LTCcovid International living report on
COVID-19 and Long-Term Care

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It is compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project are moderating the entries and editing as needed.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Pharoah D (eds.) and LTCcovid contributors. LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.

PART 1.
Long-Term Care System characteristics and preparedness

1.00. Brief overview of the Long-Term Care system

Overview

Definitions of Long-Term Care:

In the World Report on Ageing and Health published in 2015 by the World Health Organization, Long-Term Care was defined as  “the activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity”. This definition supports the idea of a system to enable people to live their best lives, irrespective of their disabilities and health conditions.

Long-term care “systems”

In practice, long-term care covers a wide range of services and activities that can take place in various settings, including the beneficiary’s home, their neighbourhood, hospices, residential settings and day-care facilities.

Long-term care benefits, services and activities typically span multiple government departments (health, social welfare, labour, housing) and levels (national, regional, local, community and family), which leads to fragmentation of responsibility, difficulties in coordination and, from the point of view of the persons who could benefit from services, benefits and activities, barriers to access.

In this section we aim to provide a very brief overview of long-term care systems around the world, at national or sub-national level. The term system is used as in the WHO World report on Ageing and Health, to refer to: all caregivers and settings where care is provided, as well as the governance and support services that can help them in their roles. This definition includes care provided in the formal and informal sector, paid and unpaid, publicly and privately provided and delivered, in people’s own homes, in the community and in institutional settings.

This is a comprehensive definition of long-term care covering care and support in the community and in congregate (“institutional”) settings, by formal care providers and by unpaid carers, and for younger and older adults. Some of the definitions used in the reports from the different countries may vary in terms of the groups and types of care included.

It is important to emphasise that experiences of a “long-term care system” (and care outcomes) differ, not only depending on which country/region they live in, but also by their local context (which is why there is growing use of the term “care ecosystem” see for example Dessers & Mohr, 2020), and of their own individual and family circumstances.

References:

Dessers, E. and Mohr, B. J. (2020) ‘An ecosystem perspective on care coordination: Lessons from the field’, International Journal of Care Coordination, 23(1), pp. 5–8. doi: 10.1177/2053434519896523.

 

International reports and sources

The Organisation for Economic Co-operation and Development (OECD) publishes regularly international reports and data on long-term care (click here).

Some data on long-term care, for example on the numbers of countries that have a long-term care policy/plan/strategy is also available from the WHO’s Ageing Data portal (click here).

For European countries, the European Centre for Disease prevention and control (ECDC), also publishes data on the numbers of people in Long-Term Care Facilities (ECDC), and on number of beds (click here) There are country reports from EU countries (2018) on EU website:  (click here).

For Latin American and Caribbean countries, the Interamerican Development Bank has developed the Panorama of Aging and Long-Term Care, gathering indicators, publications and case studies to support policy development (click here).

Australia

What is understood as Long-Term Care in Australia?

In Australia the term ‘long term care’ is seldom used.  ‘Aged care’ is the more common term.

Unlike many other countries older Australians needing support and people with disabilities aged under 65 are funded and supported under two distinct Australian government policies and funding arrangements: Aged Care and the National Disability Insurance Scheme (NDIS).

Aged Care

The two main forms of government-subsidised aged care (LTC) are residential aged care and home care.

The Australian government is the primary funder and regulator of the long-term care system. The government subsidises both home care and residential care for people of all ages who have been assessed as needing care and support. There are four main types of services under aged care: the Commonwealth Home Support Programme (CHSP) Home Care Packages (HCP), residential care and flexible care. More than 1.2 million people received aged care services during 2017–2018. 77% received support in their home or other community-based settings. Of Australians over the age of 65, 7% accessed residential aged care, 22% accessed some form of support or care at home, and 71% lived at home without accessing government-subsidised aged care services (sources: Care, Dignity and Respect report; Aged Care and COVID-19 report).

The National Disability Insurance Scheme (NDIS)

The NDIS, implemented from 2013 to 2020, has established a needs-based system of care and support for people with disability with ‘permanent and significant’ disability, with assessment of need based on level of impairment. The NDIS provides individualised support for approximately 500,000 people across Australia (Hamilton et al forthcoming).

Last updated: January 17th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Lee-Fay Low  |  

Austria

Austria is a federal state and was one of the ‘early movers’ when it came to acknowledge long-term care (LTC) as a social risk that calls for solidarity and societal support for people in need of long-term care. With the introduction of the LTC allowance scheme in 1993, Austria followed its tradition as a continental, conservative welfare regime in which cash benefits dominate over the provision of social services. At the same time, the country deviated from this pathway as funding of the LTC allowances (attendance allowance) has been stipulated through general taxes rather than as a fifth pillar of the social insurance system.

With this original reform, competences between the federal state and the nine provinces were reshuffled in that the federal government became responsible for financing all cash benefits, including support for informal carers, while the provincial governments remained in charge to procure community care services and residential facilities. Indeed, home care services are almost entirely provided by private non-profit organisations (based on a long-standing tradition), while about 50% of residential facilities are managed by public entities, 25% by non-profit organisations, while the share of private for-profit providers has been increasing and is currently also at about 25%. To date, there are about 75,000 places in care homes, about 7,000 places in alternative housing and short-term facilities, while about 150,000 persons are using one or the other home care service throughout the year (Statistics Austria, 2021). As there are about 470,000 beneficiaries of the LTC allowance, it becomes evident, that the large majority of people in need of care is being cared for at home with support by an informal carer, mainly by wives, daughters and step-daughters. In total, it has been estimated that there are about 801,000 Austrians involved in caring for a loved one at home, while 146,000 are supporting a family member who is living in a care home, i.e. more than 10% of the population (Nagl-Cupal et al., 2018).

Against this backdrop, a specific feature of the Austrian LTC system has developed over the past 25 years in terms of a partial replacement (or supplementation) of family care by live-in personal carers, mainly from neighbouring Eastern European countries. Although live-in migrant care is a widespread phenomenon across Europe, the so-called ‘24-hour care’ model in Austria has a special status with dedicated legal regulations and funding since 2007 (Schmidt et al., 2016). ‘Personal carers’ are registered as self-employed at the Austrian Chamber of Commerce, although most of them are also dependent on specialised brokering agencies in their home country or in Austria (Aulenbacher et al., 2020). Due to the geographic situation as well as to unemployment and wage differentials in neighbouring countries, the share of older people in need of care relying on migrant live-in carers has increased significantly over the past 15 years. To date, more than 66,000 personal carers accompany about 33,000 Austrians in need of care in their own households (ca. 7% of total beneficiaries of the LTC allowance).

This phenomenon contributes to additional complexity in the already fragmented structural framework of LTC in Austria. The lack of coordination among different LTC settings, and in particular between these and the acute health sector, has been a constant criticism over the past decades, and related caveats became even more evident since the onset of the SARS-CoV-2 pandemic and related measures such as travel restrictions and the closing of borders (Leichsenring et al., 2021).

Current initiatives are striving to address shortcomings in information, communication and coordination by means of a pilot project to establish 150 community nurses at municipal level. However, the imminent shortage of workforce in the LTC sector and related challenges of sustainable funding are calling for urgent and more far-reaching reforms. There are currently about 60,000 professionals working in the various settings of LTC. It has been forecasted that a minimum of 30,000 additional professionals would be necessary until 2030 to replace retiring staff and to satisfy the growing demand of formal care (Rappold & Juraszovich, 2019).

References on the Long-Term Care system in Austria:

Aulenbacher, B., Leiblfinger, M. & Prieler, V. (2020). “Jetzt kümmern sich zwei slowakische Frauen abwechselnd um meinen Vater …” Institutionelle Logiken und soziale Ungleichheiten in der agenturvermittelten 24h-Betreuung. In: Seeliger, M., Gruhlich, J. (Hg.). Intersektionalität, Arbeit und Organisation. Weinheim and Basel: Beltz Juventa.

Leichsenring, K., Schmidt, A.E., Staflinger, H. (2021). Fractures in the Austrian model of long-term care: What are the lessons from the first wave of the COVID-19 pandemic? Journal of Long-Term Care, 2021, 33-42. DOI: https://doi.org/10.31389/jltc.54

Nagl-Cupal, M., Kolland, F., Zartler, U., Mayer, H., Bittner, M., Koller, M., Parisot, V., Stöhr, D., Bundesministerium für Arbeit, Soziales, Gesundheit und Konsumentenschutz (Hg.) (2018). Angehörigenpflege in Österreich. Einsicht in die Situation pflegender Angehöriger und in die Entwicklung informeller Pflegenetzwerke. Wien: Universität Wien/BMASGK.

Rappold, E. & Juraszovich, B. (2019). Pflegepersonal-Bedarfsprognose für Österreich. Wien: Bundesministerium für Arbeit, Soziales, Gesundheit und Konsumentenschutz.

Schmidt, A.E., Winkelmann, J., Leichsenring, K. & Rodrigues, R. (2016).  Lessons for regulating informal markets and implications for quality assurance – the case of migrant care workers in Austria.  Ageing & Society, 36(4), 741-763.

Statistics Austria (2021) Betreuungs- und Pflegedienste, available at http://www.statistik.at/web_de/statistiken/menschen_und_gesellschaft/soziales/sozialleistungen_auf_landesebene/betreuungs_und_pflegedienste/index.html

Last updated: January 6th, 2022   Contributors: Kai Leichsenring  |  

Chile

The majority of people with support needs receive care from their family members, mostly women.

There is some provision of subsidized institutional care. In principle all long-term care facilities should be registered with the Ministry of Health and subject to staffing requirements. However, it has been estimated that half of all care homes are not registered or unregulated.

References:

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Browne, J., Palacios, J., Madero-Cabib, I., Dintrans, P. V., Quilodrán, R., Ceriani, A., & Meza, D. (2021). Enablers and Barriers to Implement COVID-19 Measures in Long-Term Care Facilities: A Mixed Methods Implementation Science Assessment in Chile. Journal of Long-term Care, 114–123. DOI: http://doi.org/10.31389/jltc.72

 

Last updated: January 6th, 2022

China

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

Last updated: January 6th, 2022

Czech Republic

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

Last updated: January 6th, 2022

Denmark

The Long-Term Care (LTC) system in Denmark can characterised as a universal and primarily public system. Access to LTC services is at no cost for home-based care, or with a means-tested co-payment. The LTC system has strong public and political support. It is a highly decentralized system, organised, financed and provided at the municipal level. There is a strong emphasis on community-based care, re-ablement and professionalisation of care staff.

The main law regulating social service provision and, implicitly, long-term care provision is the Social Services Act, which passed in 1998. The Social Services Act emphasizes the users’ right to influence social service provision and enshrines the highly decentralized nature of the system, putting municipalities in a key position to shape long-term care.

In recent years there has been a decrease in the number of people who receive home care services, and these are increasingly focusing on personal care. This has resulted in families needing to take on more. Recent reforms have also included the introduction of for-profit providers.

Sources:

https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019.

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

 

Last updated: January 6th, 2022

Finland

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

Last updated: January 6th, 2022

France

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

In 2015 there were 1.25M beneficiaries of the personal autonomy allowance for people over 60 in need of assistance with activities of daily living. (8% of over-60s)

The domiciliary care sector is extremely fragmented, with one department (local authority) having over 100 agencies. Financing is unprofitable. The difference between hourly rates under the personal autonomy allowance  and minimum hourly rates to cover costs were of 2.2€/hour in 2017.

Health policies are implemented by the Regional health agencies at the regional level (ARS, created in 2009). Social policies are under the responsibility of the local authorities at the local decentralized level. There is a joint responsibility for tariff setting and financing of operations in care homes. ARS do not have oversight of domiciliary care, except where a nursing component is involved.

Authors: Alis Sopadzhiyan (LTCCovid profile pending)

Last updated: January 6th, 2022   Contributors: Camille Oung  |  

Germany

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

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

In 2019, out of the 15,380 residential care homes, 43% were operated by private for-profit provider, 53% by private not-for-profit providers and 5% were owned and operated by public providers (source: https://www.gbe-bund.de).

Last updated: January 6th, 2022

Ghana

A published report examined the state of elderly care in Ghana in relation to the pandemic. The paper reflects on the state of care needs for the elderly, current elderly care systems, inadequacy of data on elderly population, and social work practice in Ghana. It also raises questions on the preparedness of current elderly care systems and general social work practice in Ghana amidst COVID 19. The paper recommends professionalisation of geriatric care and formalisation of community-based care for the elderly in Ghana as the way forward.

Source:

Deku, C. S., Forkuor, J. B., & Agyemang, E. (2021, March 1). COVID 19 meets changing traditional care systems for the elderly and a budding social work practice. Reflections for geriatric care in Ghana. Qualitative Social Work. SAGE Publications Inc. https://doi.org/10.1177/1473325020973323

Last updated: January 6th, 2022   Contributors: William Byrd  |  

Iceland

Care for older people in Iceland is delivered at local level through community based services such as home health (covering personal care and nursing) and social social care services (help with domestic tasks, meals and wheels, etc), funded by the municipalities. There are also service and day care centres to support people who live in their own homes. Responsibility for home health is with the home health district and responsibility for social services with the municipalities. Residential and nursing homes are provided by both public (usually municipal) providers and private non-profit and for-profit providers, the state pays the greatest share or the cost of running care homes.

In 2011-12, 21% of older people aged 80 or more were living in institutional facilities and 43% were receiving home home help, the share of older people in institutional facilities is higher than in other Nordic countries and this has been attributed to an incentive for the municipalities to shift costs to the state.

(Source: Sigurveig H. Sigurdardottir, Omar H. Kristmundsson & Steinunn Hrafnsdottir (2016) Care of Older Adults in Iceland: Policy Objectives and Reality, Journal of Social Service Research,42:2, 233-245, DOI: 10.1080/01488376.2015.1137535)

Last updated: January 6th, 2022

India

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

Last updated: January 6th, 2022

Ireland

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

Last updated: January 6th, 2022

Israel

Israel has a fragmented LTC system with the National Insurance (NI), the Ministry of Health and the Ministry of Welfare and Social Affairs, holding different yet overlapping responsibilities for publicly funded LTC (source: Taub Centre).

Notably, Israel was one of the first countries to introduce publically financed LTC insurance. Still, it is not universal and is of partial coverage for the mild and severely disabled older people. Most of the LTC treatment in Israel is community-based. At the beginning of 2020, some 220,830 older people received publically funded LTC services at home (The National Insurance, 2020).

Last updated: January 6th, 2022   Contributors: Sharona Tsadok-Rosenbluth  |  

Italy

The public system of LTC in Italy is underdeveloped and characterised by a high degree of institutional fragmentation, as sources of funding, governance and managerial responsibilities of public services are spread over local (municipal), regional and national authorities, with different methods according to the institutional models of each region This fragmentation originates from the fact that, in contrast to the Italian National Healthcare Service (NHS, in Italian Servizio Sanitario Nazionale), the LTC sector did not originate from a clearly defined and comprehensive model but rather from multiple legislative interventions promulgated over a period of more than 30 years.

Unpaid carers – together with home care assistants privately hired by households – represent the bulk of LTC provision in Italy. There is no official data on the number of unpaid family carers, but latest estimates suggest that about 2.8 million people aged 18-64 are involved in caregiving for their older or disabled relatives. Also the total number of home care assistants (privately employed, primarily migrant care workers) is unknown, but it has been estimated that this involves over 1 million people.

Sources:

Barbarella F, Casanova G, Chiatti C and Laura G (2018) Italy: emerging policy developments in the long-term care sector. CEQUA LTC network report.

Fosti G, Notarnicola E and Perobelli E (2021) Le prospettive per il settore socio-sanitario oltre la pandemia. Rapporto Osservatorio Long Term Care 3. CERGAS, Università Bocconi.

Gabriele S and Tediosi F (2014) Intergovernmental relations and Long Term Care reforms: Lessons from the Italian case. Health Policy 116 (1) 61-70. https://doi.org/10.1016/j.healthpol.2014.01.005

ISTAT: https://www.istat.it/it/files//2019/11/Report-Conciliazione-lavoro-e-famiglia.pdf

Rotolo, A. 2014. ‘Italia.’ In Fosti, G and Notarnicola, E, (eds). Il Welfare e la Long Term Care in Europa. Modelli istituzionali e percorsi degli utenti, 93–114. Egea, Milano

Last updated: January 6th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Jamaica

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

Last updated: January 6th, 2022

Japan

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

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

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

Last updated: January 6th, 2022

Latvia

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

Last updated: January 6th, 2022

Malta

The Maltese long-term care system is not even, in that service delivery for the older person requiring care, is spread across 3 Ministries, (a) Ministry for Health in Malta, (b) Ministry for Senior Citizens and Active Ageing in Malta, and (c) Ministry for Gozo, (source: https://www.gov.mt/en/Government/Government%20of%20Malta/Ministries%20and%20Entities/Pages/default.aspx). In the case of Public Private Partnership (PPP) agreements for private and church-run insitutions, 3 separate admission/assessement/care criteria and contractual obligations are therefore employed in lieu of the differing Ministries.  The Ministry for Health is responsible for offering services to circa 314 older persons through the PPP scheme; the Ministry for Senior Citizens and Active Ageing offers a service to approximately 3148 older persons through state run and private and church-run care homes employing the PPP agreement; and the Ministry of Gozo provides a service to around 53 older persons, through the PPP scheme, within a church-run care home, (source: https://ltccovid.org/wp-content/uploads/2020/06/LTC-covid-situation-in-Malta-6-June-2020.pdf).

No information is available on the websites for the Ministry of Health and the Ministry of Gozo in respect of the eligibility criteria, assessment, successive admission of older persons to the long-term care sector, as well as to contractual obligations for the service user and service provider, with no reference to service delivery within care homes, (source: https://www.gov.mt/en/Government/Government%20of%20Malta/Ministries%20and%20Entities/Pages/Ministries%202020/health.aspx), (source: https://www.gov.mt/en/Government/Government%20of%20Malta/Ministries%20and%20Entities/Pages/Ministries%20Nov%202020/Gozo.aspx).

The Ministry for Senior Citizens and Active Ageing, through the Active Ageing and Community Care (AACC), is responsible for the state run homes and other care homes employing the PPP scheme, (source: https://activeageing.gov.mt/active-ageing-and-community-care/?lang=en). Service delivery within the long-term care sector at AACC, is mainly centred around the levels of care the older person would be in need of as of the time of assessment, as follows, (a) Level 1 care, where long-term care services with only minimal basic care is provided and (b) Level2 care, where the level of care required for the older person and as indicated by the Interdisciplinary Assessment Team goes beyond the minimal basic care, (source: https://activeageing.gov.mt/wp-content/uploads/2021/05/LN-151-2018.pdf).

Older persons, (a) over the age of 60 years, (b) live with dementia, (c) require long-term care, and (d) can no longer live within their own home environment are eligible to apply for the state run (and PPP) long-term care services, (source: https://activeageing.gov.mt/residential-care/?lang=en).

Once an application for long-term care is compiled by the older person and/or next of kin/guardian, the Multidisciplinary Team, analyses aspects of the older person’s (a) Medical Report that would have been filled by the General Practioner, (b) social and wel-being, (c) cognitive difficulties, (d) mobility and dependency levels and (e) support network, (source: https://activeageing.gov.mt/residential-care/?lang=en).  Through this assessment, the Team decides on the level of care required, considering also the priority and urgency of the case in respect of the admission to long-term care, (source: https://activeageing.gov.mt/residential-care/?lang=en).

Saint Vincent de Paul (SVP) long term-care facility is on other state facility falling within the remit of the Ministry for Senior Citizens and Active Ageing, but autonmous from the AACC mentioned earlier, (source: https://activeageing.gov.mt/st-vincent-de-paul-long-term-care-facility/?lang=en). With a population of circa 1500 older persons, SVP offers high dependency chronic care services for the older person, through the Level 2 care  tier referred to previously, (source: https://activeageing.gov.mt/wp-content/uploads/2021/05/LN-151-2018.pdf), (source: https://ltccovid.org/wp-content/uploads/2020/06/LTC-covid-situation-in-Malta-6-June-2020.pdf).

The Maltese long-term care system also offers private self-funded care by the older person herself/himself through a number of private run organisations, (source: https://www.caremalta.com/our-homes/), (source: https://simblijacarehome.com/why-simblija/), (source: https://casa-antonia.com.mt/), (source: https://goldencare.com.mt/). These care homes advertise service provision to ‘patients’ falling within the medium to high dependency category, as well as older persons requiring respite care, or to older persons needing help to perform normal activities of daily living because of cognitive difficulties or loss of muscular strength or control).

A number of small church-run institutions for older priests and religious (around 9, source: https://ltccovid.org/wp-content/uploads/2020/06/LTC-covid-situation-in-Malta-6-June-2020.pdf ) are scattered across both islands of Malta and Gozo. No information on the Archidiocese of Malta or the Diocese of Gozo websites is available in respect of assessment and admission criteria or to the level of care offered to the older priests and religious.

Last updated: January 6th, 2022   Contributors: Maria Aurora Fenech  |  

Netherlands

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

Last updated: January 6th, 2022

Poland

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

The rate of long-term care beds in Poland is not only low and their geographical distribution is uneven. In 2019, nearly one-fifth of counties had no access to long-term residential care. About 2.7 % of older people are in institutional care settings and 3.4 % use home care services. Some families draw on migrant carers, mostly from Ukraine, who tend to provide round-the-clock care (source: Ageing policies – access to services in different EU Member States).

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  

Portugal

Long-term care in Portugal is mainly provided by unpaid (mostly family and mostly women) carers, as well as a mix of public and private providers, with a strong role for non-profit providers.

In 2006 the Ministry of Health and the Ministry of Labour, Social Solidarity and Social Security established a National Network of Long-Term Integrated Care (Portuguese acronym: RNCCI), with the aim of providing care, health and social support to persons with functional dependency, with an emphasis on integrated care.

In parallel, there is a Network of Social Services (RSES) affiliated to the Ministry of Labour, Social Solidarity and Social Security, which provides social services to people with low resources or who experience social exclusion.

There is currently no mechanism for joint provision of services between the RNCCI and the RSES, but there are efforts to coordinate care happen at local level. There are concerns that the current system leads to over-institutionalisation and duplication of provision and that not enough support is in place for unpaid carers.

Sources:

Last updated: January 6th, 2022

Republic of Korea

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

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

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

Last updated: January 6th, 2022

Romania

The Romanian long-term care system is rooted in Law 17/2000 on Social Assistance for Older People, the first national legal act to regulate the provision of support services for older individuals with care needs. Subsequent legislation in 2003 and 2006 defined basic organization and functioning norms for home-based and residential care delivery at national level. In 2011, Law 292/2011 on the Social Assistance Framework defined the characteristics and the boundaries of Romania’s long-term care system, establishing eligibility criteria, the settings in which long-term care can be provided and the care services included in the service package. Since 2006, responsibilities for social service planning, financing and provision were transferred to local authorities, lead to increased fragmentation in care delivery and to large disparities in the geographical distribution and availability of services.

The Romanian long-term care system emphasizes cash benefits to the detriment of service provision, which remain severely undersized with respect to care needs and cunequally distributed across the territory. Particularly weak is the provision of home and community based care, leading to increased demand for residential care services, in turn insufficiently developed to appropriately respond to population needs. As a result, the long-term care system overwhelmingly relies on the provision of care by family member and other informal caregivers.

While data on long-term coverage are insufficient and of poor quality, available evidence indicates long-term care coverage to be very low with respect to most European countries.

Sources:

World Health Organization (2020) Romania. Country case study on the integrated delivery of long-term care. WHO Regional Office for Europe series on integrated delivery of long-term care. Copenhagen: WHO European Office.

Luana Pop (2018) ESPN Thematic Report on Challenges in long-term care Romania.

Last updated: January 6th, 2022   Contributors: Stefania Ilinca  |  

Singapore

Singapore’s approach to Long-Term Care (LTC) focuses on integrated care and active care management and coordination, aiming to reduce unnecessary utilization of institutional care. The approach is nested with an overarching Action Plan for Successful Ageing, as part of a policy shift towards a population health approach.

Singapore’s LTC policies are based on the principle of ‘Many helping hands’ that calls for individuals, families, communities, civil society, the private sector, and government to all play a role in ensuring the wellbeing of older people.

The system is designed with the aims of maximising prevention, promoting individual and family responsibility and reduce inefficiencies, with LTC as part of a wider integrated system covering public health, primary care, acute care, rehabilitation and long-term and palliative care.

Sources:

Asian Development Bank (2021) Singapore’s Long-Term Care System. Adapting to Population Ageing.

Last updated: January 6th, 2022

Spain

Responsibility for Long-Term Care in Spain is mainly at the regional level (Autonomous Communities), although provincial and local authorities also have a role in care provision. The national government has a key role in financing and defining minimum public coverage through the National Long-Term Care System (SAAD). The SAAD was established through the 2006 ‘Dependency Act’ which aimed to create new public national care coverage as the ‘fourth pillar of the welfare state’, aiming to improve personal autonomy and care for dependent people. The Act established two types of long-term care benefits: 1) in-kind services, and 2) those of an economic nature, and it gave the former a priority. The law lists social services which contribute to long-term care:  services for averting dependency and enabling personal independence; tele-assistance services; home care services (help with home tasks and personal care); day and night care centres; residential services. All benefits and services established in the law are integrated in the social services provided through the autonomous regions.

(source: CEQUA Spain Country report (filesusr.com).

Last updated: January 6th, 2022

Sri Lanka

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

Last updated: January 6th, 2022

Sweden

In 2019, over 160 000 of older people were provided with services and care in their own home and some 82 000 were provided with institutional care. A wave of closures of municipal institutional beds, resulted in a reduction of nearly 40% of all municipal places since 2000s (source: Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Last updated: January 6th, 2022

Thailand

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

Last updated: January 6th, 2022

England (UK)

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

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

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

Further reading:

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

Last updated: January 6th, 2022

Scotland (UK)

In Scotland, Long-Term Care is known as social care. This care can take the form of care services delivered in a person’s own home, for example personal care support and meals services, or care provided in the community, for example day care and social work support, to care provided within a care home. Public Health Scotland estimated that in the financial year 2018/19, at least 245,650 people of all ages received social care services. Of those, over 77% were aged 65 and over.

Data from the Care Inspectorate Scotland show that at 31st March 2020 there were 1,083 registered adult care homes in Scotland, of which 817 catered for older people. Public Health Scotland (formerly Information Services Division Scotland) data from the Scottish Adult Care Home Census show that in 2017, there were 40,926 registered care home places for adults. This figure has decreased from 42,653 in 2007. Over the period 2007-2017, the number of registered places for older people has remained relatively stable at around 38,200 throughout the period. The pandemic has highlighted the data deficiencies within the care home sector. In particular, it is “not possible to readily identify the whole care home population within national data”. The latest data available for Scotland from a report by Public Health Scotland show that in March 2017 there were 35,989 adult care home residents in Scotland.

For the last two decades, Scottish policy has favoured care provision in individuals’ own homes rather than in care homes. According to the Care Inspectorate, as of 31st March 2019, there were 1,046 registered adult care at home providers in Scotland. A Public Health Scotland report on social care statistics in Scotland estimated that 91,810 people in Scotland received home care for all or some of the year ending 31 March 2019. The same report estimated that at the end of that period,  63% of adults with long-term care needs received personal care at home. Personal care is care associated with personal hygiene, feeding, toileting and appearance.  In 2017-18, 47,070 people aged 65+ were receiving personal care funded by the Scottish Government in their own homes.

Last updated: January 6th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

United States

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

Last updated: January 6th, 2022

Vietnam

The rapidly growing ageing population in Vietnam poses a significant challenge to the social welfare system. There is particular concern about the high prevalence of non-communicable diseases (NCDs), which are the dominant cause of death, in the over-50 population (source: Global Burden of Diseases Project).

There is currently no legal policy on long-term care. Some policies relating to older people have been enacted; mostly relating to their healthcare. For example, The Elderly Law (2009), which emphasises the role of primary healthcare and access to quality healthcare services for these members of the population. It also highlights the role and responsibility of families, communities, and broader society in caring for elderly people (Van et al., 2021). Indeed, most senior citizens in Vietnam live with and are cared for by their families; hence the common phrase, tu dai dong duong (four generations under one roof).

However, some people have complex needs that require support beyond what family members can provide, or indeed do not have families to provide such long-term care (in part due to children modernising and moving to cities for work). There are some institutions that are run by the government that cater for the elderly, the disabled, and orphans – such as social protection centres. However, these are only available to social assistance beneficiaries; for the elderly, this covers people over age 85 without social insurance or pension, and lonely or poor older people (Dung et al., 2020). According to a recent report by The Vietnam National Committee on Aging (VNCA), only around 10,000 elderly people in Vietnam live in public social protection centres (out of approximately 11 million older persons nationwide). This means that there is great demand for private institutional care.

Indeed, there are some long-term care facilities provided by the private sector and by mass organisations, such as The Red Cross (the latter being run by volunteers). Religious groups also provide some nursing homes – which are free of charge to those in need. Privately run nursing homes are mainly aimed at wealthier members of the population who are able to afford the steep $400-$1000/month fee (VNCA). It should also be noted that the supply of private nursing homes in Vietnam is expanding relatively slowly, as loans for construction are difficult to obtain and there are no incentives (tax concessions) provided for setting them up (Dung et al., 2020).

There are significant gaps in the provision of care in Vietnam: nursing homes are mainly found in larger cities, there are a limited number of social protection centres (which are inefficient and do not satisfy all needs), and, in light of a limited government budget, high co-payments are mostly out of pocket (Van et al., 2021).

Care Preferences

In their 2012 study, Van Hoi et al assessed willingness to use and pay for different models of care for community-dwelling elderly in rural Vietnam. They found the most requested service was use of mobile team care, and that using a nursing centre was intended by the fewest respondents, although households were found to be more willing to pay for elderly day care and nursing centres than older participants. Willingness to use services decreased as potential fees rose.

References:

Dung, V., Thi Mai Lan, N., Thu Trang, V., Xuan Cu, T., Minh Thien, L., Sy Thu, N., Dinh Man, P., Minh Long, D., Trong Ngo, P., & Minh Nguyet, L. (2020). Quality of life of older adults in nursing homes in Vietnam: https://doi.org/10.1177/2055102920954710

Van Hoi, L., Thi Kim Tien, N., Van Tien, N., Van Dung, D., Thi Kim Chuc, N., Goran Sahlen, K., & Lindholm, L. (2012). Willingness to use and pay for options of care for community-dwelling older people in rural Vietnam. BMC Health Services Research, 12(1), 1–12. https://doi.org/10.1186/1472-6963-12-36/TABLES/7

Van, P.H., K.A. Tuan and T.T.M. Oanh (2021), ‘Older Persons and Long-term Care in Viet Nam’, in Komazawa, O. and Y. Saito (eds.), Coping with Rapid Population Ageing in Asia. Jakarta: ERIA, pp.45-56. Link

Last updated: January 6th, 2022   Contributors: Daisy Pharoah  |  

1.01. Population size and ageing context

Overview

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

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

International reports and sources

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

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

Australia

Australia has a population of just over 25 million people. In 2019, 15.9% of Australia’s population were over the age of 65 and 2% of the population is over the age of 85.  Australians are living longer than ever before. The number of Australians aged 85 years and over is expected to increase from 515,700 in 2018–2019 to more than 1.5 million by 2058 (sources: Statista; Royal Commission into Aged Care Quality and Safety).

Last updated: December 22nd, 2021   Contributors: Adelina Comas-Herrera  |  Ben Admin  |  

Austria

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

Last updated: November 23rd, 2021

British Columbia (Canada)

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

Last updated: November 6th, 2021

Chile

In 2017 there were nearly 3,500,000 people aged 60 or over in Chile, of whom 14.2% (489,000) had some degree of functional dependency (Browne et al., 2020).

References

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Last updated: December 22nd, 2021

Denmark

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

Last updated: August 3rd, 2021

Finland

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

Last updated: November 23rd, 2021

France

France has a population of 67.1 million (2018). In 2018 19.6% of the population were aged 65 years and older (13.1 million people) (source: Statistics France).

Last updated: December 3rd, 2021   Contributors: Camille Oung  |  

Germany

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

Last updated: November 23rd, 2021

Ghana

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

Last updated: August 3rd, 2021

Israel

In 2015, the total population of Israel was 8.46 million, of whom 939,000-11%- were aged 65 and over. One in four households in the country included a person aged 65 or more (source: Brookdale Report).  

Last updated: December 3rd, 2021   Contributors: Sharona Tsadok-Rosenbluth  |  

Italy

In 2020, 23.2 % of the total population in Italy was 65 years and older, the share of older people in the Italian society has been growing constantly in recent years. According to 2019 data, the country was considered to have the largest percentage of elderly population in Europe. This share is projected to rise up to 34% by 2045.

In 2019, 32.5% of people aged 65 and above reported living with chronic diseases, rising up to 47.7% among those abed 85 and over. 1 million persons aged 65+ require care or support devices.

Sources:

https://www.statista.com/statistics/785104/elderly-population-in-italy/, https://www.istat.it/it/files//2018/05/previsioni_demografiche.pdf and https://www.istat.it/it/files//2021/07/Report-anziani-2019.pdf

Last updated: November 8th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: November 25th, 2021

Malta

There was a 0.3% increase in Malta’s population from 2019 to 2020; the estimated population of residents of Malta and Gozo standing at 516,100 at the end of 2020.  People aged 65 and over amounted to 18.9% of the population, and 2,223 females and 984 males were aged 90 years and over. There was a 10.7% increase in the resident deaths in 2020 from 2019 largely, owing directly or indirectly to the COVID-19 pandemic.  In 2020, 4,084 resident deaths were registered, of these, 66% were people aged 75 or over, deaths among this group increased by 12.5% of deaths compared to 2019 (source: https://nso.gov.mt/en/News_Releases/Documents/2021/07/News2021_122.pdf).

Malta forming part of Southern Europe together with Croatia, Greece, Italy, Portugal, Serbia, Slovenia and Spain are the oldest region in the world where 21% of the population is aged 65 years and over (source: https://www.prb.org/resources/countries-with-the-oldest-populations-in-the-world/).

Last updated: November 9th, 2021   Contributors: Maria Aurora Fenech  |  

Mauritius

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

Last updated: August 3rd, 2021

Netherlands

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

Last updated: November 25th, 2021

Poland

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

Last updated: November 24th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Republic of Korea

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

Last updated: November 25th, 2021

Romania

The total population of Romania in 2019 was 19.4 million inhabitants, registering a decline of 0.4 million with respect to 2015, as result of low natality and external migration.

The age structure of the Romanian population bears the characteristic marks of a rapid demographic ageing process. While the total population has declines over the past 5 years, the group aged 65 and over has increased by 225.2 thousand persons over the same period, to reach 19.7% of the total population in 2019.

Current projections point to a continued decline over the next decades, with an expected total population of 17.7 million in 2030 and 15.5 million by 2050.

Source: National Institute of Statistics (2020) Proiectarea populaiei României pe regiuni de dezvoltare i judee, la orizontul 2070. Available at: https://insse.ro/cms/sites/default/files/field/publicatii/proiectarea_populatiei_pe_medii_de_rezidenta_la_orizontul_anului_2070.pdf

Last updated: December 5th, 2021   Contributors: Stefania Ilinca  |  

Singapore

In 2021 there are 5.4 million people living in Singapore, of whom 3.9 million are residents (comprising 3.5 million Singapore citizens and 488,700 permanent residents).

Singapore’s population is ageing rapidly, in the population aged 65 and over was 639,000 (15.9%) out of its 4 million resident population. This is expected to rise to 23.8% of the population of residents by 2030.

Sources: Department of Statistics Singapore

Last updated: November 2nd, 2021

South Africa

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

Last updated: November 23rd, 2021

Catalonia (Spain)

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

Last updated: November 6th, 2021   Contributors: Gemma Drou-Roget  |  

Sri Lanka

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

Last updated: September 8th, 2021

Sweden

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

Last updated: November 23rd, 2021

Thailand

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

Last updated: September 8th, 2021

United Kingdom

The total population in the United Kingdom in mid-2020 was 67,081,000. The median population age is 40.4, with 18.6% aged 65 and over, and 2.5% 85 and over.

 

Last updated: January 2nd, 2022

England (UK)

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

Last updated: December 4th, 2021   Contributors: Adelina Comas-Herrera  |  

Northern Ireland (UK)

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

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

Last updated: November 8th, 2021

Scotland (UK)

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

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Bell  |  David Henderson  |  Elizabeth Lemmon  |  

Wales (UK)

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

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

Last updated: November 8th, 2021

United States

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

Last updated: November 23rd, 2021

Vietnam

Vietnam is a lower-middle income country in Southeast Asia with a population of just over 97 million people (source: World Bank). Since 1999, the percentage of the population aged 65 and over has been increasing, representing 7.9% of the total population by 2020 (source: World Bank). Meanwhile, the younger population (aged 14 and below) has been decreasing. These trends are predicted to persist (source: Vietnam Population Census); thus Vietnam is undergoing a demographic transition and is predicted to be an aging population by 2040 (source: United Nations). Vietnam is also one of the fastest aging countries globally (source: WHO). The growing elderly population in Vietnam poses a challenge to the social welfare system; the World Bank have therefore stressed the importance of developing relevant and timely health and social care solutions to ensure country capacity.

People in Vietnam are considered who are 60 years and older are considered “elderly”. The majority (more than 70%) of older people live in rural areas. There are more females than males in the aging population in Vietnam; an imbalance which is also higher in rural than urban areas. A minority (5.8%) of older people live alone (with most of these individuals being women in rural areas), and few (11.5%) live only with a spouse. Most older people in Vietnam are household heads and live with a child. As such, children and grandchildren are the main caregivers (Van Hoi et al., 2012). More recently, however, increasing employment opportunities in urban centres have resulted in temporary migration of the younger generations, leaving the more elderly members of the population on their own and with less emotional and physical support from family (Van Hoi et al., 2012).

References:

Van Hoi, L., Thi Kim Tien, N., Van Tien, N., Van Dung, D., Thi Kim Chuc, N., Goran Sahlen, K., & Lindholm, L. (2012). Willingness to use and pay for options of care for community-dwelling older people in rural Vietnam. BMC Health Services Research, 12(1), 1–12. https://doi.org/10.1186/1472-6963-12-36/TABLES/7

Last updated: December 30th, 2021   Contributors: Daisy Pharoah  |  

1.02. Long-Term Care system governance

Overview

Governance has been defined as the processes and systems by which an organisation or a society operates, encompassing leadership, planning, implementation, management and accountability.

The COVID-19 pandemic has shown that fragmented responsibilities for long-term care in most countries resulted in difficulties in the adoption and implementation of measures to mitigate the impacts of the pandemic.

Strong governance in Long-Term Care requires that the roles and responsibilities of the actors and institutions involved are clear, that there are structures and mechanisms for coordination and engagement with stakeholders.

International reports and sources

Asian Development Bank (2021) Leadership and Governance in Long-Term Care Systems in Asia and the Pacific. ADB Brief. http://dx.doi.org/10.22617/BRF210448-2

Allen K et al. (2011) Governance and finance of long-term care across Europe. Overview report. Birmingham/Vienna: University of Birmingham/European Centre for Social Welfare Policy and Research (Interlinks report 4).

African Union

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

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

Last updated: January 6th, 2022

Australia

An important policy context for Long-Term Care (LTC) is the fact Australia is a federation.

LTC is primarily the responsibility of the federal (Commonwealth) government which sets LTC policy, provides funding, oversights quality standards etc. Within the states, while funded by the Commonwealth and having to comply with Commonwealth standards, there are some nursing homes run by state governments  (eg Victoria runs 178 nursing homes) and some home care is provided by local government (eg in Victoria).

There is central oversight from the Australian government, as they are responsible for regulating and funding the majority of aged care services. However, state and territorial governments also have jurisdiction over the provision of aged care, which increases the complexity of the system and leads to a division of power.

The Australian Department of Health is responsible for the development and implementation of aged care policy, including advising the Australian Government, funding, and administration. The Aged Care Quality and Safety Commission is responsible for aged care regulation. State and Territory Governments, along with the private sector, are responsible for the delivery and management of health care, including aged care.

The Australian government’s Department of Health created the Royal Commission into Aged Care Quality and Safety in 2018 to evaluate the current Aged Care sector and to provide recommendations for reform. A group of experts in this commission have identified several weaknesses of the aged care sector, especially in light of COVID, and have recently issued their final report (Royal Commission, 2020).

References:

Royal Commission into Aged Care Quality and Safety (2020) Aged care and COVID-19: a special report. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf 

Last updated: January 17th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Lee-Fay Low  |  

Austria

Governance of long-term care system in Austria is relatively fragmented, in that responsibility is divided amongst the federal government and the federal states in several ways. The federal government is in charge of the care allowance benefit, while the regional governments are responsible for the provision of care services (Fink, 2018). These responsibilities by the federal states include providing long-term care services (i.e. in-kind benefits), planning the number of beds/spots for care, and regulating tariffs and subsidies. In terms of home care services, the federal states are responsible for regulating the framework conditions as it relates to funding, collective bargaining agreements for services and out-of-pocket payments by users.  Although the federal states are responsible by law for the provision of long-term care services for older adults in Austria, in practice, the responsibility for carrying out these services is shared with several entities, such as the municipalities, non-profit organisations and private operators (Rechnungshof Österreich, 2020).

References

Fink, M. (2018). ESPN Thematic Report on Challenges in long-term care. Austria 2018, Brussels, https://ec.europa.eu/social/BlobServlet?docId=19837&langId=en

Rechnungshof Österreich, 2020 Bericht des Rechnungshofes: Pflege in Österreich. Wien: RH Österreich

Last updated: January 6th, 2022   Contributors: Cassandra Simmons  |  

Bulgaria

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

Last updated: January 6th, 2022

Canada

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

Last updated: January 6th, 2022

British Columbia (Canada)

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

Last updated: January 6th, 2022

Denmark

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, with municipalities taking a stronger role in prevention and health-oriented interventions.

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

Sources:

https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019

Last updated: January 6th, 2022

Finland

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

Last updated: January 6th, 2022

France

France has a highly fragmented LTC system with operations at multiple levels at national, regional and municipal levels and significant regional variation. There is also limited coordination across actors, which all have different remits. Local authorities (departements) have the primary responsibility for social policies including those relating to age.

Regional Health Agencies (ARS) were created in 2009 trying to represent central government at regional level, which resulted in expansion of remit of regions to social care as well as health. Regional structures (ARS) have oversight of healthcare, and some social care which is designed to provide some level of integration across the two sectors.

Author 2: Alis Sopadzhiyan (LTC Covid profile pending)

Last updated: January 6th, 2022   Contributors: Camille Oung  |  

Germany

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

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

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

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

 

Last updated: January 6th, 2022

Israel

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

Last updated: January 6th, 2022

Italy

As with the National Health System, the Long-Term Care (LTC) sector is a regional competence, with the central government only promoting guidelines for the system. In particular, the Ministry of Labour and Social Policy and the Ministry of Health are responsible for defining the national framework, producing general guidelines, and funding specific interventions to ensure regional equity. Further, at the central level, the National Social Insurance Agency (Istituto Nazionale Previdenza Sociale, INPS) is in charge of monetary contributions and cash allowances (above all, the companion allowance – CA – Indennità di Accompagnamento) that are paid directly to citizens. At the next level, the regions are the key actors because they regulate and fund in-kind services. Local health authorities (LHAs) and municipalities step into action when it comes to programming services and interventions that are delivered through care providers. The system is highly reliant on publicly funded services, which account, on average, for 85% of service providers’ revenues.

Coordination between different LTC responses is absent or left to local best practices and efforts at innovation. Citizens who access the LTC system can go through three different need evaluation systems (LHAs, municipalities, and INPS) to access the in-kind and cash services they are eligible for, without any kind of guidance or coordination between the different interventions.

Sources:

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

Last updated: January 6th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: January 6th, 2022

Lithuania

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

Last updated: January 6th, 2022

Mauritius

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

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

Last updated: January 6th, 2022

Netherlands

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

Last updated: January 6th, 2022

Seychelles

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

Last updated: January 6th, 2022

Singapore

The Ministry of Health is responsible for governance over the entirety of the health and LTC systems, including setting policy direction, projection of national-level service demand, health and LTC financing, regulatory frameworks, standards, oversight, and coordination of related bodies. There is an Ageing planning Office with responsibility for setting policy direction and implementation for successful ageing across sectors.

In 2018 the Agency for Integrated Care (AIC) was created, within the Ministry of Health, with responsibility for coordinating the delivery of Long-Term Care, enhancing service development and building capacity across health and social care. The AIC is responsible for integrating and coordinating health and care services, case assessment framework and case finding, monitoring and evaluation, case management, referral services, strengthening primary care and community care services and quality of services.

Sources:

Asian Development Bank (2021) Leadership and Governance in Long-Term Care Systems in Asia and the Pacific. ADB Brief. http://dx.doi.org/10.22617/BRF210448-2

Asian Development Bank (2020) Singapore’s Long-Term Care system. Adapting to population aging. ADB.

Last updated: January 6th, 2022

South Africa

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

Last updated: January 6th, 2022

Spain

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

Last updated: January 6th, 2022

Sri Lanka

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

Last updated: January 6th, 2022

Sweden

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

Last updated: January 6th, 2022

England (UK)

The Department of Health and Social Care (DHSC) has overall policy responsibility for setting adult long-term care policy in England and the legal framework, and is accountable to Parliament and public for the performance of the system. The Ministry of Housing, Communities & Local Government oversees the distribution of funding to Local Authorities (LAs) and the financial framework within which local authorities operate.

The Care Act 2014 sets out the responsibilities of 152 LAs in the assessment of social care needs, commissioning and organisation of care, LAs also deliver some services directly, but this is increasingly rare.

The National Health Service (NHS) in England was established by the National Health Service Act of 1946. NHS England is an arm’s-length body of the DHSC and is responsible for arranging the provision of health services in England. The DHSC sets objectives for the NHS through an annual mandate. Since 2013, Clinical Commissioning Groups have been responsible for commissioning hospital and community care for their local populations. In relation to Long-Term Care, nursing and rehabilitation services are mostly provided through the NHS, or funded by the NHS and provided by social care providers for individuals who require nursing in a social care setting or that are considered to have primarily a health need..

The Care Quality Commission regulates care providers for quality, monitoring and inspecting services to ensure they meet quality and safety standards, and also provide oversight of the financial resilience of the largest and potentially most difficult-to-replace care providers. They publish their findings, including performance ratings.

Although there are initiatives at local and regional levels which aim to integrate health and long-term care services (with varying degrees of success), they remain two separate systems. The NHS White Paper published in February 2021 sets out legislative proposals to establish Integrated Care Systems (see question 4.04 for more details).

Last updated: January 6th, 2022

United States

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

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

Last updated: January 6th, 2022

1.03. Long-term care financing arrangements and coverage

Overview

LTC financing discussions tend to focus on the sustainability of current financing arrangements, given rapidly growing demand due to population ageing and the predicted increase in the frail older people with long-term care needs. Financing refers to mechanisms that are used to raise funds (or resources) for long-term care, and to allocate those resources to particular groups or individuals.

In practice, the largest share of LTC is provided as an “in kind” resource, by unpaid carers such as family members and friends. In Europe, countries such as Denmark the Netherlands and Sweden have higher reliance on formal care, while countries such as Greece, Bulgaria, Cyprus, Estonia, Portugal, Latvia, Romania and Croatia rely almost exclusively on unpaid care. Family carers in some countries, for example Denmark, can be paid by the government for short periods of time. Family care givers may also receive income transfers and, possibly, some payments from the person receiving care. In Low and Middle Income Countries there is little availability of formal care and, while expenditure measured as a share of GDP appears relatively low, families bear very substantial costs of care with little support (see for example this article mapping the long-term care system in Jamaica).

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

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

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

International reports and sources

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

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

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

The effectiveness of social protection for long-term care in old age;

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

Aging and Health report (who.int)

www.euro.who.int/LTC Funding Systems

Help Wanted: LTC Financing.

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

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

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

Other sources include:  https://www.degruyter.com/Aging in Europe.

Australia

Public spending on Long-Term Care

In 2019-20 government spending on LTC in Australia was estimated to be $21.5 billion, 65% on residential aged care and the remainder on home care and support or other forms of care.  equivalent to 1.2% of Gross Domestic Product (Treasury, 2021)

Long-Term Care Financing mechanisms

Australia has universal public health care through Medicare. The Australian government subsidizes aged care services so anyone who received aged care is eligible for financial support. In 2018-2019, $27.0 billion was spent on aged care, $19.9 billion of which came from the Australian Government (Royal Commission, 2020a).

Co-payments

People who use aged care are expected to contribute in the form of co-payments and means tested fees. People receiving aged care services contributed $5.6 billion to the cost of their aged care in 2018–2019 (Royal Commission, 2020a)

Aged care homes are subsidised by the Australian government. The subsidies are paid directly to the aged care home and the amount of funding that a home receives is based on an assessment of individual needs by the home using a tool called the Aged Care Funding Instrument (ACFI) and how much an individual can afford to contribute to the cost of their care and accommodation (using a means assessment).

Access to publicly funded aged care

Aged care services are rationed and access is determined by where people live, their needs, and availability of services. The Royal Commission into Aged Care Quality and Safety highlighted that in practice there is no universal entitlement to aged care as services are strictly rationed and access is determined by where people live, their needs, and availability of services (Royal Commission, 2020b).

Reliance on unpaid carers

There is significant reliance on unpaid (mostly family) carers in the community, to reduce the need for formal care. In 2018, there were around 428,500 unpaid primary carers providing support to someone aged 65 years or older (sources: health.gov; Care, Dignity and Respect report; Parliament of Australia; myagedcare.gov).

Family carers have access to shared care planning tools. Professional carers are also increasingly asked to collaborate with family carers, providing skills training and directing family carers to the services available for them (source: OECD).

Public Long-Term Care coverage:

In Australia 80 per cent of older people will access some form of government funded aged care service before death (2012-2014) (AIHW, 2018).

In 2019-20, over one million people received support from aged care services, around 840,000 used the Commonwealth Home Support Programme, and around 245,000 people lived in residential aged care facilities at some point during the year (AIHW, 2021).

References:

Australian Institute of Health and Welfare (2018) Cause of death patterns and people’s use of aged care: A Pathway in Aged Care analysis of 2012–14 death statistics. Cat. no. AGE 83. Canberra: AIHW.

Australian Institute of Health and Welfare (2021) GEN Aged Care Data https://www.gen-agedcaredata.gov.au

Deloitte Access Economics (2020) Commonwealth Home Support Programme Data Study. Department of Health, Australia. https://www.health.gov.au/sites/default/files/documents/2021/06/commonwealth-home-support-programme-data-study_0.pdf

Royal Commission into Aged Care Quality and Safety (2020a) Financing Aged Care, consultation paper 2. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2020-06/consultation_paper_2_-_financing_aged_care_0.pdf

Royal Commission into Aged Care Quality and Safety (2020b) Aged care and COVID-19: a special report. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf 

Treasury (2021) 2021 Intergenerational Report. Australian Government. https://treasury.gov.au/publication/2021-intergenerational-report

Last updated: January 17th, 2022

Austria

In 2016 public spending on LTC represented 1.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Long-term care is financed in Austria through a combination of public-sector taxed- based support and out-of-pocket payments by care users. The responsibility for long-term care financing is divided amongst the federal government and the federal states. The federal government is responsible for funding the long-term care allowance (Pflegegeld) and various measures for supporting informal carers, while the federal states cover benefits in-kind (i.e. care services) and are responsible for financing social assistance when a care user cannot cover their costs of care (source: ESPN Thematic Report on Challenges in LTC for Austria at https://ec.europa.eu/social/main.jsp?advSearchKey=espnltc_2018&mode=advancedSubmit&catId=22&policyArea=0&policyAreaSub=0&country=0&year=0). Although the federal states are in charge of in-kind services and social assistance, as the federal government is responsible for collecting taxes, the federal government provides transfers to the federal states to cover these costs through the general fiscal eualisation scheme and the long-term care funds (Pflegefonds) (source:  ESPN Thematic Report on Challenges in LTC for Austria at https://ec.europa.eu/social/main.jsp?advSearchKey=espnltc_2018&mode=advancedSubmit&catId=22&policyArea=0&policyAreaSub=0&country=0&year=0). Since 2011, there is a LTC fund (“Pflegefonds”) for the federal government to redistribute to the states and municipalities to help cover home care and nursing home services, as well as palliative and hospice care (source: https://apps.who.int/iris/bitstream/handle/10665/330188/HiT-20-3-2018-eng.pdf?sequence=7&isAllowed=y)

The long-term care allowance (Pflegegeld) is a key aspect of the Austrian long-term care system, with over 467,000 beneficiaries in 2020 amounting to €2.71 billion (source: http://www.statistik.at/web_de/statistiken/menschen_und_gesellschaft/soziales/sozialleistungen_auf_bundesebene/bundespflegegeld/index.html). The care allowance is intended to be a contribution towards the cost of care to cover care-related expenses, whether it be formal care services, either privately or publicly provided, or to cover informal care (i.e. routed wage) provided by relatives. Care allowance beneficiaries may use the allowance however they see fit, with no oversight/control on how the allowance is used. The allowance consists of seven levels, characterized by the number of hours needed per month for home help and personal and nursing-related care tasks. To receive the care allowance, the recipient must fulfill several requirements: 1) be in need of support and help for more than 6 months because of a physiological, cognitive or mental health impairment or an impairment of the senses and 2) need support for at least 65 hours per month. To obtain the care allowance, the recipient must first submit a claim to the pension insurance institution before being visited by a certified doctor or nurse who assess their needs regarding (instrumental) activities of daily living.

The federal government also finances support for informal carers, through a number of avenues. In 2016, support for informal care amounted to €72.8 million, primarily covering the social insurance of informal carers (€49.2 million), followed by for respite care (€11 million), for care leave (€10.7 million) and finally for quality assurance (€1.9 million) (Schrank, 2017).

In 2019, gross expenditure on LTC services amounted to €4.2 billion, primarily covered by the federal states and municipalities (59%), followed by out-of-pocket pockets by care users and their families (36%) and the rest (5%) from other sources (i.e. contributions by health insurances). Approximately 84% of this went towards (semi-)residential care facilities, and the rest towards mobile care services (16%) (source: http://www.statistik.at/web_de/statistiken/menschen_und_gesellschaft/soziales/sozialleistungen_auf_landesebene/betreuungs_und_pflegedienste/index.html).

Last updated: November 29th, 2021   Contributors: Cassandra Simmons  |  

Belgium

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

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

Last updated: November 23rd, 2021

Brazil

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

Last updated: November 23rd, 2021

Bulgaria

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

Last updated: November 23rd, 2021

British Columbia (Canada)

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

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

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

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

Last updated: November 6th, 2021

Cyprus

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

Last updated: November 23rd, 2021

Czech Republic

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

Last updated: November 23rd, 2021

Denmark

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

Denmark spent 2.5% of GDP on publicly funded LTC in 2016, almost twice the EU average (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

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

It has been estimated that 16% of the total population provides unpaid care for a relative, neighbour or friend at least once a week (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019). The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements. Unpaid caregivers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the European Union countries (source: https://www.euro.centre.org/publications/detail/415).

Family members may apply to be formally recognised as informal carers by applying to the municipality. If eligible, and after consultation with the person with care needs, the caregiver is employed by the municipality, up to six months, with a pre-specified salary calculated based on the national yearly income. Alternatively, municipalities can compensate for lost earnings individuals caring for close relatives with a terminal illness. Additional services for caregivers include training and education programmes, often focused on improving knowledge and ability to provide the needed support and on attaining coping skills, such as self-help and peer groups (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: November 1st, 2021

Estonia

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

Last updated: November 23rd, 2021

Finland

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

Last updated: November 23rd, 2021

France

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

LTC funding is fragmented and divided across a complex web of actors, at a local level (local authorities), health insurance (CNAM), not-for-profit (mutuelles) and private insurance policies, National Solidarity Fund for Autonomy (CNSA), central government, pensions, municipalities and individuals (source: https://www.alzheimer-europe.org/Policy/Country-comparisons/2007-Social-support-systems/France)

In terms of public spending, costs are shared between: National Solidarity Fund for Autonomy (CNSA), regions, the state, which in 2011 contributed approximately 9.7bn€, health insurance (CNAM), which contributed 11bn€, accommodation costs 7.5bn€ adding to a total of 21bn€, which amounted to 1.05% of GDP. Including the costs of household contributions would brought total spending to 28bn€, 1.41% of GDP.

A market for private insurance for long-term care has developed as contributions are tax-free and is reported to be one of the largest – although take up is still relatively low.

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

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

Last updated: December 21st, 2021   Contributors: Camille Oung  |  Alis Sopadzhiyan  |  

Germany

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

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

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

Last updated: November 23rd, 2021

Greece

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

Last updated: November 25th, 2021

Hungary

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

Last updated: November 25th, 2021

Iceland

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

Last updated: August 2nd, 2021

India

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

Last updated: August 2nd, 2021

Israel

In 2016 the total LTC expenditure in Israel was estimated to represent 0.6% of Gross Domestic Product (source: OECD). The National Insurance (NI) is the primary public funder of home-based long-term care services and does so through the Long-Term Care Insurance Program (LTCIP).  LTCIP is income-tested to exclude the highest income earners. As of 2014, the NII subsidizes the care of approximately 160,000 seniors at the cost of NIS 5.31 billion (appx. 1.2 bill GBP). Assisted living (e.g. LTCFs) is primarily funded by the Ministries of Health and of Labour and Social Affairs, and accounts for 14% of publicly-funded LTC services. Complex inpatient care is funded by the health system and accounts for 6% of public LTC funds. In all, public funds account for 55% of LTC services, with the remaining 45%  privately funded (sources: Taub Centre)

Home care and community-based services are the main LTC service for older people in Israel. At the beginning of 2020, 220,830 individuals (of retirement age) were eligible to receive publicly financed LTC services at home (sources: International LTC Policy NetworkNational Insurance Institute of Israel).

There are also geriatric hospitals and sheltered housing facilities, many of which are owned and managed by the coordinated governmental healthcare system via the four non-profit health plans (HP’s). These provide long-term geriatric treatment (including wards for older people with cognitive disabilities) as well as departments for active geriatric care (including complex nursing, hospice, and rehabilitative care) (source: Tsadok-Rosenbluth et al, 2021); they became the primary source for concern and emergency response during the COVID-19 pandemic.

LTC insurance in Israel is universal ,and LTC services are substantially funded by private and out-of-pocket expenditure (45%). In April 2018, as part of the LTC reform, the National Insurance launched a program to entitle home-based unpaid caregivers to long-term care benefits. Made a national policy in August 2019, family members can be paid as caregivers under certain conditions; statistics on the implementation of the policy are unavailable (source: Adva Centre).

Last updated: December 5th, 2021   Contributors: Sharona Tsadok-Rosenbluth  |  

Italy

In 2020 public Long-Term Care (LTC) expenditure in Italy was estimated to represent 1.9% of Gross Domestic Product. 74.1% of this expenditure is devoted to over 65 people. Public expenditure on LTC includes three components: i) LTC  services to dependent people provided by the public health care system, ii) the social component of LTC provisions provided by municipalities and  iii) attendance allowances. The social component of LTC services are generally means-tested. Admission to services based on needs but also on income levels. Co-payments play an important role, together with waiting lists, in shaping the profile of people who use services.

As in many other countries, the bulk of LTC is provided, unpaid, by family carers. Also, a large share of home care is provided by privately employed, primarily migrant care workers. The annual estimated expenditure in this type of household-based care is €17.000 per family. Almost 60% of these care workers are employed totally or partially irregularly, with an annual average estimated expenditure of €11.000.

Access criteria to LTC services are determined at the regional level (with a high level of heterogeneity) and Local Health Authorities (LHA) can established further criteria. Hence, it is very difficult to establish an overreaching picture of access and affordability for these services. The only major intervention that is subject to nationally established criteria is the companion allowance (CA), a cash transfer given to all those with a very severe disability regardless income or other personal features.

On a general level, the general practitioner submits a request to the LHA to require access to a LTC service for his/her patient.  At the LHA a committee will decide whether the citizen is entitled to access services or not. If the application is successful, usually citizens may choose the provider they prefer. Still, the shortage of public – funded services leads people to providers that have capacity. As concerns social services, they are usually activated by the family itself.

Practically all LTC services are based on co-payments and, given the fact that the coverage rate is relatively low, waiting lists are common, although there are no official data on the size of the phenomenon.

Sources:

Barbarella F, Casanova G, Chiatti C and Lamura G (2018) Italy: emerging policy developments in the long-term care sector. CEQUA LTC network report.

European Commission (2016) Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee.

European Commission (2021). 2021 Long Term Care report. Country provides Vol. 2. Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG Empl).

Fosti G, Notarnicola E, Perobelli E (2021) Le prospettive per il settore socio-sanitario oltre la pandemia. Rapporto Osservatorio Long Term Care 3. Egea. CERGAS. Università Bocconi.

Ministero dell’Economica e delle Finanze (2021) Le tendenze di medio-lungo periodo del sistema pensionistico e socio sanitario. Rapporto n.22.

Last updated: November 9th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

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

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

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

Last updated: December 4th, 2021

Latvia

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

Last updated: November 25th, 2021

Luxembourg

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

Last updated: November 25th, 2021

Netherlands

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

Last updated: November 25th, 2021

Norway

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

Last updated: November 25th, 2021

Poland

Public LTC expenditure in Poland was estimated to represent 0.5% of Gross Domestic Product in 2016 (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Public care for dependent older people is provided through health care sector, which includes cases of dependency or palliative care requiring a range of medical and rehabilitation services, and the social care sector, which includes care for dependent older people who are in a socially difficult situation (i.e. those who live alone, come from dysfunctional families, or are poor). Care for older dependent people is predominantly a family domain in Poland. In most cases, caregivers are family members who – in case of care for older dependent people – receive little or no financial remuneration for the care provided. In wealthier households, family carers may be supported by immigrants employed informally (source: Poland Country (filesusr.com).

Last updated: November 18th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Portugal

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

Last updated: November 25th, 2021

Republic of Korea

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

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

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

Last updated: November 23rd, 2021

Romania

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

Last updated: November 23rd, 2021

Singapore

Nursing homes in Singapore fall into three categories: public (~31%), private (~40%) and charitable/ not-for-profit (NFP) (~29%). There are a total of 77 nursing homes and 16,221 beds. Substantial government subsidies and donor funding financially assist most of the public and NFP homes, but they also require co-payment from clients. The Ministry of Health subsidy scheme does not cover private nursing homes, for which direct out-of-pocket expenses must be covered by clients (Udod et al., 2021).

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

Last updated: January 11th, 2022

Slovakia

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

Last updated: November 23rd, 2021

Slovenia

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

Last updated: November 23rd, 2021

Spain

In 2016 public LTC expenditure in Spain was estimated to represent 0.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Spain has a tax-based long-term care financing system, with national eligibility criteria and defined benefits, run at regional level and financed by national, regional and local funding. National funding aims to take into account differences in population need (equalization function). Co-payments are means-tested (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en). Overall, funding and coverage of LTC services in Spain is considered to be highly inadequate to meet people’s needs, and long waiting lists to receive services are a pressing issue nationwide and at a regional level (source: LTCcovid-Spain-country-report-28-May-1.pdf).

Last updated: December 2nd, 2021

Sri Lanka

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

Last updated: September 6th, 2021

Sweden

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

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

Last updated: November 23rd, 2021

Switzerland

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

Last updated: November 23rd, 2021

Thailand

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

References:

Asian Development Bank (2020) Country Diagnostic Study on Long-Term Care in Thailand. ADB.

Last updated: December 17th, 2021

Turkey

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

Last updated: November 23rd, 2021

England (UK)

A large share of the resources that fund long-term care are provided in kind, through the time and effort of unpaid carers. Formal long-term care services in England are funded differently for health care, which is free at the point of use through the National Health Service (NHS) and social care, which is means-tested. Individuals who need care and their families also contribute to the costs of care through purchasing services privately or out-of-pocket payments for services. There is strong consensus on the need to reform social care funding and reforms are under way (see question 4.02).

As an illustration of who bears the costs of long-term care in England, it is useful to look at this study of the costs of dementia, which found that, in 2015, 42% of the £24.2 billion costs of care of people with dementia were attributable to unpaid care, formal social care services represented another 42% and health care 16%. Out of the £10.2 billion social care costs, £6.2 billion were met by people who use care and their families, and £4.0 by the government. This means that the public sector only funds one third (32.6%) of the costs of dementia, leaving users and families to shoulder the rest of the costs through unpaid care or care fees. The cost of dementia estimates include health care costs that are not strictly “long-term care”, for example diagnostic services and hospitalisations, meaning that the share of public funding for long-term care for people with dementia is even lower than this estimate (Wittenberg et al., 2019).

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

The King’s Fund Social Care 360 annual report provides a useful overview on public funding for social care in England. In 2019/20, gross social care spending through LAs was £23.3 billion. Of this, £7.5 billion was spent on long-term support for working-age adults (£2.5 billion on nursing or residential care, £451 million on supported accommodation and £4.6 billion on community support, including home care). They also spent £159 million on short-term support for working-age adults. Spending for long-term support for older people was £7.9 billion (£5 billion on nursing or residential care, £121 million on supported accommodation and £2.7 billion on community support, including home care). Theyalso spent £450 million on short-term support for older people (Bottery and Ward, 2021).

During the last decade, funding to councils has been cut by almost 50% (source: National Audit Office), which has put pressure on councils to spend less on care either through reducing the rates they pay providers or by reducing the number of people they fund. Because local authorities have a responsibility to raise revenue locally to subsidise the grant they receive from national government, those local authorities in more affluent areas are able to raise more (source: Institute for Fiscal Studies). The result is wide variation in the eligibility for care between local areas, despite the intention of the Care Act (2014) being to standardise eligibility.

The distinction between ‘health’ and ‘care’ creates further inequity. A person deemed to have health needs may be able to access social care via the NHS’s continuing healthcare programme (although subject to restrictive eligibility criteria and long waiting times), but someone with personal care needs (e.g. arising from dementia) and no medical requirements is subject to the means test (source: Nuffield Trust).

In 2018, LTC expenditure in the United Kingdom was estimated by the OECD to represent 1.8% of Gross Domestic Product.

References:

Bottery S and Ward D (2021) Social Care 360. The King’s Fund. https://www.kingsfund.org.uk/publications/social-care-360

Wittenberg, RKnapp, MHu, B, et al. The costs of dementia in EnglandInt J Geriatr Psychiatry2019341095– 1103https://doi.org/10.1002/gps.5113

Last updated: December 20th, 2021   Contributors: Joanna Marczak  |  Adelina Comas-Herrera  |  

Scotland (UK)

Principal responsibility for providing services to social care clients falls on Scotland’s 32 local authorities. For home care, each local authority has their own charging policy which, together with a financial assessment of the persons income, will determine how an individual contributes towards their care services. Since 2002, anyone in Scotland aged 65 and over, whether living at home or in a care home is entitled to Free Personal and Nursing Care if they need it.

Before entering a care home, the local authority will carry out needs assessment and a financial assessment to work out what care the individual needs and how much they need to pay towards the care home fees and services. The amount a person will have to pay depends on if they fall above or below the capital limits (lower limit £18,000 and upper limit £28,750 as of April 2021). Care home residents who have capital above the upper limit are classed as self-funders and those who have capital falling below the lower limit are funded by their local authority. Those whose capital lies in between the upper and lower limits receive some help from the local authority and fund the remainder themselves. However, Free Personal and Nursing Care in a care home means that self-funders who are aged 65+ receive a weekly payment towards their personal care (£193.50 as of 1st April 2021). Any self-funder in need of nursing care will also receive a weekly payment towards the cost of that care (£87.10 as of 1st April 2021). Finally, those who are funded by the local authority will receive personal care for free.

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

United States

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

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

Last updated: November 23rd, 2021

Vietnam

Given the large number of people in Vietnam in need of social care – a figure that is increasing rapidly – the provision of services is considered inadequate and underfunded (source: UNDP report). The state has a minimally developed LTC system and is heavily reliant on informal care, which is funded by families as out-of-pocket expenses. However, these are unaffordable by many members of the population, and family carers are not entitled to benefits other than in exceptional circumstances (source: Royal Commission into Aged Care Quality and Safety). Furthermore, according to a UNDP report, the majority of working age people in Vietnam do not have a pension to look forward to (with over half of people over age 65 unable to access one); thus, many face income insecurity at an older age and need to work until they are too frail to continue doing so. They may be entitled to social assistance payments, but total state expenditure on these payments is low compared to other middle-income countries (such as Brazil and South Africa), and even some low-income countries (such as Bangladesh). This makes the possibility of purchasing private LTC unlikely for most.

Most of the financial support that does exist is to support those who qualify for institutional care, rather than providing people with support to remain in their homes or with their families. State-funded care is based around a nationwide network of social protection centres, which provide residential accommodation for various vulnerable segments of the population, including some elderly people. There are a total of 393 social protection networks around Vietnam; 180 are run by non-state entities and 213 are publicly run. Thirteen of the social protection centres serve the elderly population. The centres are all financed by the government: the public units are financed directly, and the non-state units are financed indirectly via tariffs paid to the provider, based on what services are delivered. Expenditure is approximately $35 per person per month. A range of weaknesses have been highlighted in these public care centres; mostly due to limited financing, which translates into low-quality standards of accommodation, poor services, an absence of various key services (such as counselling) and difficulties recruiting staff due to low salaries. Furthermore, they are only available to a small segment of the elderly population, leaving many without access to LTC outside of their families (source: UNDP report).

Due to the abovementioned government-funded services failing to meet the increasing demand for LTC in Vietnam, the government provides some incentive payments for volunteer primary caregivers in the community to cover elderly members of the population who are unable to live independently, are poor, and do not family to care for them. In these cases, social assistance payment s are provided to both the recipient of care and caregiver  (source: Royal Commission into Aged Care Quality and Safety).

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

1.04. Approach to care provision, including sector of ownership

Australia

In 2018-2019, there were over 3,000 providers of aged care services. 873 of these were residential services, 928 were home care providers, and 1,458 were Commonwealth Home Support Programme providers. The majority of aged care providers are not-for-profits owned by community, charity, or religious organizations. The remaining are privately owned organizations, which are run as a commercial business. There is also a small group of government owned providers. Australia has seen a trend of aged care providers consolidating to just a few large-scale operators – in 2018-2019, 10 providers operated 39% of all aged care services (source: Care, Dignity and Respect report).

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

Last updated: January 6th, 2022

Austria

While by law the federal states are responsible for the provision of long-term care services for older adults in Austria, in practice, the responsibility for carrying out these services is shared with several entities, such as the municipalities, non-profit organisations and private operators (Rechnungshof Österreich, 2020). The share of publicly- and privately-provided care providers varies immensely between the federal states and between the home and residential care sector.

In residential care, approximately 50% of care providers are public, 25% are non-profit, and the remaining 25% are for profit (Molinuevo & Anderson, 2017; Rodrigues & Nies, 2013). Approximately 900 nursing homes were in operation in 2017, providing 78,000 beds. Around 400 of these nursing homes were run publicly, with the remainder run by mostly non-profit (religious) organisations, such as Volkshilfe, Sameriterbund and Caritas.

In the home care sector, 91% of providers are non-profit, 8% are public and 1% are for-profit (Rodrigues & Nies, 2013). Mobile services are primarily provided by non-profit (often faith-based) organisations, while day centres (not connected to inpatient facilities) are mostly run by private providers (Grossmann & Schuster, 2017).

References

Grossmann, B. & Schuster, P.  (2017). Langzeitpflege In  Österreich:  Determinanter  Der  Staatlichen Kostenentwicklung. Studie Im Auftrag Des Fiskalrats. Wien: Fiskalrat. Retrieved from https://www.oesterreich.gv.at/themen/soziales/soziale_dienste/1/Seite.1210130.html

Molinuevo, D. & Anderson, R. (2017). Care homes for older Europeans: Public, for-profit and non-profit providers. Luxembourg: Publications Office of the European Union. Retrieved from Eurofound website https://www.eurofound.europa.eu/publications/report/2017/care-homes-for-older-europeans-public-for-profit-and-non-profit-providers

Rechnungshof Österreich (2020). Bericht des Rechnungshofes: Pflege in Österreich. Wien: RH Österreich

Rodrigues, R., &  Nies, H. (2013). Making Sense of Differences – The Mixed Economy of Funding and Delivering Long-term Care. In Leichsenring, K., Billings, J., & Nies, H. (eds), Long-term care in Europe: Improving policy and practice. Basingstoke: Palgrave Macmillan.

Last updated: January 6th, 2022   Contributors: Cassandra Simmons  |  

British Columbia (Canada)

Publicly subsidized services are provided by regional health authorities who deliver them through health authority owned or contracted private/not-for-profit facilities. For-profit, private facilities are often regarded as inferior to publicly owned/health authority owned facilities in terms of care, access to equipment, and government support.

In 2020, 33% of publicly funded LTC beds are operated directly by health authorities. The remaining 18,000 beds are delivered by for-profit companies (35%) and not-for-profit societies (32%) who have been contracted by one of the five regional health authorities in B.C.

A recent paper situates the contemporary crisis of COVID-19 deaths in seniors’ care facilities within the restructuring and privatisation of this sector. Through an ethnographic comparison in a for-profit and non-profit facility, they explore what they identify as brutal and soft modes of privatisation within publicly subsidised long-term seniors’ care in Vancouver, British Columbia, and their influence on the material and relational conditions of work and care. Workers in both places are explicit that they deliver only bare-bones care to seniors with increasingly complex care needs, and they document the distinct forms and extent to which these precarious workers give gifts of their time, labour, and other resources to compensate for the gaps in care that result from state withdrawal and the extraction of profits within the sector. They nonetheless locate more humane and hopeful processes in the non-profit facility, where a history of cooperative relations between workers, management, and families suggest the possibility of re-valuing the essential work of care (Molinary and Pratt, 2021).

Sources:

https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf

https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2020/02/ABillionReasonsToCare.pdf

Molinari, N. and Pratt, G. (2021), Seniors’ Long-Term Care in Canada: A Continuum of Soft to Brutal Privatisation. Antipodehttps://doi.org/10.1111/anti.12711

Last updated: January 6th, 2022   Contributors: William Byrd  |  

Denmark

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

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

Last updated: January 6th, 2022

Finland

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

Last updated: January 6th, 2022

France

In 2020 there were 7,502 residential long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015. There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people.

Last updated: January 6th, 2022   Contributors: Camille Oung  |  

Germany

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

Between 1999 and 2019, the share of private care providers in residential care increased from 35% to almost 43%, while the share of third sector organisations declined from 57% to 53% and that of public institutions from 8.5% to 4.5%.

Among domiciliary care providers, the share of private providers increased from 51% to 67%, while the proportion of third sector decreased from 47% to 32% and that of public providers from 19% to 1% between 1999 and 2019.

Last updated: January 6th, 2022

Italy

The actors directly involved in the organisation of LTC services are municipalities, local health authorities and the National Institute of Social Security (INPS), but other players are involved in planning and funding these services – i.e. the central state, regions and provinces.

The table below classifies the Italian LTC system according to initiative and actor involved:

Typology Service/Intervention Actors involved
Cash transfer Companion Allowance (CA – Indennità di Accompagnamento) National Social Insurance Agency
Monetary vouchers to finance informal caregiving or care services Municipalities

Regions

Local Health Authorities

In-kind services Home care

Nursing homes

Day care

Informal caregiving

Local Health Authorities and Municipalities

Municipalities and regions; providers (public, private, or not for profit)

Relatives or migrant care workers

(source: https://journal.ilpnetwork.org/articles/10.31389/jltc.73/)

Informal care and migrant care workers, often with irregular contracts, play an important role in the organisation and provision of home care.

Sources:

European Commission (2016) Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee.

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

Last updated: January 6th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: January 6th, 2022

Mauritius

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

Last updated: January 6th, 2022

Poland

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

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Seychelles

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

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

Last updated: January 6th, 2022

Singapore

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

Last updated: January 6th, 2022

South Africa

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

Last updated: January 6th, 2022

Spain

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

Last updated: January 6th, 2022

Sri Lanka

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

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

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

Last updated: January 6th, 2022

sub-Saharan Africa

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

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

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

Last updated: January 6th, 2022

Sweden

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

Last updated: January 6th, 2022

England (UK)

Care is provided by approximately 9,000 home care providers and over 15,000 care home providers. Around 78% of all adult care services are privately owned and run (source: ICF report). The Care Act 2014 places a duty on local authorities to ensure that there is diversity and quality in the market of care providers. However, due to the downward pressure on fees stemming from cuts to local authority budgets, many providers find that the fees paid by local authorities fall short of covering the full costs of providing care. People who fund their own care are being charged on average 41% more than local authority funded residents because of this shortfall (source: CMA report). It is increasingly common for care providers to go out of business, struggle to stay in business, or hand back contracts to local authorities. A survey in 2019 found that some 75% of councils reported that organisations had either closed or handed back contracts in the last six months of 2020, creating enormous disruption and discontinuity for those receiving care. Because of market fragility, the government has introduced market oversight and a failure regime covering financial as well as quality failure (source: CQC).

Last updated: January 6th, 2022

Scotland (UK)

Care at home is either provided by the local authority, the health board (in the case of NHS Highland), by private firms or voluntary/not for profit firms. According to data collected by the Care Inspectorate, as of 31st March 2020, of the 1,046 registered care at home for adults’ services, 495 (47%) were run by voluntary or not for profit organisations, 406 (39%) by private firms, 136 (13%) by the local authority and in NHS Highland 9 (<1%) care at home services were provided by the health board.

Within the care home setting, ownership types are the same but unlike care at home, in Scotland most care homes are privately owned. Specifically, as of March 2020, 680 (63%) of care homes for adults were privately owed. The remainder were owned by voluntary or not for profit organisations (24%), local authorities (12%) and the Health Board (1%).

Last updated: January 6th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

1.05. Quality and regulation in Long-term care

Overview

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

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

International reports and sources

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

Australia

The Aged Care Quality and Safety Commissioner, under the Australian government, is the national regulator of aged care services. It is responsible for approving subsidies for aged care providers, accrediting aged care services, monitoring quality of care, providing education, and handling complaints. Aged care providers must comply with the Aged Care Quality Standards set by the Aged Care Act and the Aged Care Principles (source: Care, Dignity and Respect report).

Last updated: December 22nd, 2021

Austria

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

Last updated: November 23rd, 2021

Belgium

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

Last updated: November 23rd, 2021

Croatia

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

Last updated: November 23rd, 2021

Cyprus

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

Last updated: November 23rd, 2021

Czech Republic

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

Last updated: November 23rd, 2021

Denmark

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

Last updated: August 2nd, 2021

Estonia

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

Last updated: November 23rd, 2021

Finland

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

Last updated: November 2nd, 2021

France

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

Last updated: November 23rd, 2021

Germany

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

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

Last updated: November 23rd, 2021

Greece

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

Last updated: October 27th, 2021

Hungary

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

Last updated: November 25th, 2021

Ireland

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

Last updated: August 2nd, 2021

Italy

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

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

Last updated: November 8th, 2021

Lithuania

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

Last updated: November 25th, 2021

Malta

The Social Care Standards Authority (SCSA) was set up in 2018 through Act No. XV of 2018. The SCSA is a regulatory body responsible for (a) the issuing of licences and warrants for service providers within the long term care sector, (b) the setting up of regulatory standards in respect of the various areas of social care, assistance and services provided by public and private entities, and (c) inspecting the long term care sector services, ensuring that practices are safe and up to the required regulatory standards for the persons using these services.

 

Last updated: December 6th, 2021   Contributors: Maria Aurora Fenech  |  

Poland

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

Last updated: November 3rd, 2021   Contributors: Joanna Marczak  |  

Romania

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

Last updated: November 23rd, 2021

Spain

The Spanish LTC system has three instruments to ensure quality: 1) a national and regional regulatory system; 2) formal quality controls; and 3) good practices. The regulation of quality in terms of services and the training of professionals and carers is developed through the Council of the System for Autonomy and Care for Dependency (CISAAD) which sets the minimum criteria for the whole state with respect to minimum carer-to-recipient ratios, staff qualifications, and resources/equipment/documentation applied to all accredited care centres. The CISAAD also establishes essential quality standards for homecare and residential care. Accredited centres can be inspected at the request of a dependent user or randomly by the autonomous community. The formal quality controls of the LTC system (the SAAD) are based on the accreditation systems established by each regional authority. Although there is a common denominator among them, each region has its own specific regulation and quality plan. With regard to good practices, the CISAAD agreed on common criteria to define, develop, and evaluate good practices in 2011, however most regions have not developed tools to evaluate good practice (Rodriguez Cabrero et al, 2018).

Leon and colleagues have identified a weak and fragmented regulatory system as one of the factors that contributed to delays in the implementation of measures to prevent COVID-19 in care homes in Spain.

References:

León, M., Arlotti, M., Palomera, D., & Ranci, C. (2021). Trapped in a Blind Spot: The Covid-19 Crisis in Nursing Homes in Italy and Spain. Social Policy and Society, 1-20. doi:10.1017/S147474642100066X

Rodriguez Cabrero G, Montserrat Codorniu J, Arriba Gonzalez de Durana A, Marban Gallego V and Moreno Fuentes FJ (2018) European Social Policy Network Thematic Report on Challenges in Long-Term Care, Spain. European Commission, Brussels.

Last updated: November 23rd, 2021

Sri Lanka

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

Last updated: September 8th, 2021

Thailand

Last updated: September 8th, 2021

England (UK)

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

Last updated: December 4th, 2021

Scotland (UK)

The Care Inspectorate is the regulatory body charged with ensuring that high care standards are met in Scotland. It carries out regular, unannounced inspections of Scottish care homes. Where care fails to meet the expected standards, the Care Inspectorate work with the provider to suggest how improvements in care quality can be made. If a provider fails to improve quality sufficiently, the Care Inspectorate have the authority to close the service down, subject to the decision of a sheriff.

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Vietnam

Quality in state-run institutional care centres in Vietnam is reputedly poor, which is mostly down to low levels of funding (source: UNDP report). The responsibility for quality assurance in terms of staffing sits at federal level: The Ministry of Labour, Invalids and Social Affairs prescribes professional standards and training care workers. Training is not mandated, but staffing levels are: for low-level care, they are 1:8-10, and for high level care 1:3-4. Nutrition staff (food purchasers and cooks) are mandated at 1:20. All care institutions (private, public, and NGO or religious providers) must submit annual reports to the federal authorities (source: Royal Commission into Aged Care Quality and Safety).

It is unclear whether quality is higher in private care homes. However, it may be worth noting that according to a recent report, 18% of the private residential care centres in 2016 were unlicensed (this suggests that it is quite possible that they have not been submitting any quality control reports to the authorities).

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

1.06. Care coordination and personalization

Overview

As described in sections 1.00 and 1.02., responsibility for long-term care is fragmented, in very complex ways in some countries. In practice the fragmentation of the care system affects not only the delivery of services, but can also be seen during needs assessment, when accessing benefits and packages, in data collection and in the diversity of quality improvement efforts. Fragmentation of services has been linked to dual administrative procedures, hindrances in access to care and longer waiting times (Spasova et al. 2018) and has been identified as a barrier to reducing hospitalization for ambulatory care sensitive conditions (source: WHO).

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

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

References:

Spasova, Slavina, Baeten, Rita & Vanhercke, Bart. (?2018)?. Challenges in long-term care in Europe. Eurohealth, 24 (?4)?, 7 – 12. European Observatory on Health Systems and Policies, World Health Organization. Regional Office for Europe. https://apps.who.int/iris/handle/10665/332533

International reports and sources

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

WHO’s Regional Office for Europe has developed a framework for LTC integrated care and has published detailed country reports online.

Australia

The Australian government’s Ministry of Health oversees both the health and aged care sector. States and territories are responsible for the actual delivery of care. The aged care sector has been found to have less access to services, including allied health services. The Royal Commission into Aged Care Quality and Safety recommends the Australian Government to increase coordination by creating Medicare Benefits Schedule items to specifically increase the provision of allied health services, including mental health services, to people in aged care.

The aged care system is difficult to access and navigate. The Royal Commission into Aged Care Quality and Safety found that people needing care found the experience to be time-consuming, overwhelming, and intimidating. The Royal Commission also expressed concern regarding the ability for people to make informed decisions due to the lack of information available.

Last updated: January 6th, 2022

British Columbia (Canada)

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

Last updated: January 6th, 2022

Denmark

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

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

Last updated: January 6th, 2022

Finland

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

Last updated: January 6th, 2022

France

Coordination in the care sector is a longstanding preoccupation of the state and a response to the highly fragmented organization and funding of health, social and the need for ‘medico-social’  interventions in the care field.

Some level of integration at a local authority level has also been achieved through pathways and networks generally around gerontology and independence loss, as well as regional support networks and local information centres (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

Various schemes have been developed since 2010– the PTA, the MAIA, and PAERPA schemes – having in common the creation of specific functions or professionals to support the social, medico-social and health professionals in their coordination tasks. Since, other arrangements have been developed in including the DAC (schemes to promote coordination) which should merge all other schemes excepting for CLICs which are organised by local authorities.

From a public policy perspective, the analysis of these developments shows that despite their initial objective of improving coordination between the health, social and medico-social interventions and facilities, the creation of three dedicated coordination schemes has also contributed to the complexity of elderly care professional and organizational landscape. Research also highlights limited accountability with poor transparency for users, prospective users and carers  (source: CEQUA France Country report (filesusr.com).

Last updated: January 6th, 2022   Contributors: Camille Oung  |  Alis Sopadzhiyan  |  

Germany

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

Last updated: January 6th, 2022

Israel

There is a blurred line separating medical and functional assistance. Generally, the tendency is to leave patients in their homes (community-based care), with the primary task of LTC defined as practical, mental and social assistance in functioning, with limited medical intervention.  The Israeli healthcare system is a national health insurance plan that provides universal coverage to all Israeli citizens or residents. All residents register with one of four competing non-profit health plans (HP’s).  The HP’s are reponsible for geriatric and complex care and has dominated the discourse regarding services for the vulnerable during the pandemic (source: Traub Centre). Community long-term care is a branche of social insurance while institutional LTC is under the supervision of the Ministry of Health (MoH) and the Ministry of Welfare and Social Affairs (MoWSA) . The large percentage of privately funded LTC services and the widespread culture of unpaid, family caregiving suggest a lack of ease that social care users have with understanding, navigating, and accessing the full extent of LTC services.

Last updated: January 6th, 2022   Contributors: Sharona Tsadok-Rosenbluth  |  

Italy

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

Last updated: January 6th, 2022

Japan

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

Last updated: January 6th, 2022

Netherlands

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

Last updated: January 6th, 2022

Poland

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

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Singapore

Care integration is high on the policy agenda in Singapore. For example, to facilitate integrated delivery of support and services, Singapore has consolidated aging, health, and LTC under the Ministry of Health (MOH) with inter-ministerial remits, where relevant.

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

In 2012, a Regional Health System model was introduced by the Ministry of Health to support the provision of ‘seamless integrated care based on geographic location’. This model facilitates local collaboration and transitions between care settings and has been reported to strengthen management capabilities and continuity of care. Key actors are designated anchor public acute hospitals as well as ‘primary, chronic health and social care’ services in the different geographic areas.

Last updated: January 6th, 2022

Spain

The provision of LTC in Spain is fragmented, due to the intervention of many agents and the differences between the autonomic regions. There have been several initiatives to improve care coordination through: the creation of social and healthcare coordination structures, the implementation of shared information systems, improving the comprehensive assistance in social centres and promoting the creation of hospital assistance units of continuity (Guillen et al., 2017).

A published study aimed to analyse the residential care crisis in Spain in the context of the COVID-19 pandemic and its impact on high mortality and abandonment of the user population. The theoretical focus of the analysis was the comprehensive and person-centred care (CPCC) model based on the autonomy of people and the centrality of their rights. The study concludes by proposing a comprehensive reform of long-term care that includes both a change in residential care in the form of small cohabitation units and reinforcement of care in the home and the community as a growing preference for the elderly population. An optimal combination of residential and home care is the basic proposal of this work (Gallego et al., 2021).

References:

Gallego, V. M., Codorniu, J. M., & Cabrero, G. R. (2021, January 1). The impact of COVID-19 on the elderly dependent population in spain with special reference to the residential care sector. Ciencia e Saude Coletiva. Associacao Brasileira de Pos – Graduacao em Saude Coletiva. https://doi.org/10.1590/1413-81232020261.33872020

Guillen M. et al. (2017) Country Report – Spain. Quality and cost-effectiveness in long-term care and dependency prevention. CEQUA LTC Network.

Last updated: January 6th, 2022   Contributors: William Byrd  |  

Sweden

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

Last updated: January 6th, 2022

England (UK)

There is a clear policy drive towards integrated care in England. Health care has traditionally been coordinated through local National Health Service (NHS) planning and provider organisations, which are accountable to the national government. In contrast, social care contrast is under the responsibility of local authorities, which have their own governance structures and are accountable to elected local governments. Local authorities can make their own decisions about implementation and funding allocation. Since the late 1990s to 2010 the government focused on the structural elements of partnership through multiple policy reforms. A review of progress in that period concluded that there was insufficient attention to supporting joint working through building relationships and trust (Glasby et al, 2011).

Since 2010, England introduced initiatives to encourage better integration between health and social care, building on previous efforts to improve partnerships between the two sectors. A study reviewing progress on integrated health and social care in England from 2010 to 2020 has concluded that a focus on locally relevant and specific tasks or issues has resulted in the greatest progress. Broader ill-defined goals and constant policy changes are not helpful (Miller et al, 2020).

A review of the findings from three key integration pilot programmes (Integrated Care Pilots, Integrated Care and Support Pioneers, and New Care Model ‘Vanguards’ highlights the challenges of identifying the objectives of integrated care). All three programmes shared the aim of improving coordination between hospital and community-based health services and between health and social care. However, over time, the NHS narrowed the lens used to evaluate their success to impact on reducing unplanned hospital admissions, which led to a diminished role for local authorities and voluntary sector partners. The evaluations of the pilots show that integration is a long-term project and that reductions in unplanned hospital admissions are not necessarily the best way to measure success (Lewis et al, 2021).

The NHS Long Term Plan published in 2019 announced Integrated Care Systems (ICS) everywhere by April 2021, bringing together local organisations to deliver a ‘triple integration’ of primary and specialist care, physical and mental health services, and heath and social care. These ICSs are rooted in the NHS, with the expectation that local authorities, the voluntary sector and others will partner with them.

The plan also includes the expansion of the Enhanced Health in Care Homes model to the whole country by 2023/4 to strengthen links between primary care networks and care homes.

The Plan announces support for local approaches to blending health and social care budgets and that a forthcoming green paper on adult social care will set out further proposals for social care and health integration.

References:

Glasby J, Dickinson H, Miller R. Partnership working in England – where we are now and where we’ve come from. International Journal of Integrated Care. 7 March 2011; 11: 1–8. DOI: https://doi.org/10.5334/ijic.545.

Lewis, R. Q., Checkland, K., Durand, M. A., Ling, T., Mays, N., Roland, M., & Smith, J. A. (2021). Integrated Care in England – what can we Learn from a Decade of National Pilot Programmes?. International Journal of Integrated Care, 21(S2), 5. DOI: http://doi.org/10.5334/ijic.5631

Miller, R., Glasby, J., & Dickinson, H. (2021). Integrated Health and Social Care in England: Ten Years On. International Journal of Integrated Care, 21(S2), 6. DOI: http://doi.org/10.5334/ijic.5666

Last updated: January 6th, 2022   Contributors: Adelina Comas-Herrera  |  Chris Hatton  |  

Scotland (UK)

Anyone who is eligible to receive social care services in Scotland has the option of choosing Self-Directed Support for their care. Self-Directed Support was introduced in Scotland in April 2014.      This option gives individuals greater control over how they receive their care and allows them to personalise their care in a way that suits them. A Public Health Scotland report on social care estimated that in 2018/19, around 79.4% people used self-directed support to make choices about their care. However, an Audit Scotland report suggested that the accuracy of data regarding self-directed support required improvement.

Last updated: January 6th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

United States

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

Last updated: January 6th, 2022

1.07. Information and monitoring systems 

Australia

The Department of Health facilitates an Australian National Notifiable Diseases Surveillance System, which tracks a list of specific communicable diseases. The Department of Health also publishes weekly traffic light reports of the COVID-19 situation across Australia, which includes details about cases, testing, and capacity nationwide and in individual states (sources: Department of Health 1Department of Health 2).

Last updated: January 6th, 2022

Denmark

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

Last updated: January 6th, 2022

France

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

Last updated: January 6th, 2022

Germany

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

Last updated: January 6th, 2022

Israel

The Israeli National Insurance (IN) publishes annual reports and regular studies on community-based LTC resource allocation and service outcomes. Information on vulnerable and older adult populations in need of care services is also gathered through various social policy think tanks and NGOs: JDC (Joint Distribution Committee)-Eshel (source: The Joint), which conducts an extensive study of care users and produces annual reports on aging. The evaluations of resource allocation and services are shared with the Israeli Government (source: Myers-JDC-Brookdale Institute.  JDC-Eshel in partnership with Mashav produce an annual statistical yearbook of Israel’s aging and care user populations (source: Myers-JDC-Brookdale Institute).

Last updated: January 6th, 2022

Italy

For healthcare, Italy has a comprehensive information and monitoring system (National Healthcare Information System) covering population health status, budgetary and economic efficiency, organisation climate and staff satisfaction, patient satisfaction, performance indicators (appropriateness, quality) and effectiveness in reaching regional targets.

Out of the 33 indicators that monitor and assess regions’ health and LTC systems’ quality, there are only three LTC-related measures: number of care home beds and residents, number of hours of home care delivered and day care centres. Hence, the current status of LTC information system is really poor, compared to heathcare, and this led to critical consequences during the Covid-19 outbreak. As of November, 2021 we still lack official data on the pandemic outbreak in LTC services.

Sources:

European Commission (2016) Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee.

Ministerio della Salute (2021) Monitoraggio di LEA attraverso la cd. Grillia LEA. Metodologia e Risultati dell’anno 2019. Direzione Generale della Programmazione Sanitaria – Ufficio VI.

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

Last updated: January 6th, 2022

Japan

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

Last updated: January 6th, 2022

Poland

The Law on Older Persons, introduced in 2015, requires that the Council of Ministers of the Republic of Poland must provide annual information on the situation of older people (60+) regarding, among other things,  their health status, access to healthcare and long-term care services. The report also contains information about the implementation of the tasks of local governments in providing support for older people. The information is publicly available on the website of the Ministry of Family and Social Policy and the Central Statistical Office (source: Ageing policies – access to services in different EU Member States).

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Sweden

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

Last updated: January 6th, 2022

England (UK)

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

The COVID-19 crisis has stimulated some technological innovation in care homes, for example, the NHS has expanded the use of encrypted NHS emails to care home staff, developed a web portal for Personal Protection Equipment (PPE) emergency procurement, and has piloted ‘remote’ social care interventions. Some care homes and General Practices (GP) have also used tablets and video calling to allow GP visits and to communicate with families. The digital lifeline initiative during the COVID-19 crisis enabled over 5,000 adults with intellectual disabilities in England to receive internet-enabled devices, with data and local support to help people learn how to use their device, with promising impact in the short term. However, this is in the context of fundamental issues with capacity of the care home sector to engage in these initiatives due to a lack of infrastructure (e.g. broadband), or low usage of digital technology among home care staff.

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

Source:

https://ltccovid.org/2020/05/14/the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/

Last updated: January 6th, 2022   Contributors: Chris Hatton  |  Nina Hemmings  |  

United States

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

Last updated: January 6th, 2022

1.08. Care home infrastructure

Australia

There are approximately 845 residential care providers in Australia, operating across more than 2,720 sites. In terms of ownership (ACFA, 2021, table 6.1):

  • – 56% of providers and 55% places are in for not-for profit residential homes (ACFA, 2021)
  • – 10 % government operated
  • – 34% are for profit/private

The number  of residential aged care providers has been decreasing due to industry consolidation while the number of government-funded places (beds) in aged care has gradually been increasing.

Industry consolidation has seen a reduction of one owner/one-site facilities and a corresponding increase in large for-profit providers building large facilities across multiple sites.

Other contextual data:
  • – 245,000 people lived in aged care facilities at some point in 2019/2020
  • – 65% of residents in aged care are women.
  • – Average age of residents is 85
  • – NB: 4,900 aged care residents are aged under 65.

Data from: Aged care snapshot 2021  (AIHW, 2021, accessed 25 Oct 2021).

References:

Aged Care Financing Authority, ACFA (2021) Report on the Funding and Financing of the Aged Care Sector. https://www.health.gov.au/sites/default/files/documents/2021/08/ninth-report-on-the-funding-and-financing-of-the-aged-care-industry-july-2021.pdf

Australian Institute of Health and Welfare, AIHW (2021) Australia’s welfare 2021, Aged care. Australian Government. https://www.aihw.gov.au/reports/australias-welfare/aged-care

Last updated: January 17th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Lee-Fay Low  |  

Austria

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

Last updated: January 6th, 2022

Brazil

Researchers from the ‘Frente Nacional de Fortalecimento à ILPI’ have published a study estimating the number of Long-Term Care Facilities (LTCFs) in the country in 7,029 facilities, noting that 64% of the 5 570 Brazilian municipalities do not have any LTCFs for older adults. (Lacerda TTB et al., 2021 https://doi.org/10.53886/gga.e0210060)

Last updated: January 6th, 2022   Contributors: Patrick Alexander Wachholz  |  

Canada

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

Last updated: January 6th, 2022

British Columbia (Canada)

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

Last updated: January 6th, 2022

Chile

There an estimated 25,000 older people living in registered care homes (1.4% of the population aged 65 or older). Of the 994 registered care homes, 16 are public, 181 are not-for-profit (with public subsidies) and the rest are for-profit (operating under supervision of the Ministry of Health) (Browne et al., 2020).

There are many unregulated care homes operating in an informal manner, probably as many as there are in the regulated sector. Prior to the COVID-19 pandemic there were no regulations or mechanisms to survey the Infection Prevention and Control capabilities of care homes (Browne et al., 2021).

References

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Browne, J., Palacios, J., Madero-Cabib, I., Dintrans, P.V., Quilodrán, R., Ceriani, A. and Meza, D., 2021. Enablers and Barriers to Implement COVID-19 Measures in Long-Term Care Facilities: A Mixed Methods Implementation Science Assessment in Chile. Journal of Long-Term Care, (2021), pp.114–123. DOI: http://doi.org/10.31389/jltc.72

 

Last updated: January 6th, 2022

Denmark

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

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

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

Last updated: January 6th, 2022

Denmark

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

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

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

Last updated: January 6th, 2022

France

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

Last updated: January 6th, 2022

Germany

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

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

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

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

Last updated: January 6th, 2022

Iceland

There has been an important effort to upgrade care homes. Whereas in 2005 just half of people in care homes were in single rooms, and 29% had a private bathroom, by 2013 83% were in single rooms. The emphasis, since a new policy approved in 2008 is to build smaller units (for 6 to 10 people) with private rooms and and a common area for residents and staff. Minimum standards for the construction and running of care homes were issued in 2013.

(Source: Sigurveig H. Sigurdardottir, Omar H. Kristmundsson & Steinunn Hrafnsdottir (2016) Care of Older Adults in Iceland: Policy Objectives and Reality,Journal of Social Service Research,42:2, 233-245, DOI: 10.1080/01488376.2015.1137535)

Last updated: January 6th, 2022

Israel

As of 2017, amongst OECD countries, Israel had one of the lowest numbers of LTC beds available in its hospitals at 23.6 beds per 1000 people aged 65+ (the OECD average is 47.2 beds) (source: OECD). Notably, The proportion of people aged 65+ who receive LTC in institutions in Israel is the lowest among OECD countries (under 2%), while the number of recipients of care in the community is among the highest in these countries (source: Muir, 2017).

Last updated: January 6th, 2022

Italy

The actual number of nursing homes in Italy is unknown: different institutional sources indicate distinct values. In particular, the Interior Ministry counted 4,629 nursing homes for dependent older people (data confirmed also by the National Committee for the guarantee of people deprived of their freedom – Garante Nazionale dei diritti delle persone private della libertà personale). The National Health Institute provides data on 3,417 nursing homes for people living with dementia. The Ministry of Health considers 3.475 residential centers, which include nursing homes, care homes, hospice and a blurry “other type”. Such inconsistency between numbers makes it difficult to build up a comprehensive picture of the service supply.

Also the number of service providers is uncertain, estimates talk about 1.927 companies. As concerns nursing homes’ features, the Observatory on nursing homes from one of Italy’s largest trade unions pointed out that:

  • 10,3% NHs count less that 20 beds;
  • 33,1% NHs have 21 to 50 beds;
  • 38,9% NHs have between 52 and 100 beds
  • only 17.7% of NHs dispose of over 100 beds.

The average nursing home counts 67,5 beds. Moreover, the large majority (70%) of NHs is managed by private providers – generally in accreditation regime -, 38,2% are for profit companies, 6% are public owned foundations, 15% are NGOs. 14% of NHs are directly managed by municipalities or Local Health Authorities. On average, each provider manages 2,07 nursing homes and 140 beds. Hence, the typical nursing home is quite small and managed by a private provider which received an accreditation from the public sector.

The distribution of nursing homes is diversified and heterogeneous throughout the national territory, with strong consequences for equity in access. The table below shows the take up rate of care home beds with respect to the number of people with functional dependency aged 75 and over in each region, representing the population most likely to consider nursing home care.  the most vulnerable and likely target for such service

The distribution of the rate follows the Italian geography: Southern regions have the lowest rates; regions from the Centre reach middle values and the Northern regions have the highest take-up values. For example in Trento, there are 25 beds for each person aged 75 with dependency, compared to 0.65 in Basilicata, signalling the almost total absence of care home services in some areas of the country.

Region Take up rate of nursing homes’ beds with respect to dependent over75 residents in the region (2016)
Molise 0,26%
Basilicata 0,65%
Sicily 0,69%
Puglia 2,57%
Calabria 2,78%
Abruzzo 2,73%
Campania 0,73%
Marche 5,89%
Valle d’Aosta 0,25%
Tuscany 6,28%
Umbria 5,12%
Friuli – Venezia Giulia 15,36%
Liguria 9,73%
Emilia – Romagna 9,61%
Veneto 17,88%
Trento 25,66%
Lazio 2,85%
Sardinia 1,03%
Bolzano/Bozen 24,21%
Piedmont 18,15%
Lombardy 18,97%

Sources:

Berloto, S., Fosti, G., Longo, F., Notarnicola, E., Perobelli, E., Rotolo, A. (2019). La rete dei servizi di LTC e le connessioni con l’ospedale: quali soluzioni per la presa in carico degli anziani non autosufficienti? In Cergas (Eds.), Rapporto OASI 2019.

Fosti, G., Notarnicola, E. (Eds). Primo Rapporto OLTC.

Garante Nazionale dei diritti delle persone private della libertà personale (2020). Atto di sindacato ispettivo n° 3-01482.

Istituto Superiore di Sanità (2020). Mappa dei servizi.

Ministero della Salute (2021). Annuario Statistico del SSN. Anno 2019.

Ministero dell’Interno (2019). Le statistiche ufficiali del Ministero dell’Interno. Strutture per anziani. Ed. 2019.

Last updated: January 6th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: January 6th, 2022

Netherlands

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

Last updated: January 6th, 2022

Republic of Korea

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

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

Last updated: January 6th, 2022

Singapore

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

Public and NFP run long term care facilities in Singapore are particularly vulnerable to infectious diseases due to their infrastructure: most resemble dormitory-style residential conditions shared between roughly 6 – 12 residents, with communal facilities. There is more variation in the layout of private nursing homes: some have dormitory-style living conditions that have as many as 30 residents; others have single or double private rooms (Udod et al., 2021).

Last updated: January 11th, 2022

Spain

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

Last updated: January 6th, 2022

Sweden

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

Last updated: January 6th, 2022

Thailand

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

A survey of care home residents  living at two government long-term care centres during August 2020 to October 2020 found that most residents (82.5%) lived in shared rooms (government financed rooms) and the median length of stay was 5 years (Srifuengfung et al., 2021).

References:

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://dx.doi.org/10.1016/j.jad.2021.08.044

Last updated: January 14th, 2022

United States

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

Last updated: January 6th, 2022

1.09. Community-based care infrastructure

Australia

The majority of older people who use government-subsidised community care receive services through two major programs:

The CHSP provides entry level care for Australian aged 65 older and indigenous Australian aged 50 or over to live independently at home. Services include some personal care, shopping, help with meals, taking people to appointments and community nursing. In 2018-19 there were:

  • – 1,452 CHSP providers
  • – 840,984 clients in the CHSP
  • – Approx 209 individuals per 1,000 people in the target population

The HCPP provides support for people requiring higher levels of care, especially personal care and is an individualised cash for care scheme, where the government subsidy is reduced by means-tested contributions from ‘consumers’  which depend on that person’s assessed income. These fees vary between $15.81 to $31.63 per day. Consumers may also be asked to pay a ‘basic daily fee’ between $9.98 to 11.02 per day depending on the package level. Where it is charged, this fee is added to the government subsidy.

At 30 June 2021 there were

  • – 939 approved HCPP providers.
  • – 195,699 people had access to a Home Care Package (HCP)
Accessing services:

Older people must be first assessed by an aged care assessment officer, usually face-to-face, to determine the package level. There are four levels of packages ranging from Level 1 – ($9,026.45 p a) to Level 4  (45,377.50) per annum. Provider charges for services are not regulated and there are price differences between providers for various services (although records of median prices charges are kept – see Duckett et al., 2021, figure 2.3 and the national summary of home care prices) and in the amount of administration and care management fees charged which are paid out of the allocated package. Such fees average 25% of the total value of a package and be up to 50% of the HC package in some instances.

The number and level of packages in the HCPP are effectively capped and there are long waiting lists for both assessment and for access to services when a person has been allocated a package. As at June 2021, there were  53,203 older people waiting for a HCP at their approved level (Department of Health, p.15).

References:

Deloitte Access Economics (2020) Commonwealth Home Support Programme Data Study. Department of Health, Australia. https://www.health.gov.au/sites/default/files/documents/2021/06/commonwealth-home-support-programme-data-study_0.pdf

Department of Health (2021) Home care packages program. Data report 4th Quarter 2020-21. Australian Government. https://gen-agedcaredata.gov.au/www_aihwgen/media/Home_care_report/Home-Care-Data-Report-4th-Qtr-2020-21.pdf

Duckett, S. and Swerissen, H. (2021). Unfinished business: Practical policies for better care at home. Grattan Institute. https://grattan.edu.au/wp-content/uploads/2021/12/Unfinished-business-Practical-policies-for-better-care-at-home-Grattan-Report.pdf

Last updated: January 18th, 2022

Japan

Japanese formal LTC relies heavily on day care and homecare services. In 2014, 7.8% of those 65 or older used day care in Japan. In 2019, in absolute numbers there were 1,077,609 users of day care services and 971,432 users of home care services. Many day care service providers also accommodate overnight stays

With the revision on Japan’s long-term care insurance law, current ageing health policies have shifted to a more population centric approach. Group activities called “Kayoi-no-ba” have been valued in Japan as a disability prevention initiative. The Kihon Checklist – a 25-item questionnaire – has been broadly used by health experts and researchers to assess frailty in Japan. However, a new 15-item questionnaire has been newly developed to identify frailty and other health-related problems in older people of 75 years and above. This will enable the provision of necessary support to frail individuals at any healthcare facility in local communities.

Sources:

https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf

Kojima, M., Satake, S., Osawa, A., & Arai, H. (2021). Management of frailty under COVID-19 pandemic in Japan. Global health & medicine3(4), 196–202. https://doi.org/10.35772/ghm.2020.01118

Last updated: November 30th, 2021   Contributors: William Byrd  |  

Austria

There is a wide range of community-based services available across Austria, both provided in the home of care-users and in community centers, although the availability and type of services available vary drastically across and within federal states. A range of long-term care mobile services are available for supporting personal care (i.e. personal hygiene, eating, etc.) and household maintenance in the home of the care user, carried out and coordinated at the regional and municipality level, including: food delivery (i.e. meals on wheels), driving services, mobile therapeutic services, cleaning services, repair services, and laundry services. Social services also exist, such as peer-to-peer advice provided by those with disabilities and visiting services for older people who are lonely (see: https://www.oesterreich.gv.at/themen/soziales/soziale_dienste/1/Seite.1210130.html and https://www.oesterreich.gv.at/themen/soziales/soziale_dienste/1/Seite.1210140.html).

Day care centres, which are available from Monday to Friday, are another community-based care option for older people. These centers offer a wide range of services, including social contact, skills training, professional care, therapies, and general support (see: https://www.gesundheit.gv.at/leben/altern/wohnen-im-alter/altersgerecht-wohnen).

24-hour care, in which care is provided around the clock by a live-in carer (typically of migrant origin), is also a large part of the community-based care in Austria and provides a relatively cheaper option for individuals with extensive care needs to stay in their home (Aulenbacher et al., 2020).

References

Aulenbacher, B, Leiblfinger, M, Prieler, V (2020) The promise of decent care and the problem of poor working conditions: Double movements around live-in care in Austria. Socialpolicy.ch – Journal of the Division of Sociology, Social Policy, Social Work 2: 2.5.

Last updated: January 6th, 2022   Contributors: Cassandra Simmons  |  

Chile

There is a home-based care programme for people with severe dependency and also to provide health care to people who cannot access healthcare centres. Since 2016, the Ministry of Social Development has implemented a Local Support and Care Network, as part of a set of programmes towards a National System of Care. There are also initiatives to support family carers through cash benefits and respite care (Browne et al., 2020).

References

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Last updated: January 6th, 2022

Denmark

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

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

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

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

Last updated: January 6th, 2022

Finland

The Finnish government is currently proposing reforms to the Social Welfare Act that aim to strengthen and expand home-based care, including widening the services on offer and adopting measures to secure sufficient staff.

Last updated: January 6th, 2022

Germany

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

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

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

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

Last updated: January 6th, 2022

Poland

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

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  

Singapore

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

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

Last updated: January 6th, 2022

Spain

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

Last updated: January 6th, 2022

sub-Saharan Africa

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

Last updated: January 6th, 2022

Sweden

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

Last updated: January 6th, 2022

Thailand

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

Last updated: January 6th, 2022

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

Overview

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

Limited career opportunities, lack of professionalization both for supporting the knowledge and rights of this workforce, as well as a lack of support and lack of research in this area, all exacerbate the challenges in attracting workers into the LTC sector. Across the OECD, about 45% of LTC workers are in part-time employment and need to work in multiple jobs  (source: https://www.oecd.org/health/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

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

 

Australia

In 2016, there are 366,000 paid workers (84%) and 68,000 volunteers (16%) delivering aged care. 66% of the paid workers were in direct care roles, including nurses and personal care workers (source: Care, Dignity and Respect report).

Australia has trained and supervises care workers to assist nurses with medicine management. Self-managed teams to give workers more flexibility and control have been shown to boost job satisfaction and reduce turnover (source: OECD).

Last updated: January 6th, 2022

Austria

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

Last updated: January 6th, 2022

Belgium

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

Last updated: January 6th, 2022

Bulgaria

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

Last updated: January 6th, 2022

British Columbia (Canada)

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

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

 

Last updated: January 6th, 2022

Ontario (Canada)

Focussing on Ontario, a published article traces the antecedents of the COVID-19 crisis in long-term care and documents experiences of frontline staff and family members of residents during the pandemic. They argue that the marginalization of both residents and workers in Ontario’s long-term care system over two decades has eroded possibilities for recognition of their personhood. They also question broader societal attitudes toward aging, disability, and death that make possible the abandonment of the frail elderly.

Source:

Badone, E. (2021). From Cruddiness to Catastrophe: COVID-19 and Long-term Care in Ontario. Medical Anthropology: Cross Cultural Studies in Health and Illness40(5), 389–403. https://doi.org/10.1080/01459740.2021.1927023

Last updated: January 6th, 2022   Contributors: William Byrd  |  

Denmark

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

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

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

Last updated: January 6th, 2022

Finland

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

Last updated: January 6th, 2022

France

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

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

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

Last updated: January 6th, 2022

Germany

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

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

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

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

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

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

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

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

 

Last updated: January 6th, 2022

Israel

Israel holds a significantly higher ratio of LTC providers to older population compared to other countries, with 11.1 LTC

Israel holds a significantly higher ratio of LTC providers to the older population compared to other countries, with 11.1 LTC workers available per 100 people aged 65+ (e.g. the UK’s ratio is 3.3 for every 100) (source: OECD).

Israel is listed as a country that subsidizes education to attract people into LTC training, including the provision of scholarships for nurses specializing in geriatric care (source: OECD).

Personal, at-home caregivers make up approximately 90% of the LTC workforce in Israel, with the majority of around-the-clock workers consisting of migrants from Southeast Asia (70,00 migrant care workers are currently hosted by Israel, nearly 40% of whom are from the Philippines) who are contracted out to LTC users through agencies (source: OECDAdva). At-home care workers in Israel are granted certain rights (e.g. a separate and private room in the employer’s (user’s) home, weekly vacation days, and 2-hour rest periods). The hourly wage set for long-term care workers by the National Insurance is the minimum hourly wage; caregivers often hold multiple jobs and live on the poverty line. Those with valid work visas are provided with limited health insurance (source: Attal et al, 2020).

Though standards for medical service delivery are particularly high and demanding, Israel’s required training qualifications for long-term caregivers in the community are amongst the lowest among OECD countries (source: Bank of Israel). Digital aids assist personal care workers in performing tasks such as taking a care recipient’s temperature or blood pressure (source: OECD).

Last updated: January 6th, 2022

Italy

A recent report from Amnesty International on health and care workers in Italy found that:

  • 85% of care workers are women, 12% are migrant;
  • Wages in LTC services are lower than those of the NHS (€11/hour vs €15/hours respectively)
  • The care worker/persone aged 65+ ratio is among the lowest in the OECD area: 2 care workers per 100 persons 65+ vs 5 care workers per 100 persons 65+

Moreover, as other countries, Italy is experiencing a shortage of nurses: trade unions claim that healthcare and LTC services are lacking 60.000 FTE nurse. Plus, the pandemic experience showed that LTC services are seen as a transitory moment of one’s own career, since many professionals apply to move to the NHS at the first opportunity.

The estimated 1 million informal and migrant care workers are important in providing private home care in Italy, but estimates claim that only 40% are employed under a fully regular contract. The trend to rely on home-based migrant carers has been supported by different measures and policies at local, regional and national level, including training and accreditation programmes for such carers, though with scarce success in promoting regular contracts (source: Italy Country Report (filesusr.com).

Source:

Amnesty International (2021) Muzzled and unheard in the pandemic: Urgent need to address concerns of care and health care workers in Italy. EUR30/4875/202

Barbarella F, Casanova G, Chiatti C and Laura G (2018) Italy: emerging policy developments in the long-term care sector. CEQUA LTC network report.

Federazione Nazionale Ordini delle Professioni Infermieristiche. (2021) Vaccinazioni, FNOPI: “oltre 60mila infermieri liberi professionisti sono pronti, ma per loro sono indispensabili maggiori tutele”.

Last updated: January 6th, 2022   Contributors: Elisabetta Notarnicola  |  Eleonora Perobelli  |  

Japan

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

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

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

 

Last updated: January 6th, 2022

Luxembourg

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

Last updated: January 6th, 2022

Netherlands

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

Last updated: January 6th, 2022

Norway

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

Last updated: January 6th, 2022

Poland

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

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Republic of Korea

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

Last updated: January 6th, 2022

Romania

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

Last updated: January 6th, 2022

Singapore

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

Last updated: January 6th, 2022

Slovakia

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

Last updated: January 6th, 2022

South Africa

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

In line with global trends, concerns have been raised about the rapidly increasing aging population in South Africa and the ability of the current healthcare system to keep pace with patient demand, particularly nursing home residents. Evidence suggests that the current workforce in South Africa receive limited training in this area and are largely unprepared to meet the demands of the aging population. Building the capacity and skills of the workforce in South Africa is one approach that could help to improve the early detection of infection and assist the nursing home workforce to provide more effective and timely care, particularly during the current COVID-19 pandemic.

A published paper suggests that decision support tools, such as the Early Detection of Infection Scale, can help ensure consistency and ensure more timely treatment, minimising unplanned admissions and healthcare expenditure. However, the potential benefits or indeed how easily this could be integrated in to nursing homes in South Africa is unknown.

Sources:

https://www.who.int/publications/i/item/9789241513388

Carey, N., Boersema, G. C., & du Toit, H. S. (2021). Improving early detection of infection in nursing home residents in South Africa. International Journal of Africa Nursing Sciences14. https://doi.org/10.1016/j.ijans.2021.100288

Last updated: January 6th, 2022   Contributors: William Byrd  |  

Spain

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

Last updated: January 6th, 2022

sub-Saharan Africa

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

Last updated: January 6th, 2022

Sweden

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

Last updated: January 6th, 2022

Thailand

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

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

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

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

Last updated: January 6th, 2022

Turkey

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

Last updated: January 6th, 2022

England (UK)

Currently, there is no national workforce strategy for the adult social care workforce – the last strategy was published by government over a decade ago in 2009. Proposals on workforce reforms are expected to be outlined in two forthcoming white papers, on adult social care reform and health and social care integration, respectively.

On average in 2020/21, 6.8% of posts were vacant in the English social care sector, equivalent to 105,000 at any one time. Care providers continue to report difficulty recruiting and retaining workers, particularly to the roles of care worker, registered manager and nurse.

Data indicate that the sector suffers from high staff turnover, poor working terms and conditions, and 24% of the workforce are on zero-hours contracts. Pay levels are low compared to other competing sectors such as retail and hospitality. The national minimum wage has increased in recent years and is set to rise to £9.50 per hour as of April 2022. While this is positive for entry-level staff, there has been no parallel action to boost the pay of more experienced staff with 5 or more years of experience. As a result, the pay differential between junior and more senior care workers has narrowed to an average of 6 pence per hour by March 2021. There are few opportunities for training and progression, with data on qualification levels indicating only 45% of direct care-providing staff in 2020/21 held a relevant adult social care qualification.

The adult social care workforce is reliant on migrant labour. It was reported that in total, an estimated 98,710 migrant workers joined the formal care workforce between 2009 and 2019, with 9% from EU and 11% from non-EU countries. In London, more than two in five care workers are from abroad. However, under the new points-based immigration system introduced on 1st January 2021, care workers have not been recognised as eligible for the ‘skilled worker’ route. As a result, the number of new entrants to the social care sector from abroad fell from 5% in 2019 to fewer than 2% in the spring of 2021.

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Nina Hemmings  |  Chris Hatton  |  

Scotland (UK)

The Scottish Social Service Council (SSSC) has a statutory duty to keep a register of workers in social services including care homes, care at home and housing support services. It is possible for an individual to appear in more than one category covered in the SSSC register but the most recent data suggests there were 36,661 non-managerial registrants working in care homes, 58,016 non-managerial registrants working in the care at home sector, and 49,295 non-managerial registrants working in the housing support sector.

Last updated: January 6th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

United States

According to data published by the US Department of Health and Human Services, in 2015-2016 there were almost 1.5 million nursing employee full-time equivalents (FTEs) working across the five sectors of long-term care in the United States. This includes registered nurses (RNs), licensed practical or vocational nurses (LPNs or LVNs), and healthcare aides, as well as approximately 35,000 social work FTEs. The majority (63.3%, or 945,700 FTEs) work in nursing homes, 20.0% are residential care community employees, 9.7% are employed by home health agencies, 5.7% are employed by hospices, and 1.3% are adult day services centre employees. Employment conditions and required qualifications vary a great deal across the sectors; a breakdown of employment rates in each sector can be found beginning on page 18 of the CDC report.

Nursing home workforce

The nursing home workforce is composed of nursing assistants, licensed practical/vocational nurses, and registered nurses. Nursing assistants provide hands-on care with daily activities such as eating, toileting, dressing, and toileting. Licensed practical or vocational nurses administer medications or wound treatments while registered nurses oversee the overall nursing care of nursing home residents.

According to a report, 9 out of 10 nursing assistants who work in nursing homes are women. One in three has a child under the age of 18  at home and about 15% have a child under the age of five. Less than half of nursing assistants have completed education beyond high school. Approximately 54% of all nursing assistants in nursing homes are people of color, 36% of which are Black of African American. Additionally, 20% of nursing assistants are immigrants.

Last updated: January 6th, 2022   Contributors: William Byrd  |  Nerina Girasol  |  

Vietnam

Vietnam faces a shortage of qualified nursing care staff for the elderly population. Most are cared for by family or domestic workers, who usually have no training in care or medical expertise (source: Vietnam Investment Review). They also do not normally receive any financial support from the government for their informal caring duties (source: UNDP report).

Staff in formal nursing homes do not have to be formally trained. Their salaries are low due to limited funding, which results in difficulty with recruitment and difficulty reaching staffing quota levels (source: UNDP report). Staffing levels in social protection facilities are mandated by The Ministry of Labour, Invalids and Social Affairs. The ratio of care staff to recipients is 1:8-10 for low-level care needs and 1:3-4 for higher level care. The ratio for nutrition staff (preparers and purchasers of food) is 1:20 (source: Royal Commission into Aged Care Quality and Safety).

Last updated: January 6th, 2022   Contributors: Daisy Pharoah  |  

1.11. User voice, choice and satisfaction

Overview

The COVID-19 pandemic has highlighted that most countries have weak mechanisms to ensure that people who use long-term care services have a say on decisions that affect their life, and to guarantee their rights.

The UN Convention on the Rights of Persons with Disabilities states that people have a right to family and relationships.

There are important differences between countries in the extent to which people can choose the type of care and support they use, how and by whom it is delivered.

Australia

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

Last updated: December 22nd, 2021   Contributors: Joanna Marczak  |  

British Columbia (Canada)

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

Last updated: November 6th, 2021

Ontario (Canada)

Focussing on Ontario, a published article traces the antecedents of the COVID-19 crisis in long-term care and documents experiences of frontline staff and family members of residents during the pandemic. They argue that the marginalization of both residents and workers in Ontario’s long-term care system over two decades has eroded possibilities for recognition of their personhood. They also question broader societal attitudes toward aging, disability, and death that make possible the abandonment of the frail elderly.

Source:

Badone, E. (2021). From Cruddiness to Catastrophe: COVID-19 and Long-term Care in Ontario. Medical Anthropology: Cross Cultural Studies in Health and Illness40(5), 389–403. https://doi.org/10.1080/01459740.2021.1927023

Last updated: November 30th, 2021   Contributors: William Byrd  |  

Denmark

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

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

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

Last updated: November 9th, 2021

Germany

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

Last updated: September 2nd, 2021

Israel

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

Last updated: September 2nd, 2021

Italy

During the pandemic, the right of care home residents to emotional support and social interaction was recognised in a legal document for the first time.

With regards choice, for people whose application for access to services to the Local Health Authority is successful (see question 1.03), there is the possibility to choose the provider that they prefer (if the providers have capacity). Social services are normally activated directly by the family.

There is no national mechanism to measure satisfaction with care services.

Sources:

Bolcato M, Trabucco Aurilio M, Di Mizio G, Piccioni A, Feola A, Bonsignore A, Tettamanti C, Ciliberti R, Rodriguez D, Aprile A. The Difficult Balance between Ensuring the Right of Nursing Home Residents to Communication and Their Safety. International Journal of Environmental Research and Public Health. 2021; 18(5):2484. https://doi.org/10.3390/ijerph18052484

European Commission (2021). 2021 Long Term Care report. Country provides Vol. 2. Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG Empl).

Last updated: November 23rd, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  Adelina Comas-Herrera  |  

Japan

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

Last updated: November 25th, 2021

Netherlands

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

Last updated: September 2nd, 2021

Sweden

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

Last updated: November 23rd, 2021

Scotland (UK)

In Scotland 80% of the care workforce work for organisations represented by Scottish Care; a membership-based organization that provides support, training and advocates for the predominantly private workforce.

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Vietnam

A 2020 study by Dung et al. investigated the quality of life in care homes in Vietnam; measured as a subjective assessment of mental and social well-being. Participants came from public, religion-run, and private nursing homes. Results from the study showed that nursing home residents in Vietnam generally had a moderate level of quality of life; a finding similar to studies conducted in other Asian settings such as Hong Kong and Korea. Findings from the study suggest that the services provided at private and public nursing homes are of similar quality; no significant differences in quality of life were found between the two.

References:

Dung, V., Thi Mai Lan, N., Thu Trang, V., Xuan Cu, T., Minh Thien, L., Sy Thu, N., Dinh Man, P., Minh Long, D., Trong Ngo, P., & Minh Nguyet, L. (2020). Quality of life of older adults in nursing homes in Vietnam: Https://Doi.Org/10.1177/2055102920954710, 7(2).

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

1.12. Equity

Denmark

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

Last updated: November 23rd, 2021

Israel

Extensive reliance on private funding has given rise to inequality in LTC services received by Israel’s older people from different socioeconomic backgrounds (source: Taub Centre).

Last updated: December 5th, 2021

Japan

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

Last updated: November 25th, 2021

Vietnam

There is an increasing disparity in health service access between socioeconomic groups, with people in rural areas have notably less access than those in urban areas. Older people are frequently limited by mobility issues and an inability to afford health care services; in particular, long-term care. Given that chronic illness is prevalent in around 40% of older people, support for long-term elderly care has become an issue in rural areas (Hoi et al., 2011). Private nursing homes, which are more available in urban areas, are still relatively expensive for most Vietnamese people and are therefore exclusionary.

References:

Hoi, L. V., Thang, P., & Lindholm, L. (2011). Elderly care in daily living in rural Vietnam: Need and its socioeconomic determinants. BMC Geriatrics, 11. https://doi.org/10.1186/1471-2318-11-81

Last updated: December 30th, 2021   Contributors: Daisy Pharoah  |  

1.13 Pandemic preparedness of the Long-term care sector

Overview

The Organisation for Economic Co-Operation and Development (OECD) found that, while most OECD countries had some form of emergency preparedness systems, many of these overlooked the Long-Term Care (LTC) sector. They also found that only just over 50% of OECD countries had guidelines on infection control in the Long-Term Care sector, prior to the pandemic. However, this has changed in response to the pandemic: in 2021, 84% of countries have national guidelines on infection control in LTC. (Source: Rocard E., Sillitti P. and Llena-Nozal A (2021) COVID-19 in long-term care: impact, policy responses and challenges. OECD Health Working Paper No. 131).

 

Denmark

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

Last updated: January 6th, 2022

Finland

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

Last updated: January 6th, 2022

Germany

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

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

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

Last updated: January 6th, 2022

Hong Kong (China)

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

Last updated: January 6th, 2022

Japan

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

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

Last updated: January 6th, 2022

Netherlands

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

Most Dutch Long-Term Care organisations have an Infection Prevention and Control committee (van Tol et al., 2021).

References:

van Tol LS, Smaling HJA, Groothuijse JM, et al COVID-19 management in nursing homes by outbreak teams (MINUTES) — study description and data characteristics: a qualitative study 

Last updated: January 6th, 2022

Singapore

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

Last updated: January 6th, 2022

United States

The LTC sector in the United States was unprepared for the pandemic; some reports have described it as disastrous and staggering. One key systemic challenge during COVID-19 faced by the LTC sectors was the fundamental (mis)structuring of financial arrangements, which determine the reimbursement, regulatory framework, and design of the services delivered. These arrangements determine which sectors would have enough resources and systems in place (e.g. PPE, infection control training) to respond in the midst of the pandemic (source: Dawson et al., 2021; NYTimes).

Lessons on pandemic preparedness can be drawn from experiences from natural disasters, according to authors of a recent study (Peterson et al., 2021). This study explored the experiences of long-term care facilities – Nursing Homes (NH) and Assisted Living Communities (ALCs) – in Florida, following hurricane Irma in 2017. The findings showed that like pandemics, natural disasters create disruptions at organisational, community, and societal levels. Despite federal disaster preparedness regulations and ample experience with disasters like hurricane Irma, NHs and ALCs in Florida experienced issues that highlighted response gaps, illustrating that adequate preparedness goes beyond simply establishing regulations. The study highlights the importance of long-term care organisations building and maintaining connections with all those who can provide support, beyond the residents and facilities in which they live. This includes relatinonships with emergency managers, stakeholders, and – importantly – community organisations.

References

Dawson, W. D., Boucher, N. A., Stone, R., & Van Houtven, C. H. (2021). COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now. The Milbank Quarterly, 99(2), 565–594. https://doi.org/10.1111/1468-0009.12500

Peterson, L. J., Dobbs, D., June, J., Dosa, D. M., & Hyer, K. (2021). “You Just Forge Ahead”: The Continuing Challenges of Disaster Preparedness and Response in Long-Term Care. 5(4), 1–13. https://doi.org/10.1093/geroni/igab038

Last updated: January 6th, 2022   Contributors: Daisy Pharoah  |  Joanna Marczak  |  

Australia

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

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

Overall, the aged care sector in Australia struggled with pandemic preparedness even before COVID-19 – the pandemic only exposed the sector’s vulnerability (source: The Guardian).

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

Last updated: December 22nd, 2021

Canada

Among the ten Canadian provinces, Quebec has experienced the most significant excess mortality of older persons during COVID-19. A published practice paper presents the chronology of events leading to this excess mortality in long-term care facilities (LTCFs) and a comprehensive analysis of the phenomenon. Two findings emerge: the lack of preparation in LTCFs and a critical shortage of staff. The massive transfer of older persons from hospitals to LTCFs, combined with human resources management, and a critical shortage of permanent staff before and during the crisis, generated unhealthy living conditions in LTCFs.

Source:

Beaulieu, M., Cadieux Genesse, J., & St-Martin, K. (2021). High death rate of older persons from COVID-19 in Quebec (Canada) long-term care facilities: chronology and analysis. Journal of Adult Protection23(2), 110–115. https://doi.org/10.1108/JAP-08-2020-0033

Last updated: November 30th, 2021   Contributors: William Byrd  |  

British Columbia (Canada)

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

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

Last updated: November 6th, 2021

France

Following the 2003 heatwave France had mandated the use of ‘blueprints’ in LTC facilities (and other healthcare settings) to prepare against extreme health events, and these were triggered in February 2020. However, many LTCFs did not have any ‘contingency plans’ which could provide operational support to significant pressures such as high levels of staff absence. Care homes and other LTC actors were not integrated into risk simulation exercises (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf, see also Rocard E., Sillitti P. and Llena-Nozal A (2021) COVID-19 in long-term care: impact, policy responses and challenges. OECD Health Working Paper No. 131).

Last updated: October 31st, 2021

Israel

Preparedness for COVID-19 in Israel was limited, which led to considerable death toll particularly in residential care settings. A broad public outcry about the lack of testing and preparedness, as well as some contradictory directives (e.g. on visitation) ensued. On April 20th 2020, following pressure from family caregivers, and long term care managers and staff, new guidelines were established as part of the “Fathers’ and mothers’ shield” program, which specifically addressed older people in long term care settings.

Sources:

Last updated: December 5th, 2021   Contributors: LIAT AYALON  |  

Italy

Italy had only formally updated the 2006 National Pandemic Plan for Influenza, causing major shortcomings in the overall management of the COVID-19 outbreak in late February 2020.

The LTC sector was poorly prepared to the pandemic and it was not prioritised after the outbreak (in terms of Personal Protection Equipment and personnel), giving rise to multiple issues within services (high mortality rate, lack of coordination with hospitals, etc.).

The pandemic exacerbated pre-existing weaknesses within the Italian LTC sector, namely: absence of coordination between and within care sectors; national and regional investments focused on acute care, neglecting LTC services; the poor management of care personnel and a lack of dedicated workforce; poor connection with other care settings and the functioning of nursing homes as acute care settings, that are neither recognised nor funded as that.

A published article focuses on the large number of deaths that occurred in nursing homes during the first wave of the pandemic, and the weak capacity of public policy to provide them with adequate protection. The analysis focuses on the case of the Lombardy Region, where the mortality rate due to COVID-19 in nursing homes was the highest in Europe. In the search for possible causes, they investigate the situation of such facilities before the pandemic. Two aspects are analysed: their institutional embeddedness and recent trends in their management. They conclude by arguing that the negative impact of COVID-19 stems from the poor development of long-term care policy and from the marginality of residential institutions within the healthcare system.

Source:

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI: http://doi.org/10.31389/jltc.73

Arlotti, M., & Ranci, C. (2021). The Impact of COVID-19 on Nursing Homes in Italy: The Case of Lombardy. Journal of Aging and Social Policy33(4–5), 431–443. https://doi.org/10.1080/08959420.2021.1924344

Last updated: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  William Byrd  |  

Poland

The country was poorly prepared to deal with the pandemic, moreover, the shortfalls of the LTC system became more visible during the pandemic (e.g. limited financial resources for LTC system, poor access to tests, PPI, problems with isolating infected individuals (sources: Alert Zdrowotny 2; Alert Zdrowotny 3).

Last updated: December 16th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Republic of Korea

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

Last updated: November 25th, 2021

Spain

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

Last updated: November 23rd, 2021

Sweden

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

Last updated: November 23rd, 2021

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

2.00. Overview impacts of the Covid-19 pandemic on people who use and provide Long-Term Care

Australia

The first COVID-19 outbreak in Australian residential aged care occurred on 4 March 2020 at Dorothy Henderson Lodge, an 80-bed facility in Sydney. A second cluster followed in April 2020 in Newmarch House, a 102 bed facility in Sydney.

After the initial containment of COVID-19 in Australia in May 2020, in June 2020 a second wave in Victoria spread rapidly through Melbourne-bases nursing homes.

During 2020 and 2021 case numbers and deaths have been concentrated the in two most heavily populated states, NSW and Victoria.

Last updated: January 17th, 2022

Vietnam

There is little information available on the impacts of the COVID-19 pandemic on those who use and provide LTC specifically.  Compared with other countries, and as a result of strong and multidimensional solutions and a compliant population, Vietnam maintained a relatively low number of confirmed infections and older patients throughout most of the pandemic (Tung, 2020).

Economic Impact

As most elderly people in Vietnam live with their families, a major source of income for older people is family support. However, because of the pandemic and related lockdowns, more than half the workforce has been negatively affected: the income of roughly 75% of all households has reduced. This has compromised the amount of assistance that households can provide to older family members, including those with older members who need medical care. These households are therefore at increased risk of falling into poverty as a result of the pandemic (source: Aging Asia report).

References:

Tung, L. T. (2020). Social Responses for Older People in COVID-19 Pandemic: Experience from Vietnam. Journal of Gerontological Social Work, 63, 682–687. https://doi.org/10.1080/01634372.2020.1773596

Last updated: December 30th, 2021   Contributors: Daisy Pharoah  |  

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

Australia

The pandemic in Australia has hit in distinct waves, March and April 2020, July to September 2020 and July 2021. Infections have accelerated rapidly in January 2022.  Hospitalisation rates and death among recipients of aged care services have been lower during 2021 than in the 2020 waves.

The first case of COVID-19 in Australia was identified on January 25, 2020, from a man who travelled from Wuhan to Melbourne. Prime Minister Scott Morrison announced the Australian Health Sector Emergency Response Plan for Novel Coronavirus on February 27, 2020, and the first economic stimulus package on March 12, 2020. By mid-March, most states and territories were in lockdown. Cases began falling across the country in April, and on May 8, 2020, the government announced a three-stage plan to ease lockdown restrictions. Victoria entered into its second wave in late June, and by October 26, it reported no new cases or deaths.

As of the 17th of January 2022 there have been 1,378,449 confirmed COVID-19 infections in Australia, and 2,668 deaths, according to the Australian Department of Health. There are currently 712,046 estimated active cases in Australia, more than half the total since the beginning of the pandemic, showing the rapid increase in infections in just a few days. So far, deaths amount to 104 per 1 million population.

Last updated: January 17th, 2022

Bulgaria

As of December 2, 2021, there have been 697,162 confirmed cases of COVID-19 in Bulgaria, and 28,542 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 412 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

British Columbia (Canada)

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

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

Last updated: November 6th, 2021

China

As of December 2, 2021, there have been 98,897 confirmed cases of COVID-19 in China, and 4,636 deaths, according to the National Health Commission, corresponding to 0.33 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Croatia

As of December 2, 2021, there have been 613,914 confirmed cases of COVID-19 in Croatia, and 10,967 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 246 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Cyprus

As of December 2, 2021, there have been 134,965 confirmed cases of COVID-19 in Cyprus, and 598 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 49.5 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Czech Republic

As of December 2, 2021, there have been 2,193,289 confirmed cases of COVID-19 in The Czech Republic, and 33,317 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 311 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Denmark

As of February 8, 2021, there have been 202,051 confirmed cases of COVID-19 in Denmark, and 2,216 deaths, according to the Danish Health Authority, corresponding to 38.5 attributed deaths per 100,000 population.

Last updated: December 4th, 2021

Estonia

As of December 3, 2021, there have been 224,195 confirmed cases of COVID-19 in Estonia, and 1,810 deaths, according to the  European Centre for Disease Prevention and Control, corresponding to 127 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Finland

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

Last updated: August 3rd, 2021

France

As of Dec 01, 2021, there have been 7,778,575 confirmed cases of Covid-19 in France, and 120,112 deaths attributed to COVID-19 corresponding to 179.11 per 100,000 population. A summary of measures taken is available.

Last updated: December 3rd, 2021   Contributors: Camille Oung  |  

Germany

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

Last updated: August 3rd, 2021

Greece

As of December 3, 2021, there have been 951,351 confirmed cases of COVID-19 in Greece, and 18,325 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 171 attributed deaths per 100,000 population

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Hungary

As of December 3, 2021, there have been 1,134,869 confirmed cases of COVID-19 in Hungary, and 35,122 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 365.6 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Israel

As of November 23, 2021, there have been 1,341,262 cases of COVID-19 in Israel and 8,178 deaths (Source: Clalit, 2021). According to Israel’s COVID Data Dashboard, those aged 70 and older have accounted for approximately 79% of COVID-19 related deaths in Israel so far. The pandemic was maintained at a reasonably low number of infections in Israel between February 21, 2020 (first case detected) and September 2020, with an effective first lockdown easing by May. In September 2020, the first major wave coinciding with the Jewish High Holidays resulted in a second lockdown. This first wave peaked at 6,276 cases on September 27. In tandem with a record-breaking vaccination campaign rollout, a second wave began in mid-December. The daily number of cases peaked at 8,624 on January 17, 2021, with the majority of cases due to a new, more virulent strain (Source: CGD). On November 22nd, there were only 711 new cases, assumably attributed mainly to the booster shots given to 4,054,691 Israelies.

Last updated: December 5th, 2021   Contributors: LIAT AYALON  |  Shoshana Lauter  |  

Italy

As of November 3rd, 2021 4.785.867 Italians tested positive for Covid-19 since the beginning of the pandemic, 131.560 people died from the virus, and 95.1% of deaths concerned people aged 60 or more (source: Ministry of Health).

The share of people fully vaccinated against Covid-19 is higher than the average of the European Union: 72% vs 66% respectively.

Sources:

Istituto Superiore de Sanità. Epidemia COVID-19. Aggiornamento Nazionale 3 novembre 2021.

Our World in Data. Coronavirus (COVID-19 Vaccinations), accessed 5th November 2021.

Last updated: November 9th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: August 3rd, 2021

Latvia

As of December 3, 2021, there have been 255,402 confirmed cases of COVID-19 in Lativa, and 4,232 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 222.56 attributed deaths per 100,000 population.

Last updated: December 6th, 2021   Contributors: Disha Patel  |  

Liechtenstein

As of December 3, 2021, there have been 4,779 confirmed cases of COVID-19 in Liechtenstein, and 62 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 162.57 attributed deaths per 100,000 population.

Last updated: December 5th, 2021   Contributors: Disha Patel  |  

Netherlands

During the first wave of the pandemic, Southern regions of the Netherlands were hardest hit, with Carnival celebrations being one of the main catalysts. The second wave started in September 2020, and by November was most pronounced in the West, including in the large urban centres Amsterdam, Rotterdam, and the Hague. An overview of the first year of the pandemic is available here.

Sources: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf.

Last updated: January 6th, 2022

Republic of Korea

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

Last updated: August 3rd, 2021

Romania

As of December 3, 2021, there have been 1,781,957 confirmed cases of COVID-19 in Romania, and 56,684 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 293.91 attributed deaths per 100,000 population.

Last updated: December 6th, 2021   Contributors: Disha Patel  |  

Slovakia

As of December 3, 2021, there have been 1,207,728 confirmed cases of COVID-19 in Slovakia, and 14,696 deaths, according to the European Centre for Disease Prevention and Control, corresponding to 269.222 attributed deaths per 100,000 population.

Last updated: December 6th, 2021   Contributors: Disha Patel  |  

Sweden

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

Last updated: July 29th, 2021

Scotland (UK)

National Records of Scotland (NRS) publish weekly figures on death registrations where COVID-19 was mentioned on the death certificate as either confirmed COVID-19 or suspected COVID-19. According to this data, as of the 28th November 2021, there have been 12,127 deaths where COVID-19 was mentioned on the death certificate.

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

United States

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

Last updated: July 29th, 2021

Vietnam

Given high economic openness and a large population, with many people living in crowded areas, Vietnam had high risks of being devastated by COVID-19 (Tung, 2020). However, Vietnam was called a ‘COVID exemplar’ by Our World in Data, who reported that by the end of 2020 Vietnam had reported only 1,465 laboratory confirmed cases of COVID-19 and 35 deaths. By comparison, by this time the United Kingdom had suffered some 72,000 deaths (source: GOV.UK) and the USA roughly 385,000 (source: CDC). Egypt, which has a similar population to Vietnam although lower population density, had suffered around 7,000 COVID-19 deaths by the end of 2020 (source: worldometres).

This relative success may be attributed to several factors. Key containment decisions were made within a few days of the outbreak; a decision which took some other governments several weeks. It is likely that Vietnam was able to act as quickly as it did due to its experience and existing relevant infrastructure, having experienced a severe acute respiratory syndrome (SARS) epidemic in 2003 and avian influenza between 2004 and 2010.

Vietnam’s proactive containment strategy was based on comprehensive detecting, contact tracing, and containment. Testing was scaled up in areas with community transmission, and three degrees of contacts was traced each time a positive case was identified. These individuals were placed in government-run quarantine centres. Areas where community transmission had been demonstrated were immediately locked down (source: Our World in Data). Furthermore, the population in Vietnam was relatively compliant, having high reported levels of trust in the authorities (Tung, 2020).

The second half of 2021 was less of a success story for Vietnam as a fourth, and most complicated and dangerous, wave hit the nation (Minh et al., 2021). From early June, confirmed cases began to grow exponentially and went from around 7,500 to around 1.7 million by the end of the year. This was mainly due to the emergence of the new (delta) variant, which spread quickly within hospitals in Vietnam, and also in large industrialised zones and communities. The sudden spike in community cases put a huge burden on the system; in particular on healthcare services and track and trace (Minh et al., 2021). Cumulative deaths were at 48 on the 1st June 2021, but similarly grew exponentially in the second half of the year and had reached just under 32,000 by the end of 2021. The main spikes in death were in August, early September, and December (source: Our World in Data).

To date (end of December, 2021), there have been no reported cases of the Omicron variant (source: Reuters).

References:

Minh, L. H. N., Khoi Quan, N., Le, T. N., Khanh, P. N. Q., & Huy, N. T. (2021). COVID-19 Timeline of Vietnam: Important Milestones Through Four Waves of the Pandemic and Lesson Learned. Frontiers in Public Health, 9, 1587. https://doi.org/10.3389/FPUBH.2021.709067/BIBTEX

Tung, L. T. (2020). Social Responses for Older People in COVID-19 Pandemic: Experience from Vietnam. Journal of Gerontological Social Work, 63, 682–687. https://doi.org/10.1080/01634372.2020.1773596

Last updated: December 30th, 2021   Contributors: Daisy Pharoah  |  

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

Australia

On the 14th January 2022 there were 1,107 active outbreaks in residential aged care in Australia, with 3,208 residents and 3,806 staff currently affected.

The Australian Department of Health first published deaths linked to COVID-19 in care homes and among users of home care services on April 15, 2020. As of January 17, 2022, there have been 7,321 confirmed cases of COVID-19 among government-subsidized residents in aged care facilities. There have been 997 deaths so far. There have been 2,319 deaths among the whole population suggesting that 37.3% of all COVID-19 deaths in Australia have been among care home residents. These figures are based on people who have tested positive for COVID-19 and are for the place of residence, not place of death, so may include residents who died in hospital. Among people who use government-subsidized home care, there have been 205 confirmed cases of COVID-19 and 13 deaths. In 2020, there were approximately 208,500 people living in aged care residential accommodation in Australia. Therefore, the numbers of care home COVID-19 deaths would amount to 0.49% of this population (source: AIHW).

A weekly report publishes data on the number of outbreaks and staff infected in care homes. As of 14th January 2022, there have been 7,502 cases of staff with COVID-19 infections.

Last updated: January 17th, 2022

Austria

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

As of November 1st 2021, there are 69,730 residents in care homes (including all ages) Of this population, 3,953 have died. Compared to the 11,369 total deaths linked to COVID-19 in Austria on the same date, deaths of care home residents would represent 35% of all deaths.

According to data from September 17, 2020, only 0.4% of care home residents had died after the first wave. By November 2021, this number has risen to 5.7%. This is based on there being 69,730 residents in care homes in Austria (BM für Arbeit, Soziales, Gesundheit und Konsumentenschutz (2019) Pflegevorsorgebericht 2018. Vienna, BMASGK).

Last updated: December 4th, 2021   Contributors: Andrea E. SCHMIDT  |  Disha Patel  |  

Belgium

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

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

Last updated: August 4th, 2021

Brazil

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

An article published in December 2021 describing morbidity and mortality in long term care facilities in the state of Bahia, Brazil, found COVID-19 incidence of 30.71% in residents of a 175 facility sample from April 2020 to June 2021. According to this data 19.97% cases in older residents required hospitalisation and there was an 11.63% case fatality rate, which the authors noted to be lower than expected. (Source: COVID-19 morbimortality in long-term care facilities in the state of Bahia, Brazil)

Last updated: January 2nd, 2022   Contributors: Disha Patel  |  William Byrd  |  

British Columbia (Canada)

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

Last updated: November 2nd, 2021

Chile

There are no official publicly available estimates of the total number of people who use care who have died with COVID-19 infections. The lack of data on the impact of the pandemic is particularly problematic in the unregulated sector (Browne et al., 2020).

References:

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Last updated: December 22nd, 2021

Denmark

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

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

Last updated: July 29th, 2021

Finland

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

Last updated: August 2nd, 2021

France

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

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

Last updated: October 27th, 2021

Germany

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

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

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

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

Last updated: August 3rd, 2021

Greece

As of January 31, 2021 there were 1,512 cases of COVID-19 amongst nursing home residents and 228 deaths, accounting for 4% of COVID-19 related deaths according to The National Public Health Organisation and The European Centre for Disease Prevention and Control. This corresponds to 2.1 COVID-19-related deaths per 100 nursing home beds in Greece.

Last updated: December 6th, 2021   Contributors: Disha Patel  |  

Hong Kong (China)

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

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

Last updated: October 27th, 2021

Hungary

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

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

Last updated: August 2nd, 2021

Ireland

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

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

Last updated: October 27th, 2021

Israel

The first outbreak in a long-term care facility in Israel began in mid-March 2020, sixteen days after the first patient was diagnosed in Israel. Only a month after the initial outbreak, and following massive public criticism and a call for help from the managers of long-term care facilities, the Israeli government appointed a national-level team to manage the COVID-19 outbreaks in long-term care facilities. As of October 12, 2020, there have been 704 COVID-19 related deaths in long-term care facilities, which accounts for 39% of the total deaths in the population. There were 45,000 people in long-term care facilities in Israel. Therefore, the number of COVID-19 related deaths in these facilities represents 1.56% of this population . Furthermore, according to a survey, 50% of all COVID-19 related deaths occurred in residential care settings, while the overall share of people infected in care homes only amounts to 8.5%. Although the Israel Ministry of Health provides ongoing statistics concerning COVID-19 deaths, place of residence does not appear on their dashboard, even though age is used as a descriptor.

Sources:

Tsadok-Rosenbluth, S., Hovav, B., Horowitz, G. and Brammli-Greenberg, S., 2021. Centralized Management of the Covid-19 Pandemic in Long-Term Care Facilities in Israel. Journal of Long-Term Care, (2021), pp.92–99. DOI: http://doi.org/10.31389/jltc.75

Last updated: December 5th, 2021   Contributors: Shoshana Lauter  |  LIAT AYALON  |  

Italy

For the first wave of the pandemic in Italy, the only data available on the virus outbreak in LTC services are for nursing homes, thanks to the results from a survey carried out by the National Health Institute (Istituto Superiore di Sanità), which was sent to 3,292 nursing homes out of the 3,417 NHs for people living with dementia. These data cover the period between February 1st and May 5th and were published on June 17, 2020. By May 5, 2020, 1,356 nursing homes had responded. The total mortality rate during that time was 9,1% (considering all deaths). The COVID-19 related mortality rate (tests and suspected) was 3,1%.

In September, 2021 the National Health Institute published a new report on the results of the surveillance of COVID19 cases from October 5th 2020 to September 19th 2021 for a sample of Long-Term Care Facilities (LTCFs) representing 31,178 beds. Overall, 341 out of the 852 facilities were nursing homes for older adults, counting 15,031 beds. Indicators show an increase in both COVID-19 cases and deaths in the months of October and November 2020, in line with the second epidemic wave in Italy. However, in contrast with the national data, there was a progressive reduction of COVID-19 cases, hospitalizations of SARS-CoV-2 positive residents and deaths in LTCFs in the period from February to April 2021. This trend is associated with the start of the vaccination campaign, which prioritised nursing home residents and severely vulnerable people, as well as LTCFs staff.

In the months of July, August and September 2021, there was slight increase in COVID-19 cases, both in residents and among the staff. This relates to the increase in the number of new cases in the general population in the same period. However, despite the increase in new cases and outbreaks in the monitored facilities, the number of deaths from COVID-19 occurring in LTCFs remained very low (< 0.01% per week), and this is probably due to the protective effect of the SARS-CoV-2 vaccination against the most severe forms of COVID-19.

Although the surveillance showed a significant decrease in new SARS-CoV-2 positive cases in LTCFs during the period May-June 2021, a slight increase of positive cases has been observed during summer, in the period July-September 2021. Yet, the Institute claims that this trend shall not be overlooked: rather, it suggests the opportunity to strengthen the immune protection through an additional dose of vaccine, as already provided for by the Ministry of Health

At present, these reports are the only official data on deaths related to the pandemic in LTCFs, urging for a comprehensive revision of monitoring systems in the LTC sector.

Sources:

Berloto, S., Notarnicola, E., Perobelli, E., Rotolo, A. (2020) Italy: Estimates of mortality of nursing home residents linked to the COVID-19 pandemic. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 25 June 2020.

National Health Institute (2021). Surveillance of COVID19 at LongTerm Care Facilities. Italian National Report. Time course of the COVID19 epidemic. October 5th 2020 September 19th 2021

Ministry of Health (2021). Circular no. 43604 of September 27th

Last updated: November 8th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: August 3rd, 2021

Lithuania

As of November 18, 2021, there have been 6,440 COVID-19 related deaths, of which 406 were care home residents (6.3%) (Source: Ministry of Social Security and Labor of the Republic of Lithuania and the European Centre for Disease Prevention and Control). There are 12,700 care home residents in Lithuania. Therefore, the total number of COVID-19 related deaths in care homes represents 3.20% of all care home residents.

Last updated: December 5th, 2021   Contributors: William Byrd  |  Disha Patel  |  

Netherlands

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

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

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

Last updated: August 3rd, 2021

New Zealand

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

Last updated: August 2nd, 2021

Poland

Data illustrated that by 12 November 2021, there were overall 78 555 deaths attributed to Covid 19. People aged 65 years or more constituted about 80% of all Covid-19 deaths and people aged 80 years or more about 44%. Moreover, an early report showed that in June 2020 about 9% of COVID-19 cases were related to infections in long-term care facilitates in Poland: 3% in nursing and care homes and 6% in social welfare homes.

Expert highlighted that the situation in Poland in terms of absolute numbers of deaths among the elderly in LTC facilities is not as dramatic as in other countries because care is provided mainly in families rather than through formal services, e.g. less than two percent of the elderly reside in LTC facilities whilst provision of home care is also low (sources: Alert Zdrowotny 2; Ageing policies-access to services in different EU Member States).

Sources:

Raport zakazen koronawirusem (SARS-CoV-2) -Portal Gov.pl (www.gov.pl)

Sowa-Kofta, A. Responding to the Covid19 in residential long-term care in Poland

Alert Zdrowotny 2

Ageing policies – access to services in different EU Member States.

Last updated: November 24th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Portugal

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

Last updated: August 3rd, 2021

Republic of Korea

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

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

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

Last updated: July 30th, 2021

Singapore

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

Last updated: August 2nd, 2021

Slovenia

As of October 31, 2021, there have been 5,149 deaths in total, and 2,997 among the care home population, representing 58% of all deaths (Source: National Institute of Public Health). In 2017, there were 22,904 people living in long-term care institutions in Slovenia. Therefore, the share of residents who would have died linked to COVID-19 would be 13.09% (Source: https://www.stat.si/StatWeb/en/News/Index/8579).

Last updated: December 5th, 2021   Contributors: William Byrd  |  Disha Patel  |  

Spain

The Spanish National Institute of Older People and Social Services (IMSERSO) publishes weekly reports on deaths linked to COVID-19 in care homes, collecting data from all regions and including care homes for younger people. The data is collected in line with The European Surveillance System (TESSy) of the European Centre for Disease Prevention and Control (ECDC).

Due to shortage of testing at the beginning of the pandemic, there is some uncertainty about the numbers of people who were infected with COVID-19 and died in the earlier part of the pandemic. IMSERSO have reported that, in the first part of the pandemic (up to July 2020), there had been 20,268 deaths of care home residents in care homes, of which 9,904 were of people who had not been tested. That report highlighted that the national estimate for total deaths linked to COVID-19 does not include people who have not been tested and recommended adding the number of suspected deaths in care homes to the current total of confirmed deaths nationally. Using a similar approach would bring the total of confirmed and suspected deaths in the whole population to 66,467 by January 22, 2021. This would suggest that 40% of all deaths linked to COVID-19 in Spain have been among care home residents by January 2021. This share is lower than during the earlier part of the pandemic, when, according to IMSERSO’s estimates that, up to June 23 2020, 47% of COVID-attributed deaths were care home residents. This suggests that, proportionally, in the second wave care home residents have not been as badly impacted as the rest of the population, compared to the initial part of the pandemic.

During 2021 and up to 28th November, there have been 5,032 deaths of people who had tested positive for COVID-19 in care homes, 2,550 of those deaths happened up to 1st of March 2021, the date when the process of vaccination in care homes was completed. In total there would have been 31,367 deaths linked to COVID-19 among care home residents. A recent estimate suggests that there are 333,920 care home residents, according to this, therefore, the total number of COVID-19 related care home deaths would represent 9.4% of the population living in care homes

The Spanish National Institute of Older People and Social Services also publishes a monthly report on the excess mortality for people registered with the Spanish public long-term care system. Between March 2020 and October 2021, there have been 65,799 excess deaths among those who had applied for (and or received) care benefits. This was 19.9% higher than expected. The highest number of deaths were among people receiving benefits for institutional care (28,171, representing 11.31% of all recipients of this benefit). About 72.6% of care home residents are estimated to be in receipt of care benefits, and these are expected to be those who are most frail. Among people receiving benefits for care at home, there were 39,890 excess deaths, amounting to 4.6% of recipients.

Last updated: December 10th, 2021

Sweden

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

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

Last updated: August 2nd, 2021

Switzerland

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

Last updated: October 27th, 2021

Turkey

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

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

Last updated: August 3rd, 2021

England (UK)

The Office for National Statistics provide weekly updates of deaths registered in England, which include any death where COVID-19 was mentioned (by a doctor) on death certificates. Between December 28, 2019, and November 6, 2020, the ONS estimated that 15,659 people died linked to COVID-19 in care homes

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

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

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

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

Deaths linked to COVID-19 among people living with intellectual disabilities

Multiple studies using data sources have reported higher COVID-19 mortality rates among adults with intellectual disabilities in England. An analysis of notifications of deaths of people with intellectual disabilities to the LeDeR programme up to 5 June 2020 reported an estimated COVID-19 mortality rate of 3.6 for adults with intellectual disabilities compared to the general population. The ONS linked primary care record data to death certificate data from 24 January to 20 November 2020, reporting age-standardised mortality hazard ratios for COVID-19 of 3.5 for men with intellectual disabilities and 4.0 for women with intellectual disabilities aged 30+. Controlling for residence type (private household, care home and other communal establishments) reduced these COVID-19 mortality hazard ratios to 2.1 for men and 2.2 for women. A further analysis linking primary care record data (using a less expansive set of codes for intellectual disability than the ONS analysis) to death certifications reported a COVID-19 mortality hazard ratio of 8.2 for adults with intellectual disabilities aged 16+ between 1 March and 31 August 2020; and 7.4 between 1 September 2020 and 8 February 2021.

Deaths linked to COVID-19 among people living with dementia

Half (49.5%) of all COVID-19 related deaths in care homes in England and Wales between March and June 2020, were in people living with dementia (Source: ONS).

Last updated: December 20th, 2021   Contributors: William Byrd  |  Chris Hatton  |  Adelina Comas-Herrera  |  

Northern Ireland (UK)

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

Last updated: November 8th, 2021

Scotland (UK)

The same data show that, up until 28th November 2021, of those 12,127 deaths recorded in the entire population, 3,548 occurred within care homes (29%) (this definition includes deaths which occurred in hospices as national data do not differentiate these from care homes).

Since May 25, 2020, the Care Inspectorate Scotland has reported weekly data on notifications of deaths of care home residents, which has showed that up to 28th November 2021, there have been 4,083 COVID-19 related deaths of care home residents. This means that since the onset of the pandemic in March 2020, 34% of all COVID-19 deaths were accounted for by care home residents.

Assuming that the number of adult care home residents has remained stable since 2017 (35,898 adults receiving care in care homes in March 2017) the number of COVID-19 related deaths of care home residents represents 11.35% of this population.

At present, the authors are not aware of any publicly available data to identify if any care home staff died because of COVID-19.

With respect to social care provided at home, the authors are not aware of any data to identify if those receiving or providing care at home have died because of COVID-19.

Deaths linked to COVID-19 among people with learning disabilities:

A nationwide data linkage study in Scotland comparing all COVID-19 confirmed deaths of people with learning disabilities from 24 January to 15 August 2020 with a 5% sample of adults without learning disabilities reported a Standardised Mortality Ratio (SMR) of 3.20. SMRs were particularly high for people with learning disabilities aged 18-54 (SMR 6.62) and 55-64 (SMR 16.16).

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  Disha Patel  |  Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Wales (UK)

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

A nationwide study in Wales compared certified COVID-19 deaths of people with learning disabilities identified through inpatient services and all Welsh resident COVID-19 deaths, from 1 March to 19 November 2020. This reported a Standardised Mortality Ratio (SMR) of 4.60 for people with learning disabilities compared to all Welsh residents; this was particularly high for people aged under 60 (SMR 12.7).

Last updated: November 29th, 2021   Contributors: William Byrd  |  Chris Hatton  |  

United States

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

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

Last updated: August 2nd, 2021

Vietnam

There is no publicly available information that provides a breakdown of COVID-19 deaths by population group. We know that the first cases of COVID-19 deaths in Vietnam were elderly members of the population: the first was a 70-year-old man, and the second was a 63-year-old man.  Although there have been relatively few deaths as a result of the pandemic (although the number spiked in late 2021), it could be assumed that the elderly faced higher risks of fatality as compared to other population age groups (Susilowati et al., 2020).

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

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

Australia

Australia does not currently have rehabilitation centres to treat COVID-19 “long-haulers” and there is no data on the impact of COVID-19 in aged care specifically (source: ABC news).

Last updated: December 22nd, 2021

British Columbia (Canada)

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

Last updated: November 6th, 2021

Denmark

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

Last updated: November 30th, 2021

Italy

At present, there is no specific data on the impact of long Covid among people who use Long-Term Care. In July, 2021 the National Health Institute published the national guidelines to assess and manage patients affected by long Covid. The National Government established that people who recovered from severe forms of Covid-19 will have free access to follow up exams for two years (without paying the so-called “ticket” for highly specialized exams).

Sources:

Istituto Superiore di Sanità (2021). Indicazioni ad interim sui principi di gestione del Long-COVID

Quotidiano Sanità. Long Covid. Il Governo chiarisce in Parlamento modalità di monitoraggio pazienti ed esenzione dal ticket per le visite specialistiche. Published on June, 25th 2021. 

Last updated: November 8th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: August 2nd, 2021

United Kingdom

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

Last updated: January 2nd, 2022

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

Overview

This section summarises evidence of the impacts of the pandemic in terms of reduced access to health and social care for people who rely on long-term care.

The rapidly developing Omicron wave is currently resulting in staffing shortages in long-term care provision in many countries, see for example the situation in England where there are growing number of reports of care being rationed.

Evidence from previous waves

Analysis by the OECD of data from the SHARE survey covering the period June to August 2020 found that, among people who regularly receive home care and have ADL or IADL limitations, about 30% reported forgoing or postponing medical treatment, either due to fear of infection or to the services deciding to postpone. Just under 15% of respondents in the sample also reported facing more difficulties in receiving care since the pandemic.

For people living in care homes, there is consistent evidence of difficulties accessing health care services (including transfers to hospital when severely ill with COVID-19 and palliative care) during the earlier phases of the COVID-19 pandemic in many countries (see below for examples).

Australia

Impact on access to good quality care for people living in residential aged care

The pandemic has had implications for the quality of care delivered in the residential facilities with and without outbreaks. The Royal Commission into Aged Care Quality and Safety’s Special report on Covid 19 found several weakness in the Government’s preparation for the pandemic which had impacted the quality of care. These included:

  • – Initial confusion and disagreement over whether residents with COVID-19 were best cared for by ‘hospital in the home’ services or being transferred to an acute hospital.
  • – Fear among staff of working on site with infected residents.
  • – ‘Surge staff’ new staff brought into facilities were ‘unfamiliar with the care needs of residents’
  • – Inadequate infection prevention and controls in place leading to increased infections.
Impact on access to good quality care for people using home-based care

In the early stages of the pandemic, home care providers  reported high level of anxiety among home care clients and isolation stemming from fears around catching COVID-19. This was exacerbated by some difficulties with home care staff accessing PPE in the early stages. Initially some home care clients stopped all or some of their scheduled home care visits. The Australian Government prepared ‘it’s ok to have home care’ information sheets and client demand did pick back up in home care. Many home care providers stopped group services such as bus outings, group exercise classes and social groups. Providers have been given the flexibility to redirect the funds to other services such as ensuring clients have access to meals and groceries, undertaking welfare checks, and undertaking phone/video call social interactions (Charlesworth and Low, 2020).

References

Charlesworth, S & Low, L-F (2020) The Long-Term Care COVID-19 situation in Australia. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 12 October 2020. https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf

Last updated: January 18th, 2022   Contributors: Sara Charlesworth  |  Lee-Fay Low  |  Wendy Taylor  |  

British Columbia (Canada)

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

Last updated: November 6th, 2021

Finland

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

Last updated: August 4th, 2021

France

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

Last updated: January 2nd, 2022

Germany

Access to care for people living in the community

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

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

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

Access to care for people living in care homes

Lockdowns of nursing homes during the first wave led to physical activity programmes for residents being discontinued, as these were often provided by external providers. There were attempts to promote physical activity in-house although staff were not trained to provide it specifically (Frahsa et al., 2020)

References:

Frahsa A, Altmeier D, John JM, Gropper H, Granz H, Pomiersky R, Haigis D, Eschweiler GW, Nieß AM, Sudeck G and Thiel A (2020) “I Trust in Staff’s Creativity”—The Impact of COVID-19 Lockdowns on Physical Activity Promotion in Nursing Homes Through the Lenses of Organizational Sociology. Front. Sports Act. Living 2:589214. doi: 10.3389/fspor.2020.589214

Last updated: January 14th, 2022

Hong Kong (China)

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

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

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

Last updated: August 2nd, 2021

Israel

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

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

Due to the pandemic and a recurring situation in which caregivers were confined to quarantine or the care receiver was in quarantine, it had become more and more frequent that LTC recievers found themselves without a caregiver. In response, the National Insurance (NI)  published on their website a directive saying that recipients of LTC services can choose to receive the allowance in cash (instead of in-kind) if they can’t have a contracted caregiver come in.

Last updated: December 5th, 2021

Italy

During the initial spread of Coronavirus COVID-19 in Italy, care homes were isolated from the rest of the healthcare system. Hospitals in many of the regions that were under pressure during the peak of COVID-19 (such as Lombardy, Veneto, Emilia-Romagna, Marche and Piemonte), started to reject and deny admission for care homes residents who might have problems related with COVID-19 (since testing was not available for all, the evaluation was based on symptoms). As a result, many of them were cared for in facilities not equipped for high-severity conditions and lacking the specialized health care workers that you can find in other settings such as hospitals. Moreover, access to palliative care has been critical, not only for care homes residents. The associations representing palliative care and intensive care unit doctors (SICP, SIAARTI and FCP) issued a press statement in April 2020 urging for specific protocols for COVID-19 patients.  

In 2021 new rules have been implemented including testing and isolation procedures. The guidelines have been issued by the Ministry of Health through the Italian Institute for Health (ISS).

More generally in the health system, non-urgent annual health checks, appointments, and elective surgeries have been suspended from March 2020. In 2020, clinic and specialised interventions decreased by 20,3%, with respect to 2019, and non-deferrable exams decreased by 7%.

Italian data from the research on the Impact of the Covid-19 outbreak on informal carers across Europe show that 44% of carers experienced a decrease in health and/or social care services during the outbreak.

Sources:

Eurocarers/IRCCS-INRCA (2021). Impact of the COVID-19 outbreak on informal carers across Europe – Final report. Brussels/Ancona.

Istat (2021). Rapporto Annuale, anno 2020.

Rapporto ISS COVID-19, n. 6/2021, Assistenza sociosanitaria residenziale agli anziani non autosufficienti: profili bioetici e biogiuridici

Last updated: January 14th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: September 7th, 2021

Netherlands

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

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

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

Last updated: August 2nd, 2021

Poland

Community centres (centres for people with special needs (srodowiskowe domy samopomocy) and some day-care centres in social sector have been temporarily closed. Restrictions were imposed on admission to social assistance homes to safely admit new residents (source: EU: Long-term care report). Equally, some municipalities during the pandemic have issued recommendations that home-based care services should be provided only where it is most necessary, moreover,  eligibility assessments for home-based care were limited during pandemic for a number of reasons (E.g.  social workers carrying out eligibility assessments/ interviews preceding the granting of care services took place less frequently in order to minimise social contact, but also because of the numerous additional challenges that faced municipalities workers during the pandemic. Moreover, some service recipients were unwilling to receive home-based care due to fear of catching infections from care workers, especially that the latter often travel via public transport between different care recipients  (source: Opieka dlugoterminowa w Polsce raport). 

EU data from also suggest that about 28% of people over the age of 55 in Poland had the unmet needs for medical treatment during the pandemic, which was above the EU 27 average of 20% (sources: Ageing policies – access to services in different EU Member States; Jakosc zycia osób starszych w Polsce).

Overall, reports indicate lack of access to medical care among older people in Poland during the pandemic, as well as decreased physical activity among older persons (source:  Jakosc zycia osób starszych w Polsce).

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Republic of Korea

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

Last updated: August 2nd, 2021

Spain

Access to health care for people living in care homes

In Spain, in the early part of the pandemic, there were widespread difficulties for care home residents to access health care services, including at primary care level. There were many instances of hospital admissions being denied on the basis of where a person lived (a care home) or their type of disability (for example dementia), without consideration of the individual’s situation and potential to benefit from treatment. This generated great controversy and concern about human rights violations (see for example Del Pino et al., 2020 and Zalakain et al., 2020).

Access to long-term care in the community

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

References:

Del Pino E., Moreno-Fuentes F.J. , Cruz-Marti?nez G., et al. (2020) Informe Gestio?n Institucional y Organizativa de las Residencias de Personas Mayores y COVID-19: dificultades y aprendizajes. Instituto de Poli?ticas y Bienes Pu?blicos (IPP-CSIC) Madrid. http://dx.doi.org/10.20350/digitalCSIC/12636

Zalakain, J. Davey, V. & Sua?rez-Gonza?lez, A. The impact of COVID-19 on users of Long-Term Care services in Spain. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. https://ltccovid.org/wp-content/uploads/2020/10/LTCcovid-Spain-country-report-28-May-1.pdf 

Last updated: January 14th, 2022

Sweden

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

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

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

Last updated: November 30th, 2021

Thailand

A study in Thailand investigated how the COVID-19 pandemic has affected 200 older adults without dementia living at two government long-term care centres during August 2020 to October 2020. Residents reported impact on health due to having difficulties in seeing doctors and one third of residents said that their medication was insufficient.

References:

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://doi.org/https://dx.doi.org/10.1016/j.jad.2021.08.044

Last updated: January 14th, 2022   Contributors: Adelina Comas-Herrera  |  

United Kingdom

Impact on access to health and social care services for adults with learning disabilities

UK-wide interviews with approximately 500 adults with learning disabilities and surveys with approximately 300 family carers and support workers of adults with learning disabilities who could not take part in an interview at three time points during the pandemic have reported that access to a wide wide range of health services (including primary care, more specialist therapists, and annual health checks) significantly reduced from before the pandemic to the lockdown in the winter of 2020. Access has improved since then up to the summer of 2021, but not to pre-pandemic levels, with more consultations being conducted by phone rather than face to face.

The picture is similar concerning access to a wide range of social care services, including day services, community activities and short breaks, with the exception of support at home which has continued at consistent levels through the COVID-19 pandemic. Reduced access to many health and social care services was evident for a greater proportion of adults with learning disabilities with greater needs, particularly adults with profound and multiple learning disabilities.

Last updated: January 2nd, 2022   Contributors: Chris Hatton  |  

England (UK)

Omicron wave

The rapid spread of the Omicron variant has had a drastic impact on the ability of services to continue to operate due to very high rates of staff sickness. A survey of members of the National Care Forum (the largest body representing not-for-profit care providers) released on the 13th January 2022 found that 66% of homecare providers responding are having to refuse new requests for home care, 43% of providers of care homes are closing to new admissions and 21% of home care providers are handing back existing care packages as they are unable to fulfil them. The providers reported an 18% vacancy rate and 14% absences as a result of Omicron.

Also on the 13th January 2022, the Association of Directors of Adult Services reported that 49 out of 94 councils that answered a questionnaire reported taking measures to prioritise care to support the most basic tasks only (eating, drinking and going to the toilet, but not help with tasks such as getting out of bed) and having to leave people with learning disabilities, dementia or mental illness alone for longer than usual.

Previous waves of the pandemic

In the initial part of the pandemic carers reported delays in health treatment for the person they care for (57%) and for themselves (38%). More than half of carers (65%) in a Carers UK survey carried out in September 2020 reported to have postponed attending health care services for their own health needs. Reduced access to health care and social services for the person they support was also reported by carers of people with dementia (90% of 795 respondents)(Source: Alzheimers.org).

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

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

Impact on access to health and social care services for adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview, at three time points during the pandemic, have reported that access to a wide range of health services (including primary care, more specialist therapists, and annual health checks) significantly reduced from before the pandemic to the lockdown in the winter of 2020. Access has improved since then up to the summer of 2021, but not to pre-pandemic levels, with more consultations being conducted by phone rather than face to face.

The picture is similar concerning access to a wide range of social care services, including day services, community activities and short breaks, with the exception of support at home which has continued at consistent levels through the COVID-19 pandemic. Reduced access to many health and social care services was evident for a greater proportion of adults with intellectual disabilities with greater needs, particularly adults with profound and multiple intellectual disabilities.

In England, national statistics on local-authority funded social care reported that 1,500 fewer adults with learning disabilities were receiving long-term social care at the end of March 2021 compared to the end of March 2020, reversing a long-term trend of increasing numbers of adults with learning disabilities receiving long-term social care.

Last updated: January 18th, 2022   Contributors: William Byrd  |  Chris Hatton  |  Adelina Comas-Herrera  |  

Northern Ireland (UK)

Impact on access to health and social care services for adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview, at three time points during the pandemic, have reported that access to a wide range of health services (including primary care, more specialist therapists, and annual health checks) significantly reduced from before the pandemic to the lockdown in the winter of 2020. Access has improved since then up to the summer of 2021, but not to pre-pandemic levels, with more consultations being conducted by phone rather than face to face.

The picture is similar concerning access to a wide range of social care services, including day services, community activities and short breaks, with the exception of support at home which has continued at consistent levels through the COVID-19 pandemic. Reduced access to many health and social care services was evident for a greater proportion of adults with intellectual disabilities with greater needs, particularly adults with profound and multiple intellectual disabilities.

 

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  

Scotland (UK)

In August 2020, the Health and Sport Committee of the Scottish Parliament ran a survey to collect views from people who provide, or receive, care and support at home. The survey covered the period 10 August 2020 to 7 September 2020. Over half of respondents stated that their care at home support either stopped completely (33%) or reduced (21%). Respondents reported that in many cases, family members had to step in to provide care. The closure of day centres and respite activities was reported as impacting those receiving care at home. Of those staff who responded to the survey, 61% reported that home care packages changed during the pandemic. Reasons reported included reduced provision of services, suspension and even cancellation of services.

Impact on access to health and social care services for adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview, at three time points during the pandemic, have reported that access to a wide range of health services (including primary care, more specialist therapists, and annual health checks) significantly reduced from before the pandemic to the lockdown in the winter of 2020. Access has improved since then up to the summer of 2021, but not to pre-pandemic levels, with more consultations being conducted by phone rather than face to face.

The picture is similar concerning access to a wide range of social care services, including day services, community activities and short breaks, with the exception of support at home which has continued at consistent levels through the COVID-19 pandemic. Reduced access to many health and social care services was evident for a greater proportion of adults with intellectual disabilities with greater needs, particularly adults with profound and multiple intellectual disabilities.

 

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Wales (UK)

Impact on access to health and social care services for adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview, at three time points during the pandemic, have reported that access to a wide range of health services (including primary care, more specialist therapists, and annual health checks) significantly reduced from before the pandemic to the lockdown in the winter of 2020. Access has improved since then up to the summer of 2021, but not to pre-pandemic levels, with more consultations being conducted by phone rather than face to face.

The picture is similar concerning access to a wide range of social care services, including day services, community activities and short breaks, with the exception of support at home which has continued at consistent levels through the COVID-19 pandemic. Reduced access to many health and social care services was evident for a greater proportion of adults with intellectual disabilities with greater needs, particularly adults with profound and multiple intellectual disabilities.

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  

Vietnam

There is no information available on the impacts of the pandemic on access to health and social care services for those who use formal LTC. However, there are reports of elderly patients with various health conditions being reluctant to visit hospitals when they needed to due to fear of visiting crowded places. Across Vietnam, rates of inpatient care and hospital visits declined by around 30% during the pandemic (original source: DoH HCMC). This meant that healthcare work has often been done by the individual themselves or family members; neither of whom were likely to have the appropriate training or experience. As a result, there were reports of patients suffering from preventable conditions such as strokes and kidney and respiratory failure as a result of not going into hospital (source: Aging Asia report).

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

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

Overview

There is great concern about the detrimental impacts of the pandemic and the measures adopted to prevent COVID-19 infections on people who use long-term care services, particularly those in care homes. This section summarises the evidence we have gathered so far in the studies described in each of the country sections below.

Types of evidence:

So far we have found some evidence of detrimental impacts for people living in the community, particularly from the UK, see below). Most of the evidence so far is on the impacts on people living in care homes and some evidence for people living in retirement communities.

While there are only a few countries where data on the well-being, mental and physical health were available from before the pandemic, researchers have used both qualitative and quantitative approaches to ask about perceived changes.

With regards comparable data from before the pandemic, this tends to be available in countries that have information systems to collect data regularly, for example the interRAI Long-Term Care Facilities (interRAI LTCF,  a standardised vehicle to record clinical observations that is used in LTC homes more than 30 countries). Papers that have estimated the impacts of the pandemic on care home residents comparing with data from before the pandemic include McArthur et al., 2021, Pereiro et al, 2021, Levere et al., 2021).

Some quantitative studies used questions asking about perception of change, in an effort to address the lack of baseline data to compare against (see for example El Haj et al., 2020).

Most of evidence available is from qualitative studies and, due to the restrictions in place during the pandemic, it is often obtained through proxy reports from family members of staff (see for example, Paananen et al, 2021; Avidor and Ayalon 2022; Smaling et al., 2022). Some studies did interview residents (see for example Ickert et al., 2021)

Well-being, mental and physical health outcomes observed

Many studies found that increases in depression, anxiety, and stress were observed in care home residents during the pandemic (Brydon et al., 2021; Guerrero et al., 2021; Levere et al., 2021; Pereiro et al., 2021). Some studies found that this was more pronounced in residents with Alzheimer’s and Dementia (El Haj et al., 2021; Leontjevas et al., 2021; Smaling et al., 2022). However, there were some studies that found that, despite long periods of confinement, residents had no or mild symptoms of depression, anxiety, and stress and were satisfied with their lives (Arpacioglu et al., 2021; Seethaler et al., 2021; Srifuengfung et al., 2021).

In terms physical impacts, a few studies described unintentional weight loss among care home residents (Levere et al. 2021 and Ickert et al., 2021,) general deterioration of physical abilities (Paananen et all, 2021 and Avidor and Ayalon 2021) and increase in episodes of incontinence (Levere et al., 2021). A qualitative study in England of people living with dementia (not in care homes) observed a self-reinforcing vicious circle of deconditioning, highlighting the importance of support to maintain physical activity (Di Lorito et al., 2021)

Some studies reported acceleration in cognitive function (Levere et al., 2021), but not all, Pereiro et al. in a care home in Galicia, Spain, found no change from the expected cognitive decline trajectory that would be expected based on previous data (Pereiro et al., 2021).

A study in Israel interviewed residents in continuing care retirement communities carried out between April and June 2020 found that most of the residents reported substantial reductions in their mental wellbeing, including high levels of anxiety, depression, anger and despair (Ayalon and Avidor, 2021).

Attribution of impacts to particular measures:

It is difficult to assign the impacts observed to particular measures (isolation in confined spaces, lack of family contact, etc), but there is evidence, from before the pandemic, that, in addition to family life being a fundamental human right, visitors provide essential emotional, physical, and psychosocial support to care home residents (Gaugler, 2005; Bethell et al, 2020; Low et al, 2021).

Additionally, staffing shortages, reduced input from some care professionals, and more demands on the time spent on infection prevention and control (IPC) measures are expected to have resulted in a decrease in the amount and quality of care experienced by service users. The mental health of staff was also severely affected (see section 2.08 on impacts of the pandemic on the LTC workforce, and also Brydon et al., 2021).

At least two studies found that detrimental mental health impacts were partially or fully explained by differences in the amount of social isolation experienced (Arpacioglu et al., 2021, Pereiro et al., 2021).

A study focused on changes in behaviour considered challenging among care home residents who have dementia, as reported by nursing home practitioners (Leontjevas et al., 2021), found:

  • – Staff attributed both increased and decreases in these behaviours to the ban in visits in place at the time
  • – The most negative effects were attributed to residents not being allowed to go outside, being made to stay in their rooms and changes in organised activities
  • – People with mild to moderate dementia having been most affected.

 

In another study (Brydon et al, 2021) staff identified the following as potential reasons for high rates of poor mental health for residents:

  • -Visiting and outing restrictions
  • – Media exposure to COVID-19 outbreaks and concern for the safety of family and friends.

Residents in care homes in Alberta (Canada) reported missing recreational activities, loss or recreational activities, lack of services, such as physiotherapy, and the feeling that they were most affected by restrictive measures than the rest of the population (Ickert et al., 2021).

References:

Arpacioglu S, Yalçin M, Türkmenoglu F, Ünübol B, Çelebi Çakiroglu O. Mental health and factors related to life satisfaction in nursing home and community-dwelling older adults during COVID-19 pandemic in Turkey. Psychogeriatrics. 2021 Nov;21(6):881-891. doi: 10.1111/psyg.12762.

Avidor, S. and Ayalon, L. (2022). “I Didn’t Meet My Mother; I Saw My Mother”: The Challenges Facing Long-Term Care Residents and Their Families in the Age of COVID-19. Journal of Applied Gerontology41(1), 22–29. https://doi.org/10.1177/07334648211037099

Ayalon L. and Avidor S., ‘We have become prisoners of our own age’: from a continuing care retirement community to a total institution in the midst of the COVID-19 outbreak, Age and Ageing, Volume 50, Issue 3, May 2021, Pages 664–667, https://doi.org/10.1093/ageing/afab013

Bethell J, Aelick K, Babineau J, et al. Social connection in long-term care homes: A scoping review of published research on the mental health impacts and potential strategies during COVID-19. J Am Med Dir Assoc 2020; https://doi.org/10.1016/j.jamda.2020.11.025

Brydon A, Bhar S, Doyle C, Batchelor F, Lovelock H, Almond H, Mitchell L, Nedeljkovic M, Savvas S, Wuthrich V. National Survey on the Impact of COVID-19 on the Mental Health of Australian Residential Aged Care Residents and Staff. Clin Gerontol. 2021 Oct 11:1-13. doi: 10.1080/07317115.2021.1985671.

Di Lorito, C., Masud, T., Gladman, J. et al. (2021) Deconditioning in people living with dementia during the COVID-19 pandemic: qualitative study from the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) process evaluation. BMC Geriatr 21, 529. https://doi.org/10.1186/s12877-021-02451-z

El Haj M, Altintas E, Chapelet G, Kapogiannis D, Gallouj K. High depression and anxiety in people with Alzheimer’s disease living in retirement homes during the covid-19 crisis. Psychiatry Res. 2020 Sep;291:113294. doi: 10.1016/j.psychres.2020.113294

Gaugler, J. E. (2005). Family involvement in residential long-term care: A synthesis and critical review. Aging & Mental Health, 9(2), 105-118. doi:10.1080/13607860412331310245

Guerrero Z, Aliev AA, Kondrátová L, Jozefiaková B, Nesázalová N, Sa?áková JG, Winkler P. Mental Health and Quality & Safety of Care in Czech Residential Institutions during the COVID-19 Pandemic: A Mixed-Methods Study. Psychiatr Q. 2021 Dec;92(4):1393-1411. doi: 10.1007/s11126-021-09912-z.

Ickert C., Stefaniuk R., Leask B.A. (2021) Experiences of long-term care and supportive living residents and families during the COVID-19 pandemic: “It’s a lot different for us than it is for the average Joe”. Geriatric Nursing 42(6): 1547-1555 https://doi.org/10.1016/j.gerinurse.2021.10.012

Leontjevas R., Knippenberg I.A.H., Smalbrugge M., et al (2021) Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands, Aging & Mental Health, 25:7, 1314-1319, DOI: 10.1080/13607863.2020.1857695

Levere M., Rowan P., Wysocki A. (2021) The adverse effect of the COVID-19 pandemic on nursing home resident well-being. J Am Med Dir Assoc 2021; https://doi.org/10.1016/j.jamda.2021.03.010

Low L-F, Hinsliff-Smith K, Sinha S, Stall N, Verbeek H, Siette J, Dow B, Backhaus R, Devi R, Spilsbury K, Brown J, Griffiths A, Bergman C, Comas- Herrera A (2021) Safe visiting at care homes during COVID-19: A review of international guidelines and emerging practices during the COVID-19 pandemic. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 19th January 2021.

McArthur C., Saari M., Heckman G.A. et al. (2021) Evaluating the effect of COVID-19 pandemic lockdown on Long-Term Care residents mental health: a data-driven approach in New Brunswick, JAMDA; 22(1): 187–192. doi: 10.1016/j.jamda.2020.10.028

Nair P, Gill JS, Sulaiman AH, Koh OH, Francis B. Mental Health Correlates Among Older Persons Residing in Malaysian Nursing Homes During the COVID-19 Pandemic. Asia Pac J Public Health. 2021 Nov;33(8):940-944. https://doi.org/10.1177/10105395211032094

Paananen J, Rannikko J, Harju M, Pirhonen J (2021) The impact of Covid-19-related distancing on the well-being of nursing home residents and their family members: a qualitative study. International Journal of Nursing Studies Advances, 3. https://doi.org/10.1016/j.ijnsa.2021.100031.

Pereiro, A.X.; Dosil-Díaz, C.; Mouriz-Corbelle, R.; Pereira-Rodríguez, S.; Nieto-Vieites, A.; Pinazo-Hernandis, S.; Pinazo-Clapés, C.; Facal, D. (2021) Impact of the COVID-19 Lockdown on a Long-Term Care Facility: The Role of Social Contact. Brain Sci. 11, 986. https://doi.org/10.3390/brainsci11080986

Seethaler, M., Just, S., Stotzner, P., Bermpohl, F., & Brandl, E. J. (2021). Psychosocial Impact of COVID-19 Pandemic in Elderly Psychiatric Patients: a Longitudinal Study. The Psychiatric Quarterly. https://doi.org/https://dx.doi.org/10.1007/s11126-021-09917-8

Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factohttps://doi.org/https:/dx.doi.org/10.1016/j.jad.2021.08.044rs for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://dx.doi.org/10.1016/j.jad.2021.08.044

Argentina

People living with dementia

Another study reported an increase in anxiety, insomnia, depression, worsening gait disturbance, and use of psychotropics to control behavioural symptoms in people living with dementia in the community (Source: https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00866/full).

Last updated: January 2nd, 2022

Australia

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

A national online survey carried out in September and October of 2020 asked 288 senior staff working in residential aged care homes about the impact of COVID-19 on the mental health of residents and staff. The study aimed to identify the perceived impact of the pandemic on mental health, the restrictions and stressors that staff identified as affecting mental health and the views of staff about programmes and resources to support mental health. The study used mixed methods, using qualitative narratives to complement the quantitative findings. It found that the mental health of both residents and staff has been severely affected, with high rates of residents reported to be experiencing poor mental health, increased loneliness, stress and anxiety, increased behaviours considered challenging, and increased thoughts about death and suicide. In terms of the reasons identified for these high rates of poor mental health for residents, staff suggested visiting and outing restrictions, media exposure to COVID-19 outbreaks and concern for the safety of family and friends. Staff identified training in supporting the mental health of residents, on-site and tele-health counselling and having technical support for video conferencing (Brydon et al., 2021).

References:

Brydon A, Bhar S, Doyle C, Batchelor F, Lovelock H, Almond H, Mitchell L, Nedeljkovic M, Savvas S, Wuthrich V. National Survey on the Impact of COVID-19 on the Mental Health of Australian Residential Aged Care Residents and Staff. Clin Gerontol. 2021 Oct 11:1-13. doi: 10.1080/07317115.2021.1985671.

Last updated: January 12th, 2022

Brazil

A published article discusses the adoption of restrictive and protective measures to prevent the spread of the virus, aiming to keep older people healthy and mitigate the effects of the pandemic. The conclusion is that the pandemic has increased the many vulnerabilities to which institutionalised older people were already exposed, adding vulnerability to a new disease, such as COVID-19, due to its high lethality and comorbidity, aggravated by the precariousness of long-term Brazilian institutions due to the negligence of public authorities, civil society, the management of the institutions, and the families of the patients.

Reference:

de Araújo, P. O., Freitas, M. Y. G. S., de Santana Carvalho, E. S., Peixoto, T. M., Servo, M. L. S., da Silva Santana, L., … Moura, J. C. V. (2021). Institutionalized elderly: vulnerabilities and strategies to cope with Covid-19 in Brazil. Investigacion y Educacion En Enfermeria39(1), 1–11. https://doi.org/10.17533/udea.iee.v39n1e07

Last updated: January 2nd, 2022   Contributors: William Byrd  |  

Alberta (Canada)

A study carried out between July and October 2020 interviewed residents in care homes, as well as family members. The residents reported missing recreational activities, the loss of social interaction within the care home (for example meal times), lack of access to physiotherapy. Some residents described loss of weight. In terms of wellbeing, residents commonly described sadness, loneliness, fear and frustration. They also commented on the impact on others, particularly residents with dementia and expressed concern for them as they were not able to make phone calls or understand the reasons for changes in routines. Some residents expressed that they felt that the public health rules were affecting them more than the rest of the population and many were critical of the measures, particularly limits on visits. Residents also felt that more staff were needed and were concerned about the wellbeing of staff and their working conditions (Ickert et al., 2021).

References:

Ickert C., Stefaniuk R., Leask B.A. (2021) Experiences of long-term care and supportive living residents and families during the COVID-19 pandemic: “It’s a lot different for us than it is for the average Joe”. Geriatric Nursing 42(6): 1547-1555 https://doi.org/10.1016/j.gerinurse.2021.10.012

Last updated: January 7th, 2022

British Columbia (Canada)

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

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

Last updated: November 6th, 2021

New Brunswick (Canada)

A study in New Brunswick (Canada) used interRAI LTCF data to compare impacts on depression, delirium and behavioural problems in seven LTCFs. It found that, in the period studied (three months of lockdown at the beginning of the pandemic, up to June 2020, during which those homes did not experience outbreaks and had measures in place to mitigate the impacts of lockdown) the initial lockdown period had no negative impact on depression, delirium, or behavioural problems (McArthur et al, 2021).

References:

McArthur C., Saari M., Heckman G.A. et al. (2021) Evaluating the effect of COVID-19 pandemic lockdown on Long-Term Care residents mental health: a data-driven approach in New Brunswick, JAMDA; 22(1): 187–192. doi: 10.1016/j.jamda.2020.10.028

Last updated: January 14th, 2022

Ontario (Canada)

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

Last updated: November 6th, 2021

Czech Republic

A mixed methods study aimed to assess, quantitatively, the mental health of both staff and residents in long-term care facilities (LTCFs), and used qualitative methods to obtain insights into the challenges experiences in dealing with COVID-19 in care homes in the Czech Republic.

Data collection took place in April and May 2020, with a team of evaluators visiting 27 LTCFs, including children’s homes, and interviews were carried out with 378 residents, 443 members of staff and 49 managers. The study found that nearly half of residents met diagnostic criteria for anxiety or poor well-being and nearly 60% for depression. The highest rates of poor well-being were among residents in psychiatric facilities. The data from nursing homes was found to be unreliable due to high levels of cognitive impairment. There was no comparison to rates of poor mental health from before the pandemic, but the study found that COVID-related health worries were associated with poor mental health outcomes (Guerrero et al., 2021).

References:

Guerrero Z, Aliev AA, Kondrátová L, Jozefiaková B, Nesázalová N, Sa?áková JG, Winkler P. Mental Health and Quality & Safety of Care in Czech Residential Institutions during the COVID-19 Pandemic: A Mixed-Methods Study. Psychiatr Q. 2021 Dec;92(4):1393-1411. doi: 10.1007/s11126-021-09912-z.

Last updated: January 12th, 2022

Denmark

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

However, concerns were expressed that the Danish government’s response to the pandemic (e.g. care home visiting ban) was inflexible and not tailored to individuals circumstances (rather, it was based on ‘one size fits all’ rules). Combined with the late ease of restrictions, it had a negative long-term impact on older people’s mental and physical health and concerns were raised that the government should have done more to respect basic individuals’ freedoms (Source: https://www.djoef.dk/presse).

Last updated: November 30th, 2021

Finland

A qualitative study conducted during May to December 2020 with family members of residents in nursing homes in different parts of Finland found that family members perceived that distancing measures had aggravated the pre-existing conditions of their relatives. This included sudden progression in cognitive abilities and deterioration in physical abilities. Both family members and residents experienced grief, anxiety and severe stress (Paananen et al, 2021).

References:

Paananen J, Rannikko J, Harju M, Pirhonen J (2021) The impact of Covid-19-related distancing on the well-being of nursing home residents and their family members: a qualitative study. International Journal of Nursing Studies Advances, 3. https://doi.org/10.1016/j.ijnsa.2021.100031.

Last updated: January 6th, 2022

France

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

A study carried out in the early part of the COVID pandemic investigated the levels of depression and anxiety of 58 people living in Alzheimer’s Disease in retirement homes. The study sought to identify self-perceived changes in depression and anxiety compared to before the COVID-19 pandemic using questionnaires administered by care staff. It found that participants reported significantly  higher depression and anxiety during than before the pandemic. In common to other studies, there were already high levels of depression and anxiety before the pandemic (El Haj et al., 2020).

References:

El Haj M, Altintas E, Chapelet G, Kapogiannis D, Gallouj K. High depression and anxiety in people with Alzheimer’s disease living in retirement homes during the covid-19 crisis. Psychiatry Res. 2020 Sep;291:113294. doi: 10.1016/j.psychres.2020.113294

Last updated: January 12th, 2022   Contributors: Camille Oung  |  Adelina Comas-Herrera  |  

Germany

There is no information available that systematically measures the impact of COVID-19 on the health and wellbeing of people with LTC needs. However, concerns for people’s mental health are being raised, especially for people living in residential care settings whose social life has been severely disrupted. Even before COVID-19, research has estimated that among those 65 and older living in care homes, 25-45% had depression. It has further been estimated that only 40% of those received a diagnosis and only about half of those with a diagnosis received adequate treatment and support.

A study in Berlin investigated the impact of the COVID-19 pandemic on mental health and perceived psychosocial support for elderly psychiatric patients. This focused on 32 patients with affective or anxiety disorders aged over 60 years. All participants were current or former patients of the Psychiatric University Hospital of Charité at St. Hedwig Hospital, Berlin, Germany.

Telephone interviews were conducted in April/May 2020 (T1) and August 2020 (T2). The psychosocial impact (PSI) of the pandemic and psychopathology were measured and the changes between T1 and T2 were examined. There was a significant positive correlation between general PSI and depression as well as severity of illness. However, neither general PSI not psychopathology changed significantly between T1 and T2. Patients reported an increase in psychosocial support between T1 and T2 and high demand for additional support. Elderly psychiatric patients showed a negative PSI of the pandemic (Seethaler et al., 2021).

References:

https://www.aerzteblatt.de/nachrichten/98943/Wissenschaftler-Depression-bei-Heimbewohnern-seltener-behandelt

Seethaler, M., Just, S., Stotzner, P., Bermpohl, F., & Brandl, E. J. (2021). Psychosocial Impact of COVID-19 Pandemic in Elderly Psychiatric Patients: a Longitudinal Study. The Psychiatric Quarterly. https://doi.org/10.1007/s11126-021-09917-8

Last updated: January 14th, 2022   Contributors: William Byrd  |  Adelina Comas-Herrera  |  Klara Lorenz-Dant  |  

Israel

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

Research conducted in long term care settings has highlighted the negative emotional impact of lockdown on caregivers and older residents. In addition, older residents also experienced deterioration in the health and physical functioning as a result of discontinuation of “unnecessary” medical and social care during the first was of the pandemic in Israel (Avidor & Ayalon, 2021, Ayalon & Avidor, 2021).

Sources:

Avidor, S., and Ayalon, L. (2021). “I Didn’t Meet My Mother; I Saw My Mother”: The Challenges Facing Long-Term Care Residents and Their Families in the Age of COVID-19. Journal of Applied Gerontology. https://doi.org/10.1177/07334648211037099

Ayalon, L. and Avidor, S. (2021) ‘We have become prisoners of our own age’: from a continuing care retirement community to a total institution in the midst of the COVID-19 outbreak, Age and Ageing, Volume 50, Issue 3, May 2021, Pages 664–667, https://doi.org/10.1093/ageing/afab013

Last updated: January 2nd, 2022   Contributors: Shoshana Lauter  |  LIAT AYALON  |  

Italy

There is no information available that systematically measures the impact of COVID-19 on the health and wellbeing of people who use Long-Term Care.

Last updated: January 2nd, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  William Byrd  |  

Japan

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

Last updated: August 2nd, 2021

Malaysia

A survey of 224 older people living in nursing homes in Malaysia during June to August 2020 found that the majority of respondents were severely depressed and one third reported mild to moderate anxiety and very low social support. Having lived in the nursing home for over a year, not having a hobby and low social support were associated with depression. The authors comment that these rates of depression and anxiety are expected to be higher than before the pandemic (Nair et al., 2021).

References:

Nair P, Gill JS, Sulaiman AH, Koh OH, Francis B. Mental Health Correlates Among Older Persons Residing in Malaysian Nursing Homes During the COVID-19 Pandemic. Asia Pac J Public Health. 2021 Nov;33(8):940-944. https://doi.org/10.1177/10105395211032094

Last updated: January 14th, 2022

Netherlands

Impacts on people living with dementia

A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that, for people with dementia, social distancing measures resulted in a deterioration of physical health and that the impact on emotional state and behaviour depended on the stage of dementia. The authors were not able to establish if the observed cognitive decline was due to the usual disease progression or to under stimulation due to social distancing measures.

The study found that the negative impacts were more pronounced for people living in the community with more severe dementia, and in nursing homes for people with mild to moderate dementia, the authors attributed this to the loss of ability to carry to carry out meaningful activities that provide a sense of purpose (Smaling et al., 2022).

Another study focused on the changes in behaviour considered challenging among care home residents, as reported by nursing home practitioners. It found that there were reports of both increased and decreased behaviours considered challenging by staff, with a slightly higher proportion of increase. While staff attributed both increased and decreases to the ban in visits in place at the time, the most negative effects were attributed to residents not being allowed to go outside, being made to stay in their rooms and changes in organised activities, with those with mild to moderate dementia having been most affected (Leontjevas et al., 2021).

References:

Leontjevas R., Knippenberg I.A.H., Smalbrugge M., et al (2021) Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands, Aging & Mental Health, 25:7, 1314-1319, DOI: 10.1080/13607863.2020.1857695

Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

Last updated: January 9th, 2022

Poland

Report indicated that long-term isolation of people in care homes (due to visiting bans) and limiting interpersonal contacts negatively affected well-being and residents’ health, e.g. increase in personal conflict between residents or apathy, the same report indicated that  residents in care facilities faced  problems with the access to medical care.

Last updated: November 18th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Spain

A study in a care home in Galicia aimed to measure the decline in cognitive, functional and affective status among 98 older people living in the care home after a period of lockdown during the first wave of the pandemic (July to September 2020) and compared this to previous measures collected at three different time points to determine whether the decline had accelerated. The study also collected data on frequency of social contact.

The study found lower cognitive and functional scores and higher depression scores after the lockdown but these were not different to the decline that would be expected compared to the previous measurements, suggesting that decline had accelerated during the lockdown. Changes in depression scores were strongly associated with mental health and functional measures, suggesting that social contact is a strong protector against adverse effects (Pereiro et al., 2021).

References:

Pereiro, A.X.; Dosil-Díaz, C.; Mouriz-Corbelle, R.; Pereira-Rodríguez, S.; Nieto-Vieites, A.; Pinazo-Hernandis, S.; Pinazo-Clapés, C.; Facal, D. (2021) Impact of the COVID-19 Lockdown on a Long-Term Care Facility: The Role of Social Contact. Brain Sci. 11, 986. https://doi.org/10.3390/brainsci11080986

Last updated: January 12th, 2022

Sweden

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

Last updated: November 30th, 2021

Thailand

A study in Thailand investigated how the COVID-19 pandemic has affected 200 older adults without dementia living at two government long-term care centres. The prevalence of and risk factors for post-traumatic stress, depression, and anxiety were investigated during August 2020 to October 2020.

Most older people reported a moderate or severe impact of the pandemic. The most impacted area was financial due to decreased support form outside the centre. Seventy percent of respondents reported no or mild psychological stress linked to the pandemic. A minority had post-traumatic stress, depression, or anxiety. Having respiratory tract infection symptoms and receiving news via social media was independently associated with these symptoms. Residents also reported impact on health due to having difficulties in seeing doctors and experiencing financial impacts.

References:

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://doi.org/https://dx.doi.org/10.1016/j.jad.2021.08.044

Last updated: January 14th, 2022   Contributors: William Byrd  |  

Turkey

In Turkey older people were subject to curfew for prolonged periods. A study involving 133 older adults living in nursing homes and in the community carried out in December 2020 using telephone interviews shows that, in spite of long confinements, the majority of older adults reported no or mild depression, anxiety and stress and were slightly satisfied with their lives. However, those aged over 80 and older people living in nursing homes reported worse outcomes. People living in nursing homes reported higher levels of depression and anxiety, higher anxiety about death and lower life satisfaction that people living in the community. People aged 80 or over reported higher depression, anxiety, stress and death anxiety. Older people who met their relatives less frequently were found to have lower life satisfaction and higher depression scores (Arpacioglu S et al., 2021).

References:

Arpacioglu S, Yalçin M, Türkmenoglu F, Ünübol B, Çelebi Çakiroglu O. Mental health and factors related to life satisfaction in nursing home and community-dwelling older adults during COVID-19 pandemic in Turkey. Psychogeriatrics. 2021 Nov;21(6):881-891. doi: 10.1111/psyg.12762.

Last updated: January 12th, 2022

United Kingdom

Impacts on adults with learning disabilities

UK-wide interviews with approximately 500 adults with learning disabilities across the UK reported that in the four weeks before being interviewed in the summer of 2021: 13% of people said they often/always felt angry or frustrated, 15% often/always felt sad or down, 21% felt often/always worried or anxious, 12% often/always felt lonely with no-one to talk to, and 19% of people said they had a new or worsening health condition. Across all these indicators well-being had improved from previous interviews in winter 2020/21 and spring 2021. In the summer of 2021, 50% of adults with learning disabilities interviewed felt at least a little worried to leave the house – this was at a similar level to the winter of 2020/21, reversing an improvement in spring 2021.

The same project included surveys with approximately 300 family carers and support workers of adults with learning disabilities who could not take part in an interview. In the summer of 2021, family carers and support workers reported that 14% of people were often/always angry or frustrated in the four weeks before the survey, 12% of people were often/always sad or down, 25% of people were often/always worried or anxious, and 28% were reported to have had a new or worsening health condition in the four weeks before the survey.

Last updated: January 14th, 2022   Contributors: Chris Hatton  |  

England (UK)

People living in care homes

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

People living in the community who use long-term care

There is emerging evidence that reduced use of social support services has had detrimental effects on the quality of life of people affected by dementia and older adults (Giebel et al, 2021).

In a study of community-dwelling adults with dementia and their carers (Rand et al, 2021), it was found that the later stages of COVID-19 restrictions in England (specifically, from reintroduction of the tier systems in 2nd December 2020 until the end of the study in April 2021) were associated with poorer care-related quality of life outcomes when rated by proxy based on the proxy-person perspective (i.e. the proxy respondent’s rating based on their estimate of the person with dementia’s view).

Impacts on adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities across the UK reported that in the four weeks before being interviewed in the summer of 2021: 13% of people said they often/always felt angry or frustrated, 15% often/always felt sad or down, 21% felt often/always worried or anxious, 12% often/always felt lonely with no-one to talk to, and 19% of people said they had a new or worsening health condition. Across all these indicators well-being had improved from previous interviews in winter 2020/21 and spring 2021. In the summer of 2021, 50% of adults with intellectual disabilities interviewed felt at least a little worried to leave the house – this was at a similar level to the winter of 2020/21, reversing an improvement in spring 2021.

The same project included surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview. In the summer of 2021, family carers and support workers reported that 14% of people were often/always angry or frustrated in the four weeks before the survey, 12% of people were often/always sad or down, 25% of people were often/always worried or anxious, and 28% were reported to have had a new or worsening health condition in the four weeks before the survey.

Impact on people living with dementia

During the early part of the pandemic it was reported that there was evidence of substantial increases in the prescription of anti-psychotics to people with dementia (Howard, 2020). Some of this may have been due to increased need linked to delirium management or palliative care, but it is also likely to be attributable to worsened agitation and distress linked to COVID-19 restrictions (such as people in care homes being confined to their bedrooms, or not being able to receive family visits).

A qualitative study involving people living with dementia, their carers and therapists were interviewed at two time points around May 2020 and July 2020, generating evidence on the causes and effects of deconditioning. The study observed a set-reinforcing vicious cycle among participants: lockdown made the person apathetic, demotivate, socially disengaged, frailer and less confident, which reduced their activity levels, which in turn reinforced the effects of deconditioning. External supporters had an important role in motivating people to keep active and, with appropriate support and infrastructure, some participants could use tele-rehabilitation (Di Lorito, 2021).

References:

Comas-Herrera A, Salcher-Konrad M, Baumbusch J, Farina N, Goodman C, Lorenz-Dant K, Low L-F (2020) Rapid review of the evidence on impacts of visiting policies in care homes during the COVID-19 pandemic. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE.

Di Lorito, C., Masud, T., Gladman, J. et al. Deconditioning in people living with dementia during the COVID-19 pandemic: qualitative study from the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) process evaluation. BMC Geriatr21, 529 (2021). https://doi.org/10.1186/s12877-021-02451-z

Giebel, C., Cannon, J., Hanna, K., Butchard, S., Eley, R., Gaughan, A., Komuravelli, A., Shenton, J., Callaghan, S., Tetlow, H., Limbert, S., Whittington, R., Rogers, C., Rajagopal, M., Ward, K., Shaw, L., Corcoran, R., Bennett, K., & Gabbay, M. (2020). Impact of COVID-19 related social support service closures on people with dementia and unpaid carers: a qualitative study, 25(7), 1281–1288. DOI:https://doi.org/10.1080/13607863.2020.1822292

Giebel, C., Lord, K., Cooper, C., Shenton, J., Cannon, J., Pulford, D., Shaw, L., Gaughan, A., Tetlow, H., Butchard, S., Limbert, S., Callaghan, S., Whittington, R., Rogers, C., Komuravelli, A., Rajagopal, M., Eley, R., Watkins, C., Downs, M., … Gabbay, M. (2021). A UK survey of COVID-19 related social support closures and their effects on older people, people with dementia, and carers. International Journal of Geriatric Psychiatry, 36(3), 393–402. DOI:https://doi.org/10.1002/GPS.5434

Howard, R., Burns, A., & Schneider, L. (2020). Antipsychotic prescribing to people with dementia during COVID-19. The Lancet Neurology, 19(11), 892. DOI:https://doi.org/10.1016/S1474-4422(20)30370-7

Rajan, S., Comas-Herrera, A. and Mckee, M., 2020. Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic?. Journal of Long-Term Care, (2020), pp.185–195. DOI: http://doi.org/10.31389/jltc.53

Rand S.E., Silarova B, Towers A.-M. and Jones K. (2021) Social care-related quality of life of people with dementia and their carers in England. Health and Social Care in the Community. https://doi.org/10.1111/hsc.13681

Willner, P., Rose, J., Stenfert Kroese, B., Murphy, G. H., Langdon, P. E., Clifford, C., Hutchings, H., Watkins, A., Hiles, S., & Cooper, V. (2020). Effect of the COVID-19 pandemic on the mental health of carers of people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 33(6), 1523–1533. DOI:https://doi.org/10.1111/JAR.12811

Last updated: January 14th, 2022   Contributors: William Byrd  |  Chris Hatton  |  Stacey Rand  |  

Northern Ireland (UK)

Impacts on adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities across the UK reported that in the four weeks before being interviewed in the summer of 2021: 13% of people said they often/always felt angry or frustrated, 15% often/always felt sad or down, 21% felt often/always worried or anxious, 12% often/always felt lonely with no-one to talk to, and 19% of people said they had a new or worsening health condition. Across all these indicators well-being had improved from previous interviews in winter 2020/21 and spring 2021. In the summer of 2021, 50% of adults with intellectual disabilities interviewed felt at least a little worried to leave the house – this was at a similar level to the winter of 2020/21, reversing an improvement in spring 2021.

The same project included surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview. In the summer of 2021, family carers and support workers reported that 14% of people were often/always angry or frustrated in the four weeks before the survey, 12% of people were often/always sad or down, 25% of people were often/always worried or anxious, and 28% were reported to have had a new or worsening health condition in the four weeks before the survey.

Unpaid or informal carers

In a survey of approximately 300 largely family carers of adults with intellectual disabilities across the UK in July/ August 2021, carers most commonly reported their caring role had affected them in terms of feeling tired (66%), a general feeling of stress (60%), or disturbed sleep (53%), with little change compared to previous surveys in December 2020 – February 2021 and April – May 2021.

 

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  

Scotland (UK)

Responses to the Health and Sport Committee survey suggested that recipients of care felt an increased sense of loneliness and isolation. Unpaid carers also reported increased feelings of anxiety, depression and mental exhaustion.

Impacts on adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities across the UK reported that in the four weeks before being interviewed in the summer of 2021: 13% of people said they often/always felt angry or frustrated, 15% often/always felt sad or down, 21% felt often/always worried or anxious, 12% often/always felt lonely with no-one to talk to, and 19% of people said they had a new or worsening health condition. Across all these indicators well-being had improved from previous interviews in winter 2020/21 and spring 2021. In the summer of 2021, 50% of adults with intellectual disabilities interviewed felt at least a little worried to leave the house – this was at a similar level to the winter of 2020/21, reversing an improvement in spring 2021.

The same project included surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview. In the summer of 2021, family carers and support workers reported that 14% of people were often/always angry or frustrated in the four weeks before the survey, 12% of people were often/always sad or down, 25% of people were often/always worried or anxious, and 28% were reported to have had a new or worsening health condition in the four weeks before the survey.

Unpaid or informal carers

In a survey of approximately 300 largely family carers of adults with intellectual disabilities across the UK in July/ August 2021, carers most commonly reported their caring role had affected them in terms of feeling tired (66%), a general feeling of stress (60%), or disturbed sleep (53%), with little change compared to previous surveys in December 2020 – February 2021 and April – May 2021.

 

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

Wales (UK)

A published paper explores the significant and high death toll of COVID-19 on care home residents and social care staff in England and Wales. These mortality figures, alongside differential treatment of residents and staff during the pandemic, are conceptualized as a form of structural abuse. Arguments are made for the inclusion of structural abuse as a separate category of elder abuse. The lack of appropriate personal protective equipment, paucity of guidance, and high mortality rate among care home staff and residents during the pandemic is indicative of social discourses that, when underpinned by ageism, reflect structural elder abuse. If structural elder abuse was to be included in classifications, it would demand a rethink of social and health-care services and the policies and practices associated with them and would reinforce the government message that safeguarding is everyone’s business (Parker, 2021).

Impacts on adults with intellectual disabilities

UK-wide interviews with approximately 500 adults with intellectual disabilities across the UK reported that in the four weeks before being interviewed in the summer of 2021: 13% of people said they often/always felt angry or frustrated, 15% often/always felt sad or down, 21% felt often/always worried or anxious, 12% often/always felt lonely with no-one to talk to, and 19% of people said they had a new or worsening health condition. Across all these indicators well-being had improved from previous interviews in winter 2020/21 and spring 2021. In the summer of 2021, 50% of adults with intellectual disabilities interviewed felt at least a little worried to leave the house – this was at a similar level to the winter of 2020/21, reversing an improvement in spring 2021.

The same project included surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview. In the summer of 2021, family carers and support workers reported that 14% of people were often/always angry or frustrated in the four weeks before the survey, 12% of people were often/always sad or down, 25% of people were often/always worried or anxious, and 28% were reported to have had a new or worsening health condition in the four weeks before the survey.

Unpaid or informal carers

In a survey of approximately 300 largely family carers of adults with intellectual disabilities across the UK in July/ August 2021, carers most commonly reported their caring role had affected them in terms of feeling tired (66%), a general feeling of stress (60%), or disturbed sleep (53%), with little change compared to previous surveys in December 2020 – February 2021 and April – May 2021.

Source:

  • Parker, J.(2021), “Structural discrimination and abuse: COVID-19 and people in care homes in England and Wales”, The Journal of Adult Protection, Vol. 23 No. 3, pp. 169-180. https://doi.org/10.1108/JAP-12-2020-0050

Last updated: December 5th, 2021   Contributors: William Byrd  |  Chris Hatton  |  

United States

A study of 224 nursing homes in Connecticut (US) found significant deterioration among residents in a broad range of physical and mental health measures. This study used Minimum Data Set assessments to measure outcomes for nursing home residents between March and July 2020 to compare to outcomes observed in 2017-2019. The study found that nursing home resident outcomes such as depression, unplanned substantial weight loss, episodes of incontinence and cognitive function worsened during that period. Weight loss, which is considered a good indicator for physical deterioration, was greater for residents who had contracted COVID-19. Other outcomes, such as severe pressure ulcers or activities of daily living scores did not show significant changes  (Levere et al., 2021).

References:

Levere M., Rowan P., Wysocki A. (2021) The adverse effect of the COVID-19 pandemic on nursing home resident well-being. J Am Med Dir Assoc 2021; https://doi.org/10.1016/j.jamda.2021.03.010

Last updated: January 10th, 2022

Vietnam

The following section refers to the impact of the pandemic and measures adopted on the health and wellbeing of the elderly population in Vietnam, as there is little information available that is specifically on users of long-term care.

In the Vietnamese government’s response to COVID-19, there were various general policies which applied to all citizens regardless of age. For example, mass communication health messages, medical declarations in which older people were given priority, and covered costs for any testing, treatment, or quarantining. In addition to benefiting from this, older people received further support for the prevention and treatment of COVID-19 and other medical conditions (source: Aging Asia report). For example, the Ministry of Health issued two documents aimed at elderly people: one with additional guidance for COVID-19 prevention for older people living in the community and the other for older people with additional non-communicable diseases (NCDs). Up to three months’ worth of prescription medication was also made available to individuals with NCDs, and the use of telemedicine was promoted (source: Aging Asia report). At home check-ups and treatment by doctors and nurses were also offered to some, although this was generally limited to those in the bigger cities (Tung, 2020).

However, there were also reports of elderly patients with various health conditions being reluctant to visit hospitals when they needed to due to fear of visiting crowded places. Across Vietnam, rates of inpatient care and hospital visits declined by around 30% during the pandemic (original source: DoH HCMC). This meant that healthcare work has often been done by the individual themselves or family members; neither of whom were likely to have the appropriate training or experience. As a result, there were reports of patients suffering from preventable conditions such as strokes and kidney and respiratory failure as a result of not going into hospital (source: Aging Asia report).

Self-reported impact of the pandemic

A recent report documented the self- reported impact of the pandemic on older people, who were categorised into non-disadvantaged and disadvantaged groups. In both groups, a majority felt that they were negatively impacted by the pandemic. The non-disadvantaged group mainly felt impacted socially due to social distancing. The disadvantaged group reported income as their biggest concern. In both groups, very few reported concerns over health: both had strong faith in the local authorities’ response to the pandemic.

References:

Tung, L. T. (2020). Social Responses for Older People in COVID-19 Pandemic: Experience from Vietnam. Journal of Gerontological Social Work, 63, 682–687. https://doi.org/10.1080/01634372.2020.1773596

Last updated: January 2nd, 2022   Contributors: Daisy Pharoah  |  

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

Japan

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

Last updated: August 4th, 2021

Thailand

A study in Thailand investigated how the COVID-19 pandemic has affected 200 older adults without dementia living at two government long-term care centres during August 2020 to October 2020. The study found that residents in these care homes experienced negative impacts on their finances, this is because the income of most older care home residents in government care homes is from donations and this is often linked to organised activities or visits that did not take place because of infection risk reduction measures.

The residents also reported loss of freedom as they were no longer able to freely go in and out of the centre. The residents also reported more disagreements and worse relationships with family members, and with other residents and staff.

References:

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://doi.org/https://dx.doi.org/10.1016/j.jad.2021.08.044

Last updated: January 14th, 2022

England (UK)

People with intellectual disabilities and autistic people

Apart from impacts of the COVID-19 pandemic on access to health and social care services and the health and wellbeing of people with intellectual disabilities, UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers have reported a range of other impacts on people’s lives. In July-August 2021, largely after COVID-19 restrictions were lifted in England, 19% of people with intellectual disabilities with greater support needs across the UK (including people with profound and multiple intellectual disabilities) were reported to be still shielding. Over a quarter of adults with intellectual disabilities reported that someone they knew well had died (of any cause) during the COVID-19 pandemic. In terms of paid employment, most but not all people with intellectual disabilities in paid employment before the pandemic were in paid employment in the July/August 2021, often via furlough or people’s jobs being held open.

No systematic information is available concerning the impact of the COVID-19 pandemic on autistic people without intellectual disabilities in England.

 

Last updated: January 14th, 2022   Contributors: Chris Hatton  |  

Northern Ireland (UK)

People with intellectual disabilities and autistic people

Apart from impacts of the COVID-19 pandemic on access to health and social care services and the health and wellbeing of people with intellectual disabilities, UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers have reported a range of others impacts on people’s lives. In July – August 2021, largely after COVID-19 restrictions were lifted in England, 19% of people with intellectual disabilities with greater support needs across the UK (including people with profound and multiple intellectual disabilities) were reported to be still shielding. Over a quarter of adults with intellectual disabilities reported that someone they knew well had died (or any cause) during the COVID-19 pandemic. In terms of paid employment, most but not all people with intellectual disabilities in paid employment before the pandemic were in paid employment in July/ August 2021, often via furlough or people’s jobs being held open.

No systematic information is available concerning the impact of the COVID-19 pandemic on autistic people without intellectual disabilities in England.

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  

Scotland (UK)

People with intellectual disabilities and autistic people

Apart from impacts of the COVID-19 pandemic on access to health and social care services and the health and wellbeing of people with intellectual disabilities, UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers have reported a range of others impacts on people’s lives. In July – August 2021, largely after COVID-19 restrictions were lifted in England, 19% of people with intellectual disabilities with greater support needs across the UK (including people with profound and multiple intellectual disabilities) were reported to be still shielding. Over a quarter of adults with intellectual disabilities reported that someone they knew well had died (or any cause) during the COVID-19 pandemic. In terms of paid employment, most but not all people with intellectual disabilities in paid employment before the pandemic were in paid employment in July/ August 2021, often via furlough or people’s jobs being held open.

No systematic information is available concerning the impact of the COVID-19 pandemic on autistic people without intellectual disabilities in England.

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  

Wales (UK)

People with intellectual disabilities and autistic people

Apart from impacts of the COVID-19 pandemic on access to health and social care services and the health and wellbeing of people with intellectual disabilities, UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers have reported a range of others impacts on people’s lives. In July – August 2021, largely after COVID-19 restrictions were lifted in England, 19% of people with intellectual disabilities with greater support needs across the UK (including people with profound and multiple intellectual disabilities) were reported to be still shielding. Over a quarter of adults with intellectual disabilities reported that someone they knew well had died (or any cause) during the COVID-19 pandemic. In terms of paid employment, most but not all people with intellectual disabilities in paid employment before the pandemic were in paid employment in July/ August 2021, often via furlough or people’s jobs being held open.

No systematic information is available concerning the impact of the COVID-19 pandemic on autistic people without intellectual disabilities in England.

Last updated: December 5th, 2021   Contributors: Chris Hatton  |  

2.07. Impacts of the pandemic on unpaid carers

Overview

As discussed in section 3.12 (Measures to support unpaid carers)., in many countries guidance and measures to support unpaid carers was issued relatively late in the pandemic. At the same time, many carers having to provide additional care due to reductions in formal care or in care from other unpaid carers. In contrast, unpaid carers of people living in care homes were forced to reduce the amount of care they provided as their access to care homes was restricted (O’Caoimh R., et al., 2020 and Smaling et al, 2021).

Brief overview of research evidence on the impact of the pandemic on unpaid carers:

The evidence base on the impacts of the pandemic on unpaid carers is growing. A rapid review of the impacts of COVID-19 on unpaid carers of adults with long-term care needs, covering evidence up to November 2020, identified 40 studies and the following key themes (Lorenz-Dant and Comas-Herrera, 2021):

  • – Increase in the care commitment by carers and the responsibilities they shoulder
  • – Great concern about the implications of COVID for the person they care for
  • – Reduced availability of formal and informal support structures
  • – Decreased ability to maintain employment
  • – Negative physical and mental health implications
  • – Negative financial implications
  • – Women, younger carers, people with existing financial difficulties and  those from minor groups were more at risk of negative outcomes
  • – Carers of people living in residential settings have experienced reduced contact and great worry about the quality of care and adverse consequences for their relatives.

A scoping review of the impact of the COVID-19 pandemic on family carers in the community, covering evidence published up to 16th July 2021 published in English, identified 52 articles. The findings were categorised into four key themes (Muldrew et al., 2021):

  • – Decline in psychological wellbeing
  • – Concerns about personal health and wellbeing
  • – Practical/logistical concerns
  • – Removal or uncertainty of support
Positive experiences

While most of the outcomes for carers reported in the literature are negative, a qualitative study in Australia focusing on positive experiences arising from COVID-19 among unpaid carers of people with dementia found positive caring experiences in all timeframes, reporting stronger and closer caring relationships and developed self-care strategies (Tulloch et al., 2022)

References:

O’Caoimh R, O’Donovan MR, Monahan MP, Dalton O’Connor C, Buckley C, Kilty C, Fitzgerald S, Hartigan I and Cornally N (2020) Psychosocial Impact of COVID-19 Nursing Home Restrictions on Visitors of Residents With Cognitive Impairment: A Cross-Sectional Study as Part of the Engaging Remotely in Care (ERiC) Project. Front. Psychiatry 11:585373. doi: 10.3389/fpsyt.2020.585373

Lorenz-Dant, K. and Comas-Herrera, A., 2021. The Impacts of COVID-19 on Unpaid Carers of Adults with Long-Term Care Needs and Measures to Address these Impacts: A Rapid Review of Evidence up to November 2020. Journal of Long-Term Care, (2021), pp.124–153. DOI: http://doi.org/10.31389/jltc.76

Muldrew, D. H. L., Fee, A., & Coates, V. (2021). Impact of the COVID-19 pandemic on family carers in the community: A scoping review. Health & Social Care in the Community, 00, 1–11. https://doi.org/10.1111/hsc.13677

Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

Tulloch K., McCaul T and Scott T.L. (2022) Positive Aspects of Dementia Caregiving During the COVID-19 Pandemic, Clinical Gerontologist, 45:1, 86-96, DOI: 10.1080/07317115.2021.1929630

International reports and sources

Evidence Reviews:

Lorenz-Dant, K. and Comas-Herrera, A., 2021. The Impacts of COVID-19 on Unpaid Carers of Adults with Long-Term Care Needs and Measures to Address these Impacts: A Rapid Review of Evidence up to November 2020. Journal of Long-Term Care, (2021), pp.124–153. DOI: http://doi.org/10.31389/jltc.76

Muldrew, D. H. L., Fee, A., & Coates, V. (2021). Impact of the COVID-19 pandemic on family carers in the community: A scoping review. Health & Social Care in the Community, 00, 1–11. https://doi.org/10.1111/hsc.13677

Argentina

Studies suggest that unpaid carer burden has increased. Some carers have stopped paid carers coming in.

Last updated: January 2nd, 2022

Australia

A report from Australia suggests increased care needs and reduced availability of paid services. Some retired carers experienced a drop in their funds. Unpaid carers of people living in residential care settings were concerned about their well-being (Lorenz-Dant and Comas-Herrera, 2021).

Impacts of the pandemic on attitudes towards care provision

A study by Tulloch et al., (2021) revealed positive impacts of the pandemic on informal caregiving of individuals with dementia. Interviews were conducted between June and August 2020 (during the second wave of the pandemic), and participants were asked about their experiences and perceptions of care before, during, and moving forward from COVID-19. Interestingly, when asked about their perceptions of care prior to the pandemic, interviewees tended not to discuss aspects of care that related to their own strengths or benefits: answers revolved around perceptions of the experiences of the person with dementia for whom they were providing care. In contrast, when discussing the provision of care during the pandemic, participants elaborated on their own caregiving experiences and what they saw as important values in the act of caregiving. In addition to these metacognitive elements, changes in behavioural approaches to providing care during the pandemic were reported, such as engaging in self-care strategies and seeking and accepting additional help when needed. Furthermore, participants expressed a desire to continue to engage with these behaviours beyond the pandemic. This research suggests that the pandemic may have provided those who provide informal care to people with dementia with an important opportunity to find profound meaning in the care they provide, and a recognition of the importance of looking after themselves to strengthen their provision of care.

References:

Lorenz-Dant, K. and Comas-Herrera, A., 2021. The Impacts of COVID-19 on Unpaid Carers of Adults with Long-Term Care Needs and Measures to Address these Impacts: A Rapid Review of Evidence up to November 2020. Journal of Long-Term Care, (2021), pp.124–153. DOI: http://doi.org/10.31389/jltc.76

Tulloch, K., McCaul, T., & Scott, T. L. (2021). Positive Aspects of Dementia Caregiving During the COVID-19 Pandemic. Clinical Gerontologist, 45(1), 86–96. https://doi.org/10.1080/07317115.2021.1929630/SUPPL_FILE/WCLI_A_1929630_SM0674.DOCX

Last updated: January 22nd, 2022   Contributors: Daisy Pharoah  |  

Austria

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

Last updated: January 6th, 2022

Canada

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

Last updated: January 6th, 2022

Finland

A qualitative study conducted during May to December 2020 with family members of residents in nursing homes in different parts of Finland found that both family members and residents experienced grief, anxiety and severe stress. Family members were concerned that the residents lives were at risk due to lack of social contact and activity. They also expressed frustration at not being able to contribute to the care of their relatives or to touch them, when visits were allowed (Paananen et al, 2021).

References:

Paananen J, Rannikko J, Harju M, Pirhonen J (2021) The impact of Covid-19-related distancing on the well-being of nursing home residents and their family members: a qualitative study. International Journal of Nursing Studies Advances, 3. https://doi.org/10.1016/j.ijnsa.2021.100031.

Last updated: January 9th, 2022

Germany

A survey among family carers of older people found that 39% of unpaid carers agreed that they had greater care responsibility as previous support had disappeared. This was linked both to reductions in support from neighbours and family, and to a reduction in formal care (particularly day care).

Last updated: January 2nd, 2022   Contributors: Klara Lorenz-Dant  |  

India

Unpaid carers worried about protecting their relatives with dementia, keeping the occupied inside the house and adhering to hygiene measures. Unpaid carers found working and caring challenging and expressed concerns about financial implications. Formal and informal networks were less well accessible and there was difficulty in accessing medical care (Vaitheswaran et al., 2020).

References:

Vaitheswaran, S., Lakshminarayanan, M., Ramanujam, V., Sargunan, S., & Venkatesan, S. (2020). Experiences and Needs of Caregivers of Persons With Dementia in India During the COVID-19 Pandemic-A Qualitative Study. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 28(11), 1185–1194. https://doi.org/10.1016/j.jagp.2020.06.026

Last updated: January 6th, 2022

Ireland

Quantitative evidence

An online survey of 225 relatives of people living in care homes carried out in June 2020 examined the perceived  impacts of visiting restrictions on perceived loneliness, well-being and carer quality of life. The study found that many visitors experienced low psychosocial and emotional well-being during, the impacts were greater among relatives of people with cognitive impairment. Almost a fight of respondents reported that support for their role as carers from staff in the care homes had been poor and this had impacted their quality of life. Most respondents also reported that they perceived that the residents were not coping well (O’Caoimh R., et al., 2020).

References:

O’Caoimh R, O’Donovan MR, Monahan MP, Dalton O’Connor C, Buckley C, Kilty C, Fitzgerald S, Hartigan I and Cornally N (2020) Psychosocial Impact of COVID-19 Nursing Home Restrictions on Visitors of Residents With Cognitive Impairment: A Cross-Sectional Study as Part of the Engaging Remotely in Care (ERiC) Project. Front. Psychiatry 11:585373. doi: 10.3389/fpsyt.2020.585373

Last updated: January 9th, 2022

Italy

Unpaid carers of people with dementia reported that caring was more challenging, experienced high stress levels, and other negative implications (Cagnin et al., 2020).

References:

Cagnin A., Di Lorenzo R., Marra C., et al. (2020) Behavioral and Psychological Effects of Coronavirus Disease-19 Quarantine in Patients with Dementia. Frontiers in Psychiatry 11. https://doi.org/10.3389/fpsyt.2020.578015

Last updated: January 6th, 2022   Contributors: Klara Lorenz-Dant  |  

Jamaica

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

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

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

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

Last updated: January 2nd, 2022

Netherlands

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

Impacts on family carers of people living with dementia

A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that family carers of people living dementia found difficult to cope with visiting restrictions, experienced anxiety regarding safety and had higher carer burden.

Relatives of people living in care homes reported that video calling and window visits were difficult as people with dementia often found it difficult to communicate in this way or use equipments, but relatives stated that this was better than no communication. They also worried that their relatives with dementia would no longer recognise them when the restrictions were lifted. Their carer burden was reduced, but they felt sidelined as they were no longer able to continue providing care.

Carers of people living in the community tried to keep the “bubble” around the person with dementia small. They worried about professional carers not adhering to safety measures and experienced higher care burden.

References:

Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

Last updated: January 6th, 2022

England (UK)

Impacts on health, wellbeing, and quality of life

Many carers have expressed the experience of stress and a negative impact on their physical and mental health. Carers UK reported that the negative impact on the mental health of carers was greater among carers experiencing financial difficulties. Research found that variations in hours of support were associated with higher levels of anxiety and lower levels of well-being (Giebel et al, 2021).

In a survey of approximately 300 largely family carers of adults with intellectual disabilities across the UK in July/August 2021, carers most commonly reported their caring role had affected them in terms of feeling tired (66%), a general feeling of stress (60%), or disturbed sleep (53%), with little change compared to previous surveys in December 2020-February 2021 and April-May 2021 (Willner et al., 2020).

In a study of community-dwelling adults with dementia and their carers (Rand et al, 2021), there was no significant association between the phases of the COVID-19 restrictions in England and carers’ care-related quality of life. Significant positive associations were found between care-related QoL and carer self-rated good health and satisfaction with social care support; negative associations were found with high-intensity caregiving (>50 hours per week), co-residence with the person with dementia, severe cognitive impairment and financial difficulties due to caring. The sample (n=313) reported high levels of unmet social care-related QoL need, with over 50% of the sample having unmet needs in five of the seven QoL domains (except self-care (32%) and personal safety (3%)).

Increase in numbers of people providing unpaid care

Evidence suggests that, since the beginning of the COVID-19 pandemic, a substantial number of people have taken on new care responsibilities. Several reports on unpaid carers have shown that there has been an increase in unpaid carers, many of those who have cared prior to the pandemic have increased their care commitment, largely due to reduced availability of services.

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

Increase in care provided by family carers

Carers UK have reported that care responsibilities have increased for most carers, with the average time spent caring increasing by 10 hours to 65 hours of unpaid care per week. However, a small proportion of carers have provided less care. An increase in care responsibility and time spent caring was reported among most unpaid carers of people with dementia (73%). Many carers attributed the increase in time spent caring to the reduced availability of services. This proportion was particularly high among Black, Asian and Minority Ethnic (BAME) carers.

Concerns expressed by carers

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

Impact on carers’ finances

Carer’s UK published evidence in April and October 2020 of a negative impact on carers finances, with some incurring increased costs (food, bills, equipment) and a reduced ability to work or loss of employment. While some carers highlighted that working remotely provided them with greater flexibility to manage care and work, others experienced greater challenges. Research on unpaid carers caring for someone outside their household found that carers with paid jobs worked fewer hours than other people in employment, and that female carers worked fewer hours than male carers. Financial pressure on carers was also illustrated through foodbank use, with 106,450 carers (1.76% of carers) reporting that their household had to rely on foodbanks in the past month. Foodbank use was higher among female and among young carers (aged 17-30). The research also showed that in the households of 228,625 unpaid carers, someone had gone hungry in the week prior to the survey. Again, this was higher among females and young carers (aged 17-30).

Impacts on use of respite care for carers of individuals with dementia

The pandemic has heightened some of the demands of caring for people living with dementia as there have been fewer opportunities for social contact and breaks. A qualitative study conducted between March and December 2020 investigated the impact of COVID-19 on the views and expectations of 35 carers of people living with dementia about residential respite (i.e., staying in a care home for a short period of time).

Thematic analysis of interview data revealed that although residential respite is positive and provides some carers with an opportunity to take a break from caring (which is especially important during the pandemic as caregiver stressors may have been heightened), confidence in using respite was found to be compromised. This was for a variety of factors: firstly, carers described regularly negotiating the risks and stresses of the pandemic, weighing up changing family arrangements to facilitate caring and preventing infection. Secondly, the challenge of prioritising the needs of their relatives whilst bearing the impact of cumulative caregiving responsibilities was discussed. Participants in the study also revealed uncertainty about future residential respite due to anxieties around ongoing restrictions (such as quarantining before seeing visitors), availability (due to some care homes closing permanently during the pandemic), and disheartening sources of information about the pandemic (Samsi et al., 2022).

References

Giebel, C., Lord, K., Cooper, C., Shenton, J., Cannon, J., Pulford, D., Shaw, L., Gaughan, A., Tetlow, H., Butchard, S., Limbert, S., Callaghan, S., Whittington, R., Rogers, C., Komuravelli, A., Rajagopal, M., Eley, R., Watkins, C., Downs, M., … Gabbay, M. (2021). A UK survey of COVID-19 related social support closures and their effects on older people, people with dementia, and carers. International Journal of Geriatric Psychiatry, 36(3), 393–402. DOI:https://doi.org/10.1002/GPS.5434

Samsi, K., Cole, L., Orellana, K., & Manthorpe, J. (2022). Is it worth it? Carers’ views and expectations of residential respite for people living with dementia during and beyond the COVID-19 pandemic. International Journal of Geriatric Psychiatry. https://doi.org/10.1002/GPS.5680

Rand S.E., Silarova B, Towers A.-M. and Jones K. (2021) Social care-related quality of life of people with dementia and their carers in England. Health and Social Care in the Community. https://doi.org/10.1111/hsc.13681

Willner, P., Rose, J., Stenfert Kroese, B., Murphy, G. H., Langdon, P. E., Clifford, C., Hutchings, H., Watkins, A., Hiles, S., & Cooper, V. (2020). Effect of the COVID-19 pandemic on the mental health of carers of people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 33(6), 1523–1533. DOI:https://doi.org/10.1111/JAR.12811

Last updated: January 21st, 2022   Contributors: Klara Lorenz-Dant  |  Stacey Rand  |  Chris Hatton  |  

United States

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

Last updated: January 6th, 2022

Vietnam

It should be noted here that the majority of care in Vietnam is informal and provided by unpaid carers. In fact, it is written into The Elderly Law that older people in Vietnam may choose to live with their children or grandchildren at their will; and indeed, many do. Thus, while there is no information on the impact of the pandemic on unpaid carers specifically, it is likely that the effects of the pandemic on households has a significant impact on those receiving care at home.

The economic impact of the pandemic in Vietnam, not unlike in most of the world, has been enormous, and has been felt by individuals through day-to-day consumption. For example, due to an increase in demand, there was an enormous price surge of preventative goods (such as face masks, which are also commonplace in Vietnam outside of pandemic times) in 2020. This resulted in as much as 20% of the household income of an average-income four-person household going towards such preventative items (Tran et al., 2020). As in many countries, a huge number of jobs were lost or severely compromised; particularly in the service industry, which contributes around 40% of the country’s GDP (source: Statista). With schools closed or online during most of 2020, parents struggled to balance work and childcare (and presumably care of their elderly family members), resulting in further income loss (Tran et al., 2020).

As an attempt by the government to mitigate some of the economic impact of the pandemic, daily food allowances were given to individuals in quarantine. However, these payments were small (between $1.79 and $2.59 per day) and so did not make up for loss of income or inability to work. Farmers in rural areas, where poverty is not uncommon, were particularly hard-hit as a result of border closures and an inability to sell their stock  (Tran et al., 2020).

These economic difficulties are likely to have impacted availability of food, medical care, and other necessary supplies for the elderly population who require informal, unpaid care in Vietnam.

References:

Tran, P. B., Hensing, G., Wingfield, T., Atkins, S., Sidney Annerstedt, K., Kazibwe, J., Tomeny, E., Biermann, O., Thorpe, J., Forse, R., & Lönnroth, K. (2020). Income security during public health emergencies: the COVID-19 poverty trap in Vietnam. BMJ Global Health, 5(6), e002504. https://doi.org/10.1136/BMJGH-2020-002504

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

2.08. Impacts of the pandemic on people working in the Long-Term Care sector

Overview

As discussed in Part 1, the pandemic arrived at a time when there were already shortages in long-term care staff in most countries, which has been attributed to poor pay and conditions, as well as lack of professional prestige of the sector. Staff working in long-term care have been at increased risk of infections and deaths (even compared to the health sector) and have experienced particularly stressful and distressing situations, and huge increases in workload, resulting in negatives impacts on mental health, as summarised below.

Increased risk of infection and deaths:

People who work in the Long-Term Care sector, both in care homes and in community settings have been particularly exposed to infections (see for example data from England, below, showing that social care is the employment sector with the highest COVID-19 death rates, nearly double those experienced by health care sector staff).

Evidence from the United States (Xu et al., 2020)  suggests that some of the additional risks experienced by staff working in nursing homes can be linked to availability of Personal Protection Equipment (the analysis found that nursing homes with at least 1-week supply of PPE were less likely to have staff shortages during the pandemic).

Mental health impacts:

There is growing qualitative and quantitative evidence showing the negative impacts of the pandemic among staff working in care homes, although there is often a difficulty in ascertaining the extent to which this differs from before the pandemic due to lack of baseline data.

A study in Ireland shows that nursing home staff had higher prevalence of suicidal ideation and planning than that observed in studies of hospital staff. The study also found high prevalence of post-traumatic stress, mood disturbance and moral injury. Many staff also reported that they were not able to cope with work demands (Brady et al., 2021).

References:

Brady C., Fenton C. , Loughran O. , et al. (2021) Nursing home staff mental health during the Covid?19 pandemic in the Republic of Ireland. Int J Geriatr Psychiatry.1?10. https://doi.org/10.1002/gps.5648

Xu H., Intrator O., Bowblis J.R. (2020) Shortages of staff in Nursing Homes during the COVID-19 Pandemic: What are the Driving Factors? JAMDA, https://doi.org/10.1016/j.jamda.2020.08.002

Australia

Workload

An Health Services Union (HSU) survey of 1,000 aged care workers released on 13th January 2022 found 90% of respondents reported they were experiencing understaffing, 84% reported excessive workloads, 82% thought that their aged care facility was unprepared for the Omicron wave and 36% were working in facilities that had implemented 12-hour shifts.

(p. 71 – The Senate (October 2021), Select Committee on Job security, Second Interim Report)

https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/024764/toc_pdf/Secondinterimreportinsecurityinpublicly-fundedjobs.pdf;fileType=application%2Fpdf

The Royal Commission’s September 2020 special report into COVID-19 noted evidence from unions that pointed to a lack of acknowledgement of the increased staffing numbers required to support the measures in the Visitation Code and the workload this created.

Financial impacts

The Australian Services Union submission to the Royal Commission reported on a survey on the impact of COVID on its members in home care. It noted that almost half of the respondents lost hours of work due to COVID restrictions and that the situation was worse in non-local government employment.

At various points in the pandemic, workers have been prevented from working across more than one private residential aged care site. While the Commonwealth government provided providers with additional funds to allow workers to be employed for at least their normal total hours (see  https://www.health.vic.gov.au/covid-19/supporting-the-aged-care-workforce-during-covid-19), however there has been considerable variation on how this has worked in practice and there have been some industrial disputes where employers did not honour pre-single site working arrangements.

Evidence of impacts on mental health of aged care workers

A national online survey carried out in September and October of 2020 asked 288 senior staff working in residential aged care homes about the impact of COVID-19 on the mental health of residents and staff. The study aimed to identify the perceived impact of the pandemic on mental health, the restrictions and stressors that staff identified as affecting mental health and the views of staff about programmes and resources to support mental health. The study used mixed methods, using qualitative narratives to complement the quantitative findings.

It found a high prevalence of staff who demonstrated poor mental health, in particular loneliness, anxiety and stress. The most commonly identified stressors where related to media exposure to COVID-19 outbreaks, concerns about their own safety as well as the safety of residents and their own families, and fear of inadvertently infecting residents. Staff identified potential helpful having training in supporting the mental health of residents, on-site and tele-health counselling and having technical support for video conferencing (Brydon et al., 2021).

References:

Brydon A, Bhar S, Doyle C, Batchelor F, Lovelock H, Almond H, Mitchell L, Nedeljkovic M, Savvas S, Wuthrich V. National Survey on the Impact of COVID-19 on the Mental Health of Australian Residential Aged Care Residents and Staff. Clin Gerontol. 2021 Oct 11:1-13. doi: 10.1080/07317115.2021.1985671.

Last updated: January 17th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Adelina Comas-Herrera  |  

France

In early 2021, a total of 47,428 cases were recorded among social care workers, of which at least 17 have died (Source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf)

Last updated: January 2nd, 2022   Contributors: Camille Oung  |  

Ireland

Quantitative evidence of negative impacts on the mental health of nursing home staff:

An online survey of 390 nursing home staff across the Republic of Ireland during the third wave of the pandemic ( 20th November 2020 to 4th January 2021) gathered data on COVID-19 exposure and mental health. They study found that nursing home care staff reported high levels of post-traumatic stress, mood disturbance and moral injury (distress experienced when an individual witnesses or engages in acts that contradict their moral beliefs) during the pandemic. There was also high prevalence of suicidal ideation (13.8%) and planning (9.2%), a higher prevalence than that observed in hospital workers during the pandemic. 24.6% of staff also reported that they were not able to cope with work demands (work ability).

The study found significant differences between different staff groups, with health care assistants reporting a significantly higher degree of moral injury than non-clinical staff (Brady et al., 2021).

References:

Brady C., Fenton C. , Loughran O. , et al. (2021) Nursing home staff mental health during the Covid?19 pandemic in the Republic of Ireland. Int J Geriatr Psychiatry.1?10. https://doi.org/10.1002/gps.5648

 

Last updated: January 9th, 2022

Italy

A study of the self-rated mental wellbeing (depression, trauma, quality of life at work, etc) of over 300 employees (91 clinicians, nurses and physiotherapists; 99 care workers and 110 administrative personnel) in multiple nursing homes in Northern Italy found that 1 in four employees reported symptoms consistent with severe post-traumatic stress disorder, 16% reported moderate to severe depression symptoms and 11% severe anxiety. 40% of the sample declared that their mental health status had a negative impact on their social and professional life.

Last updated: January 2nd, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Netherlands

A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that professional carers experienced increased workload due to:

  • – Addditional responsibilities and care tasks, particularly due to implementing Infection Prevention and Control measures and due to additional care demands during outbreaks (in terms of providing care to people who were quarantining and increased care needs due to COVID-19 infections)
  • – Having to work extra hours due to staff shortages
  • – In the community, workers also found it burdensome to have to make decisions about reducing care and having to communicate if care needed to be stopped or reduced.

The study also found that staff in care homes experienced stress as a result of relatives of people with dementia not adhering to rules and felt conflicted about having to implement measures that they perceived to be harmful and too strict. Some also expressed guilt that they had contact with residents while their relatives were not able to visit (Smaling et al., 2022).

A study analysing the minutes and other meeting documents of Outbreak Teams operating in care homes (including residential and nursing care homes) during weeks 16 to 23 of 2020 (covering the first two waves of COVID infections in the Netherlands) shows concern about the staff mental wellbeing. In particular, the Outbreak Teams were concerned about emotional exhaustion due to high workloads, fear of infection and verbal abuse by residents’ family members (van Tol et al, 2021).

References:

Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

van Tol LS, Smaling HJA, Groothuijse JM, et al COVID-19 management in nursing homes by outbreak teams (MINUTES) — study description and data characteristics: a qualitative study 

Last updated: January 6th, 2022

England (UK)

Sickness levels during the Omicron wave

A survey of members of the National Care Forum (the largest body representing not-for-profit care providers) released on the 13th January 2022 found that providers reported an 18% vacancy rate and 14% absences as a result of Omicron.

Impact in terms of mortality

Data from the Office for National Statistics show that, between 9 March and 28 December 2020, there were 469 deaths of social care workers. People working social care had higher rates of death involving COVID-19 compared to people of similar age and sex. For men working in social care, there were 79.0 deaths per 100,000 (compared to 31.4 for the general population and 44.9 for health care workers in the same age groups) and 35.9 deaths for 100,000 for females, compared to 16.8 for the general population and 17.3 for women working in healthcare.

Mental and physical health impacts

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

Impact on wellbeing and quality of life

A recent study compared cross-sectional data from at three timepoints during the pandemic to examine how the workforce (health and social care) has been affected by the pressures of COVID-19, and how employers can help rebuild their services. Wellbeing and work-related quality of life was significantly compromised between May/July 2020 and May/July 2021, with respondents increasingly using negative avoidant coping strategies (such as substance abuse and self-blame) during this period. Between December 2020/November 2021 and May/July 2021, burnout was found to significantly increase. Consistent with other literature, the study that highlights that despite its resilience, much of the health and social care workforce has been overwhelmed by the COVID-19 pandemic (Gillen et al., 2022).

References:

Rajan, S., Comas-Herrera, A. and Mckee, M., 2020. Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic?. Journal of Long-Term Care, (2020), pp.185–195. DOI: http://doi.org/10.31389/jltc.53

Gillen, P., Neill, R. D., Manthorpe, J., Mallett, J., Schroder, H., Nicholl, P., Currie, D., Moriarty, J., Ravalier, J., McGrory, S., & McFadden, P. (2022). Decreasing Wellbeing and Increasing Use of Negative Coping Strategies: The Effect of the COVID-19 Pandemic on the UK Health and Social Care Workforce. Epidemiologia 2022, Vol. 3, Pages 26-39, 3(1), 26–39. https://doi.org/10.3390/EPIDEMIOLOGIA3010003

Last updated: January 22nd, 2022

Northern Ireland (UK)

Impact on wellbeing and quality of life

A recent study compared cross-sectional data from at three timepoints during the pandemic to examine how the workforce (health and social care) in the UK has been affected by the pressures of COVID-19, and how employers can help rebuild their services. Wellbeing and work-related quality of life was significantly compromised between May/July 2020 and May/July 2021, with respondents increasingly using negative avoidant coping strategies (such as substance abuse and self-blame) during this period. Between December 2020/November 2021 and May/July 2021, burnout was found to significantly increase. Consistent with other literature, the study that highlights that despite its resilience, much of the health and social care workforce has been overwhelmed by the COVID-19 pandemic (Gillen et al., 2022).

Gillen, P., Neill, R. D., Manthorpe, J., Mallett, J., Schroder, H., Nicholl, P., Currie, D., Moriarty, J., Ravalier, J., McGrory, S., & McFadden, P. (2022). Decreasing Wellbeing and Increasing Use of Negative Coping Strategies: The Effect of the COVID-19 Pandemic on the UK Health and Social Care Workforce. Epidemiologia 2022, Vol. 3, Pages 26-39, 3(1), 26–39. https://doi.org/10.3390/EPIDEMIOLOGIA3010003

Last updated: January 22nd, 2022

Scotland (UK)

Impact on wellbeing and quality of life

A recent study compared cross-sectional data from at three timepoints during the pandemic to examine how the workforce (health and social care) in the UK has been affected by the pressures of COVID-19, and how employers can help rebuild their services. Wellbeing and work-related quality of life was significantly compromised between May/July 2020 and May/July 2021, with respondents increasingly using negative avoidant coping strategies (such as substance abuse and self-blame) during this period. Between December 2020/November 2021 and May/July 2021, burnout was found to significantly increase. Consistent with other literature, the study that highlights that despite its resilience, much of the health and social care workforce has been overwhelmed by the COVID-19 pandemic (Gillen et al., 2022).

Gillen, P., Neill, R. D., Manthorpe, J., Mallett, J., Schroder, H., Nicholl, P., Currie, D., Moriarty, J., Ravalier, J., McGrory, S., & McFadden, P. (2022). Decreasing Wellbeing and Increasing Use of Negative Coping Strategies: The Effect of the COVID-19 Pandemic on the UK Health and Social Care Workforce. Epidemiologia 2022, Vol. 3, Pages 26-39, 3(1), 26–39. https://doi.org/10.3390/EPIDEMIOLOGIA3010003

Last updated: January 22nd, 2022

Wales (UK)

Impact on wellbeing and quality of life

A recent study compared cross-sectional data from at three timepoints during the pandemic to examine how the workforce (health and social care) in the UK has been affected by the pressures of COVID-19, and how employers can help rebuild their services. Wellbeing and work-related quality of life was significantly compromised between May/July 2020 and May/July 2021, with respondents increasingly using negative avoidant coping strategies (such as substance abuse and self-blame) during this period. Between December 2020/November 2021 and May/July 2021, burnout was found to significantly increase. Consistent with other literature, the study that highlights that despite its resilience, much of the health and social care workforce has been overwhelmed by the COVID-19 pandemic (Gillen et al., 2022).

Gillen, P., Neill, R. D., Manthorpe, J., Mallett, J., Schroder, H., Nicholl, P., Currie, D., Moriarty, J., Ravalier, J., McGrory, S., & McFadden, P. (2022). Decreasing Wellbeing and Increasing Use of Negative Coping Strategies: The Effect of the COVID-19 Pandemic on the UK Health and Social Care Workforce. Epidemiologia 2022, Vol. 3, Pages 26-39, 3(1), 26–39. https://doi.org/10.3390/EPIDEMIOLOGIA3010003

Last updated: January 22nd, 2022   Contributors: Daisy Pharoah  |  

United States

Impacts on community-based workers:

A qualitative study of the experiences of 33 home health workers in New York City carried out from March to April 2020 found that workers felt invisible even though they were on the frontline of the COVID-19 pandemic, had high risk of virus transmission and were forced to make difficult decisions between their work and personal lives, exacerbating existing inequities. The majority of respondents were women of color. The respondents were aware that, due to lack of Personal Protection Equipment and relying on public transport, they were at high risk of infection and they also posed a risk to the people they provided care to and own their families. As well as anxiety about COVID risks, the respondents were also concerned about the implications of the pandemic for their already precarious financial situation (Sterling et al., 2020).

Impacts on nursing home staff:

Qualitative analysis from an electronic survey of 152 nursing home staff from 32 states carried out from 11th May to 4th June 2020 found that staff were working under complex and stressful circumstances. Respondents reported burnout and described enormous emotional, physical and mental burdens of having to taken heavier workloads and learning new roles and processes. They expressed concern about the situation experienced by residents, which added to the emotional toll and fears about becoming infected and infecting their families as a result. Respondents also expressed feeling demoralised as a result of negative media coverage of nursing homes and feeling that hospital staff were given much more praise, resources and recognition (White et al., 2021).

References:

Sterling M.R., Tseng E., Poon A. et al. (2020) Experiences of Home Health Care workers in New York City during the Coronavirus-2019 pandemic. JAMA Intern Med. 180(11):1453-1459. doi:10.1001/jamainternmed.2020.3930

White E.M., Fox Wetle T., Reddy A. and Baier R.R. (2021) Front-line nursing home staff experiences during the COVID-19 pandemic. JAMDA 22(1):199-203. https://doi.org/10.1016/j.jamda.2020.11.022

Last updated: January 10th, 2022

Vietnam

There is no information to-date on the formal LTC workforce specifically, but some information on the impact on unpaid carers (who make up the bulk of the LTC workforce) can be found in section 2.07.

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

2.08.01. Impacts of the pandemic on migrant Long-Term Care workers

International reports and sources

Systematic review of the experiences of care home staff during the pandemic (covering evidence from March 2020 to March 2021):

Kristina Lily Gray, Heather Birtles, Katharina Reichelt & Ian Andrew James (2021) The experiences of care home staff during the COVID-19 pandemic: A systematic review, Aging & Mental Health, DOI: 10.1080/13607863.2021.2013433

Israel

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

Last updated: January 2nd, 2022   Contributors: LIAT AYALON  |  Shoshana Lauter  |  

2.09. Impact of the pandemic on workforce shortages in the Long-Term Care sector

Overview


International reports and sources


Australia

Staff shortages

Care providers have experienced staff shortages. As of 14th January, workforce surge staff have filled around 60,000 shifts in aged care facilities due to COVID-19.

Last updated: January 18th, 2022

Canada

There are media reports of a surge in COVID-19 cases driven by the  spread of the Omicron variant resulting in staffing shortages across the country, and leading to shortages of a range of services, including home care.

Last updated: January 19th, 2022

England (UK)

One of the key messages from the recent State of Care report (by the CQC) is that although staffing pressures have been felt across both the health and care service delivery sectors, the impact of the pandemic has been seen most acutely in all areas of adult social care (including care home and home-care services).

The care workforce has been under increasing pressure due to people leaving the social care sector, which happened at a steadily increasing rate throughout 2021. Various factors explain the decline in care staff over this period, for example the appeal of more attractive salaries in the retail and hospitality industries, staff from adult social care (especially nurses) taking vacant posts in hospitals, and the requirement for all care home workers to be fully vaccinated against COVID-19 (as of 11 November 2021) (CQC).

Omicron wave

The rapid spread of the Omicron variant has had a drastic impact on the ability of social care providers to continue to offer services due to very high rates of staff sickness (ADASS).  In January 2022, more than 90 care operators declared a ‘red’  alert i.e. they don’t have the staff to meet patient demands. A survey of members of the National Care Forum (the largest body representing not-for-profit care providers) released on the 13th January 2022 found that 66% of homecare providers responding are having to refuse new requests for home care, 43% of providers of care homes are closing to new admissions and 21% of home care providers are handing back existing care packages as they are unable to fulfil them. The providers reported an 18% vacancy rate and 14% absences as a result of Omicron.

Also on the 13th January 2022, the Association of Directors of Adult Services reported that, as a result of staff shortages, 49 out of 94 councils that answered a questionnaire reported taking measures to prioritise care to support the most basic tasks only (eating, drinking and going to the toilet, but not help with tasks such as getting out of bed) and having to leave people with learning disabilities, dementia or mental illness alone for longer than usual.

Last updated: January 20th, 2022

2.10. Financial and other impacts of the pandemic on Long-Term Care providers

Netherlands

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

Last updated: January 6th, 2022

England (UK)

Care home providers

Financial impact

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

Community-based care providers

Data from a survey by the CQC showed that, as of May 2 to 8, 2020, around a fifth of agencies were caring for at least one person with suspected or confirmed COVID-19. Providers also reported that access to PPE was a big concern, with many instances of wrong or poor quality items being delivered. While homecare services were experiencing lower levels of activity (homecare hours were at 94% of pre-pandemic levels), local authorities continued to pay for planned hours, which helped to protect the providers they commission from, from the decrease in activity.

Last updated: January 2nd, 2022   Contributors: William Byrd  |  

United States

Impact on workforce shortages

Data from the Bureau of Labor Statistics, reported by the KFF Health Systems Tracker shows that the number of people working in Long-Term Care Facilities has declined by substantial between February 2020 and November 2021. The number of people employed in community elder care facilities declined by 11.1%, from 976,100 employees to 867,700. The number of people working in nursing care facilities decreased by 15.0%, from 1.59 million to 1.35. This builds on a previous trend, employment on nursing homes had been declining at an average of 0.09% per month between 2017 and early 2020.

Increased wages

The KFF Health Systems Tracker also reports that average earnings rose by over 14.7% between February 2020 and October 2021, from $669.90 to $768.56 per week. Wages of home healthcare workers rose by 13.8% from $586.46 to $667.28.

Last updated: January 5th, 2022

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

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

Australia

The Royal Commission into Aged Care Quality and Safety’s special report on COVID-19 identified the following factors in terms of the ability of the aged care sector to respond (Royal Commission, 2020):

Factors linked to preparedness

In the residential facilities that have suffered the largest number of infections and deaths that have been the subject of inquiry (e.g Newmarch, St Basils) or used as case studies in reports (Epping Garden Gardens) the follow conclusions/points were made about their preparation or lack of preparedness (Royal Commission, 2020):

  • – Insufficient PPE provided residential care and home care providers
  • – Staff were excluded from the vaccination rollout.
  • – Lack of understanding that workers bring the infection into the homes as well as taking it out and infecting family members.
  • – Individual homes expecting to transfer large numbers of residents to hospital at short notice
  • – There was no National COVID Plan for Aged care. The National Covid plan was adapted.
Structural problems in the LTC system
  • – The effective casualisation of the workforce resulting in some personal care workers working across several facilities.
  • – Chronic understaffing
  • – The lack of clinical skills with the declining ratio of nursing qualified staff
  • – The outsourcing of support services such as such as cleaning  and food preparation with workers working across several sites
  • – Contested lines of responsibility between state and Commonwealth department

Academics, aged care peak bodies and unions agreed that the casualisation of the workforce, and outsourcing of some services (e.g. cleaning) resulting in a number of workers moving between aged care sties was considered to exacerbate the spread of the virus (Senate, Oct 2021 section 4.14).

References:

Royal Commission into Aged Care Quality and Safety (2020) Aged care and COVID-19: a special report. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf 

The Senate (2021) Select Committee on Job Security. Commonwealth of Australia.

Last updated: January 17th, 2022   Contributors: Lee-Fay Low  |  

Thailand

Following the declaration of a nationwide curfew in Thailand on 25 March 2020, in  April 2020, the Department of Older Persons issued a  manual of control and prevention of COVID-19 for all government care homes to ensure social distancing, which has been in place at least until February 2021.

The manual of control and prevention of COVID-19 in care homes includes the following measures (Srifuengfung et al., 2021):

Activities are to be organised in open spaces that are at least 2 metres apart

Beds and personal items must be at least 1 to 2 metres apart

There must be a one-way entry and exit system

Residents must maintain physical distancing as always be at least 1-2 metres apart, they must have their body temperature measured every day, their cutlery must be separate, was their hands regularly and wear a face mask, refrain from going in and out of the centre.

Visitors and people from outside organisations are not permitted to visit or organise activities.

References:

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://dx.doi.org/10.1016/j.jad.2021.08.044

Last updated: January 14th, 2022

Vietnam

As there is no information on people who use or provide LTC specifically, the following information pertains to measures adopted to minimize the impact of the COVID-19 pandemic on elderly people; the group most likely to use LTC (albeit often from their families).

Aside from additional support provided by the Government / Ministry of Health (see section 2.05), various socio-political organisations have played an important role in caring for and supporting vulnerable people (including elderly people and in particular, lonely elderly people) throughout the pandemic. For example, The Fatherland Fund established charity funds to help with the containment of COVID-19, and Youth Union has provided free food to vulnerable older people. The private sector has also played a role – for example, private donors set up ‘rice ATMs’ to distribute free rice to vulnerable people in some of the rural areas (Tung, 2020)..

References:

Tung, L. T. (2020). Social Responses for Older People in COVID-19 Pandemic: Experience from Vietnam. Journal of Gerontological Social Work, 63, 682–687. https://doi.org/10.1080/01634372.2020.1773596

Last updated: December 30th, 2021   Contributors: Daisy Pharoah  |  

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

Australia

The first case of COVID-19 in Australia was identified on January 25, 2020, from a man who travelled from Wuhan to Melbourne. Prime Minister Scott Morrison announced the Australian Health Sector Emergency Response Plan for Novel Coronavirus on February 27 and the first economic stimulus package on March 12. By mid-March, most states and territories were in lockdown. Cases began falling across the country in April and on May 8, the government announced a three stage plan to ease lockdown restrictions. Victoria entered its second wave in late June and by October 26, it reported no new cases or deaths. COVID-19 cases have been stable nation-wide since October 2020 (sources: WHO; health.gov; Lupton, UNSW).

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

A National Plan to transition Australia’s National COVID-19 response was agreed in August 2021, with transitions to less restrictive measures being triggered by the rates of vaccination, with a plan to move to a Phase C, with only very highly targeted lockdowns and re-opening of borders, once 80% of the population aged 16 and over are fully vaccinated (with two doses). It was expected that all jurisdictions in Australia would reach this threshold and enter phase C by the end of 2021.

Professor Deborah Lupton has characterised six phases in the management of COVID-19 risk in Australia:

  • – ‘A distant threat’ January 2020 to February 2020
  • – ‘The National Lockdown’ March 2020 to May 2020
  • – ‘COVID Zero’ June 2020 to January 2021
  • – ‘Vaccine Dilemmas’ February 2021 to May 2021
  • – ‘Delta Response’ June 2021 to September 2021
  • – ‘Living with COVID’ since October 2021

Since October 2021 the Government’s policy has been to ‘learn to live with COVID-19’, accepting higher case numbers, hospitalisations and deaths, particularly for people not yet fully vaccinated.

Last updated: January 9th, 2022

British Columbia (Canada)

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

Last updated: November 6th, 2021

Denmark

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

Last updated: September 7th, 2021

Germany

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

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

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

Last updated: September 8th, 2021

Hong Kong (China)

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

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

Last updated: September 8th, 2021

Iceland

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

In November 2021 the restrictions in place were:

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

Sources:

Directorate of Health. (October 2021). COVID-19 instructions for outdoor and indoor areas. Retrieved from https://www.landlaeknir.is/um-embaettid/greinar/grein/item43697/COVID-19-Instructions-for-outdoor-and-indoor-areas

Low LF, Feil C, Iciaszczyk N, Sinha S, Verbeek H, Backhaus R, Fadnes Jacobsen F, Hulda Tómasdóttir Þ, Ayalon L, Dixon J and Comas-Herrera. (2021) Care home visitor policies: a rapid global scan of current strategies in countries with high vaccination rates. International Public Policy Observatory and LTCcovid.org.

Last updated: November 29th, 2021

Ireland

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

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

Last updated: September 7th, 2021

Israel

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

As of November 24th 2021, a total of 8,178 people died due to COVID-19. However, due to massive vaccination, there are currently (November 2021) only 6,505 individuals defined as active COVID-19 patients, and 124 defined as severely ill. As of November 23rd 2021, only 603 new cases were identified.

The Israeli Ministry of Health was charged with leading the Government’s pandemic response, with publishing both weekly and daily press releases starting January 24, 2020. Lockdown measures were implemented the second week of March, which proved effective in terms of minimizing the rate of infection. According to the Government Stringency Index produced by the Oxford COVID-19 Government Response Tracker, the Israeli Government’s policies (e.g., stay at home orders, business closures) were most stringent in April at a score of 95 (when rates were low). In the first and second wave, the index measures were at 85 (with a significant drop to a score of 40 and a reopening of society in November 2020) (Source: Our World in Data).

 

Last updated: December 5th, 2021   Contributors: Shoshana Lauter  |  LIAT AYALON  |  

Italy

After the first two Covid-related cases in Italy were registered and confirmed in Rome on the 21st of January 2020, the Italian government suspended flights to China and declared a six-months state of emergency throughout the national territory with immediate effect on 31st of January 2020. At the same time, the Italian Council of Ministers appointed the head of the Civil Protection as Special Commissioner for the Covid-19 emergency. In the following days and weeks, additional regulations opened the possibility for the central government as well as other administrative levels (regions, cities etc.), in case of absolute need and urgency, to adopt stricter containment measures in order to manage the epidemiological emergency. At the end of February the first cases and deceased were registered in small towns in Northern Italy (Codogno, Vo’) that were placed under stricter quarantine(schools closed, public events cancelled, commercial activities closed etc.); on February 22rd carnival celebrations and some soccer matches were cancelled. On 1st of March, a Ministerial Decree established that the Italian national territory was divided in three areas: (i) Red zones (composed of Northern Italy municipalities that registered a certain level of COVID-19 cases where the population was in lockdown); (ii) Yellow zones (composed of regions of Lombardy, Veneto and Emilia-Romagna where certain activities were closed – schools, theatres – but people still had the liberty of limited movements); (iii) the rest of the nation where both safety and prevention measures were advertised but no further limitations were put in practice. On March 8th the government approved a decree to lockdown the entire region of Lombardy (and 14 other neighbouring provinces) establishing “the impossibility to move into and out of these areas” – with only few exceptions. Just a day later, on the evening of 9th of March, the government extended the Lombardy quarantine measures to the entire country. This national lockdown was expended several times until the 3rd May (Galeazzi et al., 2020).

If containment measures and lockdown were enforced by the central government, the same cannot be said for provisions detailing how the health sector and the LTC should respond to the COVID-19 crisis. In Italy, in fact, the health sector management and legislation fall within the competence of the Regional level; hence, especially during March and April all Italian Regions have adopted, at different times, plans, norms and decrees for managing the crisis.

Sources:

Galeazzi, A., Cinelli, M., Bonaccorsi, G., Pierri, F., Schmidt, A. L., Scala, A., … & Quattrociocchi, W. (2021). Human mobility in response to COVID-19 in France, Italy and UK. Scientific Reports11(1), 1-10

Last updated: November 23rd, 2021   Contributors: Elisabetta Notarnicola  |  Eleonora Perobelli  |  

Japan

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

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

Last updated: September 8th, 2021

Netherlands

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

Last updated: September 8th, 2021

Norway

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

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

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

Source:

Low LF, Feil C, Iciaszczyk N, Sinha S, Verbeek H, Backhaus R, Fadnes Jacobsen F, Hulda Tómasdóttir Þ, Ayalon L, Dixon J and Comas-Herrera. (2021) Care home visitor policies: a rapid global scan of current strategies in countries with high vaccination rates. International Public Policy Observatory and LTCcovid.org.

 

Last updated: November 29th, 2021

Republic of Korea

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

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

Last updated: September 7th, 2021

Singapore

Singapore has put in place a multi-pronged strategy with an emphasis on epidemiological surveillance, case finding, testing, mandatory reporting, contact tracing and containment.

There is a strict isolation policy for people who test positive. If they are clinically unwell  according to a set clinical protocol, they are hospitalised. If they are clinically well are housed and cared for in designated community isolation facilities. These community facilities include hotels, army barracks, stadiums, and exhibition halls which have been repurposed. Clinically well individuals are closely monitored by designated healthcare professionals at these facilities.

Extensive contact tracings done for all positive cases, in April 2020 there were more than 1,300 Singapore Armed Forces personnel and civilians deployed to contact tracing. This is complemented with the use of technology.

The country has a Disease Outbreak Response System Condition (DORSCON) framework. The severity of an outbreak and associated actions are highlighted through a colour-coded system

Source:

Last updated: November 2nd, 2021

Sweden

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

Last updated: November 30th, 2021

Thailand

Thailand experienced the first wave of COVID-19 during March and April 2020, prompting the government to declare a nationwide emergency curfew on the 25th March 2020. Even if the government relaxed the measures after the first COVID-19 outbreak was declared to be under control in May 2020, most Thai people have continued to practice social distancing (Srifuengfung et al., 2021).

References:

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://dx.doi.org/10.1016/j.jad.2021.08.044

Last updated: January 14th, 2022

Turkey

The government imposted a curfew on people aged 65 and older, as of 22nd March 2020. This became became a partial curfew on the 1st of June 2020, when infection rates had started to decrease. The hours that people were authorised to go out varied according by region and changed according to infection rates. As of 22nd November 2020, individuals aged 65?years and over have been allowed to go out between 10:00–13:00?hours (Arpacioglu et al., 2021).

References:

Arpacioglu S, Yalçin M, Türkmenoglu F, Ünübol B, Çelebi Çakiroglu O. Mental health and factors related to life satisfaction in nursing home and community-dwelling older adults during COVID-19 pandemic in Turkey. Psychogeriatrics. 2021 Nov;21(6):881-891. doi: 10.1111/psyg.12762.

Last updated: January 12th, 2022

Scotland (UK)

On the 1st March 2020, the first positive case of COVID-19 was confirmed in Scotland. Two days later, the UK Government announced its Coronavirus Action Plan; a four staged collective approach for the UK to contain and respond to the spread of the virus. The main advice given to the public at this stage was to wash their hands regularly with soap and water, for at least 20 seconds.

In the following months, a series of recommendations and guidance on isolating, social distancing and event closures were followed by the formal placement of the NHS on an emergency footing and eventually orders were enacted to ask all Scots to stay at home, as the UK entered lockdown on the 24th March 2020. School closures followed. Towards the end of May, the Scottish Government published its Routemap through the pandemic, outlining a five-phased approach to varying

Between May and July Scotland moved through Phases 1 to 3 of the Routemap. The test and protect scheme was rolled out from 28th May and the new contact tracing app was developed. By August, COVID-19 cases were increasing in certain parts of Scotland and localised restrictions were brought into place. On the 20th August 2020, the Scottish Government announced that Scotland would remain in Phase 3 and they set out updated dates for further changes.

Throughout September more localised restrictions were implemented as cases continued to spread and by November 2nd the new five-level strategic framework indicating varying levels of restrictions that would be required depending on the level of transmission of the virus came into effect.

The roll-out of the vaccination programme was announced in December with care home residents, their carers and frontline health care workers being vaccinated first. The over 80s would follow, along with other groups identified as being at risk of serious harm and death from the virus.

Further restrictions were introduced over the festive period and on 5th January mainland Scotland entered its second lockdown. All travel corridors were suspended from 18th January. At this point, the roll out of the vaccination programme was well under way and by 17th March, 44% of the adult population had received their first dose of the vaccine.

The second national lockdown would remain until restrictions began to be eased from 2nd April. From the 26th April, free lateral flow test kits were to be made available to anyone in Scotland without symptoms and Scots were encouraged to test themselves twice weekly. By the 15th May, 66.6% of eligible Scots had received their first dose of the COVID-19 vaccination.

Due to the success of the vaccination roll out, on the 19th July 2021, the whole of Scotland entered level 0. Up until November 2021, the focus of the Scottish Government has been continuing to administer vaccines, including the roll out of booster vaccinations.

Source:

https://spice-spotlight.scot/2021/11/26/timeline-of-coronavirus-covid-19-in-scotland/

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

United States

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

Last updated: September 8th, 2021

Vietnam

By the end of 2020, Vietnam had emerged as one of the few countries to effectively contain COVID-19, having gained epidemic response experience as one of the first countries in the world to successfully eliminate SARS in 2003. Vietnam had therefore made invaluable investments into its public health infrastructure prior to the current pandemic, including a national public surveillance system, a national public emergency operations centre (PHEOC), and four regional operations centres. These were all used to successfully manage the spread of COVID-19 immediately after the first outbreak (Thi Mai Oanh et al., 2021).

This experience also meant that the government was able to make quick decisions in response to the outbreak in the first wave. This included an immediate nationwide lockdown, limiting international flights, and shutting its borders. The aggressive contact tracing, testing, and quarantining of anyone who had been within three degrees of separation of any positive case, as outlined in section 2.01, also ensured that no potential cases could go undetected. Communications with the public were consistent and went out through a vast array of sources throughout the pandemic, with timely updates on the details of new cases and details of the actions being taken. A hard stance was also taken against fake news and the spreading of disinformation on social media (Thi Mai Oanh et al., 2021).

References:

Thi Mai Oanh, T., Khanh Phuong, N., & Anh Tuan, K. (2021). Sustainability and Resilience in the Vietnamese Health System Sustainability and Resilience in the Vietnamese Health System Sustainability and Resilience in the Vietnamese Health System. https://weforum.org/phssr

Last updated: December 30th, 2021   Contributors: Daisy Pharoah  |  

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

Australia

The Australian Health Protection Principal Committee (AHPPC), made up of the Chief Health Officers from each state and territory, the Chief Medical Officer, and representatives from key departments coordinates the pandemic response. The Australian government is the main funder and regulator of aged care services. Therefore, it has a key role in coordinating a response to COVID-19 in aged care services. State and territory governments also have responsibility for acute care and managing health emergencies within their jurisdictions. Responsibility was fragmented between the federal and state governments. Within the states, while funded by the Commonwealth and having to comply with Commonwealth standards, there are some nursing homes run by state governments  (eg Victoria runs 178 nursing homes) and some home care is provided by local government (eg in Victoria). (Charlesworth and Low, 2020).

The federal, state, and territory governments established a COVID-19 health sector response plan but this plan has been criticized for not specifically addressing the aged care sector. There is a need for a national COVID-19 aged care advisory body to establish protocols between the national and state governments (sources: Royal Commission, 2020; Charlesworth and Low, 2020).

Fragmentation between the Australian Government, state, and territory governments led to confusing and inconsistent messaging. It was not clear to providers and recipients who was in charge and what communication to follow. The Commission into Aged Care Quality and Safety recommended a specific aged care advisory body for COVID-19. The Australian Health Protection Principal Committee is responsible for responding to health emergencies. While they released a response plan in early in the pandemic, none of the committee’s members are aged care specialists.

Public health is a shared responsibility between the Commonwealth and the states. In respect of COVID the Commonwealth oversees whole of government (Commonwealth & state) coordination measures and the COVID national communication plan. In aged care the key COVID-19 Commonwealth roles are:

  • upskilling and supporting aged care providers to practice robust infection control—for example, stand-by infection control teams to be deployed if an aged care facility requires assistance with managing an COVID-19 outbreak
  • easing contractual restrictions on funding for services delivered in the community—for example, having the flexibility to cease group activities
  • increased funding for aged care providers—for example, additional funding to services that provide meals to people in the community
  • temporary delay in introducing new reforms and programs—for example, the introduction of payment administration changes for home care packages has been delayed
  • cross-portfolio arrangement to ease international student visa working arrangements within aged care, so they can work additional hours
  • coordinating with state and territory governments in the event of an outbreak
  • developing and making available communication material and resources for older people—for example, Coronavirus (COVID-19) advice for older people
  • funding grants—for example, the Commonwealth Home Support Programme (CHSP)—emergency support for COVID-19 and
  • introducing telephone options to support older people—for example, establishing a dedicated telephone line.

However, the states have the key responsibility for declaring and responding to emergencies, including public health emergencies such as COVID-19. “At the State level, each State has its own public health legislation to deal with a pandemic. It also has emergency legislation to deal with emergencies, including a pandemic. The States have exercised their powers to impose lockdowns, prohibit mass gatherings, limit the movement of people, close down non-essential businesses, and close schools, libraries and public facilities.” See  https://law.unimelb.edu.au/__data/assets/pdf_file/0003/3473832/MF20-Web3-Aust-ATwomey-FINAL.pdf

While cooperation during COVID between the Federal and state governments has been seen to be generally successful at a broad constitutional level, one major area of failure has been the lack of coordination between LTC run by the Commonwealth and the public hospital system run by the states: thus not “preventing the spread of coronavirus in aged care facilities… when nursing homes became infected with COVID-19, questions arose as to whether residents should be moved to hospitals, or treated in the nursing home, and who was responsible. After a number of crises in nursing homes, particularly during the second wave of the pandemic in Victoria, the Commonwealth and the State established the ‘Victorian Aged Care Response Centre’, which includes representatives from Commonwealth and State health departments, the aged care regulator, State and Commonwealth emergency management bodies and the defence force.”  See  https://law.unimelb.edu.au/__data/assets/pdf_file/0003/3473832/MF20-Web3-Aust-ATwomey-FINAL.pdf However this body has not been emulated in other states and is set to only exist until June 2022.

Other areas of state/federal jurisdictional tension in LTC have been in respect of the supply of PPE, the slow pace of the vaccine role out (and now booster role out) by the Commonwealth including of staff in LTC, adequate testing and tracing measures.

References:

Charlesworth, S & Low, L-F (2020) The Long-Term Care COVID-19 situation in Australia. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 12 October 2020 (click here)

Royal Commission into Aged Care Quality and Safety (2020) Aged care and COVID-19: a special report. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf 

Last updated: January 17th, 2022

British Columbia (Canada)

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

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

Last updated: November 2nd, 2021

Canada

A published paper critically reviews Canada’s response to the COVID-19 pandemic with a focus on the role of the federal government in this public health emergency, considering areas within its jurisdiction (international borders), areas where an increased federal role may be warranted (long-term care), as well as its technical role in terms of generating evidence and supporting public health surveillance, and its convening role to support collaboration across the country.

Source:

Allin, S., Fitzpatrick, T., Marchildon, G., & Quesnel-Valleé, A. (2021). The federal government and Canada’s COVID-19 Responses: From “we’re ready, we’re prepared” to “fires are burning.” Health Economics, Policy and Law. https://doi.org/10.1017/S1744133121000220

Last updated: November 30th, 2021   Contributors: William Byrd  |  

Chile

The Ministry of Health, the National Service for Older People (Servicio Nacional de Personas Mayores, SENAMA), and the Chilean Geriatrics and Gerontology Society (SGGCh) developed a set of prevention and management measures. Additionally, SENAMA implemented a mitigation strategy that included face to face technical support, supply of PPE, testing, and temporary transfer of residents who had tested positive to other health settings (Browne et al., 2021).

References:

Browne, J., Palacios, J., Madero-Cabib, I., Dintrans, P.V., Quilodrán, R., Ceriani, A. and Meza, D., 2021. Enablers and Barriers to Implement COVID-19 Measures in Long-Term Care Facilities: A Mixed Methods Implementation Science Assessment in Chile. Journal of Long-Term Care, (2021), pp.114–123. DOI: http://doi.org/10.31389/jltc.72

Last updated: December 22nd, 2021

Denmark

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

Lessons learned

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

Last updated: September 8th, 2021

Finland

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

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

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

Last updated: September 8th, 2021

France

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

Last updated: December 3rd, 2021   Contributors: Camille Oung  |  

Germany

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

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

Last updated: September 8th, 2021

Iceland

Before the Covid-19 outbreak, even though Iceland had systems for the healthcare sector and emergency preparedness, it was missing specific procedures for the LTC sector. For this reason, Iceland quickly advanced new LTC-specific measures which included written recommendations, webpages, and rapid response teams. For example, if a Covid-19 outbreak took place in LTC facilities, the health workers were quarantined and replaced by one of the rapid response teams. Thanks to these preventive measures, as of October 2021, LTC Covid-19 death rates in LTC facilities remained very low.

Source:

Rocard, E., P. Sillitti and A. Llena-Nozal (2021), “COVID-19 in long-term care: Impact, policy responses and challenges”, OECD Health Working Papers, No. 131, OECD Publishing, Paris, https://doi.org/10.1787/b966f837-en.

Last updated: December 12th, 2021   Contributors: Elisa Aguzzoli  |  

Ireland

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

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

Last updated: September 8th, 2021

Israel

LTC facilities in Israel are supervised by the Ministry of Health and/or the Ministry of Welfare and Social Affairs. At the same time, the National Insurance carries responsibility for LTC services in the community.

Early in the pandemic the vulnerability of people with LTC needs was recognized which led to the establishment of the ‘Fathers and Mothers Shield task force’. This taskforce was made up of representatives of all relevant government ministries, the Israeli army, Israeli intelligence organizations, and public sector organizations. Measures implemented by the task force include an increase in testing among residents and staff in residential LTC settings, setting up Corona Wards in geriatric hospitals and LTC facilities, and regulation around visiting. The authors of a paper assessing the management of COVID-19 in the long-term care sector concluded that the centralized management implemented in response to the pandemic ‘had led to a welcome change in LTC policy in Israel’.  At the decline of the 4th wave of the pandemic in Israel, it is hard to say that the centralized management of the pandemic in LTCFs will impact broader and long-term changes regarding the organization of the LTC system in Israel (Tsadok-Rosenbluth, 2021).

Sources:

Tsadok-Rosenbluth, S., Hovav, B., Horowitz, G. and Brammli-Greenberg, S., 2021. Centralized Management of the Covid-19 Pandemic in Long-Term Care Facilities in Israel. Journal of Long-Term Care, (2021), pp.92–99. DOI: http://doi.org/10.31389/jltc.75

Last updated: December 5th, 2021   Contributors: Shoshana Lauter  |  

Italy

In Italy, as in other countries, measures to mitigate the impact of COVID-19 in care homes were adopted later than in the national health services. A detailed study attributes this delay (as well as the lack of timely resources to support the implementation of measures) to policy legacies resulting in nursing homes lacking recognition and visibility and being seen as a marginal part of the Long-Term Care system.

This is also connected with the governance of LTC sector, allocating to Regions the responsibility of regulating elderly sector. This led to differences in the regional approaches, also following the spread of Covid-19 across the country.

However, the national level kept a significant role in allocating resources (such as PPE and personnel) during the first phases of the pandemic. I.e. in early April, 2020, The Ministry of Health published the operational guidelines for a “rational”  use of Personal Protection Equipment (PPE) in healthcare and LTC settings. The guidelines list the basic principle to ensure personal protection and recommends that regional authorities guarantee adequate provision of PPE and engage in training activities for care workers. Also, Ministry of Health published the first guidelines for COVID-19 management in nursing homes, requiring providers to ensure training of care workers and suggesting extensive testing.

Much of the legislation was then promoted from the Regions, since they represent the institutional level in charge of defining the operating rules and guidelines for the LTC sector. During the pandemic, Regions (and local health authorities) gave directions, regulations and instructions to the health institutions for older people, for the management of COVID-19 cases and their containment and prevention. The spread of the virus in the sector was very vast as witnessed by previously exposed data: it had a significant impact on all settings providing care to a population particularly at risk. The combination of these two factors has led to the need to define emergency and risk management plans which had to be differentiated between the LTC sector and the “rest of the world”, precisely to take into account these specificities and, in some cases, guarantee additional protection to the older population. The healthcare sector managers, for their part, have activated internal risk management strategies, aimed at protecting their structures and ensuring the maximum quality of assistance. At the same time, however, common regional instructions were also needed to coordinate action in the LTC domain, also guaranteeing homogeneous treatment consistent with the simultaneous “pure health” policies that were implemented. (Berloto et al. 2020)

Sources:

León, M., Arlotti, M., Palomera, D., & Ranci, C. (2021). Trapped in a Blind Spot: The Covid-19 Crisis in Nursing Homes in Italy and Spain. Social Policy and Society, 1-20. doi:10.1017/S147474642100066X

Berloto, Longo, Notarnicola, Perobelli, Rotolo (2020), Il settore sociosanitario per gli anziani a un bivio dopo l’emergenza Covid-19: criticità consolidate e prospettive di cambiamento, Rapporto OASI 2020, Egea Milano

Last updated: December 4th, 2021   Contributors: Elisabetta Notarnicola  |  Eleonora Perobelli  |  

Japan

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

Last updated: September 8th, 2021

Netherlands

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

Last updated: September 8th, 2021

Poland

The decentralization of authority has had negative consequences for pandemic response (particularly during the first wave of the pandemic), with local authorities responsible for social welfare homes, and the split between healthcare and social sector had a negative impact on responding to the threat quickly and comprehensively. In case of social welfare homes, the management of the crisis depended on the ability of the local authorities and managers to mobilize the resources and led to geographical differences in pandemic response (sources:  Responding to the Covid19 in residential long-term care in Poland ; ESPN Flash Report 2020/43).

Last updated: November 24th, 2021   Contributors: Joanna Marczak  |  

Republic of Korea

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

Last updated: September 8th, 2021

Singapore

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

Last updated: September 8th, 2021

Spain

In Spain, in principle, 4 different ministries were tasked with responding to the pandemic, but in practice the Ministry of Health had the most visible role (this was also the case at regional level. The governance of the pandemic in relation to the Long-Term Care system has varied by region and in the different phases of the pandemic. Local governments were also involved, specifically with regards to logistical support and in rural areas. There was also support from the army, civil protection volunteers, police, the fire service, and NGOs. A report on the organisation and governance of the pandemic response in care homes concluded that being better prepared would have reduced the reaction time, which has been identified as a key factor in the impact of the pandemic on the Spanish care home population. There was also a lack of clarity over responsibility, where 45% of the population thought that responsibility of the pandemic response in care homes was with the regional governments, 24% with the central government, and 28% with both (Del Pino et al, 2021).

The delay in adopting (and having enough resources to implement) preventative measures in care homes, compared to in health care services has been attributed to policy legacies resulting in nursing homes lacking recognition and visibility and being seen as a marginal part of the Long-Term Care system (Leon et al, 2021)

References:

Del Pino, E., Moreno Fuentes, F. J., Cruz-Martínez, G., Hernández-Moreno, J., Moreno, L., Pereira-Puga, M. and Perna, R. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Spain’, MC COVID-19 working paper 13/2021. http://dx.doi.org/10.20350/digitalCSIC/13688

León, M., Arlotti, M., Palomera, D., & Ranci, C. (2021). Trapped in a Blind Spot: The Covid-19 Crisis in Nursing Homes in Italy and Spain. Social Policy and Society, 1-20. doi:10.1017/S147474642100066X

Last updated: November 23rd, 2021

Sweden

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

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

Last updated: September 8th, 2021

England (UK)

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

Last updated: November 30th, 2021

Scotland (UK)

“For those in long term care facilities who are often frail with complex needs, HPS has published specific guidance for infection prevention and control in social or community care and residential settings.  In addition the Chief Medical Officer has published specific advice about visitors and admissions to care homes” (source: GOV.SCOT).

Further Reading:

https://www.gov.scot/publications/coronavirus-covid-19-clinical-guidance-care-at-home-housing-support-and-sheltered-housing/

https://www.webarchive.org.uk/wayback/archive/20200516095432/https://www.gov.scot/publications/coronavirus-covid-19-clinical-and-practice-guidance-for-adult-care-homes/

https://www.gov.scot/publications/coronavirus-covid-19-cmo-cno-cswa-letter-on-social-care-settings/

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  Elizabeth Lemmon  |  David Henderson  |  David Bell  |  

United States

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

Last updated: September 8th, 2021

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

Australia

The federal, state, and territory governments established a COVID-19 health sector response plan but this plan has been criticized for not specifically addressing the aged care sector. There is a need for a national COVID-19 aged care advisory body to establish protocols between the national and state governments (sources: Aged Care and COVID-19 report; Charlesworth and Low, 2020).

References:

Charlesworth, S & Low, L-F (2020) The Long-Term Care COVID-19 situation in Australia. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 12 October 2020.

Last updated: December 22nd, 2021

Austria

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

Last updated: November 2nd, 2021

British Columbia (Canada)

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

Last updated: November 6th, 2021

Chile

The Ministry of Health (MoH), the National Service of Older People (Servicio Nacional del Adulto Mayor, SENAMA), the Chilean Geriatrics and Gerontology Society (GGS), and the main non-profit organizations started a working group to coordinate the implementation of prevention and control measures (Browne et al., 2020).

References:

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Last updated: December 22nd, 2021

Denmark

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

Last updated: September 8th, 2021

Finland

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

Last updated: September 8th, 2021

France

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

Last updated: September 8th, 2021

Germany

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

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

Last updated: November 2nd, 2021

Ireland

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

Last updated: November 2nd, 2021

Israel

Following an outbreak in LTCFs in mid-March and a national outcry for the need of increased attention to LTC-specific needs, Israel’s Government rolled out a national task force and plan entitled ‘The Fathers and Mothers Shielsd’ (Magen Avot V’Emahot) in April 2020 (Source: Ministry of Health). The task force served as a coordination effort catered explicitly to the care and concerns of LTCFs, ‘to ensure national resilience and protect the elderly populations and the population of people with disabilities staying in out-of-home settings, while providing optimal care in a comprehensive national vision’ (Source: Health.Gov). Among some of the top priorities of this project were: increasing the scope of COVID-19 testing in LTCFs, including in those with no identified COVID-19 patients; upgrading protection measures for both staff and residents of LTCFS, including (dis)infection training; prohibiting LTCF staff members from working in more than one facility; and allowing families to visit only in special instances (and subject to rules of social distancing) (Source: Tsadok-Rosenbluth et al, 2021).

References:

Tsadok-Rosenbluth, S., Hovav, B., Horowitz, G. and Brammli-Greenberg, S., 2021. Centralized Management of the Covid-19 Pandemic in Long-Term Care Facilities in Israel. Journal of Long-Term Care, (2021), pp.92–99. DOI: http://doi.org/10.31389/jltc.75

 

Last updated: December 5th, 2021   Contributors: Shoshana Lauter  |  

Italy

At the end of 2020, three different national «commissions» on the future of nursing homes have been established by the central government. These are: one parliamentary investigation commission on Covid-19 death in nursing homes (Commissione Parlamentare di Inchiesta) that has the aim of assessing mortality during the first and second wave and establishing potential responsibilities of managers and public officials with this respect; one specialized commission promoted by the Ministry of Health (Commissione Monsignor Paglia) with the aim to reform nursing homes sector mainly involving geriatricians and medical experts; one specialized commission promoted by the National Agency for Excellence in Health Care Services (AGENAS) with the aim of defining effective tools for integrated care. These different commissions have a specific focus on residential care, with a medical perspective (social care experts are missing).

Sources:

AAVV, 2021, PIANO NAZIONALE DI RIPRESA E RESILIENZA MISSIONE SALUTE, Monitor, Anno II, Numero 45

Last updated: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: September 9th, 2021

Singapore

The following response does not describe a national COVID taskforce, but instead one set up by a nursing home in Singapore in the early stages of the pandemic.

In their recently published study, Udod et al. (2021) describe pandemic measures reported by a nursing home in Singapore. This home set up a nursing taskforce committee and command centre as soon as news of the COVID-19 outbreak was reported in China in January 2020. This taskforce was responsible for reviewing the latest government guidelines and liaising with key stakeholders (such as the Ministry of Health), managing a surveillance system for staff and visitor traffic, and mobilising the necessary resources. Non-nursing administrative staff were assigned to help the taskforce with resource allocation (in the face of supply shortages), data collection, and other administrative tasks. This meant that when cases when widespread community transmission caused cases to spike in May of that year, the nursing home had already established organisational guidelines and vital infrastructure to be able to cope (Udod et al., 2021).

Last updated: January 11th, 2022   Contributors: Daisy Pharoah  |  

Sweden

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

Last updated: September 9th, 2021

England (UK)

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

Additional Sources:

https://www.gov.uk/government/news/national-action-plan-to-further-support-adult-social-care-sector

https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-care-homes/coronavirus-covid-19-care-home-support-package

Last updated: December 5th, 2021   Contributors: William Byrd  |  

United States

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

Last updated: September 9th, 2021

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

Austria

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

Last updated: September 9th, 2021

British Columbia (Canada)

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

Last updated: November 2nd, 2021

Denmark

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

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

Last updated: September 9th, 2021

Finland

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

Last updated: September 9th, 2021

France

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

Last updated: September 9th, 2021

Germany

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

Last updated: November 2nd, 2021

Italy

One of the major problems with Italy’s management of the COVID-19 crisis, was the absence of care coordination between care settings. The efforts have been focused on acute hospitals, trying to preserve their safety and resilience. This implied that, in many Regions, transfers from Long Term Care services (nursing or care homes) to Hospital has been blocked, providing guidelines to treat even the most severe case without access to the NHS. The same applied for emergency care. No specific national measures have been promoted on this. In some territories (such as Lombardy and Sardinia) nursing homes were formally asked to accept patients transferred from hospitals, becoming COVID-19 centres. Nursing homes representatives refused to accept this proposal, considering that they did not have neither appropriate staff nor equipment. Concerning staff, transfer from settings happened on voluntary basis and following local necessity. We have records of situations were trained staff were moved from acute care setting to nursing homes to provide training and expertise. This happened following specific agreement between providers. At the same time, many providers reported that they have been losing nurses and care personnel following the massive campaign of recruitment from the NHS. In March an extraordinary enrolment of health staff was implemented in Lombardy, Piedmont, Veneto, Apulia and other regions, so that many professional care workers applied, attracted by public sector contractual conditions (generally better than contracts applied in private nursing homes).

With respect to the coordination measures between the health and socio-healthcare sector, an analysis (Berloto et al, 2020)  was made of whether and how integration methods were established between the hospital, regional and social-health network in the context of the COVID-19 emergency. On this, no Region among those analyzed has adopted measures specifically aimed at this objective. Even in the cases mentioned above, Liguria and Tuscany, the operational units responsible for coordination between settings had the primary objective of evaluating and managing individual cases and not the organizational supervision of the network as a whole. The topic was delegated to the local level, in the direct relationship between healthcare institutions and care homes which, on the basis of highly differentiated indications, also the result of historical relationships and dynamics, gave themselves operating methods and rules. The management of the patient/user relationships and professionals flows between the network nodes has in some cases been hampered if not blocked, for example with the prohibition of transfer to the emergency room or hospitals. The objective pursued was therefore opposite: instead of reinforcing coordination between settings, the aim was to isolate them and make them independent.

Apart from the Lazio experience, no specific guidelines or indications were identified in Phase 2 with respect to the coordination between the health and social and health sector. Also, in this Phase 2 the theme was not put on the “legislative” agenda of the Regions and indications supported by structured initiatives and regulations were not produced. Rather, nursing homes have been kept separated without regulating common elements with other services.

Source:

Perobelli, Berloto, Notarnicola, Rotolo, 2021, L’impatto di Covid-19 sul settore LTC e il ruolo delle policy: evidenze dall’Italia e dall’estero, in Le prospettive per il settore socio-sanitario oltre la pandemia. Egea: Milano

Last updated: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Netherlands

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

Last updated: November 30th, 2021

Poland

At the onset of the pandemic, significant issues were reported relating to lack of coordination between health and social care which impaired pandemic response.  Recommendations issued by experts to address shortages in LTC sector include improved coordination between health and social care and regulation (source: ESPN Flash Report 2020/43).

Last updated: November 18th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Singapore

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

Last updated: September 9th, 2021

Spain

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

Last updated: September 9th, 2021

Sweden

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

Last updated: September 9th, 2021

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

Australia

The Australian government announced $440 million Australian Dollars to train aged care staff in infection control, increase the number of staff, and for telehealth services. Additionally, $234.9 million Australian Dollars was included as a COVID-19 retention bonus to ensure adequate staffing in the workforce (source: Charlesworth and Low, 2020).

References:

Charlesworth, S & Low, L-F (2020) The Long-Term Care COVID-19 situation in Australia. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 12 October 2020.

Last updated: December 22nd, 2021

Austria

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

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

Last updated: September 9th, 2021

France

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

Last updated: September 9th, 2021

Germany

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

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

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

Last updated: September 9th, 2021

Israel

Oversight of COVID-19 has been given to the Ministry of Health, which set up the National Coronavirus Information and Knowledge Centre alongside the armed forces (IDF) Intelligence Directorate. Oversight the extension of welfare benefits is in the hands of the National Insurance.

In the COVID-19 Economic Plan first released in April 2020, under immediate civil and health provisions, measures towards the reduction of risk for high-risk populations included: 130,000 hot meals to older people and people in-need, bi-weekly groceries baskets, and food vouchers for at-risk families, people with disabilities living in the community, and people with mental health problems in the community.

Many day centers for older people were closed due to coronavirus. According to the National Insurance website, day centers contacted their service users individually to help them find alternative programs (Source: GOV.IL). However, day centers reopened in July, 2020.

It is important to note that over time, specific guidelines were developed for different types of settings. For instance, continuing care retirement communities (called sheltered housing in Hebrew). These settings that cater to independent and relatively affluent older people) now have their own specific guidelines. Hence, there is now a better understanding of the unique characteristics of different LTCFs.

Last updated: December 5th, 2021   Contributors: Shoshana Lauter  |  LIAT AYALON  |  

Italy

During the first and second waves of the pandemic access to long term care was deeply impacted. Initially, new admission have been stopped. Generally speaking, Regions were oriented to order the closure of the services (both in terms of cessation of activities and of physical limitation of access) by regulating the methods of access. The focus was on the “physical” containment of existing situations and on the prevention of new outbreaks, giving indications on the obligations of use of personal protective equipment (PPE) and on the safety procedures to follow. With respect to home care, there were opposite attitudes with Regions that blocked the services and the access to people’s homes, and others that instead incentivized them. This led to negative impact on equal accesso to care (Cipriani and Fiorino, 2020).

From Autumn 2020 access to care was re-established but this was not sufficient to restore previous levels of take up rates, with a double effect on wellbeing and health outcomes of elderlies and on economic performances of care provider. Concerning the latter, national and regional measures have been enacted to provide extra funding so to mitigate the losses of activities consequences of the first waves of the pandemic. One example is Piedmont region.

Sources:

Cipriani, G., & Di Fiorino, M. (2020). Access to care for dementia patients suffering from COVID-19. The American Journal of Geriatric Psychiatry, 28(7), 796-797.

Last updated: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Luxembourg

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

Last updated: September 9th, 2021

Netherlands

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

Last updated: September 9th, 2021

Poland

The government promoted volunteering services in the community and neighbourhood to support older people with care needs in household activities or with groceries, among others (source: Ageing policies – access to services in different EU Member States).

Last updated: November 24th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Republic of Korea

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

Last updated: September 9th, 2021

England (UK)

During March and April 2020, there was a substantial reduction in hospital admissions among care home residents. Elective admissions reduced to 58% of the 5-year historical average and emergency admissions to 85% of the 5-year historical average. By reducing admissions, care home and NHS teams may have reduced the risk of transmission, but there may have also been an increase in unmet health needs.

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

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

Additional Source:

https://www.health.org.uk/publications/reports/adult-social-care-and-covid-19-assessing-the-impact-on-social-care-users-and-staff-in-england-so-far

Last updated: December 5th, 2021   Contributors: William Byrd  |  

Scotland (UK)

The Adult social care – winter preparedness plan: 2021-22 sets out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. This includes provisions to maintain high quality integrated health and social care services across cares settings. There has been £62 million allocated for 2021/22 to help with building capacity in care at home community-based services. This funding is for:

  1. Expanding existing services, by recruiting internal staff; providing long-term security to existing staff; enabling additional resources for social work to support complex assessments, reviews and rehabilitation; commissioning additional hours of care; commissioning other necessary supports depending on assessed need; enabling unpaid carers to have breaks.
  2. Funding a range of approaches to preventing care needs from escalating, such as intermediate care, rehabilitation or re?enablement and enhanced MDT support to people who have both health and social care needs living in their own homes or in a care home.
  3. Technology-Enabled Care (TEC), equipment and adaptations, which can contribute significantly to the streamlining of service responses and pathways, and support wider agendas.

Source:

https://www.gov.scot/publications/adult-social-care-winter-preparedness-plan-2021-22/pages/4/

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

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

Australia

The Department of Health publishes weekly traffic light reports of the COVID-19 situation across Australia, which includes details about cases, testing, and capacity nationwide and in individual states. Specific systems have been developed in individual states. For example, the Victorian Aged Care Response Centre brings together Commonwealth and Victorian state government agencies in a coordinated effort to manage the impact of the COVID-19 pandemic in aged care facilities.

Last updated: December 22nd, 2021

British Columbia (Canada)

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

Last updated: November 6th, 2021

Denmark

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

Last updated: September 9th, 2021

Finland

Finland has very good data through its health and social care registers, both in terms of data and coverage. However, during the pandemic up-to-date data on, for example, deaths in care homes and among home care clients was not available. This is in part because, in order to guarantee the quality of the data, the registers take a substantial amount of time to be updated. Statistics Finland stepped in to publish preliminary data on deaths.

Source:

Last updated: November 9th, 2021

France

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

Last updated: September 9th, 2021

Germany

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

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

Last updated: September 9th, 2021

Ireland

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

Last updated: September 9th, 2021

Israel

COVID-19 is being tracked by the Israel Ministry of Health’s Data Dashboard. The Ministry has introduced a smartphone app, HaMagen (“The Shield”), for their track and trace programme. The Ministry’s Center for Disease Control also publishes a broader surveillance of respiratory viruses each week. Israel has an extensive and highly digitized online medical system. This made the creation of appointment smartphone apps to set up automatic scheduling and appointment reminders for vaccination relatively easy (Video:14:10). Nonetheless, the Dashboard does not post data concerning LTCFs. Daily reports of the monitoring and operations of the national task force were published on the task force’s website daily until February 2021 [in Hebrew].

Last updated: December 5th, 2021   Contributors: Shoshana Lauter  |  LIAT AYALON  |  

Italy

Absence of data and figures of what happened during Covid-19 in LTC sector has been acknowledged as one of the main critical issues for the sector and for the impact of the pandemic by the newly established commissions on the post-covid reforms that have been enacted in the last months (2021). At the national level, the Istituto Superiore di Sanità was the only actor collecting comparable and robust figures on what was happening in nursing homes. This was done through a voluntary national survey submitted to nursing homes providers in three rounds: April 2020, June 2020 (for an international report on this data see Lombardo et al.). Regions enacted some ex-post data collection with limited relevance and poor continuity of data. During 2021 the same institute promoted a new survey on the surveillance of vaccination and spread of Covid-19 in nursing homes, covering the period October 2020-September 2021.

Sources:

Lombardo, F. L., Salvi, E., Lacorte, E., Piscopo, P., Mayer, F., Ancidoni, A., … & Nursing Home Study Group. (2020). Adverse events in Italian nursing homes during the COVID-19 epidemic: a national survey. Frontiers in psychiatry, 11.

Last updated: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

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

Last updated: September 9th, 2021

Netherlands

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

Last updated: September 9th, 2021

Republic of Korea

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

Last updated: September 9th, 2021

Spain

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

Last updated: November 23rd, 2021

United Kingdom

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

Last updated: January 2nd, 2022

Scotland (UK)

In August 2020, the Scottish Government commissioned the use of a new web-based tool- The Turas Care Management Tool or Safety Huddle tool – to help monitor the risk of COVID-19 within Scotland’s care homes. The tool provides a central location for all Scottish care homes to record information on infection rates, demand on services and staff testing. The purpose of the tool was to provide early warning signs of emerging trends to allow homes to intervene early.

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

United States

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

Last updated: September 9th, 2021

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

Australia

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

The Australian Aged Care Quality and Safety Commission phoned all home care services to offer support during COVID-19. There has been $59.3 million AUD of funding from the government allocated to meals on wheels, $50 million AUD to fund home-delivered meals, and $9.3 million AUD on emergency food supply boxes. Additionally, $10 million AUD has been allocated to the Community Visitors Scheme, which facilitates telephone calls and virtual friends for socially isolated people in community based aged care (Charlesworth and Low, 2020).

References:

Charlesworth, S & Low, L-F (2020) The Long-Term Care COVID-19 situation in Australia. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 12 October 2020.

Last updated: December 22nd, 2021

Austria

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

Last updated: September 10th, 2021

British Columbia (Canada)

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

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

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

Last updated: November 6th, 2021

Chile

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

References:

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Last updated: December 22nd, 2021

Denmark

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

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

Last updated: September 16th, 2021

France

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

Last updated: September 10th, 2021

Germany

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

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

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

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

Last updated: September 10th, 2021

Hong Kong (China)

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

Last updated: September 10th, 2021

Ireland

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

Last updated: September 10th, 2021

Israel

At the beginning of April 2020 the LTCFs management and owners have cried for financial help. After many discussions (and one canceled High-court appeal), they received some support, mainly for the purchase of PPE. A few months later, some institutions received direct financial support mainly for openning inpatient Covid-19 wards within the facilities (primarily Geriatric institutions and hospitals) and for increasing caregivers shifts (source: Health.GOV).

Some have criticized the Ministry of Health for transferring funds to institutions without proper oversight of the intended use of those grants (source: Calcalist).

Care receivers in the community were entitled to replace the in-kind benefit with a cash benefit due to the lack of available caregivers and the concern some families had of having a non-family caregiver entering the older person’s household.

Last updated: December 5th, 2021

Netherlands

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

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

Last updated: September 10th, 2021

Norway

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

Last updated: September 10th, 2021

Poland

Providers of residential care faced financial shortages for a variety of reasons (e.g. additional costs of PPE, increasing prices of hygienic/cleaning products, food during pandemic, increasing costs of staff (both wages and food) who resided in the homes during quarantine). Additional money from the national and local governments partly addressed the financial challenges,  NGOs, firms’ as well as private donations were also invaluable in addressing financial gaps, however residential care providers were increasingly considering increasing costs for residents (source: Domy-pomocy-spolecznej-w-dobie-pandemii-19-11.pdf (hfhr.pl).

During the pandemic, the central government put additional financial resources for equipping LTC facilities. The Ministry of Family, Labour and Social Affairs decided to devote an additional 20 million z? (ca. €4.7 million) to addressing protection needs in social welfare homes. These resources have been distributed to social welfare homes by the regional authorities, and have been used to support investments in equipment, rearrange facilities according to the sanitary guidelines, and to improve access to protection and preventive measures (masks, gloves, etc.). In the healthcare sector, all financial needs related to COVID-19 are financed from the central budget. The pandemic highlighted the underfunded nature of the LTC system and experts highlight the need for increased payments for services (source: ESPN Flash Report 2020/43). 

Last updated: November 3rd, 2021   Contributors: Joanna Marczak  |  

Sweden

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

Last updated: November 30th, 2021

England (UK)

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

On May 15, a £600 million Infection Control Fund was introduced as part of a wider package of support for care homes to help providers reduce the rate of transmission in and between care homes and support wider workforce resilience. The funding is being paid in 2 tranches. The first was paid to local authorities on May 22. The second tranche was paid in early July. This money has been allocated to local authorities and is in addition to the funding already provided to support the adult social care sector during the COVID-19 pandemic. Local authorities are expected to pass 75% of the initial funding directly to care homes in their area for use on infection control measures, including to care homes with whom the local authority does not have existing contracts. The second payment will be contingent on the first being used for infection control. The remaining 25% must also be used for infection control measures, but local authorities are able to allocate this based on need.

Local authority directors responsible for administering this new fund have expressed “deep concern” that it apparently cannot be used by homes to purchase PPE, requires detailed and prescriptive accounting and reporting, does not cover domiciliary care and supported living schemes, resulting in “a confused and overly bureaucratic system, which makes it difficult for providers to claim and impossible for local authorities to deliver within the required timescales”. An independent analysis commissioned by local authorities estimated that providers could face over £6 billion in additional costs during April to September 2020, because of higher staffing costs (mainly due to cover staff who are ill or self-isolating), PPE, and extra cleaning and overhead costs.

On October 1, the Department of Health and Social Care (DHSC) announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, in particular by helping to reduce the need for staff movements between sites. Half will be paid on October 1, and the other in December. Local authorities should pass on 80% of this to care homes on a per bed basis and CQC-regulated community care providers on a per user basis, both of which must be within the local geographical area. The other 20% should be used to support care providers, allocated at the discretion of the local authority. This allocation cannot be used to pay for the cost of purchasing extra PPE.

As recently as November 3, 2020, 75 care organisations called on the government to align the Carers Allowance with Universal Credit, as it is currently in Scotland, to recognise the disproportionate impact of the pandemic on carers.

On December 23, DHSC announced £149 million to support the rollout of Lateral Flow Device (LFD) testing in care homes. This funding will be paid in January 2021. All funding must be used to support increased LFD testing in care settings. Local authorities should pass on 80% of this to care homes on a per bed basis, which must be within the local geographical area. The other 20% should be used to support care providers to implement increased LFD testing, allocated at the discretion of the local authority.

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

On January 17, 2021, DHSC announced the Workforce Capacity Fund, worth £120 million, which was to support local authorities in boosting staffing levels and deliver measures to supplement and strengthen adult social care staff capacity to ensure that safe and continuous care is achieved. This funding is available until March 31. The first £84 million (70%) will be paid in early February and the second £36 million (30%) will be paid in March.

On March 12, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support (the Rapid Testing Fund, the Infection Control Fund, and the Workforce Capacity Fund) was crucial in enabling the social care sector to function throughout the pandemic, and is due to expire at the end of March.

On March 18, LaingBuisson reported that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund. On the same day, the National Care Forum reported that there were announcements around additional funding for hospital discharge.

Updated on October 1, the 2021 to 2022 Better Care Fund is one of the national vehicles for driving health and social care integration. It requires clinical commissioning groups (CCGs) and local government to agree a joint plan, owned by the Health and Wellbeing Board (HWB). This will total approximately £6.9 billion, with a minimum NHS (CCG) contribution of nearly £4.3 billion, an improved Better Care Fund (iBCF) of just over £2 billion, and a Disabled Facilities Grant (DFG) of just over £570 million.

Additional Sources:

https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan

https://www.gov.uk/government/publications/adult-social-care-infection-control-fund/about-the-adult-social-care-infection-control-fund

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/885214/14_May_2020_-_MSC_letter_-_support_for_care_homes_1.pdf

https://www.disabilityrightsuk.org/news/2020/november/75-organisations-again-call-government-make-carer%E2%80%99s-allowance-fairer-carers

https://www.nuffieldtrust.org.uk/news-item/what-are-carers-entitled-to</