Safe visiting at care homes during COVID-19: A review of international guidelines and emerging practices during the COVID-19 pandemic

Lee-Fay Low¹, Kathryn Hinsliff-Smith², Samir Sinha^3,4, Nathan Stall^3,4, Hilde Verbeek⁵, Joyce Siette⁶, Briony Dow⁷, Ramona Backhaus⁵, Reena Devi⁸, Karen Spilsbury⁸, Jayne Brown², Alys Griffiths⁹, Christian Bergman¹⁰, Adelina Comas-Herrera¹¹

This report seeks to produce evidence-based recommendations to inform care homes and government policies on visiting in care homes during this and future pandemics. It includes a narrative review of international policy and practices relating to visitors to care homes during the COVID-19 pandemic and the impact of restrictions on residents, caregivers and staff, as well as illustrative case studies. At time of writing, ten months into the COVID-19 pandemic, many countries are experiencing increases in infections termed ‘second waves’ and ‘third waves’, care homes continue to have COVID-19 outbreaks and visitor bans have been re-instated in some regions. Care home residents and staff are being prioritised for COVID-19 vaccination, however, reducing risk of COVID-19 infection for residents will continue to be an important public health issue.

The full report is available here:

Key findings:

•            In response to rising community transmission of COVID-19 and a growing number of care home outbreaks with rapid spread and high mortality, governments and care homes across the world enacted blanket bans on visitors early in the pandemic.

•            Accumulating evidence shows that visitor bans severely negatively impacted the mood and behaviour of residents resulting in a significant increase in psychotropic medication use. Evidence also suggests that bans increased feelings of guilt, fear, worry and isolation in residents’ families.

•            Visitor bans likely contributed to reported increases in staff workload, stress and burnout. Many regular family visitors who were providing unpaid, essential care to care home residents before the pandemic were now unable to. Additionally, managing safe visits takes additional time and resources.

•            When care homes were allowed by governments to reopen to visitors, there was variability in the level of COVID-19 community transmission at reopening and safe visiting requirements (e.g. indoor or outdoor visits, frequency, number of visitors allowed). The responsibility for safe reopening was usually placed on care homes, with authorities not always providing support around implementation of safe visiting procedures (e.g. provision of additional personal protective equipment (PPE), availability and speed of testing).

•            With the exception of the Netherlands, countries have not mandated that care homes reopen to visitors.

•            Some visitor guidelines distinguish between general visitors who visit primarily for social reasons and family caregivers who undertake essential unpaid caregiving tasks; guidelines designated that ‘family caregivers’ may be allowed to visit when general social visitors are not, permitted more frequent and/or longer visits and may be able to provide hands-on care.

•            Minimal research has been conducted on visitor-introduced transmission, however, the available data suggests reopening care homes to visitors and family caregivers using safe visiting practices does not lead to COVID-19 infections when community transmission levels are low. There is a small increased risk of COVID-19 entering a home, particularly when community transmission levels are higher, and safe visiting practices are not followed.

•            Governments allowed care homes to reopen to visitors in when there was a large range in local levels of community transmission, there is no consensus on how low community transmission needs to be for safe visiting.

•            Safe visiting practices include: conducting outdoor visits where possible, indoor visits should be in well ventilated separate areas, infection control procedures should be followed (hand hygiene, wearing of masks, cleaning), visits should be booked ahead, visitors are screened on entry, limiting the number, frequency and length of visits, and visits supervised by staff.

Recommendations:

1. Blanket visitor and family caregiver bans should not be used to prevent COVID-19 infections in care homes
2. Safe on-site visiting practices should be used, with options chosen based on local levels of community transmission and in discussion with residents, families and staff and health authorities
3. ‘Family caregivers’ should be designated as essential partners in a resident’s care during the pandemic and be able to have more frequent, longer hands-on visits if they can be supported to do so safely
4. Care homes should receive additional government funding and support to implement safe visiting practices
5. Regulators should be ensuring that care homes meet residents’ rights to have visitors and that safe visiting practices are being used

To cite this report please use:

Low L-F, Hinsliff-Smith K, Sinha S, Stall N, Verbeek H, Siette J, Dow B, Backhaus R, Devi R, Spilsbury K, Brown J, Griffiths C, Bergman C, Comas- Herrera A (2021)  Safe visiting at care homes during COVID-19: A review of international guidelines and emerging practices during the COVID-19 pandemic. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 19th January 2021.

Authors affiliations:

¹University of Sydney, ²De Montfort University, ³National Institute on Ageing, Ryerson University, ⁴Department of Medicine, University of Toronto, ⁵Maastricht University, ⁶Macquarie University, ⁷National Ageing Research Institute, ⁸University of Leeds, ⁹Leeds Beckett University, ¹⁰Virginia Commonwealth University, ¹¹London School of Economics and Political Science