Sweden – Resources to support community and institutional Long-Term Care responses to COVID-19

LTCcovid Country Profile – Printable Version

1.00. Brief overview of the Long-Term Care system

In 2019, over 160 000 of older people were provided with services and care in their own home and around 82 000 were provided with institutional care. A wave of closures of municipal institutional beds since the 2000s has resulted in a reduction of nearly 40% of all municipal places (source: Johansson and Schön, 2021).

References:

Johansson L. and Schön, P. (2020), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Sweden’, MC COVID-19 working paper 14/2021. http://dx.doi.org/10.20350/digitalCSIC/13701

Update for: Sweden Last updated: February 10th, 2022

1.01. Population size and ageing context

The current population (2022) in Sweden is 10.3 million (source: World Bank). In 2019, 1% of the population were 90 years or older, 5.2% were 80 years or older, and 20% were 65 years and older (source: Statista). Like many other states globally, Sweden faces a rapidly ageing population. The share of the population aged 80 and over is projected to grow by the most (a 50% from 2018) by 2028 (source: Statistics Sweden). Life expectancy in Sweden is one of the highest in the world (source: Sweden.se).

Update for: Sweden Last updated: February 10th, 2022

1.02. Long-Term Care system governance

A brief history

Prior to the 1950s, adult children were legally responsible for the care of their elderly parents. In the 1950s, 5% of GDP was allocated to care of the elderl, pensions were raised, and children were relieved of their duty of care. For the first time, government-funded institutional care and supported home care were offered to the elderly population in Sweden. In 1982, these provisions were codified into the Social Services Act, guaranteeing the right to claim public service support if needs cannot be met in another way (source: MJIL online).

Current governance

Care in Sweden is a social right: anyone with permanent residency in Sweden is eligible for care, eligibility for which is determined only by assessment of needs (Fukushima et al., 2010). Responsibility for the provision of health and social care is divided between national, regional, and local government. As per The Community Care Reform of 1992, housing and social care needs for older people are the responsibility of local government. The Swedish LTC system is therefore provided, managed and financed by the 290 municipalities, and health and medical care (including at-home palliative care) for older people falls under the responsibilities of the 21 counties and regions. Home care provided by municipalities includes (but is not limited to) help with activities of daily living (ADLs) and personal care, and the provision of meals-on-wheels and various housing adaptations. They provide at-home care and institutional care (including residential care facilities, nursing homes, and group homes for people with dementia (Johansson and Schön, 2017).

More recently, an ‘ageing in place’ policy, based on the philosophy that people should be able to live independently for as long as possible, has dominated the long-term care landscape in Sweden, which has led to the downsizing of institutional resources, and only the most dependent being able to access institutional care (source: European Commission).

In a climate of decreased per capita spending on care for elderly people in a rapidly ageing population, The Local Government Act (1992) allowed municipalities to outsource the provision of care services to private providers (source: Sweden.se). This trend of increased marketization means that there is increased diversity and choice in provider for those in need of long-term care (source: European Commission). Although there has been a proliferation in the provision of care from the private sector, although financing for elder care through taxes still remains generous in Sweden compared to other nations (Meagher and Szebehely, 2010).

References:

Fukushima, N., Adami, J., & Palme, M. (2010). European Network of Economic Policy Research Institutes Assessing Needs of Care in European Nations THE SWEDISH LONG-TERM CARE SYSTEM. www.ceps.eu

Johansson, L. and Schön P. (2017) Country report for Sweden. CEQUA LTC network.

Update for: Sweden Last updated: February 12th, 2022 Contributors: Daisy Pharoah |

1.03. Long-term care financing arrangements and coverage

In 2016, public long-term care (LTC) expenditure represented roughly 3.2% of Gross Domestic Product (GDP) (source: The European Commission).

All care in Sweden is provided on a means-based, not means-tested, basis. About 90% of health and social care is financed by county-council and local authority taxes. Out-of-pocket payments are relatively low, set to a maximum level of 5% of the costs (family/ economic resources are not considered), and the remaining 5% is covered by national taxes (Johansson and Schon, 2017). There is also a ceiling on care fees set by central government: as of 2017, no more than 2068 SEK (209 EUR) per month can be charged for care. This applies to both at-home and institutional care (Schön and Heap, 2018w).

Recently, LTC in Sweden has been affected by financial cutbacks. These have had various negative consequences, including those relating to working conditions for care workers, as they perform their duties in increasingly under-staffed conditions (Johansson and Schon, 2020).

Eligibility for LTC is assessed at municipal level, with no national regulation. The eligibility assessments may be carried out by a general practitioner of a municipal assessor, the municipal Social Board decides on the provision of services based on the assessor’s proposals (Lorenzoni, 2021).

References:

Johansson, L. and Schön, P. (2017). Sweden: Country Report. CEQUA: LTC Network. Retrieved from: Sweden Country Report

Lorenzoni L (2021) Sweden case study in Barber SL, van Gool K, Wise S, Woods M, Or Z, Penneau A et al. Pricing long-term care for older persons. Geneva: World Health Organization, Organisation for Economic Co-operation and Development; 2021. Licence: CC BY-NC-SA 3.0 IGO. https://apps.who.int/iris/bitstream/handle/10665/344505/9789240033771-eng.pdf?sequence=1&isAllowed=y

Schön, P. and Heap J. (2018) ESPN Thematic Report on Challenges in long-term care. Sweden. European Commission. ESPN Thematic Report on Challenges in long-term careeuropa.euhttps://ec.europa.eu › social › BlobServlet

Update for: Sweden Last updated: March 6th, 2023 Contributors: Daisy Pharoah |

1.04. Approach to care provision, including sector of ownership

In Sweden, the provision of long-term care (LTC) is a local-level government responsibility. Increasingly, private care providers (including private companies as well as trusts and cooperatives) provide at home and institutional care in conjunction with municipalities, but financing, quality, and overall provision are still controlled by the municipalities (source: Sweden.se).

The provision of care provided privately has been steadily increasing. In 2018, private providers delivered around 24% of all nursing home and 18% of all homecare. It is noted that these figures vary substantially between municipalities. In general, payments to private providers follow a public tendering process, and are contract-based (sources: The Commonwealth Fund and SocialStyrelsen, 2020).

Update for: Sweden Last updated: February 10th, 2022 Contributors: Daisy Pharoah |

1.05. Quality and regulation in Long-term care

The idea behind the universal Swedish welfare system is that services are affordable for the poor, but still attractive for the wealthy. Quality of services is therefore particularly important (source: European Commission / ESPN Thematic Report).

Sweden has seen a transformation of care provision, as the previous monopoly of publicly run services has led to one with a growing share of private organisations (mostly, for-profit companies). However, all long-term care is managed and organised by municipalities, who are also therefore responsible for quality-control – in both the public and private provision of care. Despite this quality control at a municipal level, there has been a growing concern the growth of the private care sector might have negative implications for care quality. A 2017 study by Winblad et al. investigated this, exploring the relationship between care quality and ownership in nursing homes for the elderly in Sweden. Results of the study were mixed and inconclusive. Although public nursing scored better for individual accommodation and staffing levels, those that were privately operated were found to perform better in terms of medication review, screening for falls, and malnutrition. No significant differences were found in quality between private ownership types (for-profit / not-for-profit / private equity companies) (Winblad et al, 2017).

References:

Winblad, U., Blomqvist, P. & Karlsson, A. Do public nursing home care providers deliver higher quality than private providers? Evidence from Sweden. BMC Health Serv Res 17, 487 (2017). https://doi.org/10.1186/s12913-017-2403-0

Update for: Sweden Last updated: February 10th, 2022 Contributors: Daisy Pharoah |

1.06. Care coordination

Integrated care is an explicit policy goal in Sweden. The law in Sweden stipulates that municipalities and country councils should cooperate, and that individual care plans should be established as a person begins to require services from both the municipal social services and the health sector. This is to ensure coordinated care and continuity.

However, the Swedish system is highly decentralised, and the country faces great challenges of care coordination between health and social care services for older people. It has been suggested that the increased privatisation – introduced to mitigate financial strain on the system and inefficiencies – has made it even more challenging to cordinate care for individuals with complex needs (Lijas et al., 2019). Additionally, autonomy in the organisation and provision of long-term care at a local level means that the national level is unable to enforce structures for co-ordination (Johansson and Schoen, 2017).

According to an OECD report, the rate of Chronic Obstructive Pulmonary Disease (COPD) in elderly patients (over 80 years old) in Sweden is one of the highest in the OECD countries, suggesting there is scope for hospitalisations to be reduced through better coordination of care.

The Norrtaelje Model is a Swedish initiative, one of the key goals of which is to promote a common health and social care organisation to achieve greater user benefit (Back & Calltorp, 2015).

References:

Bäck, M. A., & Calltorp, J. (2015). The Norrtaelje model: a unique model for integrated health and social care in Sweden. International journal of integrated care, 15, e016. https://doi.org/10.5334/ijic.2244

Johansson, L. and Schoen P. (2017) Country report for Sweden. CEQUA LTC network.

Liljas, A., Brattström, F., Burström, B., Schön, P., & Agerholm, J. (2019). Impact of Integrated Care on Patient-Related Outcomes Among Older People – A Systematic Review. International journal of integrated care, 19(3), 6. https://doi.org/10.5334/ijic.4632

Update for: Sweden Last updated: February 10th, 2022 Contributors: Daisy Pharoah |

1.07. Information and monitoring systems

Sweden has extensive information management system which captures comprehensive health and care data. Data is provided at regional and municipal level, and compiled by the Swedish Association of Local Authorities and Regions and The National Board of Health and Welfare (source: European Commission Report).

Update for: Sweden Last updated: February 10th, 2022

1.08. Care home infrastructure

The proportion of the older population living in care homes has been declining over time, from 20% of the population aged 80 and over in 2000 to 12% in 2019, and residents have become frailer, with 70% of them having dementia. On average, people live in care homes for 22 months and 20% die in the six months since moving in (Szebehely, 2020).

A study of use of care in the last 2 years of life among people who died in 2015 and were aged 67 and over found that, on average, women lived in care homes for 7.2 months before death and men for 6.2 months (Meinow et al., 2020).

The majority of the municipal long-term care (LTC) institutions in Sweden are not dissimilar to private housing arrangements. Roughly three-quarters of LTC residents in institutional care have apartments with 1 or 1.5 bedrooms, a kitchenette, and a WC/ shower. Many also have balconies. The residents can make the apartment as home-like as possible as they provide all the furnishings. These apartments are usually located along a corridor that has a dining room and TV room attached to it, and there is often also a garden or similar outdoor space (Johansson and Schön, 2020).

References:

Meinow B, Wastesson JW, Karehold I and Kelfve S (2020) Long-Term Care use during the last 2 year of life in Sweden: Implications for policy to address increased population aging. JAMDA 21:6, 799-805. https://www.jamda.com/article/S1525-8610(20)30028-1/fulltext

Szebehely M (2020) The impact of COVID-19 on long-term care in Sweden. LTCcovid.org, Long-Term Care Policy Network, CPEC-LSE, 22 July 2020.

Update for: Sweden Last updated: March 6th, 2023

1.09. Community-based care infrastructure

Long-term care in Sweden is heavily focused on the provision of community services. The ‘ageing in place’ reform in 1992 promoted the deinstitutionalisation of old age care. After that, municipalities started to downsize the number of institutional beds they provided for older people in need of care (source: European Commisssion / ESPN report). In 2019, over 160,000 older people received care at home; almost double the 82,000 individuals who were provided residential care. It should be noted that some people – such as those with disabilies and those with dementia – are more likely to need residential care, and that an over-reliance on home-based care tends to place more burden on informal carers, most of whom are women (Johansson and Schon, 2020).

Municipalities fund home care for people who are eligible based on a a needs assessment. Local municipality assessors make decisions on the support that a person needs, the services can involve personal care (such as help with dressing and bathing), household support (such as shopping and cooking) and emotional support, for example in the form of social activities. Once services have been granted by the assessor, the persons can choose an agency to deliver the services and the agency home care staff, in consultation with the clients, develop a care plan describing how and when services should be provided (Sandberg et al., 2018, Meyer et al., 2022). Home care may be complemented by nursing care at home provided by primary care (Meinow et al., 2020)

Analysis of the Swedish Social Service Register shows that, of all people aged 70 and over, 9.1% receive home care services, compared to 4.1% living in care homes. Among those receiving services through municipalities (also 70 and over), 75.6% live in a private residence and 24.2% live in a care home, and 69.5% receive home care. Among those receive home care, 62.5% receive support with household activities, 63.2% receive personal care, 7.4% receive support with social participation and 1.2% received services to provide relief to family carers. They receive on average 41.2 hours per month, although there is high variability between municipalities (Meyer et al., 2022).

A study of use of home care services by older people with and without cognitive impairment found that, among those receiving personal care, help with showering was the most common activity. Among those receiving support for household activities, cleaning was the most common activity for which help was provided. The study also found that people with cognitive impairment were had help with more personal care activities and received higher hours of care per month compared to those without cognitive impairment (Sandberg et al., 2018).

Between 2002-03 and 2009-10 there was an important reduction in the coverage of residential care, although in principle this would have been compensated by increases in publicly funded home care, however, in practice it resulted in substantial increases in care provided by family members (mostly women), with those living alone being more likely to receive public home care. There was also a small increase in privately purchased care services amongst the most highly educated (Ulmanen and Szebehely, 2015 and Dahlberg et al., 2017).

References:

Meyer AC, Sandström G and Modig K (2022) Nationwide data on home care and care home residence: presentation of the Swedish Social Service Register, its contents and coverage. Scandinavian Journal of Public Health, 50:946-958. https://journals.sagepub.com/doi/pdf/10.1177/14034948211061016

Sandberg, L, Nilsson, I, Rosenberg, L, Borell, L, Boström, A-M, (2019) Home care services for older clients with and without cognitive impairment in Sweden. Health Soc Care Community. 2019; 27: 139– 150. https://doi.org/10.1111/hsc.12631

Ulmanen, P. and Szebehely, M. (2015), From the state to the family. International Journal of Social Welfare, 24: 81-92. https://doi.org/10.1111/ijsw.12108

Update for: Sweden Last updated: March 6th, 2023 Contributors: Adelina Comas-Herrera |

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

Organisational reforms aiming to contain costs and increase efficiency introduced since the 1980s have involved the introduction of market oriented models that have resulted in worsening working conditions (Szebehely, 2020 and Strandell, 2019). Approximately 25% of LTC workers are employed by the hour and, of those who work in care homes, one in five lack formal training (Szebehely, 2020).

There are roughly 17,000 registered nurses in social care in Sweden, and about 200,000 care workers (assistant nurses/ care aids). Around 60% of this workforce work in care homes; on average, there are 0.4 registered nurses and three care workers for each ten residents (Szebehely, 2020).

A study analysing changes in the job content and working conditions of Swedish home care workers between 2005 and 2015 found that working conditions worsened during that period, with respondents in 2015 reporting higher workloads (both in intensity of tasks and number of clients per day), less support from supervisors, less interactions with colleagues and less scope to plan their daily work. They also reported being more mentally exhausted (Strandell, 2019).

References

Strandell R. (2019) Care workers under pressure – A comparison of the work situation in Swedish home care 2005 and 2015. Health and Social Care in the Community 28(1): 137-147. https://doi.org/10.1111/hsc.12848

Szebehely M (2020) The impact of COVID-19 on long-term care in Sweden. LTCcovid.org, Long-Term Care Policy Network, CPEC-LSE, 22 July 2020.

Update for: Sweden Last updated: February 13th, 2022

1.11. Role of unpaid carers and policies to support them

Although the general principle behind LTC policy in Sweden is to provide government-financed care, unpaid caregivers provide around two-thirds of the care received by those living in the community. Unpaid carers can claim time off work and compensation from national social insurance. Carers may receive cash benefits from municipalities, which are provided at the discretion of the municipality, or carers’ allowance, whereby a family carer is employed by the municipality to provide care (notably, this is not payable to those over 65 years old). 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 (Johansson et al. 2017).

References:

Johansson, L. and Schön, P. (2017). Sweden: Country Report. CEQUA: LTC Network. Retrieved from: Sweden Country Report

Update for: Sweden Last updated: February 15th, 2022

1.12. Personalisation, user voice, choice and satisfaction

LTC Quality and Choice

The Swedish long-term care (LTC) system has been increasingly marketized over the past three decades. This has partly been driven by a want to ensure better choice for users (Meagher & Szebehely, 2013).

Swedish care services are decentralized. As they are organised and managed at a municipal level, there is a lack of standardisation of needs assessment and care processes. This means that there is some variation across local governments in the quality of services provided (source: OECD).

Predictors of Patient Satisfaction

A 2019 study by Spangler et al. investigated aspects of nursing homes in Sweden that are most associated with resident satisfaction. The most important predictor was (smaller) nursing home size (although this may be in part due to the fact that that there is less staff turnover in smaller nursing homes), followed by the activities (both physical and social) on offer to residents. Individualised care was also a factor.

References:

Meagher G., Szebehely M. (2013) Long-Term Care in Sweden: Trends, Actors, and Consequences. In: Ranci C., Pavolini E. (eds) Reforms in Long-Term Care Policies in Europe. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-4502-9_3

Spangler, D., Blomqvist, P., Lindberg, Y. et al. Small is beautiful? Explaining resident satisfaction in Swedish nursing home care. BMC Health Serv Res 19, 886 (2019). https://doi.org/10.1186/s12913-019-4694-9

Update for: Sweden Last updated: February 12th, 2022

1.14. Pandemic preparedness of the Long-term care sector

The Swedish Corona Commission highlighted that there was no overview of preparedness to tackle the pandemic. Although protecting the older population was an objective from early on in the pandemic, little attention was given to the overall lack of preparedness in the municipal social care sector until much later on. One of the factors contributing to the spread of the disease has been the large proportion of untrained casual workers in the sector.

Update for: Sweden Last updated: February 10th, 2022

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

According to the National Board of Health and Welfare, As of February 14, 2022, 15,522 people had died attributed to COVID-19 in Sweden, of these, 65.7% were aged 80 or over.

Update for: Sweden Last updated: February 22nd, 2022

2.02. Deaths attributed to COVID-19 among people using long-term care

The National Board of Health and Welfare has reported statistics about mortality by COVID-19 as recorded as the underlying cause of death on the death certificates for users of long-term care over the age of 70 since the beginning of 2020. Mortality and cases are reported separately for users of residential facilities and home care, and numbers remain provisional as death certificates are submitted within 3 weeks of the date of death. These figures may underestimate total mortality as they exclude individuals aged 69 and below.

As of April 11, 2022, there have been 16,396 deaths in Sweden from COVID-19. Of these 6,546 (40%) have occurred in residents of care homes. On October 31, 2019, there were 82,217 care home residents in Sweden. Therefore, the total number of COVID-19 related deaths in care home residents represents 7.96% of this population.

As of April 5, 2021, there were 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%). Of the deaths of care home residents, 4,887 happened in the care home (90%). The regional differences at this time were strong in Sweden. In the Stockholm region, 7 % of care home residents had died, while there were 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).

Update for: Sweden Last updated: May 3rd, 2022 Contributors: William Byrd | Disha Patel |

2.04. Impacts of the pandemic on access to care for people who use Long-Term Care

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/Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf; https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812; https://ltccovid.org/2020/12/16/the-swedish-corona-commission-on-care-of-older-people-during-the-pandemic/).

Update for: Sweden Last updated: November 30th, 2021

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

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/Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Update for: Sweden Last updated: November 30th, 2021

3.00. Overview of the pandemic response in the Long-Term Care system

In the LTCcovid report for Sweden published in July 2020, Szebehely emphasises that, despite Swedish authorities stressing the importance of protecting older people, there was no specific attention to care home residents or people who use care at home. As in many countries, the focus was on limiting the spread of infections in the community and protecting capacity in the health care sector (Szebehely, 2020).

The lack of prioritisation of the LTC sector in the initial part of the pandemic meant that it had very limited access to Personal Protection Equipment (PPE), testing, poor capacity to implement Infection and Prevention and Control measures, and that particularly people living in care homes did not have enough access to medical care (Szebehely, 2020).

There was scarcity of Personal Protection Equipment (PPE), which affected the LTC sector in particular. The Public Health Authority mentioned the use of masks and shields in LTC for the first time on the 7th May, however a proper recommendation to use shields and masks in personal care of people with confirmed or suspected COVID was not made until the 25th of June 2020.

References:

Szebehely M (2020) The impact of COVID-19 on long-term care in Sweden. LTCcovid.org, Long-Term Care Policy Network, CPEC-LSE, 22 July 2020.

Update for: Sweden Last updated: February 13th, 2022

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

The overall Public Health response to COVID-19 in Sweden was based on a tradition of voluntary measures that emphasize individual responsibility and mutual trust. Recommendations included staying at home if presenting with symptoms, good hygiene, physical distancing, and avoiding unnecessary travel. People aged 70 or over were asked to avoid all close contacts and to stay away from places where people gathered. There were some legally binding rules including a ban large public gatherings, distance learning in secondary schools and universities and restrictions on visiting in care homes (Szebehely, 2020 and Kavaliunas et al., 2020).

Despite the government stressing the importance of protecting older people, initially there were no specific measures for care home residents (see section 3.00).

References

Kavaliunas, A., Ocaya, P., Mumper, J., Lindfeldt, I., & Kyhlstedt, M. (2020). Swedish policy analysis for Covid-19. Health policy and technology, 9(4), 598–612. https://doi.org/10.1016/j.hlpt.2020.08.009

Szebehely M (2020) The impact of COVID-19 on long-term care in Sweden. LTCcovid.org, Long-Term Care Policy Network, CPEC-LSE, 22 July 2020.

Update for: Sweden Last updated: February 13th, 2022

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

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).

Update for: Sweden Last updated: September 8th, 2021

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

The National Board of Health and Welfare (NBHW) 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 (Johansson and Schon, 2020).

References

Update for: Sweden Last updated: February 12th, 2022

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

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).

Update for: Sweden Last updated: September 9th, 2021

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

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).

Update for: Sweden Last updated: November 30th, 2021

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

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).

Update for: Sweden Last updated: November 30th, 2021

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

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).

Update for: Sweden Last updated: January 12th, 2022 Contributors: Joanna Marczak |

3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, support and implementation

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 25^th 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).

Update for: Sweden Last updated: September 9th, 2021

3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes

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).

Update for: Sweden Last updated: November 2nd, 2021

3.07.03. Visiting and unpaid carer policies in care homes

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).

Update for: Sweden Last updated: September 8th, 2021

3.08. Access to testing and contact tracing for people who use and provide Long-Term Care

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

Update for: Sweden Last updated: November 23rd, 2021

3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector

There was national scarcity of Personal Protection Equipment (PPE), which affected the LTC sector in particular. The Corona Commission‘s report in December 2020 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. The Public Health Authority mentioned the use of masks and shields in LTC for the first time on the 7th May, however a proper recommendation to use shields and masks in personal care of people with confirmed or suspected COVID was not made until the 25th of June 2020 (Szebehely, 2020).

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. There was no national mechanism to assess the stocks of PPE, as the regions and municipalities were responsible for managing their own medical stocks including PPE. Many municipalities did not have sufficient stocks of PPE and rationed what was available, prioritising hospitals (Johansson and Scho?n, 2020 and Szebehely, 2020).

References:

Johansson L. and Scho?n, P. (2020), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Sweden’, MC COVID-19 working paper 14/2021. http://dx.doi.org/10.20350/digitalCSIC/13701

Szebehely M (2020) The impact of COVID-19 on long-term care in Sweden. LTCcovid.org, Long-Term Care Policy Network, CPEC-LSE, 22 July 2020.

Update for: Sweden Last updated: February 13th, 2022

3.10. Use of technology to compensate for difficulties accessing in-person care and support

Online physician consultations for care homes were implemented (https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

Update for: Sweden Last updated: November 30th, 2021

3.11. Vaccination policies for people using and providing Long-Term Care

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).

Update for: Sweden Last updated: September 7th, 2021

3.12. Measures to support unpaid carers

There were no specific measures to support unpaid carers, but there is evidence that the burden of care increased during pandemic for unpaid carers based on the analysis by Stockholm Gerontology Research Centre (paper is yet to be published by Gerontology Institute, communication from Lennarth Johansson, 27/01/2021).

The Corona Commission highlights some general financial measures which could well benefit unpaid carers (although these were not aimed specifically at unpaid carers) e.g. financial compensation to people in certain risk groups who have entirely or partly ceased undertaking paid work to avoid being infected with COVID-19.

Update for: Sweden Last updated: September 7th, 2021

4.05. Reforms to address Long-Term Care workforce recruitment, training, pay and conditions

In 2020 (partly due to pandemic) a reform was introduced in Sweden whereby LTC employees are offered paid training to become, for example, assistant nurses. Local authorities and the relevant trade union agreed to offer a permanent full-time job for those who participate in this training (source: Employment, Social Affairs & Inclusion – European Commission).

Update for: Sweden Last updated: November 30th, 2021