Nina Hemmings, Jorge Browne Salas, Siang Jye Chern, Adelina Comas-Herrera, Gemma Drou Roget, Stefanie Ettelt, Maria-Aurora Fenech, Cleusa P. Ferri, Paulo José Fortes Villas Boas, Manuela Hödl, Roxanne Jacobs, Ngaire Kerse, Florien Kruse, Shoshana Lauter, Kai Leichsenring, Klara Lorenz-Dant, Lee-Fay Low, Terry Lum, Joanna Marczak, Christine Musyimi, Elisabetta Notarnicola, Déborah Oliveira, Camille Oung, Alenka Oven, Eleonora Perobelli, Maria Pierce, Tan Maw Pin, Tara Puspitarini Sani, Andrea Schmidt, Marguerite Schneider, Joyce Siette, Cheng Shi, Heidemarie Staflinger, Marta Szebehely, Maree Todd, Lisa Van Tol, Patrick Alexander Wachholz, Petr Wija, Yida Ying, Jessica Yu
(please see below for author affiliations, acknowledgements and suggested citation).
About this series:
This is the second of a new series of international overviews that aims to provide concise and timely information on current long-term care policies and practices in relation to Covid-19. The first one was on mandatory vaccination for staff and was published in May
These overviews are generated by sending a question to a list of experts in long-term care who have volunteered through the LTCcovid initiative. If you would like to be part of the list of experts or would like to suggest a question for the next issues, please email email@example.com.
This post provides an overview of the situation in late July/early August 2021 in 23 countries. The information has been provided by national experts in long-term care through the LTCcovid collaboration.
We previously reported on the common practice of completely banning long-term care visitors in response to COVID-19 outbreaks, as well as the evidence of negative impacts on residents and family of restrictions. This paper summarises the range of visitor policies and in place in different jurisdictions as countries strive to allow visitors while minimising risk of COVID-19 infections.
What is the current situation in relation to “visiting” in care homes in your countries (and also in relation to care home residents going out?
Australia is almost ‘back to normal’ in terms of social distancing requirements, except during outbreaks and lockdowns (which by Australia’s definition means almost any case of Covid-19 with incidence of community transmission). During lockdowns, there are restrictions on visitors. In early August 2021, New South Wales (Greater Sydney and some parts of regional NSW), Victoria, and South East Queensland (Brisbane) are in short lockdowns due to the Delta variant outbreak. In Greater Sydney all visitors are excluded, except those providing essential caring functions and end of life visits, and masks need to be worn). Guidance is state/territory specific, with visitors still having to follow Covid-19 precautions, prohibiting those with Covid-19 symptoms or those who have recently returned from international travel.
Prior to the most recent lockdown, in NSW, Greater Sydney, all essential visits took place in residents’ rooms, with residents being provided with appropriate PPE and infection control advice if they needed to leave the facility for essential purposes. However, guidance now states that no visitors or non-essential staff are permitted, and residents should avoid leaving the facility, except for essential reasons. For all other facilities located in NSW, only two visitors are allowed each day and visits should take place in the residents’ rooms or another suitable location in the facility. Furthermore, according to guidance in NSW, from June 1 to September 30, 2021, visitors should not enter aged care facilities if they have not received a dose of the 2021 influenza vaccine, unless they meet the criteria under the exceptional and special circumstances.
In Victoria during the lockdown visitors are limited to 2 people and masks are mandatory. Previously there were no restrictions to number of visitors.
In South East Queensland, except for end of life care, no visitors are allowed. Residents are not allowed to leave except for healthcare, emergency or compassionate reasons.
In Western Australia, visitors must wear a mask, with two and four visitors allowed per resident per day respectively. In some states/territories, such as Australian Capital Territory, Northern Territory, and South Australia, care home visits are ‘back to normal’, with no restrictions to visitors. In Queensland the flu vaccine is required for visitors after May 31, 2021, whereas in Tasmania this is only strongly recommended.
As of May 10, 2021, new legislation sets out provisions regarding opening from lockdown. A maximum of three visitors a day are allowed for nursing home residents. However, these restrictions do not apply for visits in the context of palliative and hospice care, pastoral care, and for accompaniment during critical life events. In addition, a maximum of two persons per resident in need of support may be admitted if they provide regular support and care tasks. Visitors must present proof of low epidemiological risk, such as evidence of a negative result of a SARS-CoV-2 antigen or molecular test, medical conformation of an infection with SARS-CoV-2 survived in the last six months, or proof of vaccination against Covid-19. Visitors must wear a mask of protection class FFP2 without an exhalation valve, unless there is a suitable protective device for spatial separation that ensures the same level of protection. The same rules apply for the admission of external service providers and patient advocates. Residents shall be offered a SARS-CoV-2 antigen or molecular test at least every week, or at least every three days if they have recently left the nursing home. There are no specific provisions in this legislation regarding outings for residents.
Since the beginning of the pandemic, the country has never adopted structured national mitigation policies for Covid-19, including adopting lockdowns, even during periods of greater lethality, associated with the collapse of public and private health systems.
The technical note No. 25/2020 (January 2021), issued by the Ministry of Health, recommended that family members only visit older residents when essential, maintaining the suspension of visits for the duration of the national public health emergency, a recommendation that was already issued by the Brazilian Society of Geriatrics and Gerontology and the ‘Frente Nacional de Fortalecimento à ILPI’ since March 2020. In April 2021, this was updated, allowing short visits to occur in ventilated common areas, using face masks, maintaining a safe distance, and other protective measures.
After significant reductions in the rates of new cases, hospitalizations, and deaths among residents of LTCF, some regions issued local policies regarding visiting and outings (e.g., the State of Ceará, cities of State of São Paulo and Belo Horizonte). Most of these recommendations suggest the adoption of plans to ease the visits and outings of residents progressively. They take into account the epidemiology of the infection in the community, the local hospital capacity, the level of vaccination of residents and workers, the physical infrastructure of the facilities, and the supplies of personal protective equipment and access to laboratory testing. During outbreaks and up to 14 days after a positive test of at least one resident, outings and visits are suspended, except for compassionate visits. In the phases of greater flexibility, exits considered essential (such as medical appointments) with return on the same day may dismiss laboratory testing or isolation. For outings lasting longer than 72 hours, most recommendations suggest the need for isolation for ten days and/or laboratory testing with Qt-PCR/antigen assays. Some guidance provided authorization for people’s entry to carry out academic and research activities and volunteer work, under local prerequisites. There is no national standardisation of protocols for outings for residents yet. The National Front suggests a plan with colours (red, orange, yellow and green) to guide an opening and progressive visit of the LTC facilities.
Canada (British Columbia)
Visitor guidance for long-term care published March 30, 2021, stated that up to two adults and one child can visit a resident indoors without staff present, which may be increased when outdoors depending on current provincial guidelines. There are no restrictions on the frequency and duration of visits, with physical touching allowed as long as masks are worn. Residents may leave nursing homes for non-essential reasons and are not required to isolate upon return.
Both enabling visiting in care homes and outings for residents are regulated in “plan paso a paso” (step by step). This regulates the number of personal visits and outings allowed based on the epidemiological status of each community. For “Fase 2” (step 2), the second step after lockdown, personal visits and outings are permitted. Isolation is not required following these activities.
Currently, nursing homes are open to visitors with a prior reservation. When entering a nursing home, taking a temperature check, and showing a green ‘health code’ are required. The Health code is a QR code assigned by a color-coded system to each citizen according to their personal epidemiological status, which is related to their Covid-19 test results and whether they have visited non-low risk areas or have been in contact with infected persons recently. The same regulations are in place for staff who are working there. Voluntary activities are restricted in most areas, which depend on the specific regulations in each nursing home.
Visits in care homes are allowed, with guidance stating that visitors are obliged to pass an antigen test, unless they have been vaccinated, have recovered from Covid-19 in the last 90 days before the visit, or have had a negative PCR test in the last two days. Regarding outings for residents, recently the Deputy Ombudsman (“Public Defender of Rights”) asked the Minister of Health “to immediately lift the restrictions on the outing of clients of homes for the elderly and homes with special regimes. An extraordinary measure of the Ministry allows them to leave the facility only if they undergo two antigenic tests and subsequent isolation for several days. It is not possible to accept restrictions on these people in their fundamental rights”. Further conditions attached to outings for residents are specified in the same ‘extraordinary measure’.
Guidance states that care home residents can ‘named visitors’ who can enter the care home for regular visits, there is no limit on the number of ‘named visitors’ and no national limit on the number of visitors per day. Every care home resident can nominate an ‘essential care giver’ who may visit the care home in all circumstances, including if the care home is in an outbreak, except if the care giver or the resident are COVID-positive.
Visitors are tested with lateral flow tests, must wear PPE, maintain social distancing, and keep contact to a minimum (except for essential care givers). Guidance has recently changed so that care home residents are no longer required to quarantine for two weeks after making trips out of the care home, except in instances where the risk of infection cannot be sufficiently mitigated.
From May 19, 2021, visiting restrictions have been further relaxed as a result of increasing vaccine coverage among older people. The most recent protocol refers to the individual rights of social care users which are enshrined in law, including freedoms to see family and to “come and go”. On this basis visits to care homes (and other social care settings) must be guaranteed, transparent information must be given to residents and their families to allow them to make informed decisions. Non-vaccinated visitors must be regularly tested upon entry, except where vaccinated, and staff must be tested after return from leave and after risky situations.
Visitors are unable to visit residents that have tested positive or that have been identified through contact tracing, except during end of life treatment or if they are ‘slipping away’. Social distancing, hand hygiene, and surgical mask wearing must be maintained at all times among staff, residents, and visitors, regardless of vaccine status. Residents undertaking outings must wear a surgical mask and be offered a PCR test upon return (although they are not obliged to take it), and as far as possible they must limit their contact with other residents. Isolation of these residents upon return is not allowed.
Any changes to measures must follow a consultation with the care home’s ‘social council’ (made up of elected representatives of residents, families, and staff) and clear communications to residents and their families. Restricting the movement in and out of care homes and other long-term care settings must be the final resort.
Visiting in care homes is allowed for individuals with prior reservation who are able to show a negative test result, which has been undertaken within the last three days. For family members who have had more than two weeks since being vaccinated, they can use the result of a self-administered Covid-19 test, instead of a standard lab test result.
The Directorate of Social Rehabilitation for People with Disability under the Ministry of Social Affairs issued guideline on health protection and psychosocial support for persons with disabilities during Covid-19 outbreaks in institutional care. In this document, it was mentioned that if visitations cannot take place, interactions through video calls are encouraged. In December 2020, the Ministry of Social Affairs released a report based on a study of several long-term care facilities in Indonesia. This report found that in general most facilities banned or limited visits, including from family members. Several implemented a ban on residents leaving the facilities. In some cases, residents returned to their family home based on advice from their facility to reduce the risk of them getting Covid-19. In general, the central government managed facilities had more resources to make these adjustments, whereas the private facilities were the ones that were struggling, because they largely rely on donations. The bans on visits impacted the mental health of the residents, reporting loneliness as a result.
In May 2021, the Ministry of Health signed a new resolution that re-opened nursing homes to those relatives holding a “green certification”. After July 1, visitors need the European Green Pass, the national pass that asserts that the person either has been vaccinated, has already contracted and recovered from Covid-19 in the past, or has received a negative Covid-19 test within the previous 48 hours. Additionally, the resolution from May contains guidance on the procedures for residents going back to their houses.
In most countries in the Global North, visitor bans were implemented to help curb the spread of Covid-19. Unfortunately, the bans are likely to have caused an increase in staff workload, stress, and burn out because unpaid family members often provide essential care (bathing, dressing, feeding and toileting) within care homes (Low et al., 2021). Currently in Kenya, visiting care homes is highly discouraged, especially for individuals who have not undergone Covid-19 testing. The purpose of this guidance is to limit the exposure for residents. Covid-19 cases within care homes are quarantined in a well-ventilated room with a washroom (Musyimi, Mutunga, & Ndetei, 2020). The Ministry of Health has provided guidelines to manage visitors for those in isolation due to suspected or confirmed Covid-19 infection. Visitors are limited to those providing care and support to those in isolation, with visitors having to wear masks and practice hand hygiene when they leave the isolation centre. Additionally, effort should be made to reduce the frequency of movement in and out of the isolation facility (Ministry of Health, 2020).
The country is under its third lockdown. Intensive care units are full for the first time ever. The only visitors to care homes at the moment are the vaccination teams. No other visitors are allowed. There are currently no plans to revise the ‘no visitor’ policy in Malaysian care homes.
All older persons who had wished to avail themselves of the vaccine have to date done so. This process was completed way back in March. However, older persons are still not allowed outside the care homes. Older persons have been confined in their respective care homes, at times also confined in their own rooms only, since March 2020.
With respect to visiting in care homes, (1) visits are currently allowed for 25 minutes 3x per week where 2 members of the same household are allowed time with the older person, (2) for older persons living with dementia, they will be allowed 15-minute visits every day with 2 members of the same household (3) for both instances, visits take place either behind Perspex or at a safe 2m distance within the care home’s common area as visitors are not allowed in the older person’s room.
Moreover, the Minister responsible for the older persons has indicated that vaccinated individuals will be given priority to visit their loved ones, when the care homes open ‘properly’ in the coming months.
As of April 2021, the Dutch government ended their centralised visiting policies for the nursing home sector. Individual homes now have discretionary space to set their own rules. Several guidelines support the nursing home providers in this process. Basic rules such as social distancing and using face masks still apply. Before April 2021, government guidance stated that if 80% of nursing home residents have been fully vaccinated, then a resident can receive a maximum of two visitors per day. And if less than 80% of residents have been fully vaccinated, then a resident can receive a maximum of one visitor per day.
In New Zealand visiting is allowed, some facilities have instituted visiting hours, but there is no restriction on either visitors or residents going out of the homes on outings or to stay away. Visiting restrictions are dependent on the alert level.
In response to the national situation, visiting guidelines are regularly updated. Because recently there was a small surge of cases in the community, guidelines were adjusted and updated, lowering the number of visitors that a resident can receive from two to one per day. Outings are not permitted for residents following an inpatient hospital stay. There is currently no mandate for visitors to be vaccinated.
Visits will take place in the premises of the centre for all residents, mostly from 09:00 to 18:00. One or two healthy people are allowed to visit together. The body temperature of the visitors is measured upon arrival. They must also sign a statement that they will follow the stated rules, that they have not been in contact with a Covid-19 infected person in the last 14 days, and that they will follow all instructions of competent institutions during the epidemic.
Visits are carried out outside or in the common areas of the home on the ground floor or at the reception. For the departure of residents to a home environment, they can talk individually with social services. At the time of the departure of the resident, the relatives are obliged to ensure that all preventive measures are strictly observed. At the same time, it is recommended that the resident does not come into contact with a large number of people in a home environment. In accordance with the recommendations of the medical profession, the essential preventive measures include limiting contact to a small number of people, maintaining appropriate distance, wearing a mask, and ventilation of the premises.
The country is currently at level 1 restriction, which eases restrictions on movements. Residents are allowed to receive visitors, whilst maintaining Covid-19 safety protocols. Visits are undertaken in controlled isolated areas, mostly indoors, with no hugging allowed. If residents go home to their family, they are expected to isolate for ten days upon return. The extent to which care homes have ‘opened up’ varies from facility to facility. There is renewed fear of a third wave of Covid-19 infections, due to a 39% increase in cases over the last week, which would bring with it stricter controls on movement, especially in care homes.
Care home residents are currently able to receive visitors and are able to themselves go on outings, always with appropriate protective measures. Before vaccination, visits were restricted. However, following vaccination there have been efforts to recover normal visitation schedules that have not been observed since before the pandemic. Both short and long outings are allowed.
It has never been forbidden for care home residents to leave their care home, and from December 2020, a care home or a municipality cannot decide on imposing visitor restrictions visitors on their own. Instead, if there is a local outbreak, a care home that wants to restrict visitors has to prove that they have done what they can to arrange safe visits, and only thereafter can they ask for temporary permission from the national public health authority to restrict visitors. At the moment one municipality has restrictions.
During the first wave some nursing homes and care homes for older people took the radical step of shielding their residents entirely by not letting them see visitors or leave the home. This was strongly condemned by many stakeholders, especially the families of residents, residents themselves, and human rights advocates, who emphasised that people’s health and wellbeing should be regarded holistically and included people’s mental health and social wellbeing.
In Switzerland, canton governments have authority to devise visiting policies in care homes and some have delegated decisions about visiting policies to care homes. The Canton of Berne, for example, has since advised against any blanket bans on visiting. Individuals or groups of residents may be obliged to isolate or quarantine if there is a known infection, although it is always possible for relatives to stay if their relative is dying. Care homes also limit the number of visitors per day or make provisions for families and friends to meet outdoors or in larger spaces to reduce the risk of infection.
Contributors and affiliations:
Nina Hemmings (Nuffield Trust, UK)
Jorge Browne Salas (Facultad de Medicina, Pontificia Universidad Católica de Chile)
Adelina Comas-Herrera (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)
Gemma Drou Roget (Department of Public Health and Epidemiology, UManresa, Universitat de Vic Spain)
Stefanie Ettelt (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)
Maria-Aurora Fenech (L-Unviersita ta Malta)
Cleusa P. Ferri (Universidade Federal de São Paulo, Department of Psychiatry, Escola Paulista de Medicina – Unifesp, Brazil)
Paulo José Fortes Villas Boas (Botucatu Medical School, São Paulo State University – Unesp, Brazil)
Manuela Hödl (Institut für Pflegewissenschaft, Medical University of Graz, Austria)
Amy Hsu (Bruyère Research Institute, University of Ottawa, Canada)
Roxanne Jacobs (University of Cape Town, South Africa)
Ngaire Kerse (Department of General Practice and Primary Health Care, University of Auckland)
Florien Kruse (Radboud University Medical Center, Netherland)
Shoshana Lauter (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)
Kai Leichsenring (European Centre for Social Welfare Policy and Research, Austria)
Karla Giacomin (Center for Studies in Public Health and Aging – NESPE, Fiocruz Minas)
Klara Lorenz-Dant (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)
Lee-Fay Low (University of Sydney, Australia)
Terry Lum (Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China)
Joanna Marczak (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)
Christine Musyimi (Africa Mental Health Research and Training Foundation, Kenya)
Elisabetta Notarnicola (CERGAS – SDA Bocconi School of Management, Italy)
Déborah Oliveira (Universidade Federal de São Paulo, Department of Psychiatry, Escola Paulista de Medicina – Unifesp, Brazil and Inter-American Development Bank)
Camille Oung (Nuffield Trust, UK)
Alenka Oven (Slovenia)
Eleonora Perobelli (CERGAS – SDA Bocconi School of Management, Italy)
Maria Pierce (Independent consultant, Ireland)
Tan Maw Pin (University of Malaya, Malaysia)
Tara Puspitarini Sani (Atma Jaya University, Indonesia)
Andrea Schmidt (Austrian National Institute of Public Health, Austria)
Marguerite Schneider (University of Cape Town, South Africa)
Cheng Shi (Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China)
Joyce Siette (Macquarie University, Australia)
Heidemarie Staflinger (Chamber of Labour for Upper Austria)
Marta Szebehely (Department of Social Work, Stockholm University, Sweden)
Maree Todd (Auckland District Health Board)
Lisa Van Tol (Leiden University Medical Center, Netherlands)
Patrick Alexander Wachholz (Botucatu Medical School, São Paulo State University – Unesp, Brazil)
Petr Wija (Institute for Social Policy and Research, Czech Republic)
Yida Ying (Active Global Home & Community Care, China)
Jessica Yu (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)
This overview has been edited by Lee-Fay Low, William Byrd and Adelina Comas-Herrera. WB and AC-Hare supported by the Social Care COVID Recovery and Resilience Project (funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333)). The views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care).
Current situation in relation to “visiting” in care homes and outings for residents in 23 countries as of July/August 2021. LTCcovid international overviews of long-term care policies and practices in relation to Covid-19 (Issue 2, August 2021).