The Long-Term Care Workforce in Italy: Shortages, Skills and Sustainability

An older person receiving long-term care in Italy may depend on several workforces without ever experiencing them as one system. A nurse visits through the Servizio Sanitario Nazionale. An Operatore Socio-Sanitario supports personal care in a residential or community service. A privately employed badante provides daily continuity at home. A daughter manages appointments and medicines between visits. A general practitioner, physiotherapist or specialist becomes involved when health needs change. Each role is different, but the person's safety and independence depend on how reliably those roles fit together.

This workforce architecture sits at the centre of the wider system examined in the Italy Ageing, Long-Term Care & Community Support Knowledge Hub. Italy is expanding territorial healthcare, home-based care, Community Houses and digital services while simultaneously managing one of Europe's oldest populations. The demand for support is increasing faster than the system can assume a corresponding expansion of available labour.

The pressure is not simply a matter of vacancy numbers. Italy has relatively high physician density but fewer practising nurses than many comparable countries. Formal long-term care staffing remains comparatively limited, while a large share of everyday support is provided by families and privately employed domestic care workers. Those domestic workers are themselves ageing, predominantly female and increasingly difficult to replace.

The central workforce challenge is therefore structural. Italy needs enough people, but it also needs the right skill mix, geographic distribution, employment conditions and interfaces between health, social, private and informal care. Without that wider approach, demographic ageing risks turning workforce shortage into the binding constraint on otherwise ambitious long-term care reform.

Italy has several long-term care workforces rather than one workforce

International discussion often refers to "the long-term care workforce" as though it were a clearly bounded professional group. That description fits Italy poorly.

Care for older and non-self-sufficient people is delivered through overlapping labour markets. The SSN employs or contracts health professionals. Regions and providers organise residential, semi-residential and home-based services. Municipal social structures support social assistance. Private households directly employ domestic workers. Families provide enormous amounts of unpaid care.

The main workforce groups therefore include:

• nurses, doctors and rehabilitation professionals working through health and social-health services;
• operatori socio-sanitari and other support roles in residential, community and home settings;
• staff employed by public, private and third-sector long-term care providers;
• privately employed domestic care workers, including badanti;
• social workers and other municipal or territorial professionals coordinating support; and
• unpaid relatives and friends providing daily care, supervision and coordination.

These groups have different employment arrangements, regulation, training routes, pay structures and accountability. Their contribution is nevertheless interdependent.

A formal service may appear adequately staffed while depending heavily on a daughter to cover evenings, transport and appointments. A household may employ a live-in worker but still require professional nursing because the person's needs have become clinically complex. A residential facility may have sufficient overall headcount but lack the skill mix required for residents with advanced dementia or high nursing dependency.

This is why workforce planning needs to begin with the care model rather than the payroll. The question is not simply how many workers exist. It is which activities must be performed, by whom, at what competence level, and what happens when one part of the workforce can no longer absorb additional demand.

Formal long-term care staffing remains comparatively limited

Recent international data illustrate the scale of Italy's workforce challenge. Italy has around 1.5 formal long-term care workers for every 100 people aged 65 and over, compared with an OECD average of around 5.

This comparison should be interpreted carefully. National workforce definitions differ, and Italy relies extensively on household employment and family care that may not be captured in the same way as formal provider workforces elsewhere.

Even with that qualification, the figure reflects an important structural feature: a comparatively large proportion of care is delivered outside formal long-term care organisations.

That can create apparent labour efficiency while transferring substantial work into households.

The arrangement has historically been sustained by family involvement, migration and the widespread employment of badanti. It has allowed many older people to remain at home and has given households flexibility in organising support. But it also exposes the system to labour-market risks that are less visible in formal workforce statistics.

As family size decreases, adult children live further away and female employment patterns change, unpaid care cannot automatically expand to absorb rising demand. The private domestic workforce also has its own demographic pressures.

Italy's future workforce strategy therefore cannot be based solely on expanding one professional category. It needs to understand how formal services, household employment and family care interact.

Nursing shortage is one of the most important constraints on territorial reform

Italy's overall supply of doctors is relatively high by international standards, but its nursing workforce is much thinner. Recent OECD data place practising physician density at around 5.4 per 1,000 population, compared with an OECD average of 3.9, while practising nurse density is around 6.9 per 1,000 compared with an OECD average of 9.2.

This imbalance matters acutely for long-term care.

Population ageing shifts demand towards chronic disease management, home healthcare, rehabilitation, care coordination and repeated contact over time. Those activities depend heavily on nursing capacity.

Italy's expansion of home healthcare and the development of Case della Comunità increase that dependency further. A model built around stronger territorial care needs professionals available in the community rather than simply greater physical infrastructure.

Recent workforce analysis also points to structural challenges behind nursing supply: lower graduate growth over previous years, retirement pressures, international migration and remuneration that has struggled to make the profession sufficiently attractive relative to demand.

The policy implication is significant. New Community Houses, home-care targets and telemedicine programmes can increase expectations of territorial healthcare faster than nursing supply expands.

This makes workforce skills and practice competence in services for older people inseparable from capacity. A shortage of nurses cannot always be solved by shifting tasks to less qualified workers, particularly where clinical judgement is required. But equally, nurses should not spend scarce professional time routinely performing activities that could safely be undertaken by other appropriately trained roles.

The stronger workforce strategy therefore combines supply growth with skill-mix redesign.

Operational scenario: home-care expansion reaches the limit of nursing capacity

A local health organisation in Emilia-Romagna has successfully expanded home healthcare following PNRR investment. More older people with complex chronic conditions are now being referred from hospitals and primary care, and the service is reaching a larger population than before.

Demand initially appears manageable. Over time, however, nurses report increasing travel, growing caseload complexity and more time spent coordinating information between professionals. The number of people receiving a service continues to rise, but the intensity available for each person begins to narrow.

Management could respond simply by raising caseload thresholds. That would preserve coverage statistics while creating a risk that people with high need receive insufficient clinical attention.

Instead, the organisation reviews the work itself. Tasks are separated into those requiring registered nursing judgement and those that can appropriately be delivered by other trained professionals. Geographic scheduling is redesigned to reduce unnecessary travel. Digital follow-up is used selectively where clinically suitable. Administrative processes are simplified so nurses spend less time duplicating records.

The service also distinguishes low-intensity episodes from people requiring more sustained clinical input, rather than measuring everybody through the same activity model.

The scenario illustrates an important workforce principle: shortage should not automatically lead to dilution of care. Productivity improvement is strongest when it removes avoidable work, improves deployment and protects professional time for the activities that genuinely require that expertise.

Operatori Socio-Sanitari are essential to the skill mix

Operatori Socio-Sanitari (OSS) occupy an important position between professional healthcare and everyday assistance. They work across hospitals, residential facilities, community services and other health and social-health settings, supporting personal care and basic health-related activities within defined responsibilities.

For long-term care, this role is especially valuable because many people require a combination of support with daily living and observation of health changes.

OSS workers can contribute continuity, recognise deterioration and support implementation of plans developed by professional staff. Their effectiveness depends on training, supervision and clear boundaries.

The temptation during workforce shortage is to treat role substitution as a numerical solution. That can be unsafe if workers are expected to undertake tasks beyond competence or if delegation occurs without appropriate professional oversight.

The more sustainable approach is planned skill mix. Teams should be designed around actual need, with each role used at the highest appropriate level of contribution.

This reflects the wider principles of workforce assurance. Assurance is not achieved merely by confirming that enough people are on duty. It requires confidence that staffing, competence and supervision match the needs of the people being supported.

Residential services face a changing acuity problem

Residential long-term care workforce planning is becoming more demanding because the people entering facilities increasingly have complex combinations of frailty, dementia, multimorbidity and functional dependency.

Occupancy therefore provides only a partial staffing measure.

A 100-bed facility can be fully occupied in two different years while requiring substantially different staff input if resident acuity has increased. More residents may need two-person assistance, dementia support, clinical monitoring, end-of-life care or help with complex medicines.

Static staffing approaches can consequently lag behind changing need.

Residential providers need to connect workforce deployment with resident dependency and risk rather than treating establishment numbers as fixed independently of the population served.

This has consequences for recruitment and retention. High-dependency services place greater physical and emotional demands on staff. If staffing does not adjust, experienced workers can leave precisely because the remaining workforce is under pressure.

The Predictive Workforce Risk Module can help organisations exploring comparable workforce questions identify patterns in vacancy, turnover, retention and continuity. It is not an Italian regulatory instrument, but the principle is highly relevant: workforce risk should be identified before instability becomes visible through service deterioration.

The badante workforce remains indispensable but is ageing

Italy's privately employed domestic workforce is one of the most distinctive parts of its long-term care model.

INPS data for 2025 recorded 804,464 domestic workers with at least one social-security contribution during the year. The number declined by 2.3% from 2024 and has fallen for four consecutive years.

Just over half of registered domestic workers were classified as badanti, meaning care work had become the largest category within formal domestic employment. The workforce remains overwhelmingly female, at 88.7%.

Migration is fundamental. Approximately one-third of registered domestic workers come from Eastern Europe, while substantial groups also come from South America, the Philippines and other regions.

The age profile is increasingly important. More than one-quarter of domestic workers were aged 60 or over in 2025, while only a very small proportion were under 25.

This creates a long-term sustainability problem.

Italy is ageing not only among people requiring care but also among a workforce on which household-based care depends. Retirement and declining labour supply may occur at the same time as demand accelerates.

Migration policy will therefore remain part of long-term care policy whether or not it is formally described that way.

The challenge is to maintain ethical recruitment, legal employment, adequate working conditions and appropriate competence while recognising that privately employed care workers cannot be expected to replace every professional or family function.

Migration can relieve shortages but does not remove the need for workforce strategy

Foreign workers have helped sustain Italian household care for decades. Their contribution has enabled families to maintain relatives at home and has filled gaps that formal services could not always meet.

Current migration policy continues to recognise family and social-health assistance as an area requiring labour.

But importing workers cannot be the entire workforce strategy.

First, countries of origin also have ageing populations and their own workforce needs. International recruitment therefore raises ethical as well as economic questions.

Second, migration routes need to connect with stable legal employment. Workers whose residence status is insecure create continuity risks for households as well as personal vulnerability for the worker.

Third, increased complexity of care requires greater competence. A badante supporting an older person with advanced dementia, dysphagia and multiple medicines faces a very different role from a worker primarily providing companionship and domestic assistance.

Professionalisation therefore needs balance. Domestic care should not be medicalised unnecessarily, but workers need enough training to recognise risk, communicate with professionals and understand what falls outside their role.

This connects with staff training. Training becomes valuable when it clarifies safe practice and escalation rather than being used to justify transferring responsibilities that properly belong elsewhere.

Operational scenario: one worker becomes the entire care system

Rosa, 86, lives in Lazio with advanced Parkinson's disease and increasing cognitive impairment. Her daughter employs a live-in Romanian badante, Elena, who has supported Rosa for three years and knows her routines extremely well.

Initially, Elena's role centred on personal care, meals, mobility support and companionship. As Rosa's condition progresses, the demands change. She begins having swallowing difficulty, her medicines become more complex and she experiences episodes of severe confusion.

The family assumes that continuity with Elena means the arrangement can simply continue. Elena herself becomes increasingly anxious because she is being asked to manage needs she does not feel competent to assess.

A stronger pathway recognises that continuity and clinical capability are different things.

Elena remains an important part of the support model, but professional input increases. Clinical tasks and monitoring are clarified. She receives information about warning signs and escalation routes without being made responsible for diagnosis or professional decision-making. The family also reviews whether one live-in worker can sustainably meet the volume of care now required.

The outcome is not to replace Elena. Her relationship with Rosa is valuable. The objective is to prevent a household employment arrangement from silently becoming an unsupported high-acuity care service.

The scenario demonstrates a wider workforce principle: informal and domestic labour can complement formal services, but system sustainability depends on recognising the point at which need exceeds the competence or capacity of the existing arrangement.

Family carers are part of workforce planning even though they are not employees

Italy's formal workforce cannot be understood without unpaid family care.

Relatives provide personal assistance, transport, supervision, administrative coordination, medication support and emotional continuity. In many households they also manage the relationship with badanti and formal services.

This labour is often invisible in staffing models.

A home-care plan may show relatively few professional hours while the person's actual support needs are being met through substantial unpaid family input. If that family contribution changes, the apparent professional requirement can increase abruptly.

Workforce sustainability therefore requires information about family capacity.

This does not mean converting relatives into formal workforce units. Family relationships have different meanings, responsibilities and rights. The point is that systems need to understand dependency on unpaid care rather than assuming it will remain constant.

The principles of carer support and family partnership become central here. A spouse or daughter should be involved according to the person's wishes and their own capacity, not treated as the default solution to every shortage in formal care.

Demographic change makes this increasingly important. Smaller families, geographic mobility and longer working lives reduce the certainty that future older people will have the same level of informal support available to previous generations.

Workforce shortage is geographically uneven

Italy's workforce pressures do not occur uniformly across the country.

Regional labour markets, training capacity, provider concentration, urbanisation and migration all influence recruitment. Rural, mountain and island communities face additional barriers because travel time reduces productive capacity and professional opportunities may be perceived as less attractive.

Regional variation in services can also influence labour supply. Areas with larger residential sectors require different workforce profiles from territories where support is concentrated more heavily at home.

This creates a feedback loop.

A territory with limited service infrastructure attracts fewer professionals. Limited workforce then constrains expansion of the very services needed to improve access.

National workforce strategy therefore needs a geographic dimension.

Training additional professionals nationally does not guarantee equitable distribution. Incentives, career development, housing, transport and professional support may all affect whether workers remain in hard-to-recruit areas.

Technology can extend specialist reach but cannot eliminate the need for local hands-on care.

Operational scenario: rural staffing changes the viable service model

A home-care service covering several small municipalities in inland Calabria receives additional referrals as the older population grows. The clinical needs are not unusually complex, but travel between homes consumes a large proportion of each shift.

Using the same scheduling assumptions as a dense urban service produces unrealistic caseloads.

The local system responds by redesigning deployment around geography. Workers are organised into more stable local zones, reducing repeated long-distance travel. Some specialist follow-up is supported remotely, while hands-on care remains local. Referral planning considers journey time as part of capacity rather than treating it as non-productive overhead.

The service also develops stronger links with local general practitioners and community structures so problems can be escalated without every issue requiring travel from a central base.

The redesign does not create additional professionals. It increases the usable capacity of the workforce that already exists.

The scenario illustrates why safe staffing and deployment cannot be separated from geography. A nominal number of staff means little unless the deployment model reflects how long it takes to reach people and what support must be available locally.

Recruitment is only half of the workforce challenge

Systems experiencing shortage often concentrate heavily on recruitment targets. Retention can be equally important.

Long-term care work can be physically demanding, emotionally intense and relatively low status compared with other parts of healthcare. Residential and home-care workers may support people with dementia, end-of-life needs, mobility dependency and family distress while working irregular hours.

Replacing experienced staff repeatedly creates a hidden cost.

New workers require induction and supervision. Continuity deteriorates. Teams lose informal knowledge. Remaining staff carry vacancies while recruitment takes place.

Retention therefore depends on more than pay, although remuneration matters.

Workers also value predictable scheduling, manageable workload, supportive supervision, professional development, safety and confidence that concerns will be heard.

Violence and aggression towards health and social-health professionals provide another dimension. National monitoring recorded almost 18,000 reported incidents involving healthcare and social-health workers in 2025. Long-term care environments are different from emergency departments, but staff safety remains part of workforce sustainability wherever distress, cognitive impairment or conflict may occur.

This is why staff engagement and wellbeing should be understood as service infrastructure rather than an optional employment benefit.

Digital transformation will change jobs rather than remove the need for people

Italy's investment in telemedicine, electronic health records, Community Houses and territorial coordination will change long-term care work.

Some administrative tasks can be automated. Remote monitoring can reduce unnecessary travel. Shared records can prevent professionals repeatedly reconstructing the same history. Digital scheduling can improve deployment.

These developments can increase productivity, but they also create new work.

Someone must interpret alerts, maintain systems, explain technology to people using care and manage situations where data are incomplete or contradictory. Staff require digital confidence. Cybersecurity and privacy become frontline operational issues.

Technology therefore shifts workload rather than simply eliminating it.

The strongest workforce strategy identifies which tasks technology can safely reduce, which professional activities it can support and which parts of care remain fundamentally relational.

An older person with dementia may benefit from remote monitoring, but a sensor cannot replace reassurance during distress. A teleconsultation may reduce travel, but physical examination still requires presence. Scheduling software can optimise routes, but it cannot determine whether continuity with a familiar worker is more important than the theoretically shortest journey.

This connects with digital skills and workforce adoption.

The Digital Transformation Readiness Assessment can help organisations considering comparable technology-enabled models examine whether workforce capability is developing alongside digital infrastructure. Technology creates value when staff know how and when to use it, not simply because it has been purchased.

Skill mix will become more important as complexity rises

Italy's future workforce cannot simply replicate its existing professional composition at a larger scale.

Population ageing changes the nature of demand. More people live with several chronic conditions simultaneously. Dementia and frailty become more common. Care increasingly crosses clinical, functional and social boundaries.

This requires multidisciplinary capability.

Doctors remain essential, but high physician numbers cannot compensate for insufficient nursing, rehabilitation or care-worker capacity. Nurses cannot sustainably absorb every activity required at home. OSS workers need clear responsibilities and supervision. Domestic workers need appropriate links with formal services. Social workers are necessary where housing, income or family circumstances influence care.

The purpose of skill-mix redesign is not to create the lowest-cost workforce.

It is to ensure that each task is undertaken by somebody with appropriate competence while scarce specialist expertise is concentrated where it adds the greatest value.

This can also create stronger career pathways. Workers are more likely to remain in long-term care if roles offer meaningful development rather than permanent low-status employment with little progression.

Workforce strategy therefore connects quality, productivity and retention.

Operational scenario: redesigning a residential team around acuity

An RSA in Lombardia has experienced rising staff turnover despite relatively stable occupancy. Management initially attributes the problem to a difficult labour market.

A deeper review examines resident need.

Three years earlier, most residents required substantial personal assistance but relatively limited clinical oversight. The current population includes more people with advanced dementia, complex medicines, recurrent infections and end-of-life needs.

Staffing numbers have changed little.

The problem is therefore not only recruitment. The service model has become more complex without a corresponding change in skill mix.

The organisation reviews dependency, nursing workload, OSS deployment, supervision and access to specialist input. It strengthens dementia competence and ensures staff working with the most complex residents have enough support. Shift patterns are adjusted to reflect periods of greatest care intensity rather than distributing staff uniformly.

Turnover does not disappear, but workers report that the service feels safer and more manageable because staffing reflects actual need.

The scenario demonstrates why workforce risk and mitigation requires analysis of service demand. Vacancy can be a symptom of a poorly matched operating model rather than simply evidence that recruitment advertising is inadequate.

Better workforce data is essential

Italy has extensive data on parts of its labour market, but understanding the whole long-term care workforce remains difficult.

SSN workforce reporting captures health professionals. INPS provides detailed information on registered domestic workers. Regional systems hold data on providers and services. Yet these sources describe different segments.

Unpaid family care is harder to quantify operationally. Undeclared domestic employment may not appear in administrative datasets. Different provider models make comparison difficult.

This fragmentation matters because workforce planning depends on understanding substitution between sectors.

If formal home-care capacity is low, households may purchase more private support. If domestic labour supply falls, demand for formal services can increase. If family carers reduce their involvement, professional hours may need to rise even if population health remains unchanged.

Workforce data therefore need to connect labour supply with demand and care pathways.

The Quality Dashboard Builder can help organisations considering similar oversight structures connect vacancy, turnover, continuity, quality and demand indicators. In Italy, the specific data would need to reflect national and regional information systems, but the governance principle remains useful.

A mature workforce dashboard should answer more than "How many vacancies do we have?" It should show which services are unstable, where agency or overtime dependence is rising, how workforce pressure affects waiting and whether continuity is deteriorating for people using care.

The workforce strategy needs to include productivity without reducing care to throughput

Population ageing means Italy will need to obtain more value from scarce labour. Productivity therefore matters.

But long-term care productivity is easily misunderstood.

Increasing the number of visits per worker can improve efficiency up to a point. Beyond that point, shorter interactions can reduce observation, continuity and relationship quality. In residential care, increasing resident-to-staff ratios may improve apparent cost efficiency while raising falls, distress or hospital transfers.

Productivity should therefore focus on eliminating work that does not contribute to outcomes.

Examples include duplicated documentation, unnecessary travel, poor scheduling, repeated assessments, unclear referrals and professionals undertaking tasks that could safely be delivered by other roles.

Digital systems can help, but organisational redesign is equally important.

The strongest productivity gains often come from making the pathway simpler rather than asking individual workers to move faster.

This is especially relevant to long-term care because relationship continuity itself can be productive. A familiar worker may recognise deterioration earlier, communicate more efficiently and prevent a crisis that would otherwise consume far greater resources.

From shortage management to workforce sustainability

Italy's current workforce pressures are likely to persist because they are driven by structural rather than temporary factors.

Demand is rising as the population ages. Nursing capacity remains below international averages. General practice is under pressure. Domestic care workers are ageing. Family capacity is changing. Rural areas face recruitment and travel barriers.

A sustainable strategy therefore needs several connected responses:

• expand and retain nursing and other essential professional capacity;
• strengthen OSS and care-worker roles with clear competence and progression;
• support ethical and stable migration pathways for domestic and care workers;
• recognise family caregiving within system planning without assuming unlimited availability;
• use digital tools and skill-mix redesign to remove avoidable workload; and
• improve workforce data so national and regional decisions reflect the whole care economy.

None of these measures is sufficient alone.

Recruitment without retention creates churn. Migration without employment protection creates vulnerability. Technology without workforce adoption produces unused systems. Training without career progression can improve competence while workers continue leaving the sector.

Workforce sustainability therefore needs to be treated as a system outcome.

What Italy's experience offers international learning

Italy's workforce model reflects its SSN, regional organisation, household employment traditions and strong reliance on family care. Other countries cannot simply copy its mix of formal and informal labour.

Several lessons are nevertheless widely relevant.

First, workforce statistics can understate the labour on which long-term care actually depends. Household and family work need to be understood even where they sit outside formal service structures.

Second, expanding community care shifts workforce demand rather than eliminating it. Home-first policy requires more nursing, rehabilitation, coordination and mobile care capacity.

Third, migration can be an important part of workforce supply, but it works best within stable employment, training and ethical recruitment arrangements.

Fourth, skill mix matters as much as headcount. Ageing populations require multiple professional and support roles working around increasingly complex need.

Finally, workforce sustainability depends on retention and working conditions. A service that repeatedly replaces experienced staff loses knowledge, continuity and productivity even if establishment numbers eventually return to target.

The transferable lesson is that long-term care workforce strategy should be built around the complete care ecosystem rather than one profession or employment sector.

Conclusion

Italy's long-term care workforce challenge is larger than a shortage of any single professional group. It reflects the interaction of nursing supply, OSS capacity, residential staffing, household employment, migration and unpaid family care at a time when population ageing is steadily increasing demand.

The country retains important strengths. It has substantial professional expertise, a deeply established domestic care workforce and families that contribute enormous amounts of support. Territorial healthcare reform is also creating opportunities for new multidisciplinary roles, digital coordination and stronger care closer to home.

The pressure comes from sustainability. Nurse numbers remain comparatively low. Domestic workers are ageing and declining in number. Regional labour markets vary, while family care cannot be assumed indefinitely. At the same time, the complexity of the people requiring support is increasing.

Italy's next workforce phase therefore needs to move beyond filling vacancies. It requires better skill mix, stronger retention, clearer professional boundaries, ethical migration, realistic recognition of family capacity and productivity improvements that remove unnecessary work rather than simply intensifying frontline labour.

Long-term care reform ultimately depends on this workforce reality. Policies, facilities and digital systems can change how care is organised, but people still deliver the relationship, judgement and practical support on which safe ageing depends. Italy's ability to sustain its long-term care ambitions will therefore be determined as much by who is available to provide care as by what the system says that care should look like.