Lee-Fay Low, Cameron Feil, Natalie Iciaszczyk, Samir Sinha, Hilde Verbeek, Ramona Backhaus, Frode Fadnes Jacobsen, Þórdís Hulda Tómasdóttir, Liat Ayalon, Josie Dixon, Adelina Comas-Herrera

Members of LTCcovid, led by Lee-Fay Low, have joined forces with the UK’s International Public Policy Observatory to produce a policy note is to inform care home visitor policies in the context of jurisdictions with high vaccination rates, minimal community physical distancing and social gathering restrictions, and potentially high COVID-19 community transmission rates. It includes detailed case studies from six countries:

• Australia
• Canada
• Iceland
• Israel
• Norway
• The Netherlands

The original report was published here on 25 November 2021 and is reproduced below.

Key recommendations for visitor policies in jurisdictions with high vaccination rates

The aim of this global scan is to inform care home visitor policies in jurisdictions with high vaccination rates, minimal community physical distancing and social gathering restrictions, and potentially high COVID-19 community transmission rates. It starts with key recommendations pulled together from analysis of the six countries in focus:

• Visitors should be subject to the same entry and screening requirements as care home staff. This may include: being fully vaccinated; not being a close contact of someone who recently tested positive for COVID-19 or who is having COVID-related symptoms’ use of personal protective equipment (unless this significantly interferes with the resident’s ability to recognise and interact with the visitor); and/or rapid antigen testing.
• Physical contact (e.g. hugging, kissing and holding hands) between residents and visitors should be permitted.
• If an outbreak occurs in a care home (i.e. transmission between staff and/or residents in the care home setting), pre-designated essential carers who have a history of routinely providing hands-on or emotional support to the residents should be permitted to continue visiting, even if casual social visitors are not allowed. These essential caregivers should be trained and supported to follow the same infection control procedures as care home staff, as part of the process of designating them as essential caregivers.
• In response to high local community transmission of COVID-19, the risk of outbreak should be reduced through more tailored visiting approaches, and by increasing screening and infection risk reduction procedures during visits.
• Vaccinations (including booster shots), infection prevention control and maintaining access to high-quality healthcare should be the key strategies employed to reduce COVID-19 mortality risk, not visitor and social outing restrictions.

Residents’ rights

• The rights of care home residents to receive visitors and participate in community-based activities should be recognised and upheld, and not be more restricted than that of community-dwelling people in the same jurisdiction.
• The views of residents or their proxy decision-makers should be taken into account when determining individual care home visitor policies.
• Agencies that accredit or monitor the standards of care in homes should investigate and report on whether the rights of residents to receive visitors are met.

Analysis of care home visitor policy strategies during COVID-19

1.Visitor and recreational outing bans led to negative outcomes for residents and families

There is consistent and increasing data demonstrating the negative impacts of COVID-19 care home visitor and recreational outing restrictions on the wellbeing of residents and their families and friends. Regular visitors routinely provide essential emotional and psychosocial support, and personal care including help with activities of daily living for residents (Gaugler, 2005).

At the start of the COVID-19 pandemic, a large proportion of COVID-related deaths across many jurisdictions occurred among care home residents. In response, governments introduced policies restricting or banning visitors from entering care homes, as well as visits where residents are permitted to leave the care home on recreational outings. Consequently, many residents experienced increased feelings of loneliness and a fundamental loss of their rights and freedoms. They experienced cognitive and physical decline, had increased behavioural disturbance, and were prescribed more psychotropic medications (Ayalon & Avidor, 2021; Kaelen et al., 2021; Lood, Haak, & Dahlin-Ivanoff, 2021; Suárez-González, Rajagopalan, Livingston, & Alladi, 2021; Van Maurik et al., 2020).

Families reported feeling severe stress, anxiety and fear for their loved ones, and poorer wellbeing – particularly if their loved one had cognitive impairment (O’Caoimh et al., 2020; Paananen, Rannikko, Harju, & Pirhonen, 2021; Wammes et al., 2020).

Staff reported being concerned for: the wellbeing of the residents they cared for and their increased workloads associated with managing pandemic-related restrictions; the worsening function, cognition and behaviours experienced by many residents; and the needs of families (Kim, Coffey, Morgan, & Roghmann, 2021; Krzyzaniak et al., 2021). When visitors and family caregivers were welcomed back into homes, this was reported to have benefits for residents, families and staff (Koopmans et al., 2021; Verbeek et al., 2020).

2. Care home residents’ rights to have visitors are increasingly recognised

The UN Convention on the Rights of Persons with Disabilities states that people have a right to family and relationships. It has been argued that it is a violation of care home residents’ rights to a family life when they are denied visitors (Joint Committee on Human Rights UK, 2021; Rights for Residents, 2021; Verbeek, Peisah, Lima, Rabheru, & Ayalon, 2021).

Other ethical considerations around visiting include: the importance of supporting resident autonomy; sustaining resident trust; minimising harm from social isolation and lack of stimulation; and ‘proportionality’ – i.e. responses should be proportional to the good that can be achieved and the harm that may be caused) (Hartigan, Kelleher, McCarthy & Cornally, 2021).

Some countries, including Italy and the Netherlands, introduced legislation during the pandemic concerning the rights of residents to have visitors (Bolcato et al., 2021; Verbeek et al., 2020). However, until now, the wishes of residents and their families have only minimally been taken into account by care homes when developing their visitor policies (Hartigan et al., 2021). Residents feel they have less power than management and staff (Ayalon & Avidor, 2021).

This has begun to be rectified. For instance, in Alberta, Canada, guidance now stipulates that indoor visits are supported in care homes if the majority of residents or their substitute decision-makers desire such visits (National Institute on Ageing, 2021). There are increasing calls for family and resident committees or councils to play a part in decision-making around care home operations (Hado & Friss Feinberg, 2020).

3. COVID-19 vaccination decreases the risk of spread, severe illness and mortality in care homes

Vaccination decreases the risk of infection, hospitalisation and mortality in care home residents. For example:

• In registry data, full vaccination effectiveness was 81.5% against infection and 93.1% against mortality among Norwegian care home residents (Starrfelt et al., 2021).
• In a Danish cohort of care home residents, full vaccination effectiveness was 64% against infection (Moustsen-Helms et al., 2021).
• In English care homes between Dec 2020 and March 2021, residents who had been at least partially vaccinated had a between 32%-to-44% lower risk of infection compared with non-vaccinated residents, depending on the type of vaccine and time since vaccination (Shrotri et al., 2021).
• In Catalonia, Spain, between Dec 2020 and May 2021, double-vaccinated care home residents had only 9% the risk of infection, 5% the risk of hospitalisation and 3% the risk of mortality compared with non-vaccinated residents (Cabezas et al., 2021).
• In Los Angeles, California, between May and July 2021, infection and hospitalisation rates were 4.9 and 29.2 times higher in unvaccinated persons compared with those who had been fully vaccinated  (Griffin et al., 2021).

However, predominantly because of pre-existing co-morbidities, vaccinated care home residents still have 4.1 times the risk of dying from COVID-19 compared to vaccinated older people not in care homes (Hippisley-Cox et al., 2021).

Vaccine effectiveness appears to vary by COVID variant. American data suggests that being fully vaccinated provided 74.7% effectiveness against infection between March-May 21, which declined significantly to 53.1% effectiveness in June–July 2021 when the B.1.617.2 (Delta) variant predominated (Nanduri et al., 2021). There may also be lower vaccine effectiveness for emerging variants such as the R.1 variant (Cavanaugh et al., 2021).

4. Emerging strategies for increasing the rate of care home vaccinations

Many regions prioritised vaccinations for care home residents and achieved high vaccination rates in residents (Lauter, Comas-Herrera, & Perobelli, 2021).

Staff-related strategies include targeted communications to staff around vaccinations, increasing the convenience of being vaccinated, and allowing sufficient time for staff to discuss concerns with peers, managers and trusted professionals (Hemmings et al., 2021). 

Some jurisdictions have mandated vaccination of care home staff (e.g. UK, Australia, Ontario, Canada). While there have been court appeals around the rights of workers to refuse vaccinations, and concerns around loss of staff (Limb, 2021), in Australia these court appeals have been dismissed, and staff shortages have not occurred. Furthermore, in British Columbia and Nova Scotia in Canada, all visitors to care homes must also now be fully vaccinated.

5. Strategies for better preparedness to prevent spread in care homes, including visiting practices

Eighteen months into the pandemic, governments and care homes have better knowledge and resources to prevent COVID-19 spread in care homes, including improved access to testing and protective personal equipment, and improved infection prevention and control guidelines (Aitken, Holmes, & Ibrahim, 2021; Dykgraaf et al., 2021; Rocard, Sillitti, & Llena-Nozal, 2021).

Care homes also have increased knowledge and preparation for practices that reduce the risk of COVID-19 infection during visits. These include: visits in well-ventilated, separate areas indoors or outdoors; following infection control procedures such as hand hygiene, wearing of masks, cleaning; logging visitors and screening on entry; and visits being supervised by staff (Low et al., 2021).

6. High community vaccination rates have allowed for easing of COVID-19 restrictions

Governments have tried to balance the protections conferred by high community vaccination rates with the risk of increased COVID-19 infections through reduced physical distancing requirements (IMF, Policy Responses to COVID-19, 2021). However, even after vaccination, care home residents and people with dementia remain some of the groups at highest risk of severe COVID-19 outcomes (Iacobucci, 2021).

Country case studies

The case studies are taken from countries with high double (and for Israel, treble) vaccination rates and minimal community physical distancing requirements.

These cases illustrate a range of approaches to care home visitor policies, in terms of:

• the strength of policies in upholding the rights of residents to have visitors;
• the amount and types of requirements placed on visitors (e.g. vaccination status, wearing of masks); and
• the safeguards applied during visits.

Australia

Vaccination rates: As of 23 November 2021, 86% of people over the age of 16% were double-vaccinated against COVID-19. Vaccination rates range from 73% in Western Australia to more than 95% in the Australian Capital Territory (ACT) and New South Wales (Department of Health, 2021c). Roll-out of third doses began on 8 November.

It is a mandatory condition of employment that residential aged care workers were vaccinated for COVID-19 by 17 September 2021 (Department of Health, 2021b). This was supported through a $11M Residential Aged Care COVID-19 Employee Vaccination Support Grant Program. Because of this, 99% of residential aged care staff are currently vaccinated. Aged care residents were prioritised for vaccinations, and 90% of aged care residents were vaccinated as of 4 October 2021.

In 2020, 33% of care home residents infected with COVID-19 died. Up to the first week of October 2021, this percentage had fallen to 14% (Department of Health, 2021a). The mortality rate in Australia overall is 0.4%.

Physical distancing restrictions in place:

Victoria, New South Wales and the ACT are easing community restrictions after achieving 70% and 80% double-vaccination rates respectively. In Victoria, New South Wales and the ACT, there are currently density restrictions in public indoor areas, restrictions on the number of visitors in private homes, and for public gatherings. In states without outbreaks, there are minimal restrictions besides interstate and international border closures. Until Delta strain outbreaks starting June 2021, Australia had been pursuing a ‘COVID zero’ policy through closed international and interstate borders, hotel quarantine and testing and tracing.

Visitor policies in care homes:

As community transmission has been zero or near-zero in many states from June 2020, care homes have allowed visitors with varying conditions, and snap visitor bans were introduced whenever COVID-19 breached hotel quarantine in a state (Lauter et al., 2021). From December 2020, a Federal Partnership In Care scheme allowed recognition of an existing relationship between a resident and a family member or friend. The ‘partner in care’ is involved in the day-to-day care, and this essential service could continue during COVID-19 outbreaks (Aged Care Quality and Safety Commission, 2021).

From 11 October 2021, at 70% double vaccination, NSW care home residents have been allowed two visitors provided they are aged 12 or over, have had two COVID-19 vaccinations 14 days prior to their visit, and don’t have symptoms nor are close contacts of someone with symptoms. Masks are to be worn. Rapid antigen tests have been provided to homes in areas of high community transmission (Health, 2021).

From 15 October 2021, at 80% double vaccination, ACT care home residents have been allowed two double-vaccinated visitors (Government, 2021). As of 18 October, other jurisdictions have not yet produced revised public health orders around care home visits.

The Australian Health Protection Principal Committee (AHPPC) on 4 October 2021 agreed that all states and territories would revise their public health orders to remove restrictions on visitors, including face-to-face visits and trips outside the facility. Federally, vaccination of visitors is encouraged but has not been mandated. New South Wales and South Australia have additional requirements that visitors are fully vaccinated.

Canada

Vaccination rates: As of 13 November 2021, 89% of eligible Canadians have at least one dose of a COVID-19 vaccine, while 85% are fully vaccinated (Government of Canada, 2021a). Residents, staff and, in some provinces, essential family caregivers were prioritised for vaccination. Essential family caregivers are defined as those visiting the care home to provide direct care to meet the essential needs of a particular resident, as designated by the resident or their substitute decision-maker.

As of 24 April 2021, more than 96.68% of care home residents had received at least one vaccination dose(Government of Canada, 2021a). In Ontario and other jurisdictions, 99% of residents have been fully vaccinated against COVID-19.

In contrast, staff vaccination uptake has varied across provinces (Sinha, Feil & Iciaszczyk, 2021).For example, by 1 October 2021, 90% of staff in Ontario had received at least one dose of a COVID-19 vaccine. However, 44% of care homes had staff vaccination rates below 90% and approximately one-in-six homes had staff vaccination rates below 80% as of the same date (DeClerq, 2021; Ontario Ministry for Long-term care, 2021). The low staff vaccination rates in a minority of care homes across Canada led the provinces of British Columbia, Alberta, Manitoba, Quebec, Ontario and Nova Scotia to introduce care home staff vaccination mandates (Feil, Iciaszczyk & Sinha, 2021). In Ontario, this resulted in 98% of care home staff receiving at least one dose of a COVID-19 vaccine and 95% receiving at least two doses by 30 October 2021. Meanwhile, Prince Edward Island has adopted a ‘vaccinate or test before every workday’ approach (Feil et al., 2021).

Since care home vaccinations began on 14 December 2020, COVID-19 outbreaks, infections and deaths have rapidly declined in care homes during Canada’s third and fourth pandemic waves. For example, 2,601 (43%) of Canada’s 6,029 care homes and retirement homes had experienced a COVID-19 outbreak during the first two pandemic waves (March 2020 to February 2021). Since then, only an additional 410 (6.8%) care homes have experienced outbreaks, as of 23 November 2021.

British Columbia and Nova Scotia have also recently mandated that all visitors, including essential family carers, must be fully vaccinated before entering a care home (Feil et al., 2021). These decisions have largely been prompted by a growing number of homes that are now experiencing COVID-19 outbreaks during a fourth Delta wave.

On 28 September 2021, the National Advisory Committee on Immunization (NACI) recommended booster shots because of emerging evidence that care home residents may experience waning antibodies and vaccine protection over time (Government of Canada, 2021b). As of 12 November 2021, all 13 of Canada’s provinces and territories have announced plans to administer a third dose of COVID-19 vaccines to care home residents (Feil et al., 2021).

Care home visitor policies, including for essential family carers:

Some provinces (i.e. Alberta, Saskatchewan, Ontario, Newfoundland, and Nova Scotia) have no restrictions for essential family carers. New Brunswick and Prince Edward Island have restrictions for essential family carers based on vaccination requirements. British Columbia, Manitoba, the Yukon, Northwest Territories and Quebec all permit essential family visitors but restrict the number or conditions of the visit.

General visitors are permitted to care homes in all 13 of Canada’s provinces and territories, with the exception of the Northwest Territories. Manitoba and New Brunswick have implemented mandatory vaccination policies for general visitors. Six jurisdictions – Alberta, British Columbia, Saskatchewan, Ontario, Newfoundland and Labrador, and Nova Scotia – no longer impose any specific limits on the number of general visitors permitted to visit with a resident at a time, while Prince Edward Island also does not limit the number of general visitors if a home has achieved and maintains an 85% vaccination rate amongst its residents. On the other hand, Manitoba, New Brunswick, Nunavut, Yukon and Quebec all limit the number of general visitors who are permitted to visit a care home resident.

Manitoba, Nova Scotia, New Brunswick, Newfoundland and Labrador, Nunavut, Ontario, and Yukon require general visitors to wear masks irrespective of vaccination status. In Saskatchewan and Alberta, even if unvaccinated, general visitors are not required to wear a mask. British Columbia, Prince Edward Island and Quebec have loosened their masking requirements, depending on a resident’s and/or visitor’s vaccination status.

Iceland

Vaccination rates: As of 23 November 2021, 621,821 doses of vaccine have been given in Iceland. This represents double vaccination of 79% of the entire population, or 89% of Icelanders aged 12 years and older. In addition, 31% have received a third dose. 

Physical distancing restrictions in place:

Iceland began lifting its COVID-19 restrictions in June 2021. Even before that, from May 2021, the country’s international borders were open to travellers from selected regions meeting negative tests and (from 1 July) vaccination requirements. For travellers with close relatives in Iceland, a negative test is required within two days of entering the country.

Effective restrictions currently in place (Directorate of Health, 2021):

• The maximum number of people allowed in the same location is 50 (with certain restrictions) – in public and private locations, both indoors and outdoors. Restrictions on numbers and social distancing rules do not apply to children born in or after 2016.
• Up to 500 people may attend an organised event if additional conditions are met – namely:
  • negative rapid antigen tests for all, taken less than 48 hours ago;
  • one-metre distancing rule except when seated;
  • all guests registered; and
  • face masks obligatory.

Visitor policies in care homes:

An interdisciplinary working group on care home issues relating to COVID-19 sets Iceland’s care home infection control measures, including visiting rules. Icelandic care homes set their own visiting rules but are encouraged to follow the guidelines from this working group. Most homes have restricted visiting hours, and ask visitors to wear a mask in common areas and practice good hand hygiene.

Protecting the rights of residents to have visitors:

No policies or procedures are in place.

Israel

Vaccination rates: As of the beginning of November 2021, almost 90% of Israeli’s aged 16 and over had received one vaccination, more than 80% had received two doses, and more than 50% had received three doses (Israeli government, 2021).

Physical distancing restrictions in place:

The majority of restrictions relate to people who are not fully vaccinated.

Visitor policies in care homes:

Current restrictions are based on the status of the municipality – based on the ratio of people with COVID-19. Throughout the country, indoor visitors must wear a mask and show proof of vaccination/negative test results.

A special unit, Fathers’ and Mothers’ Shield, monitors the situation in care homes, including the conducting of sporadic tests to identify non-symptomatic cases. This body, which is appointed by the Ministry of Health, has been issuing relevant guidelines throughout the pandemic (Israeli Ministry of Health, 2021). 

Norway

Vaccination rates: As of 23 November, Norway’s single vaccination rate for people aged 18 and over is 91.7%, while the double vaccination rate is 87.6% (Norwegian Institute of Public Health, 2021).

Care home residents were the first to be vaccinated in Norway, followed by healthcare staff in direct contact with patients. Presently, persons 65+ and people in a vulnerable health condition are receiving their third dose, aimed to be completed by the end of 2021.

Social distancing restrictions in place:

Since 25 September 2021, there have been no national COVID-19 restrictions in Norway. Since 6 October, all national borders were open, with no particular COVID controls in place. However, from 26 November, some entry restrictions have been reintroduced – namely, the duty of all travellers entering the country to:

• register their entry at the border;
• produce evidence of a negative Coronavirus test if they have no valid COVID-19 certificate; and
• subject themselves to testing if they are neither fully vaccinated nor have had a COVID-19 infection during the previous six months.

Other possible national restrictions are being debated, but have not been announced as of 24 November.

Visitor policies in care homes:

There are no national restrictions on receiving visitors in care homes. However, local authorities may re-introduce some restrictions if a local outbreak of infection takes place – as, indeed, a few municipalities have done since mid-November 2021, due to recent local outbreaks of COVID-19. For example, in Bergen, Norway’s second-largest city, both care home staff and visitors have been required to wear face masks since 22 November.

Protecting the rights of residents to have visitors:

The Norwegian Directorate of Health has issued a statement declaring that residents in care homes have the right to receive visitors (Besøk – pasienter og beboere – Helsedirektoratet).

The Netherlands

Vaccination rates: As of 31 October 2021, 84.1% of people over the age of 18 have been fully vaccinated for COVID-19 in the Netherlands, while 87.5% have had at least one dose. With regard to people over the age of 12, 85.4% have had at least one dose, while 82.1% are fully vaccinated (rivm.nl).

In the Netherlands, as in many other countries, care home residents and staff were among the first to be vaccinated against COVID-19. The first residents were vaccinated on 18 January 2021. After residents had been fully vaccinated, COVID-outbreaks and deaths in care homes declined.

Visitor policies in care homes & protecting the rights of residents to have visitors:

The Netherlands was one of the first countries where, under strict conditions set by the Dutch government, the visiting ban in care homes was lifted and its impact was assessed scientifically (Verbeek et al., 2020). In October 2020, the Dutch Parliament accepted the Corona Act, a temporary legislation prohibiting complete lockdowns in care homes (Koopmans et al., 2021). The Act guarantees that each resident has the right to welcome at least one visitor in the case of COVID-19 outbreaks.

In October 2020, five months after the visiting ban in Dutch nursing homes had been lifted, there were still found to be consequences for residents, family members and staff. Although complete visiting bans are indeed prevented, not all nursing homes felt prepared for welcoming visitors in case of new COVID-19 infections (Backhaus et al., 2021).

Data collected in March and April 2021 showed that a high proportion of care homes had adjusted their visitor policies after vaccinations. Nevertheless, many restrictive rules were still often in place. For example, residents were not allowed to hug visitors, or visitors were not allowed to stay for dinner. Most nursing homes did not have concrete plans or protocols on how to further ease the protective measures and policies (Hamers, Koopmans, Gerritsen, & Verbeek, 2021).

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This overview was supported by the ‘Covid-19 and Social Care Recovery and Resilience’ study funded by the National Institute for Health and Care Research (NIHR), Policy Research Programme (PRP) – Recovery, Renewal, Reset: Research to inform policy responses to COVID-19 in the health and social care systems. Reference number: NIHR202333. The views expressed are those of the speakers and not necessarily those of the NIHR or the Department of Health and Social Care.