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NONOS Project Health Services Agency n. 5 “Bassa Friulana” Friuli Venezia Giulia.

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Presentation on theme: "NONOS Project Health Services Agency n. 5 “Bassa Friulana” Friuli Venezia Giulia."— Presentation transcript:

1 NONOS Project Health Services Agency n. 5 “Bassa Friulana” Friuli Venezia Giulia

2 2 NONOS Project A partnership between the public and non profit organization to favour the development of a community welfare system for the elderly in Friuli-Venezia Giulia Roberto Ferri Director General, Health Services Agency no.5 “Basso Friuli” Andrea Luigi Collareta Health Director, Health Services Agency no.5 “Basso Friuli” NONOS Project Director Ranieri Zuttion Community Welfare Area Retresentative, Health Services Agency no.5 “Basso Friuli” NONOS Project Leader Giulio Antonini NONOS Project Manager

3 3 Health Services Agency n.5 “Bassa Friulana” responsible partner of the project Health Service Agency no. 5 “Lower Friuli” is located in the Friuli-Venezia Giulia Region in a border land with Austria and Slovenia at the centre of the European Corridor no. 5, an access point for the countries of Central and Eastern Europe. We serve a population of about 105,000 persons, residents of the 32 townships of Lower Friuli, distributed over an area of 736 square kilometres In conformance with current regulation, Health Service Agency no. 5 is an organism governed by Regional health policies, but also enjoys its own juridical identity and administrative autonomy. Health Service Agency no. 5 guarantees territorial health assistance and services, and also provides specialised and hospital assistance through its two hospital network. 3

4 4 Ass n. 5 “Bassa Friulana” The contest 4

5 5 The themes The risk of institutionalisation for elderly persons who are not completely autonomous, combined with the strong ageing trend in our Region; The presence of an informal welfare system which indirectly supports our institutional welfare system – the over 10,000 foreign health care workers in our Region (out of a population of 1.2 million) many of which operate outside the legal labour structure; The organisation and spread of “community” nursing services and networks; The project partnership with the non-profit sector to promote and involve local communities in the development of networks assisting the elderly at home. The reinforcement of instruments to integrate services with the public sector (health and social services) and with the non-profit sector to favour approaches combining health and social planning at a regional level. 5

6 6 Demographics and indicator the Friuli-Venezia Giulia Region presents a most critical demographic structure, caused by ageing trends in the population 6

7 7 As of 31 december 2003: total regional population : 1.202.715 population ≥ 65 year-old: 261.943 % pop. ≥ 65 year-old / Total pop. : 21,8% % pop. ≥ 85 year-old / pop. ≥ 65 year-old: 11,8% Demographics and indicator N.B.: See notes for definitions of indicators IndicatorsFriuli Venezia Giulia (1) Italy (1) European Union (2) Average age45,142,340,1 (3) Old-age index185,3135,4106,8 (3) Elderly structural dependency index 33,028,925,8 (4) Birth rate8,09,110,3 (3) Death rate11,79,59,7 (3) Marriage rate4,04,54,7 (5) (1)Data Istat 1° gennaio 2004 (2)Euro-Zone: Austria, Finlandia, Germania, Grecia, Irlanda, Italia, BENELUX, Portogallo e Spagna (3)Data Eurostat 1° gennaio 2003 (4)Data Eurostati 1° gennaio 2004 (5)Estimated value taken from Eurostat 1° gennaio 2003 7

8 8 Fonte: SIE su popolazione da anagrafe Comunale fonte ISTAT anno 2003 The age pyramids of 2003 and 2051 highlight the progressive reversal of the pyramid structure. The youngest age groups are shrinking, with a consequent reduction of the pyramid base, whilst the elderly are increasing. Demographics Fonte: ISTAT – Proiezioni – ipotesi centrale 8

9 9 Today some 50,000 elderly are estimated to suffer various degrees of disability Amongst these, some 50% experience significant limitations on their own autonomy. 50% You will find notes pertaining to these definition in the table at the end of this presentation. Estimated dependent elderly Fonte: Azione e-welfare PRAI FESR FReNeSys 2002-2003, “Il modello di simulazione per il Friuli Venezia Giulia” Elderly population (≥ 65 anni) as of 31.12.2003: 261.943 Degree of disability N° of dependents % of elderly population At least three IADL lost26.71810,2% One ADL lost18.0746,9% Twoo ADL lost2.6191,0% Three or more ADL lost4.9771,9% Total dependents (≥ 65 anni)52.38920,0% 9

10 10 The number of dependent elderly is projected to increase considerably in future years, almost doubling by the year 2051 Dependent elderly projection Fonte: Azione e-welfare PRAI FESR FReNeSys 2002-2003, “Il modello di simulazione per il Friuli Venezia Giulia” 10

11 11 The dependent population will become almost equal to the active population, with the consequent problems of sustainability in terms of the economy. Dependent elderly index 11

12 12 In fact, the dependent elderly index, which shows the ratio of the elderly (over 65) to the working age population (15-64 years) will double between 2001 and 2051, passing from 0.32 to 0.68. Dependent elderly index Indice di dipendenza degli anziani Fonte: Azione e-welfare PRAI FESR FReNeSys 2002-2003, “Il modello di simulazione per il Friuli Venezia Giulia” 12

13 13 In the future we can predict a substantial reduction in number, with all the consequent problems of sustainability for the informal assistance network, especially with regards to families. Caregivers’ problems 13

14 14 The ratio between potential caregivers (women between the ages of 50- 64) and potential number of elderly receiving care (over 80) is in fact in free fall, passing from almost 2 (1.94) potential caregivers for each elderly person 80 years and over in 2001 to less than one (0.56) in 2051 Caregivers’ problems Caregiver ratio Fonte: Azione e-welfare PRAI FESR FReNeSys 2002-2003, “Il modello di simulazione per il Friuli Venezia Giulia” 14

15 15 Project’s partnership Friuli -Venezia Giulia Region– promoter and source of financing Health Services Agency n. 5 “Bassa Friulana” – project managing partner Volunteer Associations – operating partners National Association for the Third Age - Udine Italian Volunteer Movement (MOVI) – Udine Udine Diocesan Caritas Subject of the social economy – operating partner Regional Cooperative Unione CONFCOOPERATIVE Local agencies (Townships) – partners 15

16 16 The partnership’s organisation Policy Group Project Managers Scientific Commitee General Working Group Local or Thematic Groups Health Services Agency no.5 secretariat Office of volunteer services and the social economy Scientific supervisor General Administration ASS 5 FVG Regional Health Agency Central Office Local Government Agencies’ representatives Non-institutional representatives Scientific supervisor National Health and social policies experts Project Leader and Project Manager, health services agency no.5 Regional/Local Health Agency Representatives Municipal social services representatives Volunteer services Economia Sociale Territorial groups favouring training and support action for the volunteer associations and favouring forms of self- organisation of families and fragile persons 16

17 17 The problem of the project’s basis First of all, an increasing risk of institutionalisation for those elderly persons not entirely autonomous. 17

18 18 In the region there are some 10,267 beds in residential structures for the elderly. The current availability is therefore about 4 beds for every 100 residents aged 65 or over, which is greater than the national average. The number of beds in the region is in constant growth. Institutionalisation in FVG 18

19 19 As you can see, from 1994 to 2003 the number of beds in the region increased from 8,929 to 10,267 representing a growth of 15% in 9 years. Institutionalisation in FVG Beds in residential structures for the elderly – Trend from 1994 to 2003 Fonte: BUR – anni 1994-2003 19

20 20 Considering the confirmed trends, the Friuli-Venezia Giulia Region has adopted a policy in contrast to the institutionalisation of the elderly with a specific law: Law no. 10/98 “Regulation regarding the defence of health and the social promotion of elderly persons”. Thus initiating a clear strategy of facilitation designed to favour the home residence and discourage the institutionalisation of elderly persons. Institutionalisation in FVG 20

21 21 Problems of the project’s basis High risk of institutionalisation of the elderly Problems linked to informal care Loneliness of the elderly and families Inadequate institutional services to guarantee home residence Little knowledge and attention to the problems of informal caregivers Crisis of the traditional family care model Appearance of informal and black market welfare (caregivers) parallel to institutional welfare Increase of the non- self- sufficiency and care needs Increase of the elderly and disabled population Few social links Fragility of the community networks Inadequate presence of volunteer caregivers for the elderly and families Reduced presence of neighbourhood networks Little propension to create associations and self-help agencies Little accessibility to territorial services “Service supply” organisational model Rigid and insufficient services that are distant from needs Fragmented and standardised assistance 21

22 22 Project Strategy Promote and support a partnership between the public and non-profit sectors for the creation of a service culture aimed at getting beyond the “service performance” approach in favour of models oriented towards the effective assumption of responsibility for the individuals and the communities. Begin a process of involving local communities in the development of forms of self-organising of families and the elderly to re-construct social links. 22

23 23 Objectives Preventing the institutionalisation of the elderly through forms of assistance that integrate formal and informal services, and which envision families and local communities as protagonists, so that the elderly may put roots into the normal social structure from a residential point of view and contribute to social and economic life.. Building a support system for old age founded on the reinforcement of natural networks of care, both familial and community, and on the qualification of volunteers and the social economy as well as on the best integration with institutional territorial services. Developing a transfer from institutional and assistance strategies to socio-health needs with participatory forms organic to familial and social structures. 23

24 24 Actions RESEARCH AREA an analysis of the demand and institutional supply offered to elderly persons; research into new strategies and informal care research into the subject of Living Elderly, that is to say, social housing for the elderly. EXPERIMENTAL AREA the re-organisation of the network of community nurses; the creation of citizen strategies to promote volunteer work; support for the creation and development of new mutual realities of a local character, entitled Munus. SYSTEM INTEGRATION AREA mainstreaming activities into two levels: a horizontal level and a vertical level 24

25 25 Research Area principal results ANALYSIS OF SUPPLY AND DEMAND In which the limits of institutional services in relation to the increase of demand for home care are evident. RESEARCH INTO INFORMAL CARE NETWORKS - the experiences and needs of family caregivers ; - the phenomenon of foreign care workers. These care workers represent an alternative to institutionalisation and permit the elderly to remain at home at an affordable cost. 25

26 26 Research Area principal results ANALYSIS OF SUPPLY AND DEMAND The limits of institutional services in relation to the increase in demand for home care have been highlighted. Significant supply of residential structures for the elderly : – Over 10,000 beds in the Region ( = 4 beds every 100 elderly persons) – Amount higher than the national average. Home nursing services are lacking or insufficient, and characterised by: – professional resources are much less than those utilised in the residential structures for the elderly ; – the hours of nursing assistance per user followed by the service does not exceed 40 hours a year ; – the 40 hours a year of assistance also include the support activities and travel times which on the whole can exceed 50% of the total 26

27 27 Research Area principal results ANALYSIS OF SUPPLY AND DEMAND As you can see, the Home Nursing Service is lacking and insufficient, notwithstanding the fact that Friuli-Venezia Giulia is among those regions guaranteeing the greatest assistance for the elderly in Italy, with a percentage of assisted elderly at home not less than statistics in Norway or Holland. 27

28 28 Research Area principal results RESEARCH INTO INFORMAL CARE NETWORKS The experiences and needs of family caregivers (ricerca realizzata su un campione di 100 famiglie) 28

29 29  Face situations alone  Manage things by themselves  Live in conditions of resignation  not perceive any alternative to institutionalisation Principal difficulties reported by caregiver families Loneliness 29

30 30  Distant from the population  Not representing a point of reference (in terms of orientation, trustworthiness or confidence)  not well known  insufficient  rigid, barely flexible Principal difficulties reported by caregiver families Loneliness Services 30

31 31  lack of free time  impossibility of leaving the house  work activity is strongly conditioned  high levels of physical and psychological stress  worsening quality of life Principal difficulties reported by caregiver families Loneliness Services Distress and conditioning 31

32 32  uncertainty regarding the competency of the foreign caregiver  difficulty in replacing them  work without a proper work permit  difficulty in managing bureaucratic paperwork. Principal difficulties reported by caregiver familiesBadanti Foreign care workers Loneliness Services Distress and conditioning 32

33 33  High costs  Recognition of the care performed. Principal difficulties reported by caregiver familiesBadanti Costs Foreign care workers Loneliness Services Distress and conditioning 33

34 34 Living quarters  Living quarters are inadequate Principal difficulties reported by caregiver families 34 Badanti Costs Foreign care workers Loneliness Services Distress and conditioning

35 35 Critical theme: foreign caregivers In Friuli-Venezia Giulia it is estimated that some 10,000 foreign caregivers are present, almost entirely from East- Central Europe, of whom 70% are without a residency permit A hidden and unknown phenomenon that is growing without any integration with the network of services or the local community ; Foreign caregivers are at risk of ghettoisation, exploitation and burnout, especially if linked to clandestine situations: They usually assist an elderly person 24 hours a day, 6 days out of 7 ; Their adequate living environments are not always guaranteed. In many cases the foreign caregiver shares the same room as the assisted person. They need training, mediation and cultural orientation support: They do not possess adequate assistance knowledge ; They do not know Italian language, culture and traditions. 35

36 36 Elderly Residences/Social Housing Principal results of the research in coooperation with the Venice’s University: A review of international experience with housing for the elderly An analysis of the best housing methods for the elderly An analysis of the best and most suitable architectural styles An analysis of the medical, health and organisational characteristics The countries we are observing with particular attention are Denmark, Sweden, and France. We are working together with the University of Venice to arrive in a short time at a series of guidelines for the housing style solutions so that we can re-think housing, social, health and socio-health policies in a community welfare context. 36

37 37 Experimental Area The re-organisation and development of the network of community nurses The creation of citizen strategies to favour volunteer work MuNuS 37

38 38 The community nurse: a new organisational model of home nursing services 38

39 39 Awareness of the limits of the organisational model of home nursing services: 1. The Service is distant from the population and the need-based situation: - the lack of a stable reference point present (case manager) is evident - there is little awareness of needs; - there is a lack of advance planning for elderly needs. 2. The Service is rigid, hardly flexible, little known and insufficient to meet demand. 3. The organisational model on which the Service is based relates to performance and entails a(an): - assistance centred exclusively on the performance of technical services; - lack of global or personalised planning. The community nurse 39

40 40 From awareness to experimentation: a new model Guiding principles of the new model : Community care Self care Network organisational model The community nurse 40

41 41 Objectives : Integrating and creating a complementary rapport different types of care, formal and informal, promoting the active involvement of all community subjects to assure a better quality of life. In this new context of the nursing role, in addition to classical services, we add the function of activating the informal resources of the community (neighbours, volunteer groups...) favouring and reinforcing links of solidarity and promoting a cultural and organisational change, becoming one knot in the net. Developing a “ pro-active ” function of service retraining towards operative styles that actively prepare planning, even light and in advance, of health needs. Guaranteeing consistency in care during different passages of assistance. The community nurse 41

42 42 How they work : The community nurse identifies, listens to and welcomes the proposals and needs of the population. Involving in its methodology socio-health networks, general practitioners in particular, (social and home assistants), the township administrations (mayors, social service commissioners) and the informal networks present throughout the territory. Anziano Assistente sociale Assistente domiciliare Medico di base Amm. comunale Famiglia Reti di vicinato Volontariato Badanti The community nurse 42

43 43 Territorial coverage of the service: Today: 24 townships out of 32, that is, 75% of the townships of the Health Service Agency have a Community Nurse service 16 Community Nurses 62,000 persons out of 108,235, that is, 57.3% of the population of the Health Service’s territory, are able to use this service. 43

44 44 Stated concretely, this is the ACTIVATION OF A NURSING ASSISTANCE SERVICE AT THE COMMUNITY LEVEL 1 NURSE for each 2500 inhabitants This nurse should collaborate constantly with all the professionals present in the community and with the informal resources active in the local community This nurse should be present in the community and recognised by the community itself as a point of reference The community nurse 44

45 45 The action which we have undertaken has permitted us to: 1.Re-orient the organisational model, getting beyond the “performance” approach in favour of a model oriented towards the global and personalised planning for single persons and the community ; 2.Activate nursing stations throughout the territory, linked together, supported and co-ordinated at a district-wide level (by the territorial Health Service Agency); The community nurse 45

46 46 3.Entrust home nurses with the responsibility of nursing assistance in a defined community (2500 inhabitants), becoming the point of reference for families and communities, also through the opening of nursing stations throughout the territory; 4.Guarantee the continuity of care through accompanying and planning for user needs on the part of home nurses already in an intensive phase. Performing de facto the function of Case Manager. The community nurse 46

47 47 5. Activate strategies to ensure “early or light” planning of the unexpressed needs of the elderly (effecting a screening of the population to get advance knowledge of fragile subjects); 6. Activate strategies oriented towards: - favouring the empowerment of the subjects - promoting the informal care and social inclusion networks - encourage the community to assume responsibilities - increase margins for the participation of disabled and non-self- sufficient persons. The new organisational model permits us to enhance integration with other figures who operate throughout the territory, especially general practitioners, welfare assistants and physiotherapists. The professional figure that we are developing, depending on the district, is to be integrated with the network of socio- health services and will contribute to enhancing the role of the District as territorial government of health services. The community nurse 47

48 48 Promotional and development local community - Training and volunteer-support initiatives - Support for forms of self-organisation of families and fragile persons 48

49 49 Local citizenry This is a strategy used in public health promotion; It promotes and sustains “modern” volunteer work: an expression of the active and fraternal commitment of the citizenry; It aims at developing a sense of community and reinforcing the capability of the collective group to organise themselves autonomously to meet the needs of the elderly; The strategy seeks to favour the collaboration and integration of institutional and informal subjects through an action supporting the latter Training and volunteer-support Local citizenry 49

50 50 The methodology: Community/socio-health entertainment (community development); Action research; Enhances local knowledge and promotes the production of knowledge from the grass roots; Encourages the active participation of the community’s subjects; The community considers itself (and thus becomes both subject and object of study); Strategy of giving rise to, through a process of reciprocal recognition, the meeting of different groups and subjects Training and volunteer-support Local citizenry 50

51 51 Training and volunteer-support Local citizenry The strategy: 1.Promotion · Contact with subjects and groups · Creation of guide groups together with community subjects 2. Organisation · Definition of the demand and the research area · Organisation of the participatory analysis of the reality 3. Performance of the “research” 4. Definition of problem areas and priorities 5. Participatory planning 6. Action 51

52 52 Training and volunteer-support Local citizenry Results and advantages of local citizenry strategies: Ample possibility of adaptation to real community needs ; Promotion of permanent co-ordinating bodies and social observatories ; Help and promote communication throughout the territory (informal networks, neighbourhood); Integration with institutional strategies to create a local welfare system (zone plans); Favours coordination projects and conquering the social fragmentation typical of small communities (e.g. integrated projects for light home residence, creation of community gathering centres); Action begun in 6 townships under the NONOS project. 52

53 53 Origin of the name: New Mutual Aid forms of town solidarity. Operational application of a strategy of “ community development ” ; Perform active promotion of organised forms of social citizenship (mutual organisations, family community agencies, social promotion associations...) so as to: - give form to the manifestations of assuming responsibility on behalf of the local community in terms of increasing levels of reciprocity (self-help) and solidarity (hetero-help) with respect to the elderly and families; - represent an opportunity to promote the empowerment of the elderly; - an expression of the social subjectivity of families in the new community welfare system; MUNUS – New mutual aid realities 53

54 54 Still remaining: A forum for democratic participation for citizens as far as social and health policies at a local level ; An instrument which increases social cohesion and local socio-economic development; Representative of a possible operating expression of new models of public/private co-management (participatory administration); An opportunity for working and social integration for foreign caregivers; MUNUS – New mutual aid realities 54

55 55 Phase of the proposal Communication of the proposal to municipal governments; Welcoming new participants or requests for further investigation; First meetings with local governments for an in-depth presentation of the proposal; Common acceptance of the proposal and identification of one or more local promoters; Promoter training; MUNUS – New mutual aid realities 55

56 56 MuNuS: development models Phase of knowledge : Creation of a local working group (composed of promoters, social assistants, general doctors, community nurses, homecare assistants, volunteer workers, parish priests, other subjects active in local welfare activity); Creation by the promoters of a “ Mapping of the Needs and Resources Throughout the Territory ” ; Initiation of a local promotion phase through public meetings and other meetings with numerous families and elderly persons throughout the territory, aimed at gathering the first participants in the proposal to build a MuNuS and identify the action priorities; 56

57 57 MuNuS: development models Organisational and operative phase : Definition of the social base for the creation of the Munus Association. Formal creation of Munus(in the form of a “ Social Promotion Association ” ) and activity development. Launch of the first initiatives (elderly person transport, company, accompaniment, management support for work relations with foreign caregivers). Public initiatives to boost community, individual and associations ’ awareness of the possible development of Munus. 57

58 58 Status of the Munus experiment: Presentation and promotion of the proposal in 25 townships of the Region (over 30 townships have already requested the launch of a MuNuS strategy); Experiment already launched in 12 townships in the Region; To date, 23 local promoters are directly involved; 20 training and comparison meetings with the promoters; Over 30 public meetings have been organised in the various townships; Over 25 meetings with public administrators have been organised in the various townships; Several hundreds of persons have been involved in the Munus project in the different townships. MuNuS: development models 58

59 59 System integration area The NONOS project is to be integrated with social and health policy planning processes, and in particular with regional initiatives aimed at contributing to the integration of social and health assistant policies, with social inclusion policies, with housing and social habitat policies, as well as others to render work more remunerative. 59

60 60 From the NONOS Project to WIN regional initiative: The NONOS project is one step ahead in several community welfare policies and in particular with several elements that were developed by the Region in the context of the WIN initiative. THE WIN PROJECT (Welfare Innovations) Theoretical/practical laboratory for Community Welfare created by the Friuli-Venezia Giulia Region in conjunction with several international organisations: WHO, UNESCO, UNDP, UNOPS(*). It is of great satisfaction to us to note that the WIN laboratory has found its home at our Health Services Agency in Palmanova. (*) l’United Nations Educational, Scientific and Cultural Organization UNESCO), l’United Nations Development Programme (UNDP), il Centro Mediterraneo dell’Organizzazione Mondiale della Sanità per la Riduzione della Vulnerabilità (WHO-WMC) e l’United Nations Office for Project Services (UNOPS) System integration area 60

61 61 From the NONOS Project to WIN regional initiative Within the context of the “WIN-WELFARE INNOVATIONS International Laboratory for Community Welfare”, the Friuli-Venezia Giulia Region has launched MICRO-WIN, a project to create local welfare development plans which is based on inter-institutional and local citizens’ participation. In various micro-areas, some 1000-2000 inhabitants effect real integration of the health, social, housing/social habitat, and labour policies, actively involving the resident population. The MICRO-WIN experiment has as its objective (through verification of the results) the communication of these initiatives throughout the regional territory. 61

62 62 Complexities revealed through experience Governance of the partnership in an innovative project in community welfare Timeframes of the projects and welfare initiatives: Are these adequate to community needs? Are these the timeframes of those who plan or those who live the reality? On this topic we have……. A direct experience….. 62

63 63 A question “… excuse me, I’m 90 years old… … and I’ve been and elderly person for 30 years… … where the heck were you guys all these years?…” 8 June 2005 Comment by Mario, resident of Gonars, a small town of 2,500 inhabitants on the occasion of a community meeting to present our project. P.S. Mr. Mario, at his own venerable age, has enrolled in the local Munus association. 63

64 64 How do we put the individual at the centre of our initiatives? Several themes for shared reflection 1.Welfare’s unsustainable (economic) difficulty. Effective and sustainable system policies to continue guaranteeing universal welfare. 2.Possible strategies to restore the central position of the individual and the community. 3.Instruments and methods to orient welfare towards models of local development and social cohesion. 64

65 65 NOTES

66 66 Average age:Average age: average of the ages considered with the amount of the population in each of these categories. Old-age Index:Old-age Index: ratio of the over-65 population and those between the ages of 0-14. Elderly structural dependency index:Elderly structural dependency index: ratio of the over-65 population and the active population (15-64 years). Birth rate:Birth rate: ratio of annual live births to the average sum of the resident population, multiplied by 1,000. Death rate:Death rate: ratio of annual deaths to the average sum of the resident population, multiplied by 1,000. Marriage rate:Marriage rate: ratio of marriages per year to the average sum of the population, multiplied by 1,000. Index definition 66

67 67 ADL (Activities of Daily Living): These are a combination of activities that permit the satisfaction of individual fundamental needs. They are considered to evaluate the autonomy of the individual. The most used instrument is the “Katz ADL scale” which evaluates the independence of the individual on the basis of 6 fundamental functions of daily life: –washing –dressing –using the toilet –geographical mobility –continence –food ADL and IADL definition 67

68 68 IADL (Instrumental Activities of Daily Living): These are the activities considered more complicated than ADL from a physical and cognitive point of view, and are used to evaluate the autonomy of the individual. The reference instrument for the measure of self-sufficiency in IADL is the Lawton and Brody IADL scale, which includes the following activities: –using the phone –shopping –cooking –cleaning the house –doing the wash –using means of transportation –managing money –taking medication correctly ADL and IADL definition 68

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