Country reports: COVID-19 and Long-Term Care

These reports aim to document the impact of COVID-19 on people who use and provide Long-Term Care and the measures adopted by different countries to contain and mitigate the impact of the virus. They are updated regularly as new information becomes available. If you’d like to contribute a report for a country that is not listed, please email a.comas@lse.ac.uk

Australia

Report by Lee-Fay-Low published on the 24 April 2020

Key points

  • The Australian government made preparing the aged care sector for COVID a priority. On the 11th of March, $440 million was committed to aged care including addressing staff retention and surge staffing, improving infection control. Aged care providers have priority access to the national stockpile of PPE, and healthcare rapid response teams and staffing support when an outbreak occur in a facility or in home care.
  • In home care, the government has provided additional funding to support meals on wheels, televisitor schemes, allowed for flexibility in usage of funding, and asked for unsolicited proposals.
  • Nursing home visiting rules were introduced by the government on the 18th of March, limiting visitors to two people a day, to be held in private rooms. Many nursing homes introduced stricter rules, locking down facilities so that there are no visitors except for under special circumstances
  • There have been 55 nursing home residents diagnosed with COVID-19, of those 13 have died and 14 recovered, representing <1% of all COVID-19 cases and 17% of all deaths.
  • At time of writing, Australia has flattened the COVID curve and government and public discussion is shifting to softening provider-imposed total nursing home lockdowns and supporting the wellbeing of residents.

Austria

Report published by Andrea E. Schmidt, Kai Leichsenring, Heidemarie Staflinger, Charles Litwin and Annette Bauer, last updated on the 15th of May

Key points

  • The Austrian LTC system has been placed under huge pressure during the COVID19 crisis as it has not been considered the most important area of intervention from the onset. Masks and security gear were and partly still are missing in care homes and especially in home care. However, the number of cases as well as the number of deaths in care homes is likely to be much lower in Austria than in other countries.
  • The Austrian government has created a 100 million euro LTC support fund to help regional governments find alternative sources of provision, if informal carers who provide more than 70% of all care, or personal carers who cover about 6-7% of people in need of care, cannot might drop out due to illness, travel restrictions or other reasons.
  • An issue with the Austrian LTC system is its significant reliance on live-in migrant carers (personal carers) from the neighbouring Slovak and Czech Republics, but increasingly also from Romania and Bulgaria.
  • COVID19 travel restrictions are drastically challenging this model and regional governments have done little to safeguard the continuity of care at home by migrant carers.  After up to six weeks of round the clock care, carers who normally work two week shifts are suffering from physical and emotional stress, while those who are currently stranded in their home countries and are consequently unable to work, are left with no income during this period
  • Further debate about the model of ’24-hour care’ provision by live-in migrant carers in Austria is needed. This also needs to be addressed in a wider European context, as most countries are using the model without any regulations. This compromises the working conditions and social security of care workers and eventually the safety of people in need of care.
Brazil

Report by Fabiana da Mata and Deborah Oliveira, last updated on 6th May 2020

Key points:

  • The COVID-19 pandemic is on its ascending period in Brazil and mortality rates have risen exponentially;
  • Several initiatives have been implemented and recommendations have been published by the public sector to support unpaid carers, older and disable people, and Long-Term Care (LTC) professionals with regards to ways to protect from the infection;
  • There is a paucity of specific population data in relation to the pandemic (e.g. infection and mortality rates in people living in care homes vs. living at home) and most actions so far have been taken by the public health sector;
  • It is unclear the extent to which the private care sector (e.g. private care homes, health insurances) have been following national and international guidance;
  • Unpaid carers, vulnerable populations, and LTC workers have been mostly unassisted financially and with the necessary equipment to face the pandemic;
  • There is a lack of evidence on COVID-19 is affecting older people and those with disabilities living together with several other family members in vulnerable communities (such as “favelas”);
  • It appears that most of the actions so far have been carried out remotely or digitally, and there is a lack of information with regards to the extent to which such actions have reached those who do not have access to online information;
  • Brazil has a large proportion of the population who is illiterate or semi-illiterate and it is unclear the extent to which the preventative measures and recommendations implemented/published so far have taken into account individual literacy and health literacy levels.
Canada

Report by Amy T. Hsu, Natasha Lane, Samir K. Sinha, Julie Dunning, Misha Dhuper, Zaina Kahiel and Heidi Sveistrup, last updated 10 May 2020

Key points:

  • While there are many sources of data on the impact of COVID-19 on the Canadian population in general, timely information on the number of confirmed cases of COVID-19 in Canadian long-term care homes was less accessible until recent weeks.
  • As new information becomes available and cases evolved or resolved, we have observed changes to previously estimated prevalence and case fatality of residents in Canadian long-term care homes.
  • Case fatality rate among residents in Canadian long-term care homes is currently estimated to be between 26 to 29%. This is roughly 10 to 15% higher than the global case fatality rate among people over the age of 80.
  • Based on publicly available information from official sources, we have found that deaths in long-term care residents currently represent up to 82% of all COVID-19 deaths in Canada.
  • Difference in population size and density in each province, which influences the rate of community transmission, may partially affect regional differences in prevalence of COVID-19 cases in long-term care homes, rather than the proportions of provincial/territorial populations 80 years or older living in these settings.
  • Given the vulnerability of residents in long-term care homes, the proper implementation of infection prevention and control policies is the most effective strategy to reduce overall rates of deaths in this population.
  • Policy measures to ensure the adequate staffing, the limitation of movement of healthcare workers between multiple sites, access to personal protective equipment and ensuring that staff know how to use it properly will also be key in helping to prevent the continued spread of COVID-19 and associated mortality in Canadian long-term care home residents.

China

Report published on the 18th April by Cheng Shi, Bo Hu, Menglong Feng and Gloria Wong

Key points

  • In Mainland China, the national ministries and commissions have issued and updated a package of guidelines and circulars to support long-term care. Those policies mandated a high level of cross-sectoral collaboration and prioritization of long-term care services for older people.
  • A steering committee for providing guidance and integrating resources, and an integrative IT system for information and data sharing are crucial for the prompt and efficient reactions.
  • Key measures focus on coordinating acute and long-term care, preventing the virus spread in care homes, supporting for the home-dwelling older people with no or less care due to the COVID-19 and psychological counselling.
  • From the containment phase into the mitigation stage, the Chinese Government now focuses on the provision of regular health and social care services for older people.
Denmark

Report by Tine Rostgaard, last updated 27 May 2020

Key Findings:

  • COVID-19 has been contained in Denmark, with relatively few persons hospitalised and low mortality rates.
  • It has caused concern for frail older people and in particular nursing home residents, while there has been little debate about how home care users or staff are affected.
  • Nursing home residents make up 1/3 of COVID-19 related deaths (April 24th).

Reasons contributing to the relatively low number of nursing home residents affected by COVID-19 relative to other countries include: 

  • A quick lock-down of the country
  • A de-centralised and integrative approach to LTC.
  • Relatively few and large municipalities (98 in all) which ensures a more effective and co-ordinated approach.
  • Broad public support for and political attentiveness to LTC.
  • Due to de-institutionalisation, care for frail older people is more often provided in the home.
  • Care is provided by formally employed and trained staff.
  • The majority of nursing homes are public and modern in providing an individual abode.

Reasons that may have exacerbated the situation include: 

  • The testing strategy has changed a number of times and did not initially consider the need for nursing home residents and staff for being tested.
  • Initially, protective gear was prioritised for the health care sector, leaving the municipal care providers to find alternative ways to secure protection for their members of staff.
  • The guidelines regarding the use of protective gear in the nursing home sector has varied.
England

A report with estimates of mortality of care home residents linked to the COVID-19 pandemic in England, 17th May

Germany

Report by Klara Lorenz-Dant, last updated on the 26 May 2020

Key points

  • The German government has issued financial support and loosened monitoring for care providers during this pandemic so that the residential and ambulatory care that people receive can be maintained. As part of this approach, long-term care insurance will reimburse institutions providing care that incur additional costs or loss of revenue due to the COVID-19 outbreak.
  • The German government has announced an increase in care workers’ wages. In addition, care workers across Germany will receive a one-off bonus.
  • The German government has extended existing support for people with care needs and their unpaid carers.
  • Residential care settings across Germany have started to allow their residents to have visitors. The care settings must develop and implement complex safety protection plans to facilitate this.
  • The Robert Koch Institute (RKI) provides regularly updated guidance, recommendations and advice for specific care settings. This includes the establishment of zones to physically separate residents during outbreak and contact tracing.
  • The RKI issues a daily update on the number of confirmed and recovered COVID-19 cases as well as of the number of COVID-19 related deaths.
  • There is a lack of information and advice regarding the care of people living with dementia.
Hong Kong

Report by Kayla Wong, Terry Lum and Gloria Wong, updated on the 27 April

Key findings:

  • There have been 1,038 confirmed cases of COVID-19 as of 27 April 2020. On the positive side, there have been no frontline health care workers affected and no nursing home residents have been infected with the virus so far.
  • The Government and society responded very quickly and imposed strict policies to stem the spread of virus in community and long-term care facilities, including practice guidelines, financial support and special arrangements on health and social care services.
  • Non-Governmental Organisation (NGO) increased use of anti-epidemic measures and information and communication technology to support older people and their family members during the epidemic, including people living with dementia.
India

Report by Jayeeta Rajagopalan, Saadiya Hurzuk, Faheem Arshad, Premkumar Raja and Suvarna Alladi, last updated 29 May 2020

Key points

  • While there are a large number of elderly people with comorbidities in India, there is a limited data available on the proportion with long-term care needs.
  • There is no formal or organized long-term care system in the country. Long-term care is community based, with families primarily providing care.
  • The numbers of positive cases of COVID 19 in India have risen significantly since the first case was reported on January 30th 2020. As of 28th May 2020, there are 86,100 active cases, 67,691 cured cases and 4,531 deaths. There is no data on the prevalence of COVID-19 in people with long-term care needs or number of deaths.
  • The government has introduced several population level measures to contain the spread of COVID-19. These include: a nationwide lockdown to encourage physical distancing, establishing centres for COVID-19 testing, creating dedicated facilities for treatment, an app to facilitate contact tracing and guidelines/advisories for older people and people with disabilities.
  • Care homes are largely unregulated and there is limited data available on their activities. As a result, it is difficult to determine the extent to which infection protocol measures have been adopted by all care homes in the country.
  • There are no government guidelines directed specifically towards unpaid carers and people with dementia during the pandemic (as of May 28th 2020).
Ireland

Report by Maria Pierce, Fiona Keogh and Eamon O’Shea, last updated on the 13 May

Key points:

  • A census currently being undertaken across all nursing homes and other residential care facilities will provide better information on the pattern of COVID-19 and non-COVID-19 related deaths in nursing homes in Ireland.
  • The initial focus of emergency planning on the acute sector resulted in a belated prioritisation of residential care settings, which is now being addressed.
  • Ireland has a ‘mixed market’ for residential care for older people (public, private and not-for-profit providers) which presents challenges in terms of the consistent implementation of the additional measures required to contain the spread of COVID-19.
  • Nursing home providers require additional support to maintain nursing home staff availability and wellbeing during COVID-19.
  • The redistribution of home care workers to residential care will undoubtedly have implications for community care, which has received little focus during the COVID-19 emergency.
  • The shift in resources to the nursing home sector will likely place additional demands on family carers, who already provide the bulk of care to older people and people with dementia.
  • Issues raised by the COVID-19 pandemic underline the need for a thorough examination of the balance between home care and residential care for older people in need of care in Ireland after the current crisis.
Israel

Report by Sharona Tsadok-Rosenbluth, Gideon Leibner, Boaz Hovav, Gal Horowitz and Shuli Brammli-Greenberg, last updated on the 4th May 2020

Key points:

  • In Israel, as in most of the Western world, Long-Term Care is organized in a fragmented manner, with several government bodies responsible for LTC Facilities (LTCFs); this is likely to be one of the reasons for the slow response to COVID-19 in the LTFCs.
  • The first COVID-19 patient in Israel was diagnosed on February 27th and since then the number of confirmed cases has risen to 16,208 (as of May 4th), with 94 in serious condition and 232 deaths. Of the deaths, 80 were LTC residents (34%).
  • The outbreak in the Israeli LTCFs began in mid-March, sixteen days after the first patient was diagnosed in Israel.
  • Only a month after the initial outbreak, following massive public criticism and a call for help from the LTCFs managements, the Israeli government appointed a national-level team to manage the COVID-19 outbreaks in the LTCFs.

The national project called “Mothers and Fathers Shield” was initiated on April 12th, a week later, on April 20th, the project team published a national work plan which its main principles include:

  1. Establishment of a single headquarters to coordinate government efforts;
  2. Expanding the Home Front Command’s role – to train LTCF staff in protection against COVID-19 infection and to provide assistance in disinfection.
  3. Establishing COVID-19 patients care departments within each of the institutions.
  4. Increasing the scope of COVID-19 testing in LTCFs, including those with no identified COVID-19 patients.
  5. Managing the social distance of patients to mitigate loneliness.

Lessons learnt so far:

  • Covid-19 testing policy in LTCFs should be constantly updated and based on information and research that is collected and published on a daily basis. LTCFs, which are at high risk of infection, require a dynamic response and special attention to their needs.
  • In view of the fact that LTCF residents are especially vulnerable to pandemics such as COVID-19, and based on our experience so far, in the report we present a proposal of a three-step approach to controlling outbreaks in LTCFs.
Italy

Report by Sara Berloto, Elisabetta Notarnicola, Eleonora Perobelli and Andrea Rotolo, last updated on 30th April 2020

Key findings

  • The Italian government acted late on the COVID-19 outbreak management in nursing homes. The first operational guidelines were released after the country’s total lockdown on March 9th, only requiring care homes to suspend visitations. An update of the operational guidelines dedicated to nursing homes was released by the Ministry of Health only on March 25th. The first COVID-19 case was detected in Italy on January 30.
  • Regions are responsible for the operational regulation of the LTC sector: after the outbreak, they enacted late and different responses without a clear guidance from the national legislator.
  • Italy faced a massive shortage of Personal Protection Equipment (PPE): nursing homes were not prioritized for receiving new procurements. Workers and care users have not been sufficiently protected from the spread of COVID-19.
  • The National Institute of Health (Istituto Superiore di Sanità) launched a survey to investigate the incredibly high numbers of deaths registered in residential centres for older people, after the national press raised the attention on the potentially large underestimation of COVID-19-related deaths in care homes. Preliminary results confirm that the actual number of COVID-19 related deaths might be much higher than the one reported in official documents.
  • As of today, current procedures do not foresee testing older people in care homes, neither those who died after presenting symptoms.
  • Coordination with health care actors (mainly acute care but also general practitioners) has been limited and poorly implemented, mainly relying on professional linkages of individual professionals and without a regional or national framework.
  • The response to the COVID-19 emergency has been left to the initiative of each Nursing Home alone, relying on their capacity and willingness to cope with extraordinary conditions while having poor support from institutions.
Jamaica

Report by Rochelle Amour, Janelle N. Robinson and Ishtar Govia, last updated 25 May 2020

Key findings

  • While infirmaries have implemented precautionary measures against COVID-19, no formal protocol has been issued to privately owned nursing homes; these homes go largely unregulated. 
  • While some relief in the form of financial support and other provisions have been made available for essential workers, affected persons and vulnerable groups, some imperceptive procedures required to access this assistance have led to the inadvertent exclusion of unpaid caregivers and some vulnerable groups.
Jordan

Report by John Black, last updated 29 May 2020

Key actions taken to limit the spread of COVID – 19 in Jordan

So far, there have been no infection or deaths in care homes in Jordan. As of the 29 May there have been 728 cases of infection in the country and 9 deaths.

Country wide actions:

  • Travel bans, international travel with all flights to and from the country suspended since 17 March and travel limitations across the country with no cars being allowed on the road and restrictions on movement across Governorates.
  • Businesses have been closed temporarily particularly restaurants and other entertainment venues such as cinemas and children’s play activity centres. 
  • Curfews on a daily basis applied rigorously as well as occasional complete curfews lasting either 24 or 48 hours. 
  • Quarantine arrangements, with no option to either ‘agree’ to stay at home or sign a commitment to do so, with designated places, generally hotels, where you are required to stay for a minimum of two weeks. 
  • Medical and nursing staff working with those who are hospitalised with COVID-19, work a two week ‘shift’ in the hospital, without going home at all.  They then go into strict quarantine for two weeks before returning to work their next two week ‘shift’ in the hospital.  
  • Random testing for COVID-19 in areas where an infection has been confirmed. 
  • Social distancing in place for everyone. 

Long term care facilities – specific actions

  • A ban on all but absolutely essential family and other visitors to care homes with the exceptions being health visits by primary care doctors and senior officials. 
  • Staff at one long-term residential care centre working in three distinct teams and each team spends a full week working and actually living in the centre.  The three teams then alternate week about with each also then having two weeks off from work.  The same system being applied across all residential care facilities across the country. 
  • Daily monitoring of both residents and staff takes place routinely to check on their health condition. 
  • Safe hygiene practices being applied thoroughly and guidance strictly followed by all those working at the care homes.
Malaysia

Report by Kejal Hasmuk, Hakimah Sallehuddin and Maw Pin Tan, last updated 21st May 2020

Key findings

  • Malaysia has 19 government-run, 350 registered and over 1000 unregistered residential aged-care facilities
  • Home-based long-term care is currently unregulated in Malaysia
  • Welfare Department and Ministry of Health officials work closely with academics, care home representatives and civil society representatives to reach out to care homes
  • Malaysia has adopted a mass-testing strategy for all care homes, registered and unregistered, a rate of positive tests for 8% of care homes and of 0.3% staff/residents was reported after 180 of 1300 homes were screened. 
  • An “older persons” cluster has been reported which involved at least one care home.
  • Care homes lack basic PPE and have difficulty observing physical distancing within their confined spaces.
  • No visitors are allowed and care homes are discouraged from admitting any new residents
  • Care home residents with suspected COVID-19 will be admitted to COVID hospitals, with all other residents admitted for isolation and testing if necessary. 
The Netherlands

Report by Florien Kruse, Inger Abma, Patrick Jeurissen, last updated 26 May 2020

Key Findings:

  • After a significant peak in the number of deaths in week 15 (6 April – 12 April), the number of COVID-19 cases and deaths in nursing homes has been declining.
  • The Dutch government is taking a phased approach to relaxing the nursing home visitor ban while monitoring infections and deaths.
  • Nurses and carers in nursing homes and homecare organisations can apply for personal protective equipment (PPE) and can gain access to testing. However, care professionals still experience barriers in accessing (adequate) PPE.
  • Informal caregivers are also eligible to access PPE and testing.
  • Although some action has been taken to improve the collection of information in long-term care facilities (e.g. data on people with intellectual disabilities), significant information gaps remain about long-term care and COVID-19, especially how COVID-19 affects long-term care staff.   

Previous report: Florien Kruse, Toine Remers and Patrick Jeurissen, last updated 26th April 2020

Scotland

Report on deaths among care home residents in Scotland, by David Bell, David Henderson and Elizabeth Lemmon, last updated 17 May 2020

Slovenia

Report by Alenka Oven, version of the 20th April 2020

Key points:

Slovenia has made a strong commitment to testing to contain the spread of COVID-19. On the 17th April 2020 there had been 152 COVID-19 infections among health care sector staff, 117 among care home staff and 276 among care home residents.

Key challenges: 

  • Nursing homes lack skilled personnel
  • Nursing homes have space constraints that will make the effective isolation of residents that are suspected of having COVID-19 very difficult
  • Nursing homes may run out of PPE
South Korea

Report by Hongsoo Kim, last updated 7 May 2020

Key findings:

  • South Korea has not implemented massive lockdowns but the population has adhered to social distancing rules and cooperated to reduce the spread of the disease.
  • Key population-level measures that have worked well include: extensive testing and tracing using information technology; tests and treatments at no or low cost and covered by the health system; transparent communication between government and the public; extensive use of epidemiological data and travel route information.
  • So far, of 247 deaths linked to COVID-19 in South Korea on the 30th of April, 20 (8.1%) were people presumed to have been infected in nursing homes, and another 64 (25.9%) in Long-Term Care Hospitals. Deaths in both types of settings would amount to 37.6% of the total. However, there were no deaths in nursing homes as all residents with potential COVID infections were transferred to hospitals.
  • More aggressive approaches were used to contain the spread of COVID-19 in long-term care institutions and social welfare facilities, including nationwide monitoring and inspections, and cohort quarantines of selected facilities.
  • Additional preventative and supportive measures for long-term care institutions include temporary re-imbursement packages, low-cost masks for care workers and provision of guidelines.
  • No massive infections in long-term care facilities have occurred after these measures were implemented.
  • Containment measures for home-based care services have been relatively weak in comparison and have resulted in a reduction in people accessing these services and lack of support for unpaid carers.
Spain

Report by Joseba Zalakain and Vanessa Davey (with a contribution from Aida Suarez-Gonzalez), last updated 28 May 2020

Short and medium-term calls for action for Spain:

  • Infection prevention and control: from international experience we have learned that the best way to prevent COVID-19 infection in care homes is by preventing it from reaching in the home in the first place, which relies on controlling the spread of the virus in the community, or measures such as staff volunteering to live-in to shield residents from infection. However, once the virus enters a facility, a situation which has occurred in are homes throughout Spain, the most effective way to control its spread proved so far appears to be 1) blanket testing of staff and residents and 2) isolation of any positive cases. While the protocols now allow for blanket testing of staff and residents, with priority being given care homes where COVID-19 is present, testing in care homes has been slow to materialise, albeit with some notable exceptions. Given that much of the data that should have been made public has not yet been published it is not yet clear how far this has been achieved.
  • Care homes also need to be provided with resources to isolate individuals affected and, if this is not feasible (for many care homes it is unrealistic to isolate residents since their spaces are designed for communal living), local governments and institutions should provide the means for isolation to happen (e.g. transferring infected individuals to quarantine centres or other purpose-designed facilities). Such measures are central to the evolved guidelines that are in place across Spain.
  • In many areas in Spain, lack of official information on the situation in care homes is fueling anxieties. Given the complexities associated with confirming the true number of deaths from known or suspected COVID-19, the priority should be to release all available information on the current situation. Only two out of the seven items of information that the autonomous communities should be publishing relate to care home deaths (see table 3).  The remainder, are figures relating to the current situation (number of residents currently infected; number of resident hospitalised, etc.) that need to be released in order to evaluate progress with flattening the curve in care homes.
  • Adequate provision of personal protective equipment and efforts to hire and train new staff in their use are essential. The overall picture obtained during the production of this report, suggests that efforts must still be intensified. Again, greater transparency would increase trust and ensure that efforts can be targeted to where they are still required.  Best practice examples have shown that the third sector can be an important source of practical support but this requires collaboration that requires knowledge of current gaps.
  • Staff in care homes have taken on unprecedented levels of responsibility and had to work in physically and psychologically draining scenarios. The provision of psychological support does not appear to be widely available and must be prioritised. Also, financial compensation for the extra demands placed on staff (as has been employed in other countries) would help to boost morale.
  • COVID-19 has disproportionately impacted users of long-term care services, and especially care home residents. There are four types of factors which might explain this impact: a) the case-mix of care homes and the level of the spread of COVID-19 in the area where the care home is located; b) the structural factors that define the care home (size and architectural design; training, labour conditions and number of staff; private or public ownership; funding model…); c) the response of each centre when it came to preventing and treating the virus and capacity issues; and d) the support that care homes have been provided where needed, including timely provision of PPE and access to testing. It is essential to carry out a nationwide assessment in order to evaluate the measures that have been taken and clearly establish which factors have had the largest impact in the spread of the virus.
  • In the short term, clarifying the type of healthcare that care home residents should receive is urgent: when they should be admitted to hospital and when and how they should be cared for in the care home. People who become ill in a residential centre have a right to public healthcare, both general and specialized, as a result of their status as citizens. That they should have this right violated because of their age or disability status is inadmissible [118]. The rights of people with long-term care needs to access intensive care (ICU) need to be clarified and even regulated and guaranteeing that no discrimination would take place on the basis of age, long-term care needs, dementia diagnosis or other issues. Providing better health services in care homes is one of the major needs of the Spanish residential long-term care model, without necessarily converting care homes into medical centres [118].
  • Ensuring continuity of support for people living with dementia is crucial to provide compassionate care in COVID-19 times. Partners in care can be enabled to accompany their relatives or friends with dementia in hospitals and care homes by implementing appropriate infection control protocols and use of PPE. The use of technology to support video calls with friends and family when a person with dementia is isolated should be encouraged.

Longer term policy implications

  • The Spanish long-term care system lacks an adequate information management system and, more broadly, a shared innovation, evaluation and knowledge management model [73]. The COVID-19 crisis has highlighted the need for strengthening the current knowledge management and research and development efforts. For this, it is necessary to combine the central administration’s leadership with the local and regional administrations’ activity, aided by the impulse of the Territorial Board for Long-Term Care, and the creation of other inter-administrative cooperation forums. The development of an agenda for knowledge management in the field of Social Services only makes sense if it is assumed as the regional administrations’ own responsibility, although technical, political and economic support from central government will be essential [119].
  • In this context, there is also a pressing need for the development of a shared quality indicator system, not only based on structure and process indicators, but, mainly, on outcome indicators related to the quality of life. This will allow for the transition from a model that is exclusively based on the regulation and inspection of the processes to a model which is more oriented towards the impact of the care process on the users’ wellbeing and quality of life [9].
  • The COVID-19 crisis has highlighted the Spanish long-term care system’s shortcomings [120] and the need to develop a more community-based, more individualized and more person-centred model to achieving the best possible quality of life for people with long-term care needs and their families [17]. In this context, there is a need for a change in the long-term residential care model, so that older or disabled people can continue pursuing their life projects. It is vital that residential care centres provide attention which is centred on people, instead of viewing residents as objects to be taken care of. It is also necessary to evolve towards new architectural designs and organizational patterns which allow for personalized attention and smaller sized units  [118].
  • As has been stated earlier, the main shortcoming of residential centres is not just related to their economic resources but to their general orientation [17]. However, the question of economic resources is essential: a good quality long-term care system is costly, and there are a few Spanish regions which pay care homes below the rate it costs to provide care even at existing staff: resident ratios. The debate on the quality of residential care cannot be separated from the debate on the funding of the long-term care system [13].
  • The COVID-19 crisis has also brought to the surface systemic problems in relation to human resource management. Professional profiles are poorly developed in terms of competences and training, and working conditions are less than ideal. In contrast with the health care system’s response to COVID19, there has been a clear lack of leadership in the response to the crisis. The logic of the existing care home and home care  models respond more to organisational convenience than to person-centred care [120]. In this sense, professionalism within long-term care is weak and the labour conditions in care homes are often poor. This was already well known, but had not been considered a social (or political) priority. While this is not the only problem that needs to be solved in order to guarantee good quality care, it is a question that must seriously be considered [118].
  • The care home sector is increasingly dominated by private for profit providers, and there are longstanding concerns about decreasing quality standards as a result of efforts to contain costs in order to generate expected profit margins. The same issues are faced by public sector facilities that are managed by private providers. These factors may be behind the lack of preparedness to face a pandemic, which shows that most care homes are lacking infection control protocols, contingency planning for staff absences and the ability to procure personal protection equipment [120]. The private management model of public services undoubtedly requires strengthening the inspection and evaluation capacities of public administrations, as well as changes in contracting-out policies.
  • The governance of the Spanish long-term care system involves all three levels of government (central, regional and local), which makes the system very unwieldy. This complicated governance makes it very difficult to adopt and implement ambitious measures and it has created legal difficulties in relation to, for example, purchasing equipment and re-organizing the workforce in response to the pandemic [70].  The COVID-19 crisis should prompt the revision of the institutional and territorial framework of the social services system in Spain.              
  • Provision of post-diagnosis support for people living with dementia is almost non-existent in the public health and care system in Spain and, when provided, it relies mostly on the good will of healthcare professionals and third sector organisations.  Post-diagnosis support entails information, education, advice and training to live well with the condition (both for the person and the family) and other specialised support when needed such as access to psychological or speech and language therapies.  Post-diagnostic support teams, if they had been in place, might have played a major advisory role supporting people living with dementia and their families to adjust to the challenges imposed by the confinement and the disruption of other support services.
Sweden

A country report on the COVID-19 situation is under preparation, but this blog post by Marta Szebehely summarizes early evidence of impacts and key issues.

United States of America

Report by Courtney Harold Van Houtven, Nathan A. Boucher and Walter D. Dawson, last updated 24 April 2020

Key findings:

  • The US currently has the largest number of confirmed cases of COVID-19 of any country; a lack of widespread testing remains an issue.
  • Historical challenges within the US long term care (LTC) system that disproportionality impact individuals of low-socioeconomic status (SES) and certain racial and ethnic communities have been greatly exacerbated by the crisis.
  • The US federal political system ensures that individual states and the federal government have joint and overlapping responsibility for responding to the COVID-19 outbreak.
  • Significant regional differences in the impact of COVID-19 on health and social systems including LTC as well as on the response.
  • Near-term and long-term strategies for change in LTC policy are needed to adapt and respond to COVID-19.