Leader: Aleksandra Torbica (BOCCONI); Other collaborator(s): Andreea Piriu (BOCCONI)
Task 2 aims to provide an in-depth analysis of the consequences of the gap between the need and institutional response in terms of health and social disparities. The analysis in Task 2 is multifocal: the first part sheds light on the needs and user profiles observed in non-hospital long-term care provision using administrative data; in keeping with findings at Task 1, the second part develops a Healthy Ageing Index with the aim to validate a set of variables from survey data that can inform the development of a survey tool to monitor older adults with different healthy ageing profiles, exhibiting cross-region and cross-country applicability due to its construct, empirical and predictive validity when investigating different ageing trajectories. Deploying analysis based on administrative and survey data, the overarching aim of Task 2 is to inform effective ageing policies with institutional and organizational relevance across different geographical contexts and populations.
Given the role of the social/environmental component in ageing well (also confirmed by Task 1 findings of the systematic review of scientific literature on the operationalisation of the healthy ageing (HA) construct), the object of Task 2 is made by a multi-focus analysis of older adults’ needs and institutional responses that aims at informing policies of the wider systemic implications of the need-service gap, as well as conceptual and methodological challenges of operationalising a multidimensional bio-psycho-social approach of healthy ageing and the role of institutions.
Data analysis on the needs and user profiles in non-hospital long-term care provision (first part) and for the construction of the Healthy Ageing Index (second part) has started.
Brief description of the activities and of the intermediate results
The first stream of this multifocal analysis consists in a descriptive study on the older adults who access non-hospital long-term care (LTC) services in the Lombardy Region (Regione Lombardia) based on an administrative dataset. This allows to characterize the profiles (and consequently the needs) of citizens who access these services and, as a result, can lead to understanding drivers of healthcare utilization before and after access to non-hospital long-term facilities. Furthermore, the study also aims to reveal which connections exist and are activated between social care and health services.
According to the 2024 report of the Observatory on Healthcare Organizations and Policies in Italy (OASI), the current supply of LTC services is limited both in terms of the number of people that can be institutionalised in a non-hospital LTC facility (Residenza Sanitaria Assistenziale, RSA), and the specific types of services needed for an adequate level of care.
In a nutshell, descriptive statistics resulting from this step report an overall worsening of health conditions based on LTC patient characteristics at the time of the admission to the LTC facility, across a timeframe from 2013 to 2019. A typical profile emerges that is increasingly oriented towards very elderly citizens, with multiple pathologies and complex diagnoses, with respect to which the behavioral characterization is also very relevant and worsening over the years. These are also citizens who have a significant history of access to health (hospital care) services, as reported by the data on hospitalizations and access to the emergency room. The latter finding suggests that there is a lot of other information that is relevant and is not considered by the scale adopted. In fact, between 2013 and 2019, the number of elderly people using hospital services increased, even though a process of reviewing the hospital network was started nationwide in the years of the analysis. Mortality significantly increased due to the number of elderly people who died during their first year in RSAs, thus signalling a worsening of the conditions of the incoming guests. The evidence regarding the care pathways of arrival in RSAs and exit from this service, signals a lack of investment in the connection between RSAs and hospital discharge. Results are heterogeneous across Lombard territories, attributable to three factors: (a) the characteristics of the different territories (mountain vs. plain/metropolis) and care logistics; (b) the existence of different paths of service use, and between-service coordination and integration practices; (c) varying concentration of RSA services across the regional territory.
2. Constructing a Healthy Ageing Index
The second research stream of Task 2 builds on the results of the systematic review of the scientific literature on the operationalisation of healthy ageing (Task 1). The review underscored the need for a multidimensional and operational understanding of ageing healthily, emphasizing (gaps in) specific HA dimensions and their measurement.
The primary objective is to create a robust tool for assessing the diverse factors influencing HA, and eventually evaluate its potential applications in understanding drivers of different health trajectories. This involves the development of a comprehensive index that integrates intrinsic capacity (IC), functional ability (FA) and environmental (ENV) dimensions. Existing frameworks often focus narrowly on individual aspects of ageing, such as physical health or cognitive function. This approach provides a more holistic framework that incorporates different dimensions potentially capturing the dynamic interplay between physical, cognitive, psychological and environmental HA determinants, thus ensuring construct validity. Furthermore, the composite index will be empirically validated using detailed longitudinal data on individuals, supplemented with other national datasets. This step involves applying the index to real-world data to see how well it predicts known outcomes of healthy ageing.
A secondary possible outcome of Task 2 would entail an empirical analysis with primary survey data from an ad-hoc questionnaire on older Italian segments of population. The design behind this aim would mirror that of the population-based index (i.e., embodies IC, FA and ENV dimensions) and would represent a policy-informative tool that can be validated on a larger scale with stakeholders, experts and hospital care units across multiple Italian territories.
Main policy, industrial and scientific implications
Implications of the results at point (1) above must be placed in the overall Lombard institutional context, which has been changing throughout the years of the analysis. The period 2013 to 2019 was marked by various strategies to limit access to the hospital network, with repercussions also on the elderly population and, consequently, on RSAs. Between 2013 and 2019, RSAs became increasingly professional and structured, with a commitment to manage complex cases, also confirmed by the decrease in the number of hospitalizations after entry into RSAs – possibly due to the combined effect of system gatekeeping and investment in the care skills of RSAs operators.
In relation to point (2), by means of its robust construct and empirical validity (i.e., application to real-world data), with further potential to demonstrate predictive validity in terms of health and well-being outcomes, the index can be applied in diverse geographical contexts with similarly detailed data on individual socio-economic and health conditions. Policymakers and practitioners can use the index to design and implement strategies that promote healthy ageing, ultimately enhancing the quality of life for older adults.
Brief description of the activities and of the intermediate results
Data analysis on the needs and user profiles in non-hospital long-term care provision has been completed. Data analysis in relation to the composite index construction is underway.
Survey design and methodology for a possible tool gathering primary data are being explored. A pilot questionnaire identifying relevant factors has been created. Potential steps envisaged for large-scale deployment could involve pilot testing (from preparation to data and feedback collection, as well as pilot data analysis), implementation at large scale, validation and quality assurance (i.e., data validation, reliability assessment, validity assessment), final data analysis.
Main policy, industrial and scientific implications
The work undergone to identify the set of variables for the index (and, possibly, for the survey inviting new data gathering) creates a basis for an Italian holistic and multidimensional model of healthy ageing that can become an ongoing vehicle to inform healthy ageing policies effectively through continuous monitoring.
Brief description of the activities and of the intermediate results
Chapter 5 in the OASI report was presented at the 2024 OASI Conference on December 3rd 2024 (Universita' Bocconi, Milano).
The Healthy Ageing Index was presented at the 2024 Italian Health Economics Association Conference in Naples. Work to inform potential applications of this modelling tool is currently underway. Additionally, a manuscript presenting findings regarding the construction of the index was prepared and submitted to several 2025 international conferences.
Main policy, industrial and scientific implications
Informed by the conceptual, empirical and methodological gaps identified within the systematic review of scientific literature on the operationalisation of Healthy Ageing (Task 6.1), the construction of the Healthy Ageing Index uses detailed longitudinal data on individuals. We investigate potential applications in real-world contexts to predict individual health and well-being. The model has tractable utility, being highly comparable across multiple international surveys and adaptable for validation across different geographical contexts and populations.