Although the debate on a fully shared definition is still ongoing among practitioners, it is possible to define as not self-sufficient all those people who, due to chronic diseases, age or other psycho-physical limitations, need continuous assistance. In any case, the central point of the issue is the inability to carry out some of the most elementary daily actions (e.g. walking, dressing, etc.) regardless of the triggering cause, which can be as much an accident or illness as a condition closely related to the seniority of the individual subject.
Not necessarily, therefore, the condition of non-self-sufficiency is linked to age, but there is no doubt that the progressive ageing of the population makes the topical topical, even more so in the case of Italy, which with a life expectancy at 65 years (equal in 2016) to 19.1 years for men and 22.4 for women long-lived places us among the most long-lived countries in the world. However, living longer does not necessarily mean living better: about one in two elderly people suffers from at least one serious disease or is multi-chronic, with quotas among the over-80s of 59% and 64% respectively. Nearly one and a half million elderly people (11%), mostly over-75s, report serious difficulties in at least one personal care activity and people in difficulty increase further when you consider daily domestic activities: almost a third of over-65s and almost half of over-75s have serious difficulties in doing at least one daily domestic activity.
These numbers are also easy to see about the possible socio-economic impacts of non-self-sufficiency: over the next thirty years, public expenditure on non-self-sufficiency could weigh at least 3%, while it already weighs on household budgets of at least EUR 9.2 billion.
What protections from the state? Accompaniment Allowances and RSA
The prerequisite for doing so is that, when it comes to non-self-sufficiency, the purpose of all health and social care interventions is not normally healing, often impossible, but the maintenance of the best possible condition of health and psycho-physical well-being of the patient, thus considering global needs and reference context (family reality, etc.). With this in mind, at the moment, the Italian state intervenes in support of people who are not self-sufficient with different types and levels of support that, in fact, involve both central administrations and local authorities. In particular, they remember:
- the accompanying allowance, an economic benefit provided by the INPS to disabled or maimed persons, who have been recognised as not self-sufficient and, in particular, whose inability to walk without the help of a carer and/or the inability to carry out the main acts of daily life on a daily basis, in the absence of continuous assistance;
- social and health care, delegated to the Regions, which provides residential care for the elderly and disabled, non-residential care (semi-residential facilities and home care) and assistance for those suffering from addictions (alcoholics and drug addicts) or psychiatric conditions. In this case, therefore, the provision consists of the provision of services through the NHS, independent of age and income. However, the criteria for assessing the status of non-self-sufficiency to access different benefits may differ at the regional level;
- social welfare benefits provided by local authorities, mainly municipalities, and subject to the test of the means.
Attention! Assisted Health Residences, more commonly known as RSA, are therefore social and health residential facilities intended to accommodate elderly people who are not self-sufficient who need medical, nursing or rehabilitative, general or specialized care. They should therefore not be confused with the storage houses, unlike which there is a doctor 24 hours a day, one therapist for every 40 guests and one nurse for every 5. In other words, precisely because the guests of an RSA are not even partially autonomous, a constant medical and nursing presence is considered necessary, as well as ongoing help in ensuring the regular running of daily activities by the hosted subjects. On the national territory, public RSA is also joined by private facilities. Whereas in this second case, the burden of tuition is usually borne by the guest or his family members, access is normally agreed with the Office of Social Services of the Municipality in the event of public facilities. Again, a fee may be expected to be paid, but entities and modalities are generally defined on the basis of the host's income and wealth condition.
Paid leave under Law 104/92
A special mention is given to Law 104/92, which, in order to promote care, social integration and the rights of disabled people, establishes a particular type of paid leave that the employee who is in the care of a caregiver can apply to his employer. More precisely, the person requesting or requesting this type of permit must be in a particularly severe disability condition; they can therefore request:
- severely disabled people;
- parents, even adoptive or foster carers, of children with disabilities in a serious situation;
- spouse, part of the civil union, de facto cohabiting, relatives or related persons within the second degree of disabled family members in a serious situation. The law also extends to relatives and third-degree relatives or relatives if the parents or spouse or part of the civil partnership or the de facto cohabitant of the person with a severe disability are 65 years of age or are themselves suffering from disabling diseases or are deceased or missing.
In any case, only employees can apply for it, while domestic or home workers, self-employed and parasubordinate temporary agricultural workers are not entitled to it. In all cases, the disabling or non-self-sufficiency condition must be recognised through special health checks. Since the permits, which are fully paid for by the INPS, are designed to provide care and assistance, it is not possible to apply if the serious disabled person is admitted full-time to hospital, RSA or related facilities.
Once granted, paid leave under law 104/92 is translated into three days off per month for the disabled worker, even fractional in hours or, alternatively, in daily rests of one or two hours. In the case of caregivers, it is necessary to distinguish on the basis of the age of the carer; However, in the case of parents, spouses, part of the civil partnership, de facto cohabiting, relatives and relatives of the person in a serious situation, they are entitled to three days of monthly leave, even fractional in hours.
The National Non-Self-Reliance Fund
Among the state's interventions in favour of non-self-sufficiency, the National Non-Self-Reliance Fund established under Law 296/2006, with the aim of providing support to elderly people who are not self-sufficient and people with particularly serious disabling conditions, must also be mentioned. To this end, the Fund therefore provides additional resources compared to those already earmarked to cover the costs of economic, health and social welfare benefits provided through INPS, the NHS, Regions and local authorities, resources directed to ensure the essential levels of welfare benefits throughout the country and, specifically, to facilitate a dignified stay of the non-self-sufficiency at home or , however, innovative interventions in the field of independent living, so as to avoid institutionalization.
The Fund was made structural in 2015 and for 2018 the Budget Act provided, at full capacity, a budget amounting to about 450 million euros (for each year of the three-year period 2018-2020). The resources – for 2018 amounting to just over 430 million euros – are then allocated annually to the Regions according to the elderly population not self-sufficient resident and specific socio-economic indicators, by means of a special decree interministerial.
Compared to other European countries, however, Italy lags behind in reforming the system of public services aimed especially at elderly people who are not self-sufficient: as highlighted by the players in the sector, the responses to the problems posed by the progressive ageing of the population are currently inadequate both in terms of quantity and quantity, discounting the burden of a strong fragmentation of the various interventions (with consequent risk of inappropriate performance and dispersion of resources). In this context, an important reference point for a "restructuring of the system" is, however, the National Chronicle Plan (PNC).
The role of the private sector: supplementary health care and Long Term Care insurance policies
While the state has obvious difficulties in increasing its expenditure on welfare, family welfare is also becoming increasingly weak in addressing the challenge of non-self-sufficiency for various reasons: atomisation of families, difficulties in reconciling private life and work, and reducing housing in major urban centres.
Hence, the importance first of all of a new cultural approach, which puts not only the "disease" at the centre of the system, but rather the person and his project of care and life as a whole, taking into account both the clinical aspect and the economic, environmental and family context in which the patient is located who is not self-sufficient. And, secondly (but not in order of importance), also a multidimensional and integrated approach, which puts to common the activity and experience of all those involved so that it is precisely possible to achieve the construction of diagnostic-therapeutic pathways assisting – in technical jargon, PDTA – personalized and dynamic, in a logic of accompaniment and not only of care.
On the other hand, to reduce the costs and impacts of non-self-sufficiency for households, even more fundamental are the possible synergies between public and private. With this in mind, in particular, mutuality and insurance can undoubtedly help to share risks and needs related to non-self-sufficiency, for the benefit of the individual but also for the community. What tools can be used?
Not yet particularly widespread, even if the risk of non-self-sufficiency is increased, it is the so-called Long Term Care Insurance Policies (LTC), which protect against the temporary or definitive risk of loss of self-sufficiency, understood precisely as a loss of the ability to carry out the simplest activities of daily life, not necessarily due to illness or injury, but also attributable to senescence. In particular, the elementary actions also useful for the purpose of the conclusion of the contract are normally identified according to the Activities of Day Living (ADL) method are:
- dressing up and undressing
- use services
- move, move from bed to armchair and vice versa
- continence control capabilities
The minimum measure of missing ADLs for the definition of non-self-sufficiency may in any case vary from contract to contract, even in the case of collective insurance.
Simply put, the most popular covers can be of two different types. In the first case, probably the best known one, we follow the so-called "accumulation" model, which allows you to accumulate savings in a special fund: when the condition of non-self-sufficiency arises, the policyholder is then guaranteed the payment of capital or a one-off in the form of a life annuity, rendered for as long as the policyholder remains in the condition of non-self-sufficiency and of entity commensurate with what has accumulated up to that point. Precisely for this reason, the pension is activated only after the insurance company has been able to ascertain the state of non-self-sufficiency of the policyholder and persists for its benefit to the remaining condition of non-autonomy, even natural life during when necessary. In the second case, which follows the so-called "breakdown" model, the subscription of the policy implies that, once the non-self-sufficiency has been established, it is the company that will bear the possible social welfare costs – up to the fixed ceiling – for the whole condition. In a certain sense, it can therefore be said that in this case the policy does not provide annuities but services, whose suppliers tend to be identified by the insurer itself. Less frequent is the direct (total or partial) reimbursement of health and care costs or the cost of care, always within the limits of the insured ceiling.
Attention! In both cases, annuities or ceilings may, however, prove insufficient to cover all non-self-sufficiency costs, which the insurer is not obliged to guarantee.
However, the subscription of LTC policies is tax-friendly. In particular, the Decree of the Ministry of Finance of 22 December 2000 also extends to Long Term Care the tax deduction of 19% on the premiums paid, up to a maximum of 1,291 euros per year (a sum that still lives with that of other deductible insurance). However, LTC coverage is not necessarily provided on its own: it can be associated with other insurance coverage or forms of supplementary health insurance and supplementary health care, for example. In this case, however, the legislation stipulates that the specific reference legislation is that of each form of pension or insurance. 5,164.27 euros and 3,615.20 euros, respectively. Finally, a special focus is on the 2017 Budget Act, which, excluding LTC premiums from employee income, has effectively laid the groundwork for greater dissemination of the risk of non-self-sufficiency coverage within corporate welfare plans.
Therefore, each according to its own role and mode, pension funds, pension funds and health funds can also offer coverage related to the risk of non-self-sufficiency. While some funds provide for their members to automatically activate, and at no additional cost, an LTC policy, which, in case of loss of self-sufficiency, supports the enrollee thanks to the payment of a monthly allowance, some pension funds allow you to choose, at retirement, an annuity with the LTC option: the annuity paid periodically by the fund doubles in case situations of non-self-sufficiency occur. Another option sometimes offered is to activate, even before the accrual of pension requirements, an LTC policy among the so-called "ancillary benefits" that can be purchased separately from the enrollees. Finally, health funds and mutual aid companies generally offer Long Term Care benefits to their members who are not self-sufficient in two prevailing ways: by paying sums in a single solution or periodically, or by directly or indirectly covering the medical and social welfare costs that should be incurred by the member.
Techno assistance: health care apps and devices
Finally, in the debate on chronicity and non-self-sufficiency, the so-called techno-assistance, understood as the whole of health and welfare interventions made possible by the use of new technologies, also plays a leading role during this period. In its various components (home automation, telemedicine, etc.) technological evolution is in fact a strategic element to improve the adequacy of responses to the needs of the caregiver, increasing the possibilities of staying at home, improving the equity in access to care both in terms of time and types of intervention and, finally, favoring the medium to long term of spending containment. Not only that, by promoting the preservation of the levels of autonomy of the caregiver, the use of techno assistance generally results in greater satisfaction of both caregivers and caregivers. Pending any legislative changes, the technology assistance is currently only adopted in the context of experimental projects and is not part of the Essential Levels of Assistance.