The Long-Term Care (LTC) system in Denmark is a universal and primarily public system. Access to LTC services is at no cost for home-based care, and with a means-tested co-payment for residential care. The LTC system has strong public and political support. It is a highly decentralized system, organised, and financed at the municipal level. Provision is mixed, with public and for-profit providers providing home care, and in the residential sector, non-profit providers also operate. There is historically a strong emphasis on community-based care, integration, prevention and  professionalization of care staff (WHO, 2019). The development of long-term care for older people has in Denmark been heavily influenced by the various reports from the National Commission on Ageing in the 1980s. The policy recommendation was here not least to encourage the increasing use of private resources, such as the involvement of voluntary organizations, but also referred to ensuring self-care (hjælp-til- selvhjælp) in old age, and in this way encourage a more preventive and rehabilitative approach. The reports also introduced principles of continuity and normalization, meaning that regardless of need for care the provision of care should aim at ensuring the continuation of the older person’s preferred way of living. From the 1990s onwards, marketisation and, more implicit, privatisation has been encouraged (Rostgaard, 2007). In 2015, reablement was introduced in the legislation and must be offered instead of conventional home care is the older person is assessed to have so-called potential for this intervention (Rostgaard et al, 2023). The main law regulating social service provision and, implicitly, LTC 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. As health care provisions are under the scope of the Health Care Act, there is political awareness of the problems of coordinating interventions and time-consuming double documentation. At present (2022), work is therefore carried out to reform the legislation and combine the two laws under one, a Senior Citizens’ Act. In recent years there has been a decrease in the number of people who receive home care services, which resulted in unmet need and more burden placed on unpaid carers (WHO, 2019; Rostgaard, 2022 et al).

References:

Rostgaard, T., Tuntland, H. and Parsons, J., (eds.) (2023) Reablement in Long-Term Care for Older People – International Perspectives and Future Directions. Bristol: Policy Press. Rostgaard, T., Jacobsen, F., Kröger, T. & Petersen, (2022) ‘Revisiting the Nordic long-term care model for older people— still equal?’ in European Journal of Ageing. 19, 2, pp. 201-210. Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020. Rostgaard T. (2016) Socially investing in older people – reablement as a social care policy response? Res Finnish Soc. 2016;9:19–32. Rostgaard, T. (2007) Begreber om kvalitet i ældreplejen. Temaer, roller og relationer, Socialforskningsinstituttet 07:13. København: Socialforskningsinstituttet. WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019.

In 2021, Denmark had a population of just under 6 million; 19.4% of the population were over 65, with 4.1% over 80 and 1.9% 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). The ageing of the population has been driven by increases in life expectancy which has otherwise been low in comparison to other Nordic countries. In 2021, women could  expect to live until the age of 83 years and men until 80 (source: https://www.dst.dk/en/Statistik/emner/borgere/befolkning/middellevetid).

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.

In 2007 the number of municipalities was reduced from 275 to 98, creating larger administrative units. This change was accompanied by municipalities also taking charge of the rehabilitation of people who are being discharged from hospital, and  taking a stronger role in prevention and health-oriented interventions (Rostgaard, 2020).

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 was a clear move towards integrating central and strategic decision making for health and social services (WHO, 2019). During COVID-19, it meant that it was the Board of Health that oversaw the implementation of pandemic restrictions and measures. As a consequence of the heavy workload during the pandemic, the responsibility was again placed with the Ministry of Social Affairs, now called the Ministry of Social Affairs and Senior Citizens. It is now again the Board of Services which oversees and guides policy implementation.

References:

Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Public sending on Long-Term Care as % of Gross Domestic Product (GDP):

In 2016 Denmark spent 3.5% of GDP on publicly funded LTC which places Denmark along with other Nordic countries and the Netherlands in the group of highest spenders (OECD average 1.5%). Also the per capita spending is relatively high around USD 2.000 per person 65+ (OECD, 2020).

Since the late 2000s the average expenditure per person 65+ in the municipalities has fluctuated somewhat but overall tends to decrease, reflecting both the general increase in functional ability but most likely also the change to reablement and consequent cuts in home care. In 2007 municipalities on average spent DKK 44.667 (6.119 Euro) per person 65+ and by 2017 the budgeted amount is DKK 41.315 (5.659 Euro). (Source: Økonomi- og Indenrigsministeriets Kommunale Nøgletal, nd. http://www.noegletal.dk/noegletal/servlet/nctrlman.aReqManager)

Approach to public funding for LTC and eligibility:

Municipalities are responsible for allocating resources; they obtain funding from the national government, local taxes and equalization money from other municipalities. There are no co-payments for home-based care services such as cleaning and personal care, although individuals who use private providers can buy additional services. Also home nursing services are free of charge.

In nursing homes, residents pay for rent, medication, laundry and for the use of ser-vices, up to a max. ceiling of 10-20 % of income depending on the municipality. Resi-dents do, however, not pay for what can be considered home help services, including help with domestic tasks and personal care, as this is free of charge. The resident maintains his or her pension and financial means. It is possible to receive rent subsidy. Nevertheless, the rent can be considerable. There are no figures over the average rent or service fee across the various nursing homes in the country, but in Copenhagen municipality the prices for monthly rent varies from 4-8.000 DKK (550-900 Euro) monthly (http://boligertilaeldre.kk.dk/). National accounts are made for the cost of food only, which is on average 3.473 DKK (475 Euro) monthly (Økonomi- og Indenrigsministeriets Kommunale Nøgletal, n.d.)

Eligibility for LTC is based purely on needs assessment carried out by the municipalities, principle of free and equal access applies, regardless of income, wealth, age or household situation.. There are no thresholds or minimum dependence required for in-kind or cash benefits. Needs assessment is multidimensional and captures a wide range of aspects related to a person’s situation and well-being (WHO, 2019).

It has been estimated that 16% of the total population provided unpaid care at least once a week in 2016 (WHO, 2019). The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements. However, members of the household are expected to provide cleaning. In comparison with other countries, unpaid carers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the EU (Rodrigues at al., 2013). In recent years, the pressure of financing and recruiting staff has led to more pplitical voicing of the need for informal carers to provide more care, most recently expressed by the Minister in charge in the preparation of the new Senior Citizens’ Act.

References:

Rodrigues, R., Schulmann, K., Schmidt, A., Kalavrezou, N. & Matsaganis, M. (2013). The indirect costs of long-term care. European Centre for Social Welfare Policy: Research Note.

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Økonomi- og Indenrigsministeriets Kommunale Nøgletal (n.d) http://www.noegletal.dk/

Home care

Free choice of home care provider was introduced in 2003, which banned public monopolies in service provision. Municipal councils are required by law to ensure private for-providers of home care exist in each municipality. Unlike the tendency for market concentration as is the case for instance in Sweden, where for-profit provision of care is increasingly concentrated on the hands of a few, multi-national providers run by private equity firms (Erlandsson et al, 2013), the care market remains more scattered on small and locally operating providers in Denmark.

The tender rules require that municipalities either operate by competition by procurement (udbudsmodellen) or by endorsement (godkendelsesmodellen). If municipalities use the former model, they invite public as well as for-profit home care providers to compete based on a written tender. Here, there is wide possibility for providers to compete on price and quality. If they use the latter model, which was by far the most popular model until 2013, municipalities retain the power to set prices and quality standards for tendering procedures with home care providers.

Since changes in the law of 2013, many municipalities now apply the procurement model and invite competition on price as well as quality. The intention was not least to introduce real competition but also to decrease the number of contracted providers – which for instance in Copenhagen municipality alone amounted to 37 different providers – and thus make the choice more manageable for the user and make administration easier and less costly for the municipality. The total number of for-profit providers operating accordingly dropped from 459 in 2013 to 387 in 2017.

Since 2017, agencies have also been required to provide documentation of solvency. This change followed after a number of bankruptcies, affecting users and care workers, as well as the municipalities who had to introduce costly emergency response systems. The market seems to have stabilized since and the number of agencies has been reduced significantly, to around 80.

Once the individual has been assessed for need, there is the choice between the public and at least one for-profit provider. The latter is not permitted to refuse to provide care for any individual. The for-profit companies offer the same services as the public provider, personal care and practical assistance, and in addition many for-profit providers also deliver reablement services. It is possible to purchase topping up services from a for-profit provider. A study has shown that it is more expensive for the municipalities when it is the private provider that delivers cleaning services (Kjær and Houlberg, 2015).

Nursing homes

The law on free choice of provider does not apply to nursing homes, so local authorities are not obliged to contract out these services or to offer a choice of provider, but can opt to do so. Marketisation of nursing home services via user choice is, instead, facilitated by the Law on Independent Nursing Homes (Lov om friplejeboliger) which was enacted in January 2007. The aim of the legislation was to increase choice for users of nursing home care, and to introduce more variation in service delivery through competition between various providers. This includes the possibility of buying additional services which nursing home providers are allowed to offer. The municipality is not responsible for the allocation of places in the private Fripleje nursing homes, but nevertheless have to subsidize these institutions, as long as they are have achieved certification. The spectrum of nursing home providers within this model in addition to for-profit providers, however, also includes municipal as well as non-profit private providers.

There are no regular statistics on the types of providers, but as of 2013, private for-profit providers included Aleris, which operated 4 nursing homes, and Attendo Care, which operated one nursing home. Looking at the proportions of residents living in private for-profit nursing homes it is less than 1 %.

Non-profit private providers of long-term care services also deliver nursing home care under the Friplejebolig scheme and in addition also often under contract with the local municipality. Operators include Danske Diakonhjem who in 2013 operated 28 nursing homes, and Fonden Mariehjemmene with 13 nursing homes. Non-profit organisations often promote themselves as having a special value foundation. Non-profit providers in general do not operate in the home help.

References:

Erlandsson, S., Storm, P., Stranz, A., Szebehely, M. & Trydegård, G.-B. (2013). Marketising trends in Swedish eldercare: competition, choice and calls for stricter regulation, in Meagher, G. & Szebehely, M. (eds.), Marketisation in Nordic Eldercare: a Research Report on Legislation, Oversight, Extent and Consequences (Stockholm Studies in Social Work, No. 30). Stockholm University: Department of Social Work.

Kjær, S. and Houlberg, K. Hjemmehjælp. Frit valg koster i kommuner, https://www.vive.dk/da/udgivelser/hjemmehjaelp-frit-valg-koster-i-kommuner-10035/

Marczak, J., Wistow, G. (2015). ‘Commissioning long-term care services’, in Gori C, Fernandez JL, Wittenberg R (eds) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol. Accessed at Commissioning long-term care services

Rostgaard T. (2011) Care as you like it: the construction of a consumer approach in home care in Denmark. Nord J Soc Res. 2011;2..

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

The municipalities must ensure full transparency and clear separation between their function as providers and as the authority supervising quality. In accordance, the purchaser-provider model is implemented.

Quality standards for LTC apply to public and private providers. The municipalities are responsible for service and quality assurance. The overall law, the Social Service Act does not contain any specific quality stipulations that prescribe how the local municipalities should frame or even assess quality of care. The only requirement is that needs for care are met. But overall policy principles frame how quality of care is to be interpreted. Amongst other things, this includes that provisions of care should enable older people to remain at home as long as it is feasible. A quality item is also to deliver personalized services and to include the older person in decision-making. In home care, the law also specifically stipulates that care delivery should support the older person in becoming independent of services as is the goal in reablement.

As the national legislation serves as a framework law only, it does not include any national quality standards, neither on staff ratios, nor the required level of education of staff members as long as they have some education in care. However, there are certain quality requirements which the law specifies for the modern nursing homes, such that all rooms must have their own toilet, bath and kitchen facilities and that rooms much be accessible with a wheel chair.

Another way to regulate quality on a national level is to require providers to be accredited or authorized.  Here, an independent agency evaluate the quality of the care provided as well as certain structural elements such as education of staff, size of facilities etc. In Denmark, the private for-profit and non-profit providers that want to enter the market for Friplejeboliger are required to become authorized.

National standards for care are also influencing the curriculum for future care workers when they study. This ensures that the curriculum includes more or less the same subjects across the country. After having finalized the education, it may be possible to achieve authorization. This is the case in Denmark for both nurses and social care assistants (Social- og sundhedshjælper). Again, this makes it possible to set certain national standards as to the content of the education.

There are certain incentives which motivate public as well as private providers to deliver better quality of care. One of these is the introduction of competition where private and public providers compete over customers, in the Free choice of home care provider. Another is the economic incentive for municipalities to ensure that older people discharged from hospital receives the necessary care. Since 2007 municipalities finance 20 percent of the cost for a hospital bed which gives them a strong incentive for ensuring a quick discharge.

Quality control of providers takes place on the local level. The municipality must set up procedures for regular inspection. This includes supervising whether the services are delivered as planned as well as whether changes in needs are reported. Inspection takes place as unannounced as well as pre-announced visits. In nursing homes, the municipality must perform at least one unannounced visit annually. Since 2005, a private provider can carry out the inspection, but the inspection must not be outsourced to the provider also providing the services. The national agency the Board of Health (Sundhedsstyrelsen) also performs annual unannounced visits by a medical trained health officer (embedslæge).

The local standards of quality of care are communicated through the local quality standards (kvalitetsstandarder) which as accessible on-line in all municipalities. Users may also access information about the local quality of services by consulting the statistics which are collected annually and made public at Statistics Denmark as part of the project Elderly Documentation (Ældredokumentation) (source: https://www.dst.dk/da/Statistik/dokumentation/Times/aeldredokumentation ). Here local data on for instance user satisfaction can be accessed, however only in comparison with other municipalities, not broken down to the individual provider. There are 23 impact and background indicators. For general monitoring of providers, most indicators are monitored through administrative data and through user surveys.

References:

Rostgaard T. (2012)  Quality reforms in Danish home care – balancing between standardisation and individualisation. Health Soc Care Community. 20:247–54.

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 good level of integration of care across providers, people who need long-term care following hospital discharge, the hospital discharge management team works closely with the general practitioner and local home services. The administrative regions are responsible for coordinating after-hours care. After-hours clinics tend to be associated with hospital emergency department  (WHO, 2019).

An example of the integrated health and social care approach in Denmark is the preventive home visits (Forebyggende hjemmebesøg). Since 1996, municipalities have been obliged to conduct a preventive home visit for older people 80+, and from 1 July 1998 this included older people aged 75+. With improvements in functional ability the age limit has been raised again to 80+.

The visits are to be offered according to need, although at least twice a year. The visit is conducted on acceptance by the older person. It should allow the older person and the assessor to evaluate the need for help and care in order that older persons can make use of their own resources, maintain full functional abilities as long as possible, and enhance their social network. Visits may also be made to older people living in nursing homes if the municipal board decides so. The municipal board may also decide to make exceptional visits in relation to the death of a spouse, serious illness or discharge from hospital. Some municipalities offer the visit from the age of 65 years for older persons with non-Danish origin, as they have often had more strenuous work lives. The person making the visit must have thorough knowledge of general social as well as health issues.

Another example is the coordinated assessment of patients in the discharge process (Fremskudt visitation). A municipal assessor is present at the hospital weekly. Based on conversations with staff, patients and informal carers, the assessor is to assess the patient’s functional abilities and coordinate that services are in place before the actual discharge. This has proven especially important for frail older people and ensures that they feel more secure and that they do not need to wait for service delivery. It also has the potential to keep costs down and prevent readmission to hospital (Buch et al, 2016).

References:

Buch, M.S.; Jakobsen, M.; Kolodziejczyk, C. and Ladekjær, E. (2016) Evaluering af indsats for forløbskoordination – Erfaringer med fremskudt visitation i fire kommuner. København: KORA.

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

The sundhed.dk portal was launched in 2003 as a partnership between the Ministry of Health, five administrative regions and municipalities. The platform gathers information from 85 sources to enable individuals to access their medical records such as laboratory results, prescription information and scheduled visits, individuals can also enter or complement data on patient-reported outcomes. Hospitals share various information including discharge summaries and outpatient notes, and medical results with other hospitals, general practitioners and other specialists (WHO, 2019).

References:

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

 

There are 930 nursing homes in Denmark’s 98 municipalities (source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

In 1984 it was made illegal to construct multiple bed residential services, therefore all newly built nursing homes (plejebolig) 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.  Still, a number of residents still today live in nursing homes built under the old scheme, but most have been updated and offer private facilities.

There are five types of residential care facilities for older people: traditional nursing homes (plejehjem); more modern nursing home facilities (plejebolig), sheltered housing (beskyttet bolig); housing for older people (almen ældrebolig); and private for-profit nursing homes (Friplejebolig). The choice of specific type of accommodation depends on individuals’ preferences and needs, those choosing to live with their spouse or partner must be offered a facility suitable for two people (WHO, 2019).

The number of people in residential facilities has declined in both absolute and relative numbers in the last decade. In 2021 in absolute numbers there were 38.863 beneficiaries of long-term residential care services aged 67 years or older which equals to 5% of the population. In addition, 22.752 persons 67+ lived in housing for older people adapted to the needs of persons with limited functional ability while 1.190 persons 67+ lived in a for-profit Fripleje nursing home (source: https://www.dst.dk/en).

In recent years, the number has dropped. In particular the proportion of people aged 90 and over living in residential care facilities has fallen drastically, as 42 percent lived in LTC facilities and housing for older people in 2010 while the number fell to 32 percent in 2021 (source: https://www.dst.dk/da/Statistik/nyheder-analyser-publ/nyt/NytHtml?cid=34723).

References:

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Municipalities provide social and health care services for older people living at home and overall, older people can access a wide range of 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.

The number of people receiving home care has declined over the last decade, as a combined effect of the introduction of reablement and a prioritisation of resources for the most frail. As of 2021, 11% of the population 68+ receive home care. There is documentation of an increase in frail older people who live at home without anyone helping them as well as a decline in ASCOT measured quality of live among home care recipients (Rostgaard and Matthiessen, 2019 and 2020).

The municipalities have been implementing and tested reablement in various scales since 2007. In January 2015, a new legislation mandated all municipalities to consider first whether a person applying for home support could instead receive reablement services. Reablement is typically offered in the form of a 12-week exercise training course, provided by multidisciplinary teams with an involvement of physio- or occupational therapists, in which the older person together with the care worker identifies and works towards achieving one or more goals such as, showering alone or cleaning home. Individuals mainly receive home support only after the reablement failed to help, but in some cases, it can be offered parallel to the reablement intervention. Municipalities offer services in the individual’s home.

Rehabilitation training for instance after discharge from hospital are offered in municipal training centres. Services are included in the mandatory healthcare agreements between the administrative regions and the municipalities, and they ensure cooperation between the various service providers.

Individuals discharged from hospitals can receive follow-up home visits from general practitioners or nurses, which takes place a week after discharge and may be repeated at three and eight weeks after discharge if additional support is needed (WHO, 2019).

References: 

 Rostgaard, T., Tuntland, H. and Parsons, J., (eds.) (2023) Reablement in Long-Term Care for Older People – International Perspectives and Future Directions. Bristol: Policy Press.

Rostgaard T. (2016) Socially investing in older people – reablement as a social care policy response? Res Finnish Soc. 2016;9:19–32.

Rostgaard T. (2015) Failing ageing? Risk management in the active ageing society. In:  Torbenfeldt Bengtsson T, Frederiksen M, Elm Larsen J, editors. The Danish welfare state. New York: Palgrave Macmillan; 2015:153–68.

Rostgaard, T. og Matthiessen, Mads. (2020) Hjemmehjælp og omsorgsrelateret livskvalitet. VIVE rapport. København: VIVE

Rostgaard, T. og Matthiessen, Mads. (2019) Hjælp til svage ældre. VIVE rapport. København: VIVE.

WHO (2019), Denmark: Country case study on the integrated delivery of long-term care. Accessed at:  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

Social and Health Care Helpers and Assistants represent most of the long-term care workforce. The Social Care and Health Helper education has a duration of 2 years and 2 months and is focused mainly on tasks related to support with personal care and hygiene as well as household chores. It includes a 20-week introductory basic course. The remainder of the program is a mix of practical training periods and school study. The Social and Health Care Assistant education is a separate education with authorisation which takes 3 years and 10 months, and is focused on the provision of personal care, health promotion, prevention and nursing functions. The Social and Health Care Assistant training is a mix of practical training periods and school study.

In recent years especially the Health and Social Care assistants have been favoured in the sector, not least since the work tasks have become more medicalized. The aim is that all persons working with care should have taken at least the basic qualification program of a Social and Health Care Helper.  Overall, however, the proportion of social and health care staff in LTC without formal qualification has gone up from 13 percent in 2017 to 22 percent in 2021 (FOA, 2021).

While the number of personnel has stagnated or sometimes declined in most residential settings, there has been an increase by almost 10% of staff in employed in home help, following the increase in number of older people in the population. Moreover, between 2005-2015 the number of staff working part time increased (OECD, 2020).

With the introduction of reablement, it is required even more today that care workers in home care work in cross-disciplinary teams when planning and delivering services. Care workers most often work with occupational therapists in reablement services (Rostgaard and Graff, 2016). In accordance, physiotherapists and occupational therapists have increased in numbers during the past decade.

Special assessors are in charge of the assessment of need. This profession was set up in the early 1990s, in order to professionalize and improve the quality of the needs assessment, which was formerly carried out by home helpers. Assessors as a minimum receive a 2 weeks course in assessment. Many of these have worked as home helpers before and often have experience in the field, e.g. a survey carried out in 2007 showed that care assessors on average had worked within the care sector for 3.5 years (Rostgaard, 2007).

As care needs of nursing home residents and home care recipients have increased, staff in both sectors have experienced an increase in health, and nursing-related tasks. LTC workforce also reported higher work intensity (WHO, 2019). The poor working conditions in the sector are well documented as are the problems of recruitment and retainment (eg Rostgaard and Matthiessen, 2016). These problems are also acknowledged in the preparatory work behind the new Senior Citizens’ Act (Social- og Ældreministeriwewt, 2022).

References:

FOA (2021) tor stigning I antallet af ufaglærte I ældreplejen fra 2017 til 2021. Copenhagen: FOA.

OECD (2020) Who Cares? Attracting and Retaining Care Workers for the Elderly

Rostgaard T. (2014) Nordic care and care work in the public service model of Denmark: ideational factors of change. In: Leon M, editor. The transformation of care in European societies. London: Palgrave Macmillan; 2014:182–207.

Rostgaard, T. og Graff, L. (2016) Hænderne i lommen – Borger og medarbejders sam-spil og samarbejde i rehabilitering. Rapport. København: KORA.

Rostgaard T., and Matthiessen U. (2016) Arbejdsvilkår i ældreplejen: mere dokumentation og mindre tid til social omsorg [Working conditions in care for older people: more documentation and less time for social care]. Copenhagen: VIVE – the Danish Centre for Social Science Research; 2016 (KORA Report, No. 28; https:// www.vive.dk/da/udgivelser/arbejdsvilkaar-i-aeldreplejen-mere-dokumentationog-mindre-tid-til-social-omsorg-8409, accessed 20 November 2019).

Rostgaard, T. (2007) Begreber om kvalitet i ældreplejen. Temaer, roller og relationer, Socialforskningsinstituttet 07:13. København: Socialforskningsinstituttet.

Social- og Ældreministeriet (2022) Afrapportering: En ældrepleje med tid til omsorg, https://sm.dk/publikationer/2022/sep/afrapportering-en-aeldrepleje-med-tid-til-omsorg

WHO (2019), Denmark: Country case study on the integrated delivery of long-term care. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Traditionally, the extended family such as adult children or children-in-law are in Denmark more likely to provide mainly more practical tasks, such as providing transport to the doctor or assisting with administrative issues. However, as fewer people receive home care services, the family must increasingly take over and pro-vide informal care. There are no regular surveys of informal care but in a 2016 survey it was estimated that 16% of the total population provided unpaid care at least once a week (WHO, 2019). In the preparatory work for the new Senior Citizens’ Act it is specifically stated that informal carers are expected to be more involved in caring.

Unlike other Nordic countries, Denmark does not have a home care allowance paid to informal carers of frail older people as a substitute for formal care provision. Only in the case of terminal illness, an informal carer can receive a cash benefit as well as the right to take leave. Persons caring for a close relative or friend who is terminally ill and wishes to remain at home, are therefore entitled to receive compensation for loss of earnings. Payment of the benefit is conditional on the recipient of care being terminally ill and not using hospital facilities. Furthermore, the recipient of care must consent to the care arrangement. The carer must also receive consent from their employer to take the necessary leave. All public employers supposedly comply with the aim of the scheme and should grant permission to take leave. In general, the allowance is only paid on loss of earnings. Employees and self-employed, however, are covered by the scheme, but pensioners, recipients of social assistance and students are not included.

The municipal board can, however, in very special cases decide to employ a spouse or close relative as a home help. The carer then becomes employed in the municipal home help arrangement for an agreed period of time with the purpose of caring for an older person. The carer is paid the same hourly rate as public home helpers, and is covered by the same social rights and insurances. This means that the carer is entitled to sickness benefit, and earns credits for any supplementary pension and labour market pension. This scheme is hardly ever used.

The municipality must support informal carers, for instance by informing them about the possibilities of receiving supplementary help from a home help, home nurse or around-the-clock domiciliary care. Help can also be obtained if it becomes necessary to adapt the home. For the relief of the carer, the older person can stay for a short-term period in a nursing home or a day home. Additional services for caregivers include training and education, often focused on improving knowledge and ability to provide support and on improving coping skills.

In order to ensure that older people or carers do not have any extra expenses due to caring at home, help can be obtained to cover expenses for prescribed medicine, nursing supplies and such items. Relief measures apply whether or not the carer is entitled to care compensation and are provided without account of either the earnings of the carer or recipient of care.

References: 

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Overall, the aim is for LTC services to be individualised and person-centred. Not least the introduction of reablement has put focus on the need for providing care according to the person’s individual preferences and for her participation in the design of care. However, this goes hand in hand with a prioritisation of the most frail and the provision of personal care over cleaning services.

Users are given a voice in regards to the choice of provider, but mainly as a right to enter and exit service provision. Individuals can also voice a complaint to their municipality if they are not satisfied with the quality of local LTC offer and the services they receive. When a complaint is made, the municipality must review the decision and if the decision is not changed, their complaint must be sent by municipality to a National Board of Complaints (European Commission, 2021).

Users also have a direct voice in the user satisfaction surveys which the municipalities organise, although infrequently and with mainly overall questions. In these user satisfaction surveys, there is little difference between for-profit and public providers. There are no systematic surveys conducted on quality of care, for instance using ASCOT.

The user’s voice is also heard through the non-profit actors who play a main role in advocacy. The DaneAge Association, a voluntary organisation with more than 825 000 members, has the most prominent role among civil society organizations and is involved in advocating the rights and well-being of older people, whilst many volunteers are themselves 65 years or older. Another important association is the Danish Alzheimer Association.

Non-profit organizations also play an important role in organizing volunteers in nursing homes, hospices, hospitals and in the home (WHO, 2019). The traditional division of work between public and private providers has changed in regards to the involvement of voluntary organisations and actors also. In general, voluntary services are considered supplementary to the otherwise extensively public welfare system but their importance has grown, not least in the provision of social contact services. Eg. The Elders Help Elders network, a partnership among six organizations, is one of the most visible initiatives organizing volunteers with a focus on visiting services, mobility support, shopping, practical assistance in the home, sharing meals and exercise. In Denmark, there is in general both high support for and high participation in voluntary activities. The high proportion of people active in voluntary work is not least due to the culture of associations; in Denmark there is a relatively large number of small associations where people become involved offering non-paid assistance and by definition thus voluntary work. A national survey of involvement in voluntary activities from 2013 showed that 35 % of the population was active and especially the older cohorts have over time become more active (Fridberg og Henriksen, 2014). Older people often participate in volunteer activities focussed on other older people, such as visiting services for lonely older people. In this way, volunteering is an important social activity which supplements the public services, but which also has a preventive effect in maintaining activity levels among the older volunteers themselves. It Is not uncommon for older people offering voluntary services to report an increase in quality of life and health, which shows that the outcome is not only for the users of the services but also for those providing them (Ældremobilisering, 2012).

References:

European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

Fridberg, T. and Henriksen L.S. (2014) Udviklingen i frivilligt arbejde 2004-2012. København: SFI. https://www.vive.dk/media/pure/5209/276950

Olejaz, M.,  Nielsen, A., Rudkjøbing, A., Okkels Birk, H., Krasnik, A., Hernández-Quevedo, C. (2012) Denmark: Health System Review. WHO European Observatory

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Ældremobilisering (2012) Ældre hjælper Ældre – En gevinst for samfundet og delta-gerne. København: Ældremobilisering.

Denmark was as other countries little prepared for the pandemic but was favoured by the high degree of integration of the health and social care sector. The health sector was prioritized during the first wave of the pandemic, and therefore there were challenges early on with preventing infections and securing resources to protect nursing homes. Conversely, adequate measures in LTC facilities have been implemented later on. The implication for the users and staff concentrated on the nursing home sector while the effects for the home care sector was not documented in the first waves (Kjellberg et al, 2022; Rostgaard, 2020; Daly et al, 2022).

References: 

Daly, M. ; Leon, M.; Pfau-Effinger, B.; Ranci. C. & Rostgaard, T. (2022): COVID-19 and Policies for Care Homes in European Welfare States: Too little, too late?, Journal of European Social Policy, 32 (1), pp 48-59.

Kjellberg, P.K., Kjellberg, J.; Hirani, J.C., Mikkelsen, M.; Juel, K.; Christensen, J.; Lauritzen, H.H.; Thøstesen, A.; Topholm, E.H.E.; Martin, H.M.; Navne, L.E.; Johansen, M.B. & Bech, M.  (2022b) Baggrunden for covid-19-udbrud og -dødsfald på plejecentre og i hjemmeplejen i Danmark i perioden januar 2020 – april 2021. Tværgående analyse og besvarelse af opdraget. København: VIVE. https://www.vive.dk/da/udgivelser/baggrunden-for-covid-19-udbrud-og-doedsfald-paa-plejecentre-og-i-hjemmeplejen-i-danmark-i-perioden-januar-2020-april-2021-17878/

Rostgaard, T., Jacobsen, F., Kröger, T. & Petersen, (2022) ‘Revisiting the Nordic long-term care model for older people— still equal?’ in European Journal of Ageing. 19, 2, pp. 201-210.

The health sector was prioritized during the first wave of the pandemic, and therefore there were challenges early on with preventing infections and securing resources to protect care homes. Conversely, adequate measures in LTC facilities have been implemented later on (Rostgaard, 2020).

References: 

Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

Overall, and in comparison to other countries, Denmark has succeeded in keeping the number of persons infected with COVID-19, as well as mortality related to the disease, low. Also among older people 65+ the rates have been relatively lower: In an age-standardized comparison with England/Wales, Norway, Germany and Sweden, mortality among the population 65+ in the first wave of the pandemic (from April 2020) was nearly 9% in England, 6% in Sweden and only 5% in both Germany and Denmark, and 4% in Norway (Kjellberg et al, 2022).

Over time, more and more people have caught the disease. In May 2020, 458,305 persons in the population had tested positively. As of Sept 9^th 2022, this had increased to 3,097,088 confirmed cases of COVID-19 in Denmark (population of 5,873,419) and 6.968 deaths. This is based on PCR-test exclusively. 3,097,088 persons have caught COVID-19, which means there have been 182,964 reinfections, according to the Danish Health Authority.

References:

Danish Health Authority (2022) COVID-19 surveillance, https://www.sst.dk/en/english/corona-eng/status-of-the-epidemic/covid-19-updates-statistics-and-charts

Kjellberg, J.; Hirani, J.C.; Mikkelsen, M. Juel, K. (2022) Dødelighed under covid-19-epidemien januar 2020 – april 2021 Delrapport 1. En sammenligning med tidligere epidemier og andre lande. København: VIVE.

Rostgaard T (2020) The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

Data on cases and deaths within nursing homes are published weekly every Tuesday by Statens Serum Insititut under the Danish Department of Health. Deaths among confirmed residents are defined as deaths among residents who died within 30 days of a positive covid-19 PCR test (from the data first tested). In other words, these are not deaths which can positively be attributed to COVID-19 and the cause of death may be another.

As of September 9, 2022, there have been 2,439 deaths of care home residents. Therefore, with  6,068 deaths from COVID-19 in the whole population, the share of confirmed deaths among nursing home residents is 40% (Source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata). There are 38.863 nursing home residents in Denmark, which means that 6.28% of this population have died with confirmed COVID-19.

The research center VIVE has on commission from the Ministry of Health conducted a systematic analysis and evaluation of the spread of COVID-19 in the population and the LTC sector, and the following refers to the findings from this evaluation:

The daily number of infected in nursing homes grew in particular from March to April 2020, thereafter it fell and rose again at the end of the year. However, the testing strategy changed in this period and only the residents who needed to be admitted to hospital were tested in the spring. The factual number of persons infected and having died from COVID-19 would therefore be higher. In the winter 2020/21 a more systematic testing strategy was rolled out at the nursing homes and the daily number of persons infected climaxed at 80 persons, with 15-20 daily deaths in nursing homes (Hirani et al, 2022).

An excess mortality among nursing home residents can be observed in the winter of 2020/21, mainly driven by high mortality in the capital area, which was three times as high as in other regions. This was also the region where most persons were tested and found to be positive. The excess mortality was, however, only slightly higher than in comparable periods of previous flu epidemics (where there were no lockdowns) (Kjellberg et al, 2022b).

Community infection seems to be the main cause of the spread into the nursing homes (the analysis looks at the period Jan 2020-April 2021). In 36% of cases, the cause of infection is unknown, in 40% a member of staff had tested positive 14 days before, and in 8% a relative. In 17% there was both infection among staff and relatives. However, it should be noted that the testing strategy was different among staff and relatives with staff being tested regularly. Also that relatives did not have access to the nursing homes in the period March-April 2020. An analysis of the source of infection at the end of the year – where also many more test were distributed – shows fewer unknown sources and more often it is both staff and relatives who may have been the source (Hirani et al., 2022; Topholm and Kjellberg, 2022).

A separate analysis of older people living outside nursing homes shows that there are fewer persons who died in this period than during previous periods with flu epidemics. Again, there is regional variation, with proportionally more deaths in the capital and Sealand regions (Hirani et al, 2022).

Overall, the analysis shows that the increase in infection among those not living in a nursing home follow the same pattern: a small increase in March/April 2020 and then a larger increase at end of the year (Hirani et al, 2022).

A sub-analysis shows that among those older persons with home care there were approx. 70 daily cases and approx. 10 daily deaths, and 300 daily cases among older persons not receiving home care with approx. 20 daily deaths (Hirani et al, 2022).

The VIVE evaluation conclude that the nursing homes and the home care sector were “totally unprepared” when the pandemic started spreading (Jan- April 2020). There were no routines in place for disease prevention and management of disease outbreaks. There was only limited access to guidance and PPE and the test strategy only included persons who were admitted to hospital (Kjellberg et al, 2022a).

In the second phase (May-Oct 2020) the number of infections fell, and PPE and test equipment became more available, so that also relatives could be tested, but no preventive test were administered (Hirani et al, 2022.)

In the third phase, the infection rate rose in the nursing homes and more and more nursing homes introduced lockdowns. There were increasing concerns that the government’s response to the pandemic such as the lockdowns 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). Over Christmas, the visiting ban was lifted, and it was also allowed to gather up to 50 residents for celebration, the latter which receives criticism from the interviewed experts in the VIVE evaluation – who are also in general agreement that the national lockdown came too late in order to protect the nursing home sector (Kjellberg, 2022b).

References:

Hirani, J.C.; Mikkelsen, M, and Kjellberg, J. (2022) Test, smitte og covid-19-relateret dødelighed under covid-19-epidemien 2020 – 2021. Delrapport 2. https://www.vive.dk/da/udgivelser/test-smitte-og-covid-19-relateret-doedelighed-under-covid-19-epidemien-2020-2021-delrapport-2-17873/

Kjellberg, J.; Hirani, J.C.; Mikkelsen, M. Juel, K. (2022a) Dødelighed under covid-19-epidemien januar 2020 – april 2021 Delrapport 1. En sammenligning med tidligere epidemier og andre lande. København: VIVE. https://www.vive.dk/da/udgivelser/doedelighed-under-covid-19-epidemien-januar-2020-april-2021-delrapport-1-en-sammenligning-med-tidligere-epidemier-og-andre-lande-17871/

Kjellberg, P.K., Kjellberg, J.; Hirani, J.C., Mikkelsen, M.; Juel, K.; Christensen, J.; Lauritzen, H.H.; Thøstesen, A.; Topholm, E.H.E.; Martin, H.M.; Navne, L.E.; Johansen, M.B. & Bech, M.  (2022b) Baggrunden for covid-19-udbrud og -dødsfald på plejecentre og i hjemmeplejen i Danmark i perioden januar 2020 – april 2021. Tværgående analyse og besvarelse af opdraget. København: VIVE. https://www.vive.dk/da/udgivelser/baggrunden-for-covid-19-udbrud-og-doedsfald-paa-plejecentre-og-i-hjemmeplejen-i-danmark-i-perioden-januar-2020-april-2021-17878/

Rostgaard T (2020) The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

Topholm, E.H-E. and Kjellberg, p.K. (2022) Decentrale beretninger fra hjemmeplejen og plejecentre under covid-19-epidemien. Delrapport 4. København: VIVE. https://www.vive.dk/media/pure/17876/6978327

On March 11, 2020 the government introduced a national lockdown and only the provision of vital services were to continue. As a result, day care centres for older people closed down and home care was reduced or cancelled. In the nursing homes, a ban for visitors was introduced and many nursing homes introduced compartmentalization. There is general agreement that the restrictions saved lives but also came at a cost.

As part of the evaluation of the pandemic management, the national research center VIVE has conducted 29 qualitative interviews among older people and their relatives. Overall, the finding is that service provision has not been severely affected during the pandemic. It was accepted as a necessary and limited precaution. Physical training and rehabilitation may have been cancelled but has been opened up again (Martin and Navne, 2022). Interviews among management and staff from different nursing homes generally convey that the restrictions were hard for users, informal carers and also staff, but that they were necessary and that the residents supported the restrictions (Topholm and Kjellberg, 2022).

A survey among 1.419 members of the Alzheimer‘s Society conducted in mid-June 2020 (response rate 21,2%) concluded that the lock-down of respite care in day centres affected them as relatives as well as the users (Alzheimerforeningen, 2021).

Reference:

Alzheimerforeningen (2021) Livet under COVID-19. Coronakrisens betydning og konsekvenser for pårørende til per soner med demens sygdom. København: Alzheimerforeningen, https://www.alzheimer.dk/media/f4fjzr4p/livet-under-covid-19-final.pdf

Martin, H.M. and Navne, L.E. (2022) Borgeres og pårørendes perspektiver på håndteringen af covid-19-epidemien. Delrapport 5. https://www.vive.dk/da/udgivelser/borgeres-og-paaroerendes-perspektiver-paa-haandteringen-af-covid-19-epidemien-17875/

Topholm, E.H-E. and Kjellberg, P.K. (2022) Decentrale beretninger fra hjemmeplejen og plejecentre under covid-19-epidemien. Delrapport 4. København: VIVE. https://www.vive.dk/media/pure/17876/6978327

 

The national research center VIVE has a part of a national evaluation conducted 29 interviews with relatives and users of long-term care. Some relatives note in the VIVE evaluation that the service cancellations may have had a negative impact on the cognitive and physical functional ability, especially among older people with dementia. Of concern has also been the changing members of staff as this may increase the risk of infection. However, the informants in general support the restrictions and saw it as a sad period that would nevertheless pass (Martin et al, 2022).

Regarding the nursing home sector in particular, the lockdowns have left the residents feeling lonely and isolated. Also, users of home care felt that they had to reduce social contact, but they could to some degree continue to see family and friends (Martin et al, 2022).

A survey among among 1.419 members of the Alzheimer’s Society (conducted mid-June 2020; response rate 21,2%) showed that relatives to persons with dementia experienced that these declined in cognitive and physical functional ability (Alzheimerforeningen, 2021).

Reference:

Alzheimerforeningen (2021) Livet under COVID-19. Coronakrisens betydning og konsekvenser for pårørende til per soner med demens sygdom. København: Alzheimerforeningen, https://www.alzheimer.dk/media/f4fjzr4p/livet-under-covid-19-final.pdf

Kjellberg, P.K., Kjellberg, J.; Hirani, J.C., Mikkelsen, M.; Juel, K.; Christensen, J.; Lauritzen, H.H.; Thøstesen, A.; Topholm, E.H.E.; Martin, H.M.; Navne, L.E.; Johansen, M.B. & Bech, M.  (2022) Baggrunden for covid-19-udbrud og -dødsfald på plejecentre og i hjemmeplejen i Danmark i perioden januar 2020 – april 2021. Tværgående analyse og besvarelse af opdraget. København: VIVE. https://www.vive.dk/da/udgivelser/baggrunden-for-covid-19-udbrud-og-doedsfald-paa-plejecentre-og-i-hjemmeplejen-i-danmark-i-perioden-januar-2020-april-2021-17878/

Rostgaard T (2020) The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

A survey among 1.419 members of the Alzheimer’s Society (conducted mid-June 2020; response rate 21,2%) shows that relatives of persons with dementia were concerned during the first phase of the pandemic. Nearly half felt they did not receive sufficient information from the nursing home staff which led to worry and worsened mental well-being. There was in general support for the lockdowns. Relatives cohabiting with a person with dementia has been especially hit and felt lower mental well-being, caused amongst other by the closing down of respite care in day centres. Relatives in general had problems sleeping and felt lonely (Alzheimerforeningen, 2021).

Reference:

Alzheimerforeningen (2021) Livet under COVID-19. Coronakrisens betydning og konsekvenser for pårørende til per soner med demens sygdom. København: Alzheimerforeningen, https://www.alzheimer.dk/media/f4fjzr4p/livet-under-covid-19-final.pdf

A report conducted by the Danish union representing staff in the LTC sector (FOA) evaluated how LTC staff were affected by the pandemic: overall, the union members experienced that management in the LTC sector has generally communicated well how and why the various restrictions were introduced. Communication around PPE, however, has been less clear and often changed. Also, Work Environment in Denmark, the public authority in charge of regularly checking how employees are thriving, sent home their employees in the Spring of 2020 until Aug 2020, which meant that there was no focus on the work environment in these early and confusing months of the pandemic.

The FOA report is based amongst other on a member survey in the Spring 2020 (10.510 respondents), conducted with Copenhagen University. The survey shows that the fear of getting infected was most prominent among staff in the LTC sector, compared to the hospital, psychiatry, ambulant services and child-care sectors (Nabe-Nielsen et al, 2021).

As part of the national evaluation of the spread of COVID-19 and related mortality, the national research center VIVE has conducted a register analysis of all the conducted COVID-19 tests and has identified how many tests were administered to staff in the nursing home and home care sector and with what result: Staff have been regularly tested, even more often than residents in the nursing homes and relatives. As was the case of service users, an increase in infection rates was seen among staff in the LTC sector at the end of the year 2020 (Hirani et al, 2022).

The higher risk of getting infected continued also after the first wave: A report from Statens Serum Institut in Jan 2022 concluded that one in seven LTC staff had been infected (14 pct.) just within the 4 first weeks of 2022 (source:  https://www.fagbladetfoa.dk/Artikler/2022/01/25/Knap-hver-7-ansatte-i-aeldreplejen-er-blevet-smittet-i-aarAlle-er-slidte).

 

Reference:

Bredal, C.; Manniche, K. and Dam-Hansen, A. (2021) I Corona Frontlinjen. Erfaringer fra medarbejderne i ældreplejen – Danmark. Friedrich Ebert Stiftung https://library.fes.de/pdf-files/bueros/stockholm/18119.pdf

Hirani, J.C.; Mikkelsen, M, and Kjellberg, J. (2022) Test, smitte og covid-19-relateret dødelighed under covid-19-epidemien 2020 – 2021. Delrapport 2. https://www.vive.dk/da/udgivelser/test-smitte-og-covid-19-relateret-doedelighed-under-covid-19-epidemien-2020-2021-delrapport-2-17873/

Nabe-Nielsen, Kirsten; Juul Nilsson, Charlotte; Juul-Madsen, Maria; Bredal, Charlotte; Preisler Hansen, Lars Ole; Hansen, Åse Marie (2021): COVID-19 risk management at the workplace, fear of infection and fear of transmission of infection among frontline employees, in: Occupational & Environmental Medicine, 78, pp. 248–254, https://oem.bmj.com/content/oemed/78/4/248.full.pdf

As the LTC sector in Denmark is formal, there is no particular role for migrant care workers outside the sector.

Already before the pandemic, the LTC sector in Denmark was, similar to other countries, in need for the recruitment and retention of more staff.  During the pandemic the shortage of staff in the LTC sector became even more prominent. According to The Federation of European Social Employers (February 2022 report), Denmark has reported an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

The general shortage of staff has put pressure on those continuing to work in the sector.  There have been reports of more than half of staff in nursing homes being either ill themselves or being in isolation (source: https://www.fagbladetfoa.dk/Artikler/2020/06/25/Syv-dage-med-faellestillidsrepraesentant-paa-coronasmittede-Vendelbocenter-i-Hjoerring).

Service providers have struggled to keep service provision, e.g. in Dec 2021 some municipalities were forced to ask their employees to continue working even though there were supposed to be in isolation (source: https://www.fagbladetfoa.dk/Artikler/2021/12/07/Kommune-opfordrer-ansatte-i-aeldreplejen-til-at-arbejde-trods-anbefaling-om-isolation).

It was common for staff working in other areas to be deployed for social care provision. Some municipalities activated emergency plans and amongst other paid out extra salary to employees who would take an extra shift (source: https://www.fagbladetfoa.dk/Artikler/2022/01/25/Knap-hver-7-ansatte-i-aeldreplejen-er-blevet-smittet-i-aarAlle-er-slidte).

The first confirmed case of COVID-19 in Denmark was diagnosed on February 27th, 2020. Early on, general recommendations were to apply spatial distancing, self-quarantine and to maintain good hygiene, especially by frequent hand washing or disinfection. However, it was (and still is) not recommended to wear a mask in public places or in situations with many people, as there was no evidence for the positive effect.

As the number of positive cases continued to grow, the authorities recommended to cancel or postpone large gatherings, initially with more than 1,000 persons, but as of March 11, just 100 persons. This meant that concerts, football matches and the like were cancelled. On March 10th, citizens were encouraged only to use public transport outside peak hours.

Lockdown

Denmark was one of the first countries worldwide to introduce a lockdown. This was announced on March 11^th, and came into force March 13th, 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 and universities, libraries and museums closed down. Exams were cancelled.

Also, all non-essential travel was advised against and Danes who were abroad were recommended to return home. On March 14th, the Danish borders closed apart from the transportation of goods and people with a so-called legitimate reason for entering the country. Self-quarantine for 2 weeks was recommended if a person had visited a high-risk country and for health and social care staff this was a requirement since March 3rd. Over the next days also  primary and secondary schools, child care centres, restaurants, shopping malls etc. were closed and it became illegal for more than ten persons to gather at a time in public places. On April 15th the lockdown was partly lifted as day care centres and primary schools for pupils in 0-6. grade opened up again but with more space per child and strict instructions on washing and disinfecting hands regularly. Graduating students in the upper secondary schools and at social and health care educational institutions were allowed back in school.  Over the next weeks the service industry and cultural institutions re-opened but recommendations to maintain now 1 meter’s physical distance was kept into May. In areas with less infection, public employees could return to work. At the time, there was a discussion about the reasoning behind the lock-down and whether this was taken on grounds of epidemiological evidence or rather of political concerns.

Feb 1^st 2022, the far majority of restrictions were lifted in Denmark, as the first country in the EU, the reason being that more than 80% of the population had had two vaccinations. This included restrictions on nightclubs and late-night sale of alcohol.

Test strategies

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. The initial test strategy, introduced in early March 2020, 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.

As of March 15th, 2020, 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. In the period of May 1st-May 12th, the number of daily tests was fluctuating between 4-15,000.

On May 12th, 2020, a new and more aggressive testing strategy was introduced, where persons without symptoms are also to be 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.

In combination with the new testing strategy, the health authorities also introduced new and trust-based measures to confine the disease. This included a policy of encouraging those with COVID-19 to self-quarantine. The municipality must offer a place at a hospital, hotel or similar, if the person is unable to be at home. Finally, persons who have tested positive must inform other persons with whom they have been in contact with, who are then supposed to take two tests. Call centres operated by the health authorities can assist the person. Concerns were voiced that this voluntary system would not be efficient.

Over the winter 2020-2021, the mass testing strategy with free access to testing was continued. In May 2021, the test capacity peaked at 12,167 COVID-19 tests per day per 100,000 inhabitants. When society re-opened in March 2021, a negative COVID-19 test or completion of COVID-19 vaccination became compulsory for attending education, cafes and restaurants, fitness centers. Children in elementary schools were strongly urged to take biweekly COVID-19 tests, often assisted by teachers (Busk et al, 2021).

As of Sept 2022, the general recommendation is to be tested in situations only where a test result may be important for the treatment of COVID-19. However, a number of test recommendations still apply for employees and visitors to nursing homes, home care and social services with vulnerable people who are at particular risk of a serious illness in the event of infection with COVID-19 (source: https://en.coronasmitte.dk/general-information/test-for-covid-19).

PPE

As in other countries, there was a shortage of PPE in the early phases and the health care sector was prioritised. In August 2020, wearing a mask or face shield become mandatory in public transport, and it was extended to most public places in Oct 2020. In June 2021, the requirement to wear masks in public places was phased out but reinforced in Nov 2021 along with other restrictions. Feb 1^st 2022, the mask restriction was lifted for the final time.

Vaccines

The first vaccinations were rolled out Dec 27^th, 2020. Residents in nursing homes was first on the list, followed by older people with home care, older people aged 85 and over and other vulnerable groups. Denmark uses  Pfizer/BioNTech and Moderna vaccines and vaccination is free of cost. Denmark has one of the highest levels of COVID-19 vaccination in the European Union as of the end of September 2021. 81.4% of the population has received the first vaccine, 80.0% the second, and 61.7% the third. As of Oct 1^st 2022, a fourth vaccine will be offered to all persons 50 years or older. By Sept 2022 0.9% have already received the fourth vaccine (source: https://covid19.ssi.dk/overvagningsdata/vaccinationstilslutning.)

References:

Busk, P. K., Kristiansen, T. B., & Engsig-Karup, A. (2021). Assessment of the National Test Strategy on the Development of the COVID-19 Pandemic in Denmark. Epidemiologia, 2(4), 540-552. https://doi.org/10.3390/epidemiologia2040037

Overall, the Danish governance approach to governance of the pandemic has relied on general agreement within political parties and among the public about the necessity of fast-tracking and wide-ranging emergency Epidemic laws, and introducing lock-downs and restrictions. Support for such measures was high, in particular in the first phases of the pandemic. The approach in Denmark (and Finland) in terms of the government response to the pandemic, been characterised as being politics-lead and using authoritative regulatory instruments. In comparison, Sweden and to some degree Iceland used expert-based management and less invasive regulatory instruments and Norway took a middle ground by balancing politics and expert-lead management with regulatory instruments based on the treasurer (Christensen et al, 2022).

In the first phase, the government seemed to have engaged selectively with expertise.  In Feb 2021, a cross-disciplinary ‘Epidemic Commission’ of experts was set up in order to serve as an advisory board for the government and the cross-party Epidemic council. The council executes the parliamentary control of policy-making in the various ministries. Ministries can only decide on a new regulation if the commission has suggested it and the council has approved it. Also, The Danish Health Authority is chairing a number of COVID-19 related working groups, focusing on health and vaccination.

Overall, it seems that given the high level of integration of the health and social sectors and their communication structures with municipalities, the pandemic response was able to efficiently focus on the wide range of LTC services during the pandemic.

The municipalities set up working groups in the first phase, in charge of governance implementation of the new measures in the LTC sector. Central regulation included lockdowns, recommendation on hygiene, cleaning, testing, visit and isolation strategies and later on vaccination. For instance, the Danish Health Authority was in charge of communicating central guidelines to short and local instructions to be used by managers and staff. Hotlines and Q&A sessions were set up where managers could pose questions. Often specific members of staff were designated in charge of Covid-19 cleaning and work schedules were changed so that staff limited the number of residents they cared for (Danish Health Authority, n.d).

VIVE, the national welfare research center, has conducted an evaluation focusing at the de-central level and based on interviews with managers in the LTC sector (Topholm and Kjellberg, 2022). One learning is that there were insufficient hygiene measures set up. As a result, many municipalities established cross-facility organizations for promoting better hygiene and employed nurses specialized in hygiene who could be in charge of upskilling staff (Topholm and Kjellberg, 2022).

Often central regulation was to be implemented within short time and without particular knowledge of the sector and the skills-level of the staff working there. One example is that the communication should have been quicker, more direct and hands-on. Due to the shortage of PPE, the health sector was prioritized over the LTC sector and staff, management and users were concerned about the lack of PPE and the varied use of this. There is generally high support for the extensive testing strategy, although it seems to have come too late, and it seems desirable that the responsibility for testing should be at a decentral level. The roll-out of the vaccination strategy was initially demanding but over time became more manageable (Topholm and Kjellberg, 2022).

References:

Christensen, J.G., Askim, J., Gyrd-Hansen, D. and Østergaard, L (2021) Håndteringen af covid-19 i foråret 2020 Rapport afgivet af den af Folketingets Udvalg for Forretningsordenen nedsatte udredningsgruppe vedr. håndteringen af covid-19 (Copenhagen: Folketinget).

Christensen, T., Dagnis Jensen, M., Kluth, M. F., Kristinsson, G. H., Lynggaard, K., Lægreid, P., Niemikari, R., Pierre, J., & Raunio, T. (2022). The Nordic governments’ responses to the Covid-19 pandemic: A comparative study of variation in governance arrangements and regulatory instruments. Regulation & Governance.

Danish Health Authority (n.d.) https://www.sst.dk/-/media/Udgivelser/2021/Corona/Hygiejne-i-aeldreplejen/Hygiejne-i-aeldreplejen_Kommunale-erfaringer-foer-og-under-COVID-19.ashx?sc_lang=da&hash=DEA3949DA2866A8BC11203AA578F8614

Topholm, E.H-E. and Kjellberg, P.K. (2022) Decentrale beretninger fra hjemmeplejen og plejecentre under covid-19-epidemien. Delrapport 4. København: VIVE. https://www.vive.dk/media/pure/17876/6978327

There is no task force specifically identified for LTC (Source: https://www.covid19healthsystem.org/countries/denmark/livinghit.aspx?Section=5.%20Governance&Type=Chapter).

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/).

From April 2020 Statens Serum Institut has started gathering data on infections  at the nursing homes. The close monitoring of infection rates by Statens Serum Institut as well as the Danish Patiens safety Authority is considered to be a decisive tool in the management of the pandemic. Weekly data on LTC and COVID-19 is published online by Statens Serum Institute (Source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

Once a week, Danish Regions publish statistics on the stocks of masks, disinfectants and gloves (Source: https://www.regioner.dk/sundhed/coronaviruscovid-19).

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).

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/).

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/).  Denmark also provided financial help to LTC facilities to recruit unemployed or former LTC workers, as well as providing financial help to LTC facilities to recruit LTC students (Source: OECD paper).

There is a dedicated page 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, 2020 an extensive publication providing new guidelines on how to organize visits in nursing homes was published by the Board of Health.

The current guidelines (Sept 2022) from the Danish Health Authority instruct how to act if a nursing home resident is admitted to hospital and found to be positive with COVID-19. In that case, the hospital doctor must contact the nursing home and the local management must initiate testing (source: version-5_6-Vejledning-om-forebyggelse-af-smitte-paa-plejecentre-mv_-september-2022.ashx (sst.dk).

On April 8, 2020, an extensive guidelines were issued by the Board of Health, outlining 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 14^th 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 local 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/).

In the current guidelines (Sept 2022), it is still recommended to isolate residents in nursing homes if they have tested positive. If more than one resident is positive, it is recommended to establish a separate unit for these residents. In this way, the residents can have some mobility outside their own dwelling and staff do not need to change PPE in between visiting the residents. The nursing home can also choose to separate the home into zones, so that specific units are isolated. In the case where a resident does not understand the necessity for isolation, due to cognitive impairment or dementia, the guidelines emphasize the need for trying to motivate the resident to stay in their own dwelling by using pedagogical methods and means. version-5_6-Vejledning-om-forebyggelse-af-smitte-paa-plejecentre-mv_-september-2022.ashx (sst.dk)

 

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 a representative survey among with frontline managers working in municipal and private residential/home units in Denmark May–June 2020; n=649-720), the aim was to identify frontline managers’ range of actions and experiences of the COVID-19 pandemic (Balle et al. 2022). The survey showed that the nursing homes generally introduced restricted mobility for residents, organised the work in groups and tried to reduce the number of substitute workers. Over time, these strategies were relaxed somewhat: In phase one (Jan-mid-Mar 2020), 32% if nursing homes closed down for visitors, in phase two (mid-march-April 2020), 85% and in phase three (May-Aug 2020) 62%. Also, 26% introduced restricted mobility for residents in phase one, 67% in phase two and 54% in phase three. The organisation of work changed so that staff worked in smaller groups for 43% of the nursing homes in phase one, 81% in phase two and 73% in phase three. Similarly, 41% of the nursing homes used fewer or regular substitutes in phase one, 77% in phase two and 65% in phase three.

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).

References:

Balle-Hansen, M.; Bertelsen, T. M. ; Lindholst, C.; Bliksvær, T.; Lunde, B.V.; Soli, R.; Wolmesjö, M. (2020) Minimering af COVID-19 smitte i nordisk ældrepleje Udfordringer og løsninger. Aalborg: Aalborg Universitet.  20201229_COVID_19_i_nordisk_ldreomsorg_Udfordringer_og_l_sninger_mbhrev9.pdf (aau.dk)

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. 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 (source: 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 (source: 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 (source: 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. (source: 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 (source: 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 (source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

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, 2020), 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/).

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; Kommunale nyskabelser under covid-19-krisen – VIVE).

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.

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”. 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. 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”.

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. Among those receiving home care, the rate is 97.9% and 98.4% among staff working in LTC.

The fast rollout of the booster soon proved effective as the incidence rates in nursing homes started falling. By week 37 only 11 nursing homes experienced new incidences of the disease and only 22 double vaccinated residents were infected.  By September 21st (week 38), 46.5% of residents had received the booster vaccination. From this week to the following, the incidence rate increased in the general population from 43 to 52 new cases per 100.000 inhabitants, while the number fell from 18 to 4 in nursing homes, a fall of 78% just within a week.

In early November, the number of incidences among residents started increasing again and had within two weeks tripled from 36 to 87 persons infected. In the same period, the number of incidences among nursing home staff increased from 272 to 738 persons. Only 49.2% of staff had received the booster vaccination at that time. In comparison, 60.4% of hospital staff had received the booster. The Danish Patient Safety Authority reported that they were aware of nursing homes where staff needed to go to work even though they were infected, as there was a shortage of staff.

There  has been no policy for prioritizing offering the booster to staff in hospitals and nursing homes. With the Omicron variant (first reported in Denmark Nov 28th), the general roll-out of the booster vaccination was speeded up and regardless of timing of the second vaccination, every person over 40 years is currently (Dec 21^st) offered the booster. The age group 18-39 year old is offered the booster 5.5. months after the second vaccination. In the whole population, 80.9% have received their first vaccination and 76.9% their second, while 34.7% have received the booster.

As of Oct 1st 2022, a fourth vaccine will be offered to all persons 50 years or older. By Sept 2022 0.9% have already received the fourth vaccine

Data sources:

https://files.ssi.dk/covid19/brancher/vaccinationstilslutning/vaccinationstilslutning-brancher-covid19-uge50-2021-fg45  https://covid19.ssi.dk/overvagningsdata/vaccinationstilslutning

There is a dedicated page on Danish Health Authority website  on how to manage COVID-19 among older populations in the home (https://www.sst.dk/da/corona/Information-til-fagpersoner/Sundheds–og-plejesektoren).

Overall, the informal carers have not been supported systematically; there are some cash benefits for carers, but by far the majority of LTC offers are directed at the claimants and not their relatives. However, there are offers of respite care (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

There is no particular policy reform planned in Denmark to address shortcomings identified during the pandemic. The new Senior Citizen’s Act has as a focus to ensure values of dignity, freedom of choice, independence and reduced paper work for staff, but the preparatory work does not mention COVID-19.

There have been attempts to attract and retain workers to the formal care sector following the action plan ‘More hands in the older person and health sector’ of the Association of Municipalities from 2018. These have not least attempted to get more young people to start training as home and health care assistants or helpers. The measures span information campaigns, higher wages, and better collaboration between relevant partners to attract, educate and retain more workers. These efforts have so far not proven successful, perhaps partly due to the poor image of the sector with the general public, including the young people who are intended to take up education and look for work in the sector (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

References:

Lauritzen, H.H.; Jensen, M.C.F. and Kjer, M.G. (2022) Analyse af social- og sundhedsfagenes image og imageudfordringer Rekruttering til og fastholdelse i social- og sundhedsfagene https://www.vive.dk/da/udgivelser/analyse-af-social-og-sundhedsfagenes-image-og-imageudfordringer-18142/

Prior to the World Health Organization declaring a pandemic on 11 March,  Danish politicians quickly amended the national Epidemic Act, which had not been updated since the 1970s. Consequently, the decision-making authority which previously was in the hand of local epidemic commissions is now centralized within the government. The newly centralised authority, the Epidemic Comission, is primarily comprised of Danish prime minister and various Ministry representatives and experts from the Danish Health Authority, the Danish Patient Safety Authority, and virologists at Statens Serum Institut (SSI). This authority alone now has the power to make evidence-based decisions regarding public health and safety in relation to pandemic (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).