other settings such as hospitals. Moreover, access to palliative care has been critical, not only for care homes residents. The associations representing palliative care and intensive care unit doctors (SICP, SIAARTI and FCP) issued a press statement in April 2020 urging for specific protocols for COVID-19 patients.  

In 2021 new rules have been implemented including testing and isolation procedures. The guidelines have been issued by the Ministry of Health through the Italian Institute for Health (ISS)

Source:

Rapporto ISS COVID-19, n. 6/2021, Assistenza sociosanitaria residenziale agli anziani non autosufficienti: profili bioetici e biogiuridici

Guidelines have been issued by the Ministry of Health through the Italian Institute for Health (ISS), defining standards and procedures for isolation in nursing homes.

During the initial part of the pandemic, on 8th March 2020, the Italian government passed emergency legislation that, among other measures, restricted family and visitor access to Long-Term Care Facilities (LTCF), giving the administration of the LTCF the power to authorise visits, usually in end-of-life situations. Data from a care home survey showed that 88.8% if care homes interviewed had already restricted visits before the 9th March 2020.

A government circular in November 2020, recognised the importance of family and friends’ visits and provided guidance  to prevent the negative impacts of social and emotional isolation on the health, cognitive function and wellbeing of residents in LTCFs. The circular also included guidance to reduce the risk of transmission during visits. This document was the first time that the rights of care home residents to communication and social interaction had been recognised in an official document.

In May 2021, the Ministry of Health signed a new resolution that re-opened nursing homes to those relatives holding a “green certification”. This is a new national pass that asserts that the person either has been vaccinated, has already contracted and recovered from Covid-19 in the past, or has received a negative Covid-19 test within the previous 48 hours. Additionally, this resolution contains guidance on the procedures for residents going back to their houses.

From December 30th 2021 nursing home visitors need to have either a “super green pass” (two doses or a booster, or two doses and a negative test).

Sources:

Bolcato M, Trabucco Aurilio M, Di Mizio G, Piccioni A, Feola A, Bonsignore A, Tettamanti C, Ciliberti R, Rodriguez D, Aprile A. The Difficult Balance between Ensuring the Right of Nursing Home Residents to Communication and Their Safety. International Journal of Environmental Research and Public Health. 2021; 18(5):2484. https://doi.org/10.3390/ijerph18052484

https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

During the first wave in 2020, testing was not available for Long Term Care Facilities (LTCFs) and this has been considered as one of the main causes of the high mortality rate registered in LTCFs in the first months of 2020. From the second wave onwards, regional guidelines have been implemented that give LTCFs preferential access to testing.

Another relevant issue in Italy was the lack of Personal Protective Equipment (PPE) for Long Term Care services, including care home workers. Italy faced an enormous shortage of masks, tests, gowns, which deeply affected the social care and healthcare personnel. New PPE supplies were primarily directed to hospitals and nursing homes were left struggling to find the adequate equipment to protect their workers and residents. In the Lombardy Region, the first supply of masks for nursing homes arrived on the 12th of March 2020 but proved to be insufficient to cover their actual needs. In the national ISS survey, respondents stated that some of the major problems encountered during the crisis were related to the weak guidelines given to limit the spread of the disease, the lack of medical supplies, the absence of care workers, and the difficulty to promptly transfer positive patients into hospitals. All of these factors were considered to have allowed the virus to spread in LTC facilities, resulting in an incredibly high number of infected residents and care personnel, together with high mortality.

In 2021 PPE shortages are no longer an issue, but acquisition of the materials needed is still the responsibility of care providers.

To compensate for limited access to visiting in nursing homes for difficulties in meeting families and caregivers, care providers have used tools such video calls, dedicated apps and telemonitoring.

A qualitative study found that in May 2020 family carers of people living with dementia began to have access to remote support from community-based services, through mobile smartphones, tablets and personal computers, using existing applications such as Whatsapp, Skype, Google Duo, and Meet. There were examples of the use of personalised pre-recorded videos to continue activities previously done face to face such as music therapy and low-impact expercise and videoconferencing to deliver group activities such as support groups, physical activities and cognitive stimulation. These were perceived to be helpful in reducing feelings of isolation and loneliness and maintaining relationships with therapists (Chirico, 2022).

References:

Chirico, I., Ottoboni, G., Giebel, C., Pappadà, A., Valente, M., Degli Esposti, V., Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in Italy. Health & Social Care in the Community, 00, 1– 10. https://doi.org/10.1111/hsc.13758

On December 12th, 2020 the Ministry of Health published the Italian strategic plan for the vaccination against Covid-19. The plan identified three priority groups for the vaccination: 1) Front-line health and LTC personnel, 2) Nursing homes’ residents, 3) People aged 80 or above. These three categories accounted for 6,416,372 people, almost 11% of the Italian population. There was also criticism that older citizens have not been prioritized in practice as they were in the original plans (only 30% of vaccination doses have been given to those over 70). The government made a major push to accelerate vaccination rates up to 600,000 per day in March 2021.

In March 2021, Covid-19 vaccination became mandatory for health professionals working in health and in LTC settings, including GPs, nurses and pharmacists who are deployed in social care settings. Mandatory vaccination concerned only clinical staff. Those who refuse cannot have their employment terminated. The employer is responsible for either transferring the employee to another job where the risk of spreading infections is lower (without affecting salary), or enforcing unpaid leave, with suspension of pay until December 31, 2021.

There are no administrative data over the vaccination rate among LTC staff and users, but a recent study from the Ministry of Health on a sample of LTC facilities shows a sharp decrease in the number of new cases and of deaths after the launch of the vaccination campaign.

At present, 85% of people aged 12 and more have received two doses from the vaccine, and the Government is pushing the booster rollout.

Mandatory vaccination policies for staff and visitors 

In October 2021 mandatory vaccination also extended to care and administrative staff working in LTC settings, although there is lack of clarity over who is responsible for to monitoring compliance.

From December 30th 2021 nursing home visitors need to have either a “super green pass” (two doses or a booster, or two doses and a negative test).

Currently (December 2021) no reform has been implemented with regard to LTC and LTCF. In the National Plan for Recovery and Resilience, strategic objectives concerning integration of care, social housing, home care, have been included but no action was taken until today.

Sources:

AAVV, 2021, PIANO NAZIONALE DI RIPRESA E RESILIENZA MISSIONE SALUTE, Monitor, Anno II, Numero 45

In November 30th 2020, an official document recognised, for the first time, the right to the social and emotional support from family and friends for people who live in care homes.

Source:

Bolcato M, Trabucco Aurilio M, Di Mizio G, Piccioni A, Feola A, Bonsignore A, Tettamanti C, Ciliberti R, Rodriguez D, Aprile A. The Difficult Balance between Ensuring the Right of Nursing Home Residents to Communication and Their Safety. International Journal of Environmental Research and Public Health. 2021; 18(5):2484. https://doi.org/10.3390/ijerph18052484