This chapter describes and interprets disability assessments in place in Italy and its regions to determine eligibility for various national, regional, and municipal disability benefits and services. The report focuses on the situation in four regions: Campania, Lombardy, the Autonomous Region Sardinia, and the Autonomous Province of Trento. Disability assessment in Italy is highly fragmented by type of support and guided by layered pieces of legislation. Disability status assessments are medically oriented and discretionary, lacking technical and methodological guidelines and a scientific tool with strong psychometric properties. There is also no transparent link between the various disability status assessments (used for entitlement to national benefits) and the needs assessments (used for entitlement to municipal services). Current assessment practices in Italy diverge from the principles established by the Convention on the Rights of Persons with Disabilities (CRPD) and result in a lack of equitable support for, and inclusion of, people with disability.
Disability, Work and Inclusion in Italy
2. Disability status assessments and needs assessments in Italy
Abstract
This chapter discusses the many disability assessment procedures currently in force in Italy and its regions. Outdated legislation affects Italy’s ability to recognise functioning capacities of people with disability, provide adequate support and develop inclusive policies across sectors, such as social protection, labour, education, and health. In the absence of up-to-date national reference legislation, regions have adopted their own approaches, further contributing to large differences across the country in the number of people receiving and identified as needing support. The chapter focusses on four regions – Campania Region, Lombardy Region, the Autonomous Region Sardinia (henceforth, Sardinia) and the Autonomous Province of Trento (henceforth, Trentino) – which reflect the large geographic and governance variance across Italy.
2.1. Introduction
In the past 15 years, across the world the assessment of a person’s disability status has been increasingly shaped by the Convention on the Rights of Persons with Disabilities (CRPD)1, adopted by the United Nations (UN) Assembly in 2006 and ratified by Italy in 2009. The treaty characterises people with disability as “those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others”. A main feature of this characterisation of disability is the distinction it makes between people with impairments (i.e. problems at the body level) and barriers people face in interacting with their own environment (i.e. problems in performing activities because of underlying health conditions), and the emphasis it places on the latter in giving rise to disability. Such a strong emphasis on the actual experience of disability is not fully reflected in the disability assessment practices of many OECD countries yet, however. Concerns with the lack of attention to environmental factors and a strong focus on individual impairments have been repeatedly voiced by the UN Committee on the Rights of Persons with Disabilities, in its evaluations of State parties (United Nations, 2011[1]). This is usually the case for status assessment practices that rely on medical criteria, which are prone to an individualised approach and a de‑contextualisation of disability.
A parallel driver of change in disability assessment policy and practice over the last few years has been the dissemination of the International Classification of Functioning, Disability and Health (shorthand, ICF),2 an epidemiological classification instrument developed by the World Health Organization (WHO) that reflects the shift beyond elements of body impairment, to activity limitations and participation restrictions, which are reflective of the interaction of a person’s impairment and her or his environment. ICF makes a distinction between the intrinsic capacity, which reflects the expected ability of a person to perform activities considering their health condition and impairment, and performance, which reflects the actual performance of activities in the real-world environmental circumstances in which the person lives. Information about capacity typically represents the result of a clinical inference or judgment based on clinical data, while performance is a true description of what actually occurs in a person’s life. Based on a “bio-psycho-social”, or interactional, understanding of disability, assessment should adopt the latter performance perspective. To collect information of people’s performance and measure disability as understood by ICF, the WHO has developed and extensively empirically tested a Disability Assessment Schedule, the WHODAS tool. It consists of a set of questions in six basic ICF functioning domains (cognition, mobility, self-care, getting along with people, life activities, participation), which allow capturing the performance of activities by an individual in his or her daily life and the actual environment. In being aligned with ICF, and with the vision of the CPRD, WHODAS has a role to play in the modernisation of disability assessment practices needed in several countries to better reflect the person-environment interaction.
2.2. A highly fragmented legal landscape
Disability status assessment in Italy today, especially the assessment of civil invalidity, does not yet reflect the characterisation of disability used in the CRPD and reflected in ICF. In addition, the system in Italy is complex and fragmented. The fragmentation of the assessment of disability in Italy is partly explained by the historical evolution of the various pieces of legislation that laid the ground for such assessment. Basic knowledge of these laws and the institutions applying them is a requirement to further understand the different disability statuses that can be attributed to people with disability, as well as the corresponding assessment procedures that coexist and sometimes overlap (see below). The fragmentation of disability status assessments in Italy creates a system that is inefficient, difficult to navigate, and failing to ensure equality across people and regions.
The national legal framework on disability is anchored in the Italian Constitution (1948). However, law 118/1971, which establishes the concept of civil invalidity (invalidità civile), also constitutes a pillar. People with civil invalidity are those who, due to a physical or mental, congenital, or acquired disorder, either have persistent difficulties in carrying out the tasks and functions specific to their age when they are under age 18 or over age 65 (1); or, have undergone a permanent reduction in working capacity of more than a third, when of working age (18 to 65 years) (2). Additionally, applicants that are unable to perform the essential acts of daily life or to walk also fall in this group (3). Qualifying for civil invalidity is a key requirement for people with disability to access economic benefits, with the assessment process being jointly managed by the National Social Security Institute (Istituto Nazionale della Previdenza Sociale – INPS) and the local health authorities. Entitlement to different benefits is related to the percentage of disability assigned through the assessment of civil invalidity.
Importantly, some exceptions apply to those who can qualify for civil invalidity status under law 118/1971, further attesting to the fragmentation of the legal framework. Blind and deaf people are strictly speaking not people with civil invalidity, because their disability status and benefits are regulated by different legal provisions. Law 381/1970 defines deaf individuals as those with congenital deafness or deafness acquired during developmental age (under 12 years), preventing them from the normal learning of spoken language. Law 382/1970 defines civil blinds as those that are totally blind (no residual vision or residual “binocular perimetric” visual field below 3%) (a) or partially blind (residual vision that does not exceed 1/20 with possible correction, in both eyes or a reduction of the visual field below 10%), (b) Law 107/2010 was introduced at a later stage to define the concept of deafness-blindness, mostly based on a combination of the above definitions. These laws also establish specific economic benefits to support impaired individuals, and the details of the assessment process, which shares the institutional context and most steps with that for civil invalidity. However, the number of individuals going through the assessments for deafness, blindness and deafness-blindness is small compared to the number of assessments for civil invalidity. Moreover, people with hearing or vision impairment not qualifying for deafness and blindness will also have to undergo the regular assessment for civil invalidity.
A second group of exceptions relates to individuals who do not qualify for civil invalidity because their disability arose in an occupational context. Laws 1 124/1965 and 38/2000 establish occupational diseases and work accidents to be considered in assessing work invalidity (invalidità da lavoro), through a process that is under the responsibility of the National Institute for Insurance against Accidents at Work (Istituto Nazionale Assicurazione Infortuni sul Lavoro – INAIL). Disability obtained in war-related settings is also regulated by separate legal provisions, which correspond to different designations including civilian invalids of war (invalidi civili di guerra) – laws 539/1950 and 142/1953, war invalids (invalidi di guerra) – law 367/1963, and war civil invalids (invalidi per causa di servizio) – law 214/2011). The different disability statuses correspond to different pensions and allowances, with the Ministry of Economy and Finance being the responsible authority for all war and military related pensions.
Last, and although not mutually exclusive with civil invalidity, there is an alternative system to obtain economic support in the context of disability, which applies only to those persons with a recent work history and a record in contribution payments to social security. This contributory insurance system encompasses an additional legal complexity, as disability definitions and assessment procedures differ considerably depending on whether applicants were private‑sector employees or self-employed (law 222/1984), or civil servants (law 335/1995).
Furthermore, and while most of the definitions described above work as alternatives to each other in the context of economic support, two other key disability-related laws were adopted later in time, to complement the portfolio of available support. These laws created additional disability statuses that are cumulative to the definitions described above, meaning that people with disability can apply for them regardless of whether they have also been assessed for civil invalidity, blindness or deafness, work/war (military) disability or disability in the context of the contributory insurance system:
Law 104/1992 introduced the concept of “handicap”, which grants access to a range of benefits ranging from cost-sharing exemptions in healthcare to tax allowances and rights for family members, among others (see also Table 2.1). One essential difference from the definitions above is that the concept of handicap goes beyond the individualised and medical approach to disability, with more focus on the social context. It moves from only looking at the diseases/disorders and related impairments, to considering (1) how these result in limitations in performing activities and social participation, and (2) how such limitations entail a disadvantage in the social context. More specifically, law 104/1992 defines a handicap as a physical, mental, or sensory impairment, either stable or progressive, that causes learning, relational or work integration difficulties and as such is determining a process of social disadvantage or marginalisation. The law establishes two levels of handicap: an ordinary and a severe one. Individuals are attributed a severe handicap status when the single or multiple impairments that reduce their personal autonomy – compared to what is normal for the respective age group – lead to a need to receive permanent, continuous, and comprehensive assistance, either in the context of their individual tasks or when relating to others.
Table 2.1. Benefits accessed through the assessment of civil invalidity, blindness, and deafness
Note: for individuals below 18 years old the assessment does also consider whether the applicant has persistent difficulties in carrying out the tasks and functions specific to their age, but no percentage is attributed.
Source: Author’s compilation.
Law 68/1999 was introduced to promote the access to work of people with disability through support services and targeted placement, promoted by a disability employment quota. Disability in the context of this law is designated as disabilità, even though it is only one of the multiple disability statuses described in this section. In fact, disability for employment support does not have its own independent definition and specific assessment, as it is granted to those qualifying for civil invalidity (46% or more), blindness or deafness, work disability (33% or more) or war disability.
As for civil invalidity, blindness and deafness, the assessments of handicap and disability for employment support are also jointly co‑ordinated by INPS and the local health agencies. These five concepts, which coexist under the non-contributory support system and are all an assessment of disability status, are also commonly referred to in Italy as baseline or first-level assessments. Such designation differentiates them from a second set of assessments that occur mostly at the regional or municipal level, to match the needs of people with disability to the existing support services (thus, also referred to as needs assessments).
The 2021 Enabling Act (Law 227/2021) provides the legal basis for a revision of the definition of disability and the corresponding assessment system, embracing the principles of the CRPD and compliant with the ICF. Thus, disability status assessments would no longer be guided by medico-legal criteria only, but would also assess the person’s functioning, preparing the ground for stronger social participation. The Enabling Act, already mentioned in the Foreword of this report, also stipulates a unification of the different disability status assessment procedures in place, to address the fragmentation in disability legislation. The renewed disability status or baseline assessment would continue to determine eligibility for allowances, tax reliefs, and other benefits for people with disability, and could potentially be followed, at the person’s request, by a multidimensional assessment used to determine an individualised, personalised, and participatory life plan, which would entitle them to a set of social and health services.
2.3. Several disability status assessments exist in parallel
Several definitions of disability co‑exist in Italy, including those that correspond to the baseline or disability status assessments: civil invalidity, blindness, deafness, handicap, and disability for employment support. Although each of these five definitions corresponds to a different determination, described in detail in the following, they share some common aspects in the assessment process and implementation. The process followed by the baseline assessments consists mostly of three phases, in which INPS and the local health authorities alternate the level of involvement and lead. The specific responsibilities of INPS and the local health authorities in the process were modified in 2010 (law 102/2009), as part of a general process of decentralisation, thereby reinforcing the role of the former in several steps of the pathway.
General practitioners (GPs) are the starting point to apply for disability status assessments in Italy. Persons with a health impairment seeking a certification for disability (broadly defined) should turn to their GP, who in turn will orient the patient and prescribe the medical examinations necessary to certify the conditions that impair the applicant’s functioning. These medical examinations can be conducted by any certified doctor, i.e. almost all practitioners in Italy – from those employed by local health authorities such as primary care physicians (medico di assistenza primaria) to freelance doctors working for the National Health Service. The person’s GP should review the examinations and complete an introductory medical certificate (certificato medico introduttivo) on an online INPS platform.
The introductory medical certificate (form AP70) is an important element in the disability status assessment procedure, mostly because of the strong medical focus of disability determinations in Italy. GPs, therefore, play a key gatekeeping role in disability assessment, deciding the content of medical examinations and suggesting who should conduct them. This is similar in many other OECD countries, but the GP’s medical documentation plays a very significant role in Italy in the formulation of the diagnosis and (sometimes) the functional evaluation and, thus, the resulting civil invalidity percentage of the person due to limited time and resources available by those assessing the disability status.
Following the completion of the introductory medical certificate, which produces a code valid for 30 or 90 days, the next step is taken by electronically applying to INPS using this code and specifying the different definitions of disability (e.g. civil invalidity and/or handicap and/or disability for employment) the applicant would like to be assessed for. The application can be done by the person with disability or a family member, very often with the support of associations of patients specific to the applicant’s medical condition.
This second part of the process is under the oversight of the local health authorities, who electronically receive the information in the application and deal with administrative tasks such as booking an appointment with the medico-legal commission and inviting the applicant. The medico-legal commission meeting is the main event in the assessment procedure, and it should include the physical presence of the applicant. Importantly, and although differences exist across localities in the composition of the commission and in the criteria and tools used (see below), a medico-legal commission might conduct three baseline assessments at the same time: civil invalidity (or blindness/deafness, as the case may be), handicap, and disability for employment support, with only one meeting with the commission (with slightly deviating procedures across regions). How exactly the commission translates the clinical information into a civil invalidity percentage, is not very clear nor transparent but it has similarity with a barema method through which a set percentage of invalidity is attributed to a given diagnosis; a method that is based on experience but lacks scientific validity and reliability. Following the meeting with the commission and its decision, the local health authority completes the administrative process and sends relevant information and the proposed percentage of civil invalidity to INPS.
The last part of the process is the responsibility of INPS, which validates the outcome of the medico-legal commission and takes a final decision. When in agreement with the decision of the commission, INPS will communicate it to the applicant and set in motion additional eligibility testing steps needed to grant the benefits to which the applicant might be entitled, namely collecting socio‑economic and income data necessary for means-testing associated with some of the disability payments. In cases where INPS disagrees with the outcome of the medico-legal commission, the application is put on hold for further investigation. Such investigation might happen based on the information already collected or require an additional assessment of the applicant. Although quantitative data is not available, anecdotal evidence describes the validation step by INPS as an important milestone of disability status assessments, with a considerable proportion of applications being put on hold for further investigation, mostly in what concerns high degrees of civil invalidity. This additional investigation has implications for the duration of the overall process, as it generally delays the decision by several months and might also require one more visit by the applicant for assessment purposes. Therefore, several measures have been introduced in the past decade with the objective of reducing the proportion of assessments put on hold by INPS.
Law 102/2009 introduced the participation of an INPS doctor in the medico-legal commissions, which should contribute to a better alignment between the decision by the commission and its validation by INPS. More recently, in response to the COVID‑19 pandemic, INPS has also established the formal concept of a documentation-based assessment, which allows the additional collection of information for the verification procedure without requiring the applicant to appear once more before the commission. The success of these measures in streamlining the last part of the baseline assessments cannot be evaluated with the available data. However, information from field interviews suggests that the actual implementation of these efforts might be limited, due to the rare participation of INPS doctors in the medico-legal commissions. The final decision by INPS is not shared back with the corresponding local health authority, which prevents the latter from following the full assessment pathway for a considerable proportion of their applicants and to learn about the differences between its initial proposal and the final decision by INPS.
Importantly, there are some exceptions to the disability status assessment procedure described above, which is not followed by every region or province in Italy. One such exception results from a convention between INPS and some local health authorities (Convenzione Invalidità Civile, or CIC). Conventions are currently in place in some health districts of Campania (Avellino, Benevento, Caserta, and Salerno), Friuli Venezia Giulia (Pordenone), Sicilia (Trapani, Caltanissetta, and Messina) and Veneto (San Donà di Piave, Verona, and Venezia) and in all health districts of Basilicata, Calabria, and Lazio. Through these conventions, some regions or provinces have transferred the full responsibility for the disability status assessment to INPS, making the regional branches of the institute responsible for taking care of the whole process, including the parts usually performed by the local health authorities. Although the first parts of the process remain the same in principle, in these regions or provinces a simplification can be observed with the removal of the verification step, because of INPS overseeing the medico-legal commission itself. By making the outcome of the commission the final decision of the disability status assessment, such conventions reduce the overall length of the application procedure and the resources usually needed for the verification procedure. One other exception to the default procedure followed for disability status assessments is observed in autonomous regions and provinces, such as Trentino. In Trentino, benefits are not attributed by INPS, but by the corresponding agency in the autonomous province.
2.3.1. Medico-legal commissions and assessments
Despite the similarities in the procedure followed, there are also important differences in the disability status assessments for the different definitions of disability. The main differences are described below and pertain to the composition of the medico-legal commissions, the criteria and tools used in the assessment, and how the different outcomes link with access to benefits and services.
Assessment for civil invalidity, blindness, and deafness
The assessment of civil invalidity is a requirement for people with disability to access disability payments. The assessment of blindness and deafness can be considered as an equivalent to civil invalidity for these conditions, providing access to analogous benefits. Eligibility for the status of civil invalidity, blindness and deafness is, in principle, mutually exclusive, even though individuals might apply to be assessed for both civil invalidity and blindness, or deafness, if it is not clear whether they qualify for one of the latter two.
As established in law 295/1990, the medico-legal commission assessing civil invalidity should include three medical doctors, usually selected among those employed or affiliated with the local health authority. The president of the commission should be a specialist in legal medicine while one of the other doctors would be a specialist in occupational medicine. In practice, occupational doctors are often not available, and two of the three medical doctor positions are occupied by doctors of other specialties. The commission should also include a worker from the association representing the applicant’s medical condition (such as Associazione Nazionale dei Mutilati e Invalidi Civili (ANMIC), Unione Italiana dei Ciechi e degli Ipovedenti (UICI), Ente Nazionale per la protezione e l’assistenza dei Sordi (ENS) e Associazione Nazionale di Famiglie e Persone con disabilita intellettiva e disturbi del neurosviluppo (Anffas)) and a secretary. According to the respective laws, the difference in the composition of the commissions assessing civil blindness (382/1970) and civil deafness (381/1970) is the requirement of the inclusion of a specialist doctor in the conditions being assessed – either an ophthalmologist or an otolaryngologist. Lastly, and since 2010, commissions should be complemented by a doctor affiliated with the regional branch of INPS, whose contribution to the assessment should reduce the likelihood of the application to be held for additional verification by INPS, following the decision by the medico-legal commission. In practice, however, INPS doctors are rarely present.
The commission mostly relies on the information gathered in the introductory medical certificate. While it may also collect additional information on the medical condition including examining the applicants in situ, the short duration of the visit (usually less than 10 minutes) is a common practice, leaving limited opportunity to interact with the applicant. An exception to the short-duration interaction seems to be in place in Trentino, where the commission is reported to spend on average about 25 minutes with every applicant. Another considerable difference for this autonomous province is that the commission is solely composed of one doctor specialised in legal medicine.
The determination of civil invalidity is a medicalised assessment by law: it aims to capture the permanent functional impairment resulting from certain diseases or disorders, which should in turn be properly characterised through clinical and laboratory data. In theory, the commission should consider: the extent of total or partial anatomical or functional loss of organs (1); the possibility of a use of prosthetic devices to ensure full or partial restoration of a function of the injured body organs and structures (2); and the importance, in work activities or in comparison to the functional standards for the respective age group, of the organ or body structure for the anatomical or functional damage (3). In practice, the commission uses the clinical information available to classify applicants with diagnoses linked to legally pre‑defined percentages of civil invalidity. Beyond performing the diagnoses, the discretionary power of assessors is limited to choosing a value within ten percentage point intervals allowed for some health conditions or reducing/increasing percentages up to 5 percentage points, depending on the relevance of the impairment for the (potential) occupational activities of the applicant. In the case of severe cumulative impairments, the sum of percentages should be preceded by an evaluation of the real impact of additional conditions on the applicants’ functioning. Impairments corresponding to less than 10 percentage points of civil invalidity are mostly not considered in cumulative terms. The decision is based on correspondence tables last updated in 1992, which may reflect outdated medical knowledge in many cases.
Several problems exist with the use of these tables which not only include conditions that are no longer relevant but also miss others that are increasingly important for disability determination today, especially with the wide spectrum of often very prevalent but still highly stigmatised mental health conditions. Equally important, the percentages attributed to diagnosis ignore 30 years of progress in medicine, which can attenuate symptoms and impact on functioning of most known diseases. Therefore, the use of such outdated correspondence tables adds to the inadequacy of a purely medical approach which attributes standardised percentages of invalidity to a diagnosis, ignoring the role of the environmental context for each applicant and the relevance of the interaction between the impairment and the environment.
Another inconsistency of the civil invalidity assessment lies in an additional disability definition that is only evaluated for those classified with 100% of civil invalidity. In this case, the commission also assesses the applicant’s ability to walk or perform essential acts of daily life, although additional guidance on how to perform this evaluation is lacking. The output of this additional assessment is a binary decision on top of the civil invalidity percentage, giving access to additional support measures. Table 2.1 above summarises in simple terms how the output of the civil invalidity, blindness, and deafness assessments links to the availability of supports at the national level. While applicants are considered as having a civil invalidity with percentages above 33%, the most relevant supports are only available with percentages above 67%.
The recognition of a civil invalidity status is also a pre‑requirement for the recognised disability status for employment support (46% of civil invalidity, see more below), and for some of the needs-assessment procedures that are conducted for persons to determine eligibility for and access to regional and municipal benefits and services.
Handicap assessment
The assessment of handicap status results from the application of the definition provided in law 104/1992. This definition encompasses three elements and establishes that a handicapped person is someone who has a stable or progressive physical, mental or sensory impairment (1), which causes learning, relational or work integration difficulties (2), and results in social disadvantage or marginalisation (3).
While anyone can apply for a handicap assessment, including work and war invalids and those in the contributory disability insurance system, the assessment is often run in parallel with the civil invalidity assessment, including the visit to the commission. The handicap commission is similar in its composition to the civil invalidity commission except that it should also include a social worker. In Trentino, the social worker only complements a single doctor commission for the most complex cases, with a posteriori consultation happening more often. Overall, the addition of a social worker to a commission that is otherwise mostly or exclusively medical reflects the different nature of the disability definition applied for the assessment of handicap. In fact, the concept of handicap is the only one among the coexisting disability definitions in Italy that provides some room for going beyond body-related and medical models of disability and exploring the applicant’s functioning in the context of attitudinal and other barriers to functioning. While this is a positive aspect – and closer in line with the principles promoted by the ICF – it is unclear how this materialises in practice, given that no further criteria or tools are used by the commission, and the visit is nevertheless of very short duration. Handicap assessment can lead to one of three results: no handicap, handicap, and severe handicap. The distinction between the latter two categories is established by law 104/1992, which defines a handicap as severe if the decrease in personal autonomy – and accounting for the respective age of the person – leads to the need of receiving permanent, continuous, and comprehensive assistance, either in the context of performing individual tasks or in relating with others. In practice, this translates into evaluating the applicant’s need to receive permanent support and care. The requirement of permanence implies some persistence in the impairment leading to reduced functioning and social disadvantage, while allowing for changes over time. Overall, and even though its definition is more in line with the ICF approach to disability, the handicap assessment also seems to be permeated with medical considerations omnipresent in the Italian system. For example, certain health conditions have been a priori determined as directly conferring eligibility to severe handicap status. This is the case for example for applicants undergoing dialysis (Ministry of Health guidance 17 November 1998), with Down syndrome (law 290/2002), with cystic fibrosis or with deafness (INPS internal communications).
A handicap status allows access to additional support measures, with severe handicap status often being a requirement. Additional benefits range from exemptions from co-payments for medical care allowing free access to health services to benefits for the individual and their family members in the context of labour participation (such as a right to three days of care leave per month, an extension of the period of parental leave, an exemption from night shifts, and flexibility in choosing the working location) and discounts and concessions such as tax allowances for the acquisition of aids and a tax exemption for the purchase of a motor vehicle. The handicap status is also an important first step in creating eligibility for supports provided at the regional level, after undergoing a needs assessment at the local level.
Disability assessment for employment support
The assessment of disability for employment support (designated as disabilità in law 68/1999) differs from the remaining baseline assessments as it mostly consists of validating whether the applicant – who should be between 14 and 65 years old – qualifies through either civil invalidity with a percentage of at least 46% or by civil blindness or deafness, work invalidity with a percentage of at least 33%, or war invalidity.
The assessment of disability for employment support is often made in parallel with the assessment of civil invalidity and handicap. The assessment commission should be like the one evaluating the handicap status, including a social worker in addition to the medical members. While having a multidisciplinary panel would be certainly relevant for an in-depth assessment of people with disability for occupational purposes, the role of the commission in the context of law 68/1999 seems to be solely an administrative verification of other disability assessments result. Qualitative information about the applicant’s occupational abilities might be included in the assessment report, but there are no guidelines on how to do this nor any evidence that can substantiate the prevalence of this practice.
Being assessed as having a disability for employment support allows individuals to qualify for a set of tools that should facilitate their targeted placement and participation in the labour market. The main benefit consists of being listed for further support provided by employment services at the provincial level (every region in Italy consists of several provinces). Furthermore, applicants that qualify through civil invalidity may obtain additional employment-related benefits when their percentage is above cut-offs such as:
50%: Eligibility for workplace adjustments, removal of workplace barriers, teleworking set-up.
60%: Qualification for the employment quota for people with disability that employers are mandated to fulfil (including for applicants already employed at the time of the assessment).
67‑80%: Taxation for social security contributions reduced by 50% for the first five years.
80% (and with an intellectual or mental impairment): Waiver of social security contributions for the first eight years.
Intellectual or mental impairment: guaranteed placement.
2.3.2. Reassessments and appeals
Current processes of disability status assessment provide limited possibilities for an efficient re‑evaluation of the outcomes of a first decision. No strict reassessment timings or renewal obligations exist for the results of any of the five definitions of disability status. Even though the commissions might include such requirements in the assessment report, the data available does not allow taking any conclusions on whether this is a recurrent practice. While some flexibility in defining the need for reassessment might be a good practice, allowing the commission to personalise such decision to the context of the applicants and their social context, reassessment conditions and periodicity should be regulated by legislation, with guidance and transparency around the criteria (to be) used in such decisions.
For applicants who do not agree with the outcome of the assessment, the opportunities to appeal against the decision are theoretically limited to a judicial process to be submitted up to 180 days following the decision. This process has been modified since 2012 (law 111/2011), with the aim of reducing the length of the litigation procedure – which could last several years – and to avoid overburdening the civil justice. Nevertheless, it still represents a complex procedure, potentially discouraging people with disability from pursuing it, as they must also bear some of the associated costs. The modified process of appeal entails a first step that precedes an extensive involvement by the judge and the usual judicial activities such as hearings. This first step consists of a preventive technical assessment (accertamento tecnico preventivo) carried out by a consultant: a medical doctor appointed by the judge. Only when the parties disagree with the outcome of the preventive technical assessment, will the process move to the usual judicial pathway, which is lengthy and resource‑intensive (as it was already before 2012). Differently from the rest of the country, in Trentino it is possible to submit an administrative appeal within 60 days of the decision by the single‑doctor commission. The appeal results in a second instance assessment by a commission of three medical doctors, one of which should represent the relevant association of people with disability.
Interestingly, and despite the heavy appeals process, there are no restrictions to the number of times a person can apply to be assessed, thereby starting the process from scratch. Together with the complexity of the appeal procedure, this might lead to unintended incentives to submit new requests and start the process again instead of appealing. In fact, INPS procedures provide applicants with a possibility of submitting a request to cancel an ongoing process/decision, in which case documentation backing such request will be evaluated by a higher commission of INPS. This evaluation has three possible outcomes: it might confirm the previous decision, it might cancel the current process/decision and send the patient to start the process again, or it might directly change the decision to what was requested by the applicant. In practice, this process seems to be the equivalent to an (inefficient) administrative appeal. It also highlights the limitations of the current judicial procedures in ensuring rights to argue against a disability determination that relied on an over-medicalised and outdated assessment in the first place.
2.3.3. Trends in disability status assessments
The following figures summarise trends over the past decade in the rates of applications and acceptance for civil invalidity and handicap assessments. The following developments can be observed:
Applications for civil invalidity fluctuate from year to year but have been on a gradual trend rise until the COVID‑19 pandemic, especially for the total population but to a lesser degree also for the working-age population. In 2021, the number of civil invalidity applications was back to the level in 2019 (Figure 2.1, Panels A and C).
Applications for handicap are increasing sharply and have doubled between 2010 and 2017 for both the total population and the working-age population. Since 2017, the trend increase has flattened out. After a dip in 2020, the level in 2021 was higher than the pre‑pandemic level (Figure 2.1, Panels B and D).
Increases in applications for civil invalidity and handicap over the past decade for people of working age were largely driven by the regions in the middle and south of the country (Figure 2.2). The island regions (Sardinia and Sicily) are a noticeable exception, as they have seen a rapid increase in handicap assessments but no increase in civil invalidity assessments.
For civil invalidity, regions with the largest increases had higher application rates already ten years ago; hence, the North-South divide has increased further, with rates in the North often below 1.5% of the working-age population every year and rates in the South over 2.5% (Figure 2.2, Panel A). For handicap assessments, rates were more similar across all regions ten years ago, fluctuating around 0.75% of the working-age population. Today, rates in the South are typically also twice the rate in the North (2% versus 1% of the working-age population) (Figure 2.2, Panel B).
Acceptance rates are generally quite similar across regions and, overall, rather high, particularly for handicap applications. Acceptance rates for civil invalidity applications have converged to around 50‑60% in all regions of Italy, as regions that used to have higher acceptance rates – both in the North and the South – have experienced a decline in those rates (Figure 2.3).
Acceptance rates for handicap applications have remained high and largely unchanged between 2010 and 2021, around or even above 90% (Figure 2.4, Panel A). The majority is granted a “severe handicap” status but the distribution between handicap and severe handicap status differs considerably across regions (Figure 2.4, Panel B). Southern regions with a higher number of handicap applications tend to grant a severe handicap status less often than other regions.
Figure 2.1. The number of applications to civil invalidity and handicap status in Italy are increasing
Note: Applications for civil invalidity and handicap assessment for the total population include all applications, irrespective of age; applications for the working-age population refer to people aged 18 to 67. Standardised applications are applications divided by the corresponding number of residents, presented over 1 000 residents. Data cover all Italian regions except Trentino and South Tyrol.
Source: OECD calculations using Istituto Nazionale Previdenza Sociale (INPS) data prepared for the OECD.
Figure 2.2. A few Italian regions are responsible for the large increase in handicap applications
Note: Applications for civil invalidity and handicap for the working-age population aged 18‑67 divided by the number of working-age residents.
Source: OECD calculations using Istituto Nazionale Previdenza Sociale (INPS) data prepared for the OECD.
Figure 2.3. Acceptance rates for civil invalidity have converged across regions in the past decade
Note: Data shows the number of granted over the number of processed applications each year (the difference being rejected applications).
Source: OECD calculations using Istituto Nazionale Previdenza Sociale (INPS) data prepared for the OECD.
Figure 2.4. Acceptance rates for handicap are high everywhere, particularly for severe handicap
Note: Data show the number of granted over the number of processed applications each year (the difference being rejected applications). Panel A includes both handicap and severe handicap status, while Panel B distinguishes the two types of handicap status in all accepted applications.
Source: OECD calculations using Istituto Nazionale Previdenza Sociale (INPS) data prepared for the OECD.
2.3.4. Other disability status assessments
People with disability who have an employment history might (in addition) apply for alternative disability assessments (other than civil invalidity), to determine entitlement for disability insurance payments. Applicants in the contributory disability insurance system should have paid social security contributions on their income for at least five years (260 weeks), of which three years (156 weeks) should have been in the past five years. While these contributory requirements are the same for all employees, there are considerable differences in the disability definition, the assessment procedure and the key institutions involved depending on whether the applicants are private‑sector employees or self-employed (law 22/1984), or civil servants (law 335/1995). The below description refers to the assessment for the former group mostly, as this affects a much larger proportion of the population.
Private‑sector employees or self-employed workers are assessed for a reduction in their capacity to work due to a disease/disorder or a physical or mental impairment that should not be a consequence of their occupational activity. The reduction might be evaluated as partial, if above 33%, or as total. Partial and total disability correspond to different benefit payments, respectively the ordinary disability allowance (assegno ordinario di invalidità) and the ordinary disability pension (pensione ordinaria di inabilità).
At a first glance, the definition of disability in the insurance system seems to share some similarities with that of civil invalidity, which covers persons between 18 and 65 years who have undergone a permanent reduction in working capacity of more than a third. In practice, the key difference seems to lie on how the determination is done. While the civil invalidity percentage is obtained through a barema-like method, no additional methods or instruments are mandated for the assessment of disability in the insurance system. On the other hand, the evaluation of working capacity in the latter system should take into consideration existing aptitudes, and the job previously performed using those aptitudes.
The application to the contributory system follows a process like other disability status assessments, being submitted electronically to INPS and requiring a similar introductory medical certificate. There is, however, no role for the local health authorities in the whole process, which is fully conducted by INPS. The assessment is done by a single doctor from INPS who evaluates the medical conditions of the applicant. The INPS doctor should have in consideration the severity and persistence of the condition, the existence of adequate treatment and possibilities of rehabilitation, and the impact on functioning in relation to the work activity. This evaluation should include considerations about the applicant’s education and training, past job experience and attitudes towards work, as well possible alternative/adapted career prospects. Although the assessment remains strongly medicalised, such considerations create an opportunity for a better analysis of the social context and environment than the application of the barema method. Under the insurance system, identical clinical conditions could in principle lead to very different percentages of disability – depending on the applicant’s working skills, job tasks and suitable occupations. Nevertheless, the appropriate determination of disability in this context seems to be compromised by the lack of a reliable and valid instrument to convert the set of considerations above in the final numeric output required.
One other difference between civil invalidity and disability under the contributory insurance system concerns how binding the decision of INPS is in case of the latter, as applicants can choose whether they apply for the ordinary disability allowance or the ordinary disability pension: they have the right to opt for the allowance even when assessed by the commission as having total incapacity to work. In practical terms, applicants might choose the allowance due to the conditions coming with the eligibility for the ordinary disability pension: an obligation to cease any type of work activity, to be removed from professional registers and other related employment lists, and to be waived from unemployment insurance or other supplements to remuneration. There are certain professional situations, especially among self-employed and those running a family business, where applicants find incentives to pursue some professional activity even when they were assessed with full disability for that purpose. While in practice there is no data to evaluate how often this might occur, such a disconnect between the assessment decision and the benefit received highlights the limitations of the current assessment method to properly capture disability, as they might classify with full disability individuals who have the capacity, and prefer to, continue working. One last difference between contributory and civil invalidity assessment practices is that in the former those classified with partial disability and thus entitled to ordinary disability allowance must be reassessed after three years for a maximum of two times, after which the disability is finally considered permanent.
2.4. Needs assessments at the regional level vary considerably
2.4.1. Fragmented access to regional and municipal services and benefits
To access benefits and services at the regional and municipal level, people with disability must undergo a second level of assessment, in which their needs and the entitlement to health and social services and programmes to meet these needs are evaluated. While this approach has been adopted in many OECD countries, its implementation comes across many challenges in Italy. The main challenge stems from the fragmented and difficult to navigate social protection system at the regional and municipal level with a strict split between the health domain (socio-sanitario) and the social domain (socio‑assistenziale). The complexity inherent in this divide is compounded by a service‑driven approach to the needs of people, in which both the assessment and the entire client pathway are shaped by the services and programmes available and the way in which these are organised, including their sources of funding.
Entry points into the local system
Needs assessments in Italy have historically been benefit and service‑dependent, meaning that for each benefit and service offered by a region or municipality, a separate request should be placed, and a different needs assessment be conducted. In dealing with the complex needs of people with disability, regions have accumulated a considerable portfolio of services and programmes over the years. While the existence of these responses is a positive aspect, it becomes challenging for citizens to navigate the multiple application and assessment procedures of such a system, which often ends up being driven by supply rather than demand (or needs), potentially leading to a distortion of applications to fit the eligibility criteria.
Thus, the social protection system for people with disability – and more generally for vulnerable citizens – is characterised by multiple entry points and pathways to be navigated and a resulting multitude of needs assessments. In recent years, a proliferation of available programmes and benefits has only exacerbated this problem. Such a scattered system lacks efficiency and equity, as people with similar problems are likely to experience very different situations, involving different needs assessments, and different support, depending on their first contact and the interlocutor they find. This also puts a considerable weight on the individuals and their family, to navigate such a system that requires a deep understanding of administrative matters and, hence, much time and effort.
Two additional features of the Italian system increase remarkably its complexity. First, the fact that services and programmes are usually added on top of existing solutions, creating one more entry point or procedure to be followed, often depending on the part of the system that offers the service or programme and its funding source. Second, and most important, the large cleavage between health and social services at the regional level, from top (directorate‑generals within regional administrations) to bottom (local health authorities and services provided at the municipal level) of the system. Although these two domains serve a similar population and their respective services may partly overlap in scope, their organisation and ways of working, and funding, differ considerably. The Constitutional Reform in 2001 has added to the complexity through a devolution of powers to lower levels of government by which social and health policies and affairs became a predominantly regional matter.
To overcome the fragmentation and lack of harmonisation in dealing with the emergence of complex needs, several Italian regions have decided to create single points of entry into the system (known as Punto Unico di Accesso – PUA, among other designations). A definition for these single points of entry was developed together by several regions (Veneto, Liguria, Emilia Romagna, Tuscany, Marche, Lazio, Abruzzo, Calabria and Sardinia) back in 2008, with a strong focus on the contribution to better integration between the health and social domains. This would happen through several functions assigned to the single points of entry, including an extended role in taking charge (presa in carico) of people in need, throughout the assessment procedures and into the care pathway (note that PUAs serve a broader population of citizens with chronic health conditions and long-term needs and/or in a vulnerable situation, not only people with disability.) In practice, regions shaped the functions of their PUAs based on the characteristics of their host region and its institutional setting. Studies analysing the performance of PUAs several years after their initial implementation pointed to considerable heterogeneity in the ways of operating, functions adopted and links to the health and social domains (Pesaresi, 2013[2]). Most of these limitations observed among single points of entry into the Italian social protection system seem to persist.
While some PUAs can have functions that are as limited as providing information about the resources available and how to access them, most of these structures are reported to operate at an intermediate level of support, whereby they are also responsible for functions such as a pre‑assessment and referring individuals towards solutions not requiring further assessment or to multidimensional needs assessment by multidisciplinary units. This seems to be the model of PUAs preconised in the four regions studied, even though differences arise in practical terms, depending on the respective disability policy ecosystem. In Trentino, single points of entry have a limited scope, mostly due to the large role of legal medicine doctors within the local health authorities. In this region, legal medicine doctors’ functions go beyond initial disability assessments: de facto they end up being the entry point into the system. Furthermore, and due to the region’s small population size, legal medicine doctors have an oversight of the overall pathway followed by people with disability. Single points of entry in Trentino are in practice mostly used by vulnerable citizens due to their age, rather than a disability.
Beyond basic or intermediate intensity, single points of entry can also operate at a more intense level. In this case, these structures should have a role in taking charge of the most complex clients from their case registration and data collection through the multidimensional assessments of their needs, the creation and monitoring of personalised plans, and management of the client relationship with service providers. In taking charge, PUAs should play a role in improving the system’s governance and achieving an integrated and articulated process, which guarantees to individuals a smooth co‑ordination of interventions to respond to their complex needs. However, no region could be identified where PUAs would consistently perform such a comprehensive single access and case management role. The closest to such a way of operating seems to exist only for certain programmes and their respective streams of funding. In Sardinia, for example, PUAs have an extensive role in supporting people with disability that enter inclusion programmes such as “After Us” (Dopo di Noi) and “Returning home” (Ritornare a casa). In Campania, these structures collect the needs of people with disability going through multidisciplinary assessment units, but do not follow these individuals further.
One other key aspect behind the role of single points of entry is whether and to what extent they manage to provide an integrated interface for the health and social domains. In Sardinia, PUAs are designed as structures of the health domain, belonging solely to local health authorities and, therefore, corresponding to second-level entry points that should follow a first contact with social services from the municipality (social domain). In other regions, even when PUAs are envisaged as having a role in integrating health and social domains, these structures seem to be linked to the health side in most cases and are counters or facilities as part of local health authorities, and a gateway to the multidisciplinary assessment needed for some health-related residential, semi-residential and (integrated) home care services. Among the four regions studied, Campania’s Porte Uniche di Accesso display the strongest focus on the integration of health and social domains. In practice, actual integration is anecdotally only achieved in about a third of these single points of entry, with only five out of 72 located in municipal services rather than the local health authority. One of the main consequences of the failure to properly promote integration between the health and social domains is that these structures end up not performing the role of a unique entry point in the system. In fact, PUAs are likely not even the most common first point of contact, a place that is taken by social service providers of municipalities (social domain). Much like in Sardinia, municipal social workers of other regions often take charge of vulnerable individuals in a first instance, directing them to PUAs when the user has health or complex needs. The degree to which a PUA is an actual focal point for accessing multidisciplinary assessment units and health-related disability services varies between regions.
One last aspect that seems to hinder PUAs from performing according to their potential is the existing variation in the way these structures operate within regions. The four regions of interest not only differ in terms of the maturity of their single points of entry, but also with regards to existing legal provisions and guidance in how to implement them at the local level. For example, Sardinia was originally part of the regions that conceptualised the PUAs, while in Lombardy there seems to be less of a whole‑of-region vision for the equivalent structures – Sportelli Unici per il Welfare (SUW). Lombardy seems to be the region with the poorest coverage of single points of entry and the largest internal variation, given that the existence of the structures is a direct result of local-level action and co‑ordination between each local health authority (Aziende Socio Sanitarie Territoriali – ASST) and its corresponding group of municipalities (ambito). Nevertheless, within-region variation prevails even when regional standards are defined, such as in Sardinia and Campania. This is because the operational features of the single points of entry are also defined at the territorial/local level, with the articulation being left to the collaboration between local health authorities and territorial/municipal services, which in some circumstances appears to be flawed. Different ways of implementing their functions such as the fact that every PUA decides how to perform the pre‑assessment of needs leads to heterogeneity in the pathways followed by individuals from their entry into the system onwards and hinders the capacity of PUAs to promote equity. Overall, and although flexibility to adapt PUAs to the regional and local context might allow a more targeted response to the needs of the population, it also increases the likelihood of geographical inequalities and inefficiency, and ultimately prevents these structures from being easily identifiable and actionable instruments, and to achieve their integration goal. In their current form, PUAs fall short in truly representing a gateway to all the services and benefits available to people with disability. Lack of available data on the use of these instruments means that nothing is known about the actual proportion of individuals accessing care through PUAs.
2.4.2. Disability assessments as a starting point
Second-level assessments at the regional level serve the purpose of matching applicants’ needs with the support available (thus, also called needs assessments). It would, therefore, be reasonable to expect needs assessments to be carried out as a continuation of an earlier process of disability determination, and more specifically to build on the information and conclusions from the disability status assessments. In practice, there is a large disconnect between disability status and needs assessments, with limited usefulness of the former to the latter. Several reasons are likely to be behind such disconnect; reasons that are all connected to each other:
The over-medicalised perspective of disability status assessments, which limits their utility for the evaluation of needs, where the role of the environment stands out as an important component.
The format of the output of disability status assessments, as both the percentage of civil invalidity derived from medical records predominantly and the two handicap categories provide very limited information on the actual disability of the applicant.
Considerable limitations in data sharing; assessment reports from the medical-legal commissions might contain additional information but there is no systematic mechanism in place to make these materials available for the purpose of the needs assessments.
The limitations described above are particularly salient for the status of civil invalidity, which, although the most relevant status for people with disability to access support, is barely relevant and considered for the needs assessment. Having a (severe) handicap status is more often a requirement for accessing services at the regional level, namely the eligibility for programmes such as “After Us“, or the “Non-self-sufficiency fund“ (see the next chapter for details on those schemes). Even though a requirement for eligibility, the information obtained from the assessment of handicap is still of limited usefulness to a needs assessment. To compensate for the disconnect between disability status and needs assessments, several needs assessments still involve general practitioners or other medical doctors, to start the determination process from scratch. Doctors must provide information on the person’s pathologies, thereby duplicating the compilation of the medical certificate in the first step of the disability status assessment application. In Sardinia, for example, the assessment report issued by the civil invalidity commission might be integrated into the process of applying for domiciliary support, but it is not an essential requirement.
2.4.3. A multitude of needs assessments exist in parallel
Needs assessments are performed at the regional and local level in at least three contexts. First, the multidimensional assessment conducted by multidisciplinary teams that work closely with single points of entry. As the PUAs themselves, these teams should also have a role in the integration between the health and the social domains, and their respective services. In practice, needs assessments performed by these teams are mostly a requirement to access services provided by the health domain (including residential, semi-residential and integrated homecare approaches, and some inclusion programmes like “After Us”), rather than a comprehensive assessment that would provide direct access to the entire portfolio of existing services in an integrated way. Therefore, needs assessments are also carried out by other actors in the disability system. This includes especially two types of assessments. On the one hand, service‑specific needs assessments are conducted mostly by social workers affiliated with municipalities, to provide access to services of the social domain. On the other hand, needs assessment can be multidimensional and multidisciplinary but performed at the provider level, mostly by provider staff and often including the general practitioner or a social worker from the social/health domain, who accompany the applicant. For example, in Lombardy the multidimensional assessment for semi-residential services is carried out by the team of the facility (involving the co‑ordinator and healthcare professionals) with the participation of municipal social workers. While provider-led assessments exist in several regions for direct access to private structures, Lombardy seems to be a special case. Due to the high degree of privatisation on the supply side, provider-led assessments are also possible for applicants that are publicly funded.
Multidisciplinary and multidimensional needs assessment
Most needs assessments currently available at the regional level aim to be multidimensional, a concept that evolved from the geriatric assessment of need and was proposed in the early 2000s to promote the efficacy and appropriateness of social health services.3 The multidimensional assessment method should allow to ″define the integrated complex needs of the applicant with regards to health, assistance, custodial, psychological and socio-economic aspects, for example by observing both the cognitive and functional aspects in the social-residential context: income, type of dwelling, possible presence of architectural barriers, presence of care giver in the family, etc.″
A multidimensional assessment is most often performed by a multidisciplinary team, although not always. In the Italian setting, there seem to be mostly two types of multidisciplinary teams: those that operate in the context of service providers, assessing applicants for a specific service; and the multidisciplinary assessment units, which are integrated/interinstitutional teams working closely together with the PUAs. These multidisciplinary assessment units can be named differently depending on the region – i.e. integrated assessment units (Unità di Valutazione Integrata – UVI) in Campania, multidimensional evaluation units (Unità di Valutazione Multidimensionale – UVM) in Lombardy, territorial assessment unit (Unità di Valutazione Territoriale – UVT) in Sardinia and multidisciplinary assessment unit (Unità Valutativa Multidisciplinare – UVM) in Trentino. Nevertheless, their composition shows common features across the four regions. For example, they usually include a medical doctor – either a general practitioner or a doctor affiliated with the local health authority, or both – and a social worker. Other possible members often include a nurse, or a doctor specialised in the medical condition behind the disability. Importantly, it seems to be commonplace across the four regions that the social worker participating in the assessment unit is either affiliated with the local health district (health domain) or the municipality (social domain). The latter will most likely be present when the person with disability first entered the system through the social services side and is then guided by a municipal-level social worker either to the single point of entry or directly to the multidisciplinary assessment unit, due to health needs. Campania seems to be an exception, as municipal social workers are described as being part of the units by default. When a municipal-level social worker is not present, multidisciplinary units will be fully composed by professionals linked to the health domain, and not truly interinstitutional. Given that the needs assessments performed are mostly targeted to the services available from the health side, these teams seem to have limited scope to foster integration themselves. Furthermore, the health-focused composition of the teams might favour a medical approach of disability in needs assessment, as applying a medical criterion is often perceived by assessors as reducing the discretion of the assessment. The medicalisation of multidimensional assessments in Italy is likely explained by the predominant use of these assessments for determining eligibility for services from the health domain. In other countries, needs assessments often involve social workers only, or social workers and rehabilitation specialists.
In the four regions examined, applicants with health needs can also be referred to the unit by general practitioners, municipal-level social workers or other actors. For example, medical-legal doctors from the local health authority are entitled to refer applicants to be needs-assessed by the UVM in Trentino, where they also hold a major responsibility in disability status assessments.
One further aspect to highlight concerning the procedures followed by multidisciplinary assessment teams is the lack of a specific protocol for assessing needs. While recognising that multidimensional assessment teams should apply scientifically validated scales and tools critically reviewed at national or international level, the choice of these tools is usually left to each team or in the best case harmonised at the regional level. In the case of Campania, it has been set by a Regional Council resolution (324/2012) that UVI should use the multidimensional assessment card for people with disability (Scheda di Valutazione Multidimensionale per le persone con Disabilità – SVaMDi). The SVaMDi tool used in Campania is an adaptation of the instrument originally developed in the Veneto region to standardise the provision of essential levels of social and health support across places and to support teams in designing projects/plans targeted to the applicants. SVaMDi should provide information that facilitates the organisation of services at the regional level and allow for the monitoring of applicants’ pathways. In its original form, this tool consisted of five parts, of which four are closely related with ICF domains (impairments to body functions, restrictions to activities and participation, environmental factors, and social evaluation) and would allow for the profiling of individuals in terms of functioning and severity. Completing each one of the four parts would be under the responsibility of different professionals, including general practitioners and social workers. The fifth part would be a cover (copertina) that would summarise the information provided in the remaining tool and conclude with the targeted plan, under the responsibility of the multidisciplinary assessment unit. Campania’s adaptation of the original SVaMDi is described in Box 2.1. Although the different parts of the assessment card are defined at the regional level, each multidisciplinary assessment team has the flexibility to decide exactly which instruments and scales it uses within those different parts.
Box 2.1. Multidimensional assessment card for people with disability used in Campania (SVaMDi)
Form A: Health assessment for access to local health services. It reports pathological conditions, level of functionality of some physiological functions, environmental factors that could represent facilitators or barriers for the quality of life of the patient, and co-morbid classes, and it also includes service proposals.
Form B: Specialised assessment for admission to local services. This form is further divided into five parts, which include a cognitive‑behavioural evaluation, a functional evaluation, and the mobility evaluations. These assessments are carried out using validated tools.
Form C: Social evaluation. Collects personal data, including employment status, educational qualification, economic condition, housing and family condition, and support of the social network.
Form D: Multidisciplinary evaluation, which aims at creating the path for the patient.
Multidisciplinary assessment units of other regions are reported to be using tools with a similar structure, in a first step completing a set of instruments and scales and in a second step compiling the information and making recommendations, with the tools used depending on the services or programmes concerned. A tool like SVaMDi but focused on the elderly is used, for example, in Sardinia for the assessment of home care service entitlements (multidimensional assessment card for adults and elderly – Scheda Valutazione Multidimensionale dell’Adulto e dell’Anziano – SVaMA). On the other hand, Sardinia uses a specific needs assessment form defined by a Regional Council Resolution (63/12 of 11 December 2020) to assess applicants for the programme “Returning Home”, which also includes the use of home care. In the case of residential and semi-residential services, Sardinia’s UVTs use a set of clinical and functional scales and measures (e.g. CIRS, Bernardini, Barthel, Short Questionary and condition-specific ones if applicable) which are brought together with information on the social environment of the applicant to attribute him or her a profile. This profile should reflect three levels of intensity of the support needed in terms of healthcare (medium, moderate, low, according to the Bernardini tool) and in terms of social assistance (medium, medium-high, high, according to the Barthel scale). In Trentino, the different scales and instruments used depend on the patient profile and the type of structure identified as a potential service, but the UVM should also complete a multidimensional evaluation form (Scheda per la Valutazione Multidimensionale – SVM). In the case of the assessment for the individualised life projects, Trentino’s UVM use an adapted version of the Veneto SVaMDi. Lombardy has introduced a similar tool in 2022 (Scheda Individuale del Disabiie – SIDi).
Most of the multidimensional assessment tools aim to provide a module for the design of a customised project, describing an (integrated) care pathway that responds to the applicant’s needs. The role of the multidisciplinary assessment units could also be extended beyond the sheer assessment, for example, to periodically monitoring the implementation of the plan, and performing adjustments as necessary. In practice, both the design and the follow-up of personalised plans seem to have limited coverage for people with disability. While the approach is followed for specific programmes with their own funding stream (e.g. “After Us”, “Returning Home” in Sardinia), the outcome of the multidisciplinary assessment units will more often be driven by, and directed to, a type of service, rather than being a truly integrated tool that allows entitlement to across-the‑board support.
Disability status and needs assessments in Italy are a complex matter, for two reasons: a multiplicity of different disability status assessments at the national level, uncommon in an international perspective; the regional-municipal responsibility for needs assessments which are often service or provider-led; and the absence of any link between disability status and needs assessment. The result is a system that is difficult to understand and therefore difficult to navigate and a system that creates considerable inequality, both between region and municipalities and between people in comparable situations or with similar level of disability. Streamlining, harmonising, and better connecting the different assessment tools will be important to make the system more efficient and more effective.
References
[2] Pesaresi, F. (2013), “Le funzioni dei punti unici di accesso”, Welfare Oggi 1/2013, pp. 15-22, https://www.periodicimaggioli.it/rivista/welfare-oggi/1615069/2013/fascicolo/1618637.
[1] United Nations (2011), Including the rights of persons with disabilities in United Nations programming at country level: A Guidance Note for United Nations Country Teams and Implementing Partners, United Nations Development Group, https://www.un.org/disabilities/documents/iasg/undg_guidance_note_final.pdf.