COVID-19 and the Long-Term Care system in Italy

Structural characteristics of the LTC system, impact of the pandemic, measures adopted and new reforms

This country profile brings together information on the experience of the long-term care sector (focussing on people who use and provide care) during the COVID-19 pandemic in Italy from a living international report on COVID-19 Long-Term Care. It also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in Italy.

Experts on COVID-19 and long-term care in Italy that have contributed to this report:

Eleonora Perobelli, Elisabetta Notarnicola

Living report: COVID-19 and the Long-Term Care system in Italy

PART 1 – Long-Term Care System characteristics and preparedness
PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
PART 3 -Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
  • 3.01. Brief summary of the overall pandemic response (not specific to Long-Term Care)

    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 Reports11(1), 1-10

  • 3.02. Governance of the Long-Term Care sector's pandemic response

    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

  • 3.02.01. National or equivalent Covid-19 Long-Term Care care taskforce 

    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

  • 3.02.02. Measures to improve coordination between Health and Social Care in response to the pandemic

    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

  • 3.02.03. Measures to support, facilitate and compensate for disruptions to access to care

    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.

  • 3.03. Monitoring Covid-19 impacts in the Long-Term Care sector: data and information systems

    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.

  • 3.05. Long-Term Care oversight and regulation functions during the pandemic

    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.

  • 3.06. Support for care sector staff and measures to ensure workforce availability 

    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 the 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 (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

  • 3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, training and implementation support

    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

  • 3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings

    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

  • 3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes

    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.

  • 3.07.03. Care homes: visiting and unpaid carer policies

    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.

    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/

  • 3.07.04. Deployment of "squads" or rapid response teams to support care homes with outbreaks or staff shortages

    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.

  • 3.08. Access to testing and contact tracing for people who use and provide Long-Term Care

    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.

  • 3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector

    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.

  • 3.10. Use of technology to compensate for difficulties accessing in-person care

    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.

  • 3.11. Vaccination policies for people using and providing Long-Term Care

    On December 12th, 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. The vaccination rollout has been considered relatively slow, with only 1.4 million people having received both doses so far due to supply chain issues in February. There has also been 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 is making a major push to accelerate vaccination rates up to 600,000 per day in March (https://ltccovid.org/wp-content/uploads/2021/01/COVID-19-vaccine-and-LTC-prioritization-and-data-18-January-update.pdf; https://www.ft.com/content/fd60a722-2019-4094-a778-750a0e8a0931; https://www.thelocal.it/20210302/56-million-by-june-italys-plan-to-accelerate-vaccines-under-new-pandemic-commissioner/).

    As of March 2021, Covid-19 vaccination is mandatory for health professionals working in health and social welfare settings, which may include, for example, GPs, nurses and pharmacists who are deployed in social care settings (https://www.reuters.com/article/us-health-coronavirus-italy-vaccine-idUSKBN2BN34F). Those who refuse cannot have their employment terminated (https://www.ipsoa.it/documents/lavoro-e-previdenza/amministrazione-del-personale/quotidiano/2021/05/15/vaccino-anti-covid-obbligo-personale-sanitario-tanti-dubbi-certezza).

    Instead the employer is responsible for either transferring the employee to another job where the risk of spreading infections is lower (without affecting salary) (https://www.politico.eu/article/italy-health-workers-coronavirus-vaccinations/), or enforcing unpaid leave, with suspension of pay until December 31, 2021 (https://www.politico.eu/article/italy-health-workers-coronavirus-vaccinations/; https://www.filodiritto.com/vaccino-covid-e-obbligatorio-riflessioni-critiche). There is a lack of clarity over which health and/or social care professionals must be vaccinated by law (https://www.ipsoa.it/documents/lavoro-e-previdenza/amministrazione-del-personale/quotidiano/2021/05/15/vaccino-anti-covid-obbligo-personale-sanitario-tanti-dubbi-certezza). There are questions about whether this applies to new employees given the need to respect private information when hiring new staff. There has been much discussion on making vaccination compulsory for long-term care staff, however the vast majority of political parties are against such an approach (https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/).

PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies

Printable version of this country profile:

https://ltccovid.org/country/italy/

To cite this report (please note the date in which the report was accessed):

Perobelli E., Notarnicola, E. COVID-19 and the Long-Term Care system in Italy. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) LTCcovid International Living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6


Ongoing research projects on COVID-19 and Long-Term Care in Italy:

https://ltccovid.org/completed-or-ongoing-research-projects-on-covid-19-and-long-term-care/?_country=italy

Most recent LTCcovid report:

https://ltccovid.org/wp-content/uploads/2020/09/LTC-COVID19-situation-in-Italy-31-July-2020.pdf

Acknowledgement and disclaimer

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.

Copyright: LTCCovid and Care Policy and Evaluation Centre, LSE