International report on COVID-19 and Long-Term Care users and providers: context, impacts, measures and lessons learnt

Edited by: Adelina Comas-Herrera, Joanna Marczak, William Byrd, Klara Lorenz-Dant

Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science

DRAFT Please do not share/cite yet

About this report

This “live report” aims to provide an overview of Long-Term Care systems around the world, how the people who use and provide long-term care have been affected by the COVID-19 pandemic, the measures adopted to mitigate the impacts of the pandemic in the long-term care sector, and the actions and reforms that countries are adopting to strengthen their care systems and be better prepared for future pandemics and shocks that may impact people who use and provide long-term care.

This report does not seek to provide detailed or comprehensive information for each country, but instead aims to summarize key reports and articles and point the reader towards those. It builds on the country reports published in this website. It is being developed collaboratively, by answering a list of questions for as many countries as possible and updating as new information and research become available.

An initial version of the report has been developed by the team working on the Social Care COVID Recovery and Resilience and the information for each country is being expanded, updated and validated by LTCcovid contributors who are are experts on Long-Term Care in their respective countries (we will build a list of all the contributors that will appear at the end of this page)

PART 1.
Long-Term Care System characteristics and preparedness

1.01. Population size and ageing context

Overview

In the absence of global estimates on the numbers of people who receive care from others and are supported by long-term care services, increases in the numbers of older people are often used to approximate expected increases in need for care. This is because, while there are many reasons why people rely on care and support by others that are not linked to age, as people reach older ages, they are more likely to need some support from others in their daily lives. Out of a global population of nearly 7,713 million people in 2019 (https://population.un.org/wpp/), 703 million people were aged 65 years or over. This number is expected to grow to 1.5 billion by 2050, when older people would represent 16% of the global population. The number of people aged 80 and over is expected to grow from 143 million in 2019, to 426.4 in 2050, with the largest increases projected for Northern Africa, and Western Asia. (https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_worldpopulationageing_report.pdf).

As the proportion and total number of people requiring assistance increases, health and care systems need to prepare for increases in demand for treatment, care and support. Cardiovascular diseases, cancer and nervous system disorders are the leading causes of death and disability-adjusted life-years, whereas musculoskeletal disorders, sense organ diseases and cardiovascular diseases are the leading causes of years lived with disability (Institute for Health Metrics and Evaluation http://www.healthdata.org). The COVID-19 pandemic is only exacerbating these pressures.

International reports and sources

The World Health Organization’s Ageing Data Portal brings together data on global indicators to monitor the health and well-being of older people:  https://www.who.int/data/maternal-newborn-child-adolescent-ageing/ageing-data. 

Data on global population projections is also available from United Nations at:  https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_worldpopulationageing_report.pdf.

Australia

Australia has a population of just over 25 million people. In 2019, 15.9% of Australia’s population were over the age of 65 and 2% of the population is over the age of 85.  Australians are living longer than ever before. The number of Australians aged 85 years and over is expected to increase from 515,700 in 2018–2019 to more than 1.5 million by 2058 (sources: https://www.statista.com/statistics/608088/australia-age-distribution/; https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Last updated: August 3rd, 2021   Contributors: Adelina Comas-Herrera  |  Ben Admin  |  

Austria

In 2016 Austria had a population of 8.6 million, of whom 0.81 million required help from others to carry out activities of daily life (source: https://ec.europa.eu/info/sites/default/files/economy-finance/ip105_en.pdf). Furthermore, 18.2% of the Austrian population (1.5 million people) are aged 65 years and older, with demographic ageing being observed particularly in rural areas. Approximately 20% of Austrians with LTC needs live in one of the 930 care homes. These homes, on average, can house about 80 people (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

Last updated: August 3rd, 2021

Canada (British Columbia)

As of 2019, the total population in BC is 5,071,336. There are 948,062 people over the age of 65 and 118,479 people over the age of 85 (source: https://bcstats.shinyapps.io/popApp/).

Last updated: August 3rd, 2021

Catalonia (Spain)

In 2019, the total population in Catalonia was estimated to be 7.619.494, of which 51% were women and 49% were men. Like most European regions, Catalonia has an ageing population, with 18,9% of the population aged 65 or older, and 6% of the population aged 80 or older. These figures follow an increasing tendency over the last decades and are expected to continue to do so (22,3% of the population is expected to be aged 65 or older in 2030 according to mid-range scenario projections). (Source: https://www.idescat.cat/pub/?id=aec&n=253&t=2010)

 

Last updated: September 13th, 2021   Contributors: Gemma Drou-Roget  |  

Chile

In 2017 there were nearly 3,500,000 people aged 60 or over in Chile, of whom 14.2% (489,000) had some degree of functional dependency (source: https://ltccovid.org/2020/07/27/new-report-policy-response-to-covid-19-in-long-term-care-facilities-in-chile/).

Last updated: August 3rd, 2021

Denmark

Denmark has a population of just under 6 million (5 840 045 in 2021). In 2021, 19.4% of the population were over 65 (1, 134, 564) with 4.1% over 80 (240, 398) and 1.9% (110, 396) over 85 (source: https://www.dst.dk/en/Statistik). These numbers are expected to rise significantly, and according to calculations from Statistics Denmark, by 2053, 10% of the population will be over 80 (source: https://www.sst.dk/da/viden/aeldre).

Last updated: August 3rd, 2021

England (UK)

By mid-2020 the population in England was estimated to be 56,550,000, representing 84% of the total population of the United Kingdom. The median population age in England was 40.2 years. The share of the population aged 65 years and over was 18.5% and the share aged 85 and over was 2.5%.

(Source: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2020#population-change-for-uk-countries).

Last updated: September 6th, 2021

Finland

The current population of Finland is 5,546,270. As of 2019, the number of people aged 70 and over was 874,314. Finland is a rapidly aging country, with the number of people over 70 growing by 100,000 in just three years (source: https://findikaattori.fi/en/14).

Last updated: August 3rd, 2021

France

France has a population of 67.1 million (2018). In 2018 19.6% of the population were aged 65 years and older (13.1 million people) (source: https://www.insee.fr/fr/statistiques/3303333?sommaire=3353488#:~:text=La%20proportion%20des%2065%20ans,2%25%20entre%202006%20et%202016).

Last updated: August 3rd, 2021

Germany

Germany has a population of 83.1 million. In 2018, 17.9 million people were aged 65 years and older (22% of the population). According to the German Federal Statistical Office (Destatis), in 2019 there were 4.1 million people with long-term care needs, 62% women (source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf). Furthermore, population age is not distributed evenly across the country. A larger share of population with care needs have been identified in Federal States in the East of Germany, which may in part be due to higher average age and a larger share of women, who more frequently experience care needs compared to men of the same age (source: https://www.iwkoeln.de/fileadmin/publikationen/2015/244405/IW-Trends_2015-03-04_Kochskaemper_Pimpertz.pdf).

Last updated: August 3rd, 2021

Ghana

WHO has estimated that in Ghana, more than 50% of people between the ages of 65 years and 75 years require some assistance with daily activities. For those 75 years and older, the percentage jumps to more than 65% (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 3rd, 2021

Israel

In 2015, the total population of Israel was 8.46 million, of whom 939,000-11%- were aged 65 and over. One in four households in the country included a person aged 65 or more (source: https://brookdale.jdc.org.il/wp-content/uploads/2018/02/MJB-Facts_and_Figures_Elderly-65_in_Israel-2018_English.pdf). 

Last updated: August 3rd, 2021

Italy

In 2020, 23.2 % of the total population in Italy was 65 years and older, the share of elderly people in the Italian society has been growing constantly in recent years. According to 2019 data, the country was considered to have the largest percentage of elderly population in Europe (source: https://www.statista.com/statistics/785104/elderly-population-in-italy/).

Last updated: August 3rd, 2021

Japan

Japan has one of the largest populations of older adults in the world. In 2020, 28.4% of the population was over the age of 65? (source: https://www.stat.go.jp/english/data/handbook/pdf/2020all.pdf#page=23).

Last updated: August 3rd, 2021

Mauritius

The Government of Mauritius foresees rising rates of dementia and disability and increased overall demand for long-term care. It is planning for a 52% increase in publicly funded residential bed capacity by 2030 (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 3rd, 2021

Netherlands

Data shows that in 2020, the Netherlands had a population of about 17.4 million. Nearly 114,000 people aged 65 and over live in residential care and nursing homes.

Last updated: August 3rd, 2021

Northern Ireland (UK)

In mid-2020 the total population in Northern Ireland was 1,896,000, which represents 2.8% of the total population of the United Kingdom. The median population age was 39.2. The share of the population aged 65 and more was 16.9% and share aged 85 and over was 2.1%.

Source: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2020#population-change-for-uk-countries

Last updated: September 6th, 2021

Poland

Poland has one of the most rapidly ageing populations in the European Union (EU): by 2060, the proportion of the population aged 65–79 is expected to double and the proportion of the population aged 80+ is expected to triple (source: Poland Country (filesusr.com).

 

Last updated: August 3rd, 2021

Republic of Korea

In 2020, the population was 51.27 million out of which 8.10 million (16%) were aged 65+. This proportion is projected to almost 43% by 2060 (source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: August 3rd, 2021

Scotland (UK)

In mid-2020, the total population of Scotland was 5,466,000, representing 8.1% of the total population of the United Kingdom. The media population age was 42.1 years. The share of population aged 65 or over was 19.3% and the share aged 85 or over was 2.3%.

Source: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2020#population-change-for-uk-countries

Last updated: September 6th, 2021

Singapore

In 2019, 14.4% of Singapore’s population of 3.9 million people was aged 65 years or older, and by 2030, this figure is expected to rise to 25%: The number of older people is projected to increase by 317,000 -from 583,000 to 900,000 by 2030. Consequently, the  demand for LTC is expected to accelerate the coming 2 decades (sources: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf; Aging Asia and the Pacific: Singapore’s Long-Term Care System-Adapting to Population Aging (adb.org).

Last updated: August 3rd, 2021

South Africa

In South Africa, 35% of people between the ages of 65 years and 75 years require some assistance with daily activities. For those 75 years and older, the percentage increases to 45% (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 3rd, 2021

Sri Lanka

In 2019, approximately 15.9% of the population of Sri Lanka was older than 60 years of age, with 9.2% aged 60–69 years, 5.1% aged 70–79 years, and 1.6% over 80 years of age. Projections suggest that these proportions will increase, more than doubling between 2030 and 2050; 60% will be women. This also represents a significant increase in absolute numbers. The “old-age dependency ratio” is projected to rise steadily, from 20% in 2015 to 43% in 2050 (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (adb.org).

Last updated: September 8th, 2021

Sweden

In 2019 Swedish population was 10.33 million. Twenty percent of the Swedish population were 65 years and older; 5.2 % were 80 years and older and 1 % were 90 years or older (source: https://www.statista.com/statistics/525637/sweden-elderly-share-of-the-total-population-by-age-group/)

Last updated: August 3rd, 2021

Thailand

The Thai population was 69,625,582 in 2019, life expectancy at birth was 73.12 years for men and 80.62 years for women in 2019. The number of older persons is expected to increase from 11.3 million (16.7% of the Thai population) in 2017 to 22.9 million (33% of the Thai population) by 2040 (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org)).

Last updated: September 8th, 2021

United States

As of 2019, approximately 16.5% of Americans were aged 65 and older, constituting more than 54 million people in a population of 320+ million (source: https://www.census.gov/topics/population/older-aging.html). Moreover, the number of people aged 65 and older is expected to double in the next 40 years (source: https://www.urban.org/policy-centers/cross-center-initiatives/program-retirement-policy/projects/data-warehouse/what-future-holds/us-population-aging).

Last updated: August 3rd, 2021

Wales (UK)

In mid-2020 the total population of Wales was 3,170,000, which represents 4.7% of the total population in the United Kingdom. The median age of the population was 42.4. The share of the population aged 65 and over was 21.1% and the share aged 85 and over was 2.7.

Source: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2020#population-change-for-uk-countries

Last updated: September 6th, 2021

1.02. Brief description of the Long-Term Care system

Overview

Meeting the needs of people who require care and support from others for their daily lives is not limited to addressing the symptoms or disability associated with disease. It encompasses promoting the development and maintenance of the functional ability that allows wellbeing and enables people to live a fulfilling life in accordance with their values.  The World Health’s Organization defines long-term care as “the activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity” (https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf?sequence=1).

Long-term care covers a wide range of health and social services that can be delivered in various settings, including the beneficiary’s home, hospice and day-care facilities (Source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip105_en.pdf).

Long-term care benefits, services and activities typically span multiple government departments (health, social welfare, labour, housing) and levels (national, regional, local). This fragmentation is not limited to the delivery of services; it also can be seen during needs assessment, when accessing benefits and packages, in data collection and in the diversity of quality improvement efforts. Fragmentation of services has been linked to dual administrative procedures, hindrances in access to care and longer waiting times (https://apps.who.int/iris/handle/10665/332533) and has been identified as a barrier to reducing hospitalization for ambulatory care sensitive conditions (http://www.euro.who.int/en/health-topics/Health-systems/primary-health-care/publications/2016/assessing-health-services-delivery-performance-with-hospitalizations-for-ambulatory-care-sensitive-conditions-2016).

This section provides a very brief overview of long-term care systems around the world. The term system is used as in the WHO World report on Ageing and Health, to refer to all caregivers and settings where care is provided, as well as the governance and support services that can help them in their roles. This definition includes care provided in the formal and informal sector, paid and unpaid, publicly and privately provided and delivered, in people’s own homes, in the community and in institutional settings. (https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf?sequence=1).

In this report we use a comprehensive definition of long-term care, to cover care and support in the community and in institutional settings, by formal care providers and by unpaid carers, and for younger and older adults. Some of the definitions used in the reports from the different countries may vary on the groups and types of cared included.

International reports and sources

The Organisation for Economic Co-operation and Development (OECD) publishes regularly international reports and data on long-term care (https://www.oecd.org/els/health-systems/long-term-care.htm).

Some data on long-term care, for example on the numbers of countries that have a long-term care policy/plan/strategy is also available from the WHO’s Ageing Data portal (https://www.who.int/data/maternal-newborn-child-adolescent-ageing/ageing-data).

For European countries, the European Centre for Disease prevention and control (ECDC), also publishes data on the numbers of people in Long-Term Care Facilities (ECDC), and on number of beds (https://www.ecdc.europa.eu/en/all-topics-z/coronavirus/threats-and-outbreaks/covid-19/prevention-and-control/LTCF-data) There are country reports from EU countries (2018) on EU website:  (https://ec.europa.eu/social/main.jsp?catId=792&langId=en).

For Latin American and Caribbean countries, the Interamerican Development Bank has developed the Panorama of Aging and Long-Term Care, gathering indicators, publications and case studies to support policy development (https://www.iadb.org/en/panorama/panorama-aging).

Australia

The Australian government is the primary funder and regulator of the long-term care system. The government subsidises both home care and residential care for people of all ages who have been assessed as needing care and support. There are four main types of services under aged care: the Commonwealth Home Support Programme (CHSP) Home Care Packages (HCP), residential care and flexible care. More than 1.2 million people received aged care services during 2017–2018. 77% received support in their home or other community-based settings. Of Australians over the age of 65, 7% accessed residential aged care, 22% accessed some form of support or care at home, and 71% lived at home without accessing government-subsidised aged care services. (sources: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf; https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf)

Last updated: August 3rd, 2021

Austria

The LTC system is based on three pillars: cash benefits, care services and measures to support unpaid carers. Cash benefits (“Pflegegeld”) are needs based and not means-tested, they are intended to be used to buy formal care or to reimburse informal care provision (source: https://ec.europa.eu/info/sites/default/files/economy-finance/ip105_en.pdf), since 2007 there is an additional subsidy to facilitate the hiring of 24-hour carers in private households (source: https://apps.who.int/iris/bitstream/handle/10665/330188/HiT-20-3-2018-eng.pdf?sequence=7&isAllowed=y).

A comprehensive, tax-based funding for the long-term care cash-for-care allowance was introduced in 1993 and remains the responsibility of the federal state, while in-kind services fall under the realm of provincial governments. This means that both the federal republic and the nine states are responsible for social care. All states are obliged to provide a minimum standard of long-term care services such as mobile care services, residential care facilities, short-term care services and case and care management.

There is growing reliance on live-in migrant personal carers, mainly from neighbouring Eastern European countries. In 2018 there were about 462,000 Austrians assessed as eligible for the federal care allowance, of which 33,000 relied on migrant live-in carers, 70,000 were in care homes and 153,000 used professional home-based care (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

LTC services are provided by private and public home care providers. Residential facilities are planned, regulated and funded by state governments and municipalities (source: https://apps.who.int/iris/bitstream/handle/10665/330188/HiT-20-3-2018-eng.pdf?sequence=7&isAllowed=y).

Last updated: August 3rd, 2021

Canada (British Columbia)

Approximately 42,000 people live in BC’s LTC homes. In 2012/2013, 38,810 people received home support services (source: Bedlam_in_BC_Continuing_Care_Sector.pdf (bccare.ca). The average age of residents in LTC facilities is 85 years; 59% are aged 85 or older (source: QuickFacts2018-Summary.pdf (seniorsadvocatebc.ca).

Last updated: August 3rd, 2021

Chile

The majority of people with support needs receive care from their family members, mostly women (source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

There is some provision of subsidized institutional care. In principle all long-term care facilities should be registered with the Ministry of Health and subject to staffing requirements. However, it has been estimated that half of all care homes are not registered or unregulated (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.72/)

Last updated: August 3rd, 2021

China

Long-term care is mostly provided by family and other unpaid carers, with some provision by paid carers for those who can afford it. The Government covers the costs of care for people who fit the “Three No’s” category: no ability to work, no income and no family. Relying on families as the main source of care is increasingly under question given demographic and social changes resulting in smaller and geographically dispersed families. In response to this, the government has increased its focus on developing a formal long-term care system, initially through encouraging the rapid development of a private institutional care sector, setting targets for numbers of beds. This took place before developing regulation and quality assurance mechanisms and has led to the lack of development of community-based care. There are shortages of trained care professionals. There have been pilots of social long-term care insurance in 16 cities since 2016, with strong policy interest on these as a mechanism for long-term care financing. For a good overview read Feng et al. (2020).

 

 

Last updated: October 1st, 2021

Czech Republic

Informal care constitutes a major part of care provided to older and dependent people. It is estimated that roughly 52% to 75% of care is provided by relatives, at home. The introduction of care allowance in 2007 has been the most significant change in the social services system since the 1990s, and the allowance has been used to compensate informal carers. Formal LTC is based on a two-tiered system of regulation, funding, and services provision—separate for the health sector and for the social services sector and some private provision of LTC services have been developing, including a rise of unregistered LTC services (source: CEQUA – Czech Country Report (filesusr.com).

Last updated: August 3rd, 2021

Denmark

TheLTC system in Denmark has strong public and political support. The main law regulating social service provision and, implicitly, long-term care provision is the Social Services Act, which passed in 1998. The Social Services Act emphasizes the users’ right to influence social service provision and enshrines the highly decentralized nature of the system, putting municipalities in a key position to shape long-term care. It is a highly decentralized system, with a strong emphasis on community-based care, reablement and professionalisation of care staff (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 3rd, 2021

England (UK)

The majority of long-term care in England is provided by unpaid carers. Formal long-term care in England is provided by a complex system involving organisations in charge of health, social care, housing and other services. There is an important distinction between means-tested social care (non-medical services aimed at supporting people with LTC needs with their daily living activities) and health care services, which are free at the point of use and funded from general taxation.

Formal care services include home-based care services, personal assistants, residential/institutional care, day care and professional services such as social work, occupational therapy and aids and adaptations. Most publicly funded services are commissioned at local level, but, as a large share of the population who use long-term care is not covered by the public system, a large share of care is purchased directly from private providers.

There is strong consensus on the urgent need to reform the social care system in England.

For further reading:

CEQUA report on England (2017), LTCcovid report on England (2020), Report on the problems with the social care system in England (2018)

Last updated: September 6th, 2021

Finland

Care for older people in Finland is primarily delivered at home and in the community. Over 90% of the older population (75+) live in their own home, with the majority receiving no formal care (~75%), some receive regular home care, or informal care. Less than 10% of the older population receives some kind of 24-hour sheltered housing or institutional care (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 3rd, 2021

France

Currently, there are 7,502 long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 256 care homes for autonomous older people and 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015. There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

In 2015 there were 1.25M beneficiaries of Long-Term Care Insurance for older people (8% of over-60s) (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

The domiciliary care sector is extremely fragmented, with one department (sub-regional authority) having over 100 agencies (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). Financing is unprofitable, with the difference between pay from LTCI and hourly costs in 2017 of 2.2€/hour (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Organisation largely befalls the regional structures (ARS) around healthcare matters, and departments (sub-regional structures) manage social care matters, but there is a joint responsibility for tariff setting and financing of operations in care homes (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). ARS do not have oversight of domiciliary care, except where a nursing component is involved (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: August 3rd, 2021

Germany

In 2019, there were about 4.13 million people with LTC needs that have been allocated into care levels 1 to 5. Out of these, approximately 0.91 million people were living in residential care homes, while most people receive care and support at home (80%). Of those living in their own homes, more than 60% were supported by informal carers only while almost 30% use care and support from both unpaid and domiciliary carers or domiciliary carers only. Approximately 80% of people with LTC needs living at home have a level 2 and 3 care need. (source: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Pflege/Tabellen/pflegebeduerftige-pflegestufe.html;jsessionid=D36A8A29106991E309E81E1FD2976D71.live712).

Care needs are classified into five categories. Level 1 reflects lower needs, while level 5 represents severe needs. The assignment for the overall levels is based on assessment of six core areas (mobility, cognitive and communicative abilities, behaviour and psychological issues, ability to take care for oneself independently, handling of illness and therapy as well as illness related strain, and therapy and organisation of everyday life and of social contacts). The degree of support provided varies between the different levels of care need (source: https://academic.oup.com/gerontologist/article/58/3/588/3100532).

In 2019, out of the 15,380 residential care homes, 43% were operated by private for-profit provider, 53% by private not-for-profit providers and 5% were owned and operated by public providers (source: https://www.gbe-bund.de/gbe/pkg_olap_tables.prc_sort_time?p_uid=gastd&p_aid=11066930&p_sprache=D&p_help=2&p_indnr=397&p_ansnr=12428255&p_version=3&p_sortorder=d).

Last updated: August 3rd, 2021

India

There is no formal or organized public LTC system in India, however a number of schemes cover some aspects of care for older people or people with disabilities and mental health conditions. Families (particularly women) are the main source of care, as well as untrained care workers such as “home attenders”. There are some formal care services available, mostly provided by private and not-for-profit organisations (source: https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID-situation-in-India-30th-May.pdf).

Last updated: August 3rd, 2021

Ireland

Most LTC in Ireland is provided by unpaid carers supplemented by home care services. There are more public resources available for residential care than for home care services. By December 2018, 581 nursing homes in Ireland registered with the Health Information and Quality Authority offered 31,250 places for people with care needs. More than 460 of the homes are operated by private or voluntary (not-for-profit) providers), supporting 25,000 people. Ireland also has some ‘psychiatry of later life units’. Most of the residents are 65 years and older. Publicly funded support for home care can be obtained following a needs assessment conducted by a healthcare professional. So far financial means are not taken into consideration. Most home care services are provided by private providers, but these providers are contracted by the State. The role of the public sector in the delivery of home care is relatively small (source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: August 3rd, 2021

Israel

Israel organizes its LTC system in a fragmented manner, with the Ministry of Health, the Ministry of Labor and Social Affairs, and the National Insurance Institute (NII) holding separate yet overlapping responsibilities for publicly funded LTC (source: http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf).

Last updated: August 3rd, 2021

Italy

The public system of LTC in Italy is underdeveloped and characterised by a high degree of institutional fragmentation, as sources of funding, governance and managerial responsibilities of public services are spread over local (municipal), regional and national authorities, with different methods according to the institutional models of each region (source: https://www.sciencedirect.com/science/article/abs/pii/S0168851014000086). Unpaid carers – together with home care assistants privately hired by households – represent the bulk of LTC provision in Italy (source: Italy Country Report (filesusr.com).

Last updated: August 3rd, 2021

Jamaica

There is relatively little published information on the long-term are system in Jamaica. An article that set out to map long-term care in Jamaica found that care is largely provided by informal carers (both unpaid and paid). There is a high prevalence of unregulated care homes and limited formal home and community-based services. NGOs and places of worship are an important part of the few community-based services available.

Last updated: September 8th, 2021

Japan

Most of Japan’s LTC services are covered by the public long-term care insurance (LTCI) system that was introduced in 2000. The LTCI is administered by municipal governments and operates independently of the medical insurance system. The LTCI subsidizes non-medical services including residential care (long and short-term), day care, care services in people’s own homes and home adaptations. The insurance benefits do not cover room and board, but other than this, the level of re-imbursement is a relatively low level of co-payment (10%) (source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

The Japanese LTC system has a large non-residential care sector: just under 1?million older people (2.6% of adults aged over 65) live in care facilities and 4 million older persons utilize day care facilities (2019) (source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675525/).

In 2017 there were 24.1 LTC beds per 1,000 older adult population (source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). In 2014, 7.8% of those aged 65 or older used day care in Japan. Unlike many European countries, the Japanese LTC system does not offer cash benefits to people who need care or to family carers (source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

Last updated: August 3rd, 2021

Latvia

The key players in the provision of formal LTC are the national government, 119 local governments and 110 municipalities. The number of organizations providing state-funded services decreased from 17 institutions in 2010 to 15 in 2015, the number remaining unchanged since then. The 15-state financed social care institutions provided LTC social services for 5,353 clients; 86 local government and other organization social care centres provided LTC social services for 6,134 clients. Additionally, there were 83 such institutions in the country provided by local government in 2010, and the number increased to 86 institutions by 2015 (source: CEQUA Latvia Country report (filesusr.com).

Last updated: August 3rd, 2021

Netherlands

Since 2015, LTC is governed through three separate legal acts: the Long-term Care Act (WLZ 2014), the Social Support Act (WMO 2015) and the Health Expenses Act (Zvw 2008). As a result, there are different rules and funding streams for care-related (LTC insurance), social support related (municipalities) and health and nursing related (health insurance) services. LTC is needs assessed but not means assessed (source: https://drive.google.com/file/d/1P5J1JQlr-ts65lknBwBFtTkJNXHLDyrL/view).

Last updated: August 3rd, 2021

Poland

By law and by tradition, families are primarily responsible for care provision, with social institutions’ intervening when families are incapable of undertaking adequate care measures and LTC is provided mostly by unpaid carers in Poland. Some home care as well as residential care services are however also available through health and social care sector and more recently day care centres have gained prominence in providing support for people with LTC needs (source: Poland Country Report).

Last updated: August 3rd, 2021

Singapore

Singapore’s approach to LTC focuses on home and  community-based care, aiming to reduce unnecessary utilization of institutional care, Singapore’s LTC policies are based on a principle that calls for individuals, families, communities, civil society, the private sector, and government to all play a role in ensuring the well-being of older people although it emphasises the primacy of the family in aged care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).

Last updated: August 3rd, 2021

South Korea

In 2008, South Korea introduced a universal, public long-term care insurance to complement the existing national health insurance. The LTCI covers residential, domiciliary and community-based care. By the end of 2018, approximately 9% of the population aged 65 and older were eligible for LCTI coverage (source: https://www.tandfonline.com/doi/full/10.1080/01634372.2020.1797977).

A shortage of qualified home-based care services in South Korea means that most older people have no choice but to depend heavily on residential institutional care. From 2012 to 2017, the number of long-term residential care facility beds per thousand people aged 65 years old and over significantly increased from 51.1 to 60.9, and the number of beds in long-term care hospitals was  36.7 per thousand people, the highest among OECD countries  (source: https://www.tandfonline.com/doi/full/10.1080/01634372.2020.1797977).

Long-term care hospitals (LTCHs) under the national health insurance play a role in long-term care provision; the average length of stay at such hospitals was about 168 days per year in 2016 Lengthy hospitalizations are likely a result of residential institutional care being financially supported by the national health insurance (NHI) and Long-Term Care Insurance (LTCI) (source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: August 3rd, 2021

Spain

In Spain, the 2006 ‘Dependency Act’ created new public national care coverage as the ‘fourth pillar of the welfare state’, aiming to improve personal autonomy and care for dependent people. The Act established two types of long-term care benefits: 1) in-kind services, and 2) those of an economic nature, and it gave the former a priority. The law lists social services which contribute to long-term care:  services for averting dependency and enabling personal independence; tele-assistance services; home care services (help with home tasks and personal care); day and night care centres; residential services. All benefits and services established in the law are integrated in the social services provided through the autonomous regions (source: CEQUA Spain Country report (filesusr.com).

Last updated: August 3rd, 2021

Sri Lanka

Long-term care provision has remained mainly with families, and formal LTC service provision is considered inadequate to meet even current needs and demand.  Home and community-based care services that support aging in place for elders with limitations in
ADL and IADL are rare; residential care is not appropriate in terms of available services or eligibility. Informal care at home is often provided by family members, usually,  a female relative. Untrained domestic workers are sometimes hired as caregivers.

Last updated: September 6th, 2021

Sweden

In 2019, over 160 000 of older people were provided with services and care in their own home and some 82 000 were provided with institutional care. A wave of closures of municipal institutional beds, resulted in a reduction of nearly 40% of all municipal places since 2000s (source: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Last updated: August 3rd, 2021

Thailand

Families provide most of the care given to older persons, at home and without payment. Home-based care provided by trained volunteers or paid caregivers is growing, and helps to support informal care-support systems (source: Country Diagnostic Study on Long-Term Care in Thailand | Asian Development Bank (adb.org).

Last updated: September 6th, 2021

United States

In the United States, there are five major types of LTC services: adult day centre, home health agencies, nursing homes, hospices, and residential living facilities. As of 2016, there were approximately 15,300 nursing homes and 28,900 residential care (‘assisted living’) facilities. Approximately 24 in every 1,000 people aged 65+ use nursing homes, and 15 in every 1,000 people aged 65+ live in residential care. 75 in every 1000 people aged 65+ use home health agencies for at-home services (source: https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf).

Last updated: August 3rd, 2021

1.03. Long-term care financing arrangements and coverage

Overview

LTC financing discussions tend to focus on the sustainability of current financing arrangements, given rapidly growing demand due to population ageing and the predicted increase in the frail older people with long-term care needs.

In practice, the largest share of LTC is provided, “in kind” by unpaid carers such as family members and friends. In Europe,  countries such as Denmark the Netherlands and Sweden have higher reliance on formal care, while countries such as Bulgaria, Cyprus, Estonia, Lithuania, Latvia, Romania and Croatia rely almost exclusively on unpaid care (Source: The 2018 Ageing Report: Economic and Budgetary Projections for the EU Member States (2016-2070) (europa.eu). Family carers in some countries, for example Denmark, can be paid by the government for short periods of time. Family care givers may also receive income transfers and, possibly, some payments from the person receiving care.

Despite the high concern about the fiscal sustainability of long-term care costs, in most countries long-term care expenditure represents a small share of Gross Domestic Product (GDP). In 2017 total spending on public LTC across OECD countries, was estimated to account for 1.5% of GDP or 730 American dollars (USD) per capita (after adjusting for differences in price levels). This ranged from less than 0.2% of GDP in Greece, and the Slovak Republic to a high of around 4% of GDP in the Netherlands, 3% in Sweden and 2.5% in Denmark. In the US and Republic of Korea the spending was about 1% of GDP, in Canada 1.5%, followed by Germany (2.2%) and the UK and France (2.5% in each). It is important to note, as highlighted in this OECD report, that estimating LTC financing accurately is very difficult as very few countries have information systems that record all out-of-pocket spending on long-term care services.

Countries with the highest LTC spending overall i.e. Sweden and the Netherlands – are also nations where the public share of LTC financing is the highest (at 92-93%). On average across the OECD in 2017, 76% of inpatient LTC was financed by public schemes compared to 91% for home-based care, the gap was widest in Austria, Korea and the United Kingdom, where there was a 30-percentage point difference or more.

Systems with a single universal LTC coverage tend to provide publicly funded nursing and personal care to all individuals assessed as eligible due to their care-dependency status. They may apply primarily to the old population (e.g. in Japan, Korea), or to all people with assessed care-need regardless of the age-group (e.g. the Netherlands). Universal coverage systems have been located typically among Nordic countries such as Sweden, Finland, Denmark although in those countries provision/access often depends on local area and municipal availability of services. Means-tested systems operate in such countries as England, US as well as in many Eastern European countries where free LTC services are available for people with greatest needs and with lowest financial needs, although some services may be universal, needs tested (e.g. such as reablement in England). In some countries co-payments have been introduced, which are either means-tested e.g. in parts of Canada, Japan, France. The rate of co-payments is often means-tested and can vary from 10% to 90%, although it can be a set amount as in parts of Canada. Some countries have LTC insurance which provides a universal coverage (namely Germany, South Korea). LTC insurance in Israel is income-tested (it excludes highest earners) and is available only for home-based personal care.  Differences in social values may also influence the distribution of support between users with and without informal carers. Moreover, in most OECD countries , public coverage is higher for home-based LTC than for inpatient LTC (Source:LTC-Spending-Estimates-under-the-Joint-Health-Accounts-Questionnaire.pdf (oecd.org).

 

International reports and sources

This new report from WHO’s Centre for Health Development focusses on pricing long-term care for older persons in high-income countries, with case studies on Australia, France, Germany, Japan, Republic of Korea, the Netherlands, Spain, Sweden and the USA: https://apps.who.int/iris/bitstream/handle/10665/344505/9789240033771-eng.pdf?sequence=1&isAllowed=y

Reports on LTC public coverage and co-payments policies can be found on OECD website, including:

LTC-Spending-Estimates-under-the-Joint-Health-Accounts-Questionnaire.pdf (oecd.org);

2592f06e-en.pdf (oecd-ilibrary.org);

There are several World Health Organization reports covering LTC financing, including:

9789240694811_eng.pdf (who.int)

www.euro.who.int/__data/assets/pdf_file/0011/64955/E92561.pdf

Phase2sansTOC.book (oecd.org).

 

Several reports can be found about LTC financing and coverage across EU Member States:

https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en).

Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Other sources include:  https://www.degruyter.com/document/doi/10.1515/9783110444414-032/html.

 

Austria

In 2016 public spending on LTC represented 1.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Funding for long-term care is the responsibility of the federal state, through taxes (national, regional and local) and using cash for care allowances, with universal cash-benefits and co-payments for some services (but assets are not included in means-test) (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en).

There is a LTC fund (“Pflegefonds”) for the federal government to redistribute to the states and municipalities, which also covers palliative and hospice care (source: https://apps.who.int/iris/bitstream/handle/10665/330188/HiT-20-3-2018-eng.pdf?sequence=7&isAllowed=y).

Last updated: August 2nd, 2021

Australia

In 2018-19 government spending on LTC in Australia was estimated to be equivalent to 0.9% of Gross Domestic Product (source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-06/consultation_paper_2_-_financing_aged_care_0.pdf).

Australia has universal health care through Medicare. The Australian government subsidizes aged care services so anyone who received aged care is eligible for financial support. In 2018-2019, $27.0 billion was spent on aged care, $19.9 billion of which came from Australian Government (source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-06/consultation_paper_2_-_financing_aged_care_0.pdf). People who use aged care are expected to contribute in the form of co-payments and means tested fees. People receiving aged care services contributed $5.6 billion to the cost of their aged care in 2018–2019. Aged care homes are subsidised by the Australian government. The subsidies are paid directly to the aged care home and the amount of funding that a home receives is based on an assessment of individual needs by the home using a tool called the Aged Care Funding Instrument (ACFI) and how much an individual can afford to contribute to the cost of their care and accommodation (using a means assessment).  Aged care services are rationed and access is determined by where people live, their needs, and availability of services. There is significant reliance on informal carers in the community, to reduce the need for formal care. In 2018, there were around 428,500 informal primary carers providing support to someone aged 65 years or older (sources: https://www.health.gov.au/about-us/the-australian-health-system; https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf; https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1819/Quick_Guides/AgedCare2019; https://www.myagedcare.gov.au/aged-care-homes).

Family carers have access to shared care planning tools. Professional carers are also increasingly asked to collaborate with family carers, providing skills training and directing family carers to the services available for them (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

The Royal Commission into Aged Care Quality and Safety found that there is no universal entitlement to aged care as services are strictly rationed and access is determined by where people live, their needs, and availability of services (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Last updated: August 2nd, 2021

Belgium

In 2016 public spending on long-term care was estimated to represent 2.3% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Long-term care is part of an integrated system of health care, complemented by social service provision. Medical care is financed by the federal health insurance system, whereas personal care is organized and financed by the regional governments. Cash benefits only play a small role in the system. Co-payments are means-tested and subject to a maximum limit. Additionally, Flanders has a compulsory social insurance system specifically for non-medical help services that provides cash benefits to people with reduced self-sufficiency (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en).

Last updated: August 2nd, 2021

Brazil

Some public LTC services are provided through the Unified Social Assistance System, this is means-tested and targeted to people without family support, and increasing availability of private care options (source: https://ltccovid.org/wp-content/uploads/2020/05/COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf).

Last updated: August 2nd, 2021

Bulgaria

In 2016 public LTC represented 0.4% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). People in need of care are covered by social assistance, which is managed at municipal level and by disability benefits (as a supplement to pensions for older people, for example). The country was reported in need to develop governance, financing and regulatory framework for LTC (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en).

Last updated: August 2nd, 2021

Canada (British Columbia)

In total, LTC services in British Columbia  cost $2 billion CAD per year, with the majority, $1.3 billion CAD, spent in the contracted sector (source: https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2020/02/ABillionReasonsToCare.pdf).

LTC services are available through publicly subsidized and privately funded services. Some publicly subsidized home and community care services are provided free of charge. For example, British Columbia has the highest recommended funded hours per resident day at 3.36 hours, higher than the Canadian average of 3.30. For other services, the cost is shared between the Ministry of Health and the person receiving services. The amount paid by individuals receiving care is called the client rate. Client rates are determined by BC’s health authorities and may be calculated based on income or set as a fixed rate, depending on the type of care received. For most LTC facilities, the person receiving care pays up to 80% of their income taxation and can also apply for a reduced rate due to financial hardship (source: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/who-pays-for-care; https://rsc-src.ca/sites/default/files/LTC%20PB%20%2B%20ES_EN_0.pdf).

Unpaid carers (commonly referred to as family caregivers in Canada) are represented by the Family Caregivers of British Columbia (FCBC), a provincial non-profit. FCBC represents over 1 million people in British Columbia. Although there is no data yet on how many family caregivers are present in the province. FCBC provides access to information and education and acts as a voice for family caregivers when liaising with other stakeholders in the health and social sector (source: https://www.familycaregiversbc.ca/).

LTC residents and individuals receiving continuous care in the community are charged a portion of their after-tax income. Individuals may apply for a reduction in rates due to financial hardship. For the most part, anyone requiring care should be able to receive it (source: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/who-pays-for-care).

Last updated: August 2nd, 2021

Cyprus

Public LTC expenditure in Cyprus was estimated to represent 0.3% of the Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Czech Republic

Public LTC expenditure in the Czech Republic was estimated to represent 1.3% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Some LTC services such as home care are covered by the health insurance system (if indicated by a general practitioner). Institutional care costs are mostly paid by out-of-pocket payments (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en). Informal care plays an important role in the sustainability of LTC, there is growing emphasis on support of informal carers and on improving the availability of respite services and counselling, and the coordination and management of care (source: CEQUA – Czech Country Report (filesusr.com).

Last updated: August 2nd, 2021

Denmark

Denmark spent 2.5% of GDP on publicly funded LTC in 2016, almost twice the EU average (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Denmark is one of the few EU countries to spend more on outpatient care than inpatient care. Municipalities are responsible for allocating resources; they obtain funding from the national government, local taxes and equalization money from other municipalities. Health expenditure per capita is €3831, comprising 10.2% of the country’s gross domestic product (GDP). No co-payments are applied for using long-term home-based care services (cleaning and personal care), although users who choose private providers can purchase additional optional services. Help with personal care and domestic tasks are not subject to fees (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Eligibility for long-term care is based entirely on needs assessment carried out by the municipalities. There are no thresholds or minimum dependence required for in-kind or cash benefits. Needs assessment for long-term care is multidimensional in nature and generally captures a wide range of aspects related to a person’s situation and well-being. Access is based on the principle of free and equal access, regardless of income, wealth, age or household situation (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

It has been estimated that 16% of the total population provides unpaid care for a relative, neighbour or friend at least once a week (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019). The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements. Unpaid caregivers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the EU (source: https://www.euro.centre.org/publications/detail/415). Family members may apply to be formally recognised as informal carers by applying to the municipality. If eligible, and after consultation with the person with care needs, the caregiver gets employed by the municipality, up to six months, with a prespecified salary calculated based on the national yearly income. Alternatively, municipalities can compensate for lost earnings individuals caring for close relatives with a terminal illness. Additional services include training and education programmes, often focused on improving knowledge and ability to provide the needed support and on attaining coping skills, such as self-help and peer groups (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 2nd, 2021

England (UK)

In 2018, LTC expenditure in the United Kingdom was estimated to represent 1.8% of Gross Domestic Product (source: https://stats.oecd.org/Index.aspx?QueryId=30140).

Local authorities are funded largely through a combination of a grant from central government and local revenue-raising mechanisms, including council tax for example. Social care funding is not ring-fenced, which means that local authorities can decide how much of their budget they allocate to care. Unlike the NHS, where healthcare is free to those using it, access to social care is determined by both need and means. A restrictive means test, which has not been adjusted since 2010, means that people with property (including housing), savings or income in excess of £23,250 must meet the entirety of their care costs alone. Those with means below the threshold of £23,250 may be eligible for part or full state funding for their care but they must also be deemed to have sufficiently severe care needs.

The distinction between ‘health’ and ‘care’ creates further inequity. A person deemed to have health needs may be able to access social care via the NHS’s continuing healthcare programme (although subject to restrictive eligibility criteria and long waiting times), but someone with personal care needs (e.g. arising from dementia) and no medical requirements is subject to the means test (source: https://www.nuffieldtrust.org.uk/news-item/other-types-of-support-how-do-the-countries-compare#support-for-health-needs).

In 2018/19, total expenditure on social care by councils amounted to £22.2 billion. There are few estimates of private spending on care, however the National Audit Office has estimated the size of the self-funder market (i.e. those who pay for their care) at £10.9 billion in 2016/17 (source: https://www.kingsfund.org.uk/publications/social-care-360/expenditure).

During the last decade, funding to councils has been cut by almost 50% (source: https://www.nao.org.uk/wp-content/uploads/2018/07/Adult-social-care-at-a-glance.pdf), which has put pressure on councils to spend less on care either through reducing the rates they pay providers or by reducing the number of people they fund. Because local authorities have a responsibility to revenue locally to subsidise the grant they receive from national government, those local authorities in more affluent areas are able to raise more (source: https://www.ifs.org.uk/uploads/publications/bns/BN227appA.pdf). The result is wide variation in the eligibility for care between local areas, despite the intention of the Care Act (2014) being to standardise eligibility.

Last updated: August 2nd, 2021

Estonia

In 2016 public LTC expenditure in Estonia was estimated to represent 9.9% of Gross Domestic Product (source: The 2018 Ageing Report: Economic and Budgetary Projections for the EU Member States (2016-2070) (europa.eu).

Last updated: August 2nd, 2021

Finland

Public LTC expenditure in Finland represented 2.2% of Gross Domestic Product in 2016 (source https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). LTC services are part of the universal health and social care system in Finland, with organization of services allocated primarily to local municipalities. The state government and municipalities are the major funders of LTC care, however despite most costs being covered by taxes, there are client fees. For example, in 2014, clients paid 18.5% of the costs of elderly people’s services (source: http://urn.fi/URN:ISBN:978-952-302-236-2). These LTC fees are defined by the user’s ability to pay. There are differences in the LTC provisions between different municipalities, as population demographics as well as availability of services vary between municipalities. Although Finland assigns its municipalities a legal responsibility to provide care services, families still play a major role in unpaid care provision. A restructuring of elder care services over the past few decades has resulted in an increased responsibility for care on individual families, which is financially supported through various cash-for-care schemes (e.g. informal care allowances); amounts and access to these types of supports is, however, relatively low. Municipal informal care support requires a contract between the municipality and the caregiver (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 2nd, 2021

France

In 2016 public LTC expenditure in France was estimated to represent 1.7% of Gross Domestic Product (https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

LTC funding is fragmented and divided across a complex web of actors, at a regional level (conseils generaux), health insurance (CNAM), not-for-profit (mutuelles) and private insurance policies, long-term care insurance (CNSA), central government, pensions, towns (municipalities) and individuals (source: https://www.alzheimer-europe.org/Policy/Country-comparisons/2007-Social-support-systems/France)

In terms of public spending, costs are shared between: long-term care insurance (CNSA), regions, the state, which in 2011 contributed approximately 9.7bn€, health insurance (CNAM), which contributed 11bn€, accommodation costs 7.5bn€ adding to a total of 21bn€, which amounted to 1.05% of GDP. Including the costs of household contributions would brought total spending to 28bn€, 1.41% of GDP (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

A market for private insurance for LTCI has developed as contributions are tax-free and is reported to be one of the largest (source: https://www.kingsfund.org.uk/sites/default/files/media/commission-background-paper-social-care-health-system-other-countries.pdf).

The country’s LTC policy is based on cash-for-care scheme called the Allocation Personalisee a l’Autonomie (APA), which provides some assistance to people over 60 with care needs above a government determined threshold of need (AGGIR 1-6) and is concerned mostly with homecare. In 2018 8% of people over 60s were APA beneficiaries (Source: https://halshs.archives-ouvertes.fr/halshs-02058183/document). APA is means-tested based on taxable income and some assets. There are high levels of out-of-pocket payments, individuals pay up to 90% of the care costs. For example, whereas individuals with below a monthly income of €800 do not contribute to the funding of the care, those with income of above €2945 contribute 90% of the care costs. Moreover, the level of the allowance depends on the need level (source: document (archives-ouvertes.fr).  Median cost of a room in a care home in 2018 was 1977€.

There were 4.8 million carers recorded in France in 2011. France is a country with a strong family tradition, where unpaid informal carers have always played an essential role. Support is delivered in-kind rather than in-cash. Some of the benefits for carers include the ability to take unpaid leave from employment and paid ‘solidarity’ leave for 3 months with an additional maximum 3 months which must be justified by medical certificate. Although researchers suggested that there is low take up and awareness of these schemes. Other services to support carers include respite care and training (sources: CEQUA France Country report (filesusr.com); https://halshs.archives-ouvertes.fr/halshs-02058183/document).

Last updated: August 2nd, 2021

Germany

In 2018, Germany’s expenditures for LTC amounted to 2.1% of GDP, including voluntary insurance and out-of-pocket-spending. Expenditures for compulsory government schemes amounted to 1.5% of the GDP, which is below the OECD average of 1.7% Germany has a LTC insurance system, which is the dominant financing scheme for LTC and is mandatory for enrolees in the statutory or private health insurance (source: Germany_draft.pdf (who.int). The LTC insurance is financed through equal contribution between employer and employees. Childless people pay a slightly higher contribution rate than those with children (3.30% of gross wages versus 3.05%) (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). Financial situation of LTC funds in 2020 can be found online.

In 2019, 4.25 million inhabitants received benefits from the LTCI. Of them, 3.34 million received home care and 0.91 million received residential care, and 4 million were covered by social LTCI and 0.25 million by private compulsory LTCI (source: Germany_draft.pdf (who.int). The LTC insurance is designed to cover only a share of the LTC-related costs. With regards to residential care, people in need of long-term care have to pay up to €2,400 per month out of pocket. This includes costs for food and the resident’s room. Where individuals/families cannot shoulder these costs, this will be provided through social security mechanisms. Costs vary substantially between the different Lander. While the private share of costs for care in residential care settings amounts to more than €1,000 in Baden-Württemberg, they are less than €450 in Thuringia (source: http://www.sozialpolitik-aktuell.de/files/sozialpolitik%20aktuell/_Politikfelder/Gesundheitswesen/Datensammlung/PDF-Dateien/abbVI49_Thema_Monat_02_2020.pdf).

LTCI grants access to services on the basis of LTC needs and it is not means-tested. Everyone with LTC needs is entitled to receive the services they require regardless of age, income, wealth, personal circumstances (such as living with a carer) and medical diagnosis (whether physical or cognitive). A needs assessment recognizes whether an individual should receive benefits and the amount. Individuals have to take a needs-based, uniform assessment test, which assigns them to one out of five potential “care degrees” ranging from 1 – “little impairment of independence” to 5 – “hardship”. The “care degrees” define the amount of benefits that the individual receives (source: Germany_draft.pdf (who.int).

Last updated: August 2nd, 2021

Greece

In 2016 public expenditure on LTC was estimated to represent 0.1% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Hungary

In 2016 public LTC expenditure in Hungary was estimated to represent 0.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Iceland

In 2018 total LTC expenditure in Iceland was estimated to represent 1.7% of Gross Domestic Product (https://stats.oecd.org/Index.aspx?QueryId=30140).

Last updated: August 2nd, 2021

India

Public funding for LTC is very limited, but there are a few public benefit schemes such as disability benefits and pension schemes that offer modest support. Most formal LTC is paid for through out of pocket payments (source: https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID-situation-in-India-30th-May.pdf).

Last updated: August 2nd, 2021

Israel

In 2016 total LTC expenditure in Israel was estimated to represent 0.6% of Gross Domestic Product (source: https://stats.oecd.org/Index.aspx?QueryId=30140). The National Insurance Institute (NII) is the primary public funder of home-based long-term care services and does so through the Long-Term Care Insurance Program (LTCIP).  LTCIP is income-tested with the aim of excluding the highest income earners. As of 2014, the NII subsidizes the care of approximately 160,000 seniors at a cost of NIS 5.31 billion (appx. 1.2 bill GBP). Assisted living (e.g. LTCFs) is primarily funded by the Ministries of Health and of Labour and Social Affairs, and accounts for 14% of publicly-funded LTC services. Complex inpatient care is funded by NII and accounts for 6% of public LTC funds. In all, public funds account for 55% of LTC services, with the remaining 45% found in the private sector (sources: http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf; The Long-Term Care Insurance Program in Israel: solidarity with the elderly in a changing society | Israel Journal of Health Policy Research | Full Text (biomedcentral.com).

Home care and community-based services are the main LTC service for older people in Israel. At the beginning of 2020, 220,830 individuals (of retirement age) were eligible to receive publicly financed LTC services at home (sources: https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4-May.pdf; https://www.btl.gov.il/English%20Homepage/Publications/AnnualSurvey/2016/Documents/Chapter%203_Long-term%20care.pdf).

There are also geriatric hospitals and sheltered housing facilities, many of which are owned and managed by the coordinated governmental healthcare system, Kupoth Cholim. These provide long-term geriatric treatment (including wards for older people with cognitive disabilities) as well as departments for active geriatric care (including complex nursing, hospice, and rehabilitative care) (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.75/); they became the primary source for concern and emergency response during the COVID-19 pandemic.

LTC insurance in Israel is neither universal or mandatory and LTC services are substantially funded by private and out-of-pocket expenditure (45%). This is a reality many Israeli social policy think tanks and NGOs believe to be unsustainable alongside the rapid increase in Israel’s older population (sources: http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf; https://www-tandfonline-com.gate3.library.lse.ac.uk/doi/full/10.1080/13537121.2020.1832329). The country heavily relies on unpaid carers: an estimated million and a half Israelis, mostly women,  serve as primary caregivers and typically provide 21 hours of caregiving a week (source: https://www.scirp.org/journal/paperinformation.aspx?paperid=67223). In April 2018, as part of the LTC reform, the National Insurance Institute launched a program to entitle home-based unpaid caregivers to long-term care benefits. Made a national policy in August 2019, family members can be paid as caregivers under certain conditions; statistics on the implementation of the policy are unavailable (source: https://adva.org/wp-content/uploads/2019/03/Care-Deficit-EN.pdf).

Last updated: August 2nd, 2021

Italy

In 2016 public LTC expenditure in Italy was estimated to represent 1.7% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Public expenditure on Long Term Care (LTC) includes three components: i) LTC  services to dependent people provided by the  public health care system, ii) the social component  of LTC provisions provided by municipalities and  iii) attendance allowances (source: update_joint-report_it_en.pdf (europa.eu). Unpaid carers provide the bulk of LTC services in the country, it has been estimated in 2017 that the overall number of carers of adult people in Italy was well over 4 million. The country also heavily relies on privately employed, primarily migrant care workers in household-based care (source: Italy Country Report (filesusr.com).

Last updated: August 2nd, 2021

Japan

Japan has a relatively well-funded system, based on mix of tax, social insurance and individual co-payments. Revenue raising mechanisms are flexible to allow for extra top ups in difficult times. However, the system is under financial pressure due to the rapid rise in need as a result of rapid ageing. Its generosity has been reduced over time over affordability concerns (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan).

On being assessed as needing care by the Long-Term Care Insurance system (LTCI), service users are assigned a monthly in-kind budget to spend on care according to their level of need. Service users pay a co-payment on accessing services which ranges from 10% for most people to 30% for most affluent. Co-payments are capped at fixed monthly level on a sliding scale according to income. People can opt to buy more care beyond assigned level at 100% cost, but care packages are thought to be generous and few people top up beyond their allocated budget. The re-imbursement for care services from the LTCI does not cover room or board.

The 50% of the funding for the LTCI system is from mandatory insurance contributions from all residents aged 40 and older and the rest is from taxation: 25% from the national government and 12.5% each from the prefectural and municipal governments. The insurance rates are set by each municipality on the basis of the insured resident’s income levels (source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

The extent to which the system relies on unpaid care is unclear. The recent reforms were successful in largely shifting the responsibility of caring from families to the state by offering in-kind benefits to those in need. However, there are no cash benefits for people with needs, hence there is no option to use cash benefits to pay for care to relatives or friends. At first, there was concern that people would not take the in-kind benefits up due to stigma attached to using public care provision (traditionally it has always been a family duty), however the design and generosity of the system quickly changed societal views. However, there still is reliance on unpaid care – benefits are generous but may not cover all needs. There is also a 10% co-payment on accessing care, therefore poorer people may need to avoid using formal care for that reason (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan).

Last updated: August 2nd, 2021

Latvia

Public LTC expenditure in Latvia was estimated to represent 0.4% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). The availability of unpaid carers is considered during assessment for formal provision of home care, consequently, home care is provided mostly for people living alone who have no help from family or close neighbours. No policy planning concerning support for informal carers have been developed in Latvia. In 2017, there were neither cash nor in-kind benefits for carers of dependent adults (source: CEQUA Latvia Country report (filesusr.com).

Last updated: August 2nd, 2021

Luxembourg

Public LTC expenditure in Luxembourg was estimated to represent 1.3% of Gross Domestic Product in 2016 (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Netherlands

Public expenditure on LTC as percentage of GDP was estimated to be 3.5% in 2016, more than twice the European Union average of 1.6% (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Seventy five percent of spending is allocated to residential care. Private expenditure on LTC (co-payments and out of pocked payments) is relatively low. However, in residential care, residents have to contribute to their board and accommodation. Co-payments have increased considerably for those with higher incomes. Cash for care has been a recent addition for people receiving community care, but in 2016, only 4.7% of recipients of home care aged 65 and over had a personal budget. Benefits are universal but needs tested. There has been a marked shift over time from institutionalisation to community care, with substantial involvement from patient and client organisations. There has been another more recent shift from collective (state) responsibility to individual responsibility and self-reliance. Involvement of unpaid carers, especially families, is now part of the official policy. This however goes against the widespread view that the state should take responsibility for older people in need of care. It is also recognised that this shifts the burden of care back to women (source: https://drive.google.com/file/d/1P5J1JQlr-ts65lknBwBFtTkJNXHLDyrL/view).

Last updated: August 2nd, 2021

Norway

In 2016 public LTC expenditure in Norway was estimated to represent 3.7% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Portugal

In 2016 public LTC expenditure in Portugal represented an estimated 0.5% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Republic of Korea

Total LTC expenditure in Korea represented 1.0% of Gross Domestic Product (GDP) in 2019 (source: https://stats.oecd.org/Index.aspx?QueryId=30140), of this, expenditure through the public LTC Insurance system accounts for 0.37% of GDP (source: https://www.sciencedirect.com/science/article/pii/S016885102030275X).

A universal, public LTC insurance (LTCI) for the older population was introduced in 2008, and it requires no means-test (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf ). Services include institutional and home/community care (https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

In terms of eligibility, the intended beneficiaries of the system are all Koreans, it mainly targets older people (age 65+).  In 2018 around 8.8 % of the total older population were covered by LTCI (source: https://www.sciencedirect.com/science/article/pii/S016885102030275X), which comprises 2.7% of older adults living in LTCFs (2018) and 6.2% of older adults in receipt of community based LTC (2018) (source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: August 2nd, 2021

Romania

In 2016 public LTC expenditure in Romania represented 0.3% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Singapore

Financing for LTC and support to older adults exists within an overall health-care financing that, in turn, is linked to the way in which social care and pension funding is organized. There are three complementary insurance schemes for disability cover: ElderShield and ElderShield Plus, and CareShield. ElderShield is a severe disability insurance scheme under which all citizens and permanent residents born before 1979 who have a MediSave account are automatically covered from 40 years of age (opt-out is possible). To be eligible for the scheme, individuals must be unable to carry out at least three out of six basic activities of daily living. ElderShield Plus offers higher monthly payouts or payouts for a longer period or a combination of both. CareShield Life is a compulsory insurance policy introduced in 2020 that provides payouts for people who are severely disabled. Everyone born between 1980 and 1990 is enrolled automatically and younger cohorts will be enrolled as they turn 30. Another funding scheme introduced in 2020, ElderFund, provides financial support for low income, severely disabled Singaporeans. Additional subsidies and schemes exist to finance LTC. Some schemes focus on financial support to informal caregivers and home-based care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).

Last updated: August 2nd, 2021

Slovakia

In 2016 public LTC expenditure represented 0.9% of Gross Domestic Product in Slovakia (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Slovenia

In 2016 public LTC expenditure represented 0.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

Sri Lanka

Health spending was 3.8% of GDP in 2017, of which 1.6% was accounted for by public health expenditure and 2.2% by other financing. The government finances most social services, while non-profit sector and private donation financing is limited.  Families currently bear most LTC costs.  Residential care homes are financed by the non-profit sector and fees are paid by the resident or covered by charitable donations. In-home nursing care services are financed by out-of-pocket payments (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (adb.org).

Last updated: September 6th, 2021

Sweden

In 2016 public long-term care expenditure represented an estimated 3.2% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). About 90% of health and social care is financed by local government, the counties and municipalities, through taxation. The user pays only a fraction (4% or 5%) of the cost and the remaining 5% is covered by national taxes (source: Sweden Country Report (filesusr.com). LTC in Sweden has been affected by financial cutbacks, which has had negative consequences for e.g. care workers’ working conditions as care workers are increasingly working in under-staffed conditions (source: Johansson-L.-Schön-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf (aldrecentrum.se).

Public policies and programmes providing social services and support, as well as healthcare, are comprehensive. There are no national eligibility regulations, however for home care and institutional care, local governments decide on the service levels, eligibility criteria and a range of services provided. Although the general principle behind LTC policy in Sweden is to provide publicly subsidised, widely available in-kind services thereby removing the burden of providing services from the family; approximately two-thirds of all care for community-living older people is provided by unpaid caregivers. Unpaid carers can claim time off work (care leave) with compensation from national social insurance. Carers may receive cash benefits from municipalities (however these are not covered by national regulation and municipalities can choose whether or not to offer the allowances). Another option is carers’ allowance which involves the municipality employing a family member to provide care work, however it is not payable for people 65 years or older. Direct in-kind support for carers is provided by all municipalities as a general service and not based on needs assessment, it can be in the form of information and advice, counselling, support groups, respite care. The intensity, content and quality of the provided support can, however, vary between the municipalities (source: Sweden Country Report (filesusr.com).

Last updated: August 2nd, 2021

Switzerland

In 2018 LTC expenditure was estimated to represent 2.4% of Gross Domestic Product in Switzerland (source: https://stats.oecd.org/Index.aspx?QueryId=30140).

Last updated: August 2nd, 2021

Thailand

Total public spending on health-related LTC was 1.7 billion in 2012. The Ministry of Public Health is the major source of finance (1.6 billion). Spending by nongovernment organizations (NGOs) on health-related LTC was 70.3 million. Finance from family members is a major source of funding for LTC in Thailand. Government revenue is a source of finance for the Community-Based Long-Term Care Program, under the National Health Security Office (NHSO). But out-of-pocket payments are the main source of funding for LTC in private residential facilities (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org).

Last updated: September 6th, 2021

Turkey

Turkey has a familiarist welfare, placing intergenerational obligations to provide care on family members, but there are concerns about the sustainability of this model. There is growing support from the non-profit sector and other private providers, some of whom receive public funding from provision of services, this support is means and needs-tested (source: https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19-Long-Term-Care-situation-in-Turkey-1.pdf).

Last updated: August 2nd, 2021

United States

In 2018 LTC expenditure represented 0.8% of Gross Domestic Product in the United States (source: https://stats.oecd.org/Index.aspx?QueryId=30140). The financing of LTC in the United States is a continuous and growing challenge. Medicaid is the primary payer for formal LTC services, accounting for over half of national spending in 2017, however it is means-tested: it requires proof of need and exhaustion of individual financial resources (e.g. low-income status and/or limited savings). In 2016, the majority of Medicaid LTC funding was spent on home and community-based services (57%), but several states still apply their Medicaid dollars primarily to institutional care. Coverage and spending on LTC schemes also vary significantly by state (source: https://ldi.upenn.edu/sites/default/files/pdf/LDI%20Issue%20Brief%202019%20Vol.%2023%20No.%201_7_0.pdf).

Some states fund home and community-based services through Medicaid waivers, and some even allow for self-directed Medicaid funds for payment of informal carers (source: https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf; https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf). An estimated 7.4 million Americans own private LTC insurance policy (around 15% of persons 65 and over). The system relies heavily on informal (unpaid) caregivers: 75% of those needing LTC rely solely on informal caregivers and approximately 41 million Americans are unpaid caregivers (source: https://ldi.upenn.edu/sites/default/files/pdf/LDI%20Issue%20Brief%202019%20Vol.%2023%20No.%201_7_0.pdf). These demands are also disproportionately experienced by women, individuals of low socioeconomic status, and minority racial and ethnic populations. Over the past 10 years some states used provisions in the Affordable Care Act to redistribute some Medicaid funds towards at-home, informal caregiving, nationally this shift has been small (source: https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf).

Last updated: August 2nd, 2021

1.04. Long-term care system governance

Lithuania

Public LTC expenditure in Lithuania represented 1.0% of Gross Domestic Product in 2016 (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021

African Union

The Executive Council of the African Union recently adopted a Common African Position on Long-Term Care Systems for Africa. Despite this progress, few regional or national frameworks exist to guide more specific action. Focused debate has been largely absent, reflecting the low policy and political priority accorded to long-term care, combined with a belief that the issue has little impact on economic development. With the exception of a few countries, little organized service capacity or national coordination exists. Rather, the provision of long-term care rests overwhelmingly with family members, which is fuelled by a belief among some that western models of organized long-term care pose a threat to African values (source: https://www.who.int/publications/i/item/9789241513388). ~

The African Union has drafted several policy frameworks relevant to long-term care. These include the AU Policy Framework and Plan of Action on Ageing; the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Older Persons in Africa; and the Common African Position on Long-term Care Systems for Africa. At the national level, several countries including Ethiopia, Ghana, Kenya, Mauritius, Uganda, and the United Republic of Tanzania have adopted consistent overarching ageing policies or national legislation relevant to older people, such as the Older Persons Acts of South Africa and Zimbabwe. However, with few exceptions, national policies and legislation overlook significant aspects of sustainable systems of long-term care. In general, they do not provide a framework or roadmap for integrating long-term care across a range of settings and often do not examine the cultural norms and expectations inherent in substantial family involvement in long-term care provision. In addition, they do not specify mechanisms for preparing and supporting caregivers and rarely specify how to ensure a sustainable financing mechanism and workforce supply as the older population grows. Few of the frameworks address how to improve access and affordability for poor and marginalized groups (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: September 10th, 2021

Australia

There is central oversight from the Australian government, as they are responsible for regulating and funding the majority of aged care services. However, state and territorial governments also have jurisdiction over the provision of aged care, which increases the complexity of the system and leads to a division of power (source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

The Australian Department of Health is responsible for the development and implementation of aged care policy, including advising the Australian Government, funding, and administration. The Aged Care Quality and Safety Commission is responsible for aged care regulation. State and Territory Governments, along with the private sector, are responsible for the delivery and management of health care, including aged care (sources: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf; https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

The Australian government’s Department of Health created the Royal Commission into Aged Care Quality and Safety in 2018 to evaluate the current Aged Care sector and to provide recommendations for reform. A group of experts in this commission have identified several weaknesses of the aged care sector, especially in light of COVID, and have recently issued their final report (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Last updated: August 3rd, 2021

Bulgaria

LTC consists of a wide range of medical and social services and is understood as lying across the boundary between medical and social care and is subject to a number of social and healthcare regulations. LTC under social services are provided in the community and in specialized institutions. LTC services are also regulated by the Health Act and are provided by different types of specialized medical institutions (source: CEQUA Bulgaria Country report (filesusr.com).

Last updated: August 3rd, 2021

Canada (British Columbia)

Five regional health authorities are accountable for all LTC including residential facilities and community care. However, public health authority owned facilities receive more support and oversight compared to privately owned facilities (source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).  BC has five regional health authorities and a Provincial Health Services Authority (PHSA), is responsible for managing the quality, coordination, accessibility and cost of certain province-wide health care programs. Each health authority has oversight over their own publicly owned LTC facilities. However, there is lack of coordination between health and social care. Healthcare is monitored more by the national government although jurisdiction is under the provincial government, whereas social care is almost exclusively provided and monitored by regional health authorities within the province (source: https://www.bcauditor.com/online/pubs/775/782#:~:text=The%20province’s%20six%20health%20authorities,responsible%20for%20health%20service%20delivery).

 

Last updated: August 3rd, 2021

Canada

Provinces in Canada have jurisdiction over the health care sector but are governed under the Canada Health Act, which establishes “criteria and conditions related to insured health services and extended health care services that the provinces and territories must fulfil to receive the full federal cash contribution under the Canada Health Transfer”. LTC facilities are not included under the Canada Health Act and are solely under the jurisdiction of the 5 regional health authorities (source: https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html).

Last updated: August 3rd, 2021

Denmark

In 2015, the responsibility for regulating services and support for older people was transferred from the Ministry of Social Affairs and the Interior to the Ministry of Health. This transfer of responsibilities for regulation and oversight of care for older people represents a step towards integrating central and strategic decision making for health and social services. In 2016, a position of Minister for Senior Citizens was created within the Ministry of Health, transferring to it a portfolio that was previously under the control of the Minister for Health.

Although national legislation sets a broad framework for service provision, municipalities maintain responsibilities for long-term care policies. These include establishing eligibility and entitlement criteria and the level and content of service delivery, regulating services’ delivery and organizing the public provision of services. Healthcare agreements are political and administrative documents agreed on by each municipality and the corresponding administrative region at the beginning of each election cycle and are renewed every four years. The goal of these agreements is to provide a platform for negotiation between the main stakeholders and a framework for the practical collaboration of actors at different government levels. These agreements include six mandatory thematic areas: hospitalization and discharge processes, rehabilitation, devices and aids, disease prevention and health promotion, mental health and follow-up on adverse events and feedback mechanisms (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

 

Last updated: August 3rd, 2021

England (UK)

The Department of Health and Social Care has overall policy responsibility for adult long-term care policy in England. The assessment of care needs, and the commissioning and organisation of care is the responsibility of 152 local authorities, a small minority of which also run and deliver some care services. Government financial support for local authorities, including their social care responsibilities, is channelled through the Ministry of Housing, Communities and Local Government. Although there are initiatives at local and regional levels which aim to integrate health and long-term care services (with varying degrees of success), they remain two separate systems.

Last updated: August 3rd, 2021

Finland

The Ministry of Social Affairs and Health oversees the planning and drafting of all social care policy; it also monitors its service standards through 1) the National Supervisory Authority for Welfare, Valvira, which grants licenses to private and public care program, and 2) six Regional State Administrative Agencies (AVIs), which ensure standardization of care across the country. However, local municipalities hold vast discretionary power: they are responsible for arranging and supervising the social and health services in their own area. They act as self-governing administrative units and form the majority of public administration in Finland. LTC is a policy priority for Finland’s Ministry of Social Affairs and Health, especially in the context of a rapidly growing older population with increasingly formal/institutional care needs. Clarity of accountability, assessment and monitoring when determining LTC service plans is a legislative priority. Implementation of legislative priorities is however challenging; the promoted value of self-determination often conflicts with ensuring the quality care provision plans (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 3rd, 2021

France

France has a highly fragmented LTC system with operations at multiple levels at national, regional and municipal levels and significant regional variation. There is also limited coordination across actors, which all have different remits. Regional Health Agencies (ARS) were created in 2009 trying to represent central government at regional level, which resulted in expansion of remit of regions to social care as well as health. Regional structures (ARS) have oversight of healthcare, and some social care which is designed to provide some level of integration across the two sectors. Some level of integration has also been achieved through pathways and networks generally around gerontology and independence loss, as well as regional support networks and local information centres (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

Last updated: August 3rd, 2021

Germany

The government has laid out the legal framework, providing an overview of the different actors, their roles and the list of benefits in the Social Code Book XI (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). The German Federal Government has a dedicated person responsible for care. This role was created in 2014 and the responsible person was appointed in 2018. The role of this position is to advocate for the interests of people with care needs in the political arena and to ensure that the health- and care system are centred around them. This office is involved in all matters (legal, orders etc.) to do with care. (source: https://www.pflegebevollmaechtigter.de/amt-und-person.html).

By law, 50% of residential care workers are required to be trained as skilled workers. This requirement, however, is not always met. From March to October 2020 quality controls were suspended during the pandemic to relieve the burden on domiciliary and residential care (source: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html; https://www.mdk.de/aktuelles-presse/meldungen/artikel/ab-oktober-persoenliche-pflegebegutachtungen-und-qualitaetspruefungen/).

The medical service of the health insurances (Medizinischer Dienst der Krankenversicherung (MDK)) ensures that services provided through health- and long-term care insurance are provided to people based on objective medical criteria and that all people with insurance coverage receive services based on the same conditions. It aims to ensure that people receive necessary services but also are protected from those that are unnecessary or potentially harmful. The MDK evaluates quality of services on an annual basis. The Social bill ensures that members of the MDK are independent.

TheLTC insurances funds are required to publish the quality reporting of the MDK. The report consists of 59 criteria in the areas ‘care and medical care’, ‘handling of residents living with dementia’, ‘support and everyday life’ as well as ‘living, food, housekeeping and hygiene’. In addition, people living in residential care setting and people receiving support in the community are being ask about their experience (source: https://www.mdk.de/mdk/mdk-gemeinschaft-gesundheitssystem/; https://link.springer.com/content/pdf/10.1007%2F978-3-662-56822-4.pdf).

 

Last updated: August 3rd, 2021

Israel

Accountability is an issue in LTC services in Israel, due to the private and insular nature of Israel’s predominant culture of at-home LTC services. The creation and implementation of a national care coordinator and a working group to streamline LTC enrolment and increase transparency were explicit components of the 2018 governmental reform. Results of the effectiveness of this rollout have been unclear, and undoubtedly interrupted by the COVID-19 pandemic.

Last updated: August 3rd, 2021

Italy

The current LTC governance structure is fragmented, e.g. at the central level, the responsibilities for LTC lies between the Ministry for Labour and Social Policy and the Ministry of Health. Moreover, Regions implement the dual ministerial policies by defining regional policies and network of services; local health authorities and municipalities manage services and interventions at the local and individual level (https://ltccovid.org/2020/04/10/report-on-covid-19-and-long-term-care-in-italy-lessons-learned-from-an-absent-crisis-management/).

Last updated: August 3rd, 2021

Japan

Accountability for the system is clear: national framework of revenue raising, eligibility & benefits sits alongside clear role for municipalities as insurers for over 65s and market shapers with some powers to influence provision (source: https://www.nuffieldtrust.org.uk/files/2018-06/learning-from-japan-final.pdf).

Last updated: August 3rd, 2021

Mauritius

A national policy on the elderly (2001) has been adopted. There is a Protection of Elderly Persons Act 2005, which is aimed at protecting older people from all forms of neglect and abuse. Older people are afforded further rights and protections in the more general National Human Rights Action Plan (2012–2020). The Government of Mauritius oversees and funds many aspects of health and social care for older people. Day care centres offer recreational and educational programmes throughout the country. Those with demonstrated need receive free assistive devices and home health visits (source: https://www.who.int/publications/i/item/9789241513388).

The Residential Care Homes Act 2003 was enacted in order to establish standards and codes of practice and to monitor the quality of care delivered in private homes. Regular inspections of both public and private homes help to ensure that residents receive adequate care (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 3rd, 2021

Netherlands

The Ministry of Health, Welfare and Sport is responsible for care homes, social care and nursing care (i.e. all aspects of LTC), as well as health. Since 2015, community care has been devolved to private insurers and municipalities. Regional care offices contract with (WLZ and ZVW) providers and have a responsibility to ensure that there are sufficient services to meet demand. These offices are run by one private care insurer who represents all care insurers active in the region. Municipalities are responsible to provide services under the WMO and have incentives to reduce costs.

Last updated: August 3rd, 2021

Seychelles

The Government of the Seychelles has recently unified health and social care in a Ministry of Health and Social Affairs. This new Ministry has an opportunity to strengthen long-term care governance and to develop plans to ensure the quality and financial sustainability of long-term care in years to come (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 3rd, 2021

Singapore

The Ministry of Health is responsible for governance over the entirety of the health and LTC systems, including setting policy direction, projection of national-level service demand, health and LTC financing, regulatory frameworks, standards, oversight, and coordination of related bodies. The Aging planning Office is responsible for setting policy direction and implementation for successful aging across sectors; Agency for Integrated Care is responsible care integration for health and social care systems (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).

Last updated: August 3rd, 2021

South Africa

South Africa’s Older Persons Act (2006), as well as more general legal and policy instruments, guides national action on long-term care. Coordination and implementation of national policy fall mainly to the Department of Social Development and to the Department of Health. The former administers old-age pensions and finances and oversees residential, community and home-based care, while the latter addresses older people’s health care needs. The Department of Human Settlements plays a lesser role, in that it regulates retirement villages. Overall coordination of long- term care across these Departments is lacking and clinical-level integration of health and social care is limited. Organized long-term care could be expanded to include a broader range of service approaches and settings (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 3rd, 2021

Spain

Generally speaking, LTC services are under regional administrations. Delegating the provision of LTC services and benefits to the regions has entailed differences in the access to benefits in different regions. Even though social services are managed, regulated and promoted by the autonomous regions, there are some programmes promoted by the central state, for example  vacations programmes for older people which are partly subsidised by the state (source: CEQUA Spain Country report (filesusr.com).

Last updated: August 3rd, 2021

Sri Lanka

The Constitution of Sri Lanka grants all citizens the right to health care, while legislation such as the Protection of the Rights of Elders Act and the Protection of the Rights of Elders (Amendment) Act focus more on elders’ rights and welfare. The National Elderly Health Policy of Sri Lanka was launched in February 2017, and the delivery plan mandated the redevelopment of underutilized inpatient health-care facilities into LTC facilities. The Ministry of Health, together with the established State Ministry of Primary Health Care, Epidemics and COVID
Disease Control, are responsible for policy and formulating LTC services for older persons (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (adb.org).

Last updated: September 6th, 2021

Sweden

The Community Care Reform of 1992 was the major policy initiative which defined responsibilities and accountability in LTC for older people. Responsibility for health care and social services is divided between three levels of government. At the national level, parliament and the government set out policy aims and directives by means of legislation and economic steering measures. At the regional level, the county councils and regions are responsible for the provision of health and medical care. At the local level, the municipalities are legally obliged to meet the social care and housing needs of older people. The Swedish LTC system is therefore provided, managed and financed by the 290 municipalities and the 21 counties and regions.  Municipalities are responsible for home care, including help with activities of daily living (ADLs) and personal care; for providing home health care, day care, and short-and long term institutional care including nursing homes, residential care facilities and group homes for persons with dementia (source: https://1d520973-35f0-4e46-8af0-304ac08d8794.filesusr.com/ugd/e1a359_f271d4f46fe240b3b7ebcd660142459f.pdf; https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812). Although municipalities are responsible for care of older people, there are various care providers within the municipalities – these may be public or private (source: https://www.government.se/legal-documents/2020/10/dir.-202074/).

Last updated: August 3rd, 2021

United States

The governance of LTC in the United States is complex and uncoordinated, primarily because of the variation by state regarding fund allocation and aging populations. There is a shortage of an appropriate, nationwide system to address the health and social care needs of the population. There has been a recent increase in attention given to the issue at the national level, despite this, fragmented and under-resourced systems remain in place. Federal services tend to be scattered across agencies with minimal collaboration. Various LTC programs are in nascent stages, operating independently (source: https://academic-oup-com.gate3.library.lse.ac.uk/innovateage/article/4/1/igz044/5688188).

Federal?level attempts at financing reform have either ended in failure or produced incremental changes to the financing arrangements. Demands for reform and reconsideration of the direct-care workforce have increased particularly in light of the pandemic (source: https://onlinelibrary-wiley-com.gate3.library.lse.ac.uk/doi/full/10.1111/1468-0009.12500#milq12500-bib-0016).

Last updated: August 3rd, 2021

1.05. Quality and regulation in Long-term care

Overview

While quality of long-term care is a common aspiration in many countries,
our report reveals a diversity of approaches to defining and measuring quality.

The quality of LTC can be, and often is, approached from various angles, and relevant dimensions often include: the quality of life of the person with care needs, supporting people to have lives that are as empowered and independent as possible; improving, or limiting the deterioration in, medical conditions; protecting people’s human rights or a mixture of all these different elements. Furthermore, different stakeholders, including providers, policy makers, unpaid carers, may understand quality from different angles. For example, there is no formal national definition of long-term care quality in any of the EU Member State and many countries use the existing broad quality definitions applicable to healthcare and social care services. Such approaches to defining quality, however limited, usually apply to formal long-term care, while the quality of informal lcare is even less addressed (Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

International reports and sources

EU Report on LTC (2021) covers LTC quality in Member States.

Greece

There is no national or sub-national definition of LTC quality in Greece neither in the context of the healthcare sector nor for the social care sector. There is also a lack of a general LTC quality framework that would apply to all types of support (residential or home care) and to various providers (public, for-profit, not-for-profit). Quality assurance is mainly based on a set of pre-determined standards which are included in the different legal regulatory frameworks that govern the licensing and operation of the various types of LTC facilities and providers, while monitoring and control of the operation of the LTC facilities and providers is subject to on-site inspections by the competent services of the regional authorities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

 

Last updated: August 2nd, 2021

Australia

The Aged Care Quality and Safety Commissioner, under the Australian government, is the national regulator of aged care services. It is responsible for approving subsidies for aged care providers, accrediting aged care services, monitoring quality of care, providing education, and handling complaints. Aged care providers must comply with the Aged Care Quality Standards set by the Aged Care Act and the Aged Care Principles (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Last updated: August 2nd, 2021

Austria

As of 2021 there is no clearly defined and integrated quality framework, covering the different sectors of LTC. The ‘15a agreement’ on LTC between the Federal Republic and the federal provinces defines general quality criteria and leaves considerable room for interpretation. On the subnational level, the federal provinces enacted more detailed regulation to promote the quality of LTC services. These regulations address the structural and procedural aspects of LTC quality, and usually do not give much emphasis to outcome-related aspects (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Belgium

The quality of LTC is ensured through initiatives and laws at different levels of governance and for different sectors or professionals. At federal level, healthcare professionals are regulated through the Ministry of Health and Social Affairs. Overall, quality in nursing homes is ensured through inspections, but also through set standards. In Flanders, the quality standards are related to the quality decree of 2003 setting the framework and quality criteria and indicators covering quality of care, safety, providers and organisation quality, and quality of life (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Croatia

The LTC quality framework in Croatia is implemented under the by-law on the standard of quality of social services, based on the Social Care Act in force since 2014. Quality standards have become mandatory for all providers of residential and non-residential social services, private and public ones. The Healthcare Quality Act regulates the qualitative framework for LTC in health services (Source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Cyprus

There is no quality framework that applies to all LTC services, and no relevant legislation exists to regulate quality standards for all LTC services. However, there is legislation regarding the quality of services in some areas of LTC, such as residential care and day-care centres. Homecare provision is monitored via visits made by social services officers, who are required to follow a specific evaluation/assessment protocol, made up of three competency themes: self-care, household tasks, and mental state. Regarding LTC in residential care and day-care centres, quality is monitored by reference to the minimum standards set out in the respective legislation and through regular inspections of the centres. Residential and daycare providers, either public or private sector, must meet certain minimum quality standards such as: the suitability and qualifications of employees; the ratio of employees to beneficiaries; the suitability and condition of facilities; the bedroom area ratio and shared areas ratio for each beneficiary; hygiene facilities; buildings safety and physical access; the suitability and range of LTC services provided; and the provision of socialisation and entertainment activities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Czech Republic

The tools introduced by the legal framework to ensure the quality of formal services in social care sector are the provider’s registration (each provider must be registered to provide services, registration can be withdrawn if quality standards are not met), inspections, and qualifications and training requirements for social workers. Current standards of quality focus on processes within institutions and on personnel capacities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Denmark

While the municipalities are responsible for service and quality assurance they need to comply with standards set by national framework legislation. Quality standards for long-term care apply to public and private providers. The municipalities must ensure full transparency and clear separation between their function as providers and as the authority supervising quality. The municipal quality standards describe in detail the services available at the local level and are intended to be sufficiently objective and transparent to allow users to evaluate the performance of the provider themselves. For general monitoring of providers, municipal governments and the Ministry for Social Affairs and the Interior have developed 23 impact and background indicators as part of the agreement on care for older people. Most indicators are monitored through administrative data and, every two years, user surveys (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 2nd, 2021

England (UK)

The Care Quality Commission (CQC) is an executive non-departmental public body of the Department of Health and Social Care and serves as the independent regulator for both health and long-term care (source: Care Quality Commission (cqc.org.uk).

Last updated: August 2nd, 2021

Estonia

Since 2018 (following the Estonian Social Welfare Act) there are quality principles that must be followed in the provision of social services (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Finland

An important device to monitor the quality of care is the personal care and service plan, which specifies the services and support measures that a client should receive. It is a care contract between the client (or their representative) and the municipal authorities. The care contract is used in residential and home care settings. At the institutional level, the National Supervisory Authority for Welfare and Health (Valvira) and six regional state administrative agencies supervise all the LTC provisions. They give directives and provide licenses to the private LTC producers which fulfil the basic requirements set in legislation, they also process complaints centrally, which enables them to get an overall picture and conduct broader investigations of the LTC facilities. Unannounced inspections are also carried out by the supervisory authorities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

France

No formal, comprehensive definition of LTC quality has been produced by national or local public authorities. Nevertheless, the reforming the social care sector act of 2002 describes the different components of quality and three main dimensions can be identified: 1) The obligation for social care providers to carry out a double evaluation: an internal one carried out by the provider and focused on quality improvement; and an external evaluation (which guarantees renewed authorisation) carried out by an external body; 2) The respect of different basic user right and 3) Multiannual contracts (five years) of objectives and means are signed between social care providers and pricing authorities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Germany

Quality of LTC has been a government focus, and addressed through different laws, including new procedures for quality assurance and reporting in residential care settings, financing of 13,000 additional posts, LTC pay rates required to be set according to collective wage agreements and the development of a test to calculate adequate staffing levels (Personalbemessungsverfahren) in LTC settings (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view; https://www.gs-qsa-pflege.de/wp-content/uploads/2020/09/Abschlussbericht_PeBeM.pdf).

Responsibility for quality of services sits with the providers, however they operate in close collaboration with LTC funds and municipalities. Länder and local authorities are responsible for an efficient infrastructure, including that facilities are available and accessible (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).

Last updated: August 2nd, 2021

Hungary

There are national definitions of LTC quality provided by the responsible ministries in the form of government decrees or recommendations. Reflecting the dual structure of the LTC system, quality is defined separately regarding home nursing care as well as social care. Quality of services is typically defined by inputs, such as minimal requirements on personnel (number of employees and their qualification), physical conditions, infrastructure and equipment. For some services, procedures such as care planning are also prescribed in the decrees. The quality frameworks are mandatory and apply to all providers irrespective of their legal background (private, for or non for profit, or public providers) (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Ireland

Since 2008, there have been independent, unannounced inspections of all public, private and voluntary nursing homes. These inspections are carried out by the Health Information and Quality Authority (HIQA). Since July 2012, a system of approved service providers has been put in place under home support services. The approved providers must meet a uniform level of national standards. There are some 35 standards including a person-centred approach, autonomy, safeguarding, the promotion of rights and dignity as well as standards in relation to provision and use of resources. It is planned that home care services will be independently inspected but as of 2021 there was no statutory basis to do so (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Italy

There is no overall definition of LTC quality either at national or regional/local level. The national government is responsible for quality control at system level, this responsibility is shared with the regions. The latter adopt slightly different solutions and, to varying degrees, have been able to implement quality-assurance measures. Given the absence of a quality framework, LTC quality is assured through the following tools: authorisation and accreditation; the ratio between beneficiaries and different kinds of professional staff; legislation addressing abuses and mistreatment of LTC recipients; and professional requirements for workers employed in the. The use of these tools varies according to whether the services are residential/home-based, or alternatively whether they are related to healthcare or social care (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Lithuania

There are two different quality-assurance systems for LTC, integrated within either the healthcare system or welfare social services. Some quality requirements are enshrined in national law, while others are defined by municipalities or service-providers themselves including national quality regulations of LTC (e.g. hygiene norms) (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Poland

There is no formal quality framework regarding LTC services in particular, though various regulations address the presence of goal and process-oriented measures with respect to quality assurance separately in the healthcare and social sector. In the social sector, standards are set particularly in respect to residential care, covering minimum standards of the room size, access to toilets and kitchen, sanitation requirements, rooms furnishings and equipment, food as well as minimal staff requirements. Community day care services are standardised within dedicated programmes, such as ‘Senior+’ where minimum requirements regarding facilities and staff are set. Standards in home care are set covering broadly the types of services available and staff qualifications (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: August 2nd, 2021

Romania

The quality of LTC social and socio-medical services is regulated by the law regarding the quality assurance of social services. The Social Policies and Services Directorate is in charge of designing the minimum quality standards for social services for dependent older people and the accreditation of all public and private service providers. The minimum quality standards cover residential care, community-based care and homecare. The National Agency for Payments and Social Inspection can undertake unannounced control visits and conduct inquiries when problems are signalled with regards to quality in LTC ; yet it is not responsible for systematically monitoring of service providers or services (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu). 

Last updated: August 2nd, 2021

Spain

The Spanish LTC system has three instruments to ensure quality: 1) a national and regional regulatory system; 2) formal quality controls; and 3) good practices. The regulation of quality in terms of services and the training of professionals and carers is developed in detail through the CISAAD which sets the minimum criteria for the whole state with respect to minimum carer-to-recipient ratios, staff qualifications, and resources/equipment/documentation applied to all accredited care centres. The CISAAD also establishes essential quality standards for homecare and residential care. Accredited centres can be inspected at the request of a dependent user or randomly by the autonomous community. The formal quality controls of the LTC system (the SAAD) are based on the accreditation systems established by each regional authority. Although there is a common denominator among them, each region has its own specific regulation and quality plan. With regard to good practices, the CISAAD agreed on common criteria to define, develop, and evaluate good practices in 2011, however most regions have not developed tools to evaluate good practice (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

 

Last updated: August 2nd, 2021

Sri Lanka

Since 2011 every person or organization, voluntarily or otherwise, that is engaged in the establishment and maintenance of any institution intended for providing residential care to more than five elders must register with the NSE, failure to comply with this requirement is an offense. Nursing care service providers are required to register with the Private Health Sector Regulatory Council (PHSRC) as a private medical institution. Registration must be done annually through the Provincial Director of Health Services (PDHS). The PHSRC will direct unregistered institutions to register. The PHSRC may shut down any institution that fails to comply with the registration requirement. The PHSRC sets guidelines for the operation of in-home nursing care services. The PDHS is required to check that an institution renewing its registration meets the guidelines and is, therefore, responsible for overseeing the quality standards for in-home nursing care institutions (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (adb.org).

Last updated: September 8th, 2021

Thailand

Last updated: September 8th, 2021

France

In 2020 there were 7,502 long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 256 care homes for autonomous older people and 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015. There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: August 4th, 2021

1.06. Approach to care provision, including sector of ownership

Australia

In 2018-2019, there were over 3,000 providers of aged care services. 873 of these were residential services, 928 were home care providers, and 1,458 were Commonwealth Home Support Programme providers (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

The majority of aged care providers are not-for-profits owned by community, charity, or religious organizations. The remaining are privately owned organizations, which are run as a commercial business. There is also a small group of government owned providers. Australia has seen a trend of aged care providers consolidating to just a few large-scale operators – in 2018-2019, 10 providers operated 39% of all aged care services (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

The CHSP is an “entry-level” programme designed to help people remain independent and safe at home, with home support services and respite care, transport, nursing care.  The HCP programme is aimed at people requiring more support to stay at home and offers coordinated packages of care from an approved home care provider, there are four levels of HCP, according to the levels of care needs. Residential care is subsidized by the government and provided by approved providers. Flexible care aims to offer more innovative care approaches, for example to support recovery following hospitalisations, to serve rural and remote communities and to support Indigenous Australians in ways that are culturally appropriate. There is a single entry point for government-funded care (source: https://www.myagedcare.gov.au), people assessed as eligible for subsidized care can select approved providers who have availability. Approved providers may be not-for-profit, for-profit or public (source: https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp2021/Quick_Guides/AgedCare2021).

Last updated: August 4th, 2021

Canada (British Columbia)

Publicly subsidized services are provided by regional health authorities who deliver them through health authority owned or contracted private/not-for-profit facilities. For-profit, private facilities are often regarded as inferior to publicly owned/health authority owned facilities in terms of care, access to equipment, and government support (source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

In 2020, 33% of publicly funded LTC beds are operated directly by health authorities. The remaining 18,000 beds are delivered by for-profit companies (35%) and not-for-profit societies (32%) who have been contracted by one of the five regional health authorities in B.C (source: https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2020/02/ABillionReasonsToCare.pdf).

Last updated: August 4th, 2021

Denmark

Since 2003, free choice of provider was introduced, banning public monopolies in service provision.  Municipal councils have been required by law to ensure private offers in each municipality, based on contracts with accredited companies. In 2017, Denmark had 320 private for-profit home care agencies. (sources: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019; https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Municipalities typically use competition with fixed prices for tendering home care and competition takes place on quality by, for example, ensuring continuity of workforce. Municipalities are obliged to contract with any private-for-profit provider that meets the requirements on quality standards and the price. Public and for-profit providers co-exist and the latter are not permitted to refuse to provide care for any individual. Recent legislation allows private home care providers to compete on price in the privately-paid for sector and, although municipalities are no longer obliged to contract with all bidders who meet minimum tender specifications, they must contract with at least two such providers (source: Commissioning long-term care services – Policy Press Scholarship (universitypressscholarship.com).

Last updated: September 16th, 2021

England (UK)

Care is provided by approximately 9,000 home care providers and over 15,000 care home providers. Around 78% of all adult care services are privately owned and run (source: https://www.skillsforcare.org.uk/Documents/About/sfcd/Economic-value-of-the-adult-social-care-sector-England.pdf). The Care Act 2014 places a duty on local authorities to ensure that there is diversity and quality in the market of care providers. However, due to the downward pressure on fees stemming from cuts to local authority budgets, many providers find that the fees paid by local authorities fall short of covering the full costs of providing care. People who fund their own care are being charged on average 41% more than local authority funded residents because of this shortfall (source: https://assets.publishing.service.gov.uk/media/5a1fdf30e5274a750b82533a/care-homes-market-study-final-report.pdf). It is increasingly common for care providers to go out of business, struggle to stay in business or hand back contracts to local authorities. A survey in 2019 found that some 75% of councils reported that these organisations had either closed or handed back contracts in the last six months of 2020, creating enormous disruption and discontinuity for those receiving care (source: https://www.adass.org.uk/media/7295/adass-budget-survey-report-2019_final.pdf). Because of market fragility, the government has introduced market oversight and a failure regime covering financial as well as quality failure (source: https://www.cqc.org.uk/guidance-providers/market-oversight-corporate-providers/market-oversight-adult-social-care).

Last updated: August 4th, 2021

Finland

Municipalities determine whether they provide services themselves, work with other municipalities, purchase services from for- or non-profit actors, or set up cash benefit informal care systems (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 4th, 2021

Germany

Over the past three decades, Germany has seen an overall increase in home care and residential care providers. However, the increase in beneficiaries has been even steeper, leading to a higher number of beneficiaries per provider. Both homecare and residential care recorded a change in the market structure from private non-profit to private for-profit providers. The change is however more pronounced in home care than in residential care (source: Germany_draft.pdf (who.int).

Between 1999 and 2019, the share of private care provider in residential care increased from 35% to almost 43%, while the share of third sector organisations declined from 57% to 53% and that of public institutions from 8.5% to 4.5% (source: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=875&p_ansnr=13711351&p_version=8&D.000=1&D.374=3&D.983=2).

Among domiciliary care providers, the share of private providers increased from 51% to 67%, while the proportion of third sector decreased from 47% to 32% and that of public providers from 19% to 1% between 1999 and 2019 (source: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=876&p_ansnr=98223306&p_version=2&D.000=1&D.374=2&D.983=1).

Last updated: August 4th, 2021

Italy

The actors directly involved in the organisation of LTC services are municipalities, local health authorities and the National Institute of Social Security (INPS), but other players are involved in planning and funding these services – i.e. the central state, regions and provinces. Additionally, in Italy individual households play an important role in the organisation and provision of long-term care (source: update_joint-report_it_en.pdf (europa.eu).

Last updated: August 4th, 2021

Japan

There is a mixed market of provision in most parts of the market (except nursing care, where market entry is restricted to medical and non-profit providers). The 2000 LTC insurance reforms sought to create a competitive and mixed market of provision, especially for home care and has largely succeeded. Providers are paid according to a national fee schedule although municipalities have some freedoms to adjust it to suit local needs (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan).

Last updated: August 4th, 2021

Mauritius

LTC is typically viewed as a family responsibility, although this is being challenged as society undergoes change. The government acknowledges that family caregivers require support and allocates a monthly allowance to caregivers of older people experiencing significant declines in capacity. Some efforts have been made to provide practical training to family caregivers. A number of residential facilities also exist. Currently, approximately 25 charitable homes are operated by nongovernmental organizations and funded by the government. Nursing and medical care is provided on site. Access to these homes is first-come, first-served and based on means testing. Overall, the demand for admission into these homes far outweighs their bed capacity. The number of private retirement homes, for those who can afford them, has increased in recent years (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021

Poland

LTC services in Poland are provided by both private and public providers. The former includes unpaid carers and a grey zone (including immigrant carers) as well as non-for profit and for-profit residential care providers. Non-governmental organizations are active in the provision of care for older people – in supporting hospitals, care, and nursing facilities (source: Poland Country (filesusr.com).

Last updated: August 4th, 2021

Seychelles

The right to health care and social protection for all citizens is enshrined in the Seychelles’ Constitution of 1993. A number of government-funded long-term care services are available, including both home care and residential services. Long-term care provision remains mainly in the public sector, with some involvement of civil society and limited participation of the private sector. The country’s home care scheme was established in 1987. This programme makes it possible for people to remain at home rather than using residential or institution-based care. Caregivers are chosen by the beneficiary, usually a family member of the older person (source: https://www.who.int/publications/i/item/9789241513388).

Public residential facilities take the form of regional homes for older people and one 136-bed long- term care nursing facility. The regional homes usually consist of ten single-occupancy independent living units. Residents do not pay rent but are responsible for living costs. The country’s sole long-term nursing facility is in high demand: the waiting list is long (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021

Singapore

LTC in the community is mostly provided informally by family and surrogate carers. Formal community services (e.g. day care) and residential care are largely provided through Voluntary Welfare Organisations or Social Service Agencies. In 2019, Singapore had 7,600 day care places, 10,300 home care places, 1,986 community hospital beds and 16,059 nursing home beds. Of the available nursing home beds, 75% were supplied through the Social Service Agencies and the government and 25% through private providers (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: August 4th, 2021

South Africa

Traditionally, long-term care has been seen as a family responsibility yet few schemes are in place to support family caregivers. Private retirement villages cater mainly to older people with financial means. Publicly funded long-term care is available to only a small fraction of the older population. The majority of this type of care is provided in residential facilities which tend to be clustered in urban settings. Applicants are subject to a comprehensive assessment of their current living situation, family support, financial means and care needs. Only those who meet the criteria are eligible for admission. Individual care homes usually have their own admission policies and procedures, in addition to the formal criteria for obtaining public financial support. Availability of beds is another hurdle: most facilities have waiting lists for admission (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021

Spain

Due to limits in public spending on LTC, a number of public services are provided by private entities, both for and non-profit. In the care home sector. Although marketization has led to an increase in the available places, this has been at the expense of the quality of services, and public administrations have difficulties in terms of inspecting and evaluating services. Additionally, migrant workers, often without an official contract, provide a share of home care in Spain (source: LTCcovid-Spain-country-report-28-May-1.pdf).

Last updated: August 4th, 2021

Sri Lanka

State and NGO operated day-care centers. The NSE supports 662 day-care centers around the country.  HelpAge Sri Lanka and other NGOs have also supported day-care centers. There may be other day-care centers and Elders’ Clubs operated by small NGOs and village-level
committees.

Sri Lanka has two main types of residential facilities: those primarily designed to provide housing for older people who lack shelter, and those that aim to provide LTC support and nursing care. Most facilities fall into the first category and are known as “elders’ homes” or “eldercare homes.” Even if the primary aim is to provide shelter, some residents have or develop needs for LTC support over time. Sri Lanka currently has around 255 eldercare homes serving approximately 7,100 elder residents, two owned by the central government and three by provincial councils. The private sector operates around 20 homes; others are not-for-profit and funded by private donations and some government funding. Not-for-profit eldercare homes are usually operated by faith-based organizations and NGOs. Homes for elders registered under the Department of Social Services increased from 68 in 1987 to 162 in 2003. Five public eldercare homes house 7% of all elder residents, and 220 private (i.e., not for-profit) eldercare homes house 85% of all elder residents.

The 2017 survey of eldercare provider institutions, it was estimated that there were about 25 home nursing care service providers, although the exact number is not known due to gaps in the implementation and monitoring of the formal registration system of such providers and regulation of the industry. These home nursing care services provide 24-hour nursing care to about 900 older clients. The services are usually expensive and not affordable for lower-income families (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (adb.org).

Last updated: September 6th, 2021

sub-Saharan Africa

Within sub-Saharan Africa, national efforts to develop long-term care systems exist only in Mauritius, Seychelles, and South Africa. The expansion of organized long-term care has been organic and uneven in terms of geographical spread, populations served, and services offered. Most organized care is clustered in urban metropolitan settings. Two major service models appear to dominate: charitable care for the most destitute older people (usually operated with few resources by faith-based, civil society or public welfare bodies) and private for-profit services, mostly in the form of residential homes for those who are able to pay. There appear to be few, if any, organized services for the majority of older people who fall between these extremes of the spectrum (source: https://www.who.int/publications/i/item/9789241513388).

Because organized systems of long-term care are generally lacking, families constitute the major source of care for older people who are no longer able to live independently. However, evidence also reveals that a substantial group of older people receive no family care whatsoever. The majority of family care is provided by female relatives, ranging in age from children to older adults, although some studies document significant involvement of men in caregiving. Some further evidence points to a role played by unorganized and unregulated domestic workers in long-term care provision. Care is provided either in older people’s homes or in the home of caregiving relatives (source: https://www.who.int/publications/i/item/9789241513388).

Many researchers and some policy-makers in sub-Saharan Africa have concluded that it is no longer feasible to rely on kin as the mainstay of long-term care provision, given a perceived weakening of extended family support systems. Key factors assumed to underly this shift include increased rural to urban migration and labour force participation, especially among young women; increasingly monetized economies; the impact of the HIV/AIDS epidemic (increased deaths among younger adults); and loosening norms and structures for extended family solidarity. Although perhaps intuitive, it is important to note that presumed declines in family care provision have not yet been studied formally and considerable debate continues about the ways in which social trends are shaping the experiences of families and later life in sub-Saharan Africa (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021

Sweden

Municipalities and county councils can decide on how to organise the provision of LTC, including collaboration with different providers. Institutional and home care may be provided either by a municipality or a private provider (which can include private companies but also trusts and cooperatives). However, even when care is provided by the private sector, municipalities and country councils still have the exclusive responsibility for ensuring financing, provision and ensuring an adequate level of quality. In 2018 around 24 % of homecare was delivered by private providers (source: https://ec.europa.eu/info/sites/info/files/file_import/joint-report_se_en_2.pdf;  https://sweden.se/society/elderly-care-in-sweden/).

Last updated: August 4th, 2021

1.07. Care coordination and personalization

Overview

Most countries have made an active effort to facilitate coordinated care, at least at policy level. Despite the policy efforts, shortcomings have been identified in health and social care coordination/integration across countries at both national and local level undermining the performance of care provision.  E.g.: Analyses of integrated care policies in European countries indicate that although at governmental level integration documents tend to be produced involving health and social care sectors, at regional and local level integration between health and social care services often involves separate coordination institutions for each of the sectors (https://www.cequa.org/copy-of-all-publications).

Overall, LTC services are often separate from health services?and countries frequently distribute responsibility for LTC across national, regional and local actors. In many countries, an absence of coordination between health and social care often translates to parallel but not aligned systems for oversight, financing, staffing, and collection/management of data (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).  Other more intangible factors pertaining to the health and social care divide include values and social standing of professionals (hierarchies) that impact the joint working of staff (https://www.euro.centre.org/downloads/detail/1537).

International reports and sources

The CEQUA project provides an overview of policies on integration in 11 European countries including England, France, Germany, Spain, Sweden, Finland, Austria, Poland, Latvia, Bulgaria, Czech Republic and Italy. There are also two case studies on integrated care, from Sweden and one from France (https://www.cequa.org/).

WHO has developed a framework for LTC integrated care and has published detailed country reports online.

Australia

The Australian government’s Ministry of Health oversees both the health and aged care sector. States and territories are responsible for the actual delivery of care. The aged care sector has been found to have less access to services, including allied health services. The Royal Commission into Aged Care Quality and Safety recommends the Australian Government to increase coordination by creating Medicare Benefits Schedule items to specifically increase the provision of allied health services, including mental health services, to people in aged care (source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf). The aged care system is difficult to access and navigate. The Royal Commission into Aged Care Quality and Safety found that people needing care found the experience to be time-consuming, overwhelming, and intimidating. The Royal Commission also expressed concern regarding the ability for people to make informed decisions due to the lack of information available (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Last updated: August 5th, 2021

Canada (British Columbia)

There is a lack of integration between health and social care both at a national and provincial level. Healthcare is broadly regulated by the Canada Health Act but provinces have jurisdiction over the operational aspects, funding, and services offered. Social care, including home and continuing care, are not covered under the Canada Health Act. Although the health and social care sectors are not governed under the same regulations, it is the same five regional health authorities providing both social and health care. The system is fragmented and power dynamics are difficult to understand (source: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html).

Last updated: August 5th, 2021

Denmark

Coherence and coordination in service delivery is a stated goal of the Danish Health Act of 2005 and one of the key drivers behind the major reform of local government of 2007. In reducing the number of municipalities and administrative regions, the reform effectively represented a large step towards centralizing health and social services and has actively pursued the coordination between the administrative regions and municipalities in providing care. The Danish Health Authority has also established chronic disease management strategies that bring together efforts by the administrative regions and the municipalities under a single model.

There is a fair level of integration of care across providers. For beneficiaries who need long-term care on discharge, the hospital discharge management team communicates and works closely with the general practitioner and local home services. The administrative regions are responsible for coordinating after-hours care. The first contact with beneficiaries after hours is via a devoted phone line staffed by a physician or a nurse. Based on algorithms, the practitioner decides whether to refer the patient to a home visit or an after-hours clinic. After-hours clinics are usually nested within or next to a hospital emergency department (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 5th, 2021

Finland

Integration of health and social care services for older people has taken place particularly in home care services. Integration of home care has been viewed as an instrument to increase the possibilities for independent living of older people. The most common practice aiming to increase care coordination is structural integration where municipal home care units are organizationally merged with health and welfare departments. The care coordination has led to more integrated management processes with some impact on actual care-taking practices or quality of care among home-dwelling and institutionalized patients (source: CEQUA Finland Policy Brief (filesusr.com). However, despite attempts at standardization of care services across the nation, there are major differences between municipalities due to their demographics; this appears to affect individuals ability to navigate the system (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 5th, 2021

France

Coordination in the care sector is a longstanding preoccupation of the state and a response to the highly fragmented organization and funding of health, social and the need for ‘medico-social’  interventions in the care field. Three different schemes have been developed since 2010– the PTA, the MAIA, and PAERPA schemes – having in common the creation of specific functions or professionals to support the social, medico-social and health professionals in their coordination tasks. From a public policy perspective, the analysis of these developments shows that despite their initial objective of improving coordination between the health, social and medico-social interventions and facilities, the creation of three dedicated coordination schemes has also contributed to the complexity of elderly care professional and organizational landscape. Research also highlights limited accountability with poor transparency for users, prospective users and carers  (source: CEQUA France Country report (filesusr.com).

 

Last updated: August 5th, 2021

Germany

A report provided by the German Society of Nursing Science focusing on domiciliary care highlights that structural barriers exist through the organisational silos in which service providers work. Data protection causes additional challenges to the effective communication between service providers, such as domiciliary care workers and GPs. Communication and coordination between different service providers are often not part of the services for which the care providers can be reimbursed by the LTC insurance and case conferences across professions are not established, requiring domiciliary care providers and GPs to coordinate services without an established framework (source: https://www.awmf.org/uploads/tx_szleitlinien/184-002l_S1_Haeusliche-Versorgung-soziale-Teilhabe-Lebensqualitaet-bei-Menschen-mit-Pflegebedarf-COVID19-Pandemie_2020-12.pdf).

Last updated: August 5th, 2021

Israel

From the 2017 Taub Center Report: ““It is often a thin and undefined line that separates medical and functional assistance. Generally speaking, the tendency is to leave patients in their homes (community care), with the primary task of long-term care defined as practical, mental and social assistance in functioning, with limited medical intervention. In other words, the tendency is to minimize, to the extent possible, the medical aspect of long-term care, while expanding the social aspect. Thus, the healthcare and long-term care systems are commonly viewed as separate branches of social insurance (page 9).” (http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf). The large percentage of privately funded LTC services, as well as the widespread culture of unpaid, family caregiving, suggest a lack of ease that social care users have with understanding, navigating and accessing the full extent of LTC services. The hospital system, Kupoth Cholim, which function as HMOs, is the primary provider of health care and has dominated the discourse regarding services for the vulnerable during the pandemic.

Last updated: March 23rd, 2021

Israel

There is a blurred line that separates medical and functional assistance. Generally, the tendency is to leave patients in their homes (community care), with the primary task of LTC defined as practical, mental and social assistance in functioning, with limited medical intervention. Overall, the healthcare and long-term care systems are commonly viewed as separate branches of social insurance  The large percentage of privately funded LTC services, as well as the widespread culture of unpaid, family caregiving, suggests a lack of ease that social care users have with understanding, navigating and accessing the full extent of LTC services. The health system, Kupoth Cholim, which functions as four HMOs, is the primary provider of geriatric health care and has dominated the discourse regarding services for the vulnerable during the pandemic (source: http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf).

Last updated: August 5th, 2021

Italy

The Italian care system remains fragmented. Italy’s LTC fragmentation is related to the fact that the essential functions (such as health and social care as well as basic care training) are decentralized and managed at regional level. An increasing trend to reorganize the LTC system via a ‘decentralisation’ of the health and social care functions from the national to the regional and local level can be observed in Italy. In the social care sector, this development has made local administrations the core governance centres of the system, as they are able to develop their own LTC policies. The only body in charge of ensuring inter-institutional coordination in this context is the State-Regions Conference (source: Italy Country Report (filesusr.com).

Last updated: August 5th, 2021

Japan

LTC services include some nursing, so much of what we would count as healthcare comes under LTC. Individuals are assigned a care manager on becoming eligible for care and, if the person is in hospital, they facilitate discharge. At a national level, the LTC and health systems are reviewed together every 6 years – this is where provider rates and regulations are reviewed (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan). Japan has an ambition to create integrated care communities but these are wider than health and care and include community services and voluntary organisations too (source: https://www.researchgate.net/publication/260612267_Towards_community-based_integrated_care_Trends_and_issues_in_Japan’s_long-term_care_policy). Individuals assessed and deemed to have care needs are assigned a care manager who helps people to navigate the system (source: https://pubmed.ncbi.nlm.nih.gov/21885099/).

Last updated: August 5th, 2021

Netherlands

The Netherlands has been experimenting with various integrated care initiatives over the past years (source: WHO | World Health Organization).

Last updated: August 5th, 2021

Poland

LTC in Poland is organised by national health care and local social services. The coordination of activities between sectors has been hampered by different governance priorities. The health sector concentrates on the long-term goals formulated in the National Health Programme. In the social services sector, ‘senior policy’ was formulated, aimed at the social activation (e.g. day care facilities) and social integration of older people (source: Poland Country (filesusr.com).

Last updated: August 5th, 2021

Singapore

Care integration is high on the policy agenda in Singapore. For example, to facilitate integrated delivery of support and services, Singapore has consolidated aging, health, and LTC under the Ministry of Health (MOH) with inter-ministerial remits, where relevant (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).

The Agency for Integrated Care has taken on the role of a National Care Integrator in 2009. It is the agency’s role to match people with LTC needs with available services. The agency further is ‘responsible for supporting community care service partners in manpower development, quality improvement, programme development, and crisis management’.

In 2012, a Regional Health System model was introduced by the Ministry of Health to support the provision of ‘seamless integrated care based on geographic location’. This model facilitates local collaboration and transition between care settings and has been reported to strengthen management capabilities and continuity of care. Key actors are designated anchor public acute hospitals as well as ‘primary, chronic health and social care’ services in the different geographic areas (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: August 5th, 2021

Spain

The provision of LTC in Spain is fragmented, due to the intervention of many agents and the differences between the autonomic regions. There have been several initiatives to improve care coordination through: the creation of social and healthcare coordination structures, the implementation of shared information systems, improving the comprehensive assistance in social centres and promoting the creation of hospital assistance units of continuity (source: CEQUA Spain Country report (filesusr.com).

Last updated: August 5th, 2021

Sweden

In Sweden, integrated care is an explicit policy goal, both within the care systems and between health and social care. The obligation on municipalities and county councils to cooperate is enshrined in legislation, regulations and agreements. The law also stipulates that an individual care plan should be established when a person requires services from both municipal social services and the health sector within the county council to ensure coordinated care with continuity.  However, challenges of care coordination and in particular coordination between health and social care services for older people exist e.g. shortening of hospital stays translated into increasing burden placed on community care. Moreover, local autonomy means that the national government has no power to enforce these kinds of structures for care coordination at a local government level (source: https://1d520973-35f0-4e46-8af0-304ac08d8794.filesusr.com/ugd/e1a359_f271d4f46fe240b3b7ebcd660142459f.pdf; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659761/).

Last updated: August 5th, 2021

United States

Despite Medicaid and Medicare’s central role in the funding of long-term care services, the long-term care and health care sectors are not integrated at the governmental and health systems levels. Differences in how medical care and long-term care are paid for and prioritized in each state, as well as the ownership of healthcare organizations (i.e. hospitals) compared to the LTC sector, disallows coordination of services and impedes opportunities for a seamless care delivery system (source: https://onlinelibrary-wiley-com.gate3.library.lse.ac.uk/doi/full/10.1111/1468-0009.12500).

Last updated: August 5th, 2021

1.08. Information and monitoring systems 

Australia

The Department of Health facilitates an Australian National Notifiable Diseases Surveillance System, which tracks a list of specific communicable diseases. The Department of Health also publishes weekly traffic light reports of the COVID-19 situation across Australia, which includes details about cases, testing, and capacity nationwide and in individual states (source: https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-casedefinitions.htmhttps://www.health.gov.au/resources/collections/coronavirus-covid-19-common-operating-picture).

Last updated: August 5th, 2021

Denmark

The sundhed.dk portal was launched in 2003 as a partnership between the Ministry of Health, the five administrative regions and municipalities, this platform integrates information from 85 different sources and aims to improve communication between patients and the health systems enabling beneficiaries to access their medical records. Beneficiaries can consult laboratory results, prescription information and scheduled visits and enter or complement data on patient-reported outcomes. Hospitals share discharge summaries and outpatient notes, laboratory work, and medical imaging results with other hospitals, general practitioners and other medical specialists. A national medication database includes data on dispensed products in public and private (non-hospital) pharmacies (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 5th, 2021

England (UK)

There is no national minimum dataset for care homes, or social care in England (source: UK Report).During the pandemic, the limited existing data was supplemented by data collections from several bodies (the NHS, providers themselves, the death registration system, Public Health England, and the regulator, CQC). Those working in the sector report that this has led to repeated collection of similar data, by multiple stakeholders. This reflects the lack of data and technology infrastructure in the social care sector, which by comparison with the health care sector in England and Wales, has received little investment.

The COVID-19 crisis has stimulated some technological innovation in care homes; for example, the NHS has expanded the use of encrypted NHS email to care home staff, developed a web portal for Personal Protection Equipment (PPE) emergency procurement, and has piloted ‘remote’ social care interventions. Some care homes and General Practices (GP) have also used tablets and video calling to allow GP visits and to communicate with families. However, this is in the context of fundamental issues with capacity of the care home sector to engage in these initiatives due to a lack of infrastructure (e.g. broadband), or low usage of digital technology among home care staff.

At a provider and individual level, data and information sharing are limited. There have been several successful partnerships between the health and local authority sector across England to link social care data collected by councils with health care data. However, this only covers people whose social care provision is provided by local authorities, not those who pay themselves. There are no national datasets on social care utilisation or individual expenditure and the complex and fragmented nature of the provider market makes data collection difficult. The development of the Capacity Tracker (source: About Capacity Tracker – NECS (necsu.nhs.uk) for care homes, mandated during Covid-19, is a welcome addition with potential to provide market intelligence, although there are concerns about the accuracy of data entered, with implications for planning and prioritisation in central government (source:  Covid story_v5.docx (laingbuisson.com). It remains impossible to obtain an accurate estimate of the number of self-funders or total social care spend across all care settings (source: Adult social care statistics: the potential for change | The Nuffield Trust).

Last updated: August 5th, 2021

France

There are limited information systems at a national level. The regional administrations (ARS) have some level of information collecting. There have been efforts to transfer the recording of deaths away from paper records to a secure app available to doctors (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: August 5th, 2021

Germany

Reports show that the health and long-term care insurance funds collect data on clients’ service use. Some of the information can be accessed (anonymised) for research purposes.

Last updated: August 5th, 2021

Israel

The National Insurance Institute publishes annual reports and regular studies on LTC resource allocation and service outcomes. Information on vulnerable and older adult populations in need of care services is also gathered through various social policy think tanks and NGOs: JDC (Joint Distribution Committee)-Eshel (source: https://www.thejoint.org.il/en), which conducts an extensive study of care users and produces annual reports on the aging and uses its evaluations of resource allocation and services in partnership with the Israeli government (source: MJB-Facts_and_Figures_Elderly-65_in_Israel-2018_English.pdf (jdc.org.il).  JDC-Eshel in partnership with Mashav produce an annual statistical yearbook of Israel’s aging and care user populations (source: http://mashav.jdc.org.il/?CategoryID=233&ArticleID=162).

Last updated: August 5th, 2021

Italy

Italy has a comprehensive information and monitoring system (National Healthcare Information System) – using 130 indicators and covering population health status, budgetary and economic efficiency, organisation climate and staff satisfaction, patient satisfaction, performance indicators (appropriateness, quality) and effectiveness in reaching regional targets. Several regions have adopted the system (Source: update_joint-report_it_en.pdf (europa.eu).

Last updated: August 5th, 2021

Japan

As almost all people in need of care go through the municipality-funded needs assessment process to qualify for care, there is good data available on numbers of service users that is used to inform policy and reviews of care benefits by Ministry of Health, Labour & Welfare. It’s not clear whether the data is used for evaluation (source: https://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-elderly/dl/ltcisj_e.pdf).

Last updated: August 5th, 2021

Sweden

Sweden overall has extensive information management and statistics systems on health and social care, data is provided at county/ region and municipal level and compiled by the Swedish Association of Local Authorities and Regions together with the National Board of Health and Welfare (source: joint-report_se_en_2.pdf (europa.eu)).

Last updated: August 5th, 2021

United States

While states differ in their collection of data, federal evaluations of LTC services and needs use the Center for Disease Control’s (CDC) recently renamed National Post-Acute and Long-Term Care Studies (NPALS). Information and statistics on adult day centre services and participants as well as residential care communities can be accessed dating back to 2012 on the CDC website (source: https://www.cdc.gov/nchs/npals/reports.htm).

Last updated: August 5th, 2021

1.09. Care home infrastructure

Australia

Care home infrastructure and design guidelines vary between states. Aged care homes are allocated through the online platform, My Aged Care, which advertises “hotel-type services” including furnishing and bedding, meals, laundry, and social activities. The Royal Commission into Aged Care Quality and Safety found that care homes lacked the appropriate infrastructure to provide adequate care as space was often limited and facilities did not have enough staff and allied health professionals (source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

Last updated: August 5th, 2021

Austria

In 2015, about 850 nursing homes or residential care facilities provided 75 632 inpatient care places while 12 019 persons lived in alternative housing forms. Since 2000, the number of places in nursing homes or residential care facilities increased by more than 30%, as a result of population ageing and increasing demand for long-term care (BMGF, 2017k). Also, the number of hospitals and beds in rehabilitative care increased by around 40% between 2007 and 2016. In 2020 about 90,000 people are cared for in about 870 care homes (about 50% public, 25% private for-profit, 25% non-profit) (source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Austria-13-July-1.pdf).

Last updated: August 5th, 2021

Canada (British Columbia)

89% of the rooms in long-term care are single-occupancy rooms, 7% are double-occupancy, and 4% are multi-bed rooms (3 or more beds). 76% of residents reside in single-occupancy rooms. In health authority owned facilities, 57% of residents reside in single-occupancy rooms compared to 85% in contracted facilities (source: QuickFacts2020-Summary.pdf (seniorsadvocatebc.ca).

Last updated: August 5th, 2021

Canada

There are longstanding problems in the LTC homes in Canada, which have been the subject of many reports, commissions and enquiries. A review carried out for the Royal Society of Canada Working Group on LTC found that, between 1998 and 2020, there were 80 reports making recommendations on the Long-Term Care system and LTC homes. The most common recommendations were for increased funding (66.7% of reports), standards/regulation/audits of LTC quality of care (58.3%), and regulation/reform/standardisation of education and training for staff (https://f1000research.com/articles/10-87).

Last updated: August 5th, 2021

Chile

There an estimated 25,000 older people living in registered care homes (1.4% of the population aged 65 or older). Of the 994 registered care homes, 16 are public, 181 are not-for-profit (with public subsidies) and the rest are for-profit (operating under supervision of the Ministry of Health) (source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

There are many unregulated care homes operating in an informal manner, probably as many as there are in the regulated sector. Prior to the COVID-19 pandemic there were no regulations or mechanisms to survey the Infection Prevention and Control capabilities of care homes (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.72/).

Last updated: August 5th, 2021

Denmark

In Denmark’s 98 municipalities, there are around 930 nursing homes with over 40,000 residents  (source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

The number of people in residential facilities and receiving home care has declined in both absolute and relative numbers in this decade.  In 2018, in absolute numbers there were 65,573 beneficiaries of long-term residential care services aged 65 years or older which equals to 5.8% of the population (source: https://www.dst.dk/en). In particular the proportion of people age 90 and over living in residential care facilities has fallen drastically, as 41.7 percent  lived in LTC facilities and senior housing in 2010 while the number fell to 33.1 percent in 2019 (source: https://www.dst.dk/da/Statistik/nyt/NytHtml?cid=30746#)

Social care act made it illegal for the government to build any multiple bed residential services, hence currently all nursing homes are private rooms with personal space, kitchenette and living space. Denmark is the only country in the EU in which the construction of traditional old-age and nursing institutions has been legally banned. Early in the 1980s, the government phased out large institutions with multiple beds in each room and infrastructure for long-term care that resemble hospital environments, replacing them with nursing homes to ensure that users have individual living spaces. By 2011, the vast majority of older individuals living in residential care were housed in modern nursing home facilities. There are five types of residential care facilities: nursing homes, which are institutions with permanent staff and service areas; sheltered housing, which are connected to nursing homes with associated staff and service areas; housing for older people, which are dwellings for older people with associated staff and service areas; general homes for older people, which are suitable for older people and people with disabilities but without permanent staff or service areas;  private care accommodation, which provides rental facilities for people with extensive disabilities, including personal staff and service areas outside the municipal sector. The choice of specific type of accommodation depends on individuals’ preferences and needs. Beneficiaries choosing to live with their spouse or partner must be offered a facility suitable for two people (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 5th, 2021

France

Of the 7,502 LTCFs for older people, 50% are public, 31% are not-for-profits, and 24 are for-profit. In 2020, the National Assembly noted that the home care infrastructure is largely outdated, often with shared rooms (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: August 5th, 2021

Germany

A report by the University of Cologne suggests that the increasing demand for residential care requires establishing additional as well as maintaining existing resources (source: https://www.iwkoeln.de/fileadmin/publikationen/2015/244405/IW-Trends_2015-03-04_Kochskaemper_Pimpertz.pdf). According to Federal reporting, the majority of care homes in 2019 (8,115 homes, 521,720 spaces) were owned by Not-for-profit organisations, followed by private providers (6,570 homes; 393,308 spaces) and public providers (695 homes, 54,525 spaces). (Source: https://www.gbe-bund.de/gbe/pkg_isgbe5.prc_menu_olap?p_uid=gastd&p_aid=15610743&p_sprache=D&p_help=2&p_indnr=570&p_indsp=&p_ityp=H&p_fid=)

Following the implementation of single room quotas in care homes put in place in many of the Länder over a decade ago (which gave providers 10-15 years to make the necessary changes), care homes in several federal states have to provide a certain percentage of single rooms (e.g. 80% in North-Rhine Westphalia, 100% for new builds; Berlin 60%; Lower Saxony no quota). In Baden-Wurttemberg, every single room needs to have its own bathroom. Older buildings with shared bedrooms and without individual bathrooms should only be used for short-term stays. While this increases privacy of residents it also reduces the number of spaces. People who choose to live together (e.g. couples) can share double rooms of sufficient size (source: https://www.deutschlandfunk.de/einzelzimmerquote-in-der-pflege-mehr-privatsphaere-weniger.769.de.html?dram:article_id=466416; https://www.aerzteblatt.de/nachrichten/105668/Baden-Wuerttemberg-lockert-Einzelzimmervorgabe-fuer-Pflegeeinrichtungen; https://www.swp.de/suedwesten/landespolitik/umbau-oder-schliessung_-neue-vorschriften-29392427.html).

According to a newspaper article, single rooms should be at least 14 square meters, double rooms, 20 square meters. In addition, 25% of rooms need to be wheelchair accessible and have wheelchair accessible bathrooms (source: https://www.tz.de/muenchen/stadt/neue-standards-pflegeheimen-mehr-platz-aber-weniger-plaetze-zr-6706663.html).

Research conducted by the Bertelsman group found that residential care across Germany are in good geographical proximity to other care homes: the longest average distance between care setting identified amounted to 8.2km. Within urban areas distances between care settings can be as small as 0.5km, while in rural areas distances may be larger (source: https://www.bertelsmann-stiftung.de/fileadmin/files/BSt/Publikationen/GrauePublikationen/Studie_VV_FCG_Pflegeinfrastruktur.pdf).

Last updated: August 5th, 2021

Israel

As of 2017, amongst OECD countries, Israel had one of the lowest numbers of LTC beds available in its hospitals at 23.6 beds per 1000 people aged 65+ (the OECD average is 47.2 beds) (source: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en).

Last updated: August 5th, 2021

Italy

There are concerns about the lack of long-term care facilities overall in the country, moreover, the distribution of nursing homes is diversified and heterogeneous throughout the national territory: for example in Trentino Alto-Adige Region, there are 25 beds per 100 not-self-sufficient over75; in Basilicata there are 0.65, signalling the almost total absence of services in some areas of the country (source: https://ltccovid.org/2020/04/10/report-on-covid-19-and-long-term-care-in-italy-lessons-learned-from-an-absent-crisis-management/).

Last updated: August 5th, 2021

Japan

The majority of nursing care facilities are run by non-profit social welfare or medical institutions (for profit organisations are restricted from entering the care market for the individuals with high needs). The rest of the market operates with a mixed market of provision, ownership types and sizes. For-profit assisted living facilities tend to cater to the more independent and hence less vulnerable population. They cannot provide LTC services unless they are specially licensed by the respective prefectural governments to do so, even if they have a licence, such facilities have to contract external licensed LTC service providers if the residents need nursing care. Providers are paid according to a national fee schedule, so they compete on quality and convenience, not price.  All providers must be licenced by the prefectural government (source: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf; https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

Last updated: August 5th, 2021

Netherlands

Care homes are distinguished by whether they have an WLZ (Wet langdurige zorg, LTC) accreditation. These mostly include nursing homes and residential care homes with a nursing department. Care homes without a WLZ accreditation do not provide nursing care or medical treatments, but are residential homes that provide small-scale elderly housing and apartments linked to nursing homes, in which additional care can be provided as needs increase. In addition, there are private care homes for more affluent residents who contribute more to the costs of housing and facilities (such as entertainment). There is also small-scale housing where people pool their WLZ cash (provided as a personal budget) and which are self-organised or provided by entrepreneurs. Nearly 114,000 people aged 65 and over live-in residential care and nursing homes (source: https://drive.google.com/file/d/1P5J1JQlr-ts65lknBwBFtTkJNXHLDyrL/view).

 

Last updated: August 5th, 2021

Republic of Korea

Providers of institutional care facilities are mostly private; the majority are individual-owned, small-size homes, and their numbers have rapidly increased, resulting in fierce competition (source: https://www.sciencedirect.com/science/article/pii/S016885102030275X). Services comprise residential care homes, long term care hospitals, and community services. There has historically been a reliance on institutional care, and in 2018 the Government announced a “Community Care” policy, to shift care to home and the community.

The recent outbreak revealed that care institutions are particularly vulnerable to COVID-19 for the following reasons: (a) the high population density of long-term care hospitals: the number of beds in one room is 5.12 on average in long-term care hospitals compared to 3.61 in general hospitals, (b) difficulties in requiring people with dementia or respiratory disease to observe needed hygiene and/or to wear masks; (c) the pre-existing health conditions of most residents in care institutions that make them more susceptible to infection (source: https://www.tandfonline.com/doi/full/10.1080/01634372.2020.1797977).

Last updated: August 5th, 2021

Singapore

Singapore relies heavily on community-based care, however older adults who cannot receive care appropriate for their needs at home are able to seek accommodation in a LTCF. Singapore has over 16,000 LTCF places as of 2019 of which 40% are run by the government, 37% by non-profit organisations and 23% by the private sector (source: ageingasia.org).

Last updated: August 5th, 2021

Spain

In 2020 three in every four LTCFs in Spain were privately run and many residents had some of their costs publicly funded. The fees received by the institutions had not changed for a long time, a result of years of austerity in Spain, and many private facilities had to make cuts to make a profit, whilst some lacked equipment even before the pandemic, many operated with minimum staff (source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241030).

Last updated: August 5th, 2021

Sweden

LTC institutions are similar to regular apartment houses, namely three quarter of residents have an apartment with 1 or 1½ room, with cooking facilities, a WC and a shower. Many units have balconies attached at each floor.  A garden or outdoor space at ground floor is also frequently available. The main problem relates to shortages of facilities (which are municipal with eligibility criteria for admission) since a wave of closures of municipal institutional beds, which began in the 2000s, resulted in a reduction of nearly 40% of all institutional places (source: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf). Consequently, the older people moving into institutional care are more frail and more dependent both in terms of functional and cognitive capacity than before (source: Sweden Country Report (filesusr.com).

Last updated: August 5th, 2021

Thailand

Residential nursing care and specialist care are less available than community care, but they are  growing as well. Most residential care services for dependent older persons are found in private nursing homes and private hospitals, although some residential homes and homes for poor older persons are financed by the government and charitable organizations. The Ministry of Social Development and Human Security manages public homes called “Social  Welfare Development Centers for Older Persons,” which aim to provide shelter, but also a degree of care for residents if they develop care support needs.  Services at residential care facilities range from basic to complex care, including accommodations, help with personal hygiene, assistance with ADL and moving about, care that requires nursing skills, rehabilitation, day care, respite care, and hospice care (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org).

Last updated: September 8th, 2021

United States

The Center for Disease Control (CDC) studies LTCFs vis-a-vis the following categories: adult day services centres, nursing homes, residential care communities, hospices and home-health agencies. State-by-state information on the number of each kind of LTCF, the number of people they serve, ownership (i.e. for-profit or governmental), certification, staffing, and services provided can be found in the CDC’s National Post-Acute and LTC Study (source: https://www.cdc.gov/nchs/data/nsltcp/2016_CombinedNSLTCPStateTables_opt.pdf).

Last updated: August 5th, 2021

1.10. Community-based care infrastructure

Chile

There is a home-based care programme for people with severe dependency and also to provide health care to people who cannot access healthcare centres. Since 2016 the Ministry of Social Development has implemented a Local Support and Care Network, as part of a set of programmes towards a National System of Care. There are also initiatives to support family carers through cash benefits and respite care (source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

Last updated: September 2nd, 2021

Denmark

The number of people receiving home care has declined in both absolute and relative numbers in this decade. Older people can access a wide array of social services that enable them to remain in their homes even if they are chronically or terminally ill. These services include day care services, extensive home help and nursing care. Home help is available for those who need support for activities of daily living. Municipalities provide social services for older people.

In January 2015, a new legislation came into force mandating that all municipalities consider first whether a person applying for home support could instead receive reablement services. Reablement is often offered in the form of a 12-week exercise training course, provided by multidisciplinary teams with an involvement of physiotherapists, in which the older person together with the care worker identifies and works towards achieving one or more specific goals such as, showering alone or carrying out basic home cleaning activities. Users receive home support only after the reablement failed to help them regain the capacity to function independently.

Municipalities offer services in the beneficiary’s home or in rehabilitation centres. Rehabilitation services are included in the mandatory healthcare agreements between the administrative regions and the municipalities, thus ensuring cooperation between the various actors providing services.

Beneficiaries discharged from hospitals can receive follow-up home visits from general practitioners or nurses. These visits take place one week from discharge and may be repeated at three and eight weeks after discharge if additional support is considered necessary (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: September 2nd, 2021

Germany

The municipalities/ local authorities are primarily responsible for the care infrastructure in their area. A study conducted by Bertelsmann found that the care infrastructure differs across Germany. In many areas in East Germany, domiciliary care is more dominant, while in Hessen and in the Rhineland a disproportionate amount of care is provided by family carers. The study further found that in the Federal States located in the South a more balanced provision of services is prevailing, while in Schleswig-Holstein and Mecklenburg Western Pomerania more people receive care in residential care settings. Further analysis provided in the report suggests that the less purchasing power is available in a region, the more unpaid care is being provided. The more unpaid care is being provided, the lower are expected future staffing shortages (source: https://www.bertelsmann-stiftung.de/fileadmin/files/BSt/Publikationen/GrauePublikationen/Studie_VV_FCG_Pflegeinfrastruktur.pdf).

Another report raises questions regarding the future feasibility of community-based care as it often requires unpaid support in addition to domiciliary and community services. Increasing numbers of people living on their own, increasing number of people without children as well as potential implications of an increasing participation of women in the labour force poses challenges to the availability of unpaid carers.

A second important component of community-based care includes day and night (part-residential) care. These services also include the transport between people’s homes and the day care centres. As with other LTC services in Germany, people with LTC needs can receive financial support for attending these services depending on the assessment of their level of care need (source: https://www.bundesgesundheitsministerium.de/tagespflege-und-nachtpflege.html).

Care statistics for 2019 show that 14.5% of people with (assessed) LTC needs receive day care services. Since 2017, the number of day care places has increased by 24.3%.

Last updated: September 2nd, 2021

Japan

Japanese formal LTC relies heavily on day care and homecare services. In 2014, 7.8% of those 65 or older used day care in Japan. In 2019, in absolute numbers there were 1,077,609 users of day care services and 971,432 users of home care services.  Many day care service providers also accommodate overnight stays (source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

Last updated: September 2nd, 2021

Poland

Community services include home-based care comprised of nursing services provided through the health sector and services provided through the social sector. Home care services cover assistance with everyday activities, personal hygiene, tasks related to housework, nursing (if prescribed by a physician), and support in social networking. Specialist home care is adjusted to the specific medical and rehabilitation needs of the recipients, and services are provided by qualified personnel, such as physiotherapists. An important and recently developing type of care is day care centres offering leisure time activities for older people and people with disabilities. Activities ranging from education, culture, to excursions are provided for persons living at home, whose family members are not able to provide care because of work responsibilities, during working hours (source: Poland Country (filesusr.com).

Last updated: September 2nd, 2021

Singapore

Singaporean LTC relies heavily on home-based and community care services and aims to reduce unnecessary utilization of institutional care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf). In 2019, there were 7,600 day care places, 10,300 home care places and 1,986 community hospital beds in Singapore (source: Analysis of variable COVID-19 mortality among older people in Asia Pacific, by forms of long-term care (ageingasia.org).

There are different types of day care services in Singapore. These include: ‘senior care centres, day rehabilitation centres, general and enhanced dementia day care and day hospices’. Home care services for bed-bound older people living in their own homes include ‘medical, nursing, therapy, personal care and hospice’ are. In addition, there are meals-on-wheels services and Medical Escort and Transport Services available. Community hospitals offer short-term (2-4 weeks) rehabilitative inpatient care for people who experienced acute medical care needs. It is their role to facilitate transition back into the community (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 2nd, 2021

Spain

Spain characterises insufficient community support for people with moderate of sever needs who live in their own homes, moreover there are visible inter-regional disparities regarding the quality, coverage or funding of services, which creates unequal access to services. A high number of people with LTC needs receive cash allowances to family caregivers in lieu of services, which heightened the responsibility of families in providing care. Migrant care workers, often hired with no legal contract, often provide private care at home (source: CEQUA Spain Country report (filesusr.com)

Last updated: September 2nd, 2021

sub-Saharan Africa

Because organized systems of LTC are generally lacking, families constitute the major source of care for older people who are no longer able to live independently. Numerous concerns about quality of care have been documented. These range from general neglect of older people to exclusion, marginalization, and abuse. Care inadequacies may result in older people being unable to maintain their functional ability or lead to depression or early death. Inadequacies in family care arise particularly in contexts of poverty and vulnerable employment. In these cases, the family members who provide long-term care lack the resources to give better care and are faced with a choice between neglecting their work, training or other economic activities or neglecting their dependent older relative (source: https://www.who.int/publications/i/item/9789241513388).

 

Last updated: September 2nd, 2021

Sweden

Swedish LTC is focused on provision of community services: the deinstitutionalisation of old age care started in 1992, this trend was further entrenched during the 2000s as the municipalities started to downsize the number of institutional beds. In 2019 over 160 000 older people were provided services and care in their own home compared to 82 000 individuals who were provided institutional care. It has however been noted that many frail and disabled people as well as those living with dementia may well need institutional care whereas overreliance of home-based care places more burden on informal carers, mostly women  (source: Johansson-L.-Schön-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf (aldrecentrum.se).

Last updated: September 2nd, 2021

Thailand

For many years, Thailand has explored models of home- and community-based care, with an emphasis on services provided at home, initiatives over the years including training volunteers to provide care services in the community (e.g. home visits, assistance with meals, assistance with taking medicine etc); and various integrated community-based care projects.  The Community-Based Long-Term Care Program, under the National Health Security Office (NHSO), started in 2016 and had provided care to some 193,000 older persons by 2018; there are plans to expand it throughout the country (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org).

Last updated: September 8th, 2021

1.11. Workforce conditions: pay, employment conditions, qualification levels, shortages

Overview

There is a shortage of workers in all countries including in this study and indeed for most countries around the world. At this pace of an ageing population, it is estimated that the need for LTC workers needs to increase by 40 – 100% if current ratios are to be maintained, which are largely deemed insufficient. The long-term care workforce ranges from specialized professionals (geriatricians, nurse case management workers, physiotherapists) to so-called low skilled care workers. This latter group can make up, up to 70% of the workforce that is responsible for ensuring older people’s activities of daily living (Source: https://www.oecd.org/health/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm). They are predominantly women and often middle-aged. Overall, the LTC workforce is ageing itself: in the EU in 2016, the median age of long-term care workers was 45 whilst the share of those aged 50 or over was close to 38 % in 2019. Low wages and limited training relative to the health workforce, stress, onerous working conditions and a heavy workload that does not reflect their training, all make it hard to attract and retain people in the LTC sector (Source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/country-assessment-framework-for-the-integrated-delivery-of-long-term-care-2019).

Limited career opportunities, lack of professionalization both for supporting the knowledge and rights of this workforce, as well as a lack of support and lack of research in this area, all exacerbate the challenges in attracting workers into the LTC sector (Source: https://www.oecd.org/health/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Where data is available it tends to identify the workforce working in institutions or suggest that larger portions of the workforce is working in institutions. This reflects a lack of visibility of home care workers but also the distinction between formal and informal workers (family carers) which is not as clear cut in long term care where informal carers provide a large proportion of the care to older people. Comprehensive policies are needed when it comes to the workforce and no single policy can be used to address workforce availability, the recruitment, retention and competencies of a sustainable supply of fit for purpose LTC workers. A range of approaches exist in addressing some of the key policy issues facing the LTC workforce (Sources: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/country-assessment-framework-for-the-integrated-delivery-of-long-term-care-2019;

Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu). 

 

Australia

In 2016, there are 366,000 paid workers (84%) and 68,000 volunteers (16%) delivering aged care. 66% of the paid workers were in direct care roles, including nurses and personal care workers (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Australia has trained and supervises care workers to assist nurses with medicine management. Self-managed teams to give workers more flexibility and control have been shown to boost job satisfaction and reduce turnover (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: September 2nd, 2021

Austria

In Austria more than 66,000 personal carers (mostly migrants from neighbouring countries) provide live-in care to around 33,000. About 47,100 staff provide care to care home residents and 18,300 provide home-based care. The share of social care staff who are migrants from neighbouring (Eastern European) countries has increased in recent years. These workers are registered as self-employed, but in practice they are dependent on brokering agencies in their home countries and have precarious working conditions as well as few entitlements to social protection and labour rights. The majority of these workers are women and work in alternate rotas of two weeks or a month (sources: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/; https://journal.ilpnetwork.org/articles/10.31389/jltc.51/).

Last updated: September 2nd, 2021

Belgium

In Belgium, the Wallonia region allows personal care workers to perform nursing tasks when the elderly person needs them and no other care options are available (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: September 2nd, 2021

Bulgaria

Excellence programmes established in LTC for nurses (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm). However, the country, alongside other Eastern European countries, experiences so called  “care drain’ where many long-term care workers are working in other EU countries, mostly for better salaries and working conditions (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 2nd, 2021

Canada (British Columbia)

Majority of LTC and AL health care workers in BC are represented by a union, the largest being The Hospital Employers Union (HEU) (source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Normally, to become a health care assistant, one must complete six to eight months of post-secondary education at their own expense before applying for a position. Due to staffing shortages during COVID-19, BC has launched the subsidized Career Access Program, a sponsorship program where individuals will work as a health support worker while training to become a health care assistant. Applications for the program began in early 2021 (source: https://www2.gov.bc.ca/gov/content/economic-recovery/work-in-health-care; https://www.choose2care.ca/hcap/).

 

Last updated: September 2nd, 2021

Denmark

In addition to GPs, Nurses, Physiotherapists, Occupational Therapists there are two kinds of professionalized social care helpers. Social and health helpers and assistants represent most of the long-term care workforce. Physiotherapists and occupational therapists have grown in numbers and in influence during the past decade, especially after the reablement programme was implemented. In most residential settings, the number of personnel has stagnated or even declined while personnel employed in home help has increased by almost 10%. Between 2005-2015 there has been an increase in part-time working: 49% of practitioners employed in home care worked 30–35 hours per month in 2016 versus 21% in 2005. Greater professionalization of the workforce has also been observed, 46% of the practitioners in residential care facilities held relevant qualifications that require training of more than two years in 2016 versus 33% in 2005. As care needs of residents have increased, nursing home personnel also experienced an increase in health- and nursing-related tasks. Personnel also reported higher work intensity in both home and residential care, especially related to administrative workload. Although more than 75% of those interviewed perceived their work in long-term care as highly meaningful, about 40% have considered switching jobs because of deteriorating working conditions, especially less autonomy, less support from superiors and insufficient training (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

The Danish Health Authority provides accreditation and licensing services for practitioners, including physicians, nurses, dentists, clinical dental technicians, dental auxiliaries, social and health care assistants, physiotherapists, chiropractors, midwives and optometrists (source: https://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf).

Social and health helpers can become accredited after 1.5 years of training, including a basic course of 20 weeks and a period of alternating practical and theoretical courses. Social and health helpers can perform tasks related to support with personal care and hygiene as well as household chores. A further module of 32 weeks of theoretical training and 48 weeks of practice leads to the next level as social and health assistants. These can carry out nursing functions, including planning of activities. Social and health assistants may choose the traditional nursing education that encompasses 3.5 years for a university bachelor’s degree (source: https://pubmed.ncbi.nlm.nih.gov/20626496/). Modular training for personal carers is under development  for those seeking to access managerial roles or for nurse aides wanting to become nurses (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: September 2nd, 2021

England (UK)

There is no national workforce strategy for the adult social care workforce – the last strategy was published by government over a decade ago in 2009 (source: https://webarchive.nationalarchives.gov.uk/20130105063710/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098481).

The number of vacant posts in the English social care sector has climbed steadily since 2012/13, reaching 122,000 or 8% of the total workforce in 2019 (source: https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-size-and-structure-of-the-adult-social-care-sector-and-workforce-in-England.aspx), with providers having difficulty recruiting and retaining workers, particularly to the roles of care worker, registered manager and nurse (source: https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/690/690.pdf). Data indicate that the sector also suffers from high staff turnover, poor working conditions, and 24% of the workforce are on zero-hours contracts. Pay is low and there are few opportunities for training and progression. The adult social care workforce is reliant on migrant labour. It was reported that in total, an estimated 98,710 migrant workers joined the formal care workforce between 2009 and 2019, with 9% from EU and 11% from non-EU countries. In London, more than two in five care workers are from abroad (source: https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/documents/Regional-reports/Regional-report-London.pdf). Care workers have not been recognised as eligible for the ‘skilled worker’ route, in the forthcoming points-based immigration system, due to be implemented on 1 January, 2021 (source: https://www.gov.uk/government/publications/uk-points-based-immigration-system-further-details-statement).

Last updated: September 2nd, 2021

Finland

Municipal outsourcing to the private and for-profit sector for provision of sheltered, round-the-clock LTC has significantly increased over the past decade; in recent years, reports of insufficient care and serious maltreatment in these spaces have been met with public outcry for their review. The Act on care services for older people is thus under reform and a minimum number (0.7) of nurses per clients will be required by April 2023. See pages 6-7 of LTC Covid report (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf). Municipalities appear to be struggling to maintain/keep up with growing need for more formal care services. Additionally, with the population aging and working-age population decreasing, there is a growing concern about the shortage of employees in LTC services.

Last updated: March 22nd, 2021

France

France reported to OECD that it increased wages in LTC and that this was associated with greater recruitment of workers, longer tenure and lower turnover. However, wage increases need to be financed and regulated. Otherwise, wage increases that are not matched by increases in resources lead to increased workload and duties. One-third of institution-based LTC workers were temporary agency workers (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

The distribution of different workforce roles is as follows:  domiciliary care nurses (SSIAD), 117 093 in 2014; domiciliary care workers, registered with NFPs and public organisations, around 535 000 in 2011; private companies for domiciliary care employ approximately 4% of the workforce. There has been limited success with attempts at professionalisation to improve quality in delivery. There was no increase in staff to resident ratios in care homes between 2011-15 despite increase in demand. Diplomas have been developed over the years, and 62% of workforce has some level of qualification, but despite these workers report low levels of satisfaction and there are frequent strikes. Only 30% of the workforce is employed full-time and wages are low in the sector (c.882€/month, which is equivalent to minimum wage) (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

Due to the limited attractiveness of the sector, especially in domiciliary care, 20% of demand for places could not be fully allocated in 2019, 25% of businesses have recorded a decrease in the number of supported places, and over 30% of directors of domiciliary care agencies have highlighted lack of staff as a direct cause of place refusals, moreover, 80% of directors think the situation is worsening. The existence of nursing roles in domiciliary care is an additional pressure, as the gap between pay has doubled (200€) (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Last updated: September 2nd, 2021

Germany

In 2019, the rate of LTC workers per 100 inhabitants 65 years and above in Germany was slightly above the OECD average, at 5.1 compared to 4.9. Of all LTC workers, about one third full-time equivalents was employed in home care and the remaining two thirds were employed in residential care. The workforce is predominantly female and works part-time (source: Germany_draft.pdf (who.int).

In 2019, approximately 976,500 (mostly qualified) people worked in residential care settings. Almost two thirds (more than 85% women) were employed part-time (source: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_page?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=406&p_ansnr=61388070&p_version=3&D.499=1000529&D.993=1000518&D.991=23746).

The creation of an additional 13,000 additional care workers in residential care settings has been criticised as too low and efforts to make jobs more attractive through pay increase have been insufficient to attract people. This law came was prepared in 2018 and came into effect in large parts in 2019 (source: Gesundheitspolitik – Gesetze und Verordnungen 19. Wahlperiode: seit 2017 (vdek.com). LTC workforce shortage is one of the main concerns. Projections estimated that Germany will have a shortage of 263,000 full time care workers by 2030. (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).

Working conditions are considered poor, especially given the wages and social standing are low, while working hours are unfavourable and physical and psychological strain is high (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).

A 2020 report on care (Barmer Pflegebericht) found that, due to insufficient staffing levels, care workers had to work more overtime, duty rosters couldn’t be adhered to and care workers were called in when they were on leave. This can lead to reduced working ethic and lower quality of care. A comparison of psychological burden of LTC workers in comparison with other jobs showed that burden was higher in a number of the aspects compared. The report also showed that while the majority of care workers felt their job was important, 53% of care workers reported that they felt their work was socially recognised.

In 2019, LTC workers earned a median gross salary of €2146- 3032 per month (FTE-adjusted) depending on their level of qualification, although salaries in residential care tend to be higher than in homecare. Salaries in LTC sector have increased by about 28% from 2012 to 2019, however the salaries are considerably below the median salary of nurses working in hospitals, and Germany might see a drift of the LTC workforce from the LTC sector to the inpatient sector (source: Germany_draft.pdf (who.int). The share of LTC workers who are unhappy with their incomes (almost half) is higher than among employees in other jobs (less than 30%). Among people working care 53% report having difficulty to live off their income. Among LTC workers, 52% think that their retirement pay will not be sufficient (source: https://www.barmer.de/blob/278006/6b0313d72f48b2bf136d92113ee56374/data/barmer-pflegereport-2020.pdf).

A report by the Bertelsmann Stiftung found that future availability of workforce is likely to differ across the country. In most local authority areas and districts in Eastern Germany an increasing number of people with care needs is unlikely to be met by decreasing number of care workers. Challenges were also identified for Bavaria and Schleswig-Holstein, while parts of Westphalia, Hessen and Baden-Wuerttemberg do not expect to experience the same challenges.

On 2 June 2021 the German government has passed a new care reform (Pflegereform 2021) that sets out that all LTC workers in care homes need to pay their staff according to tariff. It is also planned that care homes will be able to recruit more staff. This should be enabled through national guidelines. The reform also plans to provide LTC workers with more responsibility to make independent decision as part of domiciliary care. These changes are scheduled to come to effect in September 2022 (source: Pflegereform – Altenpflege wird besser bezahlt und der Beruf attraktiver – Bundesgesundheitsministerium).

 

Last updated: September 2nd, 2021

Israel

Israel holds a significantly higher ratio of LTC providers to older population compared to other countries, with 11.1 LTC workers available per 100 people aged 65+ (e.g. the UK’s ratio is 3.3 for every 100) (source: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en;jsessionid=CTkqke4qXqinDQ1QDC9SriKb.ip-10-240-5-113).

Israel is listed as a country that subsidizes education to attract people into LTC training, including provision of scholarships for nurses specialising in geriatric care (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Personal, at-home caregivers make up approximately 90% of the LTC workforce in Israel, with the majority of around-the-clock workers consisting of migrants from Southeast Asia (70,00 migrant care workers are currently hosted by Israel, nearly 40% of whom are from the Philippines) who are contracted out to LTC users through agencies (source: https://www.oecd-ilibrary.org/sites/b768405f-en/index.html?itemId=/content/component/b768405f-en; https://adva.org/wp-content/uploads/2019/03/Care-Deficit-EN.pdf). At-home care workers in Israel are granted certain right (e.g. a separate and private room in the employer’s (user’s) home, weekly vacation days, and 2-hour rest periods). The hourly wage set for long-term care workers by the National Insurance Institute is the minimum hourly wage; caregivers often hold multiple jobs and live on the poverty line. Those with valid work visas are provided with limited health insurance (source: https://ijhpr.biomedcentral.com/articles/10.1186/s13584-020-00422-0).

Though standards for medical service delivery are particularly high and demanding, Israel’s required training qualifications for long-term caregivers in the community are amongst the lowest among OECD countries (source: https://www.boi.org.il/en/Research/Pages/pp201801h.aspx). Digital aids assist personal care workers performing tasks such as taking a care recipient’s temperature or blood pressure (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: September 2nd, 2021

Italy

Migrant workers are important in providing private home care in Italy, not all of them are employed under a regular contract. The trend to rely on home-based migrant carers has been supported by different measures and policies at local, regional and national level, including training and accreditation programmes for such carers (source: Italy Country Report (filesusr.com).

Last updated: September 2nd, 2021

Japan

In 2017 there were 5.9 formal LTC workers per 100 older adult population. It is estimated that by 2025 Japan will have a shortage of 380,000 LTC workers.  The country experiences severe and widespread staff shortages and high staff turnover which stem from a number of factors, including: a combination of high requirements for qualifications and low pay compared to other sectors (e.g. retail); low status; very low immigration (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan; https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Care workers are required to hold a qualification earned by sitting a formal examination at worker’s own expense. Providers are required to observe strictly-enforced rules around staff to service user ratios (source: https://www.researchgate.net/publication/231843369_Rationale_Design_and_Sustainability_of_Long-Term_Care_Insurance_in_Japan_-_In_Retrospect).

Japan has sponsored basic training programmes for both new students and experienced workers willing to return to work after a long break. These initiatives led to an increase in the number of LTC workers of around 20% between 2011 and 2015. The country also provides scholarships for nurses specialising in geriatric care. Japan has workplace counselling services to promote prevention of accidents and burnout (https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

 

Last updated: September 2nd, 2021

Luxembourg

In 2018, there were 10.7 FT LTC staff per 100 people aged 65 and over, one of the highest in the EU. Wages in the LTC sector are very attractive, especially for commuters from the neighbouring countries. Provides recruit about 45% of their workforce from outside the country, mostly commuters from France, Belgium, and Germany, even though language barriers can be problematic (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 2nd, 2021

Netherlands

The government provides subsidies for people wishing to go into LTC training. Dual career track is available for nurses working in general care and geriatrics. The Netherlands has developed stress management/coaching programmes on healthier work environment and prevention of work-place accidents for LTC centres to help decrease absenteeism  (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: September 2nd, 2021

Norway

The Norwegian Men in Health Recruitment Programme was set up to recruit (unemployed) men aged 26-55 to the health and care sector. It entails eight weeks of guided training as health recruits in a regional health institution or health care service. The Programme has been very effective in the Norwegian context to motivate employment of men in LTC sector. A new nationwide strategy has been introduced to improve the digital skills of care workers during initial education (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: September 2nd, 2021

Poland

LTC employment is low compared to other EU countries, namely in 2016 there were 0.5 LTC workers per 100 older people (EU-27 average was 3.8). There are inequalities in working conditions and wages between the healthcare and the social sector. The number of carers is increasing, however the country is experiencing ageing of LTC staff will put additional pressure on ensuring adequate staffing levels (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 2nd, 2021

Republic of Korea

In 2018, there were 3.9 Formal LTC workers per 100 older adult population. Ninety percent of workforce is personal support workforce. LTC facilities in Korea have mandated staff to resident ratios and a national curriculum of minimum requirements for LTC workers has been established whereby care workers must pass certificate tests. Training and career development options are available for care workers in the form of modular training (sources: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm; https://www.oecd-ilibrary.org/sites/b768405f-en/index.html?itemId=/content/component/b768405f-en; https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: September 2nd, 2021

Romania

With 1 LTC worker per 100 older people in 2016, compared to 3.8 for the EU-27 average, Romania is among the countries with the lowest number. This situation is partly attributed to Romanian nationals migrating to work in health and social care sectors in the neighbouring, more affluent EU countries. Romania is among the top 20 countries to provide LTC workforce to OECD countries, e.g. Romanian nurses account for half of all foreign trained nurses in Italy. The COVID-19 pandemic may reverse the trend to some extent, increasing the availability of the LTC workforce, due to higher unemployment in the country (hence more people available to work in LTC sector) as well as returned migration during pandemic (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 2nd, 2021

Scotland (UK)

In Scotland 80% of the care workforce is organized and represented by SCOTTISH CARE, a membership-based organization that provides support, training and advocates for the predominantly private workforce (source: https://scottishcare.org/meet-the-national-team/).

Last updated: September 2nd, 2021

Singapore

The country operates with shortages of workers in LTC sector, which poses challenges to staffing facilities (source: Responding to COVID-19 in Residential Care: The Singapore Experience – Resources to support community and institutional Long-Term Care responses to COVID-19 (ltccovid.org).

Last updated: September 2nd, 2021

Slovakia

The number of LTC workers per 100 people aged 65 and over is 1.5 worker, representing less than half the EU-27 average. Care provided by family members remains the main form of LTC in Slovakia.  More than 90 % of the total LTC workforce in 2016 were women. The majority of LTC workers have a medium level of education, including upper secondary education and post-secondary, non-tertiary education. Non-standard employment is not very widespread in the LTC sector, e.g. the share of temporary employment is less than 10 %. Shift work is experienced by less than 40 % of the LTC workforce, far below the EU-27 average (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 2nd, 2021

South Africa

South Africa has National Norms and Standards (2008) that outline acceptable levels of service to be provided to older people. Recent audits have found many facilities in partial non-compliance. In addition, informal racially discriminatory practices were observed in some facilities, both in terms of admissions and quality of care (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: September 2nd, 2021

Spain

Low public spending on LTC, is related to low wages in the sector. The monthly cost per member of staff in the sector is 67% of the average wage per worker in Spain. Poor working conditions are the norm in a sector where women are the majority. In care homes, staff ratios vary markedly between regions and are generally inadequate (LTCcovid-Spain-country-report-28-May-1.pdf).

Last updated: September 2nd, 2021

sub-Saharan Africa

Most family caregivers are left to provide support with little or no guidance on how to address complex issues that sometimes arise. Dementia is a key example: few caregivers understand the nature of the condition, the ways it can influence behaviour and what responses can ease the burden and enhance the lives of care recipients. Unpaid family caregivers also pay a price in terms of foregone education and/or income-earning opportunities. Study findings further highlight adverse effects on caregivers’ physical health, including fewer opportunities for self-care, and their mental health, including depression. Some evidence documents the considerable financial costs of caregiving borne by families, particularly in households with dependent children (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: September 2nd, 2021

Sweden

Ninety percent of LTC workforce is personal support workforce (source: https://www.oecd-ilibrary.org/sites/b768405f-en/index.html?itemId=/content/component/b768405f-en). Approximately a quarter [reports vary from 25% to between 30-40% in different sources) of LTC workers in care homes and in homecare are on hourly and/or temporary employment contracts.  It has been reported that this may have been an additional risk factor in the care sector during the pandemic as such workers often cannot afford to stay home if they get sick, they are not covered by the Swedish health insurance, and they may infect older persons and colleagues. Moreover, temporary staff works across different care settings, which, during the pandemic increased the risk of passing on the infection.  One in five care workers in care homes lacks formal training. On average, there are three care workers and 0.4 registered nurses per ten residents in a care home (sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: September 2nd, 2021

Thailand

In general, care for older persons in Thailand is provided by informal caregivers. After informal caregivers, volunteers are the next most important group providing LTC, Volunteers are usually officially trained in the basics of caring for older persons. Although they work without pay, those who volunteer for government projects receive transport allowances. The roughly 1 million village health volunteers (VHVs) in
Thailand play an important role in the country’s care system, but they do not have any specific responsibility or training for LTC.

The two main government programs that utilize volunteer caregivers are: 1) the Home Care Volunteers for the Elderly (HCVE); 2) the Community-Based Long-Term Care Program, under the National Health Security Office (NHSO), which uses volunteer caregivers in
about 75% of the participating districts and paid caregivers in the other 25%. The HCVE volunteers are trained for 3 days, for a total of 18 hours, in basic personal care of older persons, the role of the volunteer, welfare and social services for older persons, and health promotion for older persons. The caregivers involved in the Community- Based Long-Term Care Program receive 70 hours of training whether they are
volunteers or paid caregivers.

Professional care personnel  encompasses professionals who work in the health and social professions, including doctors, nurses,  physiotherapists, occupational therapists, and other health personnel who receive payment for the provision of care services.

Nonprofessional care personnel encompasses people who actually provide private care for older persons, especially at home and in the community. They do not necessarily have formal training, but use past experience in caring for their own family members or their own knowledge and skills to provide care for others. This group includes care assistants, trained paid caregivers, untrained paid care givers, domestic workers (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org).

Last updated: September 8th, 2021

Turkey

When LTC is provided formally within care settings, women remain the primary providers. With low female labour participation rates, LTC is seen as a potentially suitable sector to enhance women’s training and employability. Recent evidence highlights the role of informally employed domestic and migrant live-in care workers to provide LTC at home when the family cannot meet such needs, funded either through cash-for care schemes or out-of-pocket by the private households (source: https://www.mdpi.com/2071-1050/13/11/6306/htm).

Last updated: September 2nd, 2021

United States

Almost 1.5 million nursing employee full-time equivalents (FTEs), which includes registered nurses (RNs), licensed practical or vocational nurses (LPNs or LVNs), and healthcare aides, as well as approximately 35,000 social work FTEs, are employed across the five sectors of long-term care in the US (source: https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf). The majority (63.3%, or 945,700 FTEs) work in nursing homes, 20.0% are residential care community employees, 9.7% are employed by home health agencies, 5.7% are employed by hospices, and 1.3% are adult day services centre employees. Employment conditions and required qualifications vary a great deal across the sectors; a breakdown of employment rates in each sector can be found beginning on page 18 of the CDC report (source: https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf).

Last updated: September 2nd, 2021

1.12. User voice, choice and satisfaction

Australia

People who use aged care may choose between different types of aged care services, including care within their own home, community, or in residential aged care settings. Home Care Packages allow people to choose the care bundle that they require, along with their preferred providers and services. “My Aged Care” is the single point of entry for Australian government subsidized care. It is a virtual service, without face-to-face assistance, and it was found to decrease user satisfaction due to less personalized support. Overall, a report by Royal Commission published in 2021 noted that users of aged care found the experience of seeking out services to be time-consuming, overwhelming, and intimidating (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Last updated: September 2nd, 2021

Canada (British Columbia)

Individuals receiving LTC may choose between privately or public owned LTC facilities, day services, home support, assisted living, etc. which are all publicly subsidized (source: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost). A survey by the Angus Reid Institute found that two-thirds of Canadians (66%) would like the government to take over – or nationalize – LTCFs in order to increase the health and safety outcomes for people requiring long-term care (source: http://angusreid.org/covid19-long-term-care/).

Last updated: September 2nd, 2021

Denmark

All municipalities partner with voluntary organizations to roll out community programmes to engage and reach out to older people (source: https://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf) .

Non-profit actors play mainly a role in advocacy (rather than in providing services), although some are active in nursing home care (Danish Deaconess Foundation and OK Foundation) while others are taking a lead role in organizing self-support and peer-support activities in the community (DaneAge Association and Danish Alzheimer Association). The DaneAge Association, a voluntary association with more than 825 000 members, has the most prominent role among civil society organizations. The DaneAge Association is heavily involved in advocating the rights and well-being of older people and is recognized as a stable partner in the political dialogue, whilst many volunteers are themselves 65 years or older. The Elders Help Elders network, a partnership among six older people organizations, is one of the most visible initiatives organizing older people volunteers for supporting other older people throughout Denmark. Most volunteering activities through the network focus on visiting services, mobility support, shopping, practical assistance in the home, sharing meals, exercise, walking, biking and telephone security services. Non-profit organizations also play a crucial role in organizing volunteers in nursing home, hospices and hospitals (https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

 

Citizens can complain to their municipality if they are not satisfied with the quality of their LTC offer and the package of services they receive. If a citizen complains about a decision the municipality must review the decision and if the municipality does not change the decision their complaint must be sent to a National Board of Complaints  (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 2nd, 2021

Germany

LTC users living at home have choice in a sense that once their care needs are assessed they can choose whether they prefer financial or in-kind support. This is embedded in the principles of the LTC insurance, which aims to support people in living a self-determined and independent life. The Care Charta emphasises people’s choice regarding where to live, care and support and their daily routine as well as financial and legal aspects (source: https://www.der-paritaetische.de/fileadmin/user_upload/Schwerpunkte/Mensch-du-hast-recht/doc/VT2018_WS-Selbstbestimmung-Pflege_ThorstenMittag.pdf; https://www.pkv.de/wissen/pflegeversicherung/so-funktioniert-die-pflegeversicherung/). The task force on LTC recognises the importance of self-determination among people with LTC needs during COVID-19 (source: https://sozialministerium.baden-wuerttemberg.de/fileadmin/redaktion/m-sm/intern/downloads/Downloads_Gesundheitsschutz/Corona_Positionspapier-TF-Langzeitpflege-EGH_Selbstbestimmung-Teilhabe_20201204.pdf).

Last updated: September 2nd, 2021

Israel

Choice of LTC service is highly dependent on financial means and ability to acquire private LTC services. Eligibility with NII to receive state-funded services is dependent on certain proofs of retirement, disability, need, lack of income.

Last updated: September 2nd, 2021

Japan

Once an individual is found to have needs, they are assigned a notional budget to spend on care. In theory, they can choose between competing providers, assisted by a care manager. However the care managers are mostly employed by providers. There are safeguards in place to prevent them refering all their clients to one providers but they are weak and do not fully address the conflict of interest. (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan).

Last updated: March 23rd, 2021

Netherlands

In the Netherlands all care homes are required, by law, to have “client councils” that have the right to participate in decisions that affect their daily lives. The members of the councils are residents or their representatives, and the councils have the right to participate in the strategic management of the care homes. They need to be consulted about organisational issues and have a right to consent to decisions that affect the residents’ daily lives. They also have the right to provide advice (source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181203/ and https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 2nd, 2021

Sweden

Ensuring choice for service users is an important part of the Swedish system, which is partly driving marketisation of services (sources: https://ec.europa.eu/info/sites/info/files/file_import/joint-report_se_en_2.pdf; https://rd.springer.com/chapter/10.1007/978-1-4614-4502-9_3).

Last updated: September 2nd, 2021

1.13. Equity

Denmark

Denmark is one of the European countries with the lowest income inequality and high coverage of social and health services. The rate of poverty or social exclusion for the entire population is 14.8%, significantly lower than the EU average. Among older people, this rate was 8.7%, about half the EU average (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: September 2nd, 2021

Israel

Extensive reliance on private funding has given rise to inequality in LTC services received by Israel’s elderly from different socioeconomic backgrounds (source: http://taubcenter.org.il/blog/is-israel-prepared-for-an-aging-population/).

Last updated: September 2nd, 2021

Japan

A national framework for eligibility and benefits based on need only, creates consistency. Co-payment operates on a sliding scale according to income. Monthly cap on co-payments protects against high costs (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan ).

Last updated: September 2nd, 2021

1.14 Pandemic preparedness of the Long-term care sector

Overview

A summary of factors that explain lack of effective crisis management by Del Pino and colleagues identifies incredulity, excess of confidence, perceived remoteness of threat, short window of opportunity when action will be effective, lack of clarity about who is in charge  (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf). 

Australia

In a study analysing pandemic preparedness in 2009, researchers found that pandemic plans varied in detail, consistency, completeness, and usability depending on the state that issued it. Crisis communication and pharmaceutical interventions were completely missing in some states.

Another study published in 2018 found issues with infection prevention and control strategies and cited scepticism towards staff influenza vaccinations, effort required to read national guidelines, and lack of infrastructure to physically separate residents during an outbreak as the three main barriers to the management of outbreaks.

Overall, the aged care sector in Australia struggled with pandemic preparedness even before COVID-19 – the pandemic only exposed the sector’s vulnerability (source: https://www.theguardian.com/commentisfree/2020/jul/27/aged-care-has-been-failing-for-years-coronavirus-has-merely-highlighted-systemic-problems).

In April 2020, the Aged Care Quality and Safety Commission contacted all aged care providers to complete an online self-assessment survey that asked about infection control systems and preparedness for a COVID-19 outbreak. 99.5% of providers claimed that their infection control and respiratory outbreak management plan covered all areas identified in the survey. The same proportion assessed their service’s readiness in the event of a COVID-19 outbreak as either satisfactory (56.8%) or best practice (42.7%). This survey suggests that providers believed that they were more prepared than they were. The commission also found that most providers required further Infection Prevention and Control (IPC) and PPE training throughout the pandemic (sources: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf; https://www.agedcarequality.gov.au/news/assessment-contact-preparing-covid-19-home-services).

Last updated: September 10th, 2021

Canada (British Columbia)

Information on pre-pandemic prepared in the LTC sector is lacking. However, in terms of Canadian pandemic preparedness for the general population, there is evidence that some lessons were learnt from SARS, which affected Canada more than any other country outside of Asia. While responses differed across provinces, funding for infection control in hospitals increased and legislative changes were made to allow for better collaboration between federal and provincial actors (source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30670-X/fulltext?hss_channel=tw-27013292).

An independent review of the LTC response to COVID-19 was completed in October 2020 and released to the public in January 2021. The review provides a detailed analysis of the government’s and LTC sector’s preparedness. While quick policy decisions prevented further outbreaks in LTC facilities, the pandemic highlighted issues with staffing and Infection Prevention and Control (IPC) training. Data availability presents a key challenge in managing pandemic, for example, lack of baseline data made it difficult to calculate excess staffing needs and costs during COVID-19 (source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 7th, 2021

Denmark

The health sector was prioritized first and therefore there were challenges early on with preventing infections and securing resources to protect care homes, however, the characteristics of the care system seem to have supported the implementations of measures later on (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 7th, 2021

Finland

Despite a robust Pandemic Preparedness plan in Finland, social welfare units (including care homes) were only briefly mentioned. It was reported that pandemic preparedness in Finland provided insufficient guidance on care of older people during crisis (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: September 7th, 2021

France

Following the 2003 heatwave France had mandated the use of ‘blueprints’ in LTCF facilities (and other healthcare settings) to prepare against extreme health events, and these were triggered in February 2020. However, many LTCFs did not have any ‘contingency plans’ which could provide operational support to significant pressures such as high levels of staff absence. Care homes and other LTC actors were not integrated into risk simulation exercises (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Last updated: September 7th, 2021

Germany

Each of the 16 Federal States carries responsibility for the pandemic in their area. On a national level, the Robert Koch-Institute (RKI) takes a key role in infectious disease monitoring and prevention. The Institute also provides pandemic plans. Tasked by the government, the RKI has maintained a regularly updated National Pandemic Plan for Influenza since the early 2000s. The pandemic plan includes consideration for residential LTC as well as advice on PPE stockpiling, vaccination and training of staff. This plan has been amended to respond to the COVID-19 pandemic in March 2020. A second federal authority with the task to reduce health related risks is the Federal Office for Civil Protection and Disaster Assistance. As early as in 2013, it already warned of the risk of a pandemic through a virus of the ‘virus family Coronaviridae’. Despite this systemic preparedness, in practice there has been divergence in handling and applying hygiene plans, the experience that not all LTC settings had developed specific plans or not developed them in sufficient detail and that not all care workers, especially assistants, had not been sufficiently trained as well as a shortage of protective equipment. The existing shortage in the care workforce posed additional challenge to the response during the pandemic. While the government has taken some measures to increase the attractiveness of working in the LTC sector and the quality of care provided, more needs to be done (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).

A paper reviewing the implications of the LTC sector due to COVID-19 established that the LTC sector was not adequately prepared for a crisis. It was highlighted that residential care settings that need to operate under economic principles have been particularly unprepared to manage crisis. Consequently, providers have been imposing strict measures to prevent blame and legal claims. The measures have severe implications on people’s self-determination and quality of life. It was also noted that closer interdisciplinary partnership could help to prepare LTC for crisis situations (source: https://www.springermedizin.de/gesundheitsversorgung-und-pflege-fuer-aeltere-menschen-in-der-zu/18584958).

A survey conducted among care providers in April/May 2020 found that almost two thirds of care home were not specifically prepared for handling a pandemic during their apprenticeships, university degrees or training. Most surveyed institutions (90.7%) have run training on PPE. Among institutions that did not have training the proportion of those that have been more severely affected by outbreaks was higher. Among part-residential care settings almost 60% (n=96) stated that they had not been specifically prepared for a pandemic. More than half of these settings responded by setting up crisis teams. Two-thirds of domiciliary care providers surveyed did not report specific pandemic preparedness prior to COVID-19 (source: https://media.suub.uni-bremen.de/bitstream/elib/4331/4/Ergebnisbericht%20Coronabefragung%20Uni-Bremen.pdf).

Last updated: September 7th, 2021

Hong Kong

After the experience of the SARS epidemic in 2003, which resulted in the deaths of 72 care home residents, the Government published the first “Guidelines on Prevention of Communicable Diseases in Residential Care Homes for the Elderly” in 2004 and required all care home operators to designate an Infection Control Officer to coordinate and implement infection control measures (source: https://www.tandfonline.com/doi/full/10.1080/08959420.2020.1773192).

Last updated: September 7th, 2021

Israel

Preparedness for COVID-19 in Israel was limited, which led to considerable death toll particularly in residential care settings (source: https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4-May.pdf). A broad public outcry about the lack of testing and preparedness, as well as some contradictory directives (e.g. on visitation) ensued (source: https://www.jpost.com/israel-news/calling-in-the-calvary-israel-fights-coronavirus-analysis-623672).

Last updated: September 7th, 2021

Japan

Japan had well-established routine protocols of prevention and control in Long-Term Care Facilities (LTCFs). Each LTCF has a mandatory infection control committee which meets regularly. Practices such as isolating residents in LTCFs suspected to have a contagious infection, such as flu, were already in place before the COVID-19 pandemic. As soon as threat level was raised (as it would be for new TB outbreak or flu), LTCFs responded rapidly, as they were already familiar with protocols to isolate residents.

At the beginning of the pandemic in 2020 many LTCFs were in full or semi-lockdown already due to seasonal flu-outbreaks in January and February, this may have inadvertently helped protect care homes from COVID-19 outbreaks (sources: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf; https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

Last updated: September 7th, 2021

Netherlands

The Netherlands had a national pandemic action plan in place as well as various obligations on hospitals and others to have disaster relief plans. However, these were seen as insufficient. It was also criticised that the government had ignored recommendations provided by experts following the 2014 Ebola outbreak and the 2018 influenza epidemic. The national plan had specific appendices for care and nursing homes (source: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

Last updated: September 7th, 2021

Republic of Korea

While Korea faced similar challenges as other countries in terms of initial shortages of PPE and staff, the memory of MERS facilitated a quick and decisive response from government. This prior experience of a pandemic left a legacy which enabled 1) a good level of societal buy-in with infection control measures (eg wearing facemasks); 2) legislation was already in place to allow for close monitoring of personal data.

 

Last updated: September 7th, 2021

Singapore

Singapore drew many lessons from the SARS-CoV outbreak of 2002, which exposed the ill-preparedness of the country to deal with pandemics. Following the 2002 outbreak, the government established 900 rapid response public health preparedness clinics (PHPCs) across the country, ear-marked for improved response to pandemics and outbreaks. The PHPCs serve as an intermediary between the community and hospitals, screening all patients with flu-like or pneumonia symptoms into low-risk and high-risk groups. The high risk group is referred to an infectious disease hospital for further assessment and management (https://www.liebertpub.com/doi/10.1089/omi.2020.0077).

Last updated: September 7th, 2021

Spain

In a study of the institutional and organisational management of the COVID-19 pandemic in care homes, Del Pino and colleagues identify lack of preparedness in care homes, as well as lack of protection resources, as key factors in the slow response. Prior to COVID-19, the Spanish Ministry of Health had a plan in place that had developed to respond to Influenza (H5N1), which was used in 2009 during the H1N1 outbreak. There were also plans in place to respond to Ebola, Dengue and Zika, and one for MERS-CoV. The study found that people responsible for regional responses were not aware of those plans, potentially because they had not been in post for long. None of the plans in place had any provision for interventions in care homes (or any other collective living establishments). Although, in principle, these establishments should form part of the “critical infrastructures”, as for most people living in these centres there is no other housing alternative and these centres are needed to maintain basic social, health and wellbeing of the people living there. The fact that Spain ranked very highly in the Global Health Security Index in 2019 may have generated over-confidence in the ability of the health care system to respond, coupled with the experience of having “over-prepared” for the flu pandemic in the past. There was a lack of recognition of the increased risk this virus posed to care home residents in particular, despite awareness of the impact of flu among the older population.

Last updated: September 7th, 2021

Sweden

Overall, the Corona Commission highlighted that there was no overview of preparedness to tackle the pandemic, protecting the older population was a stated objective from the beginning, but there was no attention to the lack of preparedness and shortcomings in the municipal social care sector until later. The large proportion of casual and untrained care workers in the social care sector has been seen as contributing to the spreading of the disease (source: https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

Last updated: September 7th, 2021

United States

The LTC sector in the United States was unprepared for the pandemic; some reports have described it as disastrous and staggering. One key systemic challenge during COVID-19 faced by the LTC sectors was the fundamental (mis)structuring of financial arrangements, which determine the reimbursement, regulatory framework, and design of the services delivered. These arrangements determine which sectors would have enough resources and systems in place (e.g. PPE, infection control training) to respond in the midst of the pandemic (source: https://onlinelibrary-wiley-com.gate3.library.lse.ac.uk/doi/full/10.1111/1468-0009.12500#milq12500-bib-0016; https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html).

Last updated: September 7th, 2021

PART 2.
Impacts of the COVID-19 pandemic on people who use and provide Long Term Care

2.01. Impact of the COVID-19 pandemic on the country (total population)

Australia

As of the April 8, 2021, there have been 29,385 confirmed COVID-19 infections in Australia, and 909 deaths, according to the Australian Department of Health, corresponding to 3.56 COVID-19 attributed deaths per 100,000 population. The first case of COVID-19 in Australia was identified on January 25, 2020, from a man who travelled from Wuhan to Melbourne. Prime Minister Scott Morrison announced the Australian Health Sector Emergency Response Plan for Novel Coronavirus on February 27, 2020, and the first economic stimulus package on March 12, 2020. By mid-March, most states and territories were in lockdown. Cases began falling across the country in April, and on May 8, 2020, the government announced a three-stage plan to ease lockdown restrictions. Victoria entered into its second wave in late June, and by October 26, it reported no new cases or deaths. As of April, 2021, COVID-19 cases have been stable nation-wide since October (Sources: https://covid19.who.int/?gclid=Cj0KCQiAvvKBBhCXARIsACTePW9yMx1R31Uav8H6oLh3wEAVV68EZmmy7lb_v-FDkgTaL5mwurWha24aApaFEALw_wcB; https://www.health.gov.au/resources/publications/coronavirus-covid-19-at-a-glance-27-february-2021; https://deborahalupton.medium.com/timeline-of-covid-19-in-australia-1f7df6ca5f23).

Last updated: August 2nd, 2021

Canada (British Columbia)

As of February 7, 2021, there have been 69,716 confirmed COVID-19 infections in British Columbia and 1,246 deaths attributed to COVID-19, corresponding to 25.45 COVID-19 attributed deaths per 100,000 population (Source: https://resources-covid19canada.hub.arcgis.com/app/cases-cases-per-100k-population-webapp).

The first presumptive positive case of COVID-19 in British Columbia was identified on January 28, 2020. The first case of community transmission was announced on March 5, 2020. On March 18, a provincial state of emergency was declared in British Columbia, and by the end of March, all schools, personal service establishments, and dine-in restaurant services were closed. Health officials considered British Columbia to be successful in flattening the curve by late April and on June 24, the province entered phase 3 of its restart plan, where most establishments were allowed to reopen and non-essential travel within the province resumed. A second wave of COVID-19 was declared in British Columbia on October 19 and in November, mandatory mask policies and new restrictions against social gatherings were introduced. In December, Pfizer and Moderna vaccines were approved for use in Canada. The first dose of COVID-19 vaccine in British Columbia was administered on December 15. As of January 29, 2021, 129.421 vaccine doses have been administered. Current restrictions on social gatherings, restaurant services, fitness centres, and travel have been extended indefinitely (Source: https://bc.ctvnews.ca/scroll-through-this-timeline-of-the-1st-year-of-covid-19-in-b-c-1.5284929).

Last updated: August 4th, 2021

Denmark

As of February 8, 2021, there have been 202,051 confirmed cases of COVID-19 in Denmark, and 2,216 deaths, according to the Danish Health Authority, corresponding to 1,097 attributed deaths per 100,000 population.

Last updated: August 3rd, 2021

Finland

As of February 21, 2021 there have been 53,742 confirmed cases of COVID-19 in Finland, and 726 deaths, according to Our World in Data. These numbers have been steadily rising since March 2020, when the first lockdown measures were announced and the first death was reported (March 20) (Source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view). Numbers of cases, testing, and deaths are being recorded by the Finnish Institute for Health and Welfare (THL) (Source: https://experience.arcgis.com/experience/92e9bb33fac744c9a084381fc35aa3c7).

Last updated: August 3rd, 2021

France

As of Feb 12, 2021, there have been 3,406,685 confirmed cases of Covid-19 in France, and 80,803 deaths attributed to COVID-19 (Source: https://www.gouvernement.fr/info-coronavirus/carte-et-donnees), corresponding to 120.4 per 100,000 population (Source: https://coronavirus.jhu.edu/data/mortality). A summary of measures taken is available.

Last updated: August 3rd, 2021

Germany

As of February 24, 2021, there have been 2,402,818 confirmed COVID-19 infections in Germany, and 68,740 deaths attributed to COVID-19, according to the RKI.
The first wave has been relatively mild, however, the second wave, experienced mostly during December 2020 and January 2021, has been a lot more severe (Source: https://www.zdf.de/nachrichten/heute/coronavirus-ausbreitung-infografiken-102.html). It is anticipated that Germany is going into a third wave as mutations are becoming more widespread (Source: https://www.spiegel.de/politik/ausland/coronavirus-angela-merkel-sieht-deutschland-in-dritter-welle-a-2e8dc0f6-88db-44aa-8432-1cc8c687dbfa).

Last updated: August 3rd, 2021

Israel

As of February 4, 2021, there have been 675,618 cases of COVID-19 in Israel and 5,001 deaths, corresponding to 57.78 deaths per 100,000 population (Source: https://ourworldindata.org/coronavirus/country/israel?country=~ISR). According to Israel’s COVID Data Dashboard, those aged 70 and older have accounted for approximately 79% of COVID-19 related deaths in Israel so far. The pandemic was maintained at a reasonably low number of infections in Israel between February 21, 2020 (first case detected) and September 2020, with an effective first lockdown easing by May. In September 2020, the first major wave coinciding with the Jewish High Holidays resulted in a second lockdown. This first wave peaked at 6,276 cases on September 27. In tandem with a record-breaking vaccination campaign rollout, a second wave began in mid-December. The daily number of cases peaked at 8,624 on January 17, 2021, with the majority of cases due to a new, more virulent strain (Source: https://www.cgdev.org/event/how-make-covid-19-vaccination-success-policy-priorities-and-implementation-israel-and-around).

Last updated: August 3rd, 2021

Japan

As of February 5, 2021, there have been 399,048 confirmed COVID-19 infections in Japan, and 6,135 deaths attributed to COVID-19, according to the World Health Organisation, corresponding to 4.851 COVID-19 attributed deaths per 100,000 population. Japan is among other Asian countries reporting lower infection fatality rates than other parts of the World (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). Most of the early attention on Japan was focused on the Diamond Princess cruise ship: people on board started a 2-week quarantine on February 5, 2020 (Source: https://pubmed.ncbi.nlm.nih.gov/32183930/).

Last updated: August 3rd, 2021

Netherlands

During the first wave of the pandemic, Southern regions of the Netherlands were hardest hit, with Carnival celebrations being one of the main catalysts. The second wave started in September 2020, and by November was most pronounced in the West, including in the large urban centres Amsterdam, Rotterdam, and the Hague (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: July 29th, 2021

Republic of Korea

As of February 5, 2021, there have been 80,524 confirmed COVID-19 infections in South Korea, and 1,464 deaths, according to Our World In Data, corresponding to 2.8 deaths per 100,000 population.

Last updated: August 3rd, 2021

Sweden

As of February 21, 2021, Sweden had 631,166 confirmed Covid cases and 12,649 deaths (Source: https://covid19.who.int/region/euro/country/se).

Last updated: July 29th, 2021

United States

As of early March 2021, the United States had identified 29.5 million cases of COVID-19, and over 530,000 deaths. As of this date, the United States has been the country hit hardest by the pandemic per capita.

Last updated: July 29th, 2021

2.02. Deaths attributed to Covid-19 among people who use and provide Long-Term Care

Hong Kong

As of December 2020, there have been 20 care homes with outbreaks. This has resulted in 124 residents and 29 staff members testing positive for COVID-19. Of these 124 residents, 32 have died, accounting for 19% of all COVID-19 related deaths in Hong Kong.

It is estimated that there are 73,231 care home residents in Hong Kong. Therefore, the number of deaths of care home residents linked to COVID-19 would represent 0.04% of this population (Source: https://www.swd.gov.hk/storage/asset/section/632/en/15.Number_of_Homes_Providing_Residential_Care_Services_for_the_Elderly_(By_district)(30.6.20).pdf; https://www.swd.gov.hk/storage/asset/section/632/en/3.Provision_of_RCHEs_(Subsidised_versus_Non-subsidised_Places)(30.6.20).pdf; https://www.statistics.gov.hk/pub/B72002FA2020XXXXB0100.pdf).

Last updated: August 4th, 2021

Ireland

Ireland has a centralised system to collect epidemiological information in relation to cases of COVID-19 infections (Source: https://ltccovid.org/wp-content/uploads/2020/04/Ireland-COVID-LTC-report-updated-28-April-2020.pdf). All deaths, in all care settings and dwellings, related to COVID-19 that are notified to the Health Prevention Surveillance Centre are included in the official count of deaths. While the number of outbreaks in nursing homes is published regularly, the number of notified deaths in care homes is only made publicly sporadically.

A report by the Department of Health and the Health Prevention Surveillance Centre published in December 2020, estimated that up to December 13, 2020, there had been 1,112 deaths linked to COVID-19 in nursing homes. On that date, there had been 2,110 deaths attributed to COVID-19 in Ireland. Therefore, deaths of nursing home residents represented 51% of all deaths linked to COVID-19, but this figure has changed during the pandemic, suggesting lessons from the first wave may have improved the capacity of nursing homes to fight the pandemic. Based on the data in the same report, during what was the first wave in Ireland (up to early August 2020), the proportion of COVID-19 deaths attributed to nursing home residents was 54%, but in the second wave (August to October 2020) it was 38%, and between November and mid-December the share was 34%. There are an estimated 30,000 people living in nursing homes. Therefore, 3.71% of all nursing home care residents would have died because of COVID-19 as of December 13, 2020.

Last updated: August 3rd, 2021

Lithuania

As of March 27, 2021, there have been 3,552 COVID-19 related deaths, of which 382 were care home residents (11%) (Source: https://socmin.lrv.lt/lt/veiklos-sritys/socialine-integracija/socialines-paslaugos/globos-istaigu-sarasai/covid-19-atvejai-socialines-globos-istaigose). There are 12,700 care home beds in Lithuania. Therefore, the total number of COVID-19 related deaths in care homes represents 3.02% of all care home beds.

Last updated: August 2nd, 2021

Slovenia

As of March 14, 2021, there have been 4,220 deaths in total, and 2,057 among the care home population, representing 56% of all deaths (Source: https://www.nijz.si/sites/www.nijz.si/files/uploaded/gumb_4-_smrti_v_povezavi_s_covid-19_20210315.pdf). In 2017, there were 22,904 people living in long-term care institutions in Slovenia. Therefore, the share of residents who would have died linked to COVID-19 would be 8.98% (Source: https://www.stat.si/StatWeb/en/News/Index/8579).

Last updated: August 2nd, 2021

Switzerland

Data on COVID-19-related mortality among people living in care homes is only available for a few cantons. In the canton of Geneva where these data are published regularly, and as of January 27, 2021, there have been 674 COVID- related deaths, of which 511 (76%) were care home residents, and 110 of people who received domiciliary care. An estimated 46% (310) of all COVID-19 related deaths happened in care homes, suggesting that 39% of all care home residents who died from COVID-19 did so in hospital. There are an estimated 4,125 care home beds in Geneva. Therefore, the number of COVID-19 related deaths in care homes represents 12.4% of this population (Source: https://www.bfs.admin.ch/bfs/fr/home/statistiques/sante/etat-sante/personnes-agees.assetdetail.15724050.html).

Last updated: August 4th, 2021

Australia

There have been 2,051 cases of COVID-19 and 685 COVID-19 related deaths in Australian Government–subsidised residential aged care facilities. The majority of cases occurred during the first wave, with Victoria accounting for over 90% of the cases and deaths in residential aged care (Source: https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers#cases-in-aged-care-services).

Last updated: July 30th, 2021

Australia

The Australian Department of Health first published deaths linked to COVID-19 in care homes and among users of home care services on April 15, 2020. As of April 8, 2021, there have been 2,051 confirmed cases of COVID-19 among government-subsidized residents in aged care facilities, 97% of which were in the state of Victoria. There have been 685 deaths among residents, 95% of which were in the state of Victoria, suggesting that 75% of all COVID-19 deaths in Australia have been among care home residents. These figures are based on people who have tested positive for COVID-19 and are for the place of residence, not place of death, so may include residents who died in hospital. Among people who use government-subsidized home care, there have been 81 confirmed cases of COVID-19 and 8 deaths. In 2020, there were approximately 208,500 people living in aged care residential accommodation in Australia. Therefore, the numbers of care home COVID-19 deaths would amount to 0.33% of this population (Source: https://www.aihw.gov.au/reports/australias-welfare/aged-care).

A weekly report includes data on the number of outbreaks and staff infected in care homes. As of April 1, 2021, there have been no active cases of COVID-19 among people living in care homes since October 28, 2020. In total, there have been 2,238 staff with COVID-19 infections.

Last updated: August 3rd, 2021

Austria

During the earlier part of the pandemic, Austria was among those countries that had reported fewer deaths in care homes. During the second wave of the COVID-19 pandemic, Austria experienced very high rates of infections, reflected in a steep rise in infections and deaths due to COVID-19 in care homes (Source: https://ltccovid.org/2020/11/27/the-second-wave-has-hit-austria-harder-also-in-care-homes/). As of January 2021, infection growth rates are decreasing again, as are the number of COVID-19 cases in care homes.

As of January 24, 2021, 18,080 residents in care homes (including all ages) have tested positive for COVID-19, and of these, 3,243 have died. Compared to the 7,328 total deaths linked to COVID-19 in Austria on the same date, deaths of care home residents would represent 44% of all deaths. There have been 10,180 cases among staff in care homes, of which 1 was fatal.

According to data from September 17, 2020, only 0.4% of care home residents had died after the first wave. By January 2021, this number has risen to 4.7%. This is based on there being 69,730 residents in care homes in Austria (BM für Arbeit, Soziales, Gesundheit und Konsumentenschutz (2019) Pflegevorsorgebericht 2018. Vienna, BMASGK).

Last updated: August 2nd, 2021

Belgium

Belgium first reported official estimates of the number of deaths in care homes on April 11, 2020. The data is collected by Sciensano, a public research institution, which publishes very detailed epidemiological daily reports on COVID-19, which include data on the number of deaths in care homes (“maisons de repos”). As of April 15, 2020, reports have also included the number of tests done within care homes. For deaths outside hospitals, Belgium reports both “confirmed” cases (through a test or, since April 1, a chest scan), and “suspected” cases where the patient had not been tested but a doctor confirmed that their symptoms were consistent with COVID-19.

As of March 24, 2021, there have been 22,763 deaths linked to COVID-19 in Belgium, and of these, 12,597 people lived in care homes (55%). This number also includes suspected cases, particularly during the earlier part of the pandemic. Of the 12,597 deaths of care home residents, 9,404 happened in care homes (75%) and the rest (3,193) in hospital (Source: https://covid-19.sciensano.be/sites/default/files/Covid19/COVID-19_Weekly_Pub_NH_FR_2021_03_24.pdf). Belgium has an estimated 125,000 people aged 65 and over living in care homes. The number of care home residents whose deaths are linked to COVID-19 so far would represent 10.08% of this population (Source: https://kce.fgov.be/fr/les-maisons-de-repos-ne-se-pr%C3%A9parent-pas-un-avenir-de-tout-repos).

Last updated: August 4th, 2021

Brazil

There is no official data on the number of cases and mortality related to COVID-19 in Brazilian care homes. A report published in September 2020, found that there had been over 4,015 confirmed cases and 937 deaths in Brazilian care homes, which represents a case fatality rate of 23.33%. This was based on data collated informally by the researchers.

Last updated: August 3rd, 2021

Canada (British Columbia)

As of February 8, 2021, there have been 235 COVID-19 related deaths from current outbreaks in long-term care in British Columbia. There was no data available for total number of deaths in long-term care for the duration of the pandemic (Source: http://www.bccdc.ca/Health-Info-Site/Documents/COVID_sitrep/LTC_AL_COVID-19_Outbreak_Report_0204_2021.pdf).

Last updated: July 29th, 2021

Canada

On March 5, 2020, the first outbreak in a Canadian long-term care home was reported in the province of British Columbia, where a staff member at the Lynn Valley Care Centre in Vancouver had tested positive for COVID-19 (Source: https://www.theglobeandmail.com/canada/article-how-the-coronavirus-took-north-vancouvers-lynn-valley-care-centre/). On March 8, a resident at the home became the first Canadian to die from COVID-19. The Public Health Agency of Canada have reported that, as of March 13, 2021, 12,337 out of 22,438 (55%) COVID-19 deaths in Canada were from these settings. According to the 2016 Census, 425,755 Canadians lived in long-term care or retirement homes as well as assisted living facilities. Therefore, the number of COVID-19 deaths in these settings would represent 2.90% of this population.

Due to variation in reporting we are unable to determine whether the location of death was in a care home. It is important to note that, in Canada, many official sources have been reporting total counts of deaths in care homes, whether COVID-19 was determined to be a contributing or underlying cause of death or not. This may have inflated the estimates of the proportion of deaths due to COVID-19. Unfortunately, given the low rates of testing early in the pandemic, and the subsequent lack of post-mortem testing, some residents who died remain suspected rather than confirmed cases.

Last updated: August 3rd, 2021

Chile

There are no official publicly available estimates of the total number of people who use care who have died with COVID-19 infections. The lack of data on the impact of the pandemic is particularly problematic in the unregulated sector (Source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

Last updated: August 2nd, 2021

Denmark

As of April 6, 2021, there have been confirmed COVID-19 infections in 42.6% of Danish nursing homes (405 out of 937). There have been 3,690 residents in nursing homes which have tested positive for COVID-19 and 924 of these have died. In the total population, 2,432 COVID-19 related deaths were confirmed. Therefore, the share of confirmed deaths among nursing home residents was 38% (Source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

There were just over 40,000 nursing home residents in Denmark, which suggests that 2.30% of this population have died from confirmed COVID-19.

Last updated: July 29th, 2021

England (UK)

The Office for National Statistics provide weekly updates of deaths registered in England, which include any death where COVID-19 was mentioned (by a doctor) on death certificates.

Between December 28, 2019, and November 6, 2020, an estimated 15,659 people died linked to COVID-19 in care homes (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales).

As of March 12, 2021, there have been 127,911 COVID-19 related deaths, with 39,196 of these occurring in care homes (23%) (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales). In terms of deaths of care home residents in England, that is, those care home residents who died from COVID-19 but did not necessarily die in a care home, the Office for National Statistics publish data on weekly deaths of care home residents that are registered in England and Wales. As of March 12, 2021, there have been 41,107 COVID-19 related deaths of care home residents in England and Wales. Subtracting the total number of care home resident deaths in Wales (1,911 deaths) gives a total of 39,196 care home resident deaths in England up until March 12, 20201. Therefore, care home residents accounted for 31% of all COVID-19 related deaths in England. There are 425,408 care home residents in England. Therefore, the number of COVID-19 related deaths of care home residents represents 9.21% of this population.

There is relatively little data on the impact of COVID-19 on people who use long-term care and reside in private households. Using data from the Care Quality Commission, The Health Foundation estimated that, between March 23 and June 19, 2020, there were an additional 4,500 deaths among people using domiciliary care from providers registered with the Care Quality Commission, compared to the previous three years during the same period (an increase of 225%). The deaths of 819 service users had been notified and published as involving COVID-19 during this period.

The Care Quality Commission published a one-off analysis of 386 death notifications of adults with intellectual disabilities using community-based social care or living in residential care from April 10 to May 15, 2020, compared to 165 death notifications for the same period in 2019. Of the 386 deaths in 2020, 206 were confirmed/suspected COVID-19 deaths and 180 were deaths notified as not COVID-19 related. An analysis of 163 people with learning disabilities who died with COVID-19 reported that 35% of these people were living in residential care, a further 19% were living in nursing care, 25% were living in supported living accommodation, and 18% were living on their own or with their family.

Half (49.5%) of all COVID-19 related deaths in care homes in England and Wales between March and June 2020, were in people living with dementia (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/deathsoccurringupto12june2020andregisteredupto20june2020provisional?WT.mc_id=f5e0eb1233c5d2a1a4a1b591e46fecbd&hootPostID=1376c0e546f27d0e33d8ce1e242a810f).

The largest number of excess deaths (compared to the last five years during the same period) between March 20 and October 30, 2020, happened in private homes (25,634, of which only 2,571, 10%, were registered as COVID-19), followed by deaths in care homes (22,948, of which 15,415, 60%, were registered as COVID-19). In contrast, there were 2,724 fewer deaths than expected in hospices during that period. These figures do not include all deaths of care home residents, as some will have died in hospital (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredweeklyinenglandandwalesprovisional/latest).

In July 2021, the Care Quality Commission published care home level data on deaths notifications involving COVID-19 for the period from April 10, 2020, to March 31, 2021. In total, the Care Quality Commission had been notified of 39,017 deaths in that period that took place in 6,765 care homes.

Last updated: September 6th, 2021

Finland

Deaths from COVID-19 have fallen disproportionately amongst the elderly; the median age of the deceased is 84. Of the deceased, 19% were in specialised medical care, 34% in primary health care units, 45% in 24-hour social welfare units (residential LTC homes) and 2% at home or elsewhere (Source (p. 17): https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: July 30th, 2021

Finland

As of April 8, 2021, 80,842 people have tested positive for COVID-19 and 866 people have died. Of those, 29% (approximately 251) died in social care 24-hour units (Source: https://thl.fi/en/web/infectious-diseases-and-vaccinations/what-s-new/coronavirus-covid-19-latest-updates/situation-update-on-coronavirus#Coronavirus_situation). In 2018, there were 50,298 residents in social care 24-hour units (Source: https://thl.fi/fi/tilastot-ja-data/tilastot-aiheittain/ikaantyneet/sosiaalihuollon-laitos-ja-asumispalvelut). Therefore, the number of COVID-19 related deaths in these units represents 0.50% of this population.

Last updated: August 2nd, 2021

France

As of Feb 12, 2021, there have been 181,965 confirmed cases in LTCFs and 23,671 confirmed deaths (Source: https://www.gouvernement.fr/info-coronavirus/carte-et-donnees). Between March 1 and Nov 22, 2020, there were 96,059 cases among residents of care homes, with significant regional variation. There were 21,644 excess deaths (COVID-19 was over 14,000 of these) of the total 50,237 from March 1 and July 7, 2020. A total of 47,428 cases were recorded among social care workers, of which at least 17 died (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It’s unclear how many excess deaths occurred at home, and among domiciliary care users. Excess deaths at home between March 1 and April 30, 2020, are estimated to have increased by 32% compared to the previous year, with the highest increase among older people. Some provisional data from Inserm, which contains biases and delays, estimated that between March 1 and May 31, 2020, at least 1,800 deaths at home were due to COVID-19 (Source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Last updated: August 4th, 2021

France

France first published official death estimates for people in care homes on March 31, 2020. Deaths linked to COVID-19 among care home residents had been stable from the end of July until the week ending September 20, when they started to increase again.

The most recent numbers published by the Ministry of Health on April 1, 2021, reported a total of 95,264 COVID-19 related deaths, of which 36,889 (39%) were residents in care homes. Of these, 26,044 (71%) died in the care homes and, particularly in the earlier part of the pandemic, were mostly “probable cases” (people who were not tested but a doctor confirmed that the symptoms were associated with COVID-19). The remaining 10,845 died in hospital and were confirmed through testing. As of April 1, 2021, there have been 201,766 confirmed infections among care home residents, and 105,980 among care home staff. Deaths among care home staff are not reported in the bulletin. There are an estimated 605,061 care home beds in France. Therefore, the number of deaths of care home residents linked to COVID-19 would represent 6.10% of all the available beds (Source: https://www.insee.fr/fr/statistiques/3676717?sommaire=3696937).

Between March 1 and November 22, 2020, there were 96,059 cases among residents of care homes, with significant regional variation. There were a total number of 50,237 deaths between March 1 and July 7, 2020, of which 21,644 were excess deaths (over 14,000 of these were COVID-19 related) (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: August 4th, 2021

Germany

According to a survey conducted in April/May 2020, 50% of COVID-19 related deaths occurred in residential care settings and 12% among people receiving domiciliary care services, while the overall share of people infected in care homes only amounts to 8.5%. It also showed that LTC workers (particularly those working in residential settings) have a higher risk of infection. The survey showed that LTC providers reported in April/May 2020 that almost every third client who tested positive for COVID-19 died. The average share among clients of domiciliary services who died is considerably smaller than among people living in residential care settings (Source: https://www.socium.uni-bremen.de/uploads/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

On February 24, 2021, the Robert Koch Institute reported that among people living in residential care settings (including asylums for refugees, homeless people, prisons), there had been 113,111 cases. Out of these, 19,760 people (17%) have died from COVID-19. For a total of 64,041 cases, the Robert Koch Institute provides detailed information. Among these, 58,986 cases were recorded in residential care settings. Out of these 11,201 people died of COVID-19. The data also contains 531 cases among people receiving domiciliary care. Out of this group, 79 people died.

Last updated: August 3rd, 2021

Germany

Germany’s Robert Koch-Institute published the first official number of infections and deaths in different care settings on April 22, 2020. People in care and nursing homes are covered under §36 of the Protection Against Infection Law (IfSG). §36 also includes people living in facilities for those with disabilities or other care needs, homeless shelters, community facilities for asylum-seekers, repatriates, and refugees, and so the data is not directly comparable with the data on care homes presented for the other countries.

Data recorded here only includes confirmed cases following a laboratory diagnosis independent of clinical assessment. In addition, the Robert Koch Institute advises that information on care setting is missing in 37% of cases, which means that the number of people affected represents the minimum number of cases in specific care settings. A report estimated that, based on a survey of care homes, the share of deaths of care home residents attributed to COVID-19 by May 2020 was 49% of all COVID-19 deaths, which is higher than the rate that would result from the Robert Koch Institute data at the time (36%).

According to a survey conducted in April/May 2020, 50% of COVID-19 related deaths occurred in residential care settings and 12% among people receiving domiciliary care services, while the overall share of people infected in care homes only amounted to 8.5%. It also showed that long-term care workers (particularly those working in residential settings) had a higher risk of infection. Additionally, the survey showed that long-term care providers reported in April/May 2020 that almost every third client who tested positive for COVID-19 died (Sources: https://www.socium.uni-bremen.de/uploads/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

Based on Robert Koch Institute data, as of March 24, 2021, 120,763 people living in communal settings and 58,736 people working in these settings (as defined by §36 IfSG) had been infected with COVID-19. Out of these, 21,372 residents as well as 163 staff have died. The total number of COVID-19 related deaths in Germany on the same date was 75,212. Therefore, deaths in communal settings represent 28% of all deaths. The total number of people living in care and nursing homes in Germany in 2017 was 818,000, and assuming that there were a similar number in 2020 and that all the deaths in communal establishment had been care home residents, 2.61% of all care home residents would have died due to COVID-19 (Source: https://de.statista.com/statistik/daten/studie/36438/umfrage/anzahl-der-zu-hause-sowie-in-heimen-versorgten-pflegebeduerftigen-seit-1999/).

Last updated: August 3rd, 2021

Hungary

As of August 27, 2020, there have been 142 COVID-19 related deaths in care homes, accounting for 23% of all deaths (142 of 614). These COVID-19 related deaths only account for people who have tested positive and died (Source: https://koronavirus.gov.hu/cikkek/idosotthonok-142-koronavirussal-fertozott-gondozott-hunyt-el-kozuluk-55-en-pesti-uton).

Because less than 3% of the population aged over 65 lives in care homes in Hungary, it is expected that the share of deaths in care homes in Hungary will be lower than in other countries. In 2018, the total number of residents of care homes was 55,170, of which 50,589 were aged 65 or more. Assuming the number of residents hasn’t changed, then the share of care home residents who have died as of August 27, 2020, would be 0.3%.

Last updated: August 2nd, 2021

Israel

The first outbreak in a long-term care facility in Israel began in mid-March 2020, sixteen days after the first patient was diagnosed in Israel. Only a month after the initial outbreak, and following massive public criticism and a call for help from the managers of long-term care facilities, the Israeli government appointed a national-level team to manage the COVID-19 outbreaks in long-term care facilities (Source: https://ltccovid.org/2020/04/30/the-impact-of-covid-19-on-people-using-and-providing-long-term-care-in-israel/). As of October 12, 2020, there have been 704 COVID-19 related deaths in long-term care facilities, which accounts for 39% of the total deaths in the population. There were 45,000 people in long-term care facilities in Israel. Therefore, the number of COVID-19 related deaths in these facilities represents 1.56% of this population (https://brookdale.jdc.org.il/publication/statistical-abstract-elderly-israel-2020/). Furthermore, according to a survey, 50% of all COVID-19 related deaths occurred in residential care settings, while the overall share of people infected in care homes only amounts to 8.5%.

Last updated: August 3rd, 2021

Italy

The only data available on the COVID-19 outbreak in nursing homes is from the results of a survey carried out by the National Health Institute (Istituto Superiore di Sanità), which was sent to 3,276 nursing homes out of the 4,629 operating in the national territory. On June 17, 2020, the National Health Institute published the results of the survey. As of May 5, 2020, 1,356 nursing homes responded. The total mortality rate during that time frame was 9.1% (considering all deaths). The COVID-19 related mortality rate (tests and suspected) was 3.1%.

Last updated: August 3rd, 2021

Japan

There is no publicly available official data on the numbers of people who use or provide care who have had COVID-19 infections or whose deaths are attributed to COVID-19. It was reported that 14% of all COVID-19 was the result of infections in care homes in early May 2020.

Last updated: August 3rd, 2021

Netherlands

During the first wave, the National Institute for Public Health and the Environment (RIVM) estimated that about 40% of nursing homes had experienced outbreaks. By May 15, 2020, about 7% of residents in nursing homes had been infected and 2% had died. A report published in November 2020 noted that approximately 50% of all COVID-19 related deaths during the second wave were residents of nursing homes.

As of March 6, 2021, there have been 8,446 COVID-19 related deaths of care home residents (Source: https://coronadashboard.rijksoverheid.nl/landelijk/verpleeghuiszorg). This accounts for 51% of the total COVID-19 deaths in the Netherlands and 7.04% of all nursing home residents. These numbers are an underestimation of the actual COVID-19 deaths because not all those who died due to COVID-19 will have been tested (especially at the beginning of the pandemic). Only people over 70 years of age are included in these statistics.

Statistics Netherlands (CBS), a governmental organisation, provides weekly updates on observed mortality. They distinguish the mortality figures by long-term care users and age. They also provide expected figures based on the previous 5 years to estimate excess mortality. These figures show that there was 13% excess mortality (observed-expected/expected) among long-term care users in 2020 compared to 7% excess mortality among the wider population (outside long-term care).

Last updated: August 3rd, 2021

New Zealand

As of March 25, 2021, there have been 16 COVID-19 related deaths in Aged Residential Care facilities, accounting for 57% of all COVID-19 related fatalities (Source: https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases#summary). The Aged Residential Care sector comprises 38,000 beds in over 650 facilities throughout the country. Therefore, the number of deaths in aged care facilities represents 0.04% of all beds.

Last updated: August 2nd, 2021

Northern Ireland (UK)

The Northern Ireland Statistics and Research Agency publish data on deaths, including those where COVID-19 (suspected or confirmed) is mentioned on the death certificate. According to this data, as of March 5, 2021, there have been 2,839 COVID-19 related deaths, with 762 of these occurring in care homes (27%). Furthermore, there have been 997 COVID-19 related deaths of care home residents. Therefore, care home residents accounted for 35% of all COVID-19 related deaths in Northern Ireland. There are 14,935 care home residents in Northern Ireland. Therefore, the number of COVID-19 related deaths of care home residents represents 6.68% of this population.

Last updated: August 3rd, 2021

Portugal

Although no official reports have been published, the Government of Portugal released the number of deaths in nursing homes to the media. According to data published in the media, as of January 10, 2021, 2,254 people have died in nursing homes, corresponding to 2.27% of all the 99,000 residents in legal care homes in Portugal. On the same date, 7,803 deaths attributed to COVID-19 had been reported in Portugal. Therefore, the deaths of care home residents as a share of total deaths would be 28.9% (Source: https://covid19.min-saude.pt/wp-content/uploads/2021/01/314_DGS_boletim_20210110.pdf).

Last updated: August 3rd, 2021

Republic of Korea

Based on data provided by the Ministry of Health and Welfare and the Korea Disease Control and Prevention Agency, as of September 7, 2020, there have been 27 COVID-19 related deaths of nursing home residents, which accounts for 8% of the total number of COVID-19 related deaths. Another 76 occurred in long-term care hospitals. Deaths of residents in both types of settings would amount to 31% of total deaths. However, there were no deaths in care homes, because all residents with potential COVID-19 infections were transferred to hospitals.

In 2018, there were 177,318 beds in nursing homes (Source: https://stats.oecd.org/Index.aspx). Therefore, 0.02% of this population have died from COVID-19. There were 483,433 patients hospitalized in the 1,560 long-term care hospitals in 2018. Therefore, 0.02% of this population have died from COVID-19 (Source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

As of December 31, 2020, there had been 316 deaths among nursing home and long-term care hospital residents (Source: https://www.reuters.com/article/us-health-coronavirus-southkorea/south-korea-moves-coronavirus-patients-out-of-nursing-homes-as-deaths-mount-idUSKBN2950JR). The number of deaths among social care staff is unknown.

Last updated: July 30th, 2021

Scotland (UK)

National Records of Scotland (NRS) publish a weekly analysis of death registrations that mention COVID-19 on the death certificate. According to this, as of March 21, 2021, there have been 9,897 COVID-19 related deaths, with 3,283 of these occurring in care homes (33%). Since May 25, 2020, the Care Inspectorate Scotland (CIS) has reported weekly data on notifications of deaths of care home residents, which has showed that up to March 21, 2021, there have been 1,813 COVID-19 related deaths of care home residents. Prior to this, NRS published data up until May 17, 2020, which showed there had been 1,777 COVID-19 related registered deaths of care home residents. Including those deaths that occurred within a care home during the week between May 17 and May 23, 2020, (124 deaths), in total there were at least 3,714 care home resident deaths due to COVID-19. This represents 38% of the total COVID-19 related deaths. There are 35,989 care home residents in Scotland. Therefore, the number of COVID-19 related deaths of care home residents represents 10.32% of this population.

Last updated: August 3rd, 2021

Singapore

As of January 24, 2021, there had been 59,308 cases of COVID-19 infection (the majority, 54,508, in dormitories of migrant workers) and 29 deaths (Source: https://www.moh.gov.sg/covid-19/situation-report). As of January 24, 2021, there have been 4 COVID-19 related deaths in nursing homes, which represents 12% of all deaths. There are 16,059 nursing home beds in Singapore. Therefore, the number of COVID-19 related deaths in nursing homes would represent 0.02% of all beds (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: August 2nd, 2021

Spain

Data on COVID-19 related mortality in care homes is reported on Spanish national television, which needs to be treated with caution because the methods and definitions used to gather the data from the regional governments are not homogeneous. According to this source, as of January 22, 2021, there have been 26,328 COVID-19 related deaths in care homes, which includes both the deaths of people who have been diagnosed with COVID-19 and the deaths of those with symptoms but who have not been diagnosed. Estimating the share of all COVID-19 deaths that the deaths of care home residents represent in Spain is complicated because the national estimates of COVID-19 deaths only include deaths of people with a confirmed diagnostic test, missing the deaths of people that were not tested at the beginning of the pandemic. The national estimate for (confirmed) COVID-19 deaths on January 22, 2021 was 56,563 (Source: https://cnecovid.isciii.es/covid19/#documentaci%C3%B3n-y-datos).

The Spanish National Institute of Older People and Social Services (IMSERSO) reported that, in the first part of the pandemic (up to July 2020), there had been 20,268 deaths of care home residents in care homes, of which 9,904 were of people who had not been tested. That report highlighted that the national estimate for total deaths linked to COVID-19 does not include people who have not been tested and recommended adding the number of suspected deaths in care homes to the current total of confirmed deaths nationally. Using a similar approach would bring the total of confirmed and suspected deaths in the whole population to 66,467 by January 22, 2021. This would suggest that 40% of all deaths linked to COVID-19 in Spain have been among care home residents. This figure is lower than the estimate of 47% produced by the Spanish National Institute of Older People and Social Services up to June 23, 2020. This suggests that, proportionally, care home residents have not been as badly impacted as the rest of the population, compared to the initial part of the pandemic. The most recent estimate suggests that there are 333,920 care home residents (Source: http://envejecimientoenred.es/nivel-de-ocupacion-en-residencias-de-personas-mayores/). Therefore, the total number of COVID-19 related care home deaths would represent 7.88% of this population.

The Spanish National Institute of Older People and Social Services also publishes a monthly report on the excess mortality for people registered with the Spanish public long-term care system. Between March and November 2020, there have been 45,665 excess deaths among those who had applied for (and or received) care benefits. This was 31.8% higher than expected. The highest number of deaths were among people receiving benefits for institutional care (22,718, representing 9.12% of all recipients of this benefit). About 72.6% of care home residents are estimated to be in receipt of care benefits, and these are expected to be those who are most frail (Source: https://www.imserso.es/InterPresent2/groups/imserso/documents/binario/gtcovid_residencias_vf.pdf). Among people receiving benefits for care at home, there were 17,612 excess deaths, amounting to 2.02% of recipients (the share was a bit lower for people receiving cash payments for family care, 1.41%, compared to people receiving benefits in kind, 2.62%).

Last updated: August 4th, 2021

Sweden

On January 6, 2021, there had been 8,556 deaths in Sweden where COVID-19 was mentioned on the death certificate, of which 4,051 (47%) were among care home residents, and 2,276 among people who use care services in their own home (45%). Of the deaths of care home residents, 3,739 happened in the care home (92%). On October 31, 2019, there were 82,217 care home residents in Sweden, and using that as the denominator for total number of residents, 4.93% of care home residents would have died from COVID-19. The regional differences have been strong in Sweden. In the Stockholm region, 7% of the care home residents have died while there have been hardly any COVID-19 deaths in care homes in several other regions (Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: July 30th, 2021

Sweden

As of April 5, 2021, there have been 12,598 deaths in Sweden where COVID-19 was mentioned on the death certificate, of which 5,446 (43%) were among care home residents, and 3,277 among people who use care services in their own home (26%) (Source: https://www.socialstyrelsen.se/statistik-och-data/statistik/statistik-om-covid-19/statistik-over-antal-avlidna-i-covid-19/). Of the deaths of care home residents, 4,887 happened in the care home (90%) (Source: https://www.socialstyrelsen.se/statistik-och-data/statistik/statistik-om-covid-19/statistik-om-covid-19-bland-aldre-efter-boendeform/).

On October 31, 2019, there were 82,217 care home residents in Sweden. Therefore, the total number of COVID-19 related deaths in care homes represents 6.62% of this population. The regional differences have been strong in Sweden. In the Stockholm region, 7 % of care home residents have died, while there have been hardly any COVID-19 deaths in care homes in several other regions (Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: August 2nd, 2021

Turkey

On September 30, 2020, the Minister of Heath announced that the official figures of COVID-19 refer to the number of COVID-19 ‘patients’ (who have received treatment), whereas COVID-19 ‘cases’ (who tested positive but do not show any symptoms) have not been included in the published data since July 29, 2020. As of October 2, 2020, the total number of patients was 321,512 and 8,325 COVID-19 related deaths have been recorded (Source: https://covid19.saglik.gov.tr/?_Dil=2).

No recent official data on deaths of care home residents has been released by the Ministry. Based on public statements of government officials provided on different platforms, as of May 7, 2020, there have been 1,030 diagnosed COVID-19 cases in care institutions where the resident had been admitted to a hospital and 150 deaths of care home patients. The deaths in nursing homes accounted for 4% of all COVID-19 deaths in Turkey (Source: https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19-Long-Term-Care-situation-in-Turkey.pdf).

Last updated: August 3rd, 2021

United States

There has been approximately 1.2 million identified cases of COVID-19 amongst residents and staff of US nursing (care) homes, resulting in the deaths of 128,285 residents and 1,591 staff. The highest death rates have occurred in the most populous states, namely California, New York, and Texas. There was a spike in cases and slight increase in death rates in December 2020-January 2021, but the vaccination campaign has led to a significant drop in nursing home cases. All of the data submitted by nursing homes to the Center for Disease Control’s National Healthcare Safety Network is available.

Last updated: August 3rd, 2021

United States

This covers cumulative deaths in US care homes (nursing facilities, assisted living facilities, and other long-term care facilities) from January 1, 2020, through to March 29, 2021. Information about deaths in care homes comes from three sources: the Center for Medicare and Medicaid Services (CMS), the Kaiser Family Foundation (KFF), and the COVID Tracking Project (CTP) produced by The Atlantic Magazine. As of March 7, 2021, COVID Tracking Project has stopped collecting data. We derived COVID-19 mortality estimates by starting with state-level figures, which were reported directly by each of the sources (Sources: https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/; https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/#long-term-care-cases-deaths; https://covidtracking.com/). We started with state-level figures to address inconsistencies between the three data systems in the number of recorded COVID-19 deaths. Because the sources draw from different sources, their state totals differ. By starting at the state level, we were able to pick the ‘best’ estimate of care home COVID-19 deaths from each state from among the three data systems. To obtain the ‘best’ estimate of care home COVID-19 deaths, we selected the highest number of deaths recorded for each state from among the three sources. The ‘best’ estimate was a cumulative number of 185,269 COVID-19 related deaths in care homes. Based on this data, care home COVID-19 related deaths account for 34% of all COVID-19 related deaths.

The number of residents in care homes was approximated by adding the residents in nursing facilities from the Center for Medicare and Medicaid Services data and the number of residents in assisted living facilities taken from a report by the National Center for Assisted Living, to get 1,937,345. Therefore, the total number of COVID-19 related deaths in care homes represents 9.56% of this population.

Last updated: August 2nd, 2021

Wales (UK)

Data published by the Office of National Statistics shows that as of March 12, 2021, there have been 7,717 COVID-19 related deaths, with 1,650 of these occurring in care homes (21%). Care inspectorate Wales (CIW) publish weekly data on notifications of deaths of care home residents by date of notification and cause. As of March 12, 2021, there have been 1,911 COVID-19 related deaths of care home residents. Therefore, care home residents accounted for 25% of all COVID-19 related deaths in Wales (Source: https://gov.wales/notifications-care-inspectorate-wales-related-covid-19-adult-care-homes-1-march-2020-12-march-2021-html). There are 23,766 care home residents in Wales. Therefore, the number of COVID-19 related deaths of care home residents represents 8.04% of this population.

Last updated: August 3rd, 2021

2.03. Impact of long COVID among people who use and provide Long-Term Care

Australia

Australia does not currently have rehabilitation centres to treat COVID-19 “long-haulers” and there is no data on the impact of COVID-19 in aged care specifically (Source: https://www.abc.net.au/news/2020-12-23/long-term-effects-of-covid-study-in-medical-journal/13007498).

Last updated: August 2nd, 2021

Canada (British Columbia)

There is no data on long COVID in the LTC sector specifically, but British Columbia has opened three clinics that offer specialized care for “long haulers”. More than 1,400 people are estimated to still have COVID-19 symptoms three months following initial symptoms (Source: https://www.theglobeandmail.com/canada/british-columbia/article-bc-now-has-three-clinics-for-long-hauler-covid-19-patients-with/).

Last updated: August 2nd, 2021

Denmark

On September 15, 2020, the Danish Health Authorities announced that they have established a special committee responsible for developing national guidelines to health services and health professionals regarding the handling of long-term COVID-19 complications. There is no data yet on long-term COVID-19 in the LTC sector.

Last updated: August 4th, 2021

Japan

There is limited data on long-term COVID-19 in Japan as yet but growing interest in it and how it should be managed (Source: https://www.japantimes.co.jp/news/2021/02/07/national/covid-aftereffects-long-lasting/).

Last updated: August 2nd, 2021

United Kingdom

A survey by the Office for National Statistics estimated that, over the four-week period ending March 6, 2021, 1.1 million people in private households in the UK were experiencing long COVID (defined as symptoms persisting more than four weeks after the first suspected coronavirus (COVID-19) episode that are not explained by something else). Approximately 62% of people with self-reported long COVID reported at least some limitation to their day to day activities and about 18% that their day to day activities had been limited a lot. While these estimates are equivalent to a prevalence rate of 1.7% for the whole population living in private households, the prevalence among health and social care workers is much higher: 3.6% and 3.1% respectively. There is no information yet on long COVID among people with LTC needs.

Last updated: August 4th, 2021

2.04. Impacts of the pandemic on access to health and social care services (for people who use Long-term Care)

Australia

A survey among home care providers in Australia in May 2020 has shown that one in three providers reported a drop in enquiries and three quarters reported cancellation of existing services during the COVID-19 pandemic. An article published in September 2020 suggests that the numbers had been restored to normal levels. It further argues that there is increasing demand in Australia for home care as government policy encourages people to continue to live at home.

Due to the relative low number of cases across Australia throughout the pandemic, health and social care services were not impacted for long amounts of time (Source: https://www.rcsed.ac.uk/news-public-affairs/news/2020/june/response-to-covid-19-in-australia-and-its-impact-on-elective-surgery).

Last updated: September 7th, 2021

Canada (British Columbia)

Elective surgeries were postponed during the first wave of COVID-19, but by January 6, 2021, 90% of postponed surgeries have been completed. Health authorities plan to add capacity for additional procedures throughout 2021 and 2022. There is no evidence of discontinuation of care in LTC facilities. However, there is a lack of data published about care in the community and by family providers (Source: https://www.theglobeandmail.com/canada/british-columbia/article-bc-has-completed-90-per-cent-of-elective-surgeries-delayed-because-of/).

Last updated: August 2nd, 2021

England (UK)

Carers have reported delays in health treatment for the person they care for (57%) and for themselves (38%). More than half of carers (65%) in a Carers UK survey have reported to have postponed attending health care services for their own health needs. Reduced access to health care and social services for the person they support was also reported by carers of people with dementia (90% of 795 respondents) (Source: https://www.alzheimers.org.uk/sites/default/files/2020-09/Worst-hit-Dementia-during-coronavirus-report.pdf).

Many community–based care services, such as day care, have been interrupted as a result of the COVID-19 pandemic. Guidance on safe delivery of day care has been published by the Social Care Excellence Institute on the July 10, 2020.

It is likely that there have been reductions in the use of domiciliary care services, such as home care, as a result of people fearing contagion through contact with staff, and as a result of staff shortages due to their own need to self-isolate or shield. Lack of access to PPE and testing for home care providers may have exacerbated this problem. There is no data yet on the extent to which services have been reduced or the degree to which this has affected the people who rely on those services and their family and other unpaid carers, although a national survey by the Association of Directors of Adult Services reported substantial increases in social care need arising from the unavailability of services, hospital discharge, carer breakdown, and concerns about abuse and safeguarding.

Last updated: August 4th, 2021

Finland

Non-urgent annual health checks, appointments, and surgeries have been suspended in Finland, affecting the elderly at-home LTC population’s access to regular healthcare.

Last updated: March 22nd, 2021

Finland

Non-urgent annual health checks, appointments, and elective surgeries have been suspended in Finland and many people voluntarily cancelled their appointments. Among the measures launched by the Finnish Government (March 16, 2020) was a plan to increase the capacity of health care and social welfare services in both the public and the private sector. New residents to care homes required testing. However, there have been reported shortcomings. It has also been reported that home care visits have been declined and day care centres have closed.

Last updated: August 4th, 2021

France

Both senate and National Assembly commissions report significant issues around access to services, both in health and social care, for service users in LTCFs and in receipt of domiciliary care. Some reports exist of care home residents being refused access to secondary care facilities at the beginning of the pandemic (Sources: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf; http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). The National Assembly report also notes difficult access to medical equipment such as oxygen therapy equipment, and a lack of named GPs within care homes led many care home workers with the responsibility to administer medical and palliative care.

Last updated: August 2nd, 2021

Germany

In Germany many people with care needs living in their own homes receive support from easter European migrant workers. The border closure around Easter 2020 left many people without their usual support (https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).

A survey among family carers of older people found that 39% of unpaid carers agreed that they had greater care responsibility as previous support had disappeared. More than 80% reported that day care had completely stopped, 40% reported that other services (e.g. foot care) had stopped or reduced (26%), 26% reported reduced care from the GP. Over 40% reported reduced support from neighbours and 30% from family members and friends (https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf). The same survey also showed that there was a slight reduction in available domiciliary LTC and 24-hour care (domestic care or foreign live in carers), but a considerable reduction in available day care programmes (Source: https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf).

A survey among care providers in April/May 2020, showed that two-thirds of part-residential care settings stopped accepting new residents or closed completely. Among domiciliary carers, less than 20% had provided care for people with a confirmed infection, and 13.4% had clients with suspected cases. Domiciliary care service providers also recorded a change in take up of services (mostly a reduction) among almost 50% of responding providers. Almost half of all domiciliary care services estimate that the provision of support for people with limited uptake of services is at risk or cannot be ensured.

Last updated: September 7th, 2021

Hong Kong

Non-urgent medical services (follow-up appointments for chronic illnesses, non-urgent surgery) started to be postponed in late January 2020. Family members of older people were invited to pick-up medications from clinics to reduce the risk of infection. There were also new service arrangements put in place for the ‘Elderly Health Centres’ in February 2020.

Day care services in Hong Kong have largely suspended their services but offered reduced services to people with special needs. Other community based services have been closed, but staff continue to provide urgent services and follow-up with members on regular basis to provide ‘social and emotional support’.

Domiciliary services continue. However, providers can operate with greater flexibility and non-essential services were either suspended or scaled back. For example, meal delivery services have moved to disposable containers (Source: https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: August 2nd, 2021

Israel

Evidence is limited, though there are some indications that adult and elderly day centres for at-home care users have closed. According to the National Insurance Institute website, day centres contacted their service users individually to help them find alternative programs.

Last updated: August 4th, 2021

Israel

A report from May 2020, described that special efforts were made to ensure access to a range of health services for people living in residential care settings. This includes management of chronic illnesses, treatment and care for acute medical problems, and the provision of preservative rehabilitation treatments.

According to the National Insurance Institute website, day centres contacted their service users individually to help them find alternative programs in case of closure.

Last updated: August 4th, 2021

Japan

Applications for LTC (both community and facility based) through the national insurance scheme decreased by more than 20% across many cities compared to the previous years due to concerns regarding infection from care assessment workers (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). At least 909 LTC services (858 are day-care and 51 are home-visit services) have temporarily suspended operations as of April 20, 2020, due to the risk of infection (Source: https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.366). It is not clear if the impact of those closures has been assessed. It is also not clear how home care has been affected.

Last updated: September 7th, 2021

Netherlands

Nursing homes (usually running waiting lists) now have empty beds because people are relucant to move into a home, in response to the visiting ban (Source: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view). However, questions have been raised about the access to health care for COVID-19 patients in nursing homes. About 48% of nursing home residents with a COVID-19 diagnosis died within 30 days, while in care home the percentage was 20% (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: August 2nd, 2021

Netherlands

Nursing homes (usually running waiting lists) now have empty beds because people are reluctant to move into a home, in response to the visiting ban, while other nursing homes had to implement temporary bans on new admissions (Sources: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view; https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf). However, questions have been raised about the access to health care for Covid-19 patients in nursing homes (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

During the first wave, people receiving care in the community who also had family support experienced a reduction or suspension of services. This approach was changed in the second wave, where home care could only be reduced following a consultation with the person with care needs. However, there were instances, such as when there was a lack of staff when services were temporarily reduced.

Efforts have also been made to continue day care, by moving services, where possible, online. Technological interventions have received increased government subsidies. During the second wave day care activities were largely not reduced, but a number of difficulties around ensuring the safety of people with LTC needs and staff were identified (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: August 2nd, 2021

Republic of Korea

In terms of wider impacts, the National Health Insurance Services has temporarily stopped providing the eligibility test for potential beneficiaries, since it requires in-person interviews and assessments of older people and families. ‘Certificate tests’ for care staff have been paused (Source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: August 2nd, 2021

Republic of Korea

In terms of wider impacts, the National Health Insurance Services has temporarily stopped providing the eligibility test for potential beneficiaries, since it requires in-person interviews and assessments of older people and families. ‘Certificate tests’ for care staff have been paused. A report from May 2020, further described that community care for older people and people with disabilities were closed in late February 2020. The Ministry has requested staff working in community-care centres to prepare for safe reopening and to support people with care and support needs with the delivery of meals, welfare checks, and supportive activities. The government also provided a supplementary budget to temporarily support economically disadvantaged groups (Source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: August 2nd, 2021

Spain

In Spain, in the early part of the pandemic, there were widespread difficulties for care home residents to access health care services, including at primary care level. There were many instances of hospital admissions being denied on the basis of where a person lived (a care home) or their type of disability (for example dementia), without consideration of the individual’s situation and potential to benefit from treatment. This generated great controversy and concern about human rights violations (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: August 2nd, 2021

Spain

In Spain, in the early part of the pandemic, there were widespread difficulties for care home residents to access health care services, including at primary care level. There were many instances of hospital admissions being denied on the basis of where a person lived (a care home) or their type of disability (for example dementia), without consideration of the individual’s situation and potential to benefit from treatment. This generated great controversy and concern about human rights violations (Sources: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf; https://ltccovid.org/wp-content/uploads/2020/10/LTCcovid-Spain-country-report-28-May-1.pdf).

A report from May 2020 outlines that day care centres were closed to reduce the risk of infection. In addition, many ‘light’ home care services were cancelled by local and municipal authorities. Recommendations issued in March 2020 by the Ministry of Social Rights envisaged that social services departments would have to ensure continuity of services where private providers suspended home care services. The recommendations also emphasised a continuation of services for people with personal care needs and people requiring support with other activities of daily living (e.g. shopping, accompanying people outside the house). The guidelines also recommended a greater combination of services than usually permitted, to reduce administrative barriers when taking on new clients, and encouraged service providers to alert social services departments if cases of people with particular needs were identified.

Last updated: August 4th, 2021

Sweden

In some regions, recommendations/guidelines were issued that people in care homes who fell ill with suspected or confirmed COVID-19, should primarily be cared for in the care home and not referred to hospital, which led to inadequate (medical) care provided to these patients. Overall, online physician consultations were reported to have led to inadequate medical care in residential care settings.

Home care services have decreased during the pandemic (during the spring 2020 in Sweden, application for homecare declined by 45 percent). Some municipalities have paused admittances to care home, to prevent further spread of infection.

(Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdfhttps://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf; https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812; https://ltccovid.org/2020/12/16/report-of-the-swedish-corona-commission-on-care-of-older-people-during-the-pandemic/).

Last updated: September 7th, 2021

2.05. Impacts of the pandemic and measures adopted on the health and wellbeing of people who use and provide Long-Term Care

Australia

Levels of depression, anxiety, confusion, loneliness, and suicide risk among aged care home residents have increased since March 2020. Some of this can be attributed to missing family, changed routines, concern about catching the virus, or fear of being isolated in their rooms. In some cases, people living in aged care homes are no longer doing the incidental exercise they were previously doing (Source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf). Dementia Australia reported that people living with dementia and the people that care for them, especially family carers, have reported adverse effects of COVID-19 on their physical, cognitive, social, and mental wellbeing.

Last updated: August 4th, 2021

Canada (British Columbia)

A recent survey by Safe Care BC found that many LTC staff had increased psychological fears and anxiety and intention to leave as a result of COVID-19. They felt a psychosocial burden responding to pandemic and had concerns about their personal safety and ability to care for residents (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: August 2nd, 2021

Canada (British Columbia)

A recent survey by Safe Care BC found that many LTC staff had increased psychological fears and anxiety and intention to leave as a result of COVID-19. They felt a psychosocial burden responding to pandemic and had concerns about their personal safety and ability to care for residents (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

A report by the office of the Seniors Advocate British Columbia highlights that the use of antipsychotics among LTC residents has increased by 7% during the COVID-19 pandemic and points towards interRAI assessments suggesting ‘unintended weight loss and worsening mood’ among residents.

Last updated: August 4th, 2021

Canada (Ontario)

A survey of prescriptions for all nursing home residents in Ontario found evidence of increased prescriptions of psychotropic drugs to nursing homes residents between March and September 2020, compared to prescription pre-pandemic. The authors interpret this as likely to be associated with the social isolation experienced by residents due to infection prevention and control measures or decreased capacity for staff to respond to responsive behaviours.

Last updated: August 4th, 2021

Denmark

The latest report on mental health from the nursing home sector indicates that the quality of life is increasing for the majority of residents. Nursing home managers report that residents sleep better, medication is reduced, there are fewer conflicts with residents suffering from dementia, more time for the individual resident, and the sickness rates among staff is now lower. The factors which have contributed to this seem to be that there are no longer any common activities for all residents, instead members of staff make activities in smaller groups of residents or engage with them one by one. Staff report a more relaxed atmosphere, one reason being that they do not have to engage with family members who at times are considered overly critical.

Last updated: August 4th, 2021

Denmark

The latest report on mental health from the nursing home sector indicates that the quality of life is increasing for the majority of residents. Nursing home managers’ report that residents sleep better, medication is reduced, there are fewer conflicts with residents suffering from dementia, more time for the individual resident and the sickness rates among staff is now lower. The factors which have contributed to this seems to be that there are no longer any common activities for all residents, instead members of staff make activities in smaller groups of residents or engage with them one by one. Staff report a more relaxed atmosphere, one reason being that they do not have to engage with family members who at times are considered overly critical.

However, concerns were expressed that the Danish government’s response to the pandemic (e.g. care home visiting ban) was inflexible and not tailored to individuals circumstances (rather, it was based on ‘one size fits all’ rules). Combined with the late ease of restrictions, it had a negative long-term impact on older people’s mental and physical health and concerns were raised that the government should have done more to respect basic individuals’ freedoms (Source: https://www.djoef.dk/presse/pressemeddelelser/2020/s-ae-rligt-de–ae-ldre-og-s-aa-rbare-har-lidt-under-begr-ae-nsninger-i-friheden-i-starten-af-coronakrisen.aspx).

Last updated: August 4th, 2021

England (UK)

During the early part of the pandemic there were reports of substantial increases in the prescription of anti-psychotics to people with dementia during the COVID-19 pandemic, some of this may have been due to increased need linked to delirium management or palliative care, but it is also likely to be attributable to worsened agitation and distress linked to COVID-19 restrictions (such as people in care homes being confined to their bedrooms, or not able to receive family visits).

Last updated: September 6th, 2021

England (UK)

During the early part of the pandemic it was reported that there was evidence of substantial increases in the prescription of anti-psychotics to people with dementia during the COVID-19 pandemic, some of this may have been due to increased need linked to delirium management or palliative care, but it is also likely to be attributable to worsened agitation and distress linked to COVID-19 restrictions (such as people in care homes being confined to their bedrooms, or not able to receive family visits).

People living in care homes

Guidance issued by the government on April 2, 2020, said that care homes should advise family and friends not to visit except in exceptional circumstances. There is concern and, increasingly, reported international evidence that some of the measures taken to reduce the risk of COVID-19 infections in care homes, such as closing care homes to visitors (including family members), reduction in social interactions and activities, and needing to isolate have had negative impacts on the wellbeing and mental health of people living in care homes. There are multiple reports warning about the alarming rate of deterioration that people with dementia are experiencing under these isolating conditions and being detached from their families. For instance, a survey conducted by the charity Alzheimer’s Society found that 79% of care homes surveyed reported that the lack of social contact is causing a deterioration in the health and wellbeing of their residents with dementia. A survey of care homes from across England found that by late May and early June, 2020, 85% of managers had detected low mood among residents.

People living in the community who use long-term care

There is emerging evidence that reduced use of social support services has had detrimental effects on the quality of life of people affected by dementia and older adults (Sources: https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292; https://pubmed.ncbi.nlm.nih.gov/32946619/).

People who are employed to work in social care

A survey of 296 frontline care workers that took place during July and August 2020, found that nearly half of the respondents (47%) indicated that their general-health had worsened since the onset of COVID-19 and 60% indicated that the amount of time their jobs made them feel depressed, gloomy, or miserable had increased since the start of the pandemic. Additionally, 81% reported an increase in the amount of time that their jobs made them feel tense, uneasy, or worried. A significant minority of 23% indicated their job satisfaction had increased, whereas 42% said that they had become a little or a lot less satisfied with their job since COVID-19. In another survey of 43 care home managers in England, 75% of managers reported that they were concerned for the morale, mental health, and wellbeing of their staff. In addition, data reported by Skills for Care indicates that the percentage of days lost to staff sickness have increased by 180% (from 2.7% before the pandemic, to 7.5% between March and August 2020).

Unpaid or informal carers

Many carers have expressed the experience of stress and a negative impact on their physical and mental health (Sources: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/morepeoplehavebeenhelpingothersoutsidetheirhouseholdthroughthecoronaviruscovid19lockdown/2020-07-09; https://www.carersuk.org/images/CarersWeek2020/CW_2020_Research_Report_WEB.pdf; https://www.alzheimers.org.uk/sites/default/files/2020-09/Worst-hit-Dementia-during-coronavirus-report.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf; https://onlinelibrary.wiley.com/doi/10.1111/jar.12811). Carers UK reported that the negative impact on the mental health of carers was greater among carers experiencing financial difficulties. Research found that variations in hours of support were associated with higher levels of anxiety and lower levels of well-being.

Last updated: August 4th, 2021

France

Both Senate and National Assembly commissions report the impact on wellbeing of the breakdown of care arrangements in the LTC population. There has been significant coverage in the reports, and in media, of the “syndrome de glissement” (slipping away syndrome), due to the depressive effects of isolation on older people. The Assembly report presents evidence of the impact on physical health due to the breakdown of OT/PT support, with considerably higher numbers of older people losing autonomy, and requiring support with walking and other activities of daily living.

Last updated: August 4th, 2021

Germany

There is no information available that systematically measures the impact of COVID-19 on the health and wellbeing of people with LTC needs. However, concerns for people’s mental health are being raised, especially for people living in residential care settings whose social life has been severely disrupted. Even before COVID-19, research has estimated that among those 65 and older living in care homes, 25-45% had depression. It has further been estimated that only 40% of those received a diagnosis and only about half of those with a diagnosis received adequate treatment and support (Sources: https://www.zeit.de/amp/news/2021-02/26/treffs-gegen-depressionen-in-alters-und-pflegeheimenhttps://www.aerzteblatt.de/nachrichten/98943/Wissenschaftler-Depression-bei-Heimbewohnern-seltener-behandelt).

Last updated: August 2nd, 2021

Israel

Israel’s Ministry of Health collaborated with JDC-ESHEL, a social policy and research incubator NGO, to provide long-term carers and service users with information and resources on pandemic-related physical and mental wellbeing. Of note was their guide for caregivers of dementia patients, and efforts to combat loneliness amongst older people (Source: https://www.haaretz.com/haaretz-labels/1.8816132). The welfare and strengthening of resilience amongst older people during times of lockdown and social isolation have been of primary concern in the national COVID-19 plan for the aging (Magen Avot V’Emahot).

One important finding was a report on the psychosocial effects of the pandemic on migrant carers which highlights a particularly unique feature of Israel’s LTC system. These carers are often vulnerable members of the workforce, working minimum wages on precarious work visas without a pathway to citizenship or permanent residency (unlike other high-income countries). During COVID-19, East Asian caregivers also faced harassment and discrimination. Issues of gender equality amongst unpaid carers were reported.

Last updated: August 4th, 2021

Jamaica

At the beginning of the pandemic, when there were curfews in place, the list of people exempt from the curfew did not include unpaid carers or paid home care workers, it is expected that this forced some caregivers to have made life changes in order to continue providing care (for example moving in together).

The loss of routine activities may have resulted in loss of the social and practical support that many carers rely on, for example through church activities.

The banning of visitors to long-term care facilities may have also affected the ability of carers to provide adequate supplies of medication and toiletries, as well as emotional support to their relatives.

Source: https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Jamaica-25-May-2020-1.pdf

Last updated: September 8th, 2021

Japan

Closure of day care and community services risks having significant impact on wellbeing (Source: https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.366 ). There is research into the impact of restrictions on the general population but so far none found on the LTC population.

Last updated: August 2nd, 2021

Sweden

Studies reported negative impact on mental health of care home residents and their families following the visiting restrictions as well as on mental health of older people following government guidance for people over 70 to limit their social contact (Source: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Last updated: August 2nd, 2021

United States

Recent studies show that the ability to receive and supply care services in long-term care facilities and at home proved very difficult across the United States during the pandemic. One study based in New York identifies the key struggles for home-care workers during this time: “invisibility, inconsistent levels of support, and difficult trade-offs between personal health and finances from nonunionized home care workers and family caregivers.” It also promotes structural reforms, such as increased provision of PPE and education; coordinated efforts between home health agencies and local public health departments to assess magnitude of infection in certain areas; and increased state support of legislation that protects said workers (regarding pay and health insurance) (Source: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769095).

Much of the coverage of COVID’s impact on wellbeing in United States long-term care facilities focuses on loneliness and isolation, highlighted by images shared online nationwide of families visiting loved ones in long-term care facilities outside of their windows. Of particular concern is the potential impact of solitude on the mental strength of those in long-term care facilities with Alzheimer’s/Dementia (Sources: https://www.nytimes.com/2020/10/30/us/nursing-homes-isolation-virus.html; https://www.nytimes.com/2021/02/26/well/family/nursing-home-covid-dementia.html).

Last updated: August 2nd, 2021

2.06. Other impacts of the pandemic on people who use and provide Long-Term Care

Argentina

Studies suggest that unpaid carer burden has increased. Some carers have stopped paid carers coming in (Sources: https://journal.ilpnetwork.org/articles/10.31389/jltc.76/;  https://pubmed.ncbi.nlm.nih.gov/32729446/#:~:text=Family%20was%20the%20primary%20provider,milder%20forms%20of%20the%20disease). Another study reported an increase in anxiety, insomnia, depression, worsening gait disturbance, and use of psychotropics to control behavioural symptoms in people living with dementia in the community (Source: https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00866/full).

Last updated: August 4th, 2021

Australia

A report from Australia suggests increased care needs and reduced availability of paid services. Some retired carers experienced a drop in their funds. Unpaid carers of people living in residential care settings were concerned about their well-being (Sources: https://journal.ilpnetwork.org/articles/10.31389/jltc.76/).

Last updated: August 4th, 2021

Austria

A survey in Austria ‘among 100 low-income informal carers’ found that reduced availability of home care and community services as well as reduced support from other family members led to an increase in the amount of care provided by unpaid carers, and among 16% of surveyed participants reported ‘a reduction of paid work’.

Last updated: August 4th, 2021

Canada

Research found that unpaid carers were worried about the impact on their relatives with dementia and reported reduced or altered formal care support, as well as anxiety and feelings of burnout (Sources: https://journal.ilpnetwork.org/articles/10.31389/jltc.76/; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952494/).

Last updated: August 3rd, 2021

England (UK)

People who are employed to work in social care

A survey of 296 frontline care workers that took place during July and August 2020, found that 81% indicated an increase in their workload since the onset of COVID-19 and 56% reported an increase in their working hours. Additionally, this found that 18% had to self-isolate, but nearly a fifth of those who needed to self-isolate did not receive any pay. The survey also found that 22% of care workers thought they had not received adequate COVID-19 training or clear guidance, and 16% had not had the necessary PPE to do their job safely. In another survey of 43 care home managers in England, staff had needed to isolate in 72% of care homes. Additionally, 43% of managers reported staffing shortages, with 1 in 3 having to use agency staff, who accounted for between 2 and 37% of their workforce. Providers generally reported receiving little support with surge staffing.

Unpaid or informal carers

Evidence suggests that, since the beginning of the COVID-19 pandemic, a substantial number of people have taken on new care responsibilities

Several reports on unpaid carers have shown that there has been an increase in unpaid carers, many of those who have cared prior to the pandemic have increased their care commitment, largely due to reduced availability of services (Sources: https://ltccovid.org/wp-content/uploads/2021/01/Lorenz_Comas_COVID_impact_unpaidcarers_preprint.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_April20_pages_web_final.pdf; https://www.carersuk.org/images/CarersWeek2020/CW_2020_Research_Report_WEB.pdf; https://onlinelibrary.wiley.com/doi/full/10.1002/gps.5434; https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01719-0; https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292; http://circle.group.shef.ac.uk/wp-content/uploads/2020/11/007_Aspect-Virtual-Cuppa-Report-4-compressed.pdf).

A Carers Week and an Office for National Statistics report show that the number of people providing unpaid care has increased substantially since the COVID-19 related lockdown measures were put in place in March 2020. The Office for National Statistics report states that 48% of people in the UK cared for someone outside their own household in April 2020. The Carers Week report estimates that 4.5 million people in the UK have become unpaid carers during the COVID-19 outbreak in the UK. The reports show that people who have taken on new care responsibilities continue to be more likely to be female, although there was a high proportion of men taking on new care responsibilities. Carers who have taken on care responsibilities since the onset of the COVID-19 pandemic were slightly younger (45-54 years) compared to the groups that are usually more like to provide care (aged 55-64). The most frequently reported reasons for an increase in care responsibility were increased care needs and the reduction or suspension of local services. The Carers Week report found that new carers were more likely to be working and to have children (under 18 years).

The amount care provided by family carers has increased

Carers UK have reported that care responsibilities have increased for most carers, with the average time spent caring increasing by 10 hours to 65 hours of unpaid care per week. However, a small proportion of carers have provided less care. An increase in care responsibility and time spent caring was reported among most unpaid carers of people with dementia (73%) (Source: https://www.alzheimers.org.uk/sites/default/files/2020-09/Worst-hit-Dementia-during-coronavirus-report.pdf). Many carers attributed the increase in time spent caring to the reduced availability of services. This proportion was particularly high among Black, Asian and Minority Ethnic (BAME) carers (Source: https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf).

Carers express concerns

A survey by Carers UK showed that a large proportion of unpaid carers are concerned about what would happen to the care recipient if the unpaid carer became unable to provide care (87%). A second concern expressed was the risk of infection due to domiciliary carers entering people’s homes. Carers of people with dementia also reported that people with dementia had difficulty following the distancing rules and to understand why their routines had been disrupted (Source: https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292).

Carers experience an impact on their finances

There is evidence of a negative impact on carers finances, with some incurring increased costs (food, bills, equipment) and a reduced ability to work or loss of employment (Sources: https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_April20_pages_web_final.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf). While some carers highlighted that working remotely provided them with greater flexibility to manage care and work, others experienced greater challenges. Research on unpaid carers caring for someone outside their household found that carers with paid jobs worked fewer hours than other people in employment, and that female carers worked fewer hours than male carers. Financial pressure on carers was also illustrated through foodbank use, with 106,450 carers (1.76% of carers) reporting that their household had to rely on foodbanks in the past month. Foodbank use was higher among female and among young carers (aged 17-30). The research also showed that in the households of 228,625 unpaid carers, someone had gone hungry in the week prior to the survey. Again, this was higher among females and young carers (aged 17-30).

People with intellectual disabilities and autistic people

Relatively little systematic information is available concerning the impact of COVID-19 on the lives of people with intellectual disabilities and autistic people in England, although there is a consistent picture from blogs run by self-advocacy and other organisations in England (Sources: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/925820/covid-and-people-with-learning-disabilities-or-autism-easy-read_v2b.pdf; https://www.learningdisabilityengland.org.uk/what-we-do/keeping-informed-and-in-touch-during-coronavirus/connecting-people-including-webinars/) and surveys of people with intellectual disabilities in Scotland (Sources: https://inclusionscotland.org/wp-content/uploads/2020/04/Initial-Findings-Report-.pdf; https://www.scld.org.uk/wp-content/uploads/2020/06/SCLD-Coronavirus-Report-FINAL.pdf) and Wales (Sources: https://allwalespeople1st.co.uk/wp-content/uploads/2020/05/The-Effect-of-the-Coronavirus-Pandemic-on-People-with-Learning-Disabilities-Across-WalesPhaseOneFinalDraft.pdf; https://allwalespeople1st.co.uk/wp-content/uploads/2020/08/AMBER-The-Effect-of-the-Coronavirus-Pandemic-on-People-with-Learning-Disabilities-Across-Wales.pdf).

Care home providers

Financial impact

There are concerns about the viability of some care home providers, due to lower occupancy rates (as a result of a high number of deaths and people putting off entering care homes), and higher costs linked to additional staffing and PPE expenditure. Analysis by the Care Quality Commission published in July 2020 shows that there has been a substantial reduction in admissions to care homes during the pandemic, although the rates vary significantly. Admissions funded by local authorities for the week ending June 7, 2020, were on average of 72% (range 43 to 113%) of the number received in the same period in 2019. In contrast, self-funded admissions, were on average at 35% of the 2019 levels (25% to 51%). One source reported that the occupancy of care home beds dropped approximately 13% over the course of the pandemic.

Community-based care

Data from a survey by the Care Quality Commission showed that, as of May 2 to 8, 2020, around a fifth of agencies were caring for at least one person with suspected or confirmed COVID-19. Providers also reported that access to PPE was a big concern, with many instances of wrong or poor quality items being delivered. While homecare services were experiencing lower levels of activity (homecare hours were at 94% of pre-pandemic levels), Local Authorities continued to pay for planned hours, which helped to protect the providers they commission from, from the decrease in activity (Source: https://www.cqc.org.uk/sites/default/files/20200715%20COVID%20IV%20Insight%20number%203%20slides%20final.pdf).

Last updated: August 4th, 2021

England (UK)

A report on unpaid carers has shown that there has been an increase in unpaid carers, many of those who have cared prior to the pandemic have increased their care commitment, largely due to reduced availability of services. Many unpaid carers experienced worse physical and mental health outcomes and some experienced financial implications.

Last updated: August 4th, 2021

Germany

Lockdowns of nursing homes during the first wave led to physical activity programmes for residents being discontinued, as these were often provided by external providers. There were attempts to promote physical activity in-house although staff were not trained to provide it specifically (Source: https://www.frontiersin.org/articles/10.3389/fspor.2020.589214/full).

Carers reported reduced availability in paid services as reasons for increased care commitment (Sources: https://journal.ilpnetwork.org/articles/10.31389/jltc.76/; https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf; https://www.dak.de/dak/download/studie-2372026.pdf).

Last updated: August 4th, 2021

India

Unpaid carers worried about protecting their relatives with dementia, keeping the occupied inside the house and adhering to hygiene measures. Unpaid carers found working and caring challenging and expressed concerns about financial implications. Formal and informal networks were less well accessible and there was difficulty in accessing medical care (Sources: https://journal.ilpnetwork.org/articles/10.31389/jltc.76/; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340037/).

Last updated: August 3rd, 2021

Italy

Unpaid carers of people with dementia reported that caring was more challenging, experienced high stress levels, and other negative implications (https://journal.ilpnetwork.org/articles/10.31389/jltc.76/; https://www.frontiersin.org/articles/10.3389/fpsyt.2020.578015/full).

Last updated: August 3rd, 2021

Japan

There is limited information. One article points to challenges in the use of technology/remote consultations with older population, plus financial pressures on care providers.

Last updated: August 4th, 2021

Netherlands

The high numbers of deaths in nursing home affected the occupancy rate of homes which led to loss of income especially of those hardest hit by the pandemic. The government sought to address this through payments for providers (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: August 3rd, 2021

Netherlands

The high numbers of deaths in nursing home affected the occupancy rate of homes which led to loss of income especially of those hardest hit by the pandemic. The government sought to address this through payments for providers (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

A report from November 2020 indicates that unpaid carers in the Netherlands have experienced more pressure and stress in their caring role since the COVID-19 pandemic.

Last updated: August 4th, 2021

United States

Many unpaid carers in the United States increased their care commitment as reduced community services were available. Carers reported experiencing delayed access to medical care and expressed financial concerns. Carers also reported increased stress, conflicts, isolation and other negative implications (https://ltccovid.org/wp-content/uploads/2021/01/Lorenz_Comas_COVID_impact_unpaidcarers_preprint.pdf; https://ucsur.pitt.edu/files/center/covid19_cg/COVID19_Full_Report_Final.pdf; https://ucsur.pitt.edu/files/center/covid19_cg/COVID19_Full_Report_Final.pdf; https://www.usagainstalzheimers.org/covid-19-surveys; https://academic.oup.com/psychsocgerontology/article/76/4/e241/5895926).

Last updated: August 3rd, 2021

PART 3.
Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care

3.01. Brief summary of the overall pandemic response (not specific to Long-Term Care)

Australia

The first case of COVID-19 in Australia was identified on January 25, 2020, from a man who travelled from Wuhan to Melbourne. Prime Minister Scott Morrison announced the Australian Health Sector Emergency Response Plan for Novel Coronavirus on February 27 and the first economic stimulus package on March 12. By mid-March, most states and territories were in lockdown. Cases began falling across the country in April and on May 8, the government announced a three stage plan to ease lockdown restrictions. Victoria entered its second wave in late June and by October 26, it reported no new cases or deaths. COVID-19 cases have been stable nation-wide since October 2020 (Sources: https://covid19.who.int/?gclid=Cj0KCQiAvvKBBhCXARIsACTePW9yMx1R31Uav8H6oLh3wEAVV68EZmmy7lb_v-FDkgTaL5mwurWha24aApaFEALw_wcB; https://www.health.gov.au/resources/publications/coronavirus-covid-19-at-a-glance-27-february-2021; https://deborahalupton.medium.com/timeline-of-covid-19-in-australia-1f7df6ca5f23).

A report was published by the Parliament of Australia, which provides a chronological overview of the measures implemented across states and territory governments in response to the COVID-19 pandemic as well as when these measures were eased again (until June 2020). Measures included border restrictions, visiting restrictions at health sites, closure of non-essential businesses and activities, and remote learning for pupils.

The country is now starting to open-up using a 3-step framework for a covidsafe Australia (Source: https://www.health.gov.au/sites/default/files/documents/2020/06/3-step-framework-for-a-covidsafe-australia-3-step-framework-for-a-covidsafe-australia_2.pdf).

Last updated: September 8th, 2021

Australia

The first case of COVID-19 in Australia was identified on January 25, 2020, from a man who travelled from Wuhan to Melbourne. Prime Minister Scott Morrison announced the Australian Health Sector Emergency Response Plan for Novel Coronavirus on February 27, and the first economic stimulus package on March 12. By mid-March, most states and territories were in lockdown. Cases began falling across the country in April and on May 8, the government announced a three stage plan to ease lockdown restrictions. Victoria entered its second wave in late June and by October 26, it reported no new cases or deaths. COVID-19 cases have been stable nation-wide since October 2020 (Sources: https://covid19.who.int/?gclid=Cj0KCQiAvvKBBhCXARIsACTePW9yMx1R31Uav8H6oLh3wEAVV68EZmmy7lb_v-FDkgTaL5mwurWha24aApaFEALw_wcB; https://www.health.gov.au/resources/publications/coronavirus-covid-19-at-a-glance-27-february-2021; https://deborahalupton.medium.com/timeline-of-covid-19-in-australia-1f7df6ca5f23).

Last updated: September 8th, 2021

Canada (British Columbia)

The first presumptive positive case of COVID-19 in British Columbia was found on January 28, 2020. The first case of community transmission was announced on March 5. On March 18, a provincial state of emergency was declared in British Columbia and by the end of March, all schools, personal service establishments, and dine-in restaurant services were closed. Health officials considered British Columbia to be successful in flattening the curve by late April and on June 24, the province entered phase 3 of its restart plan where most establishments were allowed to reopen and non-essential travel within the province resumed. A second wave of COVID-19 was declared in British Columbia on October 19 and in November, mandatory mask policies and new restrictions against social gatherings were introduced. In December, Pfizer and Moderna vaccines were approved for use in Canada. The first dose of COVID-19 vaccine in British Columbia was administered on December 15. As of January 29, 2021, 129,421 vaccine doses have been administered. Current restrictions on social gatherings, restaurant services, fitness centres, and travel have been extended indefinitely (Source: https://bc.ctvnews.ca/scroll-through-this-timeline-of-the-1st-year-of-covid-19-in-b-c-1.5284929).

Last updated: September 7th, 2021

Denmark

Denmark was one of the first countries to introduce a lock-down. This started on March 13, 2020. All persons working in non-essential functions in the public sector were ordered to stay at home for two weeks. Private employers were encouraged to ensure that their employees could work from home. All public institutions, including secondary education, universities, libraries, and museums closed down. Exams were cancelled (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 7th, 2021

France

A summary of measures taken is published online.

Last updated: September 8th, 2021

Germany

The first wave was relatively mild. However, the second wave experienced mostly during December 2020 and January 2021, was a lot more severe (Source: https://www.zdf.de/nachrichten/heute/coronavirus-ausbreitung-infografiken-102.html). Since March 2021, a third wave is developing with currently high incidence rates and mounting pressure on the health system and critical care resources (Source: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Apr_2021/2021-04-09-de.pdf?__blob=publicationFile), caused by a more infectious variant of SARS-CoV-2 (VOC B.1.1.7) becoming the dominant strain (Source: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/DESH/Bericht_VOC_2021-03-31.pdf?__blob=publicationFile) and relaxation of measures to curb transmission at the beginning of March 2021 (Source: https://www.bundesregierung.de/breg-de/themen/coronavirus/fuenf-oeffnungsschritte-1872120).

General measures agreed between the Federal and the Länder governments include the closure of restaurants, bars, and non-essential retail outlets as well as cultural venues such as cinemas, theatres, and clubs. Wearing of masks in public (shops, transportation, workplace) is mandatory and employers and employees are urged to work from home whenever possible. An evening curfew 8pm – 5am had been in place for a while in some regions and there are restrictions in the number of people that are allowed to gather privately. The measures are being regularly revisited in meetings between the chancellor and the 16 Minister presidents. The Minister presidents have decision making power to alter some of the rules, which is why slight differences in measures can be observed across Germany. The rules also differ depending on the COVID-19 incidence (there are changes in rules even at the local level) (Sources: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf; https://www.bundesregierung.de/breg-de/themen/coronavirus/corona-diese-regeln-und-einschraenkung-gelten-1734724).

On April 23, 2021, a new infection prevention bill was enacted. The aim of the bill is to unify COVID-19 related measures across the country depending on local incidence levels (Source: https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/4-bevschg-faq.html).

Last updated: September 8th, 2021

Germany

The first wave was relatively mild. However, the second wave experienced mostly during December 2020 and January 2021, was a lot more severe (Source: https://www.zdf.de/nachrichten/heute/coronavirus-ausbreitung-infografiken-102.html). It is anticipated that Germany is going into a third wave as mutations are becoming more widespread (Source: https://www.spiegel.de/politik/ausland/coronavirus-angela-merkel-sieht-deutschland-in-dritter-welle-a-2e8dc0f6-88db-44aa-8432-1cc8c687dbfa). General measures adopted to mitigate/protect include wearing of masks in public (shops & transportation). An evening curfew 8pm – 5am was in place for a while, and there are restrictions on the number of people that are allowed to meet. The measures are being regularly revisited in meetings between the chancellor and the 16 Minister presidents. The Minister presidents have decision making power to alter some of the rules, which is why slight differences in measures can be observed across Germany. The rules also differ depending on the COVID-19 incidence (there are change in rules even at the local level) (Sources: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf; https://www.bundesregierung.de/breg-de/themen/coronavirus/corona-diese-regeln-und-einschraenkung-gelten-1734724).

Last updated: September 8th, 2021

Hong Kong

Following the experience with the SARS epidemic (2003), the government quickly imposed strict policies and guidelines in community and long-term care facilities. Already in late January 2020, the Social Welfare Department provided the first COVID-19 guideline ‘for special arrangements for publicly funded welfare services’. In addition to daily updates regarding its public services arrangements, the government also offers ‘helplines for daily necessities and/or food’ for people confined at home (Source: https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

In July 2020, with the development of a third wave, containment measures across society were escalated. This included screening and quarantine for foreign domestic workers entering Hong Kong, orderly return of travellers from higher-risk countries, mandatory COVID-19 testing and medical surveillance for crew members of aircrafts and vessels, tightening of social distancing measures, limiting of the number of people in restaurants and entertainment venues, and suspension of visits to LTC facilities, rehabilitation centres, and non-acute hospitals (Source: https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 8th, 2021

Ireland

A National Action Plan in response to COVID-19 was issued in March 2020. One of the aims is to ‘maintain […] critical and ongoing services for essential patient care’. This also captures long-term care services for different groups of people with needs for care and support. There is also a specific point on ‘Caring for our people who are ‘At Risk’ or vulnerable’.

By March 2020, additional public health restrictions emphasising the importance of people staying at home were published.

Last updated: September 7th, 2021

Israel

The pandemic was maintained at reasonably low levels of infection in Israel between February 21 (first case detected) and September 2020, with an effective first lockdown easing by May. In September, the first major wave coinciding with the Jewish High Holidays resulted in a second lockdown. This wave peaked at 6,276 cases on September 27. In tandem with a record-breaking vaccination campaign rollout, a second wave began in mid-December. The daily number of cases peaked at 8,624 on January 17, 2021, with the majority of cases due to a new, more virulent strain (Source: https://www.cgdev.org/event/how-make-covid-19-vaccination-success-policy-priorities-and-implementation-israel-and-around).

Last updated: September 7th, 2021

Japan

Most of the early attention on Japan was focused on the Diamond Princess cruise ship: people on board started a 2 week quarantine on February 5, 2020 (Source: https://pubmed.ncbi.nlm.nih.gov/32183930/).

A published article gives an account of the different measures implemented in Japan during the COVID-19 pandemic.

Last updated: September 8th, 2021

Japan

Most of the early attention on Japan was focused on the Diamond Princess cruise ship: people on board started a 2 week quarantine on February 5, 2020 (Source: https://pubmed.ncbi.nlm.nih.gov/32183930/).

Last updated: September 7th, 2021

Netherlands

During the first wave of the pandemic, southern regions of the Netherlands were hardest hit, with Carnival celebrations being one of the main accelerators. The second wave started in September 2020 and by November was most pronounced in the west, including in the large urban centres Rotterdam, the Hague, and Amsterdam. The Dutch government introduced an “intelligent lockdown” during the first wave. A regional approach was attempted at the beginning of the second wave, but was abandoned by mid-October 2020, when the government introduced a second lockdown, with similar rules like the first (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf). A published paper describes the economic and public health interventions during the first wave. An overview of measures to reduce community transmission, such as an overnight curfew, have been published online.

Last updated: September 8th, 2021

Netherlands

During the first wave of the pandemic, southern regions of the Netherlands were hardest hit, with Carnival celebrations being one of the main catalysts. The second wave started in September 2020, and by November was most pronounced in the west, including in the large urban centres Rotterdam, the Hague, and Amsterdam. The Dutch government introduced an “intelligent lockdown” during the first wave. A regional approach was attempted at the beginning of the second wave, but was abandoned by mid-October 2020, when the government introduced a second lockdown, with similar rules like the first (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf). A published paper describes the economic and public health interventions during the first wave.

Last updated: September 8th, 2021

Republic of Korea

General measures introduced to manage the pandemic include early adoption of extensive testing and contact tracing, low cost tests and treatments covered by the health system, social distancing, and immigration control (Source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

The government plan to implement mass vaccination of key groups starting February 2021 (Source: https://www.reuters.com/article/us-health-coronavirus-southkorea-novavax/south-korea-in-talks-to-secure-40-million-doses-of-novavaxs-covid-19-vaccine-idUSKBN29P0BB). Laws introduced after earlier public health shocks (Sars in 2003 and Mers in 2015) allow the Korea Disease Control & Prevention Agency to access phone data, credit card records, and CCTV footage to trace people’s movements.

Last updated: September 7th, 2021

Singapore

The country has a Disease Outbreak Response System Condition (DORSCON) framework. The severity of an outbreak and associated actions are highlighted through a colour-coded system (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 8th, 2021

Sweden

The overall Public Health response to COVID-19 in Sweden included staying at home if presenting with symptoms, good hygiene, physical distancing, and avoiding unnecessary travel. The strategy aimed to protect people older than 70 years and avoid overwhelming the health system (Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455549/).

Last updated: September 8th, 2021

United States

The United States has been the country hit hardest by the pandemic per capita. Public health responses have primarily been delineated by state and local government, but general stay-at-home and mask-wearing orders have been in place across the country since March 2020 (Source: https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm).

Last updated: September 8th, 2021

3.02. Governance of the Long-Term Care sector's pandemic response

Australia

The Australian Health Protection Principal Committee (AHPPC), made up of the Chief Health Officers from each state and territory, the Chief Medical Officer, and representatives from key departments coordinates the pandemic response. The Australian government is the main funder and regulator of aged care services. Therefore, it has a key role in coordinating a response to COVID-19 in aged care services. State and territory governments also have responsibility for acute care and managing health emergencies within their jurisdictions. Responsibility was fragmented between the federal and state governments (Sources: https://www.health.gov.au/committees-and-groups/australian-health-protection-principal-committee-ahppc; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

The federal, state, and territory governments established a COVID-19 health sector response plan but this plan has been criticized for not specifically addressing the aged care sector. There is a need for a national COVID-19 aged care advisory body to establish protocols between the national and state governments (Sources: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Barriers/facilitators:

Fragmentation between the Australian Government, state, and territory governments led to confusing and inconsistent messaging. It was not clear to providers and recipients who was in charge and what communication to follow. The Commission into Aged Care Quality and Safety recommend a specific aged care advisory body for COVID-19. The Australian Health Protection Principal Committee is responsible for responding to health emergencies. While they released a response plan in early in the pandemic, none of the committee’s members are aged care specialists (https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

Last updated: September 8th, 2021

Australia

The Australian Health Protection Principal Committee (AHPPC), made up of the Chief Health Officers from each state and territory, the Chief Medical Officer, and representatives from key departments, coordinates the pandemic response. The Australian government is the main funder and regulator of aged care services. Therefore, it has a key role in coordinating a response to COVID-19 in aged care services. State and territory governments also have responsibility for acute care and managing health emergencies within their jurisdictions. Responsibility was fragmented between the federal and state governments (Sources: https://www.health.gov.au/committees-and-groups/australian-health-protection-principal-committee-ahppc; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 8th, 2021

Canada (British Columbia)

Provincial Health Officer Dr Bonnie Henry and Minister of Health Adrian Dix had a “united and consistent presence” in providing key messages to the public which may have led to greater adherence and compliance to public health recommendations. Each regional health authority mobilized an Emergency Operations Centre (EOC), which included the medical health officer (MHO). MHO has authority under the Public Health Act to manage the public health response and outbreak in their region. The British Columbia Ministry of Health set up a Health Emergency Command Centre (HECC) structure with the purpose of bringing people together and assisted with communication but HECC decision making was not well integrated into provincial decision-making and accountability frameworks. The power of HECC was not clearly defined, which led to uncertainties around who should be making key decisions and how to use funds. EOC was useful and effective in coordinating responses in health authority owned and operated (public) LTC facilities but not privately owned or affiliate facilities. While responses addressed the LTC sector, there is no evidence of TLC specific expertise being brought to these response teams (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

 

Last updated: September 8th, 2021

Canada (British Columbia)

Provincial Health Officer Dr Bonnie Henry and Minister of Health Adrian Dix had a “united and consistent presence in providing key messages to the public which may have led to greater adherence and compliance to public health recommendations. Each regional health authority mobilized an Emergency Operations Centre (EOC), which included the medical health officer (MHO). MHO has authority under the Public Health Act to manage the public health response and outbreak in their region. EOC was useful and effective in coordinating responses in health authority owned and operated (public) LTC facilities but not privately owned or affiliate facilities (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

There was a lack of coordination between health and social care. Healthcare is monitored more by the national government, although jurisdiction is under the provincial government. Social care is almost exclusively provided and monitored by regional health authorities within the provinces. While the same five health authorities oversee both health and social care, the creation of emergency committees and new medical health officer roles within these authorities created confusion regarding decision making power and authority.

Last updated: September 8th, 2021

Chile

The Ministry of Health, the National Service for Older People (Servicio Nacional de Personas Mayores, SENAMA), and the Chilean Geriatrics and Gerontology Society (SGGCh) developed a set of prevention and management measures. Additionally, SENAMA implemented a mitigation strategy that included face to face technical support, supply of PPE, testing, and temporary transfer of residents who had tested positive to other health settings (Source: https://journal.ilpnetwork.org/articles/10.31389/jltc.72/).

Last updated: September 8th, 2021

Denmark

The Danish Health Authority is chairing a “COVID-19 Intensive Task Force”, with representatives from national authorities and the Danish regions. The task force is responsible for coordinating the regional capacity of intensive care units and staff. The Danish Health Authority has published a status document with assessment of the need for ICU and ventilator capacity (Source: https://www.sst.dk/-/media/Nyheder/2020/ITA_COVID_19_220320.ashx?la=da&hash=633349284353F4D8559B231CDA64169D327F1227). Once a week, Danish Regions publish statistics on the stocks of masks, disinfectants and gloves (Source: https://www.regioner.dk/sundhed/coronaviruscovid-19).

Lessons learned

Given the high level of integration of the health and social sectors and their clear communication structures with municipalities, the pandemic response was able to efficiently focus on the wide range of LTC services during the pandemic (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 8th, 2021

Denmark

The Danish Health Authority is chairing a “COVID-19 Intensive Task Force”, with representatives from national authorities and the Danish regions. The task force is responsible for coordinating the regional capacity of intensive care units and staff. The Danish Health Authority has published a status document with an assessment of the need for intensive care units and ventilator capacity (Source: https://www.sst.dk/-/media/Nyheder/2020/ITA_COVID_19_220320.ashx?la=da&hash=633349284353F4D8559B231CDA64169D327F1227). Once a week, Danish Regions publish statistics on the stocks of masks, disinfectants, and gloves (Source: https://www.regioner.dk/sundhed/coronaviruscovid-19).

Last updated: September 8th, 2021

England (UK)

Guidance on Infection Prevention and Control for care homes was updated numerous times during the pandemic. Some of the relevant guidance was issued in policy documents from the Department of Health and Social Care, and some from Public Health England. Initial guidance on February 25, 2020, advised that it was unlikely that people receiving care would be infected (at the time there had been no known transmission within the UK). It was not until April that the guidance documents in England took into account the possibility of pre-symptomatic or asymptomatic transmission both with regards to testing and isolation policies.

Last updated: September 8th, 2021

Finland

Finland announced a state of emergency on March 16, 2020, after reaching its pandemic threshold of 156 cases on March 15 (Source https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view (p. 15)). The Ministry of Social Affairs and Health (MSAH) is responsible for the planning of the national pandemic response with the help of The Finnish Institute for Health and Welfare (THL), an independent national health research institute. Any national directive (i.e. care measures for infected LTC home residents) is then implemented by local municipalities (Source: https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620-1.pdf).

Decision-making has primarily fallen on the shoulders of the Finnish Health and Welfare research institute (THL), employed by the Ministry of Social Affairs and Health. Expertise at the municipality level is slightly unclear, although agents at the local level are clearly instrumental in bridging the gap between local need/services and nationwide policies/standards (Source: https://www.covid19healthsystem.org/countries/finland/livinghit.aspx?Section=5.%20Governance&Type=Chapter).

On the other hand, municipalities appear to have a large degree of freedom in decision making around LTC. National operators have developed guidelines for residential and domiciliary care. These guidelines were updated over time. However, most guidelines provided at the national level (including LTC guidance) were not binding for municipalities. This led to a situation that in some municipalities visiting bans were introduced ahead of the Government guideline, while others did not follow this. Other municipalities, on the other hand had implemented additional measures, such as support with shopping for older people. Regional variation of the spread of COVID-19 could have been another reason for the different application of guidelines (Source: https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620-1.pdf)

Last updated: September 8th, 2021

Finland

Finland announced a state of emergency on March 16, 2020, after reaching its pandemic threshold of 156 cases on March 15 (Source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view (p. 15)). The Ministry of Social Affairs and Health (MSAH) is responsible for the planning of the national pandemic response with the help of The Finnish Institute for Health and Welfare (THL), an independent national health research institute. Any national directive (i.e. care measures for infected LTC home residents) is then implemented by local municipalities.

Last updated: September 8th, 2021

France

An expert scientific group was set up on March 12, 2020, and a first lockdown was announced on March 14 (Source: https://www.covid19healthsystem.org/countries/france/livinghit.aspx?Section=5.1%20Governance&Type=Section). The French Senate and National Assembly reports on the management of the pandemic were highly critical of the delayed response and support in the social care sector, especially in domiciliary care. Similarly, counting of deaths in care homes was not demanded until the March 28, and published before the April 2 (Sources: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf; https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). On March 6, the Health Ministry required the activation of ‘blueprints’, a necessary document needed by care homes and other social/health services to prepare against health crises, in the wake of the high death levels which followed the 2003 heatwave.

Last updated: September 8th, 2021

Germany

On February 27, 2020, the Federal Minister of Health and the Minister of the Interior established a crisis plan as outlined in Germany’s pandemic plan. It is, however, unclear whether the crisis team specifically focused on LTC (Source: https://www.bundesregierung.de/breg-de/themen/coronavirus/krisenstab-eingerichtet-1726070).

While the Federal Government seeks expert advice on the pandemic response, it is not disclosing names or credentials of the experts involved. It is therefore impossible to know which, if any, expertise on long-term care was sought.

Last updated: September 8th, 2021

Ireland

By the end of March 2020, concerns were expressed regarding the lack of attention that was paid to nursing homes. A meeting between Nursing Homes Ireland, ‘representatives working within nursing homes’, the Minister for Health, and the Secretary General of the Department of Health took place. At the same time, the Health Service Executive provided an updated guidance document for residential care facilities.

This was followed by a request by the Minister of Health for the National Public Health Emergency Team to examine the situation of nursing homes. This led to a number of measures for nursing homes, such as supporting homes with supplies, staff and, the establishment of a national and regional outbreak team (Source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: September 8th, 2021

Israel

The Israeli Ministry of Health was charged with leading the government’s pandemic response, with publishing both weekly and daily press releases starting January 24, 2020. Lockdown measures were implemented the second week of March, which proved effective in terms of minimizing the rate of infection. According to the Government Stringency Index produced by the Oxford COVID-19 Government Response Tracker, the Israeli Government’s policies (e.g. stay at home orders, business closures) were most stringent in April at a score of 95 (when rates were low). In the first and second wave, the index measures were at 85 (with a significant drop to a score of 40 and a reopening of society in November 2020) (Source: https://ourworldindata.org/grapher/covid-stringency-index?tab=chart&stackMode=absolute&time=2020-01-22..latest&country=~ISR&region=World).

LTC facilities in Israel are supervised by the Ministry of Health and/or the Ministry of Labor, Social Affairs and Social Services, while the National Insurance Institute carries responsibility for LTC services in the community.

Early in the pandemic the vulnerability of people with LTC needs was recognised. This led to the establishment of the ‘Fathers and Mothers Shield taskforce’. This task force was made up from representatives of all relevant government ministries, the Israeli army, Israeli intelligence organizations, and public sector organizations. Measures implemented by the taskforce include an increase in testing among residents and staff in residential LTC settings, setting up Corona Wards in geriatric hospitals and LTC facilities, and regulation around visiting. The authors of a paper assessing the management of COVID-19 in the long-term care sector concluded that the centralized management implemented in response to the pandemic ‘had led to a welcome change in LTC policy in Israel’.

Last updated: September 8th, 2021

Israel

The Israeli Ministry of Health was charged with leading the government’s pandemic response, with both weekly and daily press releases published starting January 24, 2020. Lockdown measures were implemented the second week of March, which proved effective in terms of minimizing rate of infection. According to the Government Stringency Index produced by the Oxford COVID-19 Government Response Tracker, the Israeli Government’s policies (e.g. stay at home orders, business closures) were most stringent in April at a score of 95 (when rates were low). In the first and (current) second wave, the index measures at 85 (with a significant drop to a score of 40 and a reopening of society in November 2020) (Source: https://ourworldindata.org/grapher/covid-stringency-index?tab=chart&stackMode=absolute&time=2020-01-22..latest&country=~ISR&region=World).

Last updated: September 8th, 2021

Japan

Japan responded more immediately to the threat of COVID-19 in LTCFs in comparison with Western countries. This has been attributed to cultural respect for older adults, and existing high standards of hygiene and infection control as a result of frequent TB outbreaks (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). On January 29, 2020, LTCFs were contacted by the national ministry in charge and told to put in place infection control measures. On February 13, they were contacted again. On February 24, measures stepped up with restricted visits and more stringent infection control (at this point, there were only 141 confirmed cases in Japan). National lockdown started on March 14, but, by then, LTCFs had been in lockdown for 3 weeks already. (Source: https://pubmed.ncbi.nlm.nih.gov/32183930/). There are hierarchically organised government agencies whose sole missions are elderly care (at the top of the hierarchy is the Bureau of Health and Welfare for the Elderly in the MHLW). Local governments have specific departments that liaise with this Bureau. Well-established channels of communication within the sector may also have been beneficial (Source: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 8th, 2021

Japan

Japan responded more immediately to the threat of COVID-19 in LTCFs in comparison with Western countries. This has been attributed to cultural respect for older adults, and existing high standards of hygiene and infection control as a result of frequent TB outbreaks (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). Hierarchically organised government agencies whose sole missions are elderly care, plus well-established channels of communication within the sector may also have been beneficial (Source: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 8th, 2021

Netherlands

As per the national pandemic action plan, crisis response is delegated to many organisations at all system levels. However, as the crisis deepened the National Institute for Public Health and the Environment (RIVM) was made coordinator of the response and an outbreak management team was created to advise the government (Source: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

Last updated: September 8th, 2021

Republic of Korea

The Government raised the infectious disease alert level to “highest” on February 23, 2020. On January 29 they introduced a monitoring system to check social welfare facilities’ compliance with the guidelines, and from February 9, the central headquarters conducted daily monitoring on, for example, isolation of care workers. Constructive relationships with key institutions such as the president’s office, the Ministry of Health, and the Korean Centers for Disease Control and Prevention enabled a decisive response (Source: https://ourworldindata.org/covid-exemplar-south-korea). The Korean National Health Insurance Services developed and published guidance for all welfare and LTC facilities on February 20, 2020. This set out containment measures within Korean LTCFs including site monitoring, resident quarantining, identification of high risk staff and visitors, targeted screening, and stringent personal hygiene measures for staff and residents. They also published a a response plan for COVID-19 to effectively react to suspected and confirmed cases of the virus within the service boundaries of each institution (e.g. suspected/affected care recipients, suspected/affected care providers) (Source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: September 8th, 2021

Singapore

The long-term care sector in Singapore was first advised on January 23, 2020, against traveling to Wuhan (China) (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 8th, 2021

Spain

In Spain, in principle, 4 different ministries were tasked with responding to the pandemic, but in practice the Ministry of Health had the most visible role, which was similar at regional level. The governance of the pandemic in relation to the LTC sector has varied by region and in the different phases of the pandemic. Local governments were also involved, specifically with regards to logistical support and in rural areas. There was also support from the army, civil protection volunteers, police, the fire service, and NGOs. A report on the organisation and governance of the pandemic response in care homes concluded that being better prepared would have reduced the reaction time, which has been identified as a key factor in the impact of the pandemic on the Spanish care home population. There was also a lack of clarity over responsibility, where 45% of the population thought that responsibility of the pandemic response in care homes was with the regional governments, 24% with the central government, and 28% with both (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 8th, 2021

Sweden

Although the importance of protecting older people was stressed from the beginning of the pandemic, no specific attention/measures were taken to protect homecare users. The focus was to limit the spread of the infection in the community through wider population measures such as basic hygiene, social distancing, limiting non-essential travel, and social gatherings (Source: https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

The responsibility to restrict disease spreading in care homes and other forms of social care services rests with the municipalities together with the regional infection control units (Smittskydd). During the pandemic, this local/regional responsibility has been stressed by the Public Health Agency and the National Board of Health and Welfare. The latter has mainly acted by providing recommendations and check-lists, and by presenting good examples (Source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: September 8th, 2021

Sweden

The responsibility to restrict disease spreading in care homes and other forms of social care services rests with the municipalities together with the regional infection control units (Smittskydd). During the pandemic, this local/regional responsibility has been stressed by the Public Health Agency and the National Board of Health and Welfare (NBHW). The latter has mainly acted by providing recommendations and check-lists, and by presenting good examples (Source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf). In order to increase intensive care unit capacity, the government instructed the NBHW to function as a national coordinator to ensure expansion occurred to meet needs (Source: https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812).

Last updated: September 8th, 2021

United States

The United States, according to the Global Health Security Index, was considered to be the country most prepared in the world for a pandemic, and studies as to why its failures were so extreme are underway. President Trump declared COVID-19 a public health emergency on February 3, 2021. Jurisdiction regarding stay-at-home orders, travel quarantines, and sheltering in place is given to the individual states, which led to what is a considered a highly-politicized divide in local and regional responses and mandates (Source: https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf).

Last updated: September 8th, 2021

United States

The United States, according to the Global Health Security Index, was considered to be the country most prepared in the world for a pandemic, and studies as to why its failures were so extreme are underway. President Trump declared COVID-19 a public health emergency on February 3rd, 2021. Jurisdiction regarding stay-at-home orders, travel quarantines, and sheltering in place is given to the individual states, which led to what is a considered a highly-politicized divide in local and regional responses and mandates (https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf).

Last updated: March 23rd, 2021

3.02.01. National or equivalent Covid-19 Long-Term Care care taskforce 

Austria

Several task forces were put in place ‘at federal and regional government level’. They only contained two representatives from the LTC sector (Source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

Last updated: September 8th, 2021

Germany

No national COVID-19 LTC taskforce was established, as health and social care largely falls under Länder [State] authority. However, the State Secretary at the Federal Ministry of Health has in some cases sought a moderating role highlighting topics of importance (Source: https://www.pflegebevollmaechtigter.de/nws-zum-Coronavirus.html). Federal agencies like the Robert Koch Institute have not established LTC-specific taskforces.

Some Länder (e.g. Bavaria, Baden-Württemberg) have established LTC-task forces within their respective Ministries of Health. How these task forces are constituted, and work remains largely unclear.

Last updated: September 8th, 2021

Ireland

The Chief Medical Officer in the Department of Health chairs the National Public Health Emergency Team that was established in January 2020 in response to COVID-19. The role of the team is to ‘oversee and provide national direction, guidance, support and expert advice on the development and implementation of strategy to contain COVID-19 in Ireland.’ The Health Information and Quality authority that carries responsibility for inspecting nursing homes is part of the team (Source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: September 9th, 2021

Israel

Following an outbreak in LTCFs in mid-March and a national outcry for increased attention to LTC-specific needs, Israel’s government rolled out a national taskforce and plan entitled “Shield of the Fathers and Mothers” (Magen Avot V’Emahot) in April 2020 (Source: https://govextra.gov.il/ministry-of-health/care-covid19/elderly-care-covid19/). It served as a coordination effort specifically catered to the care and concerns of LTCFs, “to ensure national resilience and protect the elderly populations and the population of people with disabilities staying in out-of-home settings, while providing optimal care in a comprehensive national vision” (Source: https://www.health.gov.il/Subjects/Geriatrics/magen/magen-chapter1.pdf). Among some of the top priorities of this project were: increasing the scope of COVID-19 testing in LTCFs, including in those with no identified COVID-19 patients; upgrading protection measures for both staff and residents of LTCFS, including (dis)infection training; prohibiting LTCF staff members from working in more than one facility; and allowing families to visit only in special instances (and subject to rules of social distancing) (Source: https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

Last updated: September 9th, 2021

Australia

The federal, state, and territory governments established a COVID-19 health sector response plan but this plan has been criticized for not specifically addressing the aged care sector. There is a need for a national COVID-19 aged care advisory body to establish protocols between the national and state governments (Source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 8th, 2021

Canada (British Columbia)

There was no national taskforce because social care/LTC is governed provincially. British Columbia Ministry of Health set up a Health Emergency Command Centre (HECC) structure with the purpose of bringing people together and assisted with communication, but HECC decision making was not well integrated into provincial decision-making and accountability frameworks. The power of HECC was not clearly defined, which led to uncertainties around who should be making key decisions and how to use funds (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 8th, 2021

Chile

The Ministry of Health (MoH), the National Service of Older People (Servicio Nacional del Adulto Mayor, SENAMA), the Chilean Geriatrics and Gerontology Society (GGS), and the main non-profit organizations started a working group to coordinate the implementation of prevention and control measures (Source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

Last updated: September 8th, 2021

Denmark

There is no task force specifically identified for LTC, but there is a Danish COVID-19 Taskforce referred to as the COVID-19 Intensive Task Force (Source: https://www.covid19healthsystem.org/countries/denmark/livinghit.aspx?Section=5.%20Governance&Type=Chapter).

Last updated: September 8th, 2021

England (UK)

On June 8, 2020, the Government announced the creation of a social care sector COVID-19 taskforce in order to ensure concerted action to implement key measures taken to date (Source: https://www.gov.uk/government/groups/social-care-sector-covid-19-support-taskforce). In particular, the taskforce was intended to support the delivery of the Government’s social care action plan, published on April 15, 2020 (Source: https://www.gov.uk/government/news/national-action-plan-to-further-support-adult-social-care-sector), and its home care support package (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-care-homes/coronavirus-covid-19-care-home-support-package). The taskforce, which included representatives from across government and the care sector, was intended to ‘support the national campaign to end transmission in the community, and it will also consider the impact of COVID-19 on the sector over the next year and advise on a plan to support it through this period’. The Taskforce published its report in late September 2020, identifying a total of 52 recommendations across a range of domains including PPE, testing, workforce, and controlling infection in different settings. The learning disabilities and autistic people advisory group to this taskforce published 5 key recommendations, which the co-chairs of the advisory group have stated were not reflected in the taskforce report as a whole. These were: accessible guidance and communications, restoring and maintaining vital support services, expanding PPE and testing, tackling isolation and loneliness, and seeking and supporting people who may be in crisis.

Last updated: September 9th, 2021

Finland

While it’s difficult to determine a formal Finnish taskforce for social care during the pandemic, it’s clear that the Ministry of Social Affairs and Health and The Finnish Institute for Health and Welfare (THL) worked closely to decide certain policies (e.g. regarding LTC home visitation and self-isolation of older people). On May 4, 2020, the government announced a plan to move to a hybrid strategy, ‘test, trace, isolate and treat’. One of the main aims was to protect the elderly and high-risk groups. Their guidelines/press releases are published regularly online.

Last updated: September 8th, 2021

France

A national Covid-19 social care task force was set up under the Direction Generale de la Cohesion Sociale [Social Cohesion Unit] (DGCS), announced on March 30, 2020. To prepare for the second wave, the DGCS crisis cell reactivated its ‘open crisis cell’, to function in parallel to that held by the Health Ministry (Source: https://solidarites-sante.gouv.fr/soins-et-maladies/maladies/maladies-infectieuses/coronavirus/professionnels-du-social-et-medico-social/article/une-cellule-de-crise-de-la-covid-19-par-la-dgcs). All guidance and information pertinent to older people and people with disabilities and published by DGCS is available online.

Last updated: September 8th, 2021

Israel

Following an outbreak in LTCFs in mid-March and a national call for a taskforce on LTC-specific needs, Israel rolled out a national plan entitled “Shield of Fathers and Mothers” (Magen Avot V’Emahot) in April 2020 (Source: https://govextra.gov.il/ministry-of-health/care-covid19/elderly-care-covid19/). It served as a coordination effort specifically catered to the care and concerns of LTCFs, “to ensure national resilience and protect the elderly populations and the population of people with disabilities staying in out-of-home settings, while providing optimal care in a comprehensive national vision” (Source: https://www.health.gov.il/Subjects/Geriatrics/magen/magen-chapter1.pdf). Among some of the top priorities of this project were: the training of LTCF staff in protection against COVID-19 infection and to provide assistance in disinfection; increasing the scope of COVID-19 testing in LTCFs, including in those with no identified COVID-19 patients; and managing the social distance of patients to mitigate loneliness.

Last updated: September 9th, 2021

Japan

A national taskforce (Advisory Committee on the Basic Action Policy on Coronavirus) was established, including experts from the Ministry of Health, Labour & Welfare (that oversees long term care) (Source: https://www.universityworldnews.com/post.php?story=20200703123239310). However, it’s not clear to what extent the taskforce focused on long-term care.

Last updated: September 9th, 2021

Sweden

A published report indicates that the that NBHW (National Board of Health and Welfare) has gradually been assigned new tasks and roles that are handled by a special group that support the regions and municipalities in their work with COVID-19.

Last updated: September 9th, 2021

United States

Both President Trump and President Biden crafted national COVID-19 taskforces, with experts from varying backgrounds. President Biden’s new taskforce explicitly prioritizes the need to “protect older Americans and others at high-risk.” While this has not resulted in an explicit federal social care taskforce, the President’s program has responded to this need by introducing a COVID-19 Racial and Ethnic Disparities Task Force to address major inequities which have come to particular light within the LTC sector (Source: https://www.whitehouse.gov/priorities/covid-19/).

Last updated: September 9th, 2021

3.02.02. Measures to improve coordination between Health and Social Care in response to the pandemic

Germany

Local health authorities instruct and advise LTC providers within their jurisdiction on infection prevention measures. These measures as well as the modes of co-operation and collaboration vary between LTC providers and local health authorities. The health system (particularly the hospital system and the medical care in the community) and the long-term care system, operate independently of each other. No formal coordination exists on a local, regional, or Länder [State] level. Some states and regions have sought to establish informal modes of coordination during the pandemic. Where care providers are no longer able to provide the services for which they have been contracted, they have to contact the care insurance and work towards solutions with the relevant health and regulatory authorities (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

Last updated: September 9th, 2021

Austria

A published paper highlights the fragmented nature of the health and social care system, which leads professionals in both sectors to largely ‘work in ‘silos’’. The paper notes that there is very little exchange between LTC staff working in residential and domiciliary care. It further observes that this lack of exchange between health and LTC services, but also between different LTC services, leads to a situation where some health and LTC workers had to reduce their activities, while others experienced excess demand.

Last updated: September 9th, 2021

Canada (British Columbia)

While the same five health authorities in British Columbia oversee both health and social care, the creation of emergency committees and new medical health officer roles within these authorities created confusion regarding decision making power and authority (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

 

Last updated: September 9th, 2021

Denmark

The Board for Patient Safety enforced that the municipalities introduced restrictions preventing visitors in nursing homes. This included visits inside the institutions, and in common areas, as well as apartments or rooms. It could also include outdoor areas if necessary but this was a decision to be taken by the Municipal Board (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

On April 8, 2020, an extensive guideline was issued by the Board of Health, outlined how nursing homes and other institutions could prevent the spread of COVID-19, in the wake of the so-called controlled re-opening of the country which was planned to take place after Easter (April 14). It was intended to supplement the procedures that the municipalities had already put in place, and provided guidelines on how to organise this. It specifically addressed the handling of the disease as a responsibility of the management. The managers were encouraged to plan the daily activities so that residents gathered in smaller groups than normally, preferably no more than two (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 9th, 2021

England (UK)

In the absence of rapid and adequate support to the domiciliary care sectors, many providers have turned to local initiatives to continue to deliver care in a safe way, for instance through the use of remote monitoring technologies (Source: https://www.carecity.london/your-blog/221-expert-care-in-covid-19). Providers have furthermore reported improved relationships with the healthcare sector, with a more collaborative approach to supporting vulnerable individuals over the course of the pandemic.

Last updated: September 9th, 2021

Finland

Hospital districts became the central organising forces for the pandemic response. Concern over shortages and adequacy of healthcare personnel led to the termination of non-urgent care, most elective surgeries, medical rehabilitations, therapies, and counselling services, and annual health checks (included those of at-home care users) were suspended nationwide. However, the use of hospitals has generally been kept under control (Source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view (p. 20)). Early on, avoiding transfer from care homes to hospitals (and vice versa) was put on the mandated guidelines list (Source: https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620-1.pdf (p. 9)).

Last updated: September 9th, 2021

France

At the onset of the pandemic, significant issues were reported among care homes (and other LTC users) relating to access to healthcare facilities. Many care homes did not have named GPs or equivalent contacts which the Senate/National Assembly attributed to higher deaths. As a result, ‘geriatric territorial support pathways’ and mobile geriatric and palliative care teams for care homes were established on March 31, 2020. The geriatric hotline connected care workers to a geriatric consultant and care coordinator from 8am-7pm 7 days/week. A protocol for pharmacy delivery of indispensable products (e.g. paracetamol) and to connect care homes to pharmacies was also developed in some regions (Source: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.16687).

Last updated: September 9th, 2021

Germany

Where care providers are no longer able to provide the services for which they have been contracted, they have to contact the care insurance and work towards solutions with the relevant health and regulatory authorities (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

Last updated: September 9th, 2021

Netherlands

People interviewed for the McCovid project reported that nursing homes and hospitals collaborated well and there was some exchange of staff (nurses, gerontologists) when needed. Nursing homes were deemed to be well equipped to provide medical care themselves and by accessing health care in the community (GPs, geriatric doctors, other specialists). It is customary to treat illness in nursing homes and only to transfer to hospitals in exceptional circumstances (Source: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view). There was improved regional cooperation between nursing homes and hospitals through regional networks (RONAZ). Nursing homes also assisted hospitals in making available additional beds to increase hospital capacity (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 9th, 2021

Singapore

The Regional Health System model, and the collaborative relationships that were formed through this model prior to the COVID-19 pandemic, was reported to have contributed to the ‘allocation and sharing of infection control resources and training, and the safe transfer and management of patients between acute and community care settings’ (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 9th, 2021

Spain

In the earlier parts of the pandemic, there was lack of clarity in governance, which resulted, in some instances, in care homes being given contradictory guidance from the regional Departments of Health and by Social Services. This improved in later phases of the pandemic. To improve coordination, in some regions joint working groups were established, whereas in others the Department of Health took control. (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021

Sweden

The Corona Commission highlighted shortcomings in coordination, with fragmented organisation of the care system across regions (health), municipalities (social care) and central government agencies. There was no overview of preparedness to tackle a pandemic and there were no established communication channels to facilitate operational coordination and collaboration. In several regions, recommendations were issued that people in care homes who fell ill with suspected or confirmed COVID-19 should primarily be cared for in the care home and not referred to hospital (Source: https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

Last updated: September 9th, 2021

3.02.03. Measures to support, facilitate and compensate for disruptions to access to care

Australia

The Australian government announced $440 million Australian Dollars to train aged care staff in infection control, increase the number of staff, and for telehealth services. Additionally, $234.9 million Australian Dollars was included as a COVID-19 retention bonus to ensure adequate staffing in the workforce (Source: https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 9th, 2021

Austria

The closing of borders during the first wave of the COVID-19 pandemic posed challenges for the Austrian ’24-hour care model’ staffed with migrant care workers who tend to work extended shifts (fortnightly or monthly shifts). Migrant care workers in Austria were unable to return to their home countries and replacement staff were unable to travel into the country. In response to the impact of COVID-19 on the LTC sector, the federal government provided an ‘extraordinary crisis budget of €100 million’. Two provinces (Burgenland and Lower Austria) invested in chartered flights to bring several hundred migrant carers from Romania, Bulgaria, and Croatia into the country. Later on, corridor trains between Romania and Austria were established. Regional governments as well as the Federal Ministry provided a ‘premium of €500’ for migrant carers continuing to provide care in Austria. A hotline was established to support the coordination of care workers across the country.

In care homes, external staff (including occupational therapists/physiotherapists) were ‘extremely restricted’. It is reported that ‘18% of care homes and 15% of people living at home discontinued therapies’ (Source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

Last updated: September 9th, 2021

England (UK)

During March and April 2020, there was a substantial reduction in hospital admissions among care home residents. Elective admissions reduced to 58% of the 5-year historical average and emergency admissions to 85% of the 5-year historical average. By reducing admissions, care home and NHS teams may have reduced the risk of transmission, but there may have also been an increase in unmet health needs (Source: https://www.health.org.uk/publications/reports/adult-social-care-and-covid-19-assessing-the-impact-on-social-care-users-and-staff-in-england-so-far).

To facilitate access to crucial medicines, on April 23, 2020, the Department of Health and Social Care published new standard operating procedures for the use of medicine in care homes and hospice settings in England. The scheme allowed care homes and hospices to re-use medicine that was issued for one resident for another under specific circumstances and only in crisis situations. The guidance document contains information on the specific circumstances in which medicines labelled for one person (who no longer needs them) can be used for another person. The usually strict regulations around re-using or recycling medication were relaxed as there were ‘increasing concerns about the pressure that could be placed on the medicines supply chain during the peak of the COVID-19 pandemic’.

From May 15, 2020, the NHS was expected to ensure that care homes were able to receive clinical support from primary care and community health services.

Last updated: September 9th, 2021

France

A platform was developed in November 2020 for domiciliary/community care providers to pool resources (and regional stakeholders including integrated care pathways, regional health organisations, individual care providers etc.) in a given region to ensure continuity of care and to respond to growing demand (Source: https://solidaritedomicile.fr/solidarit%C3%A9_domicile_informations/solidarit%C3%A9_domicile_information). In May 2020, France was encouraging physician visits and offering greater remuneration after having told homes to minimise such visits in the early months of the pandemic (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 9th, 2021

France

A platform was developed in November 2020 for domiciliary/community care providers to pool resources (and regional stakeholders including integrated care pathways, regional health organisations, individual care providers etc.) in a given region to ensure continuity of care and to respond to growing demand (Source: https://solidaritedomicile.fr/solidarit%C3%A9_domicile_informations/solidarit%C3%A9_domicile_information). Some specific guidance has been published to support elderly people and to protect carers.

Last updated: September 9th, 2021

Germany

From March 17, 2020, until September 30, 2020, people wishing to take up LTC payments or care did not have to attend bi-annual care advisory meetings. Payments continued without these meetings. Since advisory meetings have started again, people with care needs can request for these meetings to take place digitally or over the phone (until March 31, 2021, and perhaps until June 30, 2021). Home visit are still not taking place (until February 28, 2021, and perhaps until June 30, 2021). Similarly, funds for adjustment of accommodation due to care needs have been provided following virtual meetings. In addition, between April 1, 2020, and March 31, 2021, additional funding for consumables to support care had been increased from 40 to 60 Euros per month.

People with limited care needs (Level 1) have been given more flexibility on what they spend the support payment of 125 Euros per month (until 31 March 2021) on (Source: https://www.pflegeberatung.de/corona). The German dementia strategy has recognised the added complexity of COVID-19 related measures to the lives of people with dementia and their carers. The strategy proposes increased remote (telephone) advice and counselling for people with dementia and their relatives, expansion of local (voluntary) networks, strengthening neighbourhood support, increased support for working family carers, support for distance carers, improving dementia training of care workers in different care settings (Source: https://www.nationale-demenzstrategie.de/fileadmin/nds/pdf/2020-07-03__Corona_und_Demenz_.pdf).

Home care providers are given permission to sub-contract services to other providers if their own workforce is currently unable to provide the required care due to the pandemic situation (Source: https://www.awmf.org/leitlinien/detail/ll/184-002.html) and individual Länder [States] may have further support measures in place. Guidelines on the provision of home care recommend a shared-decision making process with consumers to establish which services may be adjusted if the home care provider is unable to fulfil demand due to workforce restrictions or other reasons (Source: https://www.awmf.org/leitlinien/detail/ll/184-002.html).

Last updated: September 9th, 2021

Germany

From March 17, 2020, until September 30, 2020, people wishing to take up LTC payments or care did not have to attend bi-annual care advisory meetings. Payments continued without these meetings. Since advisory meetings have started again, people with care needs can request for these meetings to take place digitally or over the phone (until March 31, 2021, and perhaps until June 30, 2021). Home visit are still not taking place (until February 28, 2021, and perhaps until June 30, 2021). Similarly, funds for the adjustment of accommodation due to care needs have been provided following virtual meetings. In addition, between April 1, 2020, and March 31, 2021, additional funding for consumables to support care had been increased from 40 to 60 Euros per month.

People with limited care needs (Level 1) have been given more flexibility on what they spend the support payment of 125 Euros per month (until March 31, 2021) (Source: https://www.pflegeberatung.de/corona). The German dementia strategy has recognised the added complexity of COVID-19 related measures to the lives of people with dementia and their carers. The strategy proposes increased remote (telephone) advice and counselling for people with dementia and their relatives, expansion of local (voluntary) networks, strengthening neighbourhood support, increased support for working family carers, support for distance carers, and improving dementia training of care workers in different care settings (Source: https://www.nationale-demenzstrategie.de/fileadmin/nds/pdf/2020-07-03__Corona_und_Demenz_.pdf).

Last updated: September 9th, 2021

Israel

Oversight of COVID-19 has been given to the Ministry of Health, which set up the National Coronavirus Information and Knowledge Centre alongside the armed forces (IDF) Intelligence Directorate (Source: https://www.gov.il/en/departments/topics/corona-main-sub). Oversight of the extension of welfare benefits is in the hands of the National Insurance Institute (Source: https://www.btl.gov.il/English%20Homepage/Benefits/LongTerm%20Care/Pages/default.aspx).

In the COVID-19 Economic Plan first released in April 2020, under immediate civil and health provisions, measures towards the reduction of risk for high-risk populations included: 130,000 hot meals to older people and people in-need, bi-weekly groceries baskets, and food vouchers for at-risk families, people with disabilities living in the community, and people with mental health problems in the community (Source: https://www.gov.il/en/departments/guides/mof_economic_plan?chapterIndex=2).

Many day centres for the elderly were closed due to coronavirus. According to the National Insurance Institute website, day centres contacted their service users individually to help them find alternative programs (Source: https://www.btl.gov.il/English%20Homepage/Coronavirus_guidelines/Pages/default.aspx).

 

Last updated: September 9th, 2021

Israel

In the COVID-19 Economic Plan first released in April 2020, under immediate civil and health provisions, measures towards the reduction of risk for high-risk populations included: 130,000 hot meals to the elderly and in-need, bi-weekly groceries baskets, and food vouchers for at-risk families, people with disabilities living in the community, and people with mental health problems in the community (Source: https://www.gov.il/en/departments/guides/mof_economic_plan?chapterIndex=2).

Last updated: September 9th, 2021

Luxembourg

Measures were taken to ensure the continuity of care in residential care facilities during evenings, weekends, and public holidays (e.g. by establishing an on-call system for general practitioners, and establishing stocks of medications in care homes) (Source: https://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=8396&furtherPubs=yes).

Last updated: September 9th, 2021

Netherlands

GPs have been told they should closely monitor those who are homebound and frail and should act like a case-manager when they develop COVID-19 symptoms (Source: https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long-Term-Care-situation-in-the-Netherlands-25-May-2020-1.pdf). During the second wave, efforts were increased to ensure continuity of care and services for people receiving domiciliary care and for those requiring daytime services (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 9th, 2021

Republic of Korea

Even though 99% of community services were closed from February 28, 2020, onwards, staff members working in community care services are continuing to provide care such as delivering meals, ‘checking on welfare’, and ‘supporting activities’.

Last updated: September 9th, 2021

3.03. Monitoring Covid-19 impacts in the Long-Term Care sector: data and information systems

Australia

The Department of Health publishes weekly traffic light reports of the COVID-19 situation across Australia, which includes details about cases, testing, and capacity nationwide and in individual states. Specific systems have been developed in individual states. For example, the Victorian Aged Care Response Centre brings together Commonwealth and Victorian state government agencies in a coordinated effort to manage the impact of the COVID-19 pandemic in aged care facilities (Sources: https://www.health.gov.au/initiatives-and-programs/victorian-aged-care-response-centre/about-the-victorian-aged-care-response-centre).

Last updated: September 9th, 2021

Canada (British Columbia)

Limitations in accessing basic LTC and assisted living sector data, including human resources and expense data, created challenges in implementing COVID-19 policy and operational support initiatives (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf). LTC operators reported “spending hundreds of extra hours to respond to requests for reporting and additional inspections over the course of the pandemic” and many providers found these requests to be overwhelming. But the government saw this information as essential to evaluate how LTC sector was doing throughout COVID-19 and what further assistance/support was needed.

Last updated: September 9th, 2021

Denmark

Weekly data on LTC and COVID-19 is published online.

Last updated: September 9th, 2021

Finland

The development of the Finnish track and trace app, Koronavilkku, has had a mixed response/use. It is updated regularly (Source: https://thl.fi/en/web/thlfi-en/-/next-month-koronavilkku-users-can-get-tested-based-on-exposure-notifications?redirect=%2Fen%2Fweb%2Finfectious-diseases-and-vaccinations).

Last updated: September 9th, 2021

France

The first operational system for documenting the situation in care homes was made available only near the end of March 2020, and publicly available on April 2. Regional structures (ARS) were largely left to their own devices at the beginning of the pandemic. The Health Ministry’s infectious diseases risk register was not adapted to the recording of care home deaths. The Direction Générale de la Cohésion Sociale [General Directorate of Social Cohesion] developed an emergency oversight system on March 28, which was dependent on departments submitting information from LTCFs on observed events (e.g. probable cases, confirmed cases, deaths), recording alerts based on symptoms. This contrasted to SiVIC, the national hospital database, which collected useful personal information. The Senate criticised the system as the ARS regions had to adapt the systems they had developed to a poorer system which wasn’t as useful and required significant resources to extract and convert brute information into something useful (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf)

Last updated: September 9th, 2021

Germany

The Robert Koch-Institute (RKI) is the federal institute responsible for disease detection and health reporting. It collects data on diseases nationwide (Source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). Laboratories and medical doctors are required to inform the local health authority about COVID-19 and selected other infections. The local health authorities then transfer the aggregate data to the health authority responsible for the federal state. This main health authority then transfers the information to the RKI. The RKI works closely with the Federal Ministry of Health, other Federal authorities, and public health authorities in each of the 16 Federal states. The RKI also maintains interaction with international bodies, such as the World Health Organisation and European Centre for Disease Prevention and Control. The information routes are outlined by law (Source: https://www.gmkonline.de/documents/pandemieplan_teil-i_1510042222_1585228735.pdf).

RKI publishes a daily Situation Report on the pandemic, which includes limited information on COVID-19 morbidity and mortality in residents of care homes and clients of home care services as well as for staff of these services. Details of how this information is gathered and presented have changed over time. More fine-grained information is not generally available. Information on persons who receive only informal care in their own home is not included. Impacts on the LTC system in general, e.g. availability and usage of services, are not routinely monitored and therefore not easily available.

Last updated: September 9th, 2021

Ireland

Nursing homes in Ireland have to report any ‘outbreak of COVID-19’ to the Chief Inspector of Social Services in the Health Information and Quality Authority (Source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: September 9th, 2021

Israel

COVID-19 is being tracked by the Israel Ministry of Health’s Data Dashboard (Source: https://datadashboard.health.gov.il/COVID-19/general?utm_source=go.gov.il&utm_medium=referral). The Ministry has introduced a smartphone app, HaMagen (“The Shield”), for their track and trace programme (Source: https://govextra.gov.il/ministry-of-health/hamagen-app/download-en/). The  Ministry’s Center for Disease Control also publishes a broader surveillance of respiratory viruses each week. Israel has an extensive and highly digitized online medical system. This made the creation of appointment smartphone apps to set up automatic scheduling and appointment reminders for vaccination relatively easy (Source: https://www.cgdev.org/event/how-make-covid-19-vaccination-success-policy-priorities-and-implementation-israel-and-around (14:10)).

Last updated: September 9th, 2021

Japan

It is unclear what measures have been put in place for data and information sharing within LTC during the COVID-19 pandemic. Japan has not adopted electronic record sharing on a large scale and most records remain paper-based and mostly shared by fax (Source: https://www.healthaffairs.org/do/10.1377/hblog20200721.404992/full/).

Some of the supplementary budget provided by the government in response to the COVID-19 pandemic was for the construction of a ‘data-sharing system among hospitals, municipalities and national ministries’ to support the government with monitoring the number of people with COVID-19 infections (Source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

Last updated: September 9th, 2021

Japan

It is unclear what measures have been put in place for data and information sharing within LTC during the COVID-19 pandemic. Japan has not adopted electronic record sharing on a large scale and most records remain paper-based and mostly shared via fax (Source: https://www.healthaffairs.org/do/10.1377/hblog20200721.404992/full/).

Last updated: September 9th, 2021

Netherlands

The association of geriatric doctors, Verenso, initiated a registration system to improve data collection from nursing homes on incidence and mortality (Source: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view). Two electronic healthcare systems (i.e. Ysis and ONS) have collected the number of COVID-19 cases in nursing homes. These electronic healthcare systems cover the majority of nursing homes in the Netherlands (Source: https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf).

Last updated: September 9th, 2021

Republic of Korea

To track the movements of people with COVID-19 infections, the government used Global Positioning System (GPS) records from cellular phone or credit card records to generate a movement map. Once the movement map was made, the map was displayed on the Web or notifications were sent to inhabitants in the relevant neighbourhoods so they could take additional precautions. To monitor people under quarantine, applications on smartphones using GPS data were introduced (Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160162/).

Last updated: September 9th, 2021

Scotland (UK)

A study of care homes in the NHS Lothian region found an association between the number of beds and the likelihood of a COVID-19 outbreak. However, it warned of oversimplifying the relationship.

 

Last updated: September 9th, 2021

Spain

Until [check date] there was no national information system available to track the impact of the pandemic in the LTC system. Each region collected their own data but using different methodologies (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf). Since [check] data is collected and published regularly using European Centre of Disease Prevention and Control guidance.

 

Last updated: September 9th, 2021

Spain

No national information system was available to track the impact of the pandemic in the LTC system (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021

United Kingdom

A lack of linked datasets for care homes slowed down the pandemic response in care homes.  The number of different bodies that are collecting information, and the absence of standardisation and cross sector cooperation in how data are collated, shared, and used have prevented rapid and effective responses (Source: https://www.bmj.com/content/369/bmj.m2463).

Last updated: September 9th, 2021

United States

There are multiple on-going studies and information systems tracking the impact of the pandemic on LTC users. The official government data system for tracking COVID-19 in nursing facilities and other LTCFs is through the Center for Disease Control’s (CDC) National Healthcare Safety Network (Source: https://www.cdc.gov/nhsn/ltc/covid19/index.html). In coordination with the federal agency for health insurance programs, the Center for Medicare and Medicaid Services (CMS), this Network has produced a Nursing Home COVID-19 Public File to which over 15,000 certified nursing facilities nationwide are expected to report related data weekly. The CMS can impose financial penalties if facilities do not report, and compliance has thus been nearly 100% (Sources: https://ltccovid.org/wp-content/uploads/2021/02/LTC_COVID_19_international_report_January-1-February-1-1.pdf; https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/). Other, independent information systems tracking the impact of the pandemic in LTCFs include the Kaiser Family Foundation (KFF) and The Atlantic Magazine’s COVID Tracking Project (CTP) (Source: https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/#long-term-care-cases-deaths; https://covidtracking.com/).

Last updated: September 9th, 2021

United States

Data collection regarding COVID-19 has been extensively performed by the Center for Disease Control and Prevention, and has been published online.

Last updated: September 9th, 2021

3.04. Financial measures to support users and providers of Long-Term Care

Australia

On March 11, 2020, the Australian government announced $440 million Australian Dollars (AUD) to train aged care staff in infection control, to increase the number of staff, and for telehealth services. Additionally, $234.9 AUD was included as a COVID-19 retention bonus to ensure adequate staffing in the workforce. Additional funding was announced on August 31, 2020, where $563.3 million (AUD) was provided to reinforce the aged care sector’s response to COVID-19. This second phase of funding included $245 million AUD for COVID-19 support payments to aged care providers. The government also introduced an entitlement of up to 2 weeks of paid pandemic leave for aged care workers as well as a pandemic leave disaster payment, which is a lumpsum of $1500 to help staff after isolation or quarantine (Source: https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

The Australian Aged Care Quality and Safety Commission phoned all home care services to offer support during COVID-19. There has been $59.3 million AUD of funding from the government allocated to meals on wheels, $50 million AUD to fund home-delivered meals, and $9.3 million AUD on emergency food supply boxes. Additionally, $10 million AUD has been allocated to the Community Visitors Scheme, which facilitates telephone calls and virtual friends for socially isolated people in community based aged care (Source: https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 10th, 2021

Austria

In Austria, some of the €100 million allocated to support the LTC sector were earmarked for expanding residential care bed capacity for people who could not be cared for sufficiently in their own home because of the complexities of delivering home care during the pandemic (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf). People with care needs can receive cash-for-care allowances following a needs assessment (Source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

Last updated: September 10th, 2021

Canada (British Columbia)

At the beginning of the pandemic, LTC and assisted living providers reported spending an excessive amount on COVID-related expenditures and were unsure as to whether they would be reimbursed, because the Ministry of Health had not provided clear guidelines or timelines. Providers also reported lost revenue from an increased vacancy rate.

After the province announced additional funding to meet demands, LTC operators found funding distribution to be problematic. LTC operators were not sure how the funding was allocated and distributed. Additionally, privately-owned sites were not included in wage levelling and did not qualify for pandemic pay despite filling the same role. Managers and leaders were not included in pandemic pay, and in some instances, managers were paid less than the people working under them.

Despite supplemental funding totalling 1.3 full time equivalent per full-time staff person in order to cover additional staffing demands, operators found it difficult to fill the extra hours due to staffing shortages (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 10th, 2021

Chile

In early March 2020, the National Service of Older People (Servicio Nacional del Adulto Mayor, SENAMA) led a public-private partnership that raised approximately $15 million for COVID-19 measures for publicly subsidized care homes. This funding was used to provide on-site technical support, PPE, to provide back up staff, to transfer residents with COVID-19 to isolation facilities, and for testing. In mid-June additional funding for this project made it possible to extend the support to “non-luxury” for-profit care homes (where the average fee per resident is lower than $USD 850). By mid-July 2020, this initiative was estimated to have reached 85% of the most vulnerable for-profit care homes (Sources: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

Last updated: September 10th, 2021

Denmark

Employers will be reimbursed for any sick pay they have had to pay out due to COVID-19, an employee’s illness, unavailability due to quarantine responsibilities, or if a person has had to stay at home because they or their relatives are in a risk group. This has been extended to July 31, 2021 (source: https://www.aeldresagen.dk/viden-og-raadgivning/penge-og-pension/arbejdsliv/gode-raad/corona-nye-regler-for-udvidet-sygedagpenge).

More funds have been given to municipalities as well as to the NGO’s to provide information and individual advice to debilitated older people, including those with dementia and their relatives, on how to deal with the consequences of COVID-19. Funds have also been allocated for telephone counselling which targets older isolated people (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 16th, 2021

Denmark

The National Association for Elderly Care has published information on the extension of sickness benefits and financial support for older people (Source: https://www.aeldresagen.dk/viden-og-raadgivning/penge-og-pension/arbejdsliv/gode-raad/corona-nye-regler-for-udvidet-sygedagpenge).

Last updated: September 10th, 2021

England (UK)

The action plan for social care, published on April 15 2020, confirmed the announcement in March of £2.9 billion of funding ‘to strengthen care for the vulnerable’. Of the £2.9 billion, £1.3 billion was earmarked for collaborative efforts between the NHS and local authorities, particularly to fund additional support following hospital discharge, and £1.6 billion of the funding was allocated to support local government with the provision of services, including adult social care. The Action Plan outlines that local authorities are expected to use the additional funding to ‘protect providers’ cash flow, monitor ongoing cost of care delivery, and ‘adjust fees to meet new costs’. It is anticipated that this funding covers the cost for additional personal protective equipment (PPE) required (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). Furthermore, the government suggests that the additional money provided could also be used for backfilling shifts as well as to maintain income for workers unable to work due to physical distancing measures as far as possible. This is intended to financially support workers who may have to stop working temporarily because they are unwell or self-isolating. Furthermore, the plan made a plea for donations to support social care workers who may experience financial difficulties, similar to the donations that NHS charities have received (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). A survey examining funding access found that only 30% of care home managers reported receiving a financial uplift at the time, with 73% stating that they needed more funding.

On May 15, 2020, a £600 million Infection Control Fund was introduced as part of a wider package of support for care homes to help providers reduce the rate of transmission in and between care homes and support wider workforce resilience (Source: https://www.gov.uk/government/news/care-home-support-package-backed-by-600-million-to-help-reduce-coronavirus-infections). The funding is being paid in 2 tranches. The first was paid to local authorities on May 22. The second tranche was paid in early July (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund/about-the-adult-social-care-infection-control-fund). This money has been allocated to Local Authorities and is in addition to the funding already provided to support the Adult Social Care sector during the COVID-19 pandemic. Local authorities are expected to pass 75% of the initial funding directly to care homes in their area for use on infection control measures, including to care homes with whom the local authority does not have existing contracts. The second payment will be contingent on the first being used for infection control. The remaining 25% must also be used for infection control measures, but local authorities are able to allocate this based on need (Source: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/885214/14_May_2020_-_MSC_letter_-_support_for_care_homes_1.pdf).

Local authority directors responsible for administering this new fund have expressed “deep concern” that it apparently cannot be used by homes to purchase PPE, requires detailed and prescriptive accounting and reporting, does not cover domiciliary care and supported living schemes, resulting in “a confused and overly bureaucratic system, which makes it difficult for providers to claim and impossible for local authorities to deliver within the required timescales” (Source: https://www.adass.org.uk/media/7909/200529-adass-letter-to-minister-of-state-re-infection-control-fund.pdf). An independent analysis commissioned by local authorities estimated that providers could face over £6bn in additional costs during April to September 2020, because of higher staffing costs (mainly due to cover staff who are ill or self-isolating), PPE, and extra cleaning and overhead costs (Source: https://www.local.gov.uk/lga-social-care-providers-face-more-ps6bn-extra-covid-19-costs).

On October 1, 2020, the Department of Health and Social Care (DHSC) announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, in particular by helping to reduce the need for staff movements between sites. Half will be paid on October 1, 2020, and the other in December 2020. Local authorities should pass on 80% of this to care homes on a per bed basis and CQC-regulated community care providers on a per user basis, both of which must be within the local geographical area. The other 20% should be used to support care providers, allocated at the discretion of the local authority. This allocation cannot be used to pay for the cost of purchasing extra PPE. Local authorities must write to DHSC by October 31, confirming they have put in place a winter plan, and that they are working with care providers in their area on business continuity plans (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2).

As recently as November 3, 2020, 75 care organisations called on the government to align the Carers Allowance with Universal Credit, as it is currently in Scotland, to recognise the disproportionate impact of the pandemic on carers (Source: https://www.disabilityrightsuk.org/news/2020/november/75-organisations-again-call-government-make-carer%E2%80%99s-allowance-fairer-carers; https://www.nuffieldtrust.org.uk/news-item/what-are-carers-entitled-to).

On December 23, 2020, DHSC announced £149 million to support the rollout of Lateral Flow Device (LFD) testing in care homes. This funding will be paid in January 2021. All funding must be used to support increased LFD testing in care settings. Local authorities should pass on 80% of this to care homes on a per bed basis, which must be within the local geographical area. The other 20% should be used to support care providers to implement increased LFD testing, allocated at the discretion of the local authority (Source: https://www.gov.uk/government/publications/adult-social-care-rapid-testing-fund/adult-social-care-rapid-testing-fund-guidance).

On January 13, 2021, NHS England (NHSE) announced that the amount that local vaccination services could claim for delivering COVID-19 vaccinations in care home settings was increasing from the original £12.58 Item of Service fee and an enhanced payment of £10. This has been increased so that first doses delivered in a care home setting from December 14, 2020, to close January 17, 2021, will carry an enhanced additional payment of £30, and doses delivered in the week beginning January 18 a payment of £20. The £10 will continue to apply for all COVID vaccinations in a care home setting between January 25 and 31, as well as for the second dose for all patients and staff who received their first dose on or before January 31. Primary Care Networks (PCNs) bringing in additional workforce between now and the end of January will be eligible to claim up to £950 per week (a maximum of £2500 per PCN grouping) (Source: https://www.england.nhs.uk/coronavirus/publication/covid-19-vaccination-in-older-adult-care-homes-the-next-stage/).

On January 17, 2021, DHSC announced the Workforce Capacity Fund, worth £120 million, which was to support local authorities in boosting staffing levels and deliver measures to supplement and strengthen adult social care staff capacity to ensure that safe and continuous care is achieved (Source: https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing). This funding is available until March 31. The first £84 million (70%) will be paid in early February and the second £36 million (30%) will be paid in March (Source: https://www.gov.uk/government/publications/workforce-capacity-fund-for-adult-social-care).

On March 12, 2021, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support (the Rapid Testing Fund, the Infection Control Fund, and the Workforce Capacity Fund) was crucial in enabling the social care sector to function throughout the pandemic, and is due to expire at the end of March (Source: https://www.nuffieldtrust.org.uk/news-item/social-care-reform-running-out-of-time-and-money).

On March 18, 2021, LaingBuisson reported that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund (Source: https://www.laingbuissonnews.com/care-markets-content/news/adult-social-care-to-receive-extra-funds/). On the same day, the National Care Forum reported that there were announcements around additional funding for hospital discharge (Source: https://www.nationalcareforum.org.uk/press-releases/ncf-response-to-341m-additional-funding-for-adult-social-care/).

Last updated: September 10th, 2021

France

An investment of €6bn was made in July 2020 to enable renovations and technology upgrades across the health and social care sectors (Source: https://www.lefigaro.fr/flash-eco/castex-annonce-6-milliards-d-euros-d-investissement-dans-le-systeme-de-sante-20200715). Additionally, €7.6bn was secured for an increase in base salary for workers in public hospitals and care homes of €182/month, and €160/month in private settings, as well as a revision of salary bands by Spring 2021, maximum hours for overtime, and investment in recruitment policies (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: September 10th, 2021

Germany

In March 2020, the government announced that care facilities will be reimbursed through the LTC Insurance system for additional costs (e.g. personal protective equipment) or loss of income due to the pandemic (Sources: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.htmlhttps://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf) .

The National Association of Statutory Health Insurance Funds further outlined possibilities to reimburse other people providing care for up to three months if the usual ambulatory or replacement care cannot be provided (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

The Federal Government has improved access to basic security provision (including costs for accommodation and heating) but also for lunch provision for children with relevant needs (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf). Care workers also received a one-off, tax-free COVID-19 payment. A study on LTC workers in different care settings showed that respondents highlighted the need for better pay, which could be achieved through tax exemptions. Respondents were critical of the pandemic bonus, saying they would prefer long-term improvement in pay, and some noted that the bonus should be extended to everyone working in care settings, not just care workers (Source: https://link.springer.com/article/10.1007/s00391-020-01801-7 ).

In addition, there has been criticism regarding the limited focus of COVID-19 social protection packages on people with disabilities (Source: https://www.vdk.de/deutschland/pages/presse/presse-statement/79041/behinderung_corona).

Last updated: September 10th, 2021

Germany

In March 2020, the government announced that care facilities will be reimbursed through the LTC insurance for additional costs (e.g. personal protective equipment) or loss of income due to the pandemic (Sources: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html; https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

The National Association of Statutory Health Insurance Funds further outlined possibilities to reimburse other people providing care for up to three months if the usual ambulatory or replacement care cannot be provided (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

The Federal Government has improved access to basic security provision including costs for accommodation and heating, but also for lunch provision for children with relevant needs. Care workers also received a one-off, tax-free COVID-19 payment (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

Last updated: September 10th, 2021

Hong Kong

Some NGOs have delivered ‘surgical masks and anti-epidemic packs’, emergency financial support, contingency supplies, and Chinese medicine treatments to people in need (Source: https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 10th, 2021

Ireland

In Ireland, financial support was given directly to care homes which were able to receive immediate temporary assistance payments to respond to a COVID-19 outbreak (Sources: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf; https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: September 10th, 2021

Israel

A summary of Israel’s fiscal policy response to COVID-19 is published on the IMF COVID Policy Response page. In Spring 2020, the Israeli government approved an 80 billion New Israeli Shekel (NIS) emergency package, with 11 billion set aside for health expenses, and 20 billion designated to the social safety net. The package has steadily increased since then. Over the year, approved measures have amounted to approximately 211 billion NIS. Additionally, 72 billion NIS are designated for measures planned for 2021. A translated summary of the Ministry of Finance’s COVID-19 Economic Plan has been published online.

Last updated: September 10th, 2021

Netherlands

Public authorities launched temporary compensation schemes to help nursing homes cover extraordinary expenses related to the pandemic (e.g. personal protective equipment) and compensate for loss of income (Source: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

Care professionals received a bonus of €1000 in 2020. In 2021 there will also be a bonus provided (Source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 10th, 2021

Norway

In May/June, nurses working in the municipalities (nursing homes and home nursing) and hospitals have been striking, demanding higher salaries. The Norwegian Nursing Association (representing a large majority of Norwegian nurses) has negotiated with the municipalities and hospitals (state) for increasing wages for several years. This spring, the conflict has been heightened because of the pressures nurses working in health and care services have experienced. The authorities have given extra grants to the municipalities to cover extra expenses. However, it is the individual municipality that decides how the funds will be used. Therefore, it varies whether and how much extra resources nursing homes have received (Source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 10th, 2021

Sweden

In total, the government has proposed 20 billion Swedish Krona (SEK) in 2020 for the municipalities’ and the regions’ additional costs as a result of COVID-19. The Government has proposed an increase in general government subsidies, 26 billion SEK by 2020. Of these, 5 billion SEK was announced before the outbreak of COVIDD-19. The additional amounts totalling 21 billion SEK for 2020 have been made to strengthen the municipal sector’s ability to maintain socially important functions, such as schools and care. The proposals have been adopted by the Riksdag (the national legislature) (Source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 10th, 2021

3.05. Long-Term Care oversight and regulation functions during the pandemic

Australia

The Australian Government’s Aged Care Quality and Safety Commission is responsible for providing COVID-19 information and recommendations to aged care providers and facilities. However, state and territory health agencies also have the ability to implement policies in the aged care sector. With both the federal, state, and territorial governments having some oversight over aged care providers, there is a fragmentation of power leading to ineffective and often confusing protocols (Source https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

Last updated: September 10th, 2021

Canada (British Columbia)

Health authority owned LTC facilities were found to have had better oversight, management, and support during the pandemic. Provincial health officer orders could be interpreted differently in each health authority, for example leading to different visitor guidelines/policies. The ministry established a clinical reference group as part of the Health Emergency Management British Columbia (HEMBC) to develop clinical policy responses to COVID-19. However, it is unclear how the HEMBC differs from the Provincial Health Services Authority (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 10th, 2021

Denmark

On May 12, 2020, an extensive publication providing new guidelines on how to organize visits in nursing homes was published by the Board of Health. From the introduction, it was made clear that the Board of Health did not have the authority over who could visit, as this was the responsibility of the Board for Patient Safety, and thus underlining the general confusion over which authority was in charge (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 10th, 2021

England (UK)

The Coronavirus Act (March 25 and renewed on September 30, 2020) included provision to relax the responsibilities of local authorities under the Care Act 2014 to streamline their services in case of workforce shortages or increased demand. The Act also enabled rapid discharge of patients from hospital by allowing assessments to be delayed (Sources: https://www.legislation.gov.uk/ukpga/2020/7/contents/enacted; https://www.health.org.uk/publications/reports/adult-social-care-and-covid-19-assessing-the-policy-response-in-england). There was concern that the Care Act Easements included in the Coronavirus Act would be widely used to reduce care packages but only a small number of councils utilised them (Source: https://www.communitycare.co.uk/2020/04/30/eight-councils-triggered-care-act-duty-moratorium-month-since-emergency-law-came-force/). As of November 2020, the CQC reported that no local authorities were currently using Care Act Easements (Source: https://www.cqc.org.uk/guidance-providers/adult-social-care/care-act-easements-it).

The Care Quality Commission interrupted routine inspections on March 16, 2020 (Source: https://www.cqc.org.uk/news/stories/routine-inspections-suspended-response-coronavirus-outbreak). In May 2020, the CQC began to implement an Emergency Support Framework setting out its approach to regulation during COVID-19 (Source: https://www.cqc.org.uk/news/stories/joint-statement-our-regulatory-approach-during-coronavirus-pandemic). This involved suspending routine inspections of services and instead using and sharing information to target support where it’s needed and taking action to keep people safe and protect their human rights. CQC are now starting to resume some inspections in 300 random homes in relation to management of the pandemic, examining four key areas; safe care and treatment; staffing arrangements; protection from abuse; assurance processes monitoring and risk management (Source: https://whiteleyvillage.org.uk/whiteleys-covid-19-response-effective-in-all-key-areas-says-cqc/). Much will be conducted remotely and in person inspections will take place under exceptional circumstances only.

Last updated: September 10th, 2021

Germany

LTC quality checks and necessary patient to staff ratios were temporarily suspended. Regular quality checks will not be undertaken until at least until February 28, 2021. Quality checks were only undertaken if there was reason to suspect that quality of care was not maintained (Source: https://www.pflegeberatung.de/corona).

In March 2020, the German Government allowed care providers to divert from contractual obligations around staffing to avoid gaps. LTC insurance was also given some freedom to avoid gaps in domiciliary care (Source: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html).

Last updated: September 10th, 2021

Israel

Regulation guidelines in LTCFs during COVID-19 that overrode regular protocols were issued by the national taskforce, The Shield of the Fathers and Mothers. Three of the major policy measures that had particularly important impacts were: the increased testing in LTCFs; the re-evaluation of family visitation policies; and the opening of specialized COVID-19 wards within LTCFs (to reduce the burden on general hospitals and stop the spread of infection from LTCFs to local communities). A study has been published outlining the adaptation and level of success.

Last updated: September 10th, 2021

Israel

Oversight of the COVID-19 response has been given to the Ministry of Health, which set up the National Coronavirus Information and Knowledge Centre alongside the armed force’s (IDF) Intelligence Directorate (Source: https://www.gov.il/en/departments/topics/corona-main-sub).

Oversight of the extension of welfare benefits is in the hands of the National Insurance Institute (Source: https://www.btl.gov.il/English%20Homepage/Benefits/LongTerm%20Care/Pages/default.aspx).

Last updated: September 10th, 2021

Japan

New legislation has been brought in nationally to manage the pandemic, but when it was released, LTCFs had already responded using well-established infection control protocols (Source: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 10th, 2021

Republic of Korea

Nationwide monitoring and inspection of LTC hospitals was conducted to ensure the ‘exclusion’ of workers with a recent travel history to affected regions or countries, or those with symptoms.

Last updated: September 10th, 2021

Spain

There has been little oversight, at most reviews of written documents, which care home managers have found to be very onerous (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 10th, 2021

Sweden

The responsibility to restrict the spread of any disease in care homes and other forms of social care services rests with the municipalities together with the regional infection control units (Smittskydd). During the entire pandemic, this local/regional responsibility has been stressed by the Public Health Agency and the National Board of Health and Welfare. The latter has mainly acted by providing recommendations and check-lists, and by presenting good examples. In April 2020 the Government appointed the Health and Social Care Inspectorate (IVO) to conduct a large-scale inspection in care homes and other care units for older and disabled people to investigate the consequences of COVID-19 for quality and safety in the care services (Source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf). The regions are responsible for COVID-19 testing conducted under the Health and Medical Services Act and the Communicable Diseases Act. Under the Work Environment Act the regions also have responsibility for the health and safety of their own staff (Source: https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

Last updated: September 10th, 2021

3.06. Support for care sector staff and measures to ensure workforce availability 

Overview

Overall, in many countries at the beginning of the crisis, the long-term care sector faced shortages in personal protective equipment and tests to adequately protect employees, whilst shortages of workers worsened during the crisis, as infected carers or carers at risk of having been infected had to quarantine and were unavailable to perform their job (Source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).  Rates of sick leave have increased in many of the countries who reported during the COVID-19 pandemic (Finland, Australia, Denmark, Sweden). To meet care needs, several countries expanded recruitment either by recruiting students (Australia – although tricky – given lack of training, Netherlands), retirees (Netherlands), non-traditional sources – flight attendants, restaurant workers (Sweden), voluntary sector (S.Korea, Israel), increasing support to family carers who were already very involved (S.Korea), redeploying staff from low infection areas to high infection areas (S.Korea) and turning to newcomers with qualifications  waiting to be admitted (Germany, Turkey). To manage infections some countries started to limit the number of places care workers could work (Canada),  request that staff remain onsite of LTCFs for prolonged periods (S.Korea, Turkey) or assigned patient groups to care workers (Denmark). Several countries implemented WHO recommendations to routinely or systematically test and trace staff (Denmark, Germany, S.Korea). Another measure to promote infection prevention and control (IPC) measures, involved rolling out national training programmes on hygiene (Sweden, Netherlands, Canada) and implement guidance on how to notify system of symptoms, what to do and where to get tested (Denmark).

 

Several countries have already rolled out national commissions to assess infection control capabilities (Sweden, Germany), especially considering that most countries were delayed in securing personal protective equipment to this sector and stocks proved to be limited. Provisions for quarantine for care workers who did not want to quarantine with family were provided in Germany and S.Korea.

Denmark and Sweden added the reporting of COVID-19 infections to the list of workplace injuries to better monitor the situation (Denmark, Sweden). Several countries where Ministries of Health did not previously have oversight over the care sector increased their oversight to better document and understand who is working in LTC and where they are working (Canada). Several countries rolled out support services for their care staff. Provisions for childcare prioritized for LTC staff were provided in Denmark, Finland, and Germany. Food services were provided to staff in Germany and Finland. Several countries also re-evaluated wages which are notoriously low in this sector by topping up salaries with one time or intermittent bonuses or generally increased (Germany, Finland and Canada).

Australia

In April 2020, the Australian government announced the use of an online platform, Mable, which recruits workers in nursing, allied health, personal care, domestic assistance, and social support service. While Mable generates additional staff in the event of staffing shortages, concerns were raised about the inexperience of surge staff and their ability to provide adequate care. International students were allowed to work for up to 40 hours. The maximum number of hours worked was increased in order to better supply the health care workforce (Sources: https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf; https://www.health.gov.au/ministers/senator-the-hon-richard-colbeck/media/contingency-measures-to-ensure-continuity-of-aged-care-during-covid-19).

Last updated: September 10th, 2021

Austria

Austria implemented measures that required its hospitals to offer support to care homes in the form of personnel, expertise, and equipment (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

In Austria almost 33,000 people with LTC needs receive support from 66,000 ‘personal’ migrant live-in carers. Closed borders at the beginning of the pandemic posed challenges. Two provinces charted flights to bring live-in carers from Eastern European countries back to Austria. Carers were quarantined for two weeks (without income and having to contribute to accommodation). Carers who decided to stay were offered a €500 bonus. A hotline helped to coordinate 24-hour care. Considerable efforts were made to maintain the live-in model. Care workers experienced challenges with complex paperwork (Source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

A panel survey of over 20,000 Austrian employees conducted in May 2020 found that 46% of care professionals reported their job to be ‘mentally stressful’, while this was only the case for 11% in other jobs. In addition, only 38% of carer workers think they will reach pension age in their sector (versus 61% of other professions). During the pandemic, one third of care workers reported ‘stress due to time pressure and changing labour processes’ (Source: https://ltccovid.org/2020/11/27/the-second-wave-has-hit-austria-harder-also-in-care-homes/).

Last updated: September 10th, 2021

Austria

Austria implemented measures that required its hospitals to offer support to care homes in the form of personnel, expertise, and equipment (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 10th, 2021

Canada (British Columbia)

A single site order was introduced on March 25, 2020, meaning that workers in British Columbia’s LTC and assisted-living facilities were limited to working in a single facility. On March 26, 2020, LTC operators were asked to provide personal and employment information, including name, contact information, and Social Insurance Numbers for all staff to the ministry to support decisions about the allocation of staff among facilities. On April 10, 2020, all employees within the scope of the Single Site Order would receive a common hourly wage regardless of their facility and employer. On April 15, 2020, Regional Health Boards were ordered to establish a working group to make recommendations to their Medical Health Officer about the assignment of staff because staffing shortages became a bigger issue following the Single Site Order (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 10th, 2021

Denmark

There is ongoing work to try to collect statistics on the number of nursing home staff infected with COVID-19. In the meantime, the number of care staff reporting the disease as a work-related injury gives an indication of the situation. On April 24, 2020, a new guideline was published that underlined that COVID-19 would be regarded as a work-related injury if the person had been exposed to the disease and was tested positive. This gives the person an entitlement to claim for workers’ compensation. As of May 21, 242 people had reported COVID-19 as a work-related injury, and of these 42 people were employed in a nursing home. The majority of all cases relate specifically to the disease, while 9% relate to skin diseases caused by wearing Personal Protection Equipment (PPE) (Source: https://www.aes.dk/da/Temaer/COVID-19.aspx).

Regarding measures to increase or maintain the availability of health workers, emergency child care facilities are provided (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 10th, 2021

England (UK)

The social care action plan recognised the urgent need to increase the social care workforce during the pandemic ‘to cover for those who are not in work, and to relieve the pressure on those that are’. The action plan included an ‘ambition’ to attract 20,000 people into social care over 3 months (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-adult-social-care-action-plan) .

On March 19, 2020, Social care staff were designated as ‘key workers’ to enable them to continue to access childcare once schools were closed (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-maintaining-educational-provision/guidance-for-schools-colleges-and-local-authorities-on-maintaining-educational-provision).

The Infection Control Fund aims to ensure that all care workers isolating in line with guidance continue to receive their full wages and face no loss of income (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2/adult-social-care-infection-control-fund-round-2-guidance). Beyond this however, no specific financial support has been offered to social care workers.

On 6 May 2020, the Government launched a dedicated CARE app to support the social care workforce during COVID-19, offering access to guidance, learning resources, discounts, and other support all in one place (Source: https://www.gov.uk/government/news/dedicated-app-for-social-care-workers-launched).

On May 11, 2020, the Department of Health and Social Care (DHSC) published guidance on maintaining the health and wellbeing of the adult social care workforce. This placed the responsibility on employers to check in on team members regularly, especially those who are working remotely. It stated that employers should encourage teams to create a wellness action plan so that employees can identify how to address what keeps individuals mentally well at work. This additionally suggested that employers should encourage those who are identified as being extremely clinically vulnerable to stay at home. Where this is not possible, they should be supported to work in roles or settings that have been assessed as lower risk. Emergency funding from the adult social care winter plan can be used to cover the cost of maintaining income for social care staff that are currently unable to work because of self-isolation measures.

On 15 May 2020, the Government announced a new wellbeing package for social care staff delivered through the CARE app including two new helplines, led by the Samaritans and Hospice UK. This is intended to help support care staff with their mental health and wellbeing and support those who have experienced a traumatic death as part of their work or help with anxiety and stress (Source: https://www.gov.uk/government/news/care-home-support-package-backed-by-600-million-to-help-reduce-coronavirus-infections#history).

On October 1, 2020, DHSC announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, in particular by helping to reduce the need for staff movements between sites. This includes ensuring that staff who are isolating in line with government guidance receive their normal wages, limiting all staff movement between settings unless necessary, limiting the number of different people from a home care agency visiting a particular individual, limiting or cohorting staff, supporting active recruitment of additional staff, and providing accommodation for staff who proactively choose to stay separate from their families (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2).

On January 17, 2021, DHSC announced a £120 million Workforce Capacity Fund to help local authorities to boost staffing levels (Source: https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing). The aim of this is to strengthen social care staff capacity so that safe and continuous care is achieved by all providers of adult social care. This additionally stated that providers should not be deploying people in care homes if these people are being deployed to provide care in other settings, unless in exceptional circumstances. This places the responsibility on Local authorities for contacting private providers with excess capacity to redeploy these staff into other settings to best meet workforce demand. This fund can be used to pay overtime rates to encourage staff to work additional shifts, cover childcare costs to allow staff to take on hours they would usually be unable to work, and enable care providers to overstaff at pinch points to lessen the impact of any staff absences should they arise. Additionally, Local Authorities are responsible for considering whether there are trained individuals who have been made redundant from care providers which have exited the market and so would be able to transition quickly into a new care setting. There may be individuals without care experience who have recently been made redundant and may require support applying to the care sector and training (Source: https://www.gov.uk/government/publications/workforce-capacity-fund-for-adult-social-care).

On February 9, DHSC announced that the government was asking people to register their interest in taking up short-term paid work in the adult social care sector to meet urgent demand during winter (Source: https://www.gov.uk/guidance/short-term-paid-work-in-adult-social-care).

On March 3, DHSC published guidance on restricting workforce movement between care settings. This stated that staffing requirements should be planned so that routine movement is not required to maintain safe staffing levels, with mitigations such as exclusivity contracts and block booking used to minimise staff movement where temporary staff are needed. Additionally, should a provider need to deploy an individual between two settings, they should ensure a 10-day interval between the individual attending the two settings. The individual must have a PCR negative test in the 7 days before starting the placement. Additionally, this states that providers should cohort staff to induvial groups of residents and ensure staff movement is limited between these groups. Providers should take steps to limit the use of public transport by staff and discourage lift sharing arrangements (Source: https://www.gov.uk/government/publications/restricting-workforce-movement-between-care-homes-and-other-care-settings).

Last updated: September 10th, 2021

Finland

In Finland, retired staff and students that do not fall into high risk groups have been recruited to maintain staffing levels (Source: https://www.lse.ac.uk/lse-health/assets/documents/eurohealth/issues/eurohealth-v26n2.pdf).

Last updated: September 10th, 2021

France

High levels of staff sickness were experienced, and as a result, various platforms for redeployment of staff were put in place. Regional platforms put in place by the regional authorities (ARS) were largely more successful than the national platform, which only reached 62 care homes (Sources: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf; https://renfortrh.solidarites-sante.gouv.fr/).

A grant was announced in October to award a bonus to all social care staff, both in care homes and domiciliary care (Source: https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/vote-unanime-a-l-assemblee-nationale-sur-l-amendement-bourguignon). Those care home staff in the 40 most affected departments (sub-regions) received a bonus of €1,500, and €1,000 in the other departments, and a €1,000 pro rata bonus for domiciliary care workers. Salary bands are to be re-evaluated by April 2021 and the entry level salary will be increased by €180/month in the public and not-for-profit sector and €160/month in the private sector (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). In April 2021, the Ministry for Health and Solidarities announced that pay scales for domiciliary care workers and domiciliary care nurses would be revalued and increased by 13 to 15%, effective from October 2021 (Source: https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/avenant-43-vers-une-hausse-historique-des-salaires-des-aides-a-domicile#:~:text=Avec%20l’agr%C3%A9ment%20que%20le,services%20de%20soins%20infirmiers%20%C3%A0). This represents an annual investment of €200 million per year allocated to regional authorities. For ‘category A’ workers with 1 year of experience, this would represent a monthly increase of €33.5 from €1539 per month to €1573. For ‘category A’ workers with 10 years of experience, this would represent a monthly increase of €227 per month from €1539 per month to €1749 per month. The increases are even more significant for those holding a qualification.

More recently, the government has used ‘Intermediary Associations’ that are responsible for the reintegration of vulnerable people (out of work), to support social care workers, including in infection control and food preparation etc (Source: https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/crise-covid-19-le-gouvernement-soutient-les-associations-intermediaires-en).

Last updated: September 10th, 2021

France

High levels of staff sickness were experienced, and as a result, various platforms for the redeployment of staff were put in place. Regional platforms put in place by the regional authorities (ARS) were largely more successful than the national platform, which only reached 62 care homes (Sources: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf; https://renfortrh.solidarites-sante.gouv.fr/).

A grant was announced in October to award a bonus to all social care staff, both in care homes and domiciliary care (Source: https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/vote-unanime-a-l-assemblee-nationale-sur-l-amendement-bourguignon). Those care home staff in the 40 most affected departments (sub-regions) received a bonus of €1,500, and €1,000 in the other departments, and a €1,000 pro rata bonus for domiciliary care workers. Salary bands are to be re-evaluated by April 2021, and the entry level salary will be increased by €180/month in the public and not-for-profit sector and €160/month in the private sector (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

More recently, the government has used ‘Intermediary Associations’ that are responsible for the reintegration of vulnerable people (out of work), to support social care workers, including in infection control and food preparation (Source: https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/crise-covid-19-le-gouvernement-soutient-les-associations-intermediaires-en).

Last updated: September 10th, 2021

Germany

In January 2019, the care strengthening bill was enacted which means that there is active encouragement to increase the care workforce (Source: https://www.bundesgesundheitsministerium.de/sofortprogramm-pflege.html). This bill was developed in 2018 (Source: https://www.vdek.com/politik/gesetze/wahlperiode_19.html#ppsg). This does not solve the problem that there are not enough people available and willing to work in LTC.

In April 2020, the German government announced a stepwise increase of the minimum wage for care workers as well as additional paid leave. In addition, care workers in Germany received a one-off ‘pandemic-bonus’ of up to €1,000 as part of their July 2020 pay. In some states the bonus was topped-up to €1,500 (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf). In February 2021 the Federal Minister of Health announced a planned bonus for hospital staff. There are demands to also provide a bonus to LTC workers (Sources: https://www.aerztezeitung.de/Politik/Spahn-plant-weitere-Corona-Praemie-fuer-Klinikmitarbeiter-416931.html; https://www.aerzteblatt.de/nachrichten/121022/Deutscher-Pflegerat-will-Coronapraemie-fuer-alle-Pflegekraefte).

While children of staff working in system relevant jobs (including health and LTC) can access emergency childcare, there have been demands to expand available childcare services to reflect the demands on care workers (Source: https://www.presseportal.de/pm/17920/4816116; https://km-bw.de/,Lde/Startseite/Service/2020+04+20+Notbetreuung+wird+vom+27_+April+2020+an+erweitert).

In Bavaria, the cost of catering for staff in health and LTC settings are financially supported (€6.50 per member of staff per day) as a sign of appreciation (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

Following the national testing strategy, care workers should have access to regular testing. Rules vary between federal states, but LTC staff working in residential or domiciliary care settings should be tested regularly (Source: https://www.biva.de/besuchseinschraenkungen-in-alten-und-pflegeheimen-wegen-corona/#bw).

Earlier in the pandemic, the ‘care reserve’ initiative developed across federal states and separately in some federal states allowed people with a qualification to register. This provided an opportunity to recruit staff if there was a shortage due to infection. There have also been movements in some federal states to prioritise care-related professions when applying for permission to work in Germany and to financially incentivise training to become a care assistant (Pflegeassistenz) (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

Germany relaxed some staffing rules and operational frameworks to relieve pressure on the workforce (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 10th, 2021

Hong Kong

A survey by the Hong Kong Social Workers and Employment Union in February 2020 showed that about 10% of care workers had to take unpaid leave or experienced pay deductions. The Social Welfare Department responded with a number of measures. These measures included a special allowance for workforce support. This means that subsidised residential and domiciliary care services receive a ‘one-off special allowance for workforce support’ and to ‘maintain daily operations in the event of COVID-19 related staff absences. Costs for this measure were about 130 million Hong Kong Dollars (HKD). In addition, social care providers have received a special allowance to pay the staff in 745 subsidised homes an additional 10% of their monthly salary (capped at 4,000 HKD) for at least 4 months. The additional salary was reserved for staff working during the epidemic. The cost of this measure amounts to approximately 208 million HKD (Source: https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 10th, 2021

Ireland

The Health Information and Quality Authority provided a ‘Regulatory Assessment Framework of the preparedness of designated centres for older people for a COVID-19 outbreak’ in mid-April 2020. This framework was supposed to help care settings to prepare for a potential COVID-19 outbreak and to develop contingency plans. In Ireland, an agreement was put in place that enabled the Health Services Executive (HSE) to redeploy HSE staff to private nursing homes on a voluntary basis. (Source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Ireland launched recruitment campaigns to attract newcomers and former staff to the sector. Efforts were made to reduce staff working across different care settings. The HSE could support staff with alternative accommodation and transport to facilitate this (Source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: September 10th, 2021

Ireland

An agreement was put in place that enabled the Health Services Executive (HSE) to redeploy HSE staff to private nursing homes on a voluntary basis (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Recruitment campaigns to attract newcomers and former staff to the sector were launched (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 10th, 2021

Israel

Reports of increased volunteerism to assist NGOs and care sector staff are available, although there’s limited information on formalised processes (Source: https://www.haaretz.com/israel-news/.premium-unemployment-is-surging-ngos-are-collapsing-so-israelis-volunteer-to-turn-the-tide-1.9168388).

In Israel, the Ministry of Health made special teams available for periods of 7 to 14 days to support residential care settings that were acutely short staffed, and a 24 hour call centre was established to support LTC facility managers with medical and management advice (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 10th, 2021

Netherlands

On March 16, 2020, the Dutch Youth and Health Care Inspectorate allowed nursing home managers to recruit personnel beyond their traditional pool of employees, enabling them to hire personnel such as medical students (Source: https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf). Several initiatives have been set up to increase the number of staff working in stretched LTC settings, including an IT platform “Extra Hands for Healthcare” to match existing healthcare staff with employers. This included a campaign to recruit healthcare personnel that had left the sector or retired (called “Duty calls”), and a rapid training scheme for those with no previous healthcare training (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 10th, 2021

Republic of Korea

There have been steps taken to address worker shortages by seeking volunteers and paying family carers (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Care workers who were considered to have been in close contact with cases were quarantined at home, whilst those who continued to work were temporally housed in a hotel, or voluntarily moved into the LTC facility. In some facilities a quarantine was upheld for 14 days during which nurses and nurse assistants voluntarily agreed to be quarantined in the LTC facility to continue resident care.

To overcome shortages in areas with high outbreaks, healthcare workers were directed to sites with large clusters of infections, for example, an additional 2,400 health workers were recruited in Daegu alone (Source: https://ourworldindata.org/covid-exemplar-south-korea).

The Korean government does not appear to have offered a relief plan for workers who do not have employment insurance. They comprise 6.8 million people, and more than half are women, and allegedly many care workers belong to this group (Source: https://www.opensocietyfoundations.org/voices/care-workers-deserve-credit-for-south-koreas-covid-19-response).

 

Last updated: September 10th, 2021

Singapore

Singapore recognised the limitations of their lean workforce in residential LTC and the need to protect it. ‘The implementation of split zones and full contact precautions’ protected facilities from acute staff shortages.

To ensure the functioning of split zones, housing was organised for LTC workers who shared accommodation with staff assigned to different zones, workers in different (health and LTC) care settings, or in dormitories that did not allow for safe distancing. Many care workers working in nursing homes lived in hotels and serviced apartments, others lived on-site (adhering to split zone arrangements) between April 7 and June 1, 2020, during the Circuit Break period. The government paid for meal delivery and dedicated transportation between home and work. Health and LTC workers that were moved into temporary accommodations received $500 to facilitate the transition.

In addition to public recognition, the workforces received care packages and message of support from care facilities and could access ‘professional counselling and emotional support services’. (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 10th, 2021

Slovenia

In Slovenia, medical teams were deployed to a residential care setting if the regular staff became exhausted or overwhelmed (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 10th, 2021

Spain

In Spain care workers without the required training certificates could be legally employed (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 10th, 2021

Sweden

Staff shortages due to employees being on sick leave or in self-isolation led to a high use of casual workers, with little or no formal training.  Due to large numbers of temporary care staff with limited or no training in the sector, the government initiated a training program for 10,000 such workers. The state covers the expenses for the municipalities and the workers keep their ordinary pay while in training. To be eligible for the state subsidy, the municipalities have to offer a permanent position to workers who successfully have finished the course. In March 2020, the government abolished the requirement for a medical certificate when on sick leave for the first 14 days. In some municipalities, e.g. in Stockholm, flight attendants, restaurant staff, and other occupational groups who became unemployed due to the pandemic were quickly retrained as care assistants to help in municipal LTC and healthcare services (Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

The Government tasked the National Board of Health and Welfare with conducting an information initiative geared towards social services and municipal healthcare staff with the aim of reducing the spread of infection (Source: https://www.government.se/legal-documents/2020/10/dir.-202074/). The Corona Commission points out that an opportunity has been created for people who contracted COVID-19 when working in or being trained in healthcare facilities or in other handling of an infectious person to receive payments from work-related injury insurance (Source: https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

Last updated: September 10th, 2021

3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, training and implementation support

Overview

Care home design and Infection Prevention and Control:

Emerging evidence suggests that the characteristics of care homes play an important role on the ability to implement guidance on, for example, isolation and cohorting.

There are emerging arguments about the need to consider quality of life together with infection control in architectural design models of nursing homes (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603995/; https://link.springer.com/article/10.1007/s41999-020-00362-7; https://link.springer.com/article/10.1007/s12603-020-1447-8).

A retrospective cohort study of nursing home residents in Ontario found a correlation between nursing home crowding (i.e. bedrooms shared between 2-4 residents) and Covid-19 infection and mortality. The study developed a crowding index equalling the mean number of residents sharing bedrooms and bathrooms (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2772335). Larger nursing homes more likely to have outbreaks than smaller (among other factors) in a US study (https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.16661).

Australia

The Australian government provided over $1.5 billion to the aged care sector for COVID-19 support, a portion of which were to be used for IPC training. However, the Royal Commission into Aged Care Quality and Safety found that high-level infection control expertise was still lacking in the aged care sector and further systematic training is required. Additionally, they found that, while the Aged Care Quality and Safety Commission issued infection control self-assessment checklists, they did not conduct comprehensive on-site visits (https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 9th, 2021

Austria

In Austria responsibility for the development of guidance in LTC settings, their implementation and monitoring has been given to newly established national task forces (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 9th, 2021

Canada (British Columbia)

At the beginning of the pandemic, LTC providers did not feel confident with IPC and emergency management practices and felt unaware of emergency support resources that could be used such as IPC specialists and staffing support. Providers did not receive regular training and education on IPC, emergency management, and how to use PPE. When guidance about PPE was given, they were inconsistent and unclear. There was also a lack of guidance for community care providers and for residents with advanced dementia or behaviour and aggression challenges, who generally do not understand or comply with social distancing requirements.

These concerns have since been addressed by the BC Centre for Disease Control releasing frequently updated IPC guidelines for LTC facilities and assisted living (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf;  http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_HomeCommunityCareIPCGuidance.pdf; http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/long-term-care-facilities-assisted-living).

Last updated: September 9th, 2021

Chile

Guidance for care homes on use of PPE, cleaning and disinfection, implementation of isolation areas and clean areas for staff, and actions to manage and mitigate suspected and confirmed COVID-19 cases was issued by the Ministry of Health (MoH), the National Service for Older People (Servicio Nacional de Personas Mayores, SENAMA) and the Chilean Geriatrics and Gerontology Society (SGGCh). Additionally, the SENAMA supported care homes with face-to-face technical support, supplies of PPE, staff replacement, testing and transfer of residents with COVID to isolation facilities. A survey of care homes staff showed that, in July 2020, the majority of managers had a high degree of knowledge of COVID-19 prevention and control and reported high degrees of agreement and support for the measures. Around 20% of managers reported PPE shortages, but there were reports of improvement in availability PPE over time. Half of all managers reported that the infrastructure of the homes was inadequate to implement measures, and lack of trained staff, support for staff and trust were identified as other barriers to the implementation of Infection Prevention and Control measures (https://journal.ilpnetwork.org/articles/10.31389/jltc.72/).

Last updated: September 9th, 2021

Denmark

There is a dedicated page on Danish Health Authority website on how to manage COVID-19 among older populations on the Danish Health Authority website. These are updated on a bi-weekly basis, or more frequently, if needed. On May 12th an extensive publication providing new guidelines on how to organize visits in nursing homes was published by the Board of Health.

Last updated: September 9th, 2021

England (UK)

Guidance for home care providers was provided relatively late in the pandemic. On April 27, 2020, Public Health England issued guidance on PPE use for care workers providing domiciliary care. In addition to hand hygiene, respiratory hygiene, and avoiding touching their face, care workers should also follow standard infection prevention and control precautions (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881296/Domiciliary_care_guidance_final.pdf).

The Government published wider guidance for domiciliary care providers on May 22, 2020, much later than equivalent guidance for other long-term care settings was issued (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-home-care/coronavirus-covid-19-provision-of-home-care). This covered PPE, shielding of clinically vulnerable people, hospital discharge, and government and local authority support. The guidance has continued to be updated, including advice for providers to divide the people they care for into ‘care groups’ and allocate teams of staff to provide care specifically to those care groups (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-home-care/coronavirus-covid-19-provision-of-home-care#shielding-and-care-groups).

The government issued guidance for unpaid carers, which recommends carers to develop an emergency plan with the person they care for in case the carer becomes unable to continue to provide support, to follow hygiene rules, to maintain their own health, and advice on how to react in case the person with care needs or the carer themselves develop symptoms of COVID-19 (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-unpaid-care/guidance-for-those-who-provide-unpaid-care-to-friends-or-family).

Guidance for unpaid carers of adults with learning disabilities and autistic adults is very similar to the general advice for unpaid care (published on April 24,2020). There are, however, specific points raised around communication and coping with bereavement (https://www.gov.uk/government/publications/covid-19-providing-unpaid-care-to-adults-with-learning-disabilities-and-autistic-adults).

As of December 2020, government guidance for care staff supporting adults with intellectual disabilities and autistic adults (https://www.gov.uk/government/publications/covid-19-supporting-adults-with-learning-disabilities-and-autistic-adults/coronavirus-covid-19-guidance-for-care-staff-supporting-adults-with-learning-disabilities-and-autistic-adults)was last updated on November 5, 2020, which links to a range of other relevant guidance and resources. This includes more detailed guidance from the Social Care Institute for Excellence on supporting autistic people and people with intellectual disabilities, including guidance for social workers and occupational therapists, guidance for care staff, and guidance for carers and family (https://www.scie.org.uk/care-providers/coronavirus-covid-19/learning-disabilities-autism).

Government guidance has not always been accompanied by accessible versions for people with intellectual disabilities, autistic people, and family members, and several NGOs (including some financially supported by the government for this purpose) have been producing easy-read and other accessible information, resources and guidance (https://www.learningdisabilityengland.org.uk/what-we-do/keeping-informed-and-in-touch-during-coronavirus/information-and-guidance/).

 

Last updated: September 9th, 2021

Finland

Guidance specific to LTC units and home care was relatively timely, with specific guidelines/mandates released in March and supplemented in April and May. Most of the municipalities have acted quickly to prevent the spread of the virus and followed the given instructions. Many municipalities have also introduced additional measures on their own initiative to address regional variations in the spread of the virus.  They can be seen summarized in a table on Page 9 of this report.

In 5.6 of LTC Covid Report for Finland (page 14) there is a summary of measures/dealings with people living with dementia.

Last updated: September 9th, 2021

France

Guidance specific to social care was much delayed compared to the health care sector, for example guidance on 20th Feb includes no reference to care homes at all. As a result, 9 large stakeholders wrote to the government and media on 9th March decrying the need for guidance for care homes. No guidance was published for domiciliary care until 2nd April (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). Guidance since the second wave has been more targeted to specific groups e.g. people with disabilities (https://www.cnsa.fr/documentation/covid-19_-_developpement_des_mesures_dhygiene_au_sein_des_essms.pdf), and require LTCFs to have protocols for infection control (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf).

Guidance has also been developed for infection control among specific groups, such as people with disabilities (https://solidarites-sante.gouv.fr/IMG/pdf/covid_protocole_ph.pdf) and some specific guidance has been published to support older people and protect carers (https://solidarites-sante.gouv.fr/IMG/pdf/plan_protection-personnes_agees_a_domicile-covid-19_1_.pdf ).

 

Last updated: September 9th, 2021

Germany

Residential care

The RKI provides guidance on infection prevention and control in residential settings. These guidance documents have been regularly updated throughout the pandemic reflecting improved knowledge around virus transmission (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile ; https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Altenpflegeheime.html).

For domiciliary care only a short notice has been issued.

Domiciliary care

A working group of the German Society of Nursing Science have developed a guideline on domiciliary care during the pandemic which also discusses some of the challenges around infection prevention and control guidance but also making suggestions of how these can be overcome.

Among the barriers identified to effective infection prevention and control in domiciliary care the expert group has identified that home care service providers are not being reimbursed for tasks that are not part of the long-term care insurance scheme. This means that for instance communication and coordination between different service providers or patient, family and carer education are not covered under the reimbursement agreements with the LTC insurance, even though these services could be particularly useful in a pandemic situation.

The document also highlights that domiciliary carers are guests in the home of the person with care needs and that any measures undertaken for infection prevention and control that affect the person with care needs and other people living in the household need to be agreed with them (e.g. isolating a person with COVID-19 in the home). Domiciliary care workers can advise and inform, however, implementing requires the consent of the residents. A domiciliary carer is entitled to protect themselves. The guidance emphasises the importance of consensus between clients and the domiciliary carers.

Suggestions provided in the document include: the development of pandemic plan that centers around the dignity of the person with care needs; the development of a continuity plan should domiciliary care have to stop; domiciliary care workers to receive training on measures for infection prevention; people with care needs to have a say on treatment and care should they develop a COVID-19 infection; infection control measures in the case of a COVID-19 infection; adherence to infection prevention protocols and guidance; adjusting of communication for people with visual, hearing and cognitive impairments; supporting the person with care needs in maintaining social contacts; enabling the person with care needs to maintain and promote mobility; support with nutrition; providing relevant information on pandemic measures to people with care needs and their family carers; in case of a COVID-19 infection there should be regular contact between domiciliary carers and the GP of the person with care needs; domiciliary carers should be able to recognise signs of maltreatment, neglect and abuse and where necessary take steps to protect the person with care needs.

Day care

Day care and night care services were generally closed during the first phase of the pandemic. The states allowed these services to reopen in autumn in generally, given they had infection control measures in place. Depending on incidence rates, a reduction of the maximum number of users was mandated.

Last updated: September 9th, 2021

Hong Kong

Early on in the pandemic care home resident were advised not to leave their rooms and to avoid contact with others. Instead they were encouraged to have their meals in their rooms and to use designated toilets. If they needed to leave the room, they were advised to wear a surgical mask. Hygiene protocols were supposed to clean the rooms on a daily basis and at least twice a day for areas that were frequently touched (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 9th, 2021

Ireland

In Ireland, a new Infection Prevention and Control Hub offered residential LTC settings guidance for outbreak preparation and management, information on infection prevention and control, and support with applying national advice. Some of this support is provided via telementoring interventions and webinars for nursing homes. In addition, the national membership organisation of home care providers developed a COVID-19-specific National Action Plan (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

 

Last updated: September 9th, 2021

Israel

Guidelines, procedures, and information for professional teams (e.g. public health system, justice system, medical staff, airports, food delivery systems) regarding COVID prevention and control are accessible on the Ministry of Health’s website. Guidance was timely; reports were first published in Spring 2020 and regularly updated. JDC-Eshel’s work with the Shield of Fathers and Mothers taskforce was primarily responsible for training and implementation of support of carers/people relying on care in community.

Last updated: September 9th, 2021

Italy

In Italy, the guidelines for nursing homes published by the Ministry of Health require providers to ensure the COVID-related training of care workers. (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf)

Last updated: September 9th, 2021

Japan

Early in the response, local LTCI officials had triggered well-established infection control measures put in place and regularly used for outbreaks of TB & influenza. A disease prevention manual was published; stricter hygiene practices put in place; and staff and visitor health screening and limited resident visitation (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf; https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: September 9th, 2021

Netherlands

On 20 March 2020 the National Institute for Health and the Environment (RIVM) issued their first Covid-19 guidelines to the LTC sector. These guidelines were regularly updated and new guidance was added. Some guidelines were difficult to follow, especially where there were shortages of PPE and staff absent due to illness (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 9th, 2021

Spain

According to a study of the experience of care home managers and local officials, lack of information and guidance at the beginning of the pandemic resulted in chaos and uncertainty and made it difficult to develop adequate responses. While some care homes were able to react quickly, some care homes had not adopted any protocols until they had support from a primary health care centre in mid-April. Staff responsible for “quality reporting” were usually tasked with developing care home protocols and contingency plans but in some care homes that had medical support the protocols were developed by multidisciplinary teams. Care homes were fearful of legal repercussions if they did not get things right. All care homes were required to develop contingency plans to fight the pandemic in June 2020 and were supported by the regional governments in developing these. Too many updates and changes in the guidance made it difficult to adopt them. Quite often guidance was difficult or impossible to implement because it did not reflect the reality of care homes, for example physical layout of care homes, staffing constraints, or the characteristics of residents. Early protocols did not account for the possibility of asymptomatic transmission. Care homes would have found it helpful to have some support with checking their plans, as well as the monitoring of implementation. Care homes found it very difficult to train staff to reflect changes in guidance, in part because many members of staff were new and had had little training or relevant experience (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021

Sweden

Guidance on measures to prevent infections in elderly care was delayed due to the fact that central government agencies responsible for providing recommendations and check-lists (i.e.: The Public Health Agency of Sweden and the National Board of Health and Welfare) did not have an adequate overview of the problems and deficiencies in municipal elderly care (https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf). Moreover, the  national authorities’ main recommendation to avoid spreading the virus in LTC was to follow the legislation on basic hygiene routines. A national e-training program  focusing on hygiene was developed early and, by July 2020 has been completed by more than  140,000 care workers. It was not until the 25th of June 2020 when the Public Health Agency recommended the use of shields and facemask in personal care of care recipients with suspected or confirmed COVID-19 (https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: September 9th, 2021

United States

Guidance for LTCFs in the United States regarding COVID-19 infection prevention and control is regularly provided and updated by the Center for Disease Control (CDC). The instructions (e.g. on PPE, distancing, quarantining) can be found here (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html).

Last updated: September 9th, 2021

3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings

Australia

Approaches to hospital transfers vary depending on the state and individual aged care home. Some experts suggested not transferring COVID-19 positive residents to hospital unless it is the only solution to improve their survival rate and reduce risk of transmission. However, South Australia has an automatic transfer policy in which a resident who tests positive will immediately be transferred to a hospital. As of October 2020, the Communicable Diseases Network Australia (CDNA) has yet to introduce a specific recommendation on hospital transfers (https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

Last updated: September 9th, 2021

Austria

After 7 April 2020, which marked the peak use of capacity in hospitals during the first wave, patients were transferred from hospitals to care homes, ‘often without testing.’

By 16 April 2020, the Austrian government had announced that people discharged from hospital to care homes should be systematically tested (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

Last updated: September 9th, 2021

Canada (British Columbia)

Temporary suspension of interfacility transfers, except for cases of intolerable risk to the patient. Facilities were required to notify the receiving facility if an outbreak occurred within a 14-day period of the transfer. The outbreak protocol states that residents transferred to acute care for treatment of COVID-19 or its complications, can return to facility when medically stable. July 15, 2020 – Notification that interfacility transfers may resume if precautions are taken. Services must follow regional MHO directions (including restricting transfers between facilities with active COVID-19 outbreaks). Precautions (e.g., 14-day isolation) for interfacility transfers will be at the direction of the MHO based on assessed regional risk (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 9th, 2021

Chile

According to a report published in July 2020, at the time there was no specific protocol for hospital discharges to nursing homes and due to the high pressure on health services, people were being discharged from hospital to nursing homes without the requirement of COVID-19 testing, but discharged residents were required to remain in an isolation area for 14 days (Browne et al, 2020 https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

Last updated: September 9th, 2021

England (UK)

One of the most controversial policy decisions taken at an early stage in the management of the coronavirus crisis was the rapid discharge of older patients from hospitals to care homes around the country without testing for COVID-19. The British Medical Journal has referred to this as a ‘reckless policy’, a sentiment echoed by the Public Accounts Committee. On 17 March 2020 the Chief Executive of the NHS, instructed managers to urgently discharge all hospital patients who were medically fit to leave in order to free up substantial numbers of hospital beds. Discharges, including to care homes, may already have been taking place at this point in readiness for the expected surge in COVID-19 admissions.

Guidance issued on March 19, 2020, in support of hospital discharge arrangements, announced that the existing North of England Commissioning Support (NECS) care home tracker, designed to facilitate rapid search for available capacity in care homes, would be expanded to cover all care homes across England. All care home providers were to sign up and use the tracker to identify vacancies from Monday 23 March 2020. Even if the available care home was not their first choice, patients were to be moved to a care home as soon as possible and could be moved to their preferred care home as soon as possible. The guidance also outlined funding to provide care for people discharged from hospital into institutional care settings irrespective of whether a care assessment had been completed or where their ordinary residence was. Care homes were to receive funding out of the NHS COVID-19 budget to expand their capacity to provide care. Funding to support people leaving hospital was renewed in August with £588m being allocated to the NHS to pay for additional support and rehabilitation for up to 6 weeks (https://www.gov.uk/government/news/more-than-half-a-billion-pounds-to-help-people-return-home-from-hospital). At this time testing capacity was limited and available primarily for patients in critical care and those requiring hospital admission with symptoms of pneumonia, acute respiratory stress syndrome or flu like illness. The guidance of 2 April was explicit that ‘Negative tests are not required prior to transfers / admissions into the care home’ (https://www.northamptonshire.gov.uk/coronavirus-updates/Documents/covid-19-care-homes-guidance.pdf).

The National Audit Office estimated that around 25,000 people were discharged from hospitals to care homes between 17 March and 15 April 2020. Using an approach which also accounted for discharges for new as well as existing residents of care homes, the Health Foundation estimated that, for the period of 17 March to 30 April, 46,700 people had been discharged to care homes, 7,700 fewer than in previous years. However, the pattern of discharges differed between residential care and nursing homes. While residential care homes saw a decrease in discharges (with 12,400 discharges) compared to previous years, nursing homes saw an increase with 17,000 discharges. National bodies representing care homes complained about homes being pressured to accept residents that had not been tested. The guidance of 2 April stated that ‘patients can be safely cared for in a care home if this guidance is followed’. However, clinicians acknowledged that it was a ‘major error’ to assume ‘that care homes could cope with isolating patients and infection control measures in the same way a hospital could’. It has been reported that the Care Quality Commission had been informed by care home managers that several hospitals discharged people to their care home despite suspecting – or even knowing – they were infected. NHS Providers, the membership organisation for NHS hospitals, has strongly rejected the suggestion that hospitals ‘knowingly’ transferred infected patients to care homes but do acknowledge that some asymptomatic patients may have been transferred early though ‘not in large numbers’. Evidence is lacking for any accurate assessment of the extent to which hospital discharges in this period led to transmission of infection into care homes and genomic analyses suggest multiple routes of ingress into care homes.

In its COVID-19 adult social care action plan published on 15 April 2020, the government declared that it was ‘mindful that some care providers are concerned about being able to effectively isolate COVID-positive residents’ and in this context set out the commitment to test all residents prior to their admission to care homes, including on discharge from hospital. In cases where the results of the test cannot be obtained in time for discharge, patients should be cared for in isolation as if they had tested positive for COVID-19. Asymptomatic patients who have tested negative should also be cared for in isolation for 14 days. The same was recommended for patients with COVID-19 symptoms and a positive test result where the patient needed to be discharged from acute NHS care within the 14-day period since the beginning of the symptoms. The action plan recognised that not all providers will be able to accommodate these individuals through appropriate isolation or cohorted care (a reality supported by a survey of 43 English care home managers), and in these circumstances the individual’s local authority will be asked to secure alternative appropriate accommodation and care for the remainder of the required isolation period. For admissions from the community, it is assumed they will be tested prior to admission and in consultation with the family, the care home can decide whether isolation is appropriate.

Last updated: September 9th, 2021

Finland

A key LTC guideline, early on in the pandemic, was to avoid transfers between the care sites, such as between care homes and hospitals, whenever possible. Transfers were allowed only for medical reasons, and the new treatment site had to be notified on whether the person had had respiratory symptoms (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: September 9th, 2021

France

National Assembly report highlights that lack of support to the sector, especially in domiciliary care, meant that many services were reticent to taking on covid-positive service users, leading to discontinuity of care (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: September 9th, 2021

Germany

The Robert Koch Institute provides guidelines on infection prevention measures to be taken when transferring a person with a suspected/ confirmed COVID-19 infection between settings. ().

Last updated: September 9th, 2021

Staff in residential care settings were advised to monitor the health and body temperature of residents newly discharged from hospitals and to pay extra attention when providing personal care. Residents with respiratory symptoms must wear surgical masks and should continue isolating/cohorting. Furthermore, some nursing homes set up ‘temporary isolation wards’ for residents returning from hospital (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 9th, 2021

Israel

Different measures were introduced to minimize the transfer of LTCF residents between hospitals and facilities, including the opening of specialized COVID-19 wards within LTCFs and Geriatric Hospitals for those with mild or moderate cases. Required testing and potential quarantining following hospital visits and before returning to facilities was also introduced (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

Magen David Adom is the state ambulance and emergency medical service, providing primary assistance for testing, vaccination and ambulatory transfers between hospitals, care homes, and communities (https://www.mdais.org/en/activities/articles-covid19).

Last updated: September 9th, 2021

Netherlands

Many people died in nursing homes and were not transferred to hospitals, therefore it was seen that nursing homes reduced pressure on hospital Intensive Care Units. It is customary to treat older people when they fall ill in the nursing home, perhaps explaining why few were referred to hospital (https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

Last updated: September 24th, 2021

Singapore

As the DORSCON level reached orange in February 2020, elective surgical procedures and non-essential health/dental services were suspended. Hospitals continued to discharge residents to nursing homes throughout the Circuit Breaker period. The referrals were coordinated by the Agency for Integrated Care. At first, residents could be discharged if they did not have an acute respiratory infection and COVID-19 related symptoms. Those with an acute respiratory infection or pneumonia were required to provide a negative test. In May the policy changed as knowledge of asymptomatic COVID-19 increased. From then onwards, all patients discharged from hospital to nursing homes had to be tested (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 9th, 2021

Spain

In the early part of the pandemic residents returning to a care home, without a test, from a hospital stay for some other reason where suspected to be a main source of COVID-19 outbreaks. On the other hand, there were many instances where care homes were not able to access any health care support, from either primary care or hospitals. There were examples of hospitals that were systematically restricting admissions from care homes (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021

United States

In New York, following a hugely controversial directive from New York State’s Health Department on March 25, 2020, approximately 6,300 recovering coronavirus patients were transferred from hospitals into nursing homes throughout April (the peak of New York’s pandemic surge). The policy was defended by the Governor’s office, which argued that not only was this based on federal guidance, but that the devastation in nursing and long-term care facilities had more to do with the infection rates amongst staff. Regardless, the policy was overturned by mid-May and replaced with a new mandate such that patients could not enter nursing homes without a negative COVID test. News sources also counted over 2,700 “readmissions” of patients sent back from hospital to nursing homes they had previously lived in during that time. The executive board of The Society for Post-Acute and Long-Term Care Medicine (AMDA) estimated that 5,000 deaths in nursing homes and LTCFs are a direct result of that order (https://apnews.com/article/new-york-andrew-cuomo-us-news-coronavirus-pandemic-nursing-homes-512cae0abb55a55f375b3192f2cdd6b5; https://apnews.com/article/5ebc0ad45b73a899efa81f098330204c).

Last updated: September 9th, 2021

3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes

Sweden

Cohort care i.e. separating infected from non-infected care home residents within a care setting, was introduced; while some municipalities have used separate places for the care of people who have previously been hospitalized and infected with COVID-19. In many care homes new cleaning routines   organized, i.e. staff dedicated solely to care for people with suspected or established infection who live at home. In some care homes, COVID-19 teams have been combined with cohort care (https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Last updated: September 9th, 2021

United States

The Centers for Disease Control guidelines encourage suspected and confirmed cases amongst new and returning residents of LTCFs to be placed in a designated, in-house COVID-care unit. Details can be found here (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html).

Last updated: September 9th, 2021

Australia

If the COVID-19 positive person is a staff member, they must apply a surgical mask and leave the aged care facility by isolating at home. If the COVID-19 positive person is a resident, they must be moved to a single room, preferably with an en-suite, to isolate. The residential home may also be placed under lockdown for further testing. The local public health unit is responsible for contact tracing and the monitoring of residents (https://www.health.gov.au/sites/default/files/documents/2021/01/first-24-hours-managing-covid-19-in-a-residential-aged-care-facility-first-24-hours-managing-covid-19-in-a-residential-aged-care-facility.pdf).

Dementia Support Australia provided guidance to support people with dementia during COVID-19. They suggested 1:1 residential support as the ideal way to help a resident isolate (https://dementia.com.au/downloads/dementia/Resources-Library/Helpsheets/Managing-behaviours-during-a-pandemic.pdf).

Last updated: September 9th, 2021

Austria

In care homes, isolation was used frequently, however, this was problematic in situation where more people shared rooms. (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/)

Last updated: September 9th, 2021

Canada (British Columbia)

If a positive case is found in a LTC facility, the operator must close the affected floor/unit/ward or facility/residence to new admissions, re-admissions, or transfers, unless medically necessary and/or approved by a Medical Health Officer. COVID positive residents are not transferred to an external quarantine facility and are only transferred to acute medical care for COVID if necessary (http://www.bccdc.ca/Health-Info-Site/Documents/COVID19_LongTermCareAssistedLiving.pdf).

Last updated: September 9th, 2021

Denmark

On April 8, 2020, an extensive guideline was issued by the Board of Health, outlined how nursing homes and other institutions could prevent the spreading of COVID-19, in the wake of the so-called controlled re-opening of the country which was planned to take place after Easter (April 14th 2020). It was intended to supplement the procedures that the municipalities had already put in place, and provided guidelines on how to organize this. It specifically addressed the handling of the disease as a responsibility of the management. The managers were encouraged to plan the daily activities so that residents gathered in smaller groups than normally, preferably no more than two (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 9th, 2021

England (UK)

There have been two major difficulties in identifying and isolating infected individuals effectively in care homes in England. First, guidance issued to care homes focused only on people who were displaying symptoms (initial guidance only mentioned a persistent cough and fever as symptoms). It took a long time for official guidance to consistently recognize the potential for pre-symptomatic or asymptomatic transmission (https://ltccovid.org/2020/06/12/asymptomatic-and-pre-symptomatic-transmission-in-uk-care-homes-and-infection-prevention-and-control-ipc-guidance-an-update/). Guidance on identifying residents and staff who may have been in contact with persons who had the virus and preventive isolation became available on April 2, 2020 (https://www.gov.uk/government/publications/coronavirus-covid-19-admission-and-care-of-people-in-care-homes/coronavirus-covid-19-admission-and-care-of-people-in-care-homes).

The ability of care homes to implement existing IPC guidance was hampered by a lack of access to testing (tests for asymptomatic residents and staff only started to be available after the April 28, 2020) and PPE, staff shortages and facilities that were not suitable for effective isolation or cohorting (https://journal.ilpnetwork.org/articles/10.31389/jltc.53/). Where care homes are not able to implement adequate isolation or cohort policies, it is the responsibility of the local authority to secure alternative accommodation for the isolation period, drawing on the £1.3 billion discharge funding (https://www.gov.uk/government/news/2-9-billion-funding-to-strengthen-care-for-the-vulnerable).

Ahead of the second wave, the government set up a scheme to prepare “designated settings” that could provide safe isolation for people who were discharged from hospital while positive for Covid and who needed to move to a care home. The settings had a to meet set of standards to deliver safe care for Covid-19 positive residents.

 

Last updated: September 9th, 2021

Finland

National government guidelines to isolation have included LTC unit visiting bans, the provision of single rooms within LTC homes for symptomatic or exposed residents, restricted use of common areas in LTC units, and limited visitation of at-home care users. Some municipalities were quick to adhere to these policies, while others delayed implementation until the end of April (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: September 9th, 2021

France

Many care homes had to individually isolate service users, especially at the beginning of the pandemic, due to lack of adequate PPE. The guidance published in April 2020 around testing would test the first symptomatic resident, who would then be taken care of either in strict isolation or in single rooms. If one care worker tested positive, all workers were required to be tested and isolate. This was noted as a struggle by the Assembly Commission as many care homes had shared rooms for residents (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). This was linked to severe health impacts (https://ltccovid.org/2020/05/05/summary-sars-cov-2-related-deaths-in-french-long-term-care-facilities-the-confinement-disease-is-probably-more-deleterious-than-the-covid-19-itself/).

A study from France comparing mortality in nursing homes with staff confining with residents compared to national average showed that staff confining with residents was effective in preventing infection and reducing mortality (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2769241).

Last updated: September 9th, 2021

Germany

Guidance to support people living in care homes stress the importance of human dignity and focus on the need to ensure social participation and quality of life of residents (https://www.awmf.org/uploads/tx_szleitlinien/184-001l_S1_Soz_Teilhabe_Lebensqualitaet_stat_Altenhilfe_Covid-19_2020-10_1.pdf). Guidance on approaches to isolation of confirmed/suspected cases in care homes are provided (and regularly updated following the latest evidence) by the Robert Koch Institute.

In some federal states (e.g. Bavaria) relevant ministries can also issue guidelines (https://www.stmgp.bayern.de/wp-content/uploads/2020/08/20200818_handlungsanweisungen.pdf).

Last updated: September 9th, 2021

Ireland

Irish authorities have worked with hotels to accommodate people either with symptoms or awaiting transfer. https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf

Last updated: September 9th, 2021

Israel

Several LTC homes set up COVID wards and/or isolation areas within their institutions to limit number of people in need of ambulatory transfer to hospitals (https://ltccovid.org/2020/12/22/video-and-slides-of-the-14th-december-ltccovid-webinar-on-international-experiences-2nd-3rd-covid-19-waves-vaccines-and-beyond-in-the-long-term-care-sector/). Medical geriatric centers were also asked to open at least one ward dedicated to mild or moderates COVID-19 cases; if cases became severe, patients were transferred to a general hospital (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/). Due to lack of post-hospital geriatric support, many older COVID-19 remained in isolated recovery in hospital (https://www.haaretz.com/israel-news/.premium-israeli-icus-fill-up-with-recovered-elderly-covid-19-patients-with-nowhere-to-go-1.9232240).

Last updated: September 9th, 2021

Japan

LTCFs used well-established infection control procedures and swiftly isolated affected residents and suspended visits and social events (as they are used to do in the case of influenza/TB outbreaks). Mask-wearing was also already common practice in the event of these outbreaks. Data suggests most cases were contained with few large outbreaks within facilities (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 9th, 2021

Netherlands

The association of geriatricians has issued guidelines for infection control in care homes (Verenso). The ability to control infection has increased substantially between the first and second wave. The publicly financed programme “Dignity and Pride on Location” has developed a “roadmap” to help providers to prepare for a new pandemic (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 9th, 2021

Republic of Korea

All care home residents with confirmed COVID-19 infections were moved to quarantine centres or long-term care hospitals, so there have been no deaths registered in care homes

Last updated: September 9th, 2021

Singapore

In comparison to other countries, there were only very few cases in nursing homes in Singapore. All of the residents with COVID-19 were transferred to acute hospitals.

Nursing homes introduced mandatory split zones to reduce the number of contacts for residents and staff. The zones cannot house more than 100 residents, a fixed set of staff and need to have dedicated entry and exist points. Communication between staff in different zones should take place remotely via text messages, phone or video conference. Shared spaces, such as pantries and lifts should have staggered access that allows for cleaning between the use from different zones. Medical staff needing to move across split zones are recorded for contact tracing and have to adhere to increased infection prevention and control measures (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 9th, 2021

Spain

One of the most effective measures to contain outbreaks was the transfer of residents with COVID-19 to other temporary care settings, as well as preventing further spread, this practice was identified as positive for physical and mental wellbeing because it enabled the other residents to experience fewer constraints (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021

3.07.03. Care homes: visiting and unpaid carer policies

Overview

Following the high mortality observed in care homes around the world, many countries have closed their care homes to visitors. This had implications on residents and relatives’ wellbeing. Most countries have started to re-enable visits following strict hygiene protocols and limiting the number and frequency of visitors as well as monitoring the transmission rates.

Belgium

The use of antigen rapid tests for visitors is done under the responsibility of and in consultation with the local medical authorities. The use is optional and depends on the epidemiological situation. Factors that may influence a decision include: an increased (local) prevalence; the circulation of more contagious variants; to protect residents and staff who have not (yet) been vaccinated or have not built up sufficient immunity (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Visits are allowed for all residents. The number of visitors is limited to four close contacts (hug contacts) who don’t have to wear a face mask. Additionally, they are allowed unlimited visitors with surgical face masks, although the number present at the same time is limited in accordance with precautionary measures, such as keeping distance and the number of people that can be present in a room at the same time. Visitors are not restricted by time (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

Chile

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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Ireland

In early March, Nursing Homes Ireland announced visiting restrictions for care homes across Ireland. At that time, the Department of Health found that a blanket ban was not required. To mitigate the impact of social isolation, Nursing Homes Ireland conducted a survey of activities that could be put in place in nursing  homes to ensure that contact with families could be maintained. This was followed by the national initiative ‘Comfort Words’ that encouraged children to write to people living in nursing homes. It was anticipated that care home visiting should be reenabled as phase three of the Roadmap for Reopening Society and Businesses and to ‘return to normal’ in phase five. (https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: September 8th, 2021

Australia

The Australian government introduced visitor restrictions on March 18, 2020, which limited to two visitors at a time. Visits must be in private areas with no social activities. Children under 16, people who have travelled overseas, and people with COVID-19 symptoms were not allowed to visit. Individual state governments introduced their own visiting policies and restrictions. Queensland, Victoria, and NSW both implemented prolonged personal visitor bans and lockdowns. The Royal Commission into Aged Care Quality and Safety found that aged care residents were severely impacted by the loss of contact with loved ones and that the restrictions inside aged care facilities go beyond the restrictions for the general public (https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf; https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

In June 2021 Australia was 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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Austria

Following the first reports of cases and subsequent deaths in care homes in March 2020, some homes put in place visiting restrictions and bans, even before the general lockdown was implemented, but already by April 2020 some care homes worked towards enabling safe visits by creating ‘encounter zones’ that allowed families to meet residents at safe distance (in the garden/ divided by Plexiglas) and adhering to hygiene measures (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

In Austria, care home visiting has been possible again since May 2020 under a range of safety measures. Measures (‘visiting zone’, booth divided by plexiglass) varied between regions. The latest COVID-19 related measures issued by the government (8 February 2021) state that residents can be visited up to twice per week by up to two visitors per resident. Visitors must show a negative COVID-19 test and wear a FFP2 mask throughout their visit (https://www.sozialministerium.at/Informationen-zum-Coronavirus/Coronavirus—Aktuelle-Ma%C3%9Fnahmen.html).

It appears that Austrian visiting varied across Austria during the period from October to December 2020, when the country experienced a high number of cases. A paper reports on screening of visitors and restrictions of visits in public areas in Viennese care homes, as well as a ‘Corona traffic lights’ system in Lower Austria than put in place measures depending on local levels of infections (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

As of May 10, 2021, new legislation sets out provisions regarding opening from lockdown (https://www.ris.bka.gv.at/Dokumente/BgblAuth/BGBLA_2021_II_214/BGBLA_2021_II_214.html). 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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Brazil

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.

(Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/)

Last updated: September 8th, 2021

Canada

In Ontario, Canada, social outdoor visits were generally encouraged. From September 2020, family carers providing essential caregiving activities could enter the homes. As cases increase again, some areas limited social visits but enable family carers to continue to see their relatives. Family carers entering homes must get regular COVID-19 (bi-weekly/weekly in areas with high transmission) to be allowed to enter.

In Quebec, the government stated in November 2020 that care homes could not make the provision of a negative test a requirement for visitors (https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf).

Last updated: September 8th, 2021

Canada (British Columbia)

Visitor restrictions were put in place to only allow for essential visitors. March 19, 2020 – The definition of essential visitor was expanded and it was indicated that HAs would determine if a visit was essential. June 30, 2020 – Further amendment of the policy, stating that each facility must have a plan in place in accordance with BCCDC IPC (Infection Prevention and Control) guidance to indicate how social visits would be facilitated (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

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 (http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/long-term-care-facilities-assisted-living). 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.

Last updated: September 8th, 2021

Catalonia (Spain)

In June 2021, care home residents are 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 (https://canalsalut.gencat.cat/web/.content/_A-Z/C/coronavirus-2019-ncov/material-divulgatiu/gestio-infeccio-coronavirus-ambit-residencial.pdf).

Last updated: September 8th, 2021   Contributors: Gemma Drou-Roget  |  

China

During the worst period of the pandemic, all the nursing homes were in lockdown, meaning that no one was allowed in or out, including nursing home staff. Administration staff were asked to work from home or take leave. Currently, nursing homes are not completely open, but in low risk areas visitors with a prior reservation can enter upon taking a temperature test and showing a green ‘health code’. This signifies their personal epidemiological status, which is related to where they have been and who they have recently come into sustained contact with. The same regulations are in place for staff who are working there. Visits that are not family related are stricter and depend on the specific regulations in each nursing home.

In June 2021 nursing homes were 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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Czech Republic

In July 2021, 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 (https://covid.gov.cz/opatreni/zdravotnicka-socialni-zarizeni/omezeni-navstev-v-zarizenich-socialni-pece). Regarding outings for residents, recently the Deputy Ombudsman (“Public Defender of Rights”) askedthe 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” (https://www.ceskenoviny.cz/zpravy/simunkova-zada-zruseni-omezeni-vychazek-klientu-domovu-pro-seniory/2031948). Further conditions attached to outings for residents are specified in the same ‘extraordinary measure’.

Last updated: September 8th, 2021

Denmark

Measures were first introduced by the March 17, 2020, guidelines issued by the Board of Health, ’Håndtering af COVID-19: Besøg på institutioner hvor personer fra risikogrupper bor eller har langvarigt ophold’. These recommended that family members and friends should not visit nursing homes (or hospitals) unless strictly necessary, for instance if the person was terminally ill (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Individual institutions were asked to ensure that the visit could be conducted in a safe manner, for instance by ensuring that it was only a brief visit, that visitors did not sit in common areas and that they did not have physical contact or use common facilities. Institutions were required to inform visitors about the risk of spreading the disease and encouraging them to avoid visiting, through posters (for example a poster with the message ‘You best protect your loved ones by not visiting them’) and personal instruction. If family members had symptoms, they were not allowed to visit. Instead, it was recommended to stay in contact over the telephone, video or mail.

A formal ban of visiting was introduced temporarily on April 6, 2020, ‘Besøgsrestriktioner på plejehjem m.v. og sygehuse’. The guidelines also outlined that the manager should ensure that members of staff stayed at home if they showed signs of being infected, even with mild symptoms, and only returned after 48 hours of being symptom free. If a member of staff was suffering from respiratory diseases or the like they could be referred by the manager to take a COVID-19 test. Also, staff who had been in close contact with persons infected with COVID-19 were to be tested (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

On May 12, 2020, an extensive publication providing new guidelines on how to organize visits in nursing homes was published by the Board of Health. From the introduction, it was made clear that the Board of Health did not have the authority over who could visit, as this was the responsibility of the Board for Patient Safety, and thus underlining the general confusion over which authority was in charge (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/). It was recommended to limit the number of residents that each member of staff had access to and to avoid staff involvement in activities spread across the institution. Staff should receive instruction in the use of PPE and there should be a strong focus on hygiene and behaviour in all common rooms. It was acknowledged that residents were entitled to leave the institution but the manager and staff were encouraged to inform them about the increased risk and they should be supported in how to disinfect their hands upon returning. Staff were instructed in wearing work clothes and maintaining distance (1-2 m), regardless of whether the resident had any symptoms. Which centres have what kind of restrictions is posted here (https://stps.dk/~/media/07F68A96CC9C44B08BBDF33E1DF81C1C.ashx).

The Board for Patient Safety enforced that the municipalities introduced restrictions preventing visitors in the nursing homes. This included visits inside the institution, and in common areas as well as the apartments or rooms. It could also include outdoor areas, if necessary, but this was a decision to be taken by the Municipal Board (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

In June 2021 at most nursing homes things have returned to normal. There is again open access for relatives, volunteers and activities. Where there is an outbreak of COVID-19 at a nursing home or there is  comprehensive outbreak of COVID-19 in a municipality, the agency for patient security has the authority to issue a directive restricting access to nursing homes. In the following situations visits cannot be restricted: visits from close relatives to a critically ill person; close relatives visiting a grown adult with learning disabilities, to the degree that the person doesn’t have the ability to understand and accept the purpose of the restrictions, and by that reason has a special need to be visited; visits from the person’s guardian, personal representative or lawyer (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

England (UK)

The initial guidance in England published on March 13, 2020, advised against visits by people who had suspected COVID-19 or were feeling unwell. The main care home chains stopped non-essential visits around that time. Although no formal ban on visits to care homes was issued, the advice was not to visit except in exceptional (usually end of life) situations (https://www.bbc.co.uk/news/52674073). The Prime Minister also announced on March 16 that the physical distancing measures should also apply to care homes. Guidance on family visits was issued on the 22 July, linking the visiting policy to local levels of risk of transmission and advising that visits were limited to a “single constant visitor” (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus/update-on-policies-for-visiting-arrangements-in-care-homes).

On October 1, 2020, the Department of Health and Social Care (DHSC) announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, which includes enabling safe visiting of care homes (https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2).

On October 13, 2020, the Care Minister announced the government’s intention to pilot a care home visitor scheme, in which designated visitors would be recategorized as ‘key workers’ and given priority access to weekly rapid antigen tests and PPE (https://committees.parliament.uk/oralevidence/1032/pdf/; https://www.bbc.co.uk/news/uk-politics-54528021).

Following the announcement of the second national lockdown, more than 60 care organisations collectively called on November 3, 2020, for safe visits to care homes to continue; a similar call was made by ADASS (https://www.laingbuissonnews.com/care-markets-content/news/organisations-call-for-care-home-visits-to-continue/). In response to the ongoing restrictions, a high court judge ruled on November 3, 2020, that visits to care homes were legal (https://www.theguardian.com/society/2020/nov/03/judge-says-care-home-residents-in-england-are-legally-allowed-visitors?fbclid=IwAR1EHVzBhTUH1E7IFqzu9eYzCN7nMnkpT8MIxhwoygL7tHQgl_glve2cok4). Following this, government guidance on visiting arrangements were updated on November 5, 2020, advising directors of public health and providers to facilitate visiting where possible in a “risk-managed way” (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus/update-on-policies-for-visiting-arrangements-in-care-homes). There is ongoing concern as to whether the arrangements are sufficiently flexible and sensitive to the needs of people in care homes and their families.

On December 1, 2020, DHSC released guidance on arrangements for visiting out of the care home, which was then updated on March 8, 2021. This stated that visits out of care homes should only be considered for care home residents of working age, and although regulations could technically allow residents to form a support bubble with another household, this is not recommended. This suggested that the assumption should be that visiting is allowed unless there is evidence to take a more restrictive approach, where the needs of the individual are balanced against a consideration of the risks to others in the home. For visits to take place, the residents and all members of the household must have had a negative result from a Lateral Flow Device immediately preceding the visit. It is suggested that those involved in the visit should limit the number of people they meet for 2 weeks prior to the visit out. Upon returning to the care home, the resident should self-isolate for 14 days. In the event of an outbreak in a care home, all outward visiting should be immediately stopped (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus).

On January 21, 2021, DHSC released guidance for care homes during the winter. This stated that visits to care homes could take place with arrangements such as substantial screens, visiting pods, or behind windows. This stipulated that end-of-life visits should always be supported (https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-care-homes).

On March 12, 2021, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support in the form of the Rapid Testing Fund was crucial in enabling safe visits to occur in care homes, because it provided funding to allow every visitor to be tested. This support is due to expire at the end of March (https://www.nuffieldtrust.org.uk/news-item/social-care-reform-running-out-of-time-and-money).

On March 18, LaingBuisson announced that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund (https://www.laingbuissonnews.com/care-markets-content/news/adult-social-care-to-receive-extra-funds/).

Since May 17, every care home resident can nominate up to 5 named visitors who will be able to enter the care home for regular visits (and will be able to visit together or separately as preferred). Residents with higher care needs can choose to nominate an essential care giver who may visit the home to attend to essential care needs. The 5 named visitors may include an essential caregiver (where they have one) but excludes babies and preschool-aged children (as long as this does not breach national restrictions on indoor gatherings). To reduce the risk of infection residents can have no more than 2 visitors at a time or over the course of one day (essential caregivers are exempt from this daily limit) (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

The most recent guidance (August 2021) removes the advice on the number of ‘named visitors’ and does not limit the number of visitors a resident can have in a single day. The essential caregiver should be able to visit even if the home is in outbreak (except where carer or resident are Covid-positive), or if the caregiver is not fully vaccinated.

Last updated: September 8th, 2021

Finland

Visits to housing services for older people and at-risk groups in Finland were prohibited alongside the announcement of a nationwide state of emergency (https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

From mid-May 2020 onwards visits in care homes (e.g. outdoors/in meeting containers) became part of the national guidelines (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

 

Last updated: September 8th, 2021

France

Visits were suspended in care homes between 11th March and 20th April 2020 with a phased return to ‘normal’ by the summer (16th June). Care home managers criticised the approach of having to set up complex safe visiting protocols from almost one day to the next, and regretted not having been consulted on the proposals (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). The announcement of the second lockdown on 28th October 2020 was accompanied by a clear message that visiting in care homes would not be stopped (https://www.francetvinfo.fr/sante/maladie/coronavirus/confinement/confinement-pourquoi-les-visites-en-ehpad-vont-etre-autorisees_4160285.html), with a clear policy to ‘protect our elders without isolating them’ (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf).

From May 19, 2021, visiting restrictions have been further relaxed as a result of increasing vaccine coverage among older people (https://solidarites-sante.gouv.fr/IMG/pdf/allegement_post_vaccinal_des_mesures_de_gestion_ehpad_et_usld.pdf). 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.

Visitors must be tested upon entry, except where vaccinated. They 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’. Residents undertaking outings must wear a surgical mask and be offered a PCR test upon return, and as far as possible they must limit their contact with other residents. Isolation of these residents upon return is not allowed.

Restricting the movement in and out of care homes and other long-term care settings must be the final resort.

Last updated: September 8th, 2021

Germany

On 10 February 2020 the Federal Government noted that in some care and nursing homes staff and residents have already received the second vaccine. In addition, there has been a joint effort to undertake rapid tests in residential care settings. The Government asks federal states to develop concepts to expanded visiting rules following full vaccination. The armed forces can support rapid testing (https://www.bundesregierung.de/resource/blob/975226/1852514/508d851535b4a599c27cf320d8ab69e0/2021-02-10-mpk-data.pdf?download=1).

In December 2020, the German ethics council issued recommendations on the minimum of social contacts for people receiving long-term care during the COVID-19 pandemic. The council emphasises quality of contacts over quantity, which emphasises the importance of enabling contact with people with whom they have a close and trusting relationship. The document also recognises the important of physical closeness. Where there are no relatives, volunteers should be considered to replace important social contact. Physical contact must be enabled if people with LTC needs express this wish. Programmes supporting social contact should be realised (potentially with help from volunteers) (https://www.ethikrat.org/fileadmin/Publikationen/Ad-hoc-Empfehlungen/deutsch/ad-hoc-empfehlung-langzeitpflege.pdf).

In addition, the authorised representative of the federal government for care has provided concepts to enable safe visiting during the COVID-19 pandemic (https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/C/Coronavirus/Handreichung-Besuchskonzepte_4.12.20.pdf).

The RKI continues to provide guidance around infection prevention measures around visiting arrangements in residential care settings (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile).

Visiting rules continue to vary somewhat between the federal states. Since the Ministers of Health have agreed on expanding visits in care home again visiting rules have become more similar, but there can be some variation in the number of visitors (in some areas tied to incidence rates), (rapid) testing, hygiene protocols (masks, disinfecting hand), provision of information for contact tracing. In case of an outbreak, care homes can suspect visits in consultation with health authority (https://www.biva.de/besuchseinschraenkungen-in-alten-und-pflegeheimen-wegen-corona/#bw).

On 22 March 2021 the Ministers of Health have agreed that residential care settings are allowed to expand visiting as well as group activities again two weeks after residents received the second vaccination and if there are no active COVID-19 cases in the institutions. There is no differentiation between residents who have received the vaccination and those who have not. New residents, who have not yet been vaccinated should be offered a vaccination appointment in a timely fashion. The federal government will continue to support testing. Länder regulations vary (https://pflegenetzwerk-deutschland.de/fileadmin/files/Corona/210316-Besuchsregelungen-Pflegeheime-Uebersicht.pdf).

Last updated: September 8th, 2021

Hong Kong

In the early part of the pandemic, visits of relatives and friends were suspended, ‘unless for compassionate reasons’. In some residential care settings remote/virtual meetings were organised to sustain contact with residents’ families. Visiting professional services were also delivered remotely, suspended or reduced in scale. Volunteers were not allowed to come into the homes (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

As of July 2021, 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.(https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/)

Last updated: September 8th, 2021

Indonesia

The Directorate of Social Rehabilitation for People with Disability under the Ministry of Social Affairs issued guidelineon health protection and psychosocial support for persons with disabilities during Covid-19 outbreaks in institutional care (https://kemensos.go.id/uploads/topics/15852709524796.pdf). 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 (http://puslit.kemsos.go.id/upload/post/files/24d4dfb918f9d78c57f5f2fa0d0470aa.pdf). 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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Israel

Visiting policies in care homes were found to be very inconsistent early on, causing confusion for LTCF staff, residents and families (https://www.calcalist.co.il/local/articles/0,7340,L-3800102,00.html). In Summer 2020, the national LTC pandemic taskforce, Shield of the Fathers and Mothers, issued a statement encouraging family visitation under social distancing guidelines, citing psychological health as the primary driver. Many LTCFs however adopted stricter policies and prohibited visitation altogether. The Ministry of Health maintained a pro-visitation policy for LTCFs in low-morbidity areas after the nationwide lockdown during the September second wave. “To date, there has been no reported cases of COVID-19 infections in LTCFs arising from a family visit (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

Last updated: September 8th, 2021

Italy

In May 2021, the Ministry of Health signed a new resolution that re-opened nursing homes to those relatives holding a “green certification”. This is a new 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, this resolution contains guidance on the procedures for residents going back to their houses.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Japan

Facilities implemented well-established policies to restrict visits, as used in times of influenza or TB outbreaks. These policies were triggered swiftly (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 8th, 2021

Kenya

As of June 2021 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. 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).

Sources: https://ltccovid.org/wp-content/uploads/2020/06/COVID-19-and-Long-Term-Care-in-Kenya-30-May-1.pdf and https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

 

 

Last updated: September 8th, 2021

Malaysia

In July 2021 the country was under its third lockdown. Intensive care units were full for the first time ever. The only visitors to care homes at the time were the vaccination teams. No other visitors were allowed and there were no plans to revise the ‘no visitor’ policy in Malaysian care homes.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Malta

In July 2021, despite all older persons who had wished to avail themselves of the vaccine having been able to do so, older persons were 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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Netherlands

The Minister of Health closed all care and nursing home to visitors on 20 March 2020. Families were only allowed to visit when their relatives were dying. Older people at home were not considered as vulnerable as people in nursing home, so the rule did not apply to them. Closing care homes created significant resistance and some nursing homes took drastic actions to prevent relatives from visiting (e.g. employing a security service, create fences) there were different views among relatives about the priorities of protecting people in care homes (https://www.sciencedirect.com/science/article/pii/S1525861020308318). The legality of the ban became contested. Older people became reluctant to move to nursing homes because of the ban. Nursing homes (which usually have a waiting list) do now have empty beds for which there is no demand. Key actors of the care sector agreed a protocol to gradually open homes on 8th May. This bottom up initiative was endorsed by the Ministry of Health (https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

However, others report that the ban provided discretion to nursing homes to allow visits from close families and friends as part of end of life care (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf). Visiting policies were relaxed and localised during the second wave, delegating responsibility and decision-making to local actors and care homes, it was recognised that residents should be able to see at least one family member or next of kin. While decisions were localised the central healthcare inspectorate retained the authority to monitor the situation (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf). A study of the decision to allow visitors back in nursing homes (https://www.sciencedirect.com/science/article/abs/pii/S1525861020305260). A study of changes to behaviour during the crisis of people in nursing homes (https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1857695). According to the LTC report new legislation requires care homes to enable visits at all levels of the pandemic and even if there are COVID-19 cases in the care home. Care homes have enabled this by creating COVID-19 wards or blocking visitors from specific wards with ongoing infections (https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf).

Government guidance states that if 80% of nursing home residents have been fully vaccinated, then a resident can receive a maximum of two visitors per day (https://www.rijksoverheid.nl/onderwerpen/coronavirus-covid-19/gezondheid-en-zorg/verpleegtehuizen#:~:text=Basisregels%3A%20iedereen%20houdt%201%2C5,bezoeker%20per%20bewoner%20per%20dag). If less than 80% of residents have been fully vaccinated, then a resident can receive a maximum of one visitor per day. Basic rules such as social distancing and using face masks still apply. Individual nursing homes have some discretionary space to set their own rules (https://kennisbank.patientenfederatie.nl/app/answers/detail/a_id/3050/~/regels-m.b.t.-cli%E3%ABnten-en-pati%E3%ABnten-in-verzorgings–of-verpleeghuizen).

The “client councils” in care homes have the right to participate in decisions that affect their daily lives and need to be consulted about organisational issues and have a right to consent to decisions that affect the residents’ daily lives. It is expected that they would advise on visiting restrictions (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181203/; https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Visiting arrangements from 10 June 2021: Residents in nursing homes may receive as many visitors as people at home (when 80% of the residents have been vaccinated) (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

New Zealand

In New Zealand areas are grouped into different Alert Levels. At Alert Level 1 visits are possible following a set of hygiene rules and some providers may also put in place some additional precautions. At Alert Level 2 visits may only be possible for designated visitors and there may a limit on the number of visitors being in the building at the same time as well as limits to length of visit and places where visits can take place (https://covid19.govt.nz/everyday-life/parents-caregivers-and-whanau/visiting-an-aged-residential-care-facility/).

Last updated: September 8th, 2021

Norway

Visitors are not tested and do not need to show a negative test before the visit (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

Singapore

In-person visits to nursing homes were suspended for just over two months during the Circuit Breaker Period (April to June 2020). In July 2020, nursing home residents could ‘receive one of two designated visitors for 30 minutes each day.’ Visitors have been asked to make appointments so that nursing homes can manage the number of people present (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

In response to the national situation, visiting guidelines are regularly updated. When there are increased cases in the community, guidelines are 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. As of June 2021, there is currently no mandate for visitors to be vaccinated (https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/)

Last updated: September 8th, 2021

Slovenia

In July 2021: 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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

South Africa

In June 2021, the country is 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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Spain

As of July 2021, 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.

Last updated: September 8th, 2021

Sweden

Sweden implemented a ban of visiting care homes from 1 April 2020. These measures were lifted on 1 October but have been put in place again in some places in November 2020. The government provided Public Health Authority with the power to enact local bans (https://www.government.se/articles/2020/04/s-decisions-and-guidelines-in-the-ministry-of-health-and-social-affairs-policy-areas-to-limit-the-spread-of-the-covid-19-virusny-sida/; https://www.euronews.com/2020/11/25/serious-deficiencies-sweden-s-retirement-homes-under-fire-over-coronavirus-care; https://www.thelocal.se/20201120/sweden-brings-in-local-visit-bans-to-elderly-care-homes/). The Public Health Agency has initially advised against visiting care homes for older people. The Government subsequently introduced a corresponding ban by means of an ordinance (from April 1). However, no ban has been introduced on visiting residential accommodation for people with disabilities. Overall, government issued guidance for ‘special risk group’ including people over 70 and younger with underlying health conditions to limit their social contacts (https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf; https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

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 (https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/covid-19/information-till-varden/personal-inom-aldreomsorg/lokala-besoksforbud-pa-aldreboenden/).

On 31 May 2021, the possibility for municipalities to request the Public Health Agency to temporarily ban visits to nursing homes came to an end. The repeal of the regulation is based on the improved epidemiological situation, the increasing vaccination coverage and the continued high compliance with other rules and recommendations (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

Switzerland

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.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

United States

In the United States visitation guidelines fall into the decision-making power of the different states. States can decide whether they want to issue guidelines across the state or to provide them on an ‘individual facility basis’. A review found that most states leave care homes to make final decision on safe opening procedures (https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf).

CMS guidance on care home visiting from September 2020 can be found here: https://www.cms.gov/files/document/qso-20-39-nh.pdf. As of March 10, 2021, President Biden relaxed the federal guidelines (recommendations) on nursing and long-term care home visiting policies for the first time since September 2020 (https://www.nytimes.com/2021/03/10/us/politics/coronavirus-nursing-homes.html).

Last updated: September 8th, 2021

3.07.04. Deployment of "squads" or rapid response teams to support care homes with outbreaks or staff shortages

Singapore

If a resident in a nursing home receives a positive COVID-19 test, a COVID-19 Incident Response Team (CIRT) is called in immediately by the AIC. These response teams consist of ‘representatives from the nursing home, the supporting regional hospital, the Ministry of Health, the Agency for Integrated Care, National Public Health Laboratory as well as the National Centre for Infectious Diseases. The response teams work on containing the number of positive cases, stepping up infection control, carrying out swabbing and testing operations, contact tracing, heightening vigilance (health monitoring of staff and residents), communicate with residents’ relatives and media, develop a service continuity plan and maintain adherence to the IPC measures, ensure workforce recovery after quarantine (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 8th, 2021

Australia

In April 2020, the Australian government announced emergency response teams for major outbreaks in residential aged care facilities. The emergency response teams include nurse first responders on standby in every state and territory (https://www.health.gov.au/ministers/senator-the-hon-richard-colbeck/media/contingency-measures-to-ensure-continuity-of-aged-care-during-covid-19).

Last updated: September 8th, 2021

Finland

Preparations for possible future staff shortages began quite quickly, and a survey for a reserve of health professionals, including retired workers and students, began in early spring (https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

 

Last updated: September 8th, 2021

France

Mobile geriatric and palliative care teams were deployed to care homes from 31st March 2020. The Assembly recommends these be embedded longer-term (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: September 8th, 2021

Germany

The Ministry of Health in Bavaria introduced a long-term care group to support residential care settings in responding to COVID-19 cases in December 2020. The group includes experts in care, the authority monitoring quality of care for people with long-term care needs and disabilities and is called out as soon as one confirmed case has been established in a care home. The aim of this group is to prevent, advise and control infections and to support the task force infectious disease. Prior to the long-term care group (since March 2020), the Infectiology task force supported care homes in responding to outbreaks (https://www.stmgp.bayern.de/presse/neue-einsatzgruppe-unterstuetzt-pflege-einrichtungen-im-kampf-gegen-die-corona-pandemie/?output=pdfhttps://www.n-tv.de/regionales/bayern/Pflege-Einsatzgruppe-beraet-fast-200-Heime-article22297279.htmlhttps://www.stmgp.bayern.de/presse/huml-pflegeheime-brauchen-besonderen-schutz-vor-covid-19-handlungsanweisungen-des/?output=pdf).

In Lower Saxony care homes experiencing COVID-19 outbreaks could get support from qualified hygienists since May 2020. Health authorities can request support from these mobile teams through the Ministry of Social Affairs, Health and Equality in Lower Saxony (Niedersächisches Ministerium für Soziales, Gesundheit and Gleichstellung) (https://www.ms.niedersachsen.de/startseite/service_kontakt/presseinformationen/mobile-teams-zur-unterstutzung-von-pflegeheimen-bei-covid-19-ausbruchen-eingerichtet-kooperation-mit-medizinischem-dienst-der-krankenversicherung-188513.html).

A report from April/May 2020 showed that among residential care settings experiencing COVID-19 cases, 96.1% (n=749) receive support from a crisis team (https://www.uni-bremen.de/fileadmin/user_upload/fachbereiche/fb11/Aktuelles/Corona/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

Last updated: September 8th, 2021

Ireland

In Ireland, national and regional outbreak teams were set up to oversee, prevent and tackle COVID-19 clusters in residential LTC settings. Care home providers started to report COVID-19 outbreaks to the Health Information and Quality Authority (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 8th, 2021

Israel

The Israeli Army’s Home Front Command was called to assist in LTCF disinfection during three major facility outbreaks in mid-2020 (in a Jerusalem LTCF for older people, in a LTCF for older people in the South, and in a LTCF for disabled adults and children in central Israel) (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

As the pandemic carried on, Israel’s army supplied critical response teams to support care homes and users, providing contract tracing, testing, medics, and vaccination support, and 29 quarantine locations nationwide (https://asia.nikkei.com/Spotlight/Coronavirus/Israel-military-minds-aid-COVID-battle-and-rapid-vaccine-rollout; https://www.telegraph.co.uk/news/2021/01/11/israeli-defence-forces-medics-drafted-help-nurses-covid-vaccination/).

Last updated: September 8th, 2021

Netherlands

The Dutch army assisted some nursing homes (mostly by providing nurses) and also managed care homes in some instances, due to staff absenteeism (up to 10-12%).

Last updated: September 8th, 2021

United States

Community health teams supporting nursing home staff for example via telemedicine (https://theconversation.com/how-one-community-improved-covid-19-nursing-home-care-with-collaboration-and-communication-142464).

Last updated: September 8th, 2021

3.08. Access to testing and contact tracing for people who use and provide Long-Term Care

Belgium

For vaccinated residents with symptoms, only a PCR test can be used to detect a possible infection. An antigen rapid test can only be used for non-vaccinated symptomatic residents (symptom duration of maximum five days) and for residents with symptoms just after the first vaccination (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

England (UK)

Limitations on testing capacity meant that initial workforce testing strategy focused on NHS workers with symptoms. This was extended to social care workers (with symptoms) from 15 April 2020 (https://www.gov.uk/government/news/government-to-offer-testing-for-everyone-who-needs-one-in-social-care-settings), and on 28 April, a policy of one-off whole home testing was announced for all staff and residents of care homes with residents over 65 or with dementia and an online portal was launched on 11 May to help care homes arrange deliveries of test kits (http://www.nationalhealthexecutive.com/Health-Care-News/government-portal-care-home-testing). Although testing capacity was increasing, this was not without problems. The BBC reported that on 22 April, 159 out of 210 care providers contacted about testing reported that none of their staff had received a test (https://www.bbc.co.uk/news/health-52284281). On 12 May, the Guardian reported that care home operators accused the government of ‘a complete system failure’ regarding the promised testing in care homes. According to this article only tens of thousands had been tested so far, leaving many vulnerable people at risk. Different government agencies were accused of passing responsibilities to each other (https://www.theguardian.com/society/2020/may/12/testing-coronavirus-uk-care-homes-complete-system-failure). A survey of 43 English care home managers, which was conducted at the end of May and early June 2020, found that only 40% had accessed testing of asymptomatic residents and 50% of asymptomatic staff. At that time, only 36% of residents had been tested, with many describing a chaotic and poorly co-ordinated service (https://ltccovid.org/2020/06/09/learning-from-the-impacts-of-covid-19-on-care-homes-in-england-a-pilot-survey/). At that time, only 10% of care homes surveyed had successfully tested all residents in their care home (http://doi.org/10.31389/jltc.53).

On June 8, 2020, the Government announced that all remaining adult care homes would be able to access whole care home testing for all residents and asymptomatic staff through the digital portal, including adult care homes catering for adults with learning disabilities or mental health issues, physical disabilities, acquired brain injuries, and other categories for younger adults under 65 years (https://www.gov.uk/government/news/whole-home-testing-rolled-out-to-all-care-homes-in-england). It should be noted that these ‘whole care home’ testing arrangements do not apply to supported living settings, extra care settings, and domiciliary care. In these situations, individual tests can be applied for through self-referral. From 3 July, care home staff were promised weekly testing (https://www.gov.uk/government/news/regular-retesting-rolled-out-for-care-home-staff-and-residents), but domiciliary care staff were still only eligible for free testing if symptomatic, as the general population (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/933134/Routes_for_Coronavirus_testing_in_adult_social_care_in_England_accessible1.pdf).

In light of advice from the Government’s Scientific Advisory Group for Emergencies (SAGE) and results from the Vivaldi 1 study, regular retesting staff and residents in care homes for over 65s and those with dementia was announced to be implemented from early July (https://www.gov.uk/government/news/regular-retesting-rolled-out-for-care-home-staff-and-residents). It was reported that this had been delayed until September (https://www.thetimes.co.uk/past-six-days/2020-08-02/news/care-home-coronavirus-testing-pledge-abandoned-tqxf6mm6j), with promises of new rapid point of care tests, although these had yet to be formally approved and questions remained about the most suitable and safe tests for such a vulnerable setting (https://www.gov.uk/government/news/roll-out-of-2-new-rapid-coronavirus-tests-ahead-of-winter#:~:text=Millions%20of%20new%20rapid%20coronavirus,and%20labs%20from%20next%20week.&text=Millions%20of%20ground%2Dbreaking%20rapid,testing%20capacity%20ahead%20of%20winter).

On December 23, 2020, the Department of Health and Social Care (DHSC) announced £149 million to support the rollout of Lateral Flow Device (LFD) testing in care homes. This funding will be paid in January 2021. All funding must be used to support increased LFD testing in care settings. Local authorities should pass on 80% of this to care homes on a per bed basis, which must be within the local geographical area. The other 20% should be used to support care providers to implement increased LFD testing, allocated at the discretion of the local authority (https://www.gov.uk/government/publications/adult-social-care-rapid-testing-fund/adult-social-care-rapid-testing-fund-guidance). Care homes currently have access to 3 tests per week for their staff, with daily testing for 7 days in the event of a positive case. Care homes will have additional LFDs to test individuals working in more than one setting before the start of every shift (https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing).

On February 16, 2021, DHSC published guidance announcing that weekly COVID-19 testing is to be made available to personal assistants working in adult social care in England. These tests will be ordered online, taken at home, posted off for testing, with results available within 48 hours. After testing positive, a person does not need to test again for 90 days unless they become symptomatic. This guidance gives personal assistants responsibility for informing their employers if they receive a positive result (https://www.gov.uk/guidance/coronavirus-covid-19-testing-for-personal-assistants).

On January 17, 2021, DHSC announced a £120 million Workforce Capacity Fund to help local authorities to boost staffing levels (https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing). The aim of which is to strengthen social care staff capacity so that safe and continuous care is achieved by all providers of adult social care. If the specific way in which staff capacity is strengthened means that they do not have access to routine to routine asymptomatic testing or LFD testing, then it is suggested that the local authority could use their allocation of LFD tests for routine testing (https://www.gov.uk/government/publications/workforce-capacity-fund-for-adult-social-care).

On March 5, 2021, DHSC published guidance on LFD testing in adult social care settings. This stipulated that it is necessary to obtain consent before residents and staff are tested and their results shared. If a person receives a positive result from a LFD, then they will need to take a confirmatory PCR test and immediately self-isolate. With a negative test, the person can stop self-isolating but must continue to follow national and local rules and guidelines (https://www.gov.uk/government/publications/coronavirus-covid-19-lateral-flow-testing-in-adult-social-care-settings).

On March 12, 2021, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support in the form of the Rapid Testing Fund was crucial in enabling safe visits to occur in care homes, which is due to expire at the end of March (https://www.nuffieldtrust.org.uk/news-item/social-care-reform-running-out-of-time-and-money).

On March 18, 2021, LaingBuisson announced that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund (https://www.laingbuissonnews.com/care-markets-content/news/adult-social-care-to-receive-extra-funds/).

Last updated: September 8th, 2021

Ireland

From late March 2020, staff and residents of nursing homes were among the groups prioritised for testing. ‘Assessment and testing pathways’ for residents showing symptoms of COVID-19 in residential care settings were issues by the Health Service Executive. By early April, it was recommended that care home staff should be screened twice a day, and that staff should be prioritised for testing (https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: September 8th, 2021

Singapore

In April 2020 Singapore started routine testing of residents who showed COVID-19 relevant symptoms. At the end of April 2020 routine testing of all staff and residents began. Testing and follow-up treatment for those with positive results identified through this surveillance mechanism were provided for free by the government.

In addition, the Ministry of Health and the Agency for Integrated Care have ‘worked with the regional hospitals to train nurses in care facilities and nurses in three home care providers in testing and to support the development of ‘mass swabbing workflows’. The Agency for Integrated Care took on the coordination of sending the samples to the National Public Health Laboratory (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 8th, 2021

Australia

There has sufficient access to COVID-19 tests – testing has been available for all residents and staff in aged care facilities. Testing is typically only done if an individual shows symptoms or is suspected of having COVID-19. Regular testing for all staff and residents has not been introduced (https://www.health.gov.au/node/18602/coronavirus-covid-19-advice-for-people-in-residential-aged-care-facilities-and-visitors).

Last updated: September 8th, 2021

Austria

By 16 April 2020, the Austrian government had announced plans that staff and residents in care homes should be systematically tested. A paper reports some reluctance in the implementation of testing in LTC services, especially in community care. However, it was also reported that residents ‘were scarcely tested’ up to January 2021 and that communication of test results did not always happen in good time (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

By November 2020, care home staff had to undergo compulsory testing on a weekly basis, but regulation allowed staff to continue working following a positive test if they do not show symptoms, their Ct value is above 30 and they ware an FFP2 mask (https://ltccovid.org/2020/11/27/the-second-wave-has-hit-austria-harder-also-in-care-homes/).

Last updated: September 8th, 2021

Canada (British Columbia)

In care homes: Initially testing was only completed for symptomatic staff and patients, those experiencing “influenza-like illness (ILI) or respiratory symptoms, clients with fever without known cause, and clients experiencing other symptoms possibly due to COVID-19”. Contact tracing was completed by both public health authorities and the LTC facility itself. Residents who share rooms with the infected resident should be considered as exposed and should be monitored for symptoms at least twice a day for 14 days from last date of exposure (http://www.bccdc.ca/Health-Info-Site/Documents/COVID19_LongTermCareAssistedLiving.pdf). Staff wearing all appropriate PPE are not considered a close contact of a patient who tests positive (http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/testing-and-case-management-for-healthcare-workers).

Last updated: September 8th, 2021

Denmark

The general strategies for testing have changed a number of times in Denmark, leading to some criticism for lack of transparency or evidence-based practice (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

The initial test strategy, introduced in early March, was aimed at preventing the disease from spreading, a so-called confinement strategy. This took place by testing persons who might have been exposed to the disease, even if they did not have symptoms. These were typically persons who were exposed during travelling (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

As of March 15th, the strategy changed to a mitigation strategy, targeting test measures to alleviate the consequences of the disease. Now only persons with symptoms were tested and following a referral from the GP. This led to concerns being raised such as from the WHO, which generally advised a more aggressive testing strategy. Nationally it sparked a debate that the new test strategy was a pragmatic and not a health-based decision, mainly due to a lack of testing equipment (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Since 27 April 2020, residents and staff without symptoms could also be tested if there was an outbreak in the nursing home. Testing must take place at the nursing home and not in the regional test centres, which are set up in tents (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

On May 12th, a new and more aggressive testing strategy was introduced, where persons without symptoms were also tested. The capacity was set to 20,000 persons on a daily basis and the ambition was to increase this number over time. This would make Denmark a country with one of the highest number of tests per inhabitants. There were two tracks in the new strategy:

– A health track, which includes testing of persons with symptoms, as well as employees of hospitals and nursing homes and patients admitted to hospital, even if they do not have symptoms. The test took place at regional hospitals. The capacity for this track was 10,000 daily tests.

– A societal track, which included testing of persons without symptoms. Testing took place in 16 specially set-up tents around the country, some of them with a drive-in facility. The capacity was for an additional 10,000 daily tests. Initially, only those aged 18- 25 years old could asked to be tested. This included around 600,000 persons and 4,500 persons were tested during the first day. During the first week, other age groups were included and, as of 25th May, there were no age limitations. (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Staff, working in the health and elder sector and some parts of the social sector, should be tested twice a week if they are not fully vaccinated. It is essential to implement a systematic, regular solution, which is easily accessible for the staff to secure comprehensive support from the personnel. Fully vaccinated staff can refrain from being tested regularly. This also applies to staff working in nursing homes, assisted living facilities, respite care, and social institutions, and in hospitals and the home care sector. Unvaccinated staff should still be tested regularly (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

In case of a discovery of a COVID-19 infection among a resident or an employee, all residents, if possible, should be tested within a day after contact with someone infected with COVID-19. The test is then repeated for the residents who are not fully vaccinated, every 7 days, until there are no more instances of COVID-19 at the institution. Personnel, including temporary staff and cleaning staff have to get tested even if they have no knowledge of being in contact with the person concerned and are fully vaccinated. The test must be taken as quickly as possible. Preferably within a day after they have received information, they must get tested. The test must be repeated every days for the personnel who are not fully vaccinated until there are no more outbreaks at the institution. It is a case of extra testing on the basis of caution, and the test does not require self-isolation for the staff member/s who can work while they wait on their test results (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

Finland

Access to testing in Finland was at first relatively restricted and has been steadily increasing. Nearly 3.2 million tests for COVID-19 have been conducted as of February 21st, 2021, but the increase in access to test only began in late July 2020 (https://experience.arcgis.com/experience/92e9bb33fac744c9a084381fc35aa3c7).

Last updated: September 8th, 2021

France

As with guidance, the sector decried that testing for care homes and in the community was made widely available too late – guidance published on 21st March 2020 limited tests only to symptomatic older people. Changes were made in April to grant priority access to testing for care home workers and residents, to test and isolate the first symptomatic care home worker (leading to isolation of all workers) and the first symptomatic older person, and the following three. On 20th April 2020 pressure was raised to extend tests beyond the first three residents as many asymptomatic cases were missed (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It was only from 6th May that all contacts of symptomatic cases were tested (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It is unclear how much testing was allowed for domiciliary care workers.

Last updated: September 8th, 2021

Germany

The German Federal Ministry of Health has put in place a national testing strategy. Testing is to be provided and paid for by the sickness funds for people with COVID-19 related symptoms, people without symptoms but close contact to a person infected with COVID-19, people in shared social  spaces (e.g. schools, day care centres, refugee centres, prisons) if a positive case has been recorded, staff, patients/residents in residential care settings/hospitals following an outbreak, patients/residents before (re)-entering residential or ambulatory care and staff of health and long-term care setting. Some groups/circumstances are only eligible for rapid tests. (https://www.bundesgesundheitsministerium.de/coronatest.html).

Rules vary between federal states, but LTC staff working in residential or domiciliary care settings have to be tested regularly (https://pflegenetzwerk-deutschland.de/fileadmin/files/Corona/210317-Uebersicht-Testfrequenzen-Laender.pdf).

Health authorities are responsible for contact tracing. Earlier in the pandemic teams were expanded to at least 5 people per 20,000 residents. In addition, affected areas received support from additional teams as well as the armed forces. An app was also been issued to facilitate contact tracing. However, rates have been consistently too high to ensure that contact tracing can be done consistently. It is estimated that all contacts can be traced again when a seven-day incidence of 50 new infections per 100,000 people or below is reached again. The federal government is supporting the individual states (https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1841048https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1744224 ). A new open-source software was due to be issued to local health authorities, however, so far this software does not offer all promised features and has not been consistently taken up by all health authorities. Other associated costs will be covered by the federal ministry of health (https://www.aerztezeitung.de/Politik/Warum-die-einheitliche-Corona-Kontaktnachverfolgung-holpert-416538.html).

Robert Koch Institute guidelines recommend that contact tracing in residential care settings should be prioritised. The guidelines outline the different levels of contacts and outline responsibilities of the health authority (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Kontaktperson/Management.htmhttps://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFilel).

Two-third of care homes surveyed as part of a study conducted in April/May had implemented clinical monitoring and found that it took on average between 3 and 4 days for care workers and people who use LTC to learn the results of their COVID-19 test (https://www.uni-bremen.de/fileadmin/user_upload/fachbereiche/fb11/Aktuelles/Corona/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

Last updated: September 8th, 2021

Israel

Access to testing in Israel was considered slow in Spring 2020, and ramped up by summer with the promise of 20 million tests by the end of 2020 (https://www.gov.il/en/departments/guides/mof_economic_plan?chapterIndex=2).

Magen Avot V’Emahot changed their policy in early May 2020 from testing symptomatic staff and residents to regular screening regardless of known COVID-19 presence. Numbers gathered from these screenings were deemed key figures in determining potential outbreaks, and rates of illness decreased dramatically (and proportionally with the nationwide numbers) by early June 2020.

Last updated: September 8th, 2021

Japan

Japan did not pursue a policy of mass testing, instead focusing on the 3Cs (closed space, crowded places, close contacts (https://www.mhlw.go.jp/content/3CS.pdf) and pursuing rigorous retrospective tracing) (https://thediplomat.com/2020/06/japans-pragmatic-approach-to-covid-19-testing/).

Last updated: September 8th, 2021

Netherlands

Access to testing was limited in the beginning of the pandemic and restrictive policies prevented access to testing for care homes. Testing capacity was limited and restrictions lasted until June. 2020. A new testing policy announced on 6th April 2020 allowed all healthcare workers (including LTC staff) to get tested when they developed symptoms (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf).

Criteria for testing have been broadened over time but testing capacity remained a challenge (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 8th, 2021

Republic of Korea

South Korea is notable for the speed of their drive to mass test, as early as February/March 2020. The government built hundreds of high-capacity screening clinics and worked closely with the private sector to ensure an adequate supply of tests. This enabled early testing of care home residents and staff. In March 2020, at one care home in Daegu, more than 70 patients and employees tested positive for the contagious disease, including 17 staff (https://world.kbs.co.kr/service/news_view.htm?lang=e&Seq_Code=152108). Diagnostic tests were conducted for 460 inpatients in LTCHs who were being treated for unknown pneumonia, as early as 5th March 2020. According to the Korean Convalescent (long-term care). In October authorities focused COVID-19 testing on all employees and patients of long-term care hospitals, mental health care providers and care homes located in the wider capital area, totalling around 160-thousand people (http://world.kbs.co.kr/service/news_view.htm?lang=e&id=Dm&Seq_Code=156889).

Regarding ‘healthcare workers’ operating across various settings including long-term care centres, there were clusters of outbreaks in Daegu within long term care centres. The government tasked health officials with conducting universal Covid-19 tests by RT-PCR for everyone in those facilities. Confirmed Covid-19 patients were transferred to a designated Covid-19 hospital or a community treatment centre. These centres with outbreaks were reinspected regularly. (https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0159).

The central and local governments respond to infected cases rapidly by tracing each case and isolating contacts. For the epidemiological survey, interviews are conducted with patients, families, and also healthcare workers, if necessary more objective data including medical records, mobile GPS, CCTV, credit card records, etc., may be collected and verified. Information about the travel routes of infected cases is provided on a website run by the government, in which no information that can identify a person is provided.” (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: September 8th, 2021

Sweden

The Corona Commission and other reports elaborate on shortcomings in testing strategy, particularly a scarcity of testing kits at the beginning of the pandemic. During the peak of the first wave in April, care home residents, homecare users and eldercare staff were not prioritized for testing. The Swedish Public Health Agency’s testing strategy was initially focused on active infection tracing, from mid-March patients who came to the hospital were tested first, followed by hospital employees, and those with community-leading occupations, followed by social care staff. Municipalities and social care providers could buy tests from private companies to test social care staff and service users. However, it was not until June 2020 when the government advocated increased testing activities and promised to cover the costs. The Swedish Public Health Agency was criticised for not giving clear signals earlier to the regions to increase the testing rate and although the agency pointed out that it did not want to overburden the healthcare system, it admitted that testing of, for example, staff in long-term care should have been started earlier. Overall, by the time of the second wave tests are widely available e.g. citizens can test themselves with home test kits delivered to their doors (Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf; https://www.vilans.org/wp-content/uploads/2020/12/covid-19-in-long-term-care-until-october-31.pdf).

 

 

Last updated: September 8th, 2021

3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector

England (UK)

The Government has faced criticism and legal challenges for failures in the availability and distribution of PPE, particularly in the early phase of the pandemic. There was a significant shortage of PPE (face masks, aprons, gloves and visors). Furthermore, the central stockpile was designed for a flu pandemic (https://www.nao.org.uk/wp-content/uploads/2020/06/Readying-the-NHS-and-adult-social-care-in-England-for-COVID-19.pdf; https://goodlawproject.org/news/the-ppe-fiasco/). In the view of the British Medical Journal, the Government ‘failed to protect staff in the NHS and social care by not delivering sufficient amounts of personal protective equipment (PPE) of the right specification, again deviating from WHO advice’ (https://www.bmj.com/content/369/bmj.m1932). Directors in the social care sector specifically pointed to ‘a critical lack of PPE and testing of social care staff and service users is putting them at unnecessary risk of exposure’ (https://www.adass.org.uk/statement-by-adass-and-unions-on-ppe-in-the-care-sector). Resentment about prioritisation of the NHS for distribution of PPE has been expressed (https://www.ft.com/content/6afb06d6-abd6-4281-ac16-74f500f096d0).

Initial steps announced on 18 March 2020, included the distribution of PPE to every care home and care home provider to ensure that they had at least 300 fluid repellent face masks for immediate needs, followed by a further tranche of items of PPE in early April (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). However, the government did acknowledge PPE supply shortages and published a PPE plan on 15 April with the goal that ‘everyone should get the personal protective equipment (PPE) they need’ (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). Announcements by the government about the number of items of PPE being delivered have been questioned. According to the BBC, over half of the 1.2bn items of PPE the Department of Health’s announced on 10 May for health and social care providers in England were surgical gloves, with gloves individually counted rather than in pairs (https://www.bbc.co.uk/news/health-52254745) and faulty equipment subsequently being recalled (https://www.carehomeprofessional.com/recall-notice-issued-for-faulty-ppe-masks-sent-to-care-homes/). It is not clear how the protective equipment delivered was divided between health and social care and there have been suggestions that delivery systems have been failing to provide to care homes, requiring them to secure their own supplies individually. One example reported was that of a care provider who was provided with 400 face masks while requiring over 35,000 masks a week (https://www.theguardian.com/world/2020/may/09/uk-care-homes-scramble-to-buy-their-own-ppe-as-national-deliveries-fail). In the survey of English care homes at the end of May and early June mentioned above, 70% of care home managers reported insufficient PPE supplies, with 34% of providers purchasing supplies directly from abroad.

In the social care sector providers have traditionally organised the PPE they required through the market. The adult social care action plan announced that the Government was now stepping in with arrangements to support the supply and distribution of PPE (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879639/covid-19-adult-social-care-action-plan.pdf). A parallel supply chain has been established for emergency PPE provision, involving new logistics networks and support from the army and including a national supply disruption response (NSDR) system to respond to emergency PPE requests, and a 24/7 helpline for providers who have an urgent requirement (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan).

Last updated: September 8th, 2021

Singapore

Already in 2018, Singapore introduced National Infection Prevention and Control Guidelines for Long Term Care Facilities. In addition, the Agency for Integrated Care provided webinars to review practices outlined with care providers and to provide up-to-date guidelines. In addition, the Ministry of Health issues current advisories.

The Agency for Integrated Care also drew on the national stockpile to ensure that all nursing homes, irrespective of provider, had sufficient levels of PPE. The supply of PPE was provided based on ‘the facilities’ staff size and level of precaution required of specific care services’ (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 8th, 2021

Australia

The Australian government worked with state and territory governments since the beginning of the pandemic to provide aged care facilities with PPE. As of October 2, 2020, 17 million masks, 4 million gowns, 11 million gloves and 4 million goggles and face shields had been provided to aged care facilities. But, even with this support, unions consistently reported PPE shortages within the facilities (https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 8th, 2021

Canada (British Columbia)

Health authority owned and operated facilities were supported in procuring PPE, managing staffing availability, and IPC education and training, whereas private and affiliate sites felt that they were left to manage independently unless an outbreak occurred. For example, one Health Authority provided PPE to private providers with 3 days notice, where others only provided supplies to health authority owned and operated facilities. Private LTC providers were left to source PPE through local community initiatives or unauthorized distributors, which often did not meet proper IPC requirements. Two policies were introduced regarding PPE: Emergency Prioritization in a Pandemic Equipment (PPE) Allocation Framework March 25, 2020 and Personal Protective Equipment (PPE) Supply, Assessment, Testing and Distribution Protocol May 1, 2020 (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 8th, 2021

Denmark

The shortage of PPE (and a decision to prioritize PPE for the hospitals) has influenced the recommendations for how to handle the disease in the nursing homes. Initially, physical distance was considered sufficient but later (when the supply of PPE seemed sufficient), wearing PPE was considered essential and regardless of whether there were symptoms of the disease. The reason for the shortage of PPE in the municipalities was that early in the outbreak (March 10th), the Danish Medicines Agency approached the providers of PPE and asked them to prioritize delivery to the regions and therefore for hospitals. The municipalities therefore needed to find other providers and this led to a shortage of PPE in the municipalities (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 8th, 2021

Finland

Access to PPE was an issue for Finland early on. In late March, the Ministry of Social Affairs and Health (MSAH) requested that the National Emergency Supply Agency release and distribute its stockpile to university hospital districts and municipalities. After expressed concern over lack of PPE in social care services/spaces, MSAH conducted a survey of municipalities that revealed 67% of respondents felt it impossible to follow the pandemic regulations, mainly because of a lack of protective equipment. For that reason, on May 13th the ministry mandated that the use of protective equipment was obligatory (https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view, page 27).

 

Last updated: September 8th, 2021

France

Access to PPE was delayed across the social care sector and is considered by the Senate as the key explanation behind the high level of Covid-19 infection in care homes (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). Until the end of April 2020 there were large insufficiencies in the provision of PPE despite a communication on 13th March stating care homes would have access where need was identified, and central/local conflicts, for example with the state requisitioning regional circuits to social care settings. Domiciliary care settings were hardest hit by PPE crisis, for example with guidance to local pharmacies holding masks to limit use to domiciliary care workers. Some domiciliary care agencies estimate the PPE received covered only 40% of their needs. Even where masks were allocated additional PPE including glasses and FFP2 masks and gowns were not accessible (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). One inspection authority followed employment regulation and condemned a domiciliary care agency for not having provided adequate PPE to employees (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Last updated: September 8th, 2021

Germany

Across Germany people need to wear surgical or FFP2-masks in public transports and shops since 19 January 2021.

Occupational Health and Safety Regulations stipulate that staff in care homes (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-stationaer_Download.pdf?__blob=publicationFile) and in home care (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-ambulant_Download.pdf?__blob=publicationFile) have to wear FFP-2 masks. In addition, full PPE has to be worn in high risk situations.

At risk groups (people aged 60 and older), people with specific medical risks and people with limited means (recipients of benefits) in Germany receive FFP2 masks for free (https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/schutzmv.html?fbclid=IwAR1ZsHTuu5cNRkbvqnAlRul821iBgJfopUoqu00ygGcODkuAG3ZalNltbXk).

The Federal Government has increased its stock of PPE and increased distribution as infection rates were rising in Winter 2020. The Federal Ministry of Health has also purchased rapid tests to facilitate opening up social life again (https://www.covid19healthsystem.org/countries/germany/livinghit.aspx?Section=2.1%20Physical%20infrastructure&Type=Section). However, rapid tests promised to the German population free by the Federal Minister of Health of charge from 1 March 2021 have been delayed. According to figures for the ECDC Germany is 22nd out of 27 countries in terms of testing (https://www.zdf.de/nachrichten/politik/corona-spahn-schnelltests-verschoben-100.html).

At the beginning of the pandemic federal states have taken different routes to support care providers with protective equipment. A detailed overview can be found here (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

A study conducted among LTC workers between April and May 2020 showed that respondents found procurement of PPE was quite laborious. Respondents would have preferred a centralised storage and distribution system. Respondents also requested systematic and regular COVID-19 tests as well as rapid tests and improved communication of test results (https://link.springer.com/article/10.1007/s00391-020-01801-7).

Already in February 2020, Germany was involved in plans to procure protective equipment for medical staff through a joint European initiative.  In early March 2020, Germany prohibited the export of protective equipment to other countries and the Federal Ministry of Health took responsibility to procure protective equipment for doctors’ surgeries, hospitals and federal authorities (https://www.bundesgesundheitsministerium.de/coronavirus/chronik-coronavirus.html).

 

Last updated: September 8th, 2021   Contributors: Klara Lorenz-Dant  |  

Hong Kong

Following a survey by the Hong Kong Social Workers and Welfare Employee Union in February 2020 that showed more than one quarter of respondents did not receive adequate PPE from their organisations, the Social Welfare Department gave 3 rounds of special allowances to procure PPE and sanitising items (total costs HK$34 million) to residential care homes for older people, community care providers and others. In additional, all residential care units were informed that they would receive 1 million face masks (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 8th, 2021

Israel

Israel faced a risk of limited PPE alongside most of the globe during its first lockdown in March/April. Little has been reported on the matter since, except for some coverage in September that indicated a shortage of gloves and robes/protective suits headed into the second wave (https://www.timesofisrael.com/as-infections-stay-high-officials-warn-of-ppe-shortage-in-israel-from-september/). In April 2020, the LTCF Association submitted an ‘urgent petition’ to the Israeli  Supreme Court, which included an emergency budget for protective gear. The petition was rejected, but became one of the main objectives of the national taskforce developed soon afterwards (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

Last updated: September 8th, 2021

Japan

Last updated: September 8th, 2021

Netherlands

PPE was scarce in the early months of the pandemic and hospitals were given priority in government efforts to alleviate the problem. This was reinforced by regional networks of emergency care (ROAZ) being given responsibly for distributing PPE, which disadvantaged LTC. During the first wave, 90% of masks went to hospitals and only 10% to nursing homes. Care homes were asked to make their equipment available to hospitals (https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

During the first wave it was reported that the use of PPE was strictly regulated due to shortage, could only be used under specific circumstances. Only those LTC personnel that were at risk received PPE. The Dutch Health and Youth Inspectorate inquired whether the LTC providers have sufficient PPE (24th April 2020) (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf).

Last updated: September 8th, 2021

Republic of Korea

The Ministry ordered and distributed low-cost masks for care workers. It’s not clear whether providers had sufficient access to PPE, however the government took pains to ensure domestic supply through centralised purchasing and limiting exports.

Last updated: September 8th, 2021

Spain

During the first wave, care homes that did not purchase PPE in January or early February at the latest, were unable to obtain PPE afterwards, with example of use of plastic bags or sharing of masks between staff (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 8th, 2021

Sweden

The Corona Commission highlighted that the lack of PPE in LTC settings contributed to the spread of the virus. It took unreasonably long to clarify and define the need for PPE in LTC, there were no channels to report needs or organise delivery. On February 2020, Sweden signed an agreement to enable joint EU-wide procurement of medical counter-measures, including PPE. Companies that produce PPE and medical devices expanded their production where possible (https://www.government.se/legal-documents/2020/10/dir.-202074/). Shortages of PPE have been identified as contributing to the spread of Covid-19 in care home settings. In the initial months the government recommendation was to follow the legislation on basic hygiene routines. The Public Health Agency mentioned the use of facemasks and shields in eldercare services in May 2020, however it was left to the local care homes or home-care units to decide whether to use masks and/or shields.  Only on June 25, the Public Health Agency recommended the use of shields and facemask in personal care of all care recipients with suspected or confirmed COVID-19.  The regions and municipalities are responsible for managing their own medical stocks including PPE, consequently there was no overall national picture of national situations.  Many municipalities did not have sufficient stocks of PPE (e.g. there was a shortage of alcohol disinfectants, gloves, protective coats, and face masks, while protective visors were usually not available at all) and they began to ration available equipment and prioritize the needs of hospitals. This in turn led to the recommendations when protective equipment was necessary in e.g. care homes being surrounded by strict conditions.

During the first months of the pandemic, the country lacked sufficient organization, logistics for warehousing and distribution while guidelines for the use of PPE in various care situations were also unclear.  It was pointed out that there have previously been shortcomings in basic hygiene routines and that the staff did not have sufficient competence to protect themselves and care users from infection (https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).The National Board for Health and Welfare (NBHW) was further designated to coordinate material supply to the healthcare among the regions, in order to ensure optimal use of the critical supply (https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812).

Last updated: September 8th, 2021

3.10. Use of technology to compensate for difficulties accessing in-person care

Overview

There is very little evidence available on the effects of the use of technology to compensate for difficulties accessing in person care. There is evidence around the introduction of programmes for people with care needs and their family carers, however, so far there is limited evidence of their effectiveness. A rapid review on unpaid carers found that carers identified a number of positive aspects but also barriers, and some people with care needs, especially people with dementia appear to face difficulties in recognising virtual conversation partners (https://journal.ilpnetwork.org/articles/10.31389/jltc.76/). Other researchers, on the other hand, suggest that with the right kind of tools these barriers can be overcome (https://journals.sagepub.com/doi/10.1177/1471301220924578).

The use of Telemedicine in care homes during the pandemic is discussed in this article, which reviews data on barriers to use and availability of internet access and provides recommendations to address the challenges to wider use of telemedicine in care homes: https://www.frontiersin.org/articles/10.3389/fpubh.2020.601595/full

Australia

The government of Australia announced over $1.5 billion AUD in funding for the aged care sector during the pandemic. A portion of this amount has gone towards telehealth development for people over the age of 70. The Department of Health also recommends that older people opt for telehealth appointments instead of in person appointments (https://www.health.gov.au/node/18602/coronavirus-covid-19-advice-for-older-people-and-carers#medical-appointments-and-medicines).

Last updated: September 8th, 2021

Canada

A study among unpaid carers in Canada using remote services reported some advantages but also disadvantages and some reported technical barriers (https://ltccovid.org/wp-content/uploads/2021/01/Lorenz_Comas_COVID_impact_unpaidcarers_preprint.pdf). A report recommends the use of technology to ensure care in place for people in residential care settings (https://www.ic.gc.ca/eic/site/063.nsf/eng/h_98049.html).

Last updated: September 8th, 2021

Canada (British Columbia)

Telemedicine and telehealth are covered under the Medical Services Plan. Individuals seeking care may also contact the non-emergency medical support phone line by dialing 811.

Last updated: September 8th, 2021

Denmark

The National Association for Older People organizes supports for using technology to access friends, social networks and health services (https://www.aeldresagen.dk/om-aeldresagen/lige-nu/corona/faa-gode-raad/saadan-ser-du-den-du-taler-med?scrollto=start).

Last updated: September 8th, 2021

England (UK)

A considerable proportion of unpaid carers in the UK reported to have used technology for social contacts, a smaller proportion for health and LTC services. The use of technology for remote support received mixed feedback (see, for example: https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf; https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01719-0; https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292; http://circle.group.shef.ac.uk/wp-content/uploads/2020/11/007_Aspect-Virtual-Cuppa-Report-4-compressed.pdf). On the other hand, a report by Age UK has found that there was no significant change in the use of digital engagement during the first few months of the pandemic. The main barrier reported for peopled aged 75 and older was ‘lack of digital skills’ (https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/active-communities/digital-inclusion-in-the-pandemic-final-march-2021.pdf).

A press release by the Department of Health and Social Care on April 24, 2020, described that they, together with the Ministry for Housing Communities and Local Government, had awarded up to £25,000 to 18 innovative digital solutions as part of the TechForce19 challenge. Among these, one app that received funding aims to ‘help carers identify health risks and deterioration within elderly communities’ (https://www.gov.uk/government/news/digital-innovations-tested-to-support-vulnerable-people-during-covid-19-outbreak).

Research accompanying the virtual Cuppa project, which offered unpaid carers the possibility to connect virtually for half an hour on weekdays with others in similar situations facilitated by a professional carer coach, found that over time carers developed friendships with other members of participating in the project, shared resources and experience, and that the virtual Cuppa group became ‘a resource in its own right to develop individual resilience’ (p.22) (http://circle.group.shef.ac.uk/wp-content/uploads/2020/11/007_Aspect-Virtual-Cuppa-Report-4-compressed.pdf).

Last updated: September 8th, 2021

France

Investment of 6bn euros across the health and social care system – for renovations and technology upgrades (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf0).

Telephone support lines were rolled out with some success for support, and according to the DGCS France has performed third worldwide after the US and China in the number of teleconsultations performed over the pandemic, especially in care homes (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: September 8th, 2021

Germany

A study among unpaid carers in Germany found that a considerable proportion of respondents started using technology for social contacts (https://www.socium.uni-bremen.de/uploads/Schnellbericht_Befragung_pflegender_Angehoriger_-_print.pdf).

Last updated: September 8th, 2021

Hong Kong

NGOs in Hong Kong have provided older people with tablet computers that provided them with access to home sports videos, cognitive training games and equipment to monitor their help. The system would inform relevant persons (medical teams/family) if the health monitor registered abnormality. Other NGOs offers videos for sensory stimulating activities anti-epidemic exercise or remote activities and counselling for people with mild to moderate dementia (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 8th, 2021

Israel

The Administration of Disabilities of the Ministry of Labor and Social Affairs provides services for people with intellectual developmental disabilities and other cognitive disabilities, individuals with autism, and individuals with sensory and motor disabilities. The initial action plan for COVID-19 included a transition to virtual education and community-building programs, the upstart of a food distribution program, and technology (e.g. tablet) distribution

Last updated: September 8th, 2021

Japan

There is little information on this. However, slow adoption of remote consultations in the medical sphere may also be an issue in the LTC sector (https://asia.nikkei.com/Spotlight/Coronavirus/Screen-shunning-doctors-open-up-to-telehealth-in-pandemic-era).

Last updated: September 8th, 2021

Sweden

Online physician consultations for care homes were implemented (https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

Last updated: September 8th, 2021

United States

In the US unpaid carers used technology for social contacts but also care related needs. Most reported useful aspects of technology, but some found adapting to online services difficult (https://ucsur.pitt.edu/files/center/covid19_cg/COVID19_Full_Report_Final.pdf;https://academic.oup.com/psychsocgerontology/article/76/4/e241/5895926;https://ucsur.pitt.edu/files/center/covid19_cg/COVID19_Full_Report_Final.pdf).

Last updated: September 8th, 2021

3.11. Vaccination policies for people using and providing Long-Term Care

Australia

COVID-19 vaccination in Australia began in late February 2021 and in June 2021 in phase 1a of their national rollout strategy. Phase 1a includes quarantine and border workers, frontline health care workers, and aged care and disability care staff and residents. As of March 2, 2021, 41,907 doses have been given in Australia, which corresponds to 0.17 doses per 100 people (https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/getting-vaccinated-for-covid-19/when-will-i-get-a-covid-19-vaccine; https://github.com/owid/covid-19-data/blob/master/public/data/vaccinations/country_data/Australia.csv). Aged care staff are in the highest priority group (1a) for vaccinations, however rather than being vaccinated at work with residents, they have been asked to obtain their vaccinations through their GP or at a vaccination clinic. This means that rollout has been slow, and data is difficult to obtain on how many long-term care staff have been vaccinated (https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/information-for-aged-care-providers-workers-and-residents-about-covid-19-vaccines/covid-19-vaccine-aged-care-readiness-toolkit/information-for-residential-aged-care-providers-to-support-covid-19-vaccination-of).

From 17th September 2021, residential aged care workers must be vaccinated against Covid-19 as a condition of employment. By 7th September 2021, 39% of the population aged over 16 are fully vaccinated and 63.8% have had one dose. Among aged care workers, 85.7% had had at least one dose and 64.1% had been fully vaccinated (https://www.health.gov.au/sites/default/files/documents/2021/09/covid-19-vaccine-rollout-update-7-september-2021.pdf).

Last updated: September 7th, 2021

Austria

On 26 December 2020 the Federal Ministry of Social Affairs, Health, Care and consumer protection published their COVID-19 vaccine prioritization recommendations. In the first phase, the highest priority group included residents and staff in care and nursing home, staff in health care sector with high risk of exposure and people aged 80 years and older. The second phase included people with existing illnesses (including dementia) and their closes contacts (especially of those living in residential care settings), domiciliary care workers, people aged 75 to 79 years. Since the end of December, 1,053,599 people have been vaccinated (appx. 275,000 of whom have received both doses). Starting March 2021, those 65 and older are eligible for vaccination, indicating successfully high rates of vaccination amongst the top two priority groups (https://info.gesundheitsministerium.at/en/).

Currently there is only a recommendation to get vaccinated in place for care staff, but no obligation. An obligatory regulation is also not foreseen in the near future. However, there is a law (Epidemiegesetz 1950) that could make this possible.

It is possible, however, when hiring new staff, that employers ask for tighter tests in the hospital or care sector (e.g. for measles, hepatitis, not influenza). Only in one region (Styria) there are some legal possibilities to oblige staff to have specific vaccinations done. In general, across Austria care personnel that are still undergoing training might not be accepted if no tighter tests are provided. Care homes deviate in their views on how to handle the situation (whether or not to make vaccinations obligatory).

Information in German on COVID-19 vaccinations for care personnel: https://www.sozialministerium.at/Themen/Gesundheit/Impfen/Impfempfehlungen-Allgemein/Empfehlung-f%C3%BCr-Gesundheitspersonal.html

Last updated: September 7th, 2021

Belgium

After an initial pilot in care homes, the official COVID-19 vaccination campaign started on 5th January 2020. By 31stMarch 2021, 1,868,577 doses had been administered, by that date, 73% of people aged 85 or more had had at least one dose and 26% had both doses. Care home residents and staff were prioritized for vaccination (https://covid-19.sciensano.be/sites/default/files/Covid19/COVID-19_Weekly_report_FR.pdf). On the 23rd March 2021 it was reported that 95% of care home residents in Flanders had been vaccinated, as well as 87% of staff (https://www.rtbf.be/info/dossier/epidemie-de-coronavirus/detail_coronavirus-95-des-residents-des-maisons-de-repos-de-flandre-vaccines?id=10725504). On the 5th March that 94% of all care home residents in Brussels and 92% in Vallonia had been vaccinated (https://www.rtbf.be/info/dossier/epidemie-de-coronavirus/detail_derriere-les-chiffres-9-residents-sur-10-vaccines-en-maisons-de-repos-les-deces-en-chute-libre?id=10712029).

In long-term care, management may not simply ask if someone has been vaccinated. For many people, vaccination does appear in a medical record (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 7th, 2021

Brazil

As of March 14th, 2021, 11.5 million doses have been administered in Brazil (8.63 million recipients of Dose 1, and 2.88 recipients of both). Approximately 3.5 million of these doses were given to those 80 and older, who, alongside healthcare workers have been Brazil’s top priority vaccination group since January 2021. We are not aware of data on vaccination in care homes (https://viz.saude.gov.br/extensions/DEMAS_C19Vacina/DEMAS_C19Vacina.html).

Although recommended at the federal level, the definition of priority groups in Brazil currently follows state and local protocols. The Brazilian vaccination strategy has been primarily focused on age, rather than risk or levels of exposure (except for healthcare professionals who were the first group to be vaccinated). More recently those with comorbidities aged 44 to 60 years have been included as a priority group. While in some regions of Brazil long-term care (formal\paid) workforce were included in the first priority groups to receive vaccines against COVID-19, along with residents, in other regions they remain unvaccinated or partially vaccinated. Scientific Societies like the Brazilian Geriatric and Gerontology Society reinforced the importance of vaccination for the long-term care workforce (paid and unpaid). Managers and workers engaged with the ‘Frente Nacional de Fortalecimento à ILPI’ claim that most workers at LTC facilities have now had access to vaccines, but there is a lack of formal evidence on this specific group. There are also no figures on family/informal carers, or domiciliary formal carers, vaccination rates.

(Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Canada (British Columbia)

Phase 1 prioritized LTC: residents and staff of LTC facilities, individuals assessed and waiting for LTC, residents and staff of assisted living residences, essential visitors to LTC and AL facilities (https://www2.gov.bc.ca/gov/content/safety/emergency-preparedness-response-recovery/covid-19-provincial-support/vaccines). Distribution depends on the province/territory jurisdiction – distribution difficult in northern areas, Moderna vaccine may easier to deliver than Pfizer (https://ltccovid.org/2021/01/25/the-rollout-of-the-covid-19-vaccines-in-care-homes-in-canada/). Pfizer’s discontinuation of shipment for week of Jan 25 sets back vaccination schedule (https://ltccovid.org/2021/01/25/the-rollout-of-the-covid-19-vaccines-in-care-homes-in-canada/). All LTC facility residents and the people who care for them have been offered vaccine in all health authorities around the province, as of February 9. Uptake is quite high, 87% of long-term care residents have received their 1st dose (https://bc.ctvnews.ca/all-residents-and-staff-of-b-c-s-long-term-care-homes-have-been-offered-vaccines-top-doctor-1.5288511).

Covid-19 vaccinations are not mandatory for long-term staff or any sector. As of April 30, 2021, 142,000 healthcare, assisted-living and long-term care staff in British Columbia (B.C.) had received vaccinations but the percentage of vaccinated staff in the province is unknown because not all provincial health authorities report total number of registered staff. 82.9 per cent of Vancouver Coastal Health’s eligible staff had received a first dose of COVID-19 vaccine, leaving more than 4,200 workers unvaccinated (https://www.cbc.ca/news/canada/british-columbia/bc-health-care-worker-vaccination-1.6008486).

The Ministry of Health is taking an educational approach, informing staff working in Long-Term Care instead of making vaccines compulsory (https://vancouversun.com/news/covid-19-high-rate-of-vaccinations-among-care-home-staff-dispels-anti-vax-fears).

Last updated: September 7th, 2021

Canada

COVID-19 vaccination policies are created by each of the thirteen provinces or territories. As a result, significant variation exists across the country. As of June 23, 2021, no jurisdiction in Canada has completely mandated COVID-19 vaccinations for long-term care (LTC) workers. Instead, five provinces (Ontario, Quebec, New Brunswick, Prince Edward island, and Manitoba) have incentivized vaccination through the introduction of policies for unvaccinated or partially vaccinated LTC workers including educational requirements, testing requirements, and employment restrictions.

The rest of the Canadian provinces and territories, including British Columbia, Alberta, Saskatchewan, Nova Scotia, Newfoundland and Labrador, Yukon, Northwest Territories, and Nunavut, have no policies mandating or incentivizing COVID-19 vaccination for their LTC home workers, although some are considering it. As of June 23, 2021, each provincial or territorial government has encouraged and recommended that their citizens get a COVID-19 vaccine but have not made it compulsory.

The Ministry Health is taking an educational approach, informing staff working in Long-Term Care instead of making vaccines compulsory (https://vancouversun.com/news/covid-19-high-rate-of-vaccinations-among-care-home-staff-dispels-anti-vax-fears).

As of April 30, 2021, 142,000 healthcare, assisted-living and long-term care staff in British Columbia (B.C.) had received vaccinations but the percentage of vaccinated staff in the province is unknown because not all provincial health authorities report total number of registered staff. 82.9 per cent of Vancouver Coastal Health’s eligible staff had received a first dose of COVID-19 vaccine, leaving more than 4,200 workers unvaccinated (https://www.cbc.ca/news/canada/british-columbia/bc-health-care-worker-vaccination-1.6008486).

Until December 2019, flu shots were mandatory for nurses working in BC. Nurses had to “vaccinate or mask”, with the latter requiring nurses to wear masks for the duration of their shift (https://www.cbc.ca/news/canada/british-columbia/b-c-nurses-no-longer-required-to-get-flu-vaccine-or-wear-mask-1.5384902).

Educational Requirements:

As of July 1, 2021, the Ontario government requires that LTC workers either show proof of vaccination, provide proof of a medical exemption from vaccination, or participate in a mandatory COVID vaccine education program to understand the benefits and risks of vaccination (https://news.ontario.ca/en/release/1000230/ontario-mandates-immunization-policies-for-long-term-care-homes).

Testing Requirements:

As of April 10, 2021, healthcare workers, including workers in LTC homes in Quebec, are required to show their employer proof of at least one dose of COVID-19 vaccination. If they are unable to provide this, they are required to undergo COVID-19 screening tests at a minimum of three times per week. If the worker refuses the screening tests, they can be redeployed to other work where possible (https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/lois-reglements/AM_2021-024.pdf?1618075211).

Similarly, in New Brunswick, unvaccinated LTC workers in homes where the vaccination rate is less than 50% are required to take a COVID-19 test every other day (https://www.princeedwardisland.ca/sites/default/files/publications/ltc_nursinghomes_staffmovement20210430.pdf).

Single-Site Requirements:

In Prince Edward Island and Manitoba, vaccines are not mandatory. However, they are highly encouraged as unvaccinated LTC workers cannot work in multiple care homes, which is a common practice in the Canadian long-term care sector. (https://www.princeedwardisland.ca/sites/default/files/publications/ltc_nursinghomes_staffmovement20210430.pdf; https://news.gov.mb.ca/news/index.html?item=51142&posted=2021-04-19).

(Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Chile

Currently all Covid-19 vaccines available have “Emergency approval in Chile” so there is no legal ground to make it compulsory. This might change in the future.

In July 2021, 87% of all residents and staff in Long-Term Care facilities had been fully vaccinated, of these, 96% had received the Sinovac vaccine and 4% Pfizer/BioNTech.

Sources: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/ and https://ltccovid.org/wp-content/uploads/2021/07/Chile-vaccine-effectiveness-LTCcovid-webinar-12-July-2021.pdf

Last updated: September 7th, 2021

China

In Mainland China, long-term care staff have been identified as the priority group to receive COVID-19 vaccination in national level. For now, there is no sign that Covid-19 vaccination will be mandated in law for long term care staff, however, in practice, local government and care providers have made vaccination compulsory already without passing any regulation. Care staff and care institutions have very high willingness be vaccinated.

Other vaccinations such as flu are not compulsory.

Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/

Last updated: September 7th, 2021

Czech Republic

Covid-19 vaccination is not compulsory for anyone. However, care home workers were among the first groups, together with health care workers, who were offered vaccination. The Czech Association of Social Services Providers published several surveys on progress in vaccination in social services – we published the findings in this article (in Czech only): https://socialnipolitika.eu/2021/01/socialni-sluzby-se-potykaji-s-nedostatkem-vakcin-i-informaci

There has been no specific vaccination campaign at national level targeting long-term care staff, nevertheless they are prioritized group, and were among the first groups who got vaccinated. There has been a more general campaign to promote vaccination among vulnerable groups and prioritized group of workers.

(Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Denmark

Denmark was one of the first countries to reach near full-vaccination of people living in care homes, concluding the first round of vaccinations by mid-February 2021, and by mid-March for older people who receive long-term care (https://www.sst.dk/-/media/English/Publications/2021/Corona/Vaccination/Vaccination-calender-1-July.ashx?la=en&hash=693CEA80FDA0FEF39BEC18FC1AA919E2A90D9567)

The Danish Health Authority has determined that the target groups for the vaccination programme should be given priority in the following order:

  1. Residents in nursing homes, etc.
  2. People aged ? 65 years who receive both personal care and practical assistance.
  3. People aged ? 85 years.
  4. Personnel in healthcare, elderly care and selected parts of the social sector who are at particular risk of infection or who has been identified as performing a critical function in society.
  5. Selected persons with conditions and diseases that result in a significantly increased risk of severe illness from COVID-19.
  6. Selected relatives of persons at significantly increased risk of severe illness from COVID-19 or relatives who are indispensable as carers.
  7. People aged 80-84.
  8. People aged 75-79.
  9. People aged 65-74.
  10. People under 65 years of age who have conditions and diseases that put them at risk of severe illness from COVID-19.
  11. Staff in other sectors critical to the functioning of society.
  12. The remaining population, for example prioritised according to age.

This prioritised order is based on a professional assessment on how best to protect vulnerable citizens and frontline staff (https://www.sst.dk/en/English/Corona-eng/Vaccination-against-COVID-19/Target-groups).

In November 2020 new legislation was proposed which would give the Danish Health Authority the power to “define groups of people who must be vaccinated in order to contain and eliminate a dangerous disease” (https://www.thelocal.dk/20201113/explained-what-is-denmarks-proposed-epidemic-law-and-why-is-it-being-criticised/). The proposal applied to diseases posing threats to public health; diseases which the global community are seeking to eradicate; diseases with a high mortality rate; or in instances where a person is deemed to be a danger to themselves or others (https://www.thelocal.dk/20201221/denmark-scraps-provision-for-enforced-vaccination-in-new-epidemic-bill/). In January 2021 the proposed legislation was not passed due to concerns about the use of coercion and physical detainment to control the disease. Any proposed future interventions will instead be on a case by case basis, requiring a parliamentary vote. The Health Minister noted: “we believe that information and openness are better for the vaccination case than threats and force” (https://www.thelocal.dk/20201221/denmark-scraps-provision-for-enforced-vaccination-in-new-epidemic-bill/).

In early September 2021 the vaccination rate among care home residents was 96% and it was announced that all care home residents will be offered a third those, following an increase in infections in care home during August 2021.

Source: https://www.thelocal.dk/20210903/denmark-to-offer-third-covid-19-vaccine-dose-to-care-home-residents/

Last updated: September 7th, 2021

England (UK)

On November 27, 2020, Public Health England (PHE) published their COVID-19 vaccine guidance for health and social care workers (https://www.gov.uk/government/news/phe-publishes-covid-19-vaccine-guidance-for-health-and-social-care-workers). On December 7, NHS England (NHSE) published a standard operating procedure on vaccine deployment for care home staff. This gave care home providers the responsibility to inform their staff, organise logistics, and encourage vaccine uptake (https://www.england.nhs.uk/coronavirus/publication/standard-operating-procedure-covid-19-vaccine-deployment-programme-hospital-hub-care-home-staff/).

On December 20, NHSE published information stating that a roving model to deliver the vaccine in care home settings was to be deployed as soon as possible. (https://www.england.nhs.uk/coronavirus/publication/staffing-support-to-deliver-the-covid-19-vaccine-to-care-home-residents-and-staff/). On December 30, NHSE published information which stipulated that vaccines should still be offered to older adults in care homes which have cases, although for those who are acutely unwell or within four weeks of the onset of COVID-19 symptoms, this should be temporarily deferred (https://www.england.nhs.uk/coronavirus/publication/guidance-for-covid-19-vaccination-in-care-homes-that-have-cases-and-outbreaks/).

On December 30, the Department of Health and Social Care (DHSC) published information on vaccination priority groups. Previous publications by the Joint Committee on Vaccination and Immunisation (JCVI) had stated that the first priority group for receiving COVID-19 vaccinations were residents in care homes for older adults and their carers. Frontline social care workers, including those who work in hospice care, are to be included in the second priority group. Carers of those with an underlying health condition should be offered vaccines alongside these groups, which is group six unless the person they are caring for is in a higher group (https://www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-30-december-2020).

On January 7, 2021, NHSE published additional operational guidance, further to the guidance from December 30, 2020. This stated that by mid-January, NHS Trusts would be established as hospital hubs, which were the default provider of COVID-19 vaccinations for all healthcare and social care workers. Significant progress is expected to be made by the first week of February, with vaccinations being provided 7 days a week (https://www.england.nhs.uk/coronavirus/publication/operational-guidance-vaccination-of-frontline-health-and-social-care-workers/). On January 11, DHSC published an update to their vaccine delivery plan. This aimed to have offered a first vaccine to everyone in the top 4 priority groups by 15 February. This stated that local vaccination services had a responsibility to coordinate and deliver vaccination to people who were unable to attend a vaccination site, such as the homes of housebound individuals, and residential settings for people with learning disabilities or autism (https://www.gov.uk/government/publications/uk-covid-19-vaccines-delivery-plan).

On January 13, NHSE published information regarding the next stage of the vaccine rollout in older adult care homes. The addition of the Oxford/AstraZeneca vaccine to the schedule from the w/c January 4 meant that smaller care homes could be vaccinated. First doses were expected to be administered to care home residents and staff by January 17, and by January 24 at the latest. This was to occur 8am to 8pm, 7 days a week. It was suggested that primary care networks had a responsibility to provide mutual aid to other PCNs to ensure that all care homes had been vaccinated by the end of the w/c January 18 (https://www.england.nhs.uk/coronavirus/publication/covid-19-vaccination-in-older-adult-care-homes-the-next-stage/). On January 14, NHSE published an update outlining the next steps for eligible social care worker vaccination. This reported that a national booking system was to be made available for eligible social care workers to self-refer. Until February 28, eligible staff will be able to self-book a vaccination (https://www.england.nhs.uk/coronavirus/publication/vaccinating-frontline-social-care-workers/).

On January 26, the National Care Forum (NCF) carried out a snapshot survey across 750 care homes for older people in England between January 25 and 26. Of these 750, 715 had achieved whole home vaccination, representing 95% vaccine take up. Whilst most organisations who responded noted that 50% or more of staff had been vaccinated, only 27% reported vaccination over 70% for their staff. The NHSE target to vaccinate all residents and staff by January 24 has been missed, and the next goal is the government objective of getting all those in JCVI groups 1-4 vaccinated by February 15 (https://www.nationalcareforum.org.uk/ncf-press-releases/vaccine-take-up-in-care-homes/). On February 15, the BBC reported the announcement from the Health Secretary that a third of social care staff in England had not had the COVID-19 vaccine. Everyone in the top four groups had been offered the COVID-19 vaccine (https://www.bbc.co.uk/news/uk-56065986).

On February 24, PHE reported that the JCVI had advised that all people on the GP Learning Disability Register were to be invited for vaccination as part of the JVCI group 6 (people with Down’s syndrome are included in group 4) (https://www.gov.uk/government/news/jcvi-advises-inviting-people-on-learning-disability-register-for-vaccine). On March 8, NHSE published an operating procedure relating to COVID-19 vaccine deployment for unpaid carers who will now be part of the JCVI cohort 6. Where the person they care for is part of the JCVI vaccine cohort 6, then they are able to receive their vaccination at the same time (https://www.england.nhs.uk/coronavirus/publication/sop-covid-19-vaccine-deployment-programme-unpaid-carers-jcvi-priority-cohort-6/?dm_t=0,0,0,0,0).

On March 10, Nuffield Trust released some analysis. This showed that by the end of February, fewer than 3 in 4 staff working in care homes for older adults had received their first dose. This showed regional variation, with rates highest in the North East and Yorkshire and lowest in London. Rates for other social care staff are even lower with fewer than 3 in 5 having had their first dose (https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-variation-in-vaccinating-the-health-and-social-care-workforce).

On March 22, The Telegraph reported that leaked details of a paper, ‘‘Vaccination as a condition of deployment in adult social care and health settings’, submitted to the Covid-19 Operations Cabinet sub-committee showed that the Prime Minister and the Health Secretary had requested that vaccinations become a legal requirement for care home workers. The legal change would be likely to affect England only, with health policy the remit of the devolved administrations in Wales, Northern Ireland, and Scotland. Only around a quarter of care homes in London, and half in other parts of England, have reached the level of vaccination among staff and residents deemed safe by government scientists, which SAGE set at 80% vaccination among staff and 90% among residents of a care home (https://www.telegraph.co.uk/politics/2021/03/22/care-home-staff-face-compulsory-covid-vaccination/).

On 4th August 2021 it was announced that full Covid-19 vaccination would be mandatory for staff working in care homes by 11th November 2021, despite concerns from providers that this may worsen existing staff shortages.

By 29th August 2021, 95% of all eligible residents and 82% of staff in older adult (65+) care homes had had a second Covid-19 vaccine dose. 78.7% of all care homes in England had had at least 80% staff and 90% residents vaccinated with at least one dose. Among younger adults living in care homes, 88.9% had had a second dose (https://www.england.nhs.uk/statistics/statistical-work-areas/covid-19-vaccinations/).

Last updated: September 7th, 2021

Finland

The vaccination rollout in Finland, determined by the THL and their vaccine expert taskforce (KRAR), prioritized older people (70+) and healthcare personnel. Finland receives its vaccines through the EU joint procurement plan (https://stm.fi/en/coronavirus-vaccines). Rates of vaccination by age can be found at (https://www.thl.fi/episeuranta/rokotukset/koronarokotusten_edistyminen.html).

 

Last updated: September 7th, 2021

France

Priority has been afforded to older people residing in collective housing and vulnerable people working there – following recommendations from the High Health authority. Vaccination is free. 2nd phase to be those over 75, then 65-74, then health professionals in health and social care over 50, and/or with comorbidities (https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/strategie-de-vaccination-contre-la-covid-19-point-de-situation-avec-les-acteurs). All vaccinations were planned to be completed in care homes by week ending 5/2/21 (BFMTV 04/02).

Coverage of other vaccinations (e.g. flu, MMR) has been decreasing in care homes in recent years, especially among those with Long-term conditions, and much below WHO targets. In 2006 vaccination against flu was made mandatory for care professionals but was revoked 10 months later. The Senate recommends having an open debate around mandatory vaccination of care home staff (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Covid-19 vaccination is not mandatory, but in 2005/6, legislation was passed mandating a number of other vaccines for health and social care staff. An amendment to the Public Health code of 2016 introduced a condition that health and social care professionals should be vaccinated if it presents a risk to those they care for. With equally low numbers of covid-19 vaccination across health and social care staff groups, the National Academy of Medicine has called for mandatory vaccination, stating it to be “ethically unacceptable” for health and social care staff (including personal assistants for older people) to not do so (https://www.lefigaro.fr/sciences/covid-19-l-academie-de-medecine-pour-une-vaccination-obligatoire-des-soignants-20210309). This would however require new legislation, rather than an amendment to existing legislation (https://www.lamontagne.fr/paris-75000/actualites/est-il-legal-de-rendre-la-vaccination-contre-le-covid-19-obligatoire-pour-les-soignants_13924992/). The issue was discussed in Autumn 2020 in the context of Covid-19 Winter planning (https://www.academie-medecine.fr/communique-de-lacademie-vacciner-tous-les-soignants-contre-la-grippe-une-evidente-obligation/#:%7E:text=En%20cons%C3%A9quence%2C%20l’Acad%C3%A9mie%20nationale,auxiliaires%20de%20vie%20pour%20personnes).

Most recent visiting guidance places the ethical responsibility for vaccination on care staff and highlights that full ‘return to normal’ is not possible without high vaccination rates among staff. In absence of vaccination for staff, these must be ‘very frequently’ tested (https://solidarites-sante.gouv.fr/IMG/pdf/allegement_post_vaccinal_des_mesures_de_gestion_ehpad_et_usld.pdf).

Most residents and 70% of employees have been vaccinated (1 or 2 vaccinations), as of April 16, 2021 (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 7th, 2021

Germany

Germany’s vaccination strategy has been described here (https://ltccovid.org/2020/12/18/a-brief-overview-of-the-current-german-covid-19-vaccination-strategy/https://www.rki.de/DE/Content/Infekt/Impfen/ImpfungenAZ/COVID-19/Impfstrategie_Covid19.pdf?__blob=publicationFile).

Progress has been relatively slow, but most people living in residential care setting had received the first dose by mid-February 2021 (https://ltccovid.org/2021/02/09/roll-out-of-sars-cov-2-vaccination-in-germany-how-it-started-how-it-is-going/). Ongoing progress can be seen through the vaccination dashboard (https://impfdashboard.de/).

Persons cared for in their own homes had to visit a vaccination centre for their immunisation as no mobile teams are deployed to these individuals. This is the case even if a home care service is employed as Registered Nurses in Germany are not allowed to administer vaccinations. Restricted mobility as well as impaired social, cognitive and financial resources can impede access to the vaccination centres. Home care services can be reimbursed for some limited assistance in these cases in some Länder. Support for this user group varies between the Länder.

Many people with disabilities have been isolating since March 2020. The focus of the vaccination on older people, people living in residential care setting and health care workers means that many people with disabilities living independently continue to wait for access to vaccines as they fall into Group 2 or lower. There has been criticism that people with disabilities, many of which are at high risk, do not have the same lobby as older people (https://www.deutschlandfunk.de/coronavirus-menschen-mit-behinderung-fuehlen-sich-im-stich.1773.de.html?dram:article_id=491066).

There is no mandatory Covid-19 vaccination in Germany for any group so far. There has been some debate about introducing mandatory vaccination for health and LTC workers earlier this year, but the Government has decided against it (https://www1.wdr.de/nachrichten/themen/coronavirus/corona-impfung-faq-impfpflicht-100.html). However, it is possible that vaccination will be a condition for participation in certain services such as air travel and tourism. There is substantial debate about vaccinated people having more “freedoms” than the non-vaccinated, especially once the vaccination passport is introduced in the EU. Some researchers strongly recommend making vaccination mandatory, given that vaccination rates among care home staff are reported to be low in some areas, e.g. Nuremberg (https://www.br.de/nachrichten/bayern/studie-aus-nuernberg-corona-impfpflicht-fuer-personal-in-heimen,SW3wZxz).

As of 7th September 2021,  61.9% of the general population) were fully vaccinated (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Sept_2021/2021-09-07-en.pdf?__blob=publicationFile).

Last updated: September 7th, 2021

Hong Kong

On 1st May, following discussions with the governments of Phillipines and Indonesia, and in light of concerns raised by  labour groups, the government abandoned their proposal to make Covid-19 vaccination mandatory for foreign-born domestic care workers (many of whom provide domestic services to older people in their own homes)  (https://www.todayonline.com/world/hong-kong-scraps-mandatory-vaccines-foreign-domestic-workers_). The proposal required foreign-born domestic workers to demonstrate they had received two doses as condition of approval or renewal of work visas. Covid-19 vaccination therefore remains voluntary in Hong Kong.

The Hospital Authority usually check all their new nurses for vaccination records and will “highly recommend” them to get vaccinated before starting employment. We are unsure about the current practice in Nursing Homes. The Hong Kong government has not published any data about the adoption of vaccination among healthcare workers.

Under the Residential Care Home Vaccination Programme administered by the Department of Health, it provides free Seasonal Influenza Vaccination and Covid-19 Vaccination for all residents and staff at residential care homes. Residents and staff who wish to receive vaccination would need to provide consent. Enrolled doctors, i.e. Visiting Medical Officers (VMOs), would administer vaccinations at residential care homeshttps://www.chp.gov.hk/en/features/21702.html. Besides, residents and staff can also arrange their own appointments to receive Covid-19 Vaccination in Community Vaccination Centres, private hospitals or clinics. Staff who have completed two doses of vaccination are exempted from the regular compulsory testing of Covid-19 https://www.covidvaccine.gov.hk/pdf/RVP_DoctorsGuide.pdf.

Last updated: September 7th, 2021

India

India’s vaccination programme for those 60 and older, and those deemed 45+ and high risk, began on March 1st, 2021. This coincided with the opening of a partially private market (e.g. vaccination out of pocket): approximately 10,000 government centres nationwide are offering free vaccinations, and 20,000 private hospitals charge the state-fixed rate of 250 rupees ($4.57). Over 12 million health, long term, and frontline workers have already been vaccinated through the state-funded program

(Sources: https://www.bloomberg.com/news/articles/2021-02-24/india-to-start-giving-covid-19-shots-to-the-elderly-at-a-costhttps://www.straitstimes.com/asia/south-asia/indias-covid-19-vaccination-for-senior-citizens-launches-to-relief-and-confusion).

Last updated: September 7th, 2021

Ireland

Family carers are not currently included on the Vaccine Prioritisation Programme in Ireland, this led Care Alliance Ireland to publish a position paper calling for vaccine prioritisation for Ireland’s family carers (https://www.carealliance.ie/userfiles/files/CAI-C19Vaccine_Position_Paper.pdf).

In Ireland, an international review of policies relating to mandatory vaccination for health care professionals was undertaken by the Health Information and Quality Authority (HIQA) in April 2021 (https://www.hiqa.ie/sites/default/files/2021-04/International_review-HCPs_who_do_not_avail_of_vaccination.pdf).

A report outlining advice to the National Public Health Emergency Team (NPHET)  by HIQA relating to this issue was also produced in April 2021. In this report, the evidence from the literature and input from the COVID-19 Expert Advisory Group was considered (https://www.hiqa.ie/sites/default/files/2021-04/Advice-to-NPHET_HCPs-who-do-not-avail-of-vaccination.pdf). The report states that, among the Covid-19 Expert Advisory Group, ‘there was a general consensus that mandating Covid-19 vaccination may not be appropriate at this time as this may act as a deterrent. Additionally, such a measure may be perceived as being overly harsh on a workforce that have had a particularly traumatic year. If all lesser restrictive measures have been exhausted and there is still low uptake, consideration may be given to mandatory vaccination in the future. However, caution was expressed with regards to how far one should go to ensure high levels of vaccination, and the potential creation of a negative work environment’. The advice given to NPHET by HIQA is to maintain a ‘support and encourage’ model, whereby staff are facilitated to make the decision to become vaccinated in a supportive environment’. According to the report, anecdotally, uptake and demand for COVID-19 vaccine among healthcare workers are currently high.

Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/

Last updated: September 7th, 2021

Israel

Israel has been globally recognized for its vaccination rollout (https://govextra.gov.il/ministry-of-health/covid19-vaccine/home-en/). By early February 2021, over 90% of individuals aged 60 years and older had received their first vaccine; by end of March some reports said that almost all nursing home patients have received both doses (https://www.nature.com/articles/d41586-021-00316-4). According to Ran Balicer, Chief Innovation Officer of Clalit Health Service and Chair of the Ministry of Health’s COVID-19 National Experts Team, much of the success of the scheme was due to its simplicity of prioritization categories (https://www.cgdev.org/event/how-make-covid-19-vaccination-success-policy-priorities-and-implementation-israel-and-around). Studies of how successfully the vaccination program was able to target residents of LTCF and geriatric hospitals are underway. One recent study highlighted the key role that Israel’s emergency ambulatory services, Magen David Adom, had in coordinating paramedic-led teams that were focused almost exclusively on vaccinating geriatric hospitals (https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(21)00058-1/fulltext).

By February 2nd, 2021, Magen David Adom, the national emergency services system in charge of the vaccination rollout in LTCFs, announced it had completed its vaccination of all residents and employees of LTCFs (sheltered housing and nursing homes in Israel)– the first country in the world to do so. (source: https://www.mdais.org/en/news/first-in-the-world).

The Green Passport gives vaccinated people access to most places in society and is seen as an incentive towards vaccination. There was some discussion of mandatory vaccination but this was not taken forward (https://www.timesofisrael.com/energy-minister-proposes-enacting-mandatory-vaccinations-report/).

At the end of July 2021 it was announced that Israel would start offering a third dose of the vaccine to the whole population aged 60 or over.

 

Last updated: September 7th, 2021

Italy

On December 12th, the Ministry of Health published the Italian strategic plan for the vaccination against Covid-19. The plan identified three priority groups for the vaccination: 1) Front-line health and LTC personnel, 2) Nursing homes’ residents, 3) People aged 80 or above. These three categories accounted for 6,416,372 people, almost 11% of the Italian population. The vaccination rollout has been considered relatively slow, with only 1.4 million people having received both doses so far due to supply chain issues in February. There has also been criticism that older citizens have not been prioritized in practice as they were in the original plans (only 30% of vaccination doses have been given to those over 70). The government is making a major push to accelerate vaccination rates up to 600,000 per day in March (https://ltccovid.org/wp-content/uploads/2021/01/COVID-19-vaccine-and-LTC-prioritization-and-data-18-January-update.pdf; https://www.ft.com/content/fd60a722-2019-4094-a778-750a0e8a0931; https://www.thelocal.it/20210302/56-million-by-june-italys-plan-to-accelerate-vaccines-under-new-pandemic-commissioner/).

As of March 2021, Covid-19 vaccination is mandatory for health professionals working in health and social welfare settings, which may include, for example, GPs, nurses and pharmacists who are deployed in social care settings (https://www.reuters.com/article/us-health-coronavirus-italy-vaccine-idUSKBN2BN34F). Those who refuse cannot have their employment terminated (https://www.ipsoa.it/documents/lavoro-e-previdenza/amministrazione-del-personale/quotidiano/2021/05/15/vaccino-anti-covid-obbligo-personale-sanitario-tanti-dubbi-certezza).

Instead the employer is responsible for either transferring the employee to another job where the risk of spreading infections is lower (without affecting salary) (https://www.politico.eu/article/italy-health-workers-coronavirus-vaccinations/), or enforcing unpaid leave, with suspension of pay until December 31, 2021 (https://www.politico.eu/article/italy-health-workers-coronavirus-vaccinations/; https://www.filodiritto.com/vaccino-covid-e-obbligatorio-riflessioni-critiche). There is a lack of clarity over which health and/or social care professionals must be vaccinated by law (https://www.ipsoa.it/documents/lavoro-e-previdenza/amministrazione-del-personale/quotidiano/2021/05/15/vaccino-anti-covid-obbligo-personale-sanitario-tanti-dubbi-certezza). There are questions about whether this applies to new employees given the need to respect private information when hiring new staff. There has been much discussion on making vaccination compulsory for long-term care staff, however the vast majority of political parties are against such an approach (https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/).

Last updated: September 7th, 2021

Japan

Japan has been relatively slow to roll out vaccines. Vaccination started in April 2021 for all people aged 65 and over, followed by care home staff from June but it faces issues with high levels of vaccine hesitancy (https://www.theguardian.com/world/2021/jan/28/japan-faces-olympian-task-slow-start-covid-vaccinations). Japan also faces logistical difficulties in roll out of the Pfizer vaccine in that it lacks sufficient syringes to deliver it (https://www.theguardian.com/world/2021/feb/10/japan-pfizer-vaccine-doses-wrong-syringes). There do not appear to be plans to prioritise people who live in care homes.

Last updated: September 7th, 2021

Kenya

The Ministry of Health in Kenya prioritized the use of COVID-19 vaccine based on the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Roadmap and targeted high priority groups (at higher risk of exposure) (Africa Medical and Research Foundation (AMREF) https://amref.org/coronavirus/vaccine/) such as health care workers, other front-line workers, individuals above 50 years as well as adults with underlying conditions. Although the Ministry of Health urged eligible populations to receive the vaccines due to the high transmission rates (10-11%), it is not yet mandatory and an individual may decide not to be vaccinated. Whilst receiving the vaccine is very important for all Kenyans, the government is only able to use a phased approach to provide vaccines to different populations in order to reduce the risk of social injustice in case there is inadequate supply of vaccines.

(Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Malaysia

Covid-19 vaccination is voluntary. The government required care homes to submit name lists by end of February but, in May 2021, they had not yet delivered vaccines to care homes. So far 400 out of an estimated 1500 homes in Malaysia have submitted name lists, constituting 300 of the estimated 350 legally-registered home and only 100 out of the 1000 or so unregistered homes. So far, the Ministry of Health and Department of Welfare have not guaranteed protection against prosecution for homes that are unregistered and this may be reducing the willingness of unregistered homes to submit name lists for vaccination. Most healthcare workers have been vaccinated and the country is now well into the second vaccination phase, which targets vulnerable groups.

(Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Netherlands

Nursing home residents and residents of homes for people with intellectual disabilities were put in the top priority group alongside healthcare personnel; as of early March, 149,711 people living in nursing homes and long-term care facilities have received both doses. As of March 7th, 2021, 64% of people over 90 living at home had received their first vaccination and 12% their second. 73% of people aged 85-89 living at home, and 63% of people aged 80-84 living at home have received their first (https://www.rivm.nl/en/covid-19-vaccination/figures-on-covid-19-vaccination-programme).

Vaccinations are voluntary, according to guidelines of the ministry of Health Welfare and Sports. This statement is supported by all professional associations in the long-term care sector. In accordance with the General Data Protection Regulation (GDPR) by the European Union (EU), it is not mandatory for employees to inform their employer of their vaccination status. Among politicians and within the media, debate about making vaccinations for long-term care staff compulsory has been limited. There has been some discussion about the legal grounds on which an employer could change the terms of employment for employees who work with vulnerable people and refuse to be vaccinated (https://www.skipr.nl/nieuws/weigeren-ongevaccineerde-zorgmedewerker-mag-in-uiterste-geval/).

In December 2020, before the vaccination program was rolled out, some polls found that vaccine hesitancy among healthcare personnel (in long-term care and other healthcare sub-sectors) was about 30% (https://www.volkskrant.nl/privacy-wall/accept?redirectUri=%2Fnieuws-achtergrond%2Fvaccinatiebereidheid-onder-zorgpersoneel-laag-blijkt-uit-peiling-slechts-een-derde-wil-coronavaccin%7Eb3875965%2F&authId=b64a1a22-28ba-4848-b512-68eeb08b1dde). Currently this hesitancy is lower (https://www.ad.nl/gouda/waarom-steeds-meer-zorgmedewerkers-een-coronaprik-halen-het-besef-dringt-nu-door~a603518d/?referrer=https%3A%2F%2Fwww.google.com%2Fhttps://www.rtvoost.nl/nieuws/1493157/Ziekenhuispersoneel-in-Twente-laat-zich-massaal-vaccineren-Ongelooflijk-blij-mee). However, overall and exact numbers are missing.

The National Institute for Public Health and the Environment [RIVM] shows that among the total Dutch population approximately 90% are willing to get a vaccine, 5% are still in doubt, and 5% refuse (https://www.rivm.nl/gedragsonderzoek/maatregelen-welbevinden/vaccinatiebereidheid).

Last updated: September 7th, 2021

New Zealand

In NZ vaccinations are offered to LTC staff but not mandatory. Uptake has been high for staff. Currently vaccinations are being rolled out to Aged Residential Care facilities, and the process has been variable regionally. (Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Norway

As of June 29, 2021, 84% of nursing home residents had been vaccinated with two doses, and 7% had been vaccinated with one dose (Pfizer). Some of the nursing home residents cannot be vaccinated due to poor health (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

It is voluntary to take the vaccine. Healthcare workers cannot be fired if they do not want the vaccine. Employees in the health and care services do not lose their jobs if they don’t want to be vaccinated. The Norwegian Nurses Association and The Norwegian Medical Association have recommended to their members that they should take the vaccine. There are few people in Norway who will not take the COVID-19 vaccine (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 7th, 2021

Republic of Korea

South Korea has been relatively slower than other countries to vaccinate their population, however their inoculation strategy intends to prioritise frontline healthcare workers and older people. They aim to inoculate 10 million high risk people by July 2021. Their national pharmaceutical panel has urged caution over the use of AstraZeneca’s COVID-19 vaccine for people older than 65 (https://www.reuters.com/article/us-health-coronavirus-southkorea-astraze/south-korea-advises-caution-on-astrazenecas-covid-19-vaccine-for-elderly-idUSKBN2A508N).

On 17th August 2021, there were reports of concerns linked to outbreaks of post-vaccination infections in nursing homes (9 outbreaks  involving 159 people and 3 deaths since the last week of July. The possibility of a third “booster” dose for older adults and other people more susceptible was being discussed, but there was concern about lack of availability of vaccine supplies.

Last updated: September 7th, 2021

Singapore

Covid-19 Vaccinations have been voluntary for the whole healthcare sector (and country), but Care Providers proactively educate their staff and regularly report vaccination rates.  As of Mid-February, already 73% of healthcare workers had been vaccinated with at least 1 dose (the vaccination campaign started around Mid-Jan, so the coverage is likely much higher now) (https://www.moh.gov.sg/news-highlights/details/progress-of-covid-19-vaccination-programme/).

On the 3rd September 2021, the Expert Committee on Covid-19 Vaccination recommended that people aged 60 and over, as well as those who live in aged care facilities, should receive a booster dose of an mRNA vaccine six to nine months after the completion of vaccination with two doses.

Last updated: September 7th, 2021

South Africa

Covid-19 vaccinations are completely voluntary in South Africa.  The Constitution protects individuals’ rights to decide for themselves, without due influence.  Care homes strongly encourage vaccination of staff (flu and Covid-19) but cannot make it compulsory or preclude staff from coming to work (this would become a labour law issue).  The phase 2 of vaccination (general population – beyond health care workers) started during May 2020 and, at least the in Western Cape (if not the whole country) people in Long-Term Care Facilities and people aged 60 or over were being prioritized.

Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/

Last updated: September 7th, 2021

Spain

Spain’s vaccination programme began in early January 2021, with nursing home and long-term care facility residents in the highest prioritization group alongside frontline healthcare workers. Vaccination campaign responsibilities fall to the individual regions.

In Spain, like with any other vaccine, vaccination for COVID-19 is voluntary for all the citizens, including workers from the health sector and the long-term care sector. Workers from the health and the long-term care sector have been prioritized groups in the COVID-19 vaccination strategy, but vaccination is not compulsory (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion6_EstrategiaVacunacion.pdf).

Last updated: September 7th, 2021

Sweden

Vaccination started on 27th December 2020, after the approval of Pfizer/BioNTech vaccine by the European Union commission (Sweden is part of an EU cooperation on a joint agreement for the purchase of Covid-19 vaccines). Vaccination against Covid-19 is free of charge for everyone. The national plan for Covid-19 vaccination has been drawn up by the Public Health Agency of Sweden, the National Board of Health and Welfare, the Swedish Civil Contingencies Agency (MSB), the Swedish Association of Local Authorities and Regions (SKR), the national coordinator for Covid-19 vaccine, and infectious disease doctors and representatives from the regions. Vaccine availability will determine how quickly the vaccine can be offered to more people. The order of priority for vaccines is divided by 4 phases: Phase 1: Individuals who live in residential care homes for older people or who use home care services under the Social Services Act. Healthcare personnel working with this risk group. Adults who live with someone in this risk group. Phase 2 Other individuals aged 70 years or older. The oldest will be vaccinated first. Individuals aged 18 years and older who receive help under the Act concerning Support and Service for Persons with Certain Functional Impairments (LSS). This also applies to individuals aged 18 years and older who have been granted assistance allowance under the Swedish Social Insurance Code. Medical and care service professionals, including LSS, who work closely with patients and recipients of care (https://www.krisinformation.se/en/hazards-and-risks/disasters-and-incidents/2020/official-information-on-the-new-coronavirus/vaccine-medicine-and-treatment).

No vaccination is compulsory in Sweden and, comparatively, there is very high acceptance of all kinds of vaccines.  A survey from March 2021 showed that 91% of the population intended to take the COVID-19 vaccine when offered. There was some discussion (at the local level) that staff who refused vaccination would not be allowed to work directly with residents in care homes, but more recently that does not seem to be on the agenda (probably due to the clear evidence of the rapidly declining number of cases among residents once they have been vaccinated). From the beginning, care home staff were in the first priority group together with care home residents, but when there were problems with the amount of doses arriving, the vaccination of care home staff stopped and instead the recommendation is to prioritise only according to age (once care home residents and home care users have got their first dose).

As of June 2021, the vaccination rate of people living in LTC or receiving home care (priority group number 1 in Sweden) is 94% at least one dose, 89% fully vaccinated (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 7th, 2021

United States

The United States’ federal effort to get nursing and long-term care home residents vaccinated, known as the Pharmacy Partnership for Long-Term Care Program, partnered with pharmacies such as Walgreens and CVS to set up vaccination clinics in and around LTCFs. The federal program used a statistical formula that has significantly overestimated how many doses would be needed for long-term care facilities, leading some states such as Oklahoma and Maine to redistribute the federally-provided vaccinations to those 65 and older living at home. A map containing the number of doses distributed from this Long-Term Care Program specifically was shared on the CDC website.

On March 11th 2021, President Biden’s administration announced an updated timeline for vaccination across the country, making all adults eligible for vaccination by May 1st due to the success of vaccination rates of the highest priority groups.

On 18th August 2021, President Biden announced that the week of 20th September booster shots would start being administered to individuals who had had the second dose eight months before, the first citizens that will be eligible will be healthcare providers, residents in nursing homes and other older people. The President also announced that COVID-19 vaccinations would be mandatory for all Long-Term Care workers for Medicare and Medicaid services.

Last updated: September 7th, 2021

3.12. Measures to support unpaid carers

Overview

In the European Union, several Member States have reported increased reliance on unpaid  care during the first period of the pandemic, conse