Maria Pierce, Independent Researcher and Adjunct Faculty Member, Faculty of Science and Health, Dublin City University

Last updated: 14.04.2020

Key Points:

• Ireland reports on positive cases and deaths in all care settings and dwellings
• Nursing homes are now prioritised in emergency planning and a range of measures and assistance have been introduced in an effort to mitigate the impact of COVID-19 on people and staff in nursing homes; the impact of these measures remains to be seen
• A challenge that lies ahead is directing the measures introduced for nursing homes to where they are most needed and implementing them consistently across the country
• Maintaining nursing home staff availability and wellbeing during COVID-19 is challenging
• The redistribution of home care workers to residential care will undoubtedly have implications for community care 

1. Introduction

This is a preliminary report for Ireland on long-term care and COVID-19, providing an overview of key events and measures introduced at a national level, and responses by key relevant stakeholders, since the first case of COVID-19 was confirmed in the country at the end of February 2020. It focuses primarily on long-term care including nursing homes and community care for older people and people with dementia. This report will be updated regularly.

2. Impact of the COVID-19 pandemic to date

The National Public Health Emergency Team (NPHET) was established on 27^th January 2020 in the Department of Health, chaired by the Chief Medical Officer, to oversee and provide national direction, guidance, support and expert advice on the development and implementation of a strategy to contain COVID-19 in Ireland. HIQA is the authority with responsibility for inspecting nursing homes in Ireland, and is represented on NPHET. While not represented on the NPHET, NHI reports that it is in continuous contact with the Department of Health, NPHET, the Health Service Executive (HSE) and all relevant health authorities during the COVID-19 crisis

2.1. Number of positive cases and deaths in the general population

The first case of COVID-19 in Ireland was announced at the end of February on 29^th February 2020.  By midnight on the 10^th April, the total number of confirmed cases of COVID-19 had increased to 8,496. The incidence rate is highest for people in the age group 65 years and over. Of all cases, 1,442 (24.1%) are people aged 65 years and over. There have been 223 deaths from Covid-19; 89.7% are of people aged 65+.

2.2. Number of positive cases and deaths among residents in care homes

There has been a steady rise in the number of nursing homes with outbreaks of COVID-19. The most recent figures reveal that, to mid-night 10^th April 2020, 140 clusters of COVID-19 in nursing homes had been notified, accounting for more than one third (36.6%) of all clusters in Ireland. A cluster of COVID-19 is 2-3 or more cases of COVID-19 in the same setting within a 72-hour period.  The number of outbreaks is up from 4 clusters in nursing homes notified to midnight on the 21^st April 2020. The majority of clusters in nursing homes are in the east of the country, but there is at least one nursing home cluster in every HSE area of the country. There are a further 54 clusters (14.1%) in residential institutions and 23 clusters (6.0%) in community hospitals/long-stay units. 

The official number of deaths related to COVID-19 is reported each day in Ireland. All deaths (in all care settings and dwellings) related to COVID-19 cases are included in the official count. Deaths linked to COVID-19 in nursing homes were reported by NPHET for the first time on the 11th April 2020. The most recent data, which were released on 13^th April 2020, shows a total of 365 COVID-19 related deaths on that day, 167 (45.8%) of whom were related to residents in nursing homes. The absolute number of deaths and the proportion occurring in nursing homes will fluctuate over time.  

3. Long-term care system background and context

There are 637,567 people aged 65 years and in Ireland, making up 13.4% of the population.

Care provided to older people in Ireland is based primarily on a family system of informal care supplemented by formal home care services; public resources for home care are below those available to support residential care provision.  While most older people live at home and take care of themselves, there is a significant number who require the support of others. Where care is needed, many older people may initially need family carers to be involved at a minimal level, but generally over time this can increase significantly, as ability to self-care reduces. However, not all older people have family members available to provide care and support.

No large-scale epidemiological study has been carried out in Ireland to provide an estimate of the prevalence of dementia, and depending on the prevalence rates applied to population data, it is estimated that there are between 39,272 and 55,266 people with dementia in Ireland. It is estimated that 19,530 people with dementia reside in long-stay residential care settings and estimates of the number of community-dwelling people with dementia range from 19,742 to 35,732.[1] Based on this upper estimate, it is estimated that there are approximately 60,000 family carers of community-dwelling people with dementia.[2] 

3.1. Nursing homes in Ireland

All nursing homes in Ireland must be registered with the Health Information and Quality Authority (HIQA), the statutory body responsible for monitoring the safety and quality of care in nursing homes in Ireland.  As of Dec 2018, there were 581 nursing homes registered with HIQA.[3] More than three-quarters of nursing homes in Ireland are private or voluntary (not-for-profit) nursing homes; the remainder are public facilities. According to Nursing Homes Ireland (NHI), the national representative body for private and voluntary nursing homes in Ireland, there are over 460 private and voluntary nursing homes providing care to over 25,000 people (https://nhi.ie/). There are approximately 5,000 people resident in public nursing homes.

A significant proportion of residents in nursing homes are people with dementia; it is estimated that there are between 15,000 and 20,000 with dementia are residing in nursing homes in Ireland.[4] There are also close to 1,500 younger people with disabilities residing in nursing homes in Ireland.[5]

3.2. Home care in Ireland

Home Support services account for the bulk of long-term care services for older people in Ireland.  Most home support 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.  Formal home care is mainly supplied by approved private providers contracted by the State. The public sector is also involved in the delivery of home care, but nowadays plays a relatively small role in direct provision. However, the public sector is still responsible for arranging and financing home care services delivered by approved private providers and the public sector. There is a high prevalence of dementia among community-dwelling older people in receipt of state-funded home care.[6]

In Ireland, publicly-funded home support is allocated based on a care needs assessment by a healthcare professional and is currently not subject to a financial means assessment, although this may change as the Department of Health in Ireland is currently in the process of undertaking work to develop a new statutory home care scheme for older people.

4. Long-Term Care policy and practice measures

4.1. Whole sector measures

National Action Plan

In response to the arrival of COVID-19 to Ireland, the Irish Government prepared a National Action Plan issued on the 16^th March 2020.[7] One of its cross-cutting action areas is: maintaining critical and ongoing services for essential patient care. This includes long-term care services for older people and other groups such as people with disabilities. The Action Plan stated that capacity in long-stay settings is to be maintained. It also refers to maintaining Home Support for older people and other groups such as people with disabilities. Specific details on how capacity in long-term services and on how Home Support is to be maintained are not detailed.  The Action Plan has a specific action on Caring for our people who are ‘At Risk’ or vulnerable.

Ethical Framework for decision-making in a pandemic

An ethical framework to guide policymakers and healthcare planners has been prepared by the Government in response to COVID-19.[8]  Key principles in the framework include:

• Minimising harm: When imposing restrictions, inform people why this is necessary for public health  
• Proportionality: The least restrictive methods possible should be utilized to protect public health
• Solidarity: We must set aside self-interest, territorial focus, etc. to work collaboratively
• Fairness: Resource allocation must be intentional to give equal access to all
• Duty to provide care: Clinical staff, non-clinical healthcare workers, carers and family members
• Reciprocity: Society must support those with disproportionate burden
• Privacy: Health information may be shared on a limited basis for the benefit of public health

Guidance on ‘cocooning’ for people over 70 years

On the 27^th March 2020, the HSE issued guidance on cocooning to protect people over 70 years and those extremely medically vulnerable from COVID-19.[9] 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.

‘Cocooning’ also applies to people aged 70 years and over in long-stay residential settings. Care providers in these settings are instructed to ’carefully discuss this advice with the families, carers and specialist doctors caring for such persons to ensure this guidance is strictly adhered to’. However, ‘cocooning’ presents many issues and challenges for residents in nursing homes, their families and staff in nursing homes, and there are particular challenges for people with dementia. However, what ‘cocooning’ means in practice in nursing homes and how the issues and challenges emerging can be addressed is not covered in this guidance document.

4.2. Coordinating acute and long-term care

Another priority action area is Caring for people in Acute Services, which includes a section on: ‘maximising patient flow through our hospitals and making efficient use of existing resources’. Private nursing homes were identified as playing a key role with supporting flow, with nursing homes identified as an existing resource, which could potentially be used to facilitate the early discharge of patients from hospital or patients delayed in hospitals. Guidance on Transfer of Hospitalised Patients from an Acute Hospital to a Residential Care Facility in the Context of Covid-19 was later published by the HSE on 19^th March 2020, which was circulated by HIQA on the request of the HSE. It included guidance on both transfer from acute hospitals to residential care facilities and from residential care facilities to acute hospitals.

4.3. Long-stay residential care settings measures

Restrictions on visiting to nursing homes

After the first case of COVID-19 in Ireland was announced on 29^th February 2020, NHI began to offer advice to private and voluntary nursing homes soon after. Less than a week after the first confirmed case of COVID-19, NHI announced on 6^th March 2020 that visiting restrictions were in place across private and voluntary nursing homes in Ireland with a view to protecting residents.[10] This was a number of days before the government’s announcement to close schools and universities. NHI came in for some criticism for taking this decision unilaterally. The Department of Health’s view was that a blanket ban on visiting nursing homes at that time was unnecessary. At the time, HIQA urged service providers, and staff to follow all public health advice from the HSE as the primary source of information and guidance on COVID-19.

One of the most immediate concerns following the announcement of visiting restrictions was the impact on residents of social isolation and separation from their families. NHI carried out a survey of nursing homes to gather information on activities used to mitigate the negative impact on residents and safeguard their well-being. Following this a list was compiled of the types of activities that staff could offer to nursing homes residents and ways of ensuring residents could remain in contact with their families. Comfort Words, a national initiative encouraging children to reach out to older people in nursing homes during COVID-19 by writing to them was launched by NHI on the 23^rd March 2020.[11]

Residential respite in nursing homes has also been cancelled during the COVID-19 outbreak.

Assessment and testing

From 26^th March 2020, the case definition for Covid-19 tests changed in Ireland, and people in certain groups were prioritised for testing. Staff and residents of nursing homes were included as a priority group for testing. However, there have been ongoing delays in testing in Ireland due to global shortage of testing kits and chemical reagents needed to carry out the tests.[12] 

Guidance on the Assessment and testing pathway for symptomatic resident in Residential facilities (RF) and Long Term Care Facilities (LTCF) was issued on 27^th March 2020 by the HSE. 

Notifications of COVID-19 infections

Nursing homes are required to notify the Chief Inspector of Social Services in HIQA of any outbreak of Covid-19 as a notifiable disease, and soon after the first case of Covid-19 in Ireland, HIQA reminded nursing homes of this requirement. HIQA initially continued to carry out inspections in nursing homes, but with changes to its inspection process.[13] This decision was later changed with all routine inspections of nursing homes cancelled until further notice on the 12^th March 2020.[14] 

Managing staff availability and wellbeing

On the 17^th March 2020, the HSE launched a recruitment campaign, Be on Call for Ireland, asking all healthcare professionals from all disciplines who are not already working in the public health service to register to be on call for Ireland.[15] On the same day, NHI also launched a recruitment campaign for private and voluntary nursing homes.[16] There were concerns that an unintended consequence of the HSE’s Be on Call for Ireland campaign would be to divert staff from the private and voluntary nursing home sector to the public sector, at a time when the staff needs in private and voluntary nursing homes was increasing.

Contingency planning for care homes

On 23^rd March 2020, HIQA wrote to nursing homes asking them to review the contingency plans they have in place to manage the COVID-19 outbreak, which would involve, for example, taking account of staffing considerations, governance and management arrangements, and infection prevention and control procedures. Providers were also advised to refer to current HSE (www.hse.ie) and Government (www.gov.ie) guidance and advice when updating their plans.[17]

Upscaling Covid-19 restrictions and prioritisation of nursing homes in emergency planning

On 27^th March 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.[18]

Around this time, concerns were expressed by the NHI that the nursing home sector, rather than being prioritised in public health emergency planning for COVID-19, was being ignored and left unsupported. In response to these concerns and the rising clusters of COVID-19 in nursing homes, NHI sought an urgent meeting with the Minister of Health to discuss the nursing home sector and related issues including specific guidance for nursing homes, staff shortages in nursing homes, issues in relation to the procurement of PPE, and called on the government to regard private and voluntary nursing homes as part of the national health infrastructure during the crisis.[19]  A meeting between NHI, representatives working within nursing homes, the Minister for Health and Secretary General of the Department of Health took place on the 30^th March 2020. Challenges discussed included timely access to PPE and oxygen, priority coronavirus testing for staff working in nursing homes, the need for support around staffing, and additional funding of the sector.

This coincided with the issuing of an updated version of Preliminary COVID-19 Infection Outbreak and Control Guidance including Outbreak Control in Residential Care Facilities and other similar units by the HSE. 

The issue of nursing homes was examined by NPHET in its meeting on 31^st March 2020, following a request from the Minister of Health,[20] and efforts to tackle outbreaks in nursing homes were ramped up to interrupt the spread of COVID-19 in nursing homes.

A number of measures for nursing homes were introduced aimed at keeping residents in long-stay residential settings as far as possible, whilst preventing the spread of the virus within nursing homes. NPHET recommended that HIQA conduct a risk assessment to see which nursing homes need extra support to deal with Covid-19, with a view to ensuring the facilities have adequate PPE, oxygen and staff, including replacement staff, and helping make these available if needed. National and regional outbreak teams were set up to oversee long-term residential care settings and to tackle specific clusters of COVID-19 in nursing homes and prevent further spread within the nursing home. It was also recommended that more personal protection equipment (PPE) be made available for staff working in nursing homes, to areas where it is most needed. Health checks for nursing home staff were also recommended. Training and preparedness plans for infection outbreaks were other measures recommended.[21]

In an attempt to break the chain of transmission of the disease, it was recommended that nursing homes residents who contract COVID-19 should continue to be cared for in nursing homes, unless there is a clinical or other advantage to them being transferred to another setting. 

Moreover, in an effort to minimise the risk of onward transmission of the virus, it was recommended that restrictions may be introduced to discourage nursing home staff, particularly locum staff, from working in different homes, thereby reducing the risk of infection. Consideration is also being given to providing separate accommodation for some nursing home staff.  

Home and Care Community Ireland (HCCI), the national membership organisation for home care providers in Ireland, has agreed at the request of the government/HSE to measures aimed at the voluntary redeployment of some home care workers to support frontline staff in nursing homes.[22]

Further measures for nursing homes

With rising clusters in long-stay residential facilities, nursing homes continued to be an area of priority and ongoing concern in Ireland. Further measures for nursing homes were quickly announced. A major package of financial support for private and voluntary nursing homes is to be introduced. Other key developments include the updating of guidance on infection prevention and control in residential care facilities, and additional support for nursing homes including through tele-mentoring.  

The Minister for Health, Simon Harris, announced on 4^th April 2020 further measures to support nursing homes residents during COVID-19.[23] A range of enhanced measures were recommended to assist residents and staff in nursing homes:

• staff screening will start in nursing homes twice a day
• COVID-19 testing will be prioritised for staff in nursing home
• the HSE will provide access to PPE, expert advice and training
• each nursing home will be identifying a COVID-19 lead

The issue of nursing homes staff working in different long-stay residential settings, was again addressed, with plans to minimise staff movement across long-stay residential facilities. If required, staff are to be supported by the HSE with alternative accommodation and transport, to avoid staff who work in multiple locations sharing the same accommodation. 

Temporary Covid-19 Financial Support Scheme

The Minister for Health also announced on 4^th April 2020 that a temporary COVID-19 Financial Support Scheme is to be introduced by government to support the critical services provided by nursing homes,[24] The scheme, which has been welcomed by the NHI,[25] will provide immediate temporary assistance payment to support private and voluntary nursing homes to action measures to further mitigate against a COVID-19 outbreak and be capable of managing any outbreak that occurs in terms of providing safe staffing and a safe environment. It is envisaged that the scheme will operate for a 3-month period. It will be reviewed after the first month of operation.

The core concept of the scheme is that the State will provide additional funding to those nursing homes that require it. It is intended that the Financial Support Scheme will consist of two inter-related component parts:

1)           Assistance for nursing homes subject to a standard threshold

Funding is be provided to each applicant nursing home for COVID-19 related measures and expected costs. The expected costs are for the month ahead, the first of which will be the month of April. Financial support is be provided based on the number of NHSS residents in situ as reported for the month of March by the HSE Nursing Homes Support Office.[26] The nursing home will receive €800 per resident per month for the first 40 residents, €400 per resident per month for the next 40 residents and €200 per resident per month thereafter.

2)           Enhanced outbreak assistance business case (for the same period) in the event of COVID-19 outbreak

Where a nursing home has incurred significant further costs or undertaken necessary enhanced actions arising directly from COVID-19 outbreak as certified by the HSE, a nursing home may submit a separate business case for enhanced funding. In such cases, the nursing home in question will be required to submit evidence of the measures undertaken and the costs incurred, along with independent certification from an auditor that the expenditure was incurred and it relates directly to COVID-19. The maximum assistance available to an individual nursing home per month will be twice that of the agreed monthly support (see 1 above) or a maximum amount of €75,000 inclusive of the monthly support, whichever is the lesser.

Updated guidance on infection prevention and control in residential care facilities

The issuing of Interim Guidance on Infection Prevention and Control including Outbreak Control in Residential Care Facilities during the COVID-19 pandemic has been a key public health measure and given the rapidly changing situation, the guidance is regularly updated and new versions issued. The most recent version of the guidance released on 7^th April 2020 can be found here. Changes are informed by guidance developed in other countries (e.g. Australia and Scotland) and by WHO, evidence from rapid reviews, and with greater understanding of the support needs of staff and residents in residential care facilities. The guidance was changed in the most recent version to update sections on general preparedness, infection and control measures, and environmental hygiene and to provide updated guidance on preventing and control of outbreaks. It includes additional information about the virus, and information and guidance in relation to laboratory testing. It was also updated to reflect recent changes in roles and responsibilities; and to update and add information on transfer between care settings. The addition of sections on pastoral care, care of the dying and care of the recently deceased reflects the need to ensure access to spiritual and end of life care.  A proposal for Occupational Health Supports was appended to the guidance, in response to the need for better support to maintain the health and wellbeing of staff. 

Supporting nursing homes providers and staff

As part of the Enhanced Public Health Measures for nursing homes and other residential care settings, HIQA opened a new Infection Prevention and Control Hub on 6^th April 2020 to provide information and advice to nursing homes and other long-stay residential care settings when it comes to dealing with a COVID-19 outbreak.[27] The Hub is available to providers and staff of nursing homes, residential centres for people with a disability, special care units and Tusla children’s residential settings. It will provide:

• Guidance on how to prepare for and manage a Covid-19 outbreak in a residential service
• Offer advice on infection prevention and control measures when caring for a resident with confirmed or suspected covid-19.
• Support in understanding and applying national advice in individual settings
• Answer any general infection prevention and control queries that services and staff may have

Tele-mentoring is also being used in Ireland to provide information, training, guidance and support to nursing homes during COVID-19. The HPSC is delivering a series of webinars on preventing and managing COVID-19.[28] Another example is the Project ECHO AIIHPC Webinars for Nursing Homes. This is a collaboration between the All Ireland Institute of Hospice and Palliative Care (AIIHPC), Our Lady’s Hospice & Care Services and the Age-related Health Care Department of Tallaght University Hospital. The collaboration is being supported by a number of organisations including the HSE, Irish Hospice Foundation, NHI and Irish Gerontological Society.[29]

4.4. Measures for community-based long-term care

One of the earliest actions taken in relation to community care was the issuing of guidance for health and social care workers who visit people’s home.

Guidance for health and social care workers who visit people’s homes

One action taken by the HSE during the COVID-19 crisis has been to issue on 16^th March 2020 guidance for health and social care workers who visit people’s homes.[30] This guidance filled 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.

Home care providers

HCCI, the national membership organisation for home care providers in Ireland, with approximately 80 members across the country, developed a COVID-19 National Action Plan, published on 18^th March 2020 seeking the Government and HSE to engage with issues facing the home care sector during Covid-19.[31]

There have been anecdotal 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 undoubtedly 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 reporting 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 13^th 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[32]. 

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.[33] [34]  Increasing capacity in the home care sector is not an easy task.

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 enhanced social welfare payments for people who lose their or suffer 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. 

Home care workers listed as essential workers

On 27^th March 2020, as 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, workers in the category of essential services were permitted to travel to and from work. Home care, home help and other community services were included among the list of essential workers.[35]

Reduction in home care hours and redeployment of home care staff to long-stay residential care sector 

The reduction in the provision of community-based home help hours is the most significant change that has taken place to date in the area of home care in response to COVID-19. A decision was taken by government to ‘stand down’ some home help hours, but it was stressed that this was only for people who are relatively well, and might have had a lower level of service, or have good family supports in place. The decision to temporarily cancel home help hours is related to public health measures of physical distancing and ‘cocooning’. It is also related to the circumstances in the long-stay residential care sector, which has been experiencing a rapid rise in the number of clusters of COVID-19, and staff shortages when the need for staff capacity is growing.  In these circumstances, the HSE is seeking to deploy home care workers from home care to the long-stay residential care sector.  These measures have been agreed with HCCI,[36] who reported that between 700 and 1,000 home care workers are expected to be redeployed to work in nursing homes under the agreement. Information on how many people are affected by this decision is not available. People affected are advised to contact the local public health nurse if they have concerns about the changes. This measure will undoubtedly have implications for home care – for people in receipt of home care, and their family carers, home care workers, and home care providers.

Community Call Initiative

Community Call is a governmental national volunteering initiative announced on the 2^nd April 2020, as part of the Government Action Plan to Support the Community Response. Community Call links national and local government with the voluntary and community sectors to respond to COVID-19. Its aim is to coordinate community activity and direct it to where it is needed. It also aims to organise the large number of volunteers who have come forward to assist in their community during COVID-19.  Community Call will take place in every country in Ireland. Its activities will in the first instance be focused on providing practical support to older people and other ‘vulnerable’ people.

The Initiative is to be overseen at both national and local levels. At national level, a group has been established from the Department of The Taoiseach, the Department of Housing, Planning and Local Government, the Department of Rural and Community Development, and the County and City Management Association.  It will be overseen and managed locally by the Local Authorities, led by the County Chief Executives, who are the most senior public official in every county. They have been tasked with leading a dedicated community Forum, comprising an extensive range of state and voluntary organisations, in each county to coordinate and connect the wide range of services and support available in the area. 

A €2.5m fund has been launched to support community and voluntary organisations involved in the initiative. The fund will be administered by local authorities, to whom community and voluntary organisations can apply for funding. Priority is to be given to organisations that incur costs on direct delivery of frontline services to people, such as Meals on Wheels and other similar activities. 

Evidence from TILDA to assist with planning for COVID-19

To assist with planning for COVID-19, data from the 2018 wave of The Irish Longitudinal Study on Ageing (TILDA) has been analysed and a series of reports have been produced. The analysis has been undertaken to identify numbers in at-risk cohorts based on extant international data for a range of at-risk groups. The TILDA sampling frame does not include people living in nursing homes. People with dementia were not included in the TILDA sampling frame at baseline. Accordingly, the figures are likely to be an underestimate.

In its first overall report, TILDA analysed data to provide an overall estimate of the utilisation of home care services. The estimated number of people aged 50 years and older utilising home care services, publicly and/or privately funded is 62,100, the majority of whom are frail.[37]

The Irish government have been criticised for reducing all ‘over 70s’ in the public imagination to ‘vulnerable people’. 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.[38]

A summary of the findings from subsequent publications from TLDA reporting on further analysis to inform planning for COVID-19 will be provided in the next update report. The Irish Gerontological Society[39] has also written on the importance of support for older people at this difficult time.

4.5. Measures  for people with dementia

Over the past 10 years, community- and group-based services, interventions and activities have greatly expanded in Ireland, from a very low base, to provide a greater range of services and supports that are more personalised to the needs of people with dementia and their family carers. In addition to more traditional day care services and residential respite, there are also social clubs, a network of Alzheimer Cafés (although one Café continues to meet virtually), choirs, dancing, art gallery and museum programmes, cognitive stimulation therapy, memory rehabilitation, family carer training and education, and peer-support groups. Memory Technology Resource Rooms (MTRRs) have been established across Ireland to provide people with dementia with information and advice about assistive technologies and strategies to promote independence, safety and quality of life. None of these services and supports are available for people with dementia and/or their family carers to attend in person during COVID-19. 

Drawing on feedback from a range of sources including people with dementia, family carers, Dementia Advisers, and the National Helpline, the ASI has identified a range of issues affecting people with dementia and their family carers as a result of COVID-19.[40] People with dementia reported experiencing loneliness and social isolation as a result of being housebound and having to withdraw from social activities. Boredom and lack of routine were also reported, as well as anxiety and fears.  Family carers reported difficulties motivating people with dementia, increased levels of responsive behaviours, increased caregiving demands, greater levels of stress, and little or no support, as well as anxiety and fear about the uncertainty and unknown, especially the worry about what would happen if they themselves were to become ill. People with dementia left alone at home during the day was also a concern for family carers. Increases in responsive behaviours were also reported by Dementia Advisers. People with dementia and family carers identified the need for practical and emotional supports.

While the Alzheimer Society of Ireland can no longer offer its dementia-specific day care services, residential respite, social clubs, family carer support groups, Alzheimer Cafes (although one Café continues to meet virtually), and face-to-face family carer training during COVID-19, it is continuing to support people with dementia and their families through its National Helpline. Its online family carer training is still running. Dementia Advisers are available to work with and provide information to people with dementia and their family carers. Home care provided to people with dementia and their family carers by the ASI also continues to be provided. The ASI also provides tip sheets to help support people with dementia and their families during COVID-19 and lists supports available from organisations in Ireland during COVID-19.[41]

The Dementia Services Information and Development Centre, Ireland’s national centre for excellence in dementia, has responded by developing a collection of resources to support family carers and mitigate the impact of social isolation on people with dementia.[42] A selection of meaningful activities for people with dementia, families and carers has been compiled into a booklet by an occupational therapist attached to a Memory Technology Resource Room (MTRR). 

The Irish Centre for Social Gerontology at NUI Galway has commented on ways to combat social exclusion for older people during the COVID-19 pandemic, emphasising the continued importance of  rationing on the basis of need  at this time.[43] The Centre for Economic and Social Research on Dementia (CESRD) at NUI Galway has also written on the importance of supporting people with dementia during the crisis (HRB Open Research 2020).

5. Key lessons and messages from Ireland

Below are some of the key tentative messages/lessons to date from Ireland in relation to both nursing homes and home care

5.1. Nursing homes

• Nursing homes should be prioritised early on in public health emergency planning
• Emergency planners need to engage with and establish communication lines with nursing home providers, the nursing home workforce, their representative organisations, and organisations advocating on behalf of residents
• Guidance on infection prevention and control needs to be tailored to nursing homes, and nursing home providers and their staff need support to understand and apply guidance in individual nursing home settings
• Nursing home providers and staff need access to specialists to advise on preparing for and managing a COVID-19 outbreak, and answer specific queries
• Nursing home staff and residents should be a priority group for COVID-19 testing 
• Nursing homes and their staff need access to, and guidance and training on how to use PPE
• Nursing home staff should be considered as part of the health care system
• All nursing home staff similarly at risk, irrespective of their job title or employer should be considered in emergency planning decision-making
• The movements of nursing home staff needs to be carefully considered, given that nursing homes staff may be sharing accommodation with each other; working across different care settings; living in overcrowded accommodation; combining formal (paid) caring in a residential care setting with informal caring for school-going children and/or a child or adult with care needs 
• Contingency planning is needed for staffing shortages in nursing homes sector due to illness, self-isolation, voluntary withdrawal from work

5.2. Home care

The literature on emergency planning and the home care sector is limited. However, 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 in emergency planning decision-making
• The income of home care workers should be protected in the event of them not being able to continue in their jobs.
• Any redistribution of home care workers into residential care should be carefully considered in terms of its impact on their community clients and family carers
• 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

Suggested citation:

Pierce M (2020) The impact of COVID-19 on people who use and provide Long-Term Care in Ireland and mitigating measures. Country report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 14^th April 2020.

---

[1] Pierse, T., O’Shea. And Carney, P. (2017) Estimates of the prevalence, incidence and severity of dementia in Ireland, Irish Journal of Psychological Medicine, 36, 129–137.

[2] Pierce, M., Cahill, S., and Carney, P. (2017) ‘Informal Caregiving to People with Dementia’ in O’Shea, E., Cahill, S. and Pierce, M. (eds.) Developing and Implementing Dementia Policy in Ireland, Galway: National University of Ireland Galway.

[3] https://www.hiqa.ie/areas-we-work/older-peoples-services

[4] Pierce, M. and Pierse, T. (2017) ‘Prevalence of dementia’ in O’Shea, E., Cahill, S. and Pierce, M. (eds.) Developing and Implementing Dementia Policy in Ireland, Galway: National University of Ireland Galway.

[5] Pierce, M., Duffy, M. and Kilcullen, S. (2018) The Situation of Younger People with Disabilities living in Nursing Homes in Ireland, Dublin: Disability Federation of Ireland. 

[6] O’Brien, I., Smuts, K., Fan, C.W., O’Sullivan, M. and Warters, A. (2017) “High prevalence of cognitive impairment among community dwelling older adults in receipt of state funded home care packages: implications for health care planning,” Irish Journal of Psychological Medicine.

[7] https://www.gov.ie/en/publication/47b727-government-publishes-national-action-plan-on-covid-19/

[8] https://www.gov.ie/en/publication/a02c5a-what-is-happening/#ethical-framework-for-decision-making-in-a-pandemic

[9]  https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/vulnerablegroupsguidance/COVID-19%20Guidance%20for%20extremely%20medically%20vulnerable%20V1.pd

[10] https://nhi.ie/covid-19-coronavirus-nursing-home-care/

[11] https://nhi.ie/comfort-words-initiative-launched-to-bond-children-and-nursing-home-residents-during-covid-19/

[12] https://www.gov.ie/en/publication/55da55-daily-briefing-on-the-governments-response-to-covid-19-wednesday-1st/#testing-concerns

[13] https://www.hiqa.ie/hiqa-news-updates/regulatory-response-hiqa-and-chief-inspector-social-services-covid-19

[14] https://www.hiqa.ie/hiqa-news-updates/regulatory-response-hiqa-and-chief-inspector-social-services-covid-19-2

[15] https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/oncall/

[16] https://nhi.ie/recruitment-drive-launched-by-nursing-homes-ireland/

[17] https://www.hiqa.ie/hiqa-news-updates/regulatory-response-hiqa-and-chief-inspector-social-services-covid-19-3

[18] https://www.gov.ie/en/publication/ce3fe8-previous-updates-on-covid-19-coronavirus/

[19] https://nhi.ie/government-needs-to-urgently-meet-nursing-homes-sector/

[20] https://www.gov.ie/en/publication/6973bc-daily-briefing-on-the-governments-response-to-covid-19-monday-30-mar/

[21] https://www.irishtimes.com/news/health/people-in-residential-care-with-covid-19-should-be-kept-in-homes-crisis-team-says-1.4218071

[22] https://hcci.ie/news/

[23] https://www.gov.ie/en/news/228125-minister-for-health-announces-enhanced-measures-to-support-nursing-h/

[24] https://www.gov.ie/en/news/228125-minister-for-health-announces-enhanced-measures-to-support-nursing-h/

[25] https://nhi.ie/nhi-statement-re-measures-to-support-nursing-home-residents-in-response-to-covid-19/

[26] There are 17 local Nursing Home Support Offices in Ireland.

[27] https://www.hiqa.ie/hiqa-news-updates/hiqa-launches-new-covid-19-support-service-residential-social-care-sector

[28] https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/webinarresourcesforipc/

[29] https://www.irishgerontology.com/news/latest-news/announcement-covid-19-webinars-nursing-homes

[30] https://www.hpsc.ie/az/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/V1.0-Guidance-HealthSocialCareWorkersWhoVisitHomes.pdf

[31] https://hcci.ie/hcci-covid-19-national-action-plan/

[32] 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.

[33] 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.

[34] 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.

[35] https://www.gov.ie/en/publication/dfeb8f-list-of-essential-service-providers-under-new-public-health-guidelin/#human-health-and-social-work-activities

[36] https://hcci.ie/news/

[37] Kenny et al., 2020 https://tilda.tcd.ie/publications/reports/pdf/Report_DemographicsOver50s.pdf

[38] https://tilda.tcd.ie/publications/reports/pdf/Report_Over70sContribution.pdf

[39] https://www.irishgerontology.com/news/latest-news/principles-covid-world

[40] https://alzheimer.ie/creating-change/awareness-raising/dementia-in-the-media/

[41] https://alzheimer.ie/about-us/coronavirus-covid-19-update/

[42] http://dementia.ie/news-events/news/helpful-resources-that-may-help-with-social-isolation-during-covid-19

[43] https://www.nuigalway.ie/opinion/combatting-exclusions-and-ageism-for-older-people-during-the-covid-19-pandemic.html