Maria Pierce, Independent Research and Adjunct Faculty Member, Dublin City University
There are 637,567 people aged 65 years and in Ireland, making up 13.4% of the population.
Most older people take care of themselves. Where care is needed, many older people may need others to be involved at a minimal level, but generally over time this can increase and may reach intensive levels, as ability to self-care reduces. Care provided to older people in Ireland is based primarily on a family system of informal care supplemented by formal home care services; informal carers play a central role in providing care to many older people who need support in Ireland. However, not all older people have family members available to provide care and support.
Home Support services are one of an array of long-term care services for older people in Ireland. In Ireland, the bulk of formal home care is provided by home care workers who are engaged by approved private providers. The public sector is also involved in the delivery of home care, but plays a relatively small role. The main role for the public sector is arranging and financing home care services delivered by approved private providers and public sector. There is also a small but growing trend of older people purchasing home care privately out-of-pocket from their own resources.
Most home care workers in Ireland are employed by approved private providers, with a smaller number employed by the HSE, or directly employed by older people or their family carers.
The first case of COVID-19 in Ireland was announced on 29.02.2020, at a time when home care in Ireland is under review, and the development of a new scheme for home care underway by the Department of Health. Emergency preparedness was not an issue being addressed as part of the Department of Health’s review of home care.
In response to the arrival of COVID-19 to Ireland, the Irish Government prepared a National Action Plan. One of its cross-cutting action areas is maintaining critical and ongoing services for essential patient care. This includes maintaining Home Support as well as other long-term care services for older people and other groups such as people with disabilities.
The Action Plan has a specific action on Caring for our people who are ‘At Risk’ or vulnerable. Specific details on how Home Support is to be maintained are not included.
To assist with planning for COVID-19, data from the 2018 wave of The Irish Longitudinal Study on Ageing (TILDA) has been analysed to provide estimates of the utilisation of home care services. The figures are likely to be an underestimate as people with dementia were not included in the TILDA sampling frame at baseline. The estimated number of people aged 50 years and older utilising home care services, either publicly or privately funded is 62,100, the majority of whom are frail (Kenny et al., 2020). Further analysis of TLDA to inform planning for COVID-19 is underway.
One action taken by the HSE during the COVID-19 crisis has been to issue on 16.03.2020 guidance for health and social care workers who visit people’s homes. This guidance fills an important gap. The guidance covers providing routine home care for persons who are not suspected or confirmed cases of COVID-19; providing home care for people who are discovered to have symptoms of respiratory infection who are suspected or confirmed COVID-19; and providing planned home care for people who have suspected or confirmed COVID-19. It covers the use of personal protective equipment (PPE).
In addition to guidance for home care workers, planning for acquiring and distributing adequate supplies of PPE and training home care workers in their use is also important, although evidence from other countries suggests that this is likely to be challenging.
On 27.03.2020, Ireland moved to a more intensive phase of restrictive actions and the Irish government announced additional public health measures urging everyone to stay at home wherever possible. All people over the age of 70 and vulnerable people with certain medical conditions were advised that they must stay indoors in what is referred to as ‘cocooning’. Workers in the category of essential services are permitted to travel to and from work. Home care, home help and other community services were included among the list of essential workers.
On 27.03.2020, the HSE issued guidance on cocooning to protect people over 70 years and those extremely medically vulnerable from COVID-19. Cocooning is:
‘a measure to protect those over 70 years or those extremely medically vulnerable by minimising interaction between them and others. This means that those who are over 70 years or those extremely medically vulnerable should not leave their homes, and within their homes should minimise all non-essential contact with other members of their household. This is to protect those who are at very high risk of severe illness from COVID-19 from coming into contact with the virus’.
The guidance on cocooning is for people over 70 years of age, those who are at very high risk of severe illness from coronavirus (COVID-19) because of an underlying health condition, and for their family, friends and carers. It includes advice to those receiving home care.
The Irish government have been criticised for reducing the ‘over 70s’ in public imagination to ‘vulnerable’, In response, TILDA has produced a report showing the huge contribution that older people make to Irish society including with respect to work, caring and volunteering.
Home and Community Care Ireland, the national membership organisation for home care providers in Ireland, with approximately 80 members across the country, has developed a COVID-19 National Action Plan, published on 18.03.2020 seeking the Government and HSE to engage with issues facing the home care sector during COVID-19
The following are some key issues facing the Irish home care sector during the COVID-19 pandemic.
- There are reports that an increasing number of people in receipt of home care have decided voluntarily to ‘self-isolate’ and have temporarily cancelled Home Support during COVID-19 in response to public health messages; others have taken this decision following advice from medical doctors to self-isolate (HCCI, 2020). Cancellation of home support is likely due to fears that allowing home care workers visit the house will increase the risk of infection. It remains to be seen how people are faring without home care assistance, but it will undoubtably place an additional burden on family carers during the crisis. It also affects the employment and wages of home care workers, as well as state payments to home care providers.
- While workers in Ireland have been asked to work from home where possible during the crisis, this is not an option for home care workers. However, there are reports that an increasing number of home care workers are not available to report to work, as they are either self-isolating voluntarily in response to public health messages or on the advice of medical doctors (HCCI, 2020). Some may become sick or are caring for a relative who is sick. Child care facilities and schools have been closed in Ireland since 13th March 2020, and some home care workers may be unable to report to work due to child care responsibilities. Others may be combining work as a home care worker with caring for an ‘at risk’ or ‘vulnerable’ relative. Evidence suggests that fear and concern for their families and self, and well as fear of infecting clients may be a barrier to home care workers continuing to work during a pandemic (Baron et al., 2009).
- Retaining capacity during the COVID-19 crisis is critical for the home care sector, as many home care workers are providing care to people with high levels of need. Home care workers can also provide an important route for communicating important public health messages to older people and their families.
- Increasing home care capacity will also be important, as home care workers may provide surge capacity by, for example, providing care to patients discharged home from hospital (Baron et al., 2009; Levin et al., 2007).
- Home care workers in Ireland are low paid workers. Many work part-time and some will be in receipt of social welfare payments and/or have a medical card. While there has been much focus in Ireland on social welfare payments for people with reduced working hours as a result of COVID-19, much less attention has been paid to the impact that increased working hours will have on low paid workers and their entitlements to social welfare payments and/or a medical card. This is an issue of relevance to the home care sector.
While the literature on emergency planning and the home care sector is limited, it does provide some key messages for emergency planners as follows:
- Home support services play a crucial role during a pandemic.
- Home care workers should be considered as part of the health care system
- All home care workers similarly at risk, irrespective of their job title or employer should be considered
- Approaches to help home care workers protect their income should be considered
- Home care employers, the home care workforce, and their advocates need to establish communication networks and be integrated into the emergency planning process.
- Planning for acquiring and distributing adequate supplies of PPE and training home care workers in their use during a pandemic is important
Baron, S., McPhaul, K., Phillips, S., Gershon, R., and Lipscomb, J. (2009) Protecting Home Health Care Workers: A Challenge to Pandemic Influenza Preparedness Planning, American Journal of Public Health, 99(S2): S301-S307.
Levin, P.J., Gebbie, E.N., Qureshi, K. (2007) Can the Health-Care System Meet the Challenge of Pandemic Flu? Planning, Ethical, and Workforce Considerations, Public Health Reports, 122: 573-578.
Pierce M (2020) Report: Key issues facing the home care sector in Ireland during COVID19. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE.