This chapter explores the demographic and epidemiological context of non-self-sufficiency in Italy and the supply of home care. It first outlines the scale of population ageing and functional limitations, highlighting the growing prevalence of chronic conditions. The chapter then reviews the range of support and services available for non-self-sufficient persons, distinguishing between medical/nursing care, personal care, and assistance as framed by existing regulations. Attention is given both to the formal organisation of services and to their provision in practice. The analysis shows that social and healthcare services only partially meet the demand for long-term care. Finally, the chapter discusses the limitations of Italy’s data and monitoring systems, which constrain the capacity to assess needs and outcomes.
Towards a Structured and Systemic Integration of Home Care for the Non-Self‑Sufficient in Italy
Abstract
At the beginning of 2025, the population aged 65 and over and aged 80 and over in Italy represented 24.7% and 4.1% of the population, respectively. The population aged 65 and over will reach 37% of the total population in 2050, the second highest share in the world after South Korea, while the population aged 80 and over will represent 15% of the population (United Nations, Department of Economic and Social Affairs, Population Division, 2024[1]).
In 2021, 5% and 16.4% of the population reported severe and non-severe limitations in their usual activities, respectively. Based on this result, 12 767 000 Italians living in their own homes have limitations in performing ordinary activities due to health problems. The presence of limitations varies greatly between different age groups. While 7.9% of people under the age of 45 report limitations (severe and non-severe), the percentage increases significantly with age, reaching 59.1% in the over‑75 age group (Figure 1.1) (ISTAT, 2023[2]). This figure may represent an underestimation of the actual need for services, as it is based exclusively on information reported by people living in their own homes who participated in the survey. It should also be noted that the 2021 population census found that 4.1 million people aged 65 and over were living alone, an increase of almost 600 000 compared to 2011 (ISTAT, 2025[3]).
People with severe and non-severe limitations in their usual activities (as a percentage), by age, 2021
Source: ISTAT (2023[2]), Disabilità in cifre.
Given the high concentration of persons with limitations in their usual activities among the elderly population, an in-depth analysis of the elderly population can provide a more detailed picture of care needs in Italy. The PASSI d’Argento survey by the Istituto Superiore di Sanità (ISS) reports data on the state of health and independence of the population aged 65 and over.1 The data for the two‑year period 2023‑2024 show that 13.7% of the population aged 65 and over have at least one limitation in Activities of Daily Living (ADLs), i.e. in performing the basic functions of daily life such as eating, dressing, washing, moving from one room to another, being continent, using services to do one’s needs. Moreover, 15.9% of the population aged 65 or over have at least one limitation in Instrumental Activities of Daily Living (IADL), i.e. in complex functions such as preparing meals, carrying out housework, taking medication, getting around, managing one’s finances or using a telephone. Once again, the data show a significant increase in limitations as age increases. Among persons aged 85 years and over, 41% and 33%, respectively, require support in performing at least one ADL and IADL. The distribution of the non-self-sufficient population varies across the country, with a higher rate of persons with limitations in the south and islands and a lower rate in the northern regions.
1.2.1. The organisation of services in accordance with the regulations
Non-self-sufficient persons in Italy may receive medical/nursing care, personal care and assistance in the form of money transfers, formal services in residential or semi-residential facilities, formal services provided at home and informal support from family members, friends or personal caregivers.
Among money transfers, the most widespread is the attendance allowance provided by the National Social Security Institute (INPS) to those with a certified 100% disability. The allowance amounts to EUR 515 per month and no income criteria are required to access it. In some cases, there are also monetary transfers provided at municipal level (i.e. care allowances or vouchers), whose access criteria, amount and usage constraints vary between municipalities.
Semi-residential and residential services offer respectively daytime and 24‑hour care services to non-self-sufficient persons. The conditions of access, the services offered and the costs of these services vary between regions.
Finally, non-self-sufficient persons can access home services, as defined by Legislative Decree No 299/1999, which include:
Care services with high health integration, provided at home, i.e. those activities characterised by particular therapeutic relevance and intensity of the health component and mainly relating to the areas of maternal and childcare, the elderly, handicap, psychiatric pathologies and alcohol, drug and medicines addictions, pathologies due to HIV infections and terminal pathologies, inability or disability resulting from chronic degenerative pathologies.
Healthcare services of social relevance provided at home, i.e. activities aimed at health promotion and the prevention, detection, removal and containment of degenerative or disabling outcomes of congenital and acquired pathologies. These activities contribute, taking into account environmental components, to participation in social life and personal expression.
Certain health-related social services provided at home, i.e. social system activities that aim to support the person in need, with problems of disability or marginalisation that affect the state of health, including home care services for the activities of daily living, such as eating, washing and dressing (ADL) and home care services in the instrumental activities of daily living, such as cooking, shopping and managing finances (IADL).
Medical/nursing care
The main reference for Integrated Home Care (ADI) is Article 22 of the Prime Ministerial Decree “Nuovi LEA” (New Essential Levels of Care) of 2017, which regulates home care as a response to the needs of people who are not self-sufficient and in fragile conditions. This article relates to the provision of home healthcare services, mainly nursing and rehabilitation, in accordance with the clinical conduct of the general practitioner.
Integration refers to the processes of interaction between different healthcare professionals (originally the family doctor with the district nurse). The number of professionals involved has progressively widened and qualified, including specialised figures such as rehabilitation therapists or geriatricians. Home care is accessed in all cases after a multidimensional assessment of needs and the drawing up of an Individual Care Project.
The integration of different levels of ADI with the opportunities offered by telemedicine and teleassistance is becoming increasingly important, as is interaction with specialist services in the local area, including through teleconsultation, and interaction with assistance and protection activities.
There are various healthcare activities carried out at home that are highly complex in terms of organisation but are not focussed on home care services because they originated as “hospital therapies carried out at home”. This is a healthcare sector that has been around for many decades and is evolving in leaps and bounds, keeping pace with advances in healthcare technology, physics and engineering, and remote management, surveillance and monitoring capabilities. Sometimes these home therapies also overlap with home care services, depending on the progression of the disease and the level of independence of the individuals and their families.
From a regulatory standpoint, there is still no stable and recognised activity for long-term home care for elderly people who are not self-sufficient. The Prime Ministerial Decree “Nuovi LEA” (New Essential Levels of Care) regulates four levels of home care based on the complexity of healthcare needs and the intensity of care required. Probably the most suitable type of care for the healthcare system would be Level 3 ADI, i.e. continuous care and planned interventions, also characterised by the need to provide support to the family and/or carer. However, in the vast majority of cases, no actual provision is made for activating professional nursing care or professional personal care assistance services (50% of which are paid for by the health service), that play an essential role in long-term care. Added to this is the total “episodic fragmentation” of interactions with social home care activities provided by municipal administrations, which, at national level, continue to show low, fragile and ad hoc levels of integration (with local exceptions).
Personal care
In the case of elderly people who are not self-sufficient, home care involves assisting people who have multiple, often chronic, conditions and reduced ability to perform activities of daily living (ADL) independently. This is the key issue that needs to be addressed in order to develop any realistic prospects for long-term home care. In the case of elderly people who are not self-sufficient, home care needs to be understood in terms comparable to what Article 30 of the 2017 “New LEA” Decree defines as long-term residential social and health care for non-self-sufficient individuals.
Assistance with activities of daily living is an essential element that enables elderly people who are not self-sufficient to remain at home and receive the care they need. Like care services, assistance activities can vary in intensity and complexity, as well as over time due to various factors such as the progression of illness, living conditions, and the capabilities of the family, friends, and community network. It should also be emphasised that it is possible to respond to the various intensities and modes of personal assistance with both professional and non-professional activities, depending on the different levels of assistance required. In this regard, it should be noted that Article 29 of the aforementioned Legislative Decree 29/2024 provides for the development of specific national guidelines for the operational integration of social and health interventions provided for in-home care and assistance services and for the adoption of a continuous and multidimensional approach to caring for older adults, including those who are not self-sufficient, and their families, including through digital tools. This document aims to establish a model aimed at promoting integrated health, social, and social interventions integrated into the local network through shared management.
Assistance
The fundamental public function of “Social protection” is the responsibility of the municipality, while the regions have organisational and planning powers, and the state has powers over the Essential Levels of Social Services (LEPS) and their financing and planning. The function is regulated, implemented and financed by each municipality and may be exercised individually or in association with other local authorities. The Social Territorial Area (ATS) is the portion of the territory in which the exercise of the function is planned through the Area Plan, and in most cases its perimeter includes several local administrations (approximately 7 896 municipalities – approximately 610 ATS). The ATS is also responsible for the following functions:
co‑ordination and governance of the integrated system of social interventions and services;
planning and scheduling interventions based on a needs analysis;
provision of interventions and services;
personnel management in the various forms of association adopted.
Article 19 of Ministerial Decree 95/2012, converted by Law 135/2012, identifies the fundamental functions of municipalities pursuant to Articles 117 and 118 of the Constitution. In particular, Article 19 specifies as a fundamental function of municipalities the “planning and management of the local social services system and the provision of related services to citizens”.
This provision is the focal point of the implementation of the function. As a rule, access to municipal social services is conditional on both means testing (ISEE) and an assessment of the need for protection, assistance, support and social assistance, based on the circumstances of the individual, their family and their formal and informal support networks. The “protective” nature of the public social assistance function is expressed precisely in this access mechanism, which focusses public action on individuals and families in greatest difficulty in order to help them regain a degree of autonomy in relation to economic, social, employment, housing, training and educational inequalities, combined with individual functional and bio-psycho-social characteristics. For elderly people who are not self-sufficient, their own social vulnerability or that of their family unit can significantly compromise the possibility of providing appropriate and effective home care.
The Ministerial Decree “System for monitoring essential service levels” provided for in Article 23 of Legislative Decree 29/2024 defines the monitoring system and its operating methods, as well as the specific indicators for verifying the implementation status of the provision of the Essential Levels of Social Services (LEPS). Specifically, monitoring the implementation status of the LEPS, as identified in Article 1, paragraphs 162, letters a), b), and c), 163, and 164 of Law No. 234 of 30 December 2021, focusses on the following areas of intervention:
social home care and integrated social assistance, including health services
social relief services
social support services
financial contributions (to supplement the attendance allowance).
1.2.2. Service provision in practice
There is a high need for social and health services throughout the country that the available formal social and healthcare services cannot fully meet. The limited availability of data adds a further potential barrier to the relevance of the services offered.
Social and healthcare services only partially meet the demand
Although almost all people aged 65 and over with at least one limitation in ADL and IADL state that they receive help (99.3% and 98% respectively), most of them receive informal assistance from family members, acquaintances, friends or personal caregivers (Table 1.1).
Percentage of elderly individuals with one or more limitations in ADL and IADL receiving formal and informal care services, 2023‑2024
Note: The sum of the elderly with at least one limitation in ADL who access the services listed is greater than 100% because the services are not mutually exclusive (e.g. a non-self-sufficient person may access care services at home and receive informal assistance from family members and personal caregivers for a fee).
Source: Istituto Superiore di Sanità (2025[4]), Passi d’argento, https://www.epicentro.iss.it/passi-argento/dati/fragili.
In 2023, the Ministry of Health recorded more than 1.6 million cases treated in integrated Home Care (ADI), three‑quarters of which were related to elderly people (65+).2
The intensity of ADI services often makes it impossible to provide adequate support to non-self-sufficient persons. According to the data published by the Ministry of Health in 2023 each non-self-sufficient elderly person assisted through ADI received 14 hours of care per year, on average, 9 of which are provided by nurses, 3 by rehabilitation therapists and 2 by other professionals. These hours correspond to 9 visits – on average – per case treated, to which must be added 2 visits by medical personnel.3
Access to Home Care Services (SAD) offered by municipalities is even more limited than that of ADI. At the national level, in 2022, 5% and 1.4% of people with disabilities received social care home services and home care integrated with health services, respectively. Among people aged 65 and over, 1% and 0.5% received social care home assistance services and home care integrated with health services, respectively (ISTAT, 2020[5]). To make up for this shortage of public support for non-self-sufficient persons, in Italy there were more than 1.1 million personal caregivers (regular and non-regular) in 2021, according to estimates (CERGAS Bocconi, 2023[6]).
In 2024, the current expenditure for healthcare of the population was EUR 185.1 billion, of which 74.3% was financed by the public administration and 22.3% by direct household expenditure (ISTAT, 2025[7]). Only 2.5% of this expenditure – amounting to EUR 4.6 billion – related to home care for treatment and rehabilitation and long-term home care. Ninety-one per cent of the expenditure on home care is financed by public administration and 6% represents direct expenditure by households.
In 2022, municipalities spent EUR 281.2 and EUR 61.3 billion on social home‑based social care services and home‑based social care integrated with health services, respectively. These amounts correspond to 3.2% and 0.7% of the total annual expenditure of the municipalities. The average annual expenditure per service user was EUR 2 096 and EUR 793, respectively (ISTAT, 2025[8]).
The data and monitoring system has shortcomings
While there are data on non-self-sufficiency and on persons assisted through Integrated Home Care (ADI) or through Home Care Services (SAD), there is no database that specifically correlates non-self-sufficient persons assisted through ADI and/or SAD. This information gap is a significant obstacle to effective planning and evaluation of care policies for the non-self-sufficient population.
Moreover, the available data tend to focus mainly on the coverage of services, rather than on the intensity or quality and appropriateness of care. Information is often obtained through ad hoc surveys, which may be sample‑based and require significant latency and processing times. This practice limits their usefulness for the planning and evaluation of services. In addition, the current data collection and monitoring system offers a performance‑focussed perspective, without providing an integrated view of the care pathway. All this highlights the need to strengthen and modernise the data and monitoring system so that it can better inform policies and strategies in the field of elderly care.
References
[6] CERGAS Bocconi (2023), Il personale come fattore critico di qualità per il settore Long Term Care, https://cergas.unibocconi.eu/sites/default/files/media/attach/Def_5%20Rapporto%20OLTC.pdf?VersionId=nBCtXf8Sb8l.5ue0Ksy5vUcrNiVTCJvl (accessed on 2 November 2023).
[7] ISTAT (2025), Conti della sanità.
[3] ISTAT (2025), Rapporto annuale 2025. La situazione del Paese.
[8] ISTAT (2025), Spesa per servizi dei comuni.
[2] ISTAT (2023), Disabilità in cifre, https://disabilitaincifre.istat.it/dawinciMD.jsp?a1=u2i4W000GaG&a2=__&n=$$$1$$$$$$$&o=5L&p=0&sp=null&l=0&exp=0 (accessed on 2023).
[5] ISTAT (2020), Interventi e servizi sociali dei comuni, http://dati.istat.it/viewhtml.aspx?il=blank&vh=0000&vf=0&vcq=1100&graph=0&view-metadata=1&lang=it&QueryId=22823&metadata=DCIS_SPESESERSOC1.
[4] Istituto Superiore di Sanità (2025), Passi d’argento, https://www.epicentro.iss.it/passi-argento/dati/fragili.
[1] United Nations, Department of Economic and Social Affairs, Population Division (2024), World Population Prospects 2024.
← 1. The analysis excludes the institutionalised population, i.e. elderly persons hospitalised or residing in Residential Care Homes (Residenza Sanitaria Assistenziale – RSA), Residential Social Care Homes (Residenza Sociosanitaria Assistenziale – RSSA) or Nursing Homes.
← 2. The figure refers to the entire population aged 65 and over, with and without limitations in self-sufficiency.
← 3. These visits do not contribute to the count of the average number of hours per person assisted.