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 was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

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, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) 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

OECD countries

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

WHO data

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).

European countries

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).

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: February 15th, 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).

A survey found that many Austrians experienced barriers to accessing care services, with availability of services being a major factor, as well as cost. Compared to other countries in the European Union, Austrians reported more concerns about the availability of residential care. This lack of availability of services translate in over-reliance on informal support and low confidence on the ability of the system to address future care needs (Ilinca et al., 2022)

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

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.

Ilinca S., Simmons C., Leichsenring K., Kadi S., Ondas K. & the InCARE team (2022) Attitudes, experiences, and expectations on long-term care in Austria. InCARE Factsheet No.1.

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: March 22nd, 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: February 16th, 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 (Sowa-Kofta et al., 2017).

References:

Sowa-Kofta, A., Wija, P. (2017). Czech Republic: Emerging policy developments in long-term care. CEQUA country report.

Last updated: February 3rd, 2022

Denmark

The Long-Term Care (LTC) system in Denmark is a universal and primarily public system. Access to LTC services is at no cost for home-based care, and with a means-tested co-payment for residential care. The LTC system has strong public and political support. It is a highly decentralized system, organised, and financed at the municipal level. Provision is mixed, with public and for-profit providers providing home care, and in the residential sector, non-profit providers also operate.

There is historically a strong emphasis on community-based care, integration, prevention and  professionalization of care staff (WHO, 2019). The development of long-term care for older people has in Denmark been heavily influenced by the various reports from the National Commission on Ageing in the 1980s. The policy recommendation was here not least to encourage the increasing use of private resources, such as the involvement of voluntary organizations, but also referred to ensuring self-care (hjælp-til- selvhjælp) in old age, and in this way encourage a more preventive and rehabilitative approach. The reports also introduced principles of continuity and normalization, meaning that regardless of need for care the provision of care should aim at ensuring the continuation of the older person’s preferred way of living. From the 1990s onwards, marketisation and, more implicit, privatisation has been encouraged (Rostgaard, 2007).

In 2015, reablement was introduced in the legislation and must be offered instead of conventional home care is the older person is assessed to have so-called potential for this intervention (Rostgaard et al, 2023).

The main law regulating social service provision and, implicitly, LTC provision is the Social Services Act, which passed in 1998. The Social Services Act emphasizes the users’ right to influence social service provision and enshrines the highly decentralized nature of the system, putting municipalities in a key position to shape long-term care. As health care provisions are under the scope of the Health Care Act, there is political awareness of the problems of coordinating interventions and time-consuming double documentation. At present (2022), work is therefore carried out to reform the legislation and combine the two laws under one, a Senior Citizens’ Act.

In recent years there has been a decrease in the number of people who receive home care services, which resulted in unmet need and more burden placed on unpaid carers (WHO, 2019; Rostgaard, 2022 et al).

References:

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

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

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

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

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

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

Last updated: June 28th, 2023

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.

Last updated: February 16th, 2022   Contributors: Camille Oung  |  

Germany

In 1995/96, a statutory Long-Term Care Insurance (LTCI) Scheme has been established in Germany. LTCI is mandatory to the population. Approximately 88% of the population is insured by the social LTCIs, 11% by private funds (Blümel et al., 2020). LTC benefits based on the LTCI are not means-tested.

In 2019, there were about 4.13 million beneficiaries of the LTCI that have been allocated into care grades 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%). Those living in their own home may choose between cash and in kind-benefits from LTCI. More than 60% receive cash benefits to be supported by informal carers only while almost 30% choose in kind-benefits, partly mixed with cash-benefits, to use also formal care. Approximately 80% of people with LTC needs living at home have a level 2 and 3 care need (Destatis, 2020).

References

Blümel, M., Spranger, A., Achstetter, K., Maresso, A. & Busse, R. (2020) ‘Germany Health system review‘ Health Systems in Transition, 22(6). Available at: https://apps.who.int/iris/bitstream/handle/10665/341674/HiT-22-6-2020-eng.pdf?sequence=1&isAllowed=y (Accessed 11 February 2022).

Destatis (2020) Pflegebedürftige nach Versorgungsart, Geschlecht und Pflegegrade. Available at: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Pflege/Tabellen/pflegebeduerftige-pflegestufe.html(Acessed 31 January).

Last updated: February 16th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Ghana

Particularly in rural communities in Ghana, children are expected to provide care for their parents if they need it when they are older. However, people who have no children or cannot have their support have difficulties accessing care should they need it (Deku et al., 2020).

References:

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: February 16th, 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.

References:

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: February 16th, 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”. It is common to live in multigenerational households which providers opportunities for the rotation of carers and sharing of tasks, however, there are growing number of nuclear families, suggesting that this model of care will become less important over time (Rajagopalan et al., 2020).

There are some formal care services available, mostly provided by private and not-for-profit organisations, these include residential care, day care centres, geriatric care in some government and private hospitals and services by non-governmental organisations (Ponnuswami et al., 2017).

There are several policies and public programmes that aim to promote the welfare of older people and people with disabilities providing the legal framework. Social Welfare is implemented by the States, which means that there are important variations in the implementation of measures to support older and disabled people (UNESCAP, 2016).

References:

Ponnuswami I. and Rajasekaran R. (2017) Long-term care of older persons in India: Learning to deal with the challenges. International Journal on Ageing in Developing Countries, 2(1):59-71.

Rajagopalan. J., Huzruk. S., Arshad. F., Raja.P., Alladi. S. (2020). The COVID-19 Long-Term Care situation in India. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 30th May 2020. https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID-situation-in-India-30th-May.pdf

UNESCAP (2016) Long-Term for Older Persons in India. SDD-SPPS Project Working Papers Series: Long-Term Care for older persons in Asia and the Pacific.

Last updated: February 16th, 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 (Pierce et al., 2020).

References:

Pierce, M., Keogh, F., O’Shea, E. (2020). ‘The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures.’ Country report available at LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 13 May 2020

Last updated: February 16th, 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 publicly funded LTC services at home (source: National Insurance Institute of Israel).

Last updated: February 11th, 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 (Gabriele et al., 2014). This fragmentation relates to the fact that the LTC sector originates from multiple legislative interventions over a period of more than 30 years.  Unpaid carers as well as care assistants privately hired by households,  represent the bulk of LTC provision (Fosti et al., 2021). There is no official data on the number of unpaid family carers, but estimates from 2018 suggest that about 2.8 million people aged 18-64 were involved in caregiving for their older or disabled relatives (ISTAT, 2019). 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 (Fosti et al., 2021).

References:

Barbarella F, Casanova G, Chiatti C and Laura G (2018), ‘Italy: emerging policy developments in the long-term care sector’.  Retrieved from: 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. Retrieved from: il+welfare+e+la+long+term+care+in+europa+cover.pdf (unibocconi.it)

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 (2019): CONCILIAZIONE TRA LAVORO E FAMIGLIA. Retrieved from: 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. Retrieved from: il+welfare+e+la+long+term+care+in+europa+cover.pdf (unibocconi.it)

Last updated: February 16th, 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 (Goviat et al., 2021).

References:

Govia I, Robinson JN, Amour R, Stubbs M, Lorenz-Dant K, Comas-Herrera A, Knapp M. Mapping Long-Term Care in Jamaica: Addressing an Ageing Population. Sustainability. 2021; 13(14):8101. https://doi.org/10.3390/su13148101

 

Last updated: February 16th, 2022

Japan

Most of Japan’s LTC services are covered by the mandatory long-term care insurance (LTCI) introduced in 2000. Japan’s LTCI—which is administered by municipal governments—is operated independently of the medical insurance system and subsidizes non-medical benefits-in-kind including residential (long-term and short-term) day care services and home care services, as well as the cost of home adjustments to enable older citizens to live in their homes safely. When an insured person requires services, the municipal government evaluates and determines the level of care to be covered by LTCI. Insured persons then contract any service provider of choice within the municipality and pay a 10% co-payment. The remaining 90% of the service cost is reimbursed directly to the service providers by the municipal LTCI (Estévez-Abe and Ide 2021a).

The Japanese publicly-funded LTC system consists of residential and non-residential care sectors. The Japanese LTCI subsidizes day care services and home care services in addition to residential care services.  Unlike many European countries, the Japanese LTC system does not offer cash benefits to people in need of care (Estévez-Abe and Ide, 2021b).  Families do not receive any compensation for providing care and support to their relatives and there is almost no reliance on informal paid care by natives or migrants (Estévez-Abe and Caponio 2022).

Residential LTC facilities are broadly divided into quasi-public facilities and for-profit facilities. The LTCI subsidizes the cost of care provided in all quasi-public facilities and a sub-section of for-profit facilities (Estévez-Abe and Ide 2021a, 2021b). The quasi-public facilities include: (i) Special nursing homes; (ii) Long-term care health facilities; (iii) LTC medical facilities; (iv) Sanatorium medical facilities; (v) Social welfare facilities for older citizens. The first category of facilities provides non-medical nursing care for older people who require highest level of LTC. The second category are facilities that provide nursing care to older people who are undergoing rehabilitation with the goal of returning home. Although the official goal is that patients do not stay in these facilities for more than 3 months, many of them stay for more than 6 months. The third and fourth categories are hospitals for elderly patients requiring nursing care in addition to medical care. (The third category will be phased out and integrated into the fourth type.) The fifth category are residential social welfare facilities for older people who find it difficult to live at home due to non-age-related disabilities, lack of economic means and/or family support. Traditionally, the non-profit sector has dominated this particular LTC sector because of the quasi-public nature of the services.

The LTCI only subsidizes the cost of care provided in for-profit facilities that are specifically licensed by municipal governments (Estévez-Abe and Ide 2021a). In light of its rapidly aging population, the Japanese government is giving financial incentives to for-profit eldercare facilities to convert to proper nursing homes (Aramaki 2020).

Using the data presented in Estévez-Abe and Ide (2021a) and the population data from the Japanese government (Stat.go.jp)  we can estimate that there were roughly 26 LTC beds for every 1,000 people aged 65 and older in 2017 when we adopt the narrowest definition of LTCF—that is, excluding the second and third categories mentioned earlier (OECD estimates it to be 24.1, see OECD 2019 Figure11.26).  When we include all five categories of LTCFs, the number of beds increases to 38. When we further include the number of beds in for-profit eldercare homes not licensed to provide nursing care, the number goes up to 57.

In Japan, the non-residential care sector is significantly bigger than the residential sector. In 2014, 7.8% of those aged 65 or older used day care in Japan. According to Maeda (2020), 4 million older persons used day care facilities in 2019. This roughly translates to 11% of the population aged 65 and older.

References:

Aramaki, Seiya. 2020. “The content of the latest revision of fee schedule for for-profit nursing homes.” https://kaigo.jp/column/entry/497/ accessed on March 16, 2022.

Estévez-Abe M and Hiroo I (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

Estévez-Abe, Margarita and Hiroo Ide. (2021b). ““COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

Maeda K. Outbreaks of COVID?19 infection in aged care facilities in Japan. Geriatr. Gerontol. Int. 2020;20:1241–1242. 10.1111/ggi.14050. https://onlinelibrary.wiley.com/doi/10.1111/ggi.14050

OECD. 2019. Health at a Glance 2019. Paris: OECD.

Statistics 65: http://www.stat.go.jp/data/jinsui/2017np/index.html

Last updated: January 20th, 2023

Latvia

The main players in the provision of formal LTC are: the national government, 119 local governments and 110 municipalities. In 2015, 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 (Calite-Bordane, 2017).

References:

Calite-Bordane, D. (2017). ‘Latvia: Emerging policy developments in long-term care’. Retrieved from: CEQUA Latvia Country report

Last updated: February 16th, 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: February 16th, 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, access to institutional care is not means-tested, however residents have to contribute to their board and lodging- co-payments depend on their income (Bruquetas-Callejo and Böcker, 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021

Last updated: January 23rd, 2023

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 (Golinowska et al. 2017).

The rate of long-term care beds in Poland is  low, even though it has increased from 65 877 in 2011 to 76 090 in 2019 (source: Statista: Poland long-term care beds). There 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: 2021: Ageing policies – access to services in different EU Member States).

References:

Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: July 18th, 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.

References: 

Lopes, S., Mateus, C. & Hernandez-Quevedo, C. (2018). Ten years after the creation of the Portuguese National Network for Long-Term Care in 2006: Achievements and challenges. Health Policy 122, 210-6. doi: 10.1016/j.healthpol.2018.01.001

Tello, J.E., Pardo-Hernandez, H., Leichsenring, K., Rodrigues, R., Ilinca, S., Huber, M., Yordi Aguirre, I. & E. Barbazza (2020). A services delivery perspective to the provision of long-term care in Portugal, Public Policy Portuguese Journal, Vol. 5(1), 8-25. Retrieved from: European Centre for Social Welfare Policy and Research

Last updated: February 10th, 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 LTC system emphasizes cash benefits to the detriment of service provision, which remain severely undersized with respect to care needs and 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 LTC coverage are insufficient and of poor quality, available evidence indicates long-term care coverage to be very low with respect to most European countries.

References: 

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. Retrieved from: WHO/Europe | Healthy ageing – Romania

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

Last updated: February 10th, 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

According to the Spanish Constitution, 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. Each autonomous community has legislated and designed its own care and social services systems.

The 2006 ‘Dependency Act’ (law 39/2006)  aimed to create new public national care coverage as the ‘fourth pillar of the welfare state’. The Act aims to guarantee the rights of citizens to personal autonomy and care to people in a situation of dependency, through the creation of the System for Autonomy and Dependency Care (SAAD). This is carried out with the collaboration and participation of all public administrations, and the central government guarantees minimum common rights for all citizens in any part of the territory of the Spanish State.

The Act established two types of long-term care benefits: 1) in-kind services, and 2) economic benefits, and gives priority to the former. All benefits and services established in the law are integrated into the social services provided through the autonomous regions (Guillen et al. 2017).

The catalogue of services and economic benefits of the Law is as follows:

Services :

a) Services for the prevention of situations of dependency and those for the promotion of personal autonomy .

b) Telecare Service.

c) Home Help Service (help with home tasks and personal care);:

  • Attention to the needs of the home.
  • Personal care.

d) Day and Night Centre Service :

  • Day Centres for the older people.
  • Day Centres for those under 65 years of age .
  • Specialized Day Care Centres.
  • Night Centres.

e) Residential Care Service :

  • Residential care for the older people in a situation of dependency .
  • Care centres for people in a situation of dependency, due to the different types of disability.

Economic benefits :

a) Cash benefits linked to the service.

b) Economic provision of personal assistance.

c) Cash benefits for care in the family environment.

The economic services and benefits that the autonomous communities may recognize for people in a situation of dependency in their territory, are integrated into the network of social services of each autonomous community.

References:

Montserrat Guillen, Ramon Alemany, Manuela Alcañiz, Mercedes Ayuso, Catalina Bolancé, Helena Chuliá, Ana M. Pérez-Marín, and Miguel Santolino (2017). Country Report: Spain. Retrieved from European Network on LTC (CEQUA).

 

 

Last updated: November 3rd, 2022   Contributors: Sara Ulla Díez  |  Esther Pérez de Vargas Bonilla  |  

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 around 82 000 were provided with institutional care. A wave of closures of municipal institutional beds since the 2000s has resulted in a reduction of nearly 40% of all municipal places (source: Johansson and Schön, 2021).

References:

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

Last updated: February 10th, 2022

Taiwan, RoC

The public Long-Term Care system in Taiwan has been in development since the 1990s. Although a social insurance system was planned, public LTC in Taiwan is funded through taxes. In 2017 the government launched LTC 2.0, a new policy aiming to develop a universal LTC system with an emphasis on home and community-based care and better integrated with the health care system, particularly with primary preventive care and home-based hospital care following hospital discharge (Hsu and Chen, 2019).

References:

Hsu HC and Chen CF (2019) LTC 2.0: The 2017 reform of home- and community-based long-term care in Taiwan. Health Policy 123:10, 912-916. https://doi.org/10.1016/j.healthpol.2019.08.004

Last updated: March 2nd, 2023   Contributors: Adelina Comas-Herrera  |  

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

Turkey

There is no long-term care (LTC) insurance system in Turkey. Until recently, long-term care infrastructure has been scarce; Turkey has a familialist welfare system with the majority of the elderly population being taken care of by their families (in particular, by female family members) (Oglak et al., 2017). In fact, the Turkish Civil Code involves intergenerational obligations for family members to look after dependents. However, to some extent this system is beginning to erode, and as such that has been an expansion of LTC services in the past two decades. (Akkan & Canbazer, 2020).

A fraction of older people in Turley (0.4%) live in care homes. Of these, 61% are in public nursing homes and the remainder in private ones. Private entities were only allowed to open nursing homes from 2008, but since then the sector has been rapidly expanding. In 2020, 247 of the 426 nursing homes were private, and 179 public. Apart from these care homes, the state also provides community-based care facilities, care and rehabilitation centres (which may also be run by private entities), and day-centres  (Akkan & Canbazer, 2020).

References:

Akkan, B. (2017). “The politics of care in Turkey: Sacred familialism in a changing political context”, Social Politics: International Studies in Gender, State & Society, 25(1), 72–91, https://doi.org/10.1093/sp/jxx011.

Akkan B and Canbazer C (2020) The Long-Term Care response to COVID-19 in Turkey. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 10 June 2020.

Oglak, S., Canatan, A., Tufan, I., Acar, S., & Avci, N. (2017). Long-Term Care in Turkey: Are We Ready to Meet Older People’s Care Needs?  Innovation in Aging, 1(suppl_1), 566–566. https://doi.org/10.1093/GERONI/IGX004.1991

Last updated: January 26th, 2022   Contributors: Daisy Pharoah  |  

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.

References:

Comas-Herrera, A., Glanz, A., Curry, N., Deeny, S., Hatton, C., Hemmings, N., Humphries, R., Lorenz-Dant, K., Oung, C., Rajan, S., Suarez-Gonzalez, A. (2020). The COVID-19 Long-Term Care situation in England. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE

Marczak, J. Fernandez, JL, Wittenberg, R. (2017). Quality and cost-effectiveness in long-term care and dependency prevention: English policy landscape. CEQUA report

Thorlby, R., Starling, A., Broadbent, C., Watt, W. (2018). What’s the problem with social care, and why do we need to do better?  The Health Foundation, the Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust

Last updated: March 10th, 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 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 (Source: Care Home Census for Adults 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 data 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 (An Official Statistics publication for Scotland).

Last updated: March 10th, 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: Vital and Health Statistics).

Last updated: February 11th, 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

Global ageing context

Population ageing is a global phenomena, as most countries see a growth in the size and the proportion of older people in their population, although between 2009 and 2019 population ageing has been fastest in parts of Asia, Latin America and the Caribbean (source: UN: World Population Ageing).

In 2019, 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. The latter 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: UN: World Population Ageing).

Population ageing and LTC demand

In the absence of global estimates on the numbers of people who receive care from others and are supported by LTC 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 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.

Moreover, despite some evidence of compression of disability at old ages, the review of evidence on whether increasing life expectancies in Europe translate into more years lived in better or worse health, showed mixed results, with considerable differences between countries (Rechel et al. 2020). Consequently, as the proportion and total number of older people increases, health and care systems in many countries are expected to face increased demand for care and support (Institute for Health Metrics and Evaluation; 2021 Long-term care in the EU).

References:

Rechel, R. Jagger, C., McKee, M. (2020) Living longer, but in better or worse health? WHO European Observatory on Health Systems and Policies

International reports and sources

Global data

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. 

United Nations provides data on global population projections: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_worldpopulationageing_report.pdf.

European data

Eurostat has data on demography, population stock and balance, as well as population projections in Europe

2021 Long-term care report Volume 1 and Volume 2 – Publications Office of the EU provides some information on population ageing and LTC in Europe

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: February 15th, 2022   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 (European Commission, 2019). 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 (Leichsenring et al. 2021).

References: 

European Commission (2019) Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability, Retrieved from: Country Documents 2019 Update (europa.eu) 

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

Last updated: February 2nd, 2022

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: February 11th, 2022

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

Czech Republic

In 2020, there were 10,101,777 inhabitants in the Czech Republic. The total increase this year was 7.8 thousand inhabitants, the lowest in the last decade, while the decrease was 19.1 thousand, which was the largest in the last 100 years.

The population in the three main age groups in 2020 developed in the same direction as in previous years. The child population (0–14 years) grew by 9.5 thousand persons to 1.72 million year-on-year and thus represented 16.1% of the total population. The number of older people (aged 65 and above), which has been growing since the mid-1980s, has grown by a further 26.7 thousand to 2.16 million, and for the first time in its history its share in the population has exceeded 20% of the total residents. The increase in the share of people aged 65+ in the population of the Czech Republic was due to strong vintages – people born in the second half of the 1940s, and a long-term increase in life expectancy. However, for both children and seniors, the growth rate in 2020 was the lowest in the last ten years. The number of people of working age (15–64 years) has a declining trend in the last twelve years, in 2020 it decreased by 28.4 thousand to 6.82 million people, which was 63.8% of the total population.

From 2011 to the end of 2020, the average age of the Czech population increased by less than two years to 42.6 years. The index of economic dependence, which indicates the number of persons in the non-productive age (0–19 years and 65+ years) per 100 persons in the economically productive age (20–64 years), increased from 55 to 69 in the given period.

In 2020, mortality was fundamentally affected by the epidemic situation associated with the occurrence of covid-19. During the year, almost 129.3 thousand people died, which was 15.1% more than in 2019, while in previous years the annual declines were below 3.5%. The greatest impact of the epidemic in 2020 was observed in the age groups 75-79 and 80-84, where the number of deaths increased by more than one-fifth year-on-year – in each group by more than 3,000, and in the highest group 100+ there was an increase of two-fifths .

In 2020, diseases of the circulatory system caused the deaths of 36.5% of all men who died and 43.1% of women who died, their lower proportion being affected by the fact that a large proportion of the total number of deaths were attributed to covid-19. The second place in men and women has long been occupied by neoplasms, whose share in the total number of deaths has been relatively stable in the last decade at around 28% for men and 23% for women. In third place was placed in 2020 by a group called “Codes for special purposes”, which was filled in the Czech Republic only by covid-19. A total of 10,539 people died of the disease (8.2% of all deaths), of which 5,938 were men (8.9% of all men who died) and 4,601 women (7.3% of women who died). The fourth most common cause of death (with a share of 7.0% in men and 5.8% in women) in 2020 was respiratory diseases. Fifth, endocrine, nutritional and metabolic diseases, which make up more than four-fifths of diabetes mellitus, ranked fifth overall. Other causes include external causes – injuries, traffic accidents, diseases of the digestive and nervous systems (Source: https://www.czso.cz/csu/czso/aktualni-populacni-vyvoj-v-kostce).

 

Last updated: February 3rd, 2022   Contributors: Martina Paulíková  |  

Denmark

In 2021, Denmark had a population of just under 6 million; 19.4% of the population were over 65, with 4.1% over 80 and 1.9% over 85 (source: https://www.dst.dk/en/Statistik). These numbers are expected to rise significantly, and according to calculations from Statistics Denmark, by 2053, 10% of the population will be over 80 (source: https://www.sst.dk/da/viden/aeldre). The ageing of the population has been driven by increases in life expectancy which has otherwise been low in comparison to other Nordic countries. In 2021, women could  expect to live until the age of 83 years and men until 80 (source: https://www.dst.dk/en/Statistik/emner/borgere/befolkning/middellevetid).

Last updated: June 5th, 2023

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: February 10th, 2022

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

General population

By the end of 2021, Germany had a population of 83.2 million (Destatis, 2022).

Population 65 years and above

In 2018, 22% of the population (17.9 million people) were aged 65 years and older (Lorenz-Dant, 2020). Furthermore, population age is not distributed evenly across the country. In 2017, the share of population in the age of 65 years and older was higher in the Länder of eastern Germany (24%) than western Germany (21%) (Bundesinstitut für Bau-, Stadt- und Raumforschung, 2021).

People with long-term care needs

According to the German Federal Statistical Office (Destatis), in 2019 there were 4.1 million people with long-term care needs, 62% women (Destatis, 2020) . Given the uneven distribution of older people across the country outlined above, a difference can also be observed between the share of people living in residential care. Out of 100,000 residents living in the eastern states, there are 488,2 persons in need of long-term care compared to 394,0 in the western states (Bundesinstitut für Bau-, Stadt- und Raumforschung, 2021).

References

Bundesinstitut für Bau-, Stadt- und Raumforschung (2021) INKAR – Indikatoren und Karten zur Raum- und Stadtentwicklung. Available at: https://www.inkar.de/ (Accessed 31 January 2022).

Destatis (2020) Pflegebedürftige nach Versorgungsart, Geschlecht und Pflegegrade. Available at: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Pflege/Tabellen/pflegebeduerftige-pflegestufe.html;jsessionid=ADFD935F5EE5A0113BFA74036FB518B2.live741 (Accessed 11 February 2022).

Destatis (2022) Press – Once again no population growth expected for 2021. Available at: https://www.destatis.de/EN/Press/2022/01/PE22_027_124.html  (Accessed 3 February 2022).

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Last updated: February 13th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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: February 11th, 2022   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.

Last updated: February 4th, 2022   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: February 10th, 2022

Malaysia

The population of Malaysia is roughly 32.4 million (World Bank). Since 2014, the share of the population over age 65 has been increasing; it went from 5.6% in 2014 to 7% in 2020. Malaysia therefore faces the prospect of an aging population; this may happen by 2030 (Statista).

The National Policy Order for Older Persons (2011) defines an older person in Malaysia as someone aged 60 years or older (Hasmuk et al., 2020).

References:

Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST (2020) The Long-Term Care COVID-19 Situation in Malaysia available at LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 2 October 2020.

Last updated: February 16th, 2022   Contributors: Daisy Pharoah  |  

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, together with other Southern European, is part of 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: February 10th, 2022   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

The population of The Netherlands is around 17.4 million (source: World Bank) and the median age is 43.3 years (source: Worldometres).

In 2021, 20.5% of the total population of The Netherlands was over age 65 and just under 5% was over 80 (source: Statista).

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Pakistan

The population of Pakistan is 220.9 million, making it the sixth most populous country in the world, although it is projected to become the third most populous country by 2050. Pakistan has a predominantly young population, but in line with global trends, the elderly population in Pakistan is rising. In 2020, the population over age 60 was 6.7 million people; this is expected to rise to 40.6 million by 2050 (United Nations). In part, this is due to increasing life expectancy in Pakistan (although this is still low by global standards) (The Global Economy).

Pakistan is a developing country, with significant economic difficulties, lack of a health insurance coverage system, and low levels of savings among older people. This poses real challenges for the elderly population. Retirement age is 60 for men and 55 for women, although many do not stop working at this age.  Due to frail provision of pensions, most people work until their final days, and/or rely on their next generation to provide for them during retirement  (Jalal et al, 2014).

References:

Jalal, S., Younis, M.Z. 2014. Aging and Elderly in Pakistan. Ageing Int 39, 4–12 https://doi.org/10.1007/s12126-012-9153-4

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

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 (Golinowska et al. 2017).

References:

Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: February 10th, 2022   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:  Proiectarea populaiei României pe regiuni de dezvoltare i judee, la orizontul 2070).

Last updated: February 10th, 2022   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

Slovakia

In 2021 Slovakia had population of 5.45 million people, of whom 17.1% were aged 65 and over. While in 2011, the pre-productive age population (0-14 years) had a higher share compared with the older population (65+ years), in 2021 it is the opposite. In 2021, compared to 2011, there was a slight increase in the share of the population in the pre-productive age (0-14 years) from 15.3 % to 15.9 %, but at the same time we can observe a significant increase in the population in older ages, whose share was 12.7 % in 2011 and increased to 17.1 % in 2021. The share of the working age population (15-64 years) decreased from 72.0 % in 2011 to 67,0 % in 2021. (Source: Slovak statistical office, 2021).

Last updated: February 10th, 2022   Contributors: Miroslav Cangar  |  

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

Spain

The population in Spain, as in the rest of Western societies, is going through a marked and continuous process of ageing of its population, due to social, health and cultural factors. According to the latest data from the INE (Institute of National Statistics. Data provisional as of July 1, 2021), Spain has a total population of 47,326,687 people, of which 9,444,037 are aged 65 or older (which represents 19.95% of the total); with 1,597,298 people aged 85 or older (3.38%). In addition, this ageing is noticeable in women, who account for 56.48% of the total number of people aged 65 or over, and 65.79% of people aged 85 or over.

In addition, and in relation to the population at risk of relying upon care from others, it is estimated that there is a total of 6,044,675 people (that is, 12.77% of the total population) who can be considered as “potentially dependent” (based on factors such as age or recognized disability).

On the other hand, there is a gradual decrease in women of childbearing age and, if current demographic trends continue, the population loss in the next decade will be concentrated in the age groups of 30-49 years, with this group decreasing by 2.8 million (Martínez-Buján, et al, 2021).

References
Martínez-Buján, R.; Jabbaz, M. and Soronellas, M. (2021) El cuidado de mayores y dependientes en España ¿En qué contexto irrumpe la covid?. In Comas-d’Argemir, D. and Bofill-Poch, S. (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Last updated: July 4th, 2022   Contributors: Carlos Chirinos  |  Sara Ulla Díez  |  Esther Pérez de Vargas Bonilla  |  

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: February 10th, 2022   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

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

Last updated: February 10th, 2022

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

Turkey

The current population of Turkey is 84,339,067 (World Bank). Turkey still has a relatively young population, but the fertility rate has been steadily falling, while the percentage of the population over age 65 has been rising (Statista). The increasingly ageing population is resulting in swiftly increasing health expenditure and long-term care service needs (Oglak et al., 2017). The majority of the aging population is between ages 65 and 74 (Daily Sabah).

References:

Oglak, S., Canatan, A., Tufan, I., Acar, S., & Avci, N. (2017). Long-Term Care in Turkey: Are We Ready to Meet Older People’s Care Needs?  Innovation in Aging, 1(suppl_1), 566–566. https://doi.org/10.1093/GERONI/IGX004.1991

Last updated: January 26th, 2022   Contributors: Daisy Pharoah  |  

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: Population estimates for the UK).

Last updated: March 8th, 2022

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: March 10th, 2022   Contributors: Jenni Burton  |  David Bell  |  David Henderson  |  Elizabeth Lemmon  |  

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 (Source: ONS: Population estimates for the UK).

 

Last updated: March 8th, 2022

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: Population estimates for the UK).

Last updated: March 8th, 2022

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/us-population-aging).

Last updated: February 11th, 2022

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

Definition and goals

Governance has been defined as the processes and systems by which an organisation or a society operates, encompassing leadership, planning, implementation, management and accountability. 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 (Allen et al. 2011; ADB Briefs).

National governance arrangements

Some countries have created specific agencies or ministries with responsibility for LTC to develop national policies and strategies to support the implementation of LTC laws and policies. This may be independent or based within a another ministry such as Ministry of Health (e.g. Singapore, Australia) or ministry of Labour and Social Policy (e.g. in Poland). In some countries several ministries are responsible for parts of LTC policies (e.g. Turkey). Whilst many strategies are developed at the national level, in some countries (e.g. Spain), they are developed from the subnational/municipal level and, in some cases, may be later pulled into a national policies. Moreover, LTC policies and strategies can be stand-alone or integrated into other policies. For example, in Japan, the policy framework for LTC is outlined in LTC insurance acts.

Integration

LTC governance often involves a wide range of stakeholders, including national and regional across multiple sectors (e.g. health, public health and social care, housing, transport etc). Coordination between different stakeholders at different levels is key to effective governance, although most LTC systems are poorly coordinated (see Section 1.06 for more details on care coordination). In fact 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.

References:

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).

 

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).

European Commission (2021). Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Publications Office of the EU (europa.eu)

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

Australia is a federation and 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  (e.g. Victoria runs 178 nursing homes) and some home care is provided by local government (e.g. in Victoria).

There is central oversight from the Australian government, as it is 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 sector and have 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: February 15th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Lee-Fay Low  |  

Austria

Governance of LTC system in Austria is relatively fragmented, in that the 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 LTC 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: February 2nd, 2022   Contributors: Cassandra Simmons  |  

Bulgaria

LTC consists of a wide range of medical and social services 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 (Salchev, 2017).

References:

Salchev, P. (2017), Bulgaria: Emerging policy developments in long-term care. CEQUA country report.

Last updated: February 3rd, 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).

Last updated: February 11th, 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: Health Authority: Overview).

Last updated: February 11th, 2022

Czech Republic

Since the 1990s, experts in the Czech Republic have been working to address supply issues in long-term care because it stands between the social and health departments (Holmerová, 2018). A large number of working groups were set up to try to resolve this issue ( Holmerová, 2015).

The last group dealing with long-term care operated in the years 2018–2021. It included representatives – ministers of both ministries – the Ministry of Labour and Social Affairs of the Czech Republic and the Ministry of Health of the Czech Republic. After less than a year, the group ceased operations. Ministries have continue to prepare their own proposals and solutions that have never been published. The COVID-19 pandemic has hindered proposals for solutions or changes (Horecky et al., 2021).

In practice, post-acute care (“follow-up”) and long-term care are not always well distinguished. The term “long-term care” appears only in the Law on Health Care and in the  Bulletin 12/2019, of the Ministry of Health of the Czech Republic published   Methodological Recommendation for Follow-up and Long-Term Health Care, in which it defined as follow-up care – care for patients in need of treatment and long-term care – care for patients whose health cannot be improved and would worsen without nursing care (MZCR, 2019).

Long-term care usually follows acute or follow-up care. Long-term care can be provided in the patient’s own home-home environment, in a social care facility (residential homes and homes with special regime), in a medical facility where long-term inpatient care is involved, or in the form of palliative care (MZCR, 2019).

Long-term care is not enshrined in legislation (with the one above mentioned exception). There is growing awareness that the long-term care system in the Czech Republic needs to be reformed. It is important that both health and social groups seek solutions, and they must find a system that is financially sustainable in the long-term and for all the payers involved, be it the state, local governments, health insurance companies, long-term care clients and their families.  The disparity between long-term care needs and the insufficient capacities, quality and satisfaction with care has been attributed to the existing public policy and administration (Horecky et al., 2021).

Proposals for reforms to improve the system include the introduction of four basic principles (Horecky et al., 2021):

  1. Long-term care must be accessible, individualised and able to respond flexibly to changes in the health and needs of each person.
  2. Long-term care must be efficient in the use of financial resources and personnel, and ensure that the recipient always receives the support and care they need, taking into account their abilities and skills.
  3. Long-term care must be sustainable in the long run with a vision of development and future demand for LTC.
  4. It is important to strengthen community services – whether field or outpatient, whose proper functioning and support for people with impaired self-sufficiency in the home environment can fundamentally affect the demand for more expensive inpatient care.
 References:

HOLMEROVÁ, I. (2018) Case management v pé?i o lidi žijící s demencí: koordinace pé?e zam??ená na ?lov?ka. Praha: Fakulta humanitních studií Univerzity Karlovy, 2018. ISBN 978-80-7571-031-4.

HOLMEROVÁ, I. (2014) Dlouhodobá pé?e: geriatrické aspekty a kvalita pé?e. Praha: Grada Publishing, [2014]. ISBN 978-80-247-5439-0.

Horecky J, Potucek M, Cabrnoch M and Kalvach Z (2021) REFORMA DLOUHODOBE? PE?C?E PRO C?ESKOU REPUBLIKU. Asociace poskytovatelu? socia?lni?ch sluz?eb C?R. https://www.apsscr.cz/files/files/A4_STUDIE%20LCT%202021_FINAL.pdf

Ministerstva Zdravotnictví, MZCR (2019) Vestnik. https://www.mzcr.cz/wp-content/uploads/wepub/18287/39699/Vestnik%20MZ_12-2019.pdf

 

 

Last updated: February 6th, 2022   Contributors: Martina Paulíková  |  

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, and  taking a stronger role in prevention and health-oriented interventions (Rostgaard, 2020).

In 2015, the responsibility for regulating services and support for older people was transferred from the Ministry of Social Affairs and the Interior to the Ministry of Health. This transfer of responsibilities for regulation and oversight of care for older people was a clear move towards integrating central and strategic decision making for health and social services (WHO, 2019). During COVID-19, it meant that it was the Board of Health that oversaw the implementation of pandemic restrictions and measures. As a consequence of the heavy workload during the pandemic, the responsibility was again placed with the Ministry of Social Affairs, now called the Ministry of Social Affairs and Senior Citizens. It is now again the Board of Services which oversees and guides policy implementation.

References:

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

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

Last updated: May 24th, 2023

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.

Local municipalities are self-governing administrative units and have a key role in public administration. They are responsible for arranging and supervising the social and health services in their own area.

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 (Ylinen et al, 2021).

References:

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021. http://dx.doi.org/10.20350/digitalCSIC/13692

Last updated: February 1st, 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

Decision making powers

In the German health system as well as in the long-term care system decision-making power is shared between the Federal and the State Governments (Blümel et al., 2020). Even more importantly, the state only sets a legal framework for health and social care delivery, while major governance decisions are left to self-regulated provider and payer organisations. For long-term care the main decision-making power rests with the long-term care insurance funds on the one hand and providers of residential or community care services on the other. By law, long-term care insurance funds have to guarantee the provision of services that meet the demand by the population. Municipalities and local authorities have no authority over what services are provided within their region. The legal framework for long-term care, including the different actors, their roles and the list of benefits, is laid out in the Social Code Book XI (Lückenbach et al., 2021).

A Commissioner for Care

The German Federal Government created the role of a ‘Commissioner for Care’ in 2014 . 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 and nursing. (Die Bevollmächtigte der Bundesregierung für Pflege, n.d.) , but is not directly involved in system governance. Germany does not have a Government Chief Nurse. Since 2014 the representative for care held the position of a permanent secretary at the Department of Health, reporting directly to the Minister of Health with a dedicated team of staff. In 2022 the Government transferred the role to a Member of Parliament and scraped the dedicated staff.

The role of the medical service in providing control of provision and quality of services

The medical service (Medizinischer Dienst (MD)) 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 MD evaluates quality of services on an annual basis. The Social bill ensures that members of the MD are independent.

Public reporting of provision and quality of care

The LTC insurance funds are required to publish the quality reporting of the MD. 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 (Medizinischer Dienst, n.d.; Jacobs et al., 2018).

References

Blümel M., Spranger A., Achstetter K., Maresso A. & Busse R. (2020) ‘Germany: Health system review’. Health Systems in Transition. 22(6): pp.i–273 Available at: https://apps.who.int/iris/bitstream/handle/10665/341674/HiT-22-6-2020-eng.pdf?sequence=1&isAllowed=y (Accessed 10 February 2022).

Bundesministerium für Gesundheit (2020) Pressemitteilung – Bundesrat stimmt Gesetzespaketen zur Unterstützung des Gesundheitswesens bei der Bewältigung der Corona-Epidemie zu. Available at: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html (Accessed: 31 January 2022)

Die Bevollmächtigte der Bundesregierung für Pflege (n.d.) Amt und Person. Available at: https://www.pflegebevollmaechtigte.de/amt-und-person.html (Accessed: 31 January 2022)

Jacobs, K., Kuhlmey, A., Gre?, S., Klauber, J. & Schwinger, A. (2018) Pflege-Report 2018:  Qualität in der Pflege. Available at: https://link.springer.com/content/pdf/10.1007%2F978-3-662-56822-4.pdf (Accessed: 31 January 2022).

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Medizinischer Dienst (2020) Pressemitteilung – Ab Oktober wieder persönliche Pflegebegutachtungen und Qualitätsprüfungen. Available at: https://www.medizinischerdienst.de/aktuelles-presse/meldungen/artikel/ab-oktober-persoenliche-pflegebegutachtungen-und-qualitaetspruefungen/ (Accessed 31 January 2022).

Medizinischer Dienst (n.d.) Der Medizinische Dienst im Gesundheitssystem. Available at: https://www.medizinischerdienst.de/medizinischerdienst/medizinischer-dienst-gesundheitssystem/ (Accessed 31 January 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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, LTC sector is a regional competence. The Ministry of Labour and Social Policy and the Ministry of Health are responsible for defining the national framework, the issue general guidelines, and fund specific interventions to secure regional equity. At the central level, the National Social Insurance Agency is in charge of monetary contributions and cash allowances which are paid directly to citizens. The regions are the key actors and they regulate and fund in-kind services. Local health authorities (LHAs) and municipalities are responsible for interventions that are delivered through care providers. The system is highly reliant on publicly funded services, which account for around 85% of service providers’ revenues.

Coordination between different LTC responses is poor or left to local best practices. There are different need assessment systems (LHAs, municipalities, and INPS) which individuals can go through to access the in-kind and cash services they are eligible for, there is no guidance or coordination between the different interventions (Notarnicola et al., 2021).

References:

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: February 4th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

Accountability for the system is clear: a national framework of revenue raising, eligibility & benefits sits alongside clear roles for municipalities as insurers for over 65s and market shapers with some powers to influence provision (Curry et al. 2018).

While the municipal governments are the administrators of the LTCI, LTCI is a nationally regulated system. The menu of services and pricing is set by the Ministry of Health, Labour and Welfare (MHLW) and hence is standardized across the country. Furthermore, the MHLW sets the rules over who can operate as service providers and imposes specific requirements on the provision of services such as minimum levels of accommodation, care worker/resident ratio, the number of medical and trained care staff, nutritionists and physical therapists. The MHLW also requires municipal and prefectural governments to update their long-term care service plans every three years (Estévez-Abe and Ide 2021a).

References:

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Estévez-Abe, Margarita & Hiroo Ide (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

Last updated: January 20th, 2023

Lithuania

Public LTC expenditure in Lithuania represented 1.0% of Gross Domestic Product in 2016 (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 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 health and all aspects of long-term care (LTC). This includes care homes, social care and nursing care. 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 (Bruquetas-Callejo and Böcker, 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

Last updated: February 5th, 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

As responsibility for administering social assistance has been assumed by all the autonomous communities, the governance of the System for Autonomy and Dependency Care (SAAD) falls into the hands of the bodies established within the framework of the different social service systems. This is dependent upon the structure of each of the autonomous communities. The responsibility of the management of SAAD (both the reception of the application, assessment of the applicant, and the recognition of the situation of dependency and the benefits that can be recognized to each person), corresponds to each autonomous community. The sole exceptions to this is the management of SAAD in the Autonomous Cities of Ceuta and Melilla, which is assumed by the General State Administration through the Institute for the Elderly and Social Services.

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 (Guillen et al. 2017)

References:

Montserrat Guillen, Ramon Alemany, Manuela Alcañiz, Mercedes Ayuso, Catalina Bolancé, Helena Chuliá, Ana M. Pérez-Marín, and Miguel Santolino (2017). Country Report: Spain. Quality and cost-effectiveness in long-term care and dependency prevention. CEQUA LTC Network. Retrieved from European Network on LTC (CEQUA).

 

Last updated: July 4th, 2022   Contributors: Sara Ulla Díez  |  

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

A brief history

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

Current governance

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

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

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

References:

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

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

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

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 (Source: The Care Act 2014).

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 (Source: NHS Continuing Healthcare).

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 (Source: Integration and innovation; see question 4.04 for more details).

Last updated: March 8th, 2022

United States

The governance of LTC in the United States is complex and uncoordinated, primarily because of the state variations 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, whilst fragmented and under-resourced systems are common. Federal services tend to be scattered across agencies with minimal collaboration. Various LTC programs are often operating independently (De Biasi et al. 2020).

Federal level attempts at financing reform have either ended in failure or produced small changes to the financing arrangements. Demands for reforms have increased particularly in light of the pandemic (Dawson et al. 2021).

References:

De Biasi, A. et al. Creating an Age-Friendly Public Health System (2020). Innovation in Aging, Volume 4, Issue 1, https://doi.org/10.1093/geroni/igz044

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

Last updated: February 11th, 2022

1.03. Long-term care financing arrangements and coverage

Overview

Introduction

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. 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.

Reliance on unpaid care and its impact on LTC financing arrangements

In practice, the largest share of LTC across the world is provided as an “in kind” resource, by unpaid carers such as family members and friends (see section 1.11 of this report for more details on unpaid carers).  Family carers in some countries, for example Denmark, can be paid by the government for short periods of time. Informal carers 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, Govia et al. 2021).

Universal LTC coverage

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 LTC systems

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.

LTC insurance

Some countries have mandatory LTC insurance which provides a universal coverage (namely Germany, Japan, South Korea). In the United States private LTC insurance is the only means of sharing risk of high costs of care among people who are not covered by the public means-tested system. Private LTC insurance is also used to “top-up” public care benefits, for example in France and Germany.

Drivers of LTC spending

Expenditure on LTC is driven by a range of factors that relate to both demand (e.g. population size and structure, health status, individual and national income) and supply of LTC services (policy/institutional settings, technological advance) (source: The 2021 Ageing Report).  Differences in social values may also influence the level of public LTC spending as well as the distribution of support, for example, between users with and without informal carers. Moreover, in most OECD countries, the drive towards community-based care translates to higher public coverage of home-based rather than inpatient LTC.

Overview of LTC expenditure

Estimating LTC financing accurately and robustly is very difficult as very few countries have information systems that record all out-of-pocket spending on long-term care services. However, based on the available data, 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).

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.

References:

Govia, I.; Robinson, J.N.; Amour, R.; Stubbs, M.; Lorenz-Dant, K.; Comas Herrera, A.; Knapp, M. (2021). ‘Mapping Long-Term Care in Jamaica: Addressing an Ageing Population. Sustainability  13, 8101. https://
doi.org/10.3390/su13148101

International reports and sources

WHO sources:

WHO’s Report (2021) Pricing long-term care for older persons;  includes case studies on Australia, France, Germany, Japan, Republic of Korea, the Netherlands, Spain, Sweden and the USA

WHO (2015) Aging and Health report (who.int)

OECD sources

OECD (2020). LTC-Spending-Estimates-under-the-Joint-Health-Accounts-Questionnaire.pdf (oecd.org);

OECD (2020). The effectiveness of social protection for long-term care in old age;

OECD (2011) Public Long-term Care Financing Arrangements in OECD Countries. Help Wanted

EU publications

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

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability – Country Documents 2019 Update

Other sources

https://www.degruyter.com/Aging in Europe.

Australia

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).

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).

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).

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.  This is equivalent to 1.2% of Gross Domestic Product (Treasury, 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: February 9th, 2022

Austria

In 2016 public spending on LTC represented 1.9% of Gross Domestic Product (European Commission, 2018).  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.  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 equalisation scheme and the long-term care funds (Pflegefonds) (Fink, 2018).  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 (Bachner et al., 2018).

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).

 

References:

Bachner, F. et al. (2018), ‘Austria. Health System Review’ Health Systems in Transition, Vol. 20, No.3. European Health Observatory. Accessed at: HiT-20-3-2018-eng.pdf (who.int)

European Commission (2018), ‘The 2018 Ageing Report. Economic & Budgetary Projections for the 28 EU Member States (2016-2070)’. Luxembourg: Publications Office of the European Union

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

Schrank, S. (2017), ‘Reforms in long-term care: The Austrian long-term care system : Current challenges and reforms’. Accessed at: European Centre for Social Welfare Policy and Research

Last updated: February 2nd, 2022   Contributors: Cassandra Simmons  |  

Belgium

In 2016 public spending on long-term care was estimated to represent 2.3% of Gross Domestic Product (European Commission, 2018).

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 (European Commission, 2019).

References:

European Commission (2018), ‘The 2018 Ageing Report. Economic & Budgetary Projections for the 28 EU Member States (2016-2070)’. Luxembourg: Publications Office of the European Union

European Commission (2019), Austria Health Care & Long-Term Care Systems. An excerpt from the Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability

Last updated: February 3rd, 2022

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 in Bulgaria (European Commission, 2018). People in need of care are covered by social assistance, which is managed at municipal level and by disability benefits (e.g. as a supplement to pensions for older people). The country was reported in need to develop governance, financing and regulatory framework for LTC (European Commission, 2019).

 

References:

European Commission (2018), ‘The 2018 Ageing Report. Economic & Budgetary Projections for the 28 EU Member States (2016-2070)’. Luxembourg: Publications Office of the European Union

European Commission (2019), Bulgaria Health Care & Long-Term Care Systems. An excerpt from the Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability

Last updated: February 3rd, 2022

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: February 11th, 2022

Cyprus

Public LTC expenditure in Cyprus was estimated to represent 0.3% of the Gross Domestic Product (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

Czech Republic

Public LTC expenditure in the Czech Republic was estimated to represent 1.3% of Gross Domestic Product (European Commission, 2018). 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 (European Commission, 2019).

References:

European Commission (2018), ‘The 2018 Ageing Report. Economic & Budgetary Projections for the 28 EU Member States (2016-2070)’. Luxembourg: Publications Office of the European Union

European Commission (2019), Czech Republic Health Care & Long-Term Care Systems. An excerpt from the Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability

Sowa-Kofta, A., Wija, P. (2017). Czech Republic: Emerging policy developments in long-term care. CEQUA country report

Last updated: February 15th, 2022

Denmark

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

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

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

Approach to public funding for LTC and eligibility:

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

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

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

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

References:

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

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

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

Last updated: May 24th, 2023

Estonia

In 2016, public LTC expenditure in Estonia was estimated to represent 9.9% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

Finland

LTC services are part of the universal health and social care system in Finland. The state government and municipalities are the major funders of LTC care, however despite most costs being covered by taxes, there are user fees. For example, in 2014, older people using care services paid 18.5% of the costs of care (source: http://urn.fi/URN:ISBN:978-952-302-236-2). User fees are defined by the ability to pay.

Unpaid care from families is a major part of the LTC system, and it is argued that reforms of the care system in the past 30 years have resulted in increased reliance on families, who have been provided with support through cash-for care schemes (Ylinen et al., 2021).

According to the European Union’s Ageing report 2021, public LTC expenditure in Finland represented 2.0% of Gross Domestic Product in 2019.

References:

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021. http://dx.doi.org/10.20350/digitalCSIC/13692

Last updated: February 10th, 2022

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€.

Last updated: February 15th, 2022   Contributors: Camille Oung  |  Alis Sopadzhiyan  |  

Germany

Financing

The social LTC insurance is financed through equal contributions between employer and employees. Childless people pay a slightly higher contribution rate than those with children (3.30% of gross wages versus 3.05%) (Lückenbach et al., 2021). Retirees contribute between 3.05% and 3.30% of their pensions (Milstein, Mueller & Lorenzoni, 2021, p.83).

Financing of private compulsory LTC insurance is risk- rather than income-related, with premiums depending on health status and age. However, caps are in place to prohibit that maximum contribution rates exceed those of the social LTC insurance. As with the social LTC insurance, employers co-pay up to half of the insurance premium (Milstein, Mueller & Lorenzoni, 2021, pp. 83-84).

Coverage of the population

The Long-Term Care Insurance in Germany is statutory. It requires enrollees in both statutory sickness funds and private health insurance to also be enrolled in LTCI funds (Milstein, Mueller & Lorenzoni, 2021).

The provision of LTC insurance is needs- but not means-tested (Milstein, Mueller & Lorenzoni, 2021).  People with LTC needs receive an assessment in which their care needs are classified into five grades. Grade 1 reflects lower needs, while grade 5 represents severe needs. The assignment for the overall grades is based on the 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 grade of support provided varies between the different levels of care need (Nadash, Doty & von Schwanenflügel, 2018).

Coverage of costs

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. Costs vary substantially between the different Länder. 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 (Sozialpolitik-aktuell.de, 2020)

Where individuals/families cannot shoulder these costs, this will be covered through social security mechanisms. In 2019, 302,000 long-term care recipients depended on meats-tested social assistance support; most of them (250,000) were living in care homes (Rothgang & Müller, 2021).

References

Eggert, S., Teubner, C., Budnick, A., Gellert, P. & Kuhlmey, A. (2020) Pflegende Angehörige in der COVID-19-Krise: Ergebnisse einer bundesweiten Befragung. Available at: https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf (Accessed 31 January 2022)

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021 http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Milstein, R., Mueller, M. & Lorenzoni, L. (2021) Case study – Germany. In WHO Centre for Health Development (?Kobe, Japan)?, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (?2021)?. Pricing long-term care for older persons. World Health Organization. https://apps.who.int/iris/handle/10665/344505. License: CC BY-NC-SA 3.0 IGO

Nadash, P., Doty, P. & von Schwanenflügel (2018) ‘The German Long-Term Care Insurance Program: Evolution and Recent Developments’, The Gerontologist, 58(3), pp.588-597. https://doi.org/10.1093/geront/gnx018

Rothgang, H. & Müller, R. (2021) Barmer Pflegereport 2021 – Wirkungen der Pflegereformen und Zukunftstrends. Schriftenreihe zur Gesundheitsanalyse – Band 32. BARMER: Berlin. Available at: https://www.barmer.de/blob/361516/2ad4e5f56c47cb7b7e914190f9fae62f/data/barmer-pflegereport-2021-band-32-bifg.pdf (Accessed 03 February 2022).

Sozialpolitik-aktuell.de (2020) Hohe Eigenanteile bei der Heimpflege – mit erheblichen regionalen Unterschieden. Available at: https://www.sozialpolitik-aktuell.de/files/sozialpolitik-aktuell/_Politikfelder/Gesundheitswesen/Datensammlung/PDF-Dateien/abbVI49_Thema_Monat_02_2020.pdf (Accessed 3 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Greece

In 2016 public expenditure on LTC was estimated to represent 0.1% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

Hungary

In 2016 public LTC expenditure in Hungary was estimated to represent 0.9% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

Iceland

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

Last updated: February 10th, 2022

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. 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: Tsadok-Rosenbluth et al. 2020; National 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).

References:

Tsadok-Rosenbluth, S, Leibner G, Hovav B, Horowitz G and Brammli-Greenberg S (2020) The impact of COVID-19 on people using and providing Long-Term Care in Israel. Report available at LTCcovid.org, International Long- Term Care Policy Network, CPEC-LSE, 4 May 2020. Retrieved from: Article from ltccovid.org

Tsadok-Rosenbluth, S, et al. (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: https://doi.org/10.31389/jltc.75

Last updated: February 11th, 2022   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 (Fost et al., 2021).  Public expenditure on LTC includes three components: 1) LTC  services to dependent people provided by the public health 2) the social component of LTC  provided by municipalities and  3) attendance allowances. The social component of LTC are generally means-tested, access to services are based on needs-assessment but also on income levels (European Commission, 2016).

The bulk of LTC is provided by unpaid, 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 (Fosti, at al., 2021).

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.

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 (European Commission, 2021).

References:

Barbarella F, Casanova G, Chiatti C and Lamura G (2018), ‘Italy: emerging policy developments in the long-term care sector’. CEQUA LTC network report. Retrieved from Italy Country 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. Retrieved from update_joint-report_it_en.pdf (europa.eu)

European Commission (2021). ‘2021 Long Term Care in the EU’ Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG Empl). Retrieved from: Publications catalogue – Employment, Social Affairs & Inclusion

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. Retrieved from: 2019-2020 report Le prospettive per il sistema socio-sanitario oltre la pandemia.

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

Last updated: February 4th, 2022   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 fast rise in need as a result of rapid ageing. Its generosity has been reduced over time over affordability concerns (Curry et al. 2018)

On being assessed as needing care by the municipal government, which administers 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. A care manager meets with the service user to determine the actual menu of services needed. 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. As mentioned earlier, the re-imbursement for care services from the LTCI does not cover room or board.

Funding for the LTCI systems is raised as follows: 50% is from mandatory insurance contributions from all residents aged 40 and older and the rest is from general 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 (Estévez-Abe and Ide 2021b).

References:

Estévez-Abe, M., Hiroo Ide. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Last updated: January 20th, 2023

Latvia

Public LTC expenditure in Latvia was estimated to represent 0.4% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report). 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 (Calite-Bordane, 2017).

References:

Calite-Bordane, D. (2017). ‘Latvia: Emerging policy developments in long-term care’. Retrieved from: CEQUA Latvia Country report

Last updated: February 16th, 2022

Luxembourg

Public LTC expenditure in Luxembourg was estimated to represent 1.3% of Gross Domestic Product in 2016 (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

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% (EU Commission, 2018). 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 (Bruquetas-Callejo and Böcker, 2021).

References:

EU Commission (2018). The 2018 Ageing Report Economic & Budgetary Projections for the 28 EU Member States (2016-2070)

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

Last updated: February 1st, 2022

Norway

In 2016 public LTC expenditure in Norway was estimated to represent 3.7% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

Poland

Public LTC expenditure in Poland was estimated to represent 0.5% of Gross Domestic Product in 2016 (source: European Commission: The 2018 Ageing Report). 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 (Golinowska et al. 2017).

References:

Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: February 10th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Portugal

In 2016, public LTC expenditure in Portugal represented an estimated 0.5% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

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: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

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 (European Commission, 2018).

References:

European Commission (2018), ‘The 2018 Ageing Report. Economic & Budgetary Projections for the 28 EU Member States (2016-2070)’. Luxembourg: Publications Office of the European Union

Last updated: February 4th, 2022

Slovenia

In 2016 public LTC expenditure represented 0.9% of Gross Domestic Product (European Commission, 2018).

References:

European Commission (2018), ‘The 2018 Ageing Report. Economic & Budgetary Projections for the 28 EU Member States (2016-2070)’. Luxembourg: Publications Office of the European Union

Last updated: February 4th, 2022

Spain

In 2016 public LTC expenditure in Spain was estimated to represent 0.9% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report). 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).

The Dependency Law includes a specific financing system, which differs from a tax-based system, that establishes the participation of both the public administrations (mainly the General State Administration and the Autonomous Communities) and beneficiaries of the benefits. This is carried out via  means tested co-payment systems (source: Joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-2019-update_en). The financing system established in the Dependency Law is based on the existence of three levels of protection:

  1. The minimum level of protection provided, must be paid in full by the General State Administration (AGE). This depends on the number of people who rely on care from others who are receiving a benefit.
  2. The agreed level of protection is based upon the conclusion of the corresponding collaboration agreements between the AGE and the autonomous communities. The financing of the AGE of this level of protection is based on the annual distribution of money, which is distributed among the autonomous communities based upon a series of variables and predefined criteria.
  3. The implementation of the final level of protection is optional for autonomous communities, and they are responsible for its financing.

In a global study, recent calculations estimate that spending on care for people who rely on care from others is around 0.7% of the national GDP, although the improvement in the financing of the system will mean an increase in this amount.

Likewise, the AGE has been financing social security contributions associated with the special agreements that could be signed by non-professional caregivers of people in a situation of dependency. This helps ensure that no additional costs are incurred. It also ensures that non-professional caregivers (the vast majority of whom are women) benefit from this type of agreement, with a view to accruing future pensions (retirement, death and survival).

References:

Zalakain, J. Davey, V. & Suárez-González, A. (2020). ‘The COVID-19 on users of Long-Term Care services in Spain’. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

 

Last updated: June 29th, 2022   Contributors: Sara Ulla Díez  |  

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 (LTC) expenditure represented roughly 3.2% of Gross Domestic Product (GDP) (source: The European Commission).

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

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

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

 

References:

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

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

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

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

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

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: February 10th, 2022

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)

Overview

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

Who bears the costs? Unpaid care, formal social care and healthcare and out-of-pocket spending

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. The Office for National Statistics estimated that, between 2019 and 2020, 36.7% of care home residents paid for their own care privately.  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 the study by Wittenberg et al., 2019, 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).

Eligibility criteria for funded care

Eligibility to publicly funded social care is decided through means-testing, the levels are set nationally. People who exceed a certain level of savings and other assets (e.g. property) have to pay for care themselves. People below lower threshold,  £14,250 in 2022,  do not have to contribute anything towards their care, while people above £23,250 in 2022 have to fund all their social care costs. Between these two thresholds people have to contribute on a sliding scale. The upper threshold has not changed since 2010/11 which taking into account levels of inflation means that it went down in real terms (Bottery et al., 2022).

The distinction between ‘health’ and ‘care’ creates  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).

Social care public funding

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.

The King’s Fund Social Care 360 annual report by Bottery et al., (2022) provides a useful overview on public funding for social care in England. Between 2018/19 and 2019/20, total spending on adult social care increased by 2.2 %. 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). They also spent £450 million on short-term support for older people (Bottery et al., 2022).

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.

References:

Bottery, S., Ward, D. (2022) Social Care 360. The King’s Fund. https://www.kingsfund.org.uk/publications/social-care-360

Wittenberg, RKnapp, MHu, B, et al. (2019) The costs of dementia in EnglandInt J Geriatr Psychiatry. 341095– 1103https://doi.org/10.1002/gps.5113

Last updated: March 8th, 2022   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) (Source: Care Information Scotland, Capital limits). 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 (Source: Care Information Scotland).

Last updated: March 10th, 2022   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). 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: Long-term care financing in the US).

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 (sources: van Houtven et al. 2020; Vital and Health Statistics). An estimated 7.4 million Americans own private LTC insurance policy (around 15% of persons 65 and over).

References:

Van Houtven, CH., Boucher NA, Dawson WD (2020) The Impact of COVID-19 Outbreak on Long Term Care in the United States. Country report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24th April 2020. Retrieved from: Article from ltccovid.org

Last updated: February 15th, 2022

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

Overview

Introduction

Provision of  LTC services in recent decades have often relied on market mechanisms and New Public Management (NPM) theories. These approaches generally have led to increased provider competition, together with greater emphases on formal contracts and performance measurement. These arrangements have been based on the believes that the free markets,  competition and a split between financing/purchasing and providing services could lead to more efficient service delivery (Marczak et al. 2015).

Public and private providers (for- and non-for-profit)

Across OECD LTC services are often outsourced to private for-profit and not-for-profit providers, although public providers still play a role in some countries.  Some countries (e.g. Australia, the US or Canada) have a long history of private providers delivering publicly funded LTC services and state role involves the registration, licensing and monitoring. In other countries (e.g. UK, France, Central and Eastern European countries) involvement of private, especially for profit providers is a more recent phenomenon. In countries such as Germany and Japan entry of for-profit providers was related to the implementation of LTC insurance. In Nordic countries, despite a growth in for-profit providers, some LTC services across the region are still provided by public organisations (Marczak et al. 2015; 2021 Long-term care report).

Institutional versus community care

Most countries prioritise providing care at home and in the community to reduce reliance on (more costly) institutional care. The emphasis on providing care at home is also related to people’s preferences to be cared for at home  (Lipszyc et al., 2012; OECD, 2013). Despite of the emphasis to provide care in the community, these services are still limited in several countries (e.g. in Eastern and Southern European countries, the US).

References:

Lipszyc, B., Sail, E., & Xavier, A. (2012). Long-term care: need, use and expenditure in the EU-27 Economic Papers. Brussels European Commission.

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

OECD. (2013). Health at a glance 2013: OECD indicators: OECD Publishing.

 

 

 

International reports and sources

Europe

Some information on care provision in EU countries can be found in the following reports:

European Commission (2016) Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability.

2021 Long-term care report Volume 1 and Volume 2 – Publications Office of the EU

OECD

Gori C, Fernandez JL, Wittenberg R (2015) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol

 

 

Australia

The Aged Care Financing Authority (ACFA) produces a report providing an overview of the funding and financing of the Aged Care Industry.  In 2019-2020, there were over 3,000 providers; 845 of these were residential services, 920 were home care providers, and 1,452 were Commonwealth Home Support Programme providers (ACFA ,2021).

The number of residential care providers has decreased from 1,121 in 2010-11 to 845 in 2019-20. The number of beds has increased from 182,302 to 217,145 in the same period of time, in 2019-20 36% of all beds were from providers with more than 20 facilities. With regards sector ownership, 56% of residential care providers are not-for profit (with 55% of the beds), 33% are for-profit (41% of the beds) and 11% are public (4% of beds). Of home care providers, 12% are government owned, 36% are private for-profit and 52% are not-for profit (ACFA, 2021)

References:

Aged Care Financing Authority (2021) Ninth Report on the Funding and Financing of the Aged Care Industry – July 2021. https://www.health.gov.au/resources/publications/ninth-report-on-the-funding-and-financing-of-the-aged-care-industry-july-2021

Last updated: February 15th, 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: February 15th, 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; COVID-19_Response_Review.pdf; ABillionReasonsToCare.pdf).

References: 

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: February 11th, 2022   Contributors: William Byrd  |  

Denmark

Home care

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

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

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

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

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

Nursing homes

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

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

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

References:

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

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

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

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

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

Last updated: May 24th, 2023

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 (Ylinen et al., 2021).

References:

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021. http://dx.doi.org/10.20350/digitalCSIC/13692

Last updated: February 1st, 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

Prioritisation of private and third-sector providers

The Long-Term Care Insurance act stipulates (§ 11 (2)) that private and third sector providers take priority over public providers in the provision of long-term care (Sozialgesetzbuch-sgb.de, n.d.).

Home care

Between 1999 and 2019 the number of home care providers in Germany has grown by 36%, an increase of 3,868 providers. Over the same period the number of people using home care doubled to 982,604 recipients in 2019 (Milstein, Mueller & Lorenzoni, 2021). The press release of another report states that the share of those receiving home care has increased from 20.6% to 25.4%, while the share of those living in residential care remained constant over the same period. This may be indicating a trend towards people’s preference of remaining in the community (RWI, 2021).

The largest share of care providers in 2019 were private for-profit providers (66.52%). Private for-profit providers served over half of home care recipients (52.33%). The second largest group were private non-profit providers (32.14%), providing home care for 46.13% of recipients. The smallest group were public providers (1.35%). This group provided home care for 1.54% of recipients (Gesundheitsberichterstattung des Bundes, 2022b; Milstein, Mueller & Lorenzoni, 2021).

Residential care

In 2019, residential care providers in Germany had a capacity of 969,553 beds. In comparison to other OCED countries Germany had a greater availability of beds in residential long-term care for those aged 65 and older than (53.6 beds per 1000 inhabitants vs. 47 beds per 1000 inhabitants).

Between 1999 and 2019 the increase in the number of residential care providers was larger (74%) than that of home care providers (36%).

Over the same time period, the share of private for profit care providers in residential care increased from 34.90% to almost 43%. In comparison to private-for profit and public providers, the share of full-time places also increased from 25.82% to 40.57%.

At the same time, the share of private non-profit organisations declined from 56.63% to 52.76%. The proportion of full-time places also declined (63.01% in 1999 to 53.81% in 2019).

As with home care, the share of public providers played a declining role in the provision of residential care (8.47% in 1999 declining to 4.52% in 2019). Over the same time period the share of full-time places also declined (11.7% in 1999 to 5.62% in 2019) (Milstein, Mueller & Lorenzoni, 2021).

References

Gesundheitsberichterstattung des Bundes (2022b) Ambulante Pflege- und Betreuungsdienste (Anzahl). Gliederungsmerkmale: Jahre, Deutschland, Art der Pflege- und Betreuungsdienste, Träger. Available at: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=876&p_ansnr=98223306&p_version=2&D.000=1&D.374=2&D.983=1(Accessed 31 January 2022).

Milstein, R., Mueller, M. & Lorenzoni, L. (2021) Case study – Germany. In WHO Centre for Health Development (?Kobe, Japan)?, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (?2021)?. Pricing long-term care for older persons. World Health Organization. https://apps.who.int/iris/handle/10665/344505. License: CC BY-NC-SA 3.0 IGO

RWI (2021) Pflegeheim Rating Report 2022: Wirtschaftliche Lage deutscher Pflegeheime is angespannt, jedes fünfte im “roten Bereich”. Available at: https://www.rwi-essen.de/presse/mitteilung/462/ (Accessed 5 February 2022).

Sozialgesetzbuch-sgb.de (n.d.) Sozialgesetzbuch (SGB XI) Elftes Buch Sozial Pflegeversicherung. Available at: https://www.sozialgesetzbuch-sgb.de/sgbxi/11.html (Accessed 11 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Italy

Municipalities, local health authorities and the National Institute of Social Security (INPS) are directly involved in the organisation of LTC services, but others are involved in planning and funding these services, including 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: Notarnocola et al., 2021).

Informal care and migrant care workers, often with irregular contracts, play an important role in the organisation and provision of home care (European Commission, 2016).

References:

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. Retrieved from update_joint-report_it_en.pdf (europa.eu)

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: February 4th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

The 2000 LTC insurance reforms sought to create a competitive and mixed market of provision. Today, the Japanese LTC market consists of a mixture of public, quasi-public and for-profit service providers. Although the non-profit sector has long dominated Japan’s LTC sector, the overall picture has changed due to the growth of the for-profit sector in recent years.

Non-profit providers dominated the residential LTC market because of regulatory restrictions. Aside from public sector providers, only two types of private non-profit organizations—social welfare corporations and medical corporations—were allowed to provide residential LTC services (Estévez-Abe and Ide 2021a). Because local governments are the licensing agents of social welfare corporations, the government and private non-profit actors work in tandem to plan and provide nursing services within the jurisdiction (ibid.).  In other words, these two non-profit organizations fulfilled quasi-public roles within the Japanese LTC sector.

The government has encouraged the growth of for-profit nursing homes by introducing favourable reforms since 2006.[1] It should be noted that there are two types of for-profit eldercare facilities—one provides nursing care but the other one doesn’t. The growth of the for-profit LTC sector has increased the range of choices for users.

As for the market for day care and home care services, for-profit providers have always dominated.  It is important to note here that non-profit providers such as social welfare corporations are allowed to operate for-profit services. Many social welfare corporations, which operate non-profit quasi-public residential LTC facilities, operate as for-profit providers of day care and home care services.

Providers are reimbursed by the LTCI according to a national fee schedule although municipalities have some freedoms to adjust it to suit local needs (Curry et al. 2018).

References:

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Estévez-Abe, Margarita & Hiroo Ide (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

[1] Undated document created by the Ministry of Health, Labour and Welfare. https://www.mhlw.go.jp/file/06-Seisakujouhou-12600000-Seisakutoukatsukan/0000038009_1.pdf  accessed on March 16, 2022.

 

 

 

 

Last updated: January 20th, 2023

Malaysia

The long-term care (LTC) system in Malaysia is fragmented; this comes as a result of separate health and social care systems, as well as a divide between publicly and privately funded care. Malaysia has focused on family and community provided car; the result of this is that the burden of care tends to call on female members of the population (both in terms of formal and informal care providers. It is estimated that Malaysia’s LTC system serves only about 1% of the total population (Hasmuk et al., 2020).

For those who are terminally ill, Malaysia has 2 government-run homes and 15 government-run residential homes; there are an additional 320 registered LTC facilities, all of which are registered (as of 2020) under the Private Healthcare Facilities Act (2018). It is estimated that over a thousand care homes in Malaysia remain unregistered. There are also some facilities that are operated by non-governmental organisations (NGOs), but these generally lack the resources to care for those with nursing-level care needs and are primarily residential homes.  The majority of nursing homes are privately run, and there has recently been an emergency of privately-run day-care facilities. However, the majority of LTC in Malaysia is provided at home, often through domestic workers who are hired through agencies from the Philippines, Cambodia, Sri Lanka, and Indonesia. This home care is generally unregulated, and is not mentioned in the new Private Aged Care Facilities Act (Hasmuk et al., 2020).

References:

Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST (2020) The Long-Term Care COVID-19 Situation in Malaysia available at LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 2 October 2020.

Last updated: February 16th, 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

Pakistan

The prevalent family structure in Pakistan is the joint/extended family system: respect is shown to older people, and historically families take care of older people as they age. However, there has been a shift in recent years: an increasingly ageing population and migration of younger generations to areas where there are better career and employment opportunities as well as the entrance of women to the workforce has meant that more elderly people are compelled to reside in shelter homes (Cassum et al., 2020). There is still taboo around old-age homes, and as a result there are still relatively rare in Pakistan (Majid, 2018).

References:

Cassum, L.A., Cash, K., Qidwai, W. et al. 2020. Exploring the experiences of the older adults who are brought to live in shelter homes in Karachi, Pakistan: a qualitative study. BMC Geriatr 20, 8. https://doi.org/10.1186/s12877-019-1376-8

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

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 (Golinowska et al. 2017).

References:

Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: February 15th, 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

In Spain, a number of public services are provided by private entities, both for and non-profit. In the care home sector, although marketisation has led to an increase in the available places, this is considered to have been at the expense of the quality of services, 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 (Zalakain et al. 2020).

Data on the social care workforce in different settings:

Looking at the settings in which the social care workforce is employed gives a good indication of the scale of different types of care in Spain. Analysis by Martinez-Bujan et al (2021) shows that in 2020 there were estimated 684,949 people working in social care (based on data from the EPA survey), representing 3.7% of the total number of employed persons in Spain. 66.3% of social care workers were employed in private households, either as home carers (17.7%) or as domestic workers (82.3%).

Carers working in care homes represented 19.9% of the total care workforce (with most employed as nursing assistants), and carers in social services without accommodation (mostly home help services, usually referred to as SAD) represent 13.9% of the care workforce.

The Dependency Law

The Dependency Law states that an attempt should be made to provide adequate care for a person in a situation of dependency. If this is not possible, then money/cash will be provided to pay for care. The law also states that official/recognised benefits and services should be integrated into the Social Services Network of Autonomous Communities.

Within this starting framework, the Law itself also states that:

  • Recognised benefits and services are integrated into the social services network of the respective Autonomous Communities.
  • The network of centres will be made up of the public centres of the Autonomous Communities; the state centres for the promotion of personal autonomy and care of situations of dependency; and accredited private centres.

In short, some of the services The Dependency Law recognises are provided by public administrations aside from the autonomous communities, and by privately run centres that are regulated by the Autonomous Communities.

Non-subsidized private centres and services that provide services for people who rely on care from others must also have the proper accreditation from the corresponding Autonomous Community.

In conclusion, the services that are recognized within the framework of the Dependency Law must be provided through public or publicly funded places in private care homes . In cases where this is not possible, cash benefits can be provided for an accredited private centre to provide the service.

References:

Martínez-Buján, R.; Jabbaz, M. and Soronellas, M. (2021) El cuidado de mayores y dependientes en España ¿En qué contexto irrumpe la covid?. In Comas-d’Argemir, D. and Bofill-Poch, S. (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Zalakain, J. Davey, V. & Suárez-González, A. (2020). The COVID-19 on users of Long-Term Care services in Spain. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

Last updated: June 29th, 2022   Contributors: Carlos Chirinos  |  Sara Ulla Díez  |  

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

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

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

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

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 (ICF, 2017). 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 (CMA 2018). 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 (ADASS, 2019).  Because of market fragility, the government has introduced market oversight and a failure regime covering financial as well as quality failure (source: CQC).

References:

ADASS (2019). ADASS Budget Survey. Association of Directors of Adult Social Services

CMA (2017). Care homes market study. Competition and Market Authority

ICF (2018). The Economic Value of the Adult Social Care sector – England. ICF Consulting Limited, London

Last updated: March 8th, 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 (Source: Care Inspectorate).

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: March 8th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

1.05. Quality and regulation in Long-term care

Overview

Introduction

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

Different approaches to defining  quality in long-term care

The quality of LTC can be, and often is, viewed from various dimensions including: the quality of life of the person with care needs, supporting people’s empowerment and independence; improving, or at least limiting the deterioration in health conditions; protecting individuals’ human rights. Often quality encompasses a mixture of some or even all of these different elements. Furthermore, different stakeholders, including providers, policy makers, unpaid carers, may understand quality from different perspectives.  Such approaches to defining quality, however limited, usually apply to formal long-term care, while the defining and measuring quality of informal care is often even less addressed. Such a myriad of approaches to quality means that  there is no uniform definition of long-term care quality even in the European Union (2021 Long-term care in the EU).

Attempts to measure quality in long-term care

There are no common indicators of long-term care quality, countries use a number of different indicators to monitor care quality, which are not always specific to long-term care. Aspects of the quality of life are often considered an indicator of long-term care quality outcomes.  For example, adult social care outcomes toolkit (ASCOT) often used in the UK, measures outcomes by comparing person’s perceived outcomes after receiving care with the outcomes they would expect if no care was provided.  Patient-reported outcome measures (PROMs) and patient reported experience measures (PREMs), often used in Germany and Denmark,  collect information directly from people with needs to assess outcomes.  More recently, The Rights of Older People Index (ROPI) has been developed based on structure and process indicators, although collecting relevant data may be more challenging (2021 Long-term care in the EU).

International reports and sources

EU Report on LTC (2021), Volume 1 and 2, cover LTC quality in EU Member States.

Specific reports cover issues around care quality in Thailand, Australia, Vietnam, or Sri Lanka.

Australia

The Aged Care Quality and Safety Commission, under the Australian government, is the national regulator of aged care services. It is responsible for approving subsidies for providers, accrediting services, monitoring quality of care, providing education, handling complaints and imposing sanctions. Providers must comply with the Aged Care Quality Standards set by the Aged Care Act and the Aged Care Principles.

The Royal Commission into Aged Care Quality and Safety’s report highlighted instances of sub-standard care, concluding that the current mechanisms of oversight and market shaping have not been able to respond to changes in the provider market, arguing the need for a less centralised regional and local market governance system (Royal Commission, 2021).

References:

Royal Commission into Aged Care Quality and Safety (2021) Final Report: Care, Dignity and Respect, volume 1. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf

Last updated: February 21st, 2022

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 (European Commission, 2021).

References:

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

Last updated: February 3rd, 2022

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 (European Commission, 2021).

Reference:

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

Last updated: February 3rd, 2022

Croatia

The LTC quality framework in Croatia is implemented under the by-law on the standard of quality for social services, based on the Social Care Act (2014). Quality standards have become mandatory for all providers (both in residential and non-residential sector, private and public). The Healthcare Quality Act regulates the qualitative framework for LTC in health services (European Commission, 2021)

References:

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

Last updated: February 4th, 2022

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: 2021 Long-term care in the EU: European Commission).

Last updated: February 10th, 2022

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. Quality standards focus on institutional processes  and on personnel capacities (European Commission, 2021).

References:

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

Last updated: February 4th, 2022

Denmark

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

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

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

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

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

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

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

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

References:

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

Last updated: June 5th, 2023

Estonia

Following the Estonian Social Welfare Act in 2018, there are quality principles that must be followed in the provision of social services (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

Finland

The National Supervisory Authority for Welfare and Health (Valvira) and six Regional State Administrative Agencies (AVIs) are responsible for supervising Long-Term Care provision. Valvira’s role is to give directives and providing licenses to private providers, processing complaints and conduct major investigations and inspections. The AVIs are responsible for regional supervision and guidance of health care and welfare provision and responding to complaints.

Individuals who use care have a personal care and service plan which constitutes a contract between the client and the municipal authorities. This specifies the services and support a person should receive and responds to the idea of ‘self-supervision’, according to which clients should be involved in monitoring the quality of services. In 2019 serious failings in quality of care were found in some private sheltered care settings, which led to these institutions being closed down. New legislation set minimum personnel ratios in all care homes, as well as the requirement to assess all residents using interRAI by 2023 (EC, 2021 and Ylinen et al, 2021).

References:

European Commission (2021) Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles, volume II. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL). https://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=8396&furtherPubs=yes

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021. http://dx.doi.org/10.20350/digitalCSIC/13692

Last updated: February 1st, 2022

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

Greece

There is no definition of LTC quality in Greece neither in the healthcare nor in the social care sector. 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) is also lacking. Quality assurance is mainly based on a set of 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. 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: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

Hungary

There are national definitions of LTC quality provided in the form of government decrees or recommendations. 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 (private, for or non for profit, or public providers) (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

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 2012, a system of approved service providers has been put in place under home support services, which must meet a uniform level of national standards. There are 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, however as of 2021 there was no statutory basis to do so (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

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 sector. The use of these tools varies according to whether the services are residential/home-based, or whether they are related to healthcare or social care (European Commission, 2021).

References:

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

 

Last updated: February 4th, 2022

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: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

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: February 10th, 2022   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: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022   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  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  visits and conduct inquiries when problems are voiced regarding the quality in LTC sector; however it is not responsible for systematically monitoring service providers or services (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

Spain

The Spanish LTC system (System for Autonomy and Care for Dependency or SAAD) has three instruments to ensure quality: 1) a national and regional regulatory system; 2) formal quality controls; and 3) good practices. The responsibility for periodically inspecting and evaluating SAAD, along with ensuring that LTC Centres and service providers meet quality standards regarding the rights of service users, lie with the autonomous communities. They are also responsible for sanctioning any organisations that do not comply with quality standards.

The Territorial Council of Social Services and the System for Autonomy and Dependency Care (CTSAAD), formed by representatives of the central and the territorial governments, is responsible for setting common criteria for the accreditation of centres. It is also responsible for setting the common criteria for homecare and residential care quality plans. This is carried out within the general quality framework of the General State Administration. CTSAAD is also required to agree on quality and safety criteria for centres and services, by establishing indicators for evaluation, continuous improvement and comparative analysis of the System’s centres and services. CTSAAD is responsible for issuing guides for good practice, and for services portfolios, ensuring they are adapted to the specific conditions for people with care needs, under the principles of non-discrimination and accessibility.

CTSAAD is required by law to ensure the coherent application of social policies by working with the General State Administration and the Autonomous Communities. This is carried out by the exchange of points of view and the joint examination of any problems that may arise, along with proposing appropriate measures to solve them.

Accredited centres can be inspected at the request of recipients of publicly funded subsidies, or randomly by the autonomous community. The formal quality controls of 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, CTSAAD 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).

On June 28, 2022, CTSAAD approved a new Agreement on Common Criteria for accreditation and quality of the centres and services of the System for Autonomy and Dependency Care (SAAD), which replaces the previous agreement adopted in 2008.

This new text regulates the accreditation processes through which the Autonomous Communities authorize care centres and services to be a part of the SAAD network, after verification of compliance with the established requirements.

Accredited centres and services will be subject to adequate inspection, control and monitoring, performed by inspection services to ensure continued compliance with the requirements.

Specific criteria are also included to ensure quality in employment, and to address the professional qualification and skills of both first and second level direct care staff, along with the continuous training of care staff. Other areas that are covered by the criteria include common hiring criteria, occupational health, or coordination for social and health care, among other aspects related to quality in the SAAD network.

It is worth noting that 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: September 1st, 2022

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).

Last updated: February 21st, 2022

Sweden

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

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

References:

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

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

Thailand

Last updated: February 21st, 2022

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: March 8th, 2022

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: February 10th, 2022   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: February 21st, 2022   Contributors: Daisy Pharoah  |  

1.06. Care coordination

Overview

Introduction

Most countries have made an active effort to facilitate coordinated care, at least at policy level. Despite the policy efforts, as described in sections 1.00 and 1.02., responsibility for long-term care is fragmented, in very complex ways in some countries. LTC services are often separate from health services and countries frequently distribute responsibility for LTC across national, regional and local actors. 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.

LTC fragmentation and its practical implications

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). 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). In many countries, an absence of coordination between different sectors  (health, social care, public health, housing, transportation) 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).

Research evidence on (cost) effectiveness of coordinated care

Some emerging evidence indicated that integrated care has potential for service efficiencies and can have a positive impact on outcomes of people with care needs. For example, among the different types of integrated care models, Chronic Case Model (CCM) appears to have the greatest potential for improving effectiveness and cost-savings through reducing A&E visits, hospital emergency admissions and length of hospital. Studies illustrate that Case Management (CM) tend not to have positive effects, especially if used as a stand-alone measure (see literature reviews, e.g. Nolte & Pitchforth, 2014; Damery et al., 2016).

Some evidence also exists that large pooled budgets may be effective, however,  pooled budgets may also uncover unmet need thus leading to increased costs (Weatherly et al., 2010; Mason et al., 2015).

References:

Damery, S., Flanagan, S. Combes, G. (2016). Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open, 2016, 1-31, 10.1136/bmjopen-2016-011952.

MASON, A., GODDARD, M., WEATHERLY, H. & CHALKLEY, M. 2015. Integrating funds for health and social care: An evidence review. J Health Serv Res Policy, 20, 177-188, 10.1177/1355819614566832.

Nolte, E. Pitchforth, E. (2014). What is the evidence on the economic impacts of integrated care? European Observatory on Health Systems and Policies

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

WEATHERLY, H., MASON, A., GODDARD, M. & WRIGHT, K. (2010). Financial Integration across Health and Social Care: Evidence Review. Edinburgh: Scottish Government.

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 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.

LTC sector has been found to have less access to services, including 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 increase the provision of allied health services, including mental health services (Royal Commission, 2021).

References:

Royal Commission into Aged Care Quality and Safety (2021) Final Report: Care, Dignity and Respect, volume 1. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf

Last updated: February 15th, 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: February 11th, 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 good level of integration of care across providers, people who need long-term care following hospital discharge, the hospital discharge management team works closely with the general practitioner and local home services. The administrative regions are responsible for coordinating after-hours care. After-hours clinics tend to be associated with hospital emergency department  (WHO, 2019).

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

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

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

References:

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

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

Last updated: June 5th, 2023

Finland

Since the beginning of the 1990s there has been an effort to integrate home care at local level between social care home services and home health care, this is in the context of home care being considered as key to support people living independently for as long as possible. In 2004 a temporary law on the structural integration of health and social care was passed to remove legal obstacles to integrate home care. These processes, which at local level has involved the merger of municipal health unites with health and welfare departments, have led to more integrated care practices (Linnosmaa and Saaksvuori, 2017).

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 (Ylinen et al., 2021).

References:

Linnosmaa I and Saaksvuori L (2017) Long-Term Care policy in Finland. Policy Brief. CEQUA LTC network.

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021. http://dx.doi.org/10.20350/digitalCSIC/13692

Last updated: February 1st, 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

Organisational silos pose challenges to care coordination

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 (Fischer et al., 2021)

References

Fischer, T., Kopke, K., Sirsch, E., Büker, C., Graffmann-Weschke, K., Horn, A., Junius-Walker, U., Kümpers, S. & Meyer, G. (2021) S1 Leitlinie Häusliche Versorgung, soziale Teilhabe und Lebensqualität bei Menschen mit Pflegebedürftigkeit im Kontext ambulanter Pflege unter den Bedingungen der COVID-19-Pandemie – Living Guideline. Available at: https://www.awmf.org/uploads/tx_szleitlinien/184-002LGl_S1_Haeusliche-Versorgung-soziale-Teilhabe-Lebensqualitaet-bei-Menschen-mit-Pflegebedarf-COVID19-Pandemie_2021-04_1_01.pdf (Accessed 31 January 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Israel

The line between medical and functional assistance is unclear. 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 Israelis. All residents register with one of four competing non-profit health plans (HP’s).  The HP’s are responsible for geriatric and complex care (source: Traub Centre). Community LTC  is a branch 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) . A large percentage of LTC is privately funded  and there is a widespread culture of unpaid caregiving.

Last updated: February 11th, 2022   Contributors: Sharona Tsadok-Rosenbluth  |  

Italy

The Italian care system remains fragmented, which relates to the fact that the essential functions (e.g. health and social care as well as care training) are decentralized and managed at regional level. There is an increasing trend to reorganize the LTC system via ‘decentralisation’ of the health and social care, from the national to the regional and local level. In the social care sector, this development has led local administrations to develop their own LTC policies. The State-Regions Conference is the only body in charge of ensuring inter-institutional coordination (Barbarella et al. 2018).

References:

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

Last updated: February 4th, 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 (Curry et al. 2018). 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 (Morikawa, 2014). Individuals assessed and deemed to have care needs are assigned a care manager who helps people to navigate the system (Tamiya et al. 2011).

References:

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Morikawa, M. (2014). ‘Towards community-based integrated care: trends and issues in Japan’s long-term care policy’. International Journal of Integrated Care. Retrieved from: Japan’s long-term care policy (ijic.org)

Tamiya et al. (2011). Population ageing and wellbeing: lessons from Japan’s long-term care insurance policy. Lancet. doi: 10.1016/S0140-6736(11)61176-8

Last updated: February 10th, 2022

Netherlands

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

Last updated: February 1st, 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 (Golinowska et al. 2017).

References:

Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: February 10th, 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: February 10th, 2022   Contributors: William Byrd  |  

Sweden

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

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

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

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

References:

Bäck, M. A., & Calltorp, J. (2015). The Norrtaelje model: a unique model for integrated health and social care in Sweden. International journal of integrated care15, e016. https://doi.org/10.5334/ijic.2244

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

Liljas, A., Brattström, F., Burström, B., Schön, P., & Agerholm, J. (2019). Impact of Integrated Care on Patient-Related Outcomes Among Older People – A Systematic Review. International journal of integrated care19(3), 6. https://doi.org/10.5334/ijic.4632

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

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 by Miller et al. (2020) 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).

Lewis et al., (2021) conducted 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: March 8th, 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 (Source: Insights in Social Care: Statistics for Scotland). However, an Audit Scotland report suggested that the accuracy of data regarding self-directed support required improvement (Source: Self-directed support: 2017 progress report).

Last updated: March 10th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

United States

Despite Medicaid and Medicare’s central role in the funding of LTC services, the LTC and health care sectors are not integrated. Differences in how medical care and LTC are paid for, and prioritized in each state, as well as the ownership of healthcare organizations (i.e. hospitals) compared to the LTC sector, hampers coordination of services as well as opportunities for a joint care delivery system (Dawson et al. 2021).

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

Last updated: February 11th, 2022

Catalonia (Spain)

The Catalan Government Plan for the XII legislature, approved on September 25, 2018, highlighted the need to deploy a unique strategy of integrated social and health care due to the health and social needs of the population, especially for those people who are older or have complex needs. It was agreed to redefine the Interdepartmental Plan for Social and Health Care and Interaction (PIAISS), which was replaced by the new Integrated Social and Health Care Plan (PAISS).
The aim was, in short, to create a model of integrated care for health and social services, drawing up a work plan that would help to generate a model of coordinated global intervention, with the same overall vision, which would place the person at the center.

Last updated: March 3rd, 2022   Contributors: Cèlia Estruch  |  

1.07. Information and monitoring systems 

British Columbia (Canada)

Data availability presented 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: February 11th, 2022

Denmark

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

References:

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

 

Last updated: February 1st, 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

Data collected by Long-Term Care Insurance Funds

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 (Wissenschaftliche Institut der AOK, 2022).

References

Wissenschaftliches Insitut der AOK (2022) Publikationsdatenbank. Available at: Publikationsdatenbank | WIdO – Wissenschaftliches Institut der AOK (Accessed: 31 January 2022)

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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 (European Commission, 2016).

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 (Ministerio della Salute, 2021). The status of LTC information system is poor (particularly compared to heathcare), which led to negative consequences during the Covid-19 outbreak. As of November, 2021 there was no  official data on the pandemic outbreak in LTC services (Notarnicola et al., 2021).

References: 

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. Retrieved from:  update_joint-report_it_en.pdf (europa.eu)

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. Retrieved from: C_17_pubblicazioni_3111_allegato.pdf (salute.gov.it)

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: February 4th, 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: February 10th, 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: 2021: Ageing policies – access to services in different EU Member States).

Last updated: February 10th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Sweden

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

Last updated: February 10th, 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 (Digital Lifeline Fund, 2021)

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 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: LaingBuisson). 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).

References: 

Digital Lifeline Fund, (2021). DCMS Digital Lifeline Fund: Interim Report

Burton, J., Goodman, C., Quinn, T. (2020). The invisibility of the UK care home population – UK care homes and a minimum dataset. LTCcovid.org

Last updated: March 10th, 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: February 11th, 2022

1.08. Care home infrastructure

Overview

Prevalence of residential care

Overall, there has been a shift away from residential care towards more care provided in the community with the expectation that the latter is not only cheaper but also can offer better quality of care. Since the priority is often given to community-based care, consequently, the availability of residential care has been decreasing in many countries (Marczak et al. 2015; 2021 Long-term care in the EU).

Overall, over the years, countries such as Switzerland, Australia,  Netherlands, Sweden, Norway, Finland, Luxemburg and New Zealand had the highest rates of recipients of residential care at between 5- 6% of population 65 years and older. Conversely, in countries such as Portugal and Poland the rates were below 1% (Colombo et al., 2011). Residential care facilities appear to be limited in several Eastern and Southern European countries as well as in Japan (Marczak et al. 2015; Kubo et al. 2014, 2021 Long-term care in the EU).

Care home infrastructure

Care home infrastructure and design guidelines vary greatly between countries. For example, in some countries (e.g. Germany) there are quotas for single-room occupancy in care homes. Some countries have high percentage of single room occupancy (e.g. 80% of rooms in North-Rhine Westphalia region of Germany and 89% of room in British Columbia, Canada), whereas in other countries multi-bed room are predominant (e.g. in many Central and Eastern European countries).

References:

Colombo, F., Llena-Nozal, A., Mercier, J., & Tjadens, F. (2011). Help wanted? Providing and paying for long-term care: OECD Health Policy Studies.

Kubo, M. (2014). Long-term care insurance and market for aged care in Japan: focusing on the status of care service providers by locality and organisational nature based on survey results. Australias J Ageing, 33(3), 153-157.

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

International reports and sources

OECD

Colombo, F., Llena-Nozal, A., Mercier, J., & Tjadens, F. (2011). Help wanted? Providing and paying for long-term care: OECD Health Policy Studies.

Gori C, Fernandez JL, Wittenberg R (2015) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol

Europe

Some information on residential care in EU countries can be found in the following reports:

European Commission (2016) Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability.

2021 Long-term care report Volume 1 and Volume 2 – Publications Office of the EU

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/sitesreport

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: February 15th, 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) (Schmidt et al. 2020).

References:

Schmidt, A. at al (2020), ‘The impact of COVID-19 on users and providers of Long-Term Care services in Austria’ Accessed at: Austria report ltccovid.org

Last updated: February 2nd, 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 31st, 2022

British Columbia (Canada)

89% of the rooms in LTC facilities 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).

Last updated: February 11th, 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

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

In 1984 it was made illegal to construct multiple bed residential services, therefore all newly built nursing homes (plejebolig) are private rooms with personal space, kitchenette and living space. Denmark is the only country in the EU in which the construction of traditional old-age and nursing institutions has been legally banned.  Still, a number of residents still today live in nursing homes built under the old scheme, but most have been updated and offer private facilities.

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

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

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

References:

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

Last updated: May 24th, 2023

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

Responsibility for care homes

Regulation of the care home infrastructure is under State authority since it was devolved from the Federal level in 2006. Hence, minimal building and operational requirements as well as definitions as to what constitutes as care home (as opposed to more self-directed small-scale living arrangements for example) differ between the 16 Laender.

Demand of care homes

A report by the University of Cologne suggests that the increasing demand for residential care requires establishing additional as well as maintaining existing resources (Kochskämper & Pimpertz, 2015).

Care home providers

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) (Gesundheitsberichterstattung des Bundes, 2022).

Types of rooms & requirements

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 Laender 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-Württemberg, 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 (Deutschlandfunk, 2020; Aerzteblatt.de, 2019;  Wiedemann, 2019)

The requirements in terms of room-size and accessibility vary between the Laender. In Bavaria, for example, 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 (Wörmann, 2016).

Location of care homes

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 (Hackmann et al., 2016).

References

Aerzteblatt.de (2019) Baden-Württemberg lockert Einzelzimmervorgabe für Pflegeeinrichtungen. Available at: https://www.aerzteblatt.de/nachrichten/105668/Baden-Wuerttemberg-lockert-Einzelzimmervorgabe-fuer-Pflegeeinrichtungen (Accessed 31 January 2022)

Deutschlandfunk (2020) Einzelzimmer in der Pflege/ Mehr Privatsphäre, weniger Plätze? Available at: https://www.deutschlandfunk.de/einzelzimmerquote-in-der-pflege-mehr-privatsphaere-weniger-100.html (Accessed 31 January 2022)

Gesundheitsberichterstattung des Bundes (2022) Pflegeheime und verfügbare Plätze in Pflegeheimen. Gliederungsmerkmale: Jahre, Region, Art der Einrichtungen/Plätze, Träger. Available at: Ad-hoc-Tabelle (gbe-bund.de)(Accessed 31 January 2022)

Kochskämper, S. & Pimpertz, J. (2015) ‘Herausfoderungen an die Pflegeinfrastruktur‘ Institut der deutschen Wirtschaft Köln. Available at: IW-Trends_2015-03-04_Kochskaemper_Pimpertz.pdf (iwkoeln.de) (Accessed 5 February 2022).

Last updated: February 13th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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 estimated that there were 4,629 nursing homes for dependent older people in 2019 (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%
References:

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. Retrieved from: Cap5OASI_2019.pdf (unibocconi.eu)

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. Retrieved from: il+welfare+e+la+long+term+care+in+europa+cover.pdf (unibocconi.it)

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: February 4th, 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 (Estevez-Abe et al. 2021; covid19_and_japanese_ltcfs.pdf (harvard.edu).

References:

Margarita Estévez-Abe and Hiroo Ide. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

 

Last updated: February 10th, 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 (Bruquetas-Callejo and Böcker, 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

Last updated: February 1st, 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 Long-Term Care Facilities (LTCFs). 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 (Irving and Bloom, 2020).

Public and non-profit run long term care facilities in Singapore are particularly vulnerable to infectious diseases due to their infrastructure: most facilities resemble dormitory-style housing shared by  between roughly 6 and 12 residents living in close proximity, 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. Most public and non-profit LTCFs have substantial subsidies from the government (Goh et al., 2022).

References:

Goh, H.S.; Tan, V.; Lee, C.-N.; Zhang, H.; Devi, M.K. (2022) Nursing Home’s Measures during the COVID-19 Pandemic: A Critical Reflection. Int. J. Environ. Res. Public Health, 19, 75. https://doi.org/10.3390/ijerph19010075

Irving and Bloom (2020) COVID-19, Older Adults and Long-Term Care in the Asia Pacific. Report prepared for HelpAge International Asia Pacific. https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf

Last updated: February 11th, 2022

Spain

According to the IMSERSO report Social services aimed at older people in Spain (December, 2020), care homes are considered as Residential Care Services. They offer accommodation and support to older people on a permanent or temporary basis. Residential Centres are classed as social facilities that offer accommodation and specialized care to elderly people who, due to their family, economic and social situation, as well as their personal autonomy limitations, cannot be cared for at home.

The weekly IMSERSO report on the impact of Covid-19 in residential centres, states that care homes can be classed in the following ways:

  • Residential centres for the elderly
  • Residential centres for people with disabilities
  • Other permanent accommodation for social services aimed at the above groups.

Autonomous Communities have responsibility for care homes, and this contributes to the care home sector being remarkably heterogeneous and complex. This is due to the differences in each autonomous community’s criteria about what constitutes a care home for older people or people who are eligible for public care (Abellán García et al., 2019).

In Spain, there are 5,529 centres (1,451 publicly owned, and 4,078 privately owned) with a total of 389,677 beds, of which a total of 246,303 (63.2%) have public funding. The remaining 143,734 (26.8%) are privately financed. In general terms, the coverage index for all centres is 4.19 (number of places/population>=65)*100). Of this, 2.65 corresponds to public centres, and 1.54 to privately financed centres.

The weekly IMSERSO Report noted that as of 3rd June 2022 there are a total of 353,823 people living in residential centres, with 85.8% living in residences for the elderly. The remaining 14.2% live in residential centres for people with disabilities, and other permanent social services accommodation. The report also noted that 71% of care home residents are women, and 79.3% are over 80 years old. The annual public price of a place in a residential centre is estimated at €18,839.62, of which the beneficiaries contribute around €8,020.13 (42.6% of the total price).

The Community of Madrid has the highest proportion of private care homes (86.8%), followed by Catalonia (85.1%) and the Basque Country (74.1%) (IMSERSO, 2020). The average number of beds in care homes in Spain is 70.2, representing a notable increase compared to 2009 when centres with fewer than fifty beds prevailed (Comas-d’Argemir et al., 2021).

In 2020 three in every four long term care facilities in Spain were privately run and the fees for many residents were publicly funded. Mas Romero et al (2020) noted that the fees received by the care homes have not increased for a long time, a result of austerity measures, resulting in many private facilities making cuts to maintain their profits, for example by operating with minimum staff. They also identify this as a factor that may have affected the ability of care homes to respond to the challenges of COVID-19.

Despite concerns about large care homes (IMSERSO, 2009), the macro-residence model has been implemented especially in the Community of Madrid, where 41.9% of the centres have more than one hundred beds (compared to 17% in Catalonia and 16% in the Basque Country) (Abellán García et al., 2021). There are seventeen care homes that exceed three hundred places, and the largest has no less than 604 places. That is the case in public and privately-owned centres (Comas-d’Argemir et al., 2021).

References:

Abellán García, Antonio; Aceituno Nieto, María del Pilar y Ramiro Fariñas, Diego (2019): Estadísticas sobre residencias: distribución de centros y plazas residenciales por provincia. Datos de julio de 2019, Informes Envejecimiento en red nº 24, Enlace.

Abellán García, Antonio; Aceituno Nieto, María del Pilar; Fernández Morales, Isabel y Ramiro Fariñas, Diego (2020): Una estimación de la población que vive en residencias de mayores, Informes Envejecimiento en red, Enlace.

Comas-d’Argemir, Dolors; Legarreta, Matxalen y García Sainz, Cristina (2021), Residencias, las grandes olvidadas, en en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

IMSERSO (2009): Servicios sociales para personas mayores en España. Enero 2009, Boletín sobre Envejecimiento. Perfiles y Tendencias, 43. Enlace.

IMSERSO (2020): Servicios sociales dirigidos a personas mayores en España (Datos a 31/12/2019), Ministerio de Derechos Sociales y Agenda 2020, Enlace.

Mas Romero M, Avendaño Céspedes A, Tabernero Sahuquillo MT, Cortés Zamora EB, Gómez Ballesteros C, et al. (2020) COVID-19 outbreak in long-term care facilities from Spain. Many lessons to learn. PLOS ONE 15(10): e0241030. https://doi.org/10.1371/journal.pone.0241030

Last updated: November 21st, 2022   Contributors: Carlos Chirinos  |  Adelina Comas-Herrera  |  Sara Ulla Díez  |  

Catalonia (Spain)

In Catalonia, according to data from 2016, people living in an assisted living facilities, compared to the entire population over the age of 64, have greater dependence and clinical complexity and are on average 10 years older than those who do not live there (85.7 years vs. 75.7 years). The average age of patients admitted to a nursing home increases every year, with women being admitted on average almost 3 years older than men. However, people in assisted living facilities have more associated pathology, with dementia being up to 10 times higher than for people over the age of 64 in the general population (CAMFIC & AIFICC, 2016).

Catalan Long-Term Care facilities can have public, private or subsidized places. The facilities that are part of the Catalan Social Services System (public and private ownership), that is, that have been authorized by the DTASF or the DS (in the case of drug addiction therapeutic communities) are intended for 4 large groups of people and various residential resources are identified for:

  1. Older people:
    1. Assisted residence for the older people on a temporary or permanent basis.
    2. Sheltered housing for the older people on a temporary or permanent basis.
    3. Temporary or permanent home for the older people
  2. People with disabilities:
    1. Residences and Homes Residences for people with intellectual disabilities.
    2. Residences and Homes Residences for people with physical disabilities.
  3. People with mental illness and / or addictions:
    1. Residences for people with mental illness.
    2. Homes Residences for people with mental illness.
    3. Therapeutic communities and reintegration flats for the care of people with drug addictions.
    4. Residences for Children and Adolescents with Autism Spectrum Disorder.
  4. Child under custody:
    1. Educational Residential Centers.
    2. Residential Center for Intensive Education Action.
    3. Reception Centers.
    4. First Aid and Emergency Services.

According to 2019 data published by the Consejo Superior de Investigaciones Científicas (CSIC) in Catalonia, there were a total of 62,015 places for the older people in facilities, 12,601 (20.3%) publicly owned and 49,414 privately owned (79.7 %). (CAMFIC &AIFICC, 2016).

References: 

CAMFIC & AIFICC (2016) Model d’atencio sanitaria a les residencies de Catalunya.

Last updated: March 10th, 2022   Contributors: Cèlia Estruch  |  

Sweden

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

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

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

References:

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

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

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

Last updated: March 6th, 2023

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

England (UK)

Number of care homes and beds

The Office for National Statistics estimated that, between 2019 and 2020, there were 462,460 care home beds in England. Of these, 84.7% (391,927) were occupied. 36.7% of residents were self-funders (paid for their care privately). The Care Quality Commission (CQC) reported that occupancy levels fell during the pandemic, reaching a low of 80% during the summer of 2020.

The Future Care Capital estimated that in 2019 there were 15,661 care homes. Their report found that the number of registered care home beds has declined over time and that, at the same time, there has been a shift towards larger care homes, with the average size of care homes increasing from 26.8 beds in 2014 to 29.2 in 2019. Similarly, Kings Fund report indicated that number of care home places declined between  2012 and 2020, care home places declined from from 11.3 to 9.6 and nursing home places from 5.2 to 4.7 for every 100 people over the age of 75. There report also noted that there was a lot of regional variation.

Sector of ownership and quality

In terms of market composition, the Future Care Capital report estimated that, in 2019, 83.4% of care homes were private for-profit, 2.8% were public and 13.6% were not-for-profit. In 2019, just under 17% of all care home beds were owned by the five largest groups of providers. Quality of care,  is highest among not-for-profit providers, with 16.4% inadequate or requiring improvement by the CQC, compared to 24.8% for private companies. Care homes with fewer than 30 beds tended to be rated better than larger care homes.

Last updated: March 2nd, 2022   Contributors: Adelina Comas-Herrera  |  

England (UK)

Community support services for people living with dementia

A survey of people living with midl-to-moderate dementia and their care partners in Britain found low rates of receipt of dementia support services, with people who were female, older, and with lower education level receiving fewer services (van Horik et al, 2022).

References

van Horik J.O., Collins R., Martyr A., Henderson C., Jones R.W., Knapp M., Quinn C., Thom J.M., Victor C., Clare L., on behalf of the IDEAL Programme Team (2022) Limited receipt of support services among people with mild-to-moderate dementia: Findings from the IDEAL cohort. International Journal of Geriatric Psychiatry. 37(2). https://doi.org/10.1002/gps.5688

 

Last updated: March 21st, 2022   Contributors: Adelina Comas-Herrera  |  

United States

The Center for Disease Control (CDC) studies LTCFs with regards to 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: February 11th, 2022

1.09. Community-based care infrastructure

Overview

Many countries have attempted to invest more resources in homecare and community-based care, in an effort to move away from unnecessary reliance on residential forms of care. Despite the overall shift towards care at home, such services are limited in several Eastern and Southern European countries as well as Canada, Korea and US. Conversely, care in the community is more prevalent in several Nordic  countries, Japan or New Zealand. However, even if on average community care is available in a country, access to such care is often hampered in rural and remote areas (Marczak et al. 2015; 2021 Long-term care in the EU).

References:

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

International reports and sources

OECD

Gori C, Fernandez JL, Wittenberg R (2015) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol

Europe

Some information on care in the community in EU countries can be found in the following reports:

European Commission (2016) Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability.

2021 Long-term care report Volume 1 and Volume 2 – Publications Office of the EU

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 who need higher levels of care, especially personal care. It 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. People may also be asked to pay a ‘basic daily fee’, the level of which depends on the package level. Where the daily fee is charged, it  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  to determine the package level. There are four levels of packages which range from Level 1 –  to Level 4  per annum. 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 there are differences in the amount of administration and care management fees charged. Such fees average 25% of the total value of a package and they 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: February 15th, 2022

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 (sources: 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 (source: 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: February 2nd, 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: February 1st, 2022

Denmark

Municipalities provide social and health care services for older people living at home and overall, older people can access a wide range of services that enable them to remain in their homes even if they are chronically or terminally ill. These services include day care services, extensive home help and nursing care.

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

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

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

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

References: 

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

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

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

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

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

WHO (2019), Denmark: Country case study on the integrated delivery of long-term care. Accessed at:  https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019

Last updated: May 24th, 2023

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: February 1st, 2022

Germany

Differences in care infrastructure

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).

Future feasibility

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: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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 (Estevez-Abe, 2021; Kojima et al. 2021).

References:

Estévez-Abe, M., Hiroo Ide. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

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: August 4th, 2023   Contributors: William Byrd  |  

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 (Golinowska et al. 2017).

References:

Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: March 3rd, 2023   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: February 1st, 2022

Sweden

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

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

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

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

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

References:

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

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

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

Sandberg, LNilsson, IRosenberg, LBorell, LBoström, A-M, (2019) Home care services for older clients with and without cognitive impairment in SwedenHealth Soc Care Community201927139– 150https://doi.org/10.1111/hsc.12631

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

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

Taiwan, RoC

The 2017 Long-Term Care 2.0 reform introduced a Community-Integrated Care system. This was to be organised as a so-called ABC network, governed by local governments, where “A” is a community integration service centre (compared to an LTC flagship store), which is responsible for developing services in their area and for linking other services within a 30 minutes transportation window, “A” centres are also tasked with education, information and education. “B” are “composited service centres” (compared to an LTC speical care store) which provide major community-based services and are tasked with increasing quantiy and utilisation of services as well as helping “C” develop services. “C” are “Alley LTC stop” (compared to LTC grocery stores), with the remit of providing convenient care and temporary respite care, deliver preventative activities adn provide lunch clubs or meals on wheels. All “C” centres whould be within walking distance of users. There have been some ammendments to his original plan and reported tensions between the different types of centres (with B centres being allowed to set up with A centres) (Hsu and Chen, 2019).

The Health and Community-Based Services (HCBS) included in LTC 2.0 are home care serivces (including personal hygiene, transfers and housework), respite care, assistive devices and home modifications, tranportation and community-based services (such as day care and meals).

Another important aspect of the 2017 LTC 2.0 reform was a focus on reablement, giving care recipients who can benefit from reablement goal-oriented care plans to enhance the participation of care recipients in meaningful daily activities. A study found that care recipients with low care nees had greater potential to improve their physical function in Activities of Daily Living using reablement services and that both individuals with low and high care needs, home-based personal care supported improvement in Activities of Daily Living and Instrumental Activities of Daily Living (Yu et al., 2022).

References:

Hsu HC and Chen CF (2019) LTC 2.0: The 2017 reform of home- and community-based long-term care in Taiwan. Health Policy 123:10, 912-916. https://doi.org/10.1016/j.healthpol.2019.08.004

Yu, H-WWu, S-CChen, H-HYeh, Y-P & Chen, Y-M (2022). Relationships between reablement-embedded home- and community-based service use patterns and functional improvement among older adults in TaiwanHealth & Social Care in the Community30e4321– e4331https://doi.org/10.1111/hsc.13825

Last updated: March 2nd, 2023   Contributors: Adelina Comas-Herrera  |  

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: February 1st, 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

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

Overview

Introduction: Who are LTC workers, where and how are they employed?

The LTC workforce includes specialized professionals (geriatricians, nurse case management workers, physiotherapists) as well as so-called low skilled care workers. In various countries, the latter group can make up, up to 70% of the LTC workforce responsible for helping older people with activities of daily living (ADLs) (OECD, 2020).

LTC workers are predominantly women and overall, the LTC workforce is ageing itself: in the EU in 2016, the median age of  workers in the sector was 45; in 2019 the share of employees aged 50 or over was close to 38 %. Where data is available it indicates that larger portions of the workforce are working in institutional settings. This reflects a lack of visibility of home care workers but also the distinction between formal and informal workers (source: WHO 2019 LTC report; 2021 Long-term care in the EU). Across the OECD, about 45% of LTC workers are in part-time employment and need to work in multiple jobs (OECD, 2020).

Challenges with attracting workers into LTC sector

Various sources provide a long list of reasons behind the current shortages of LTC Workforce and highlight challenges with future recruitment. For example, an OECD 2020 report  notes lack of professionalisation, limited career opportunities, limited support for training, as exacerbating the workforce shortages  (OECD, 2020).

Similarly, a WHO report quotes 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. The report highlights that comprehensive and wide ranging set of  policies are needed to ensure a sustainable supply of LTC workers.

Workforce shortages

Workforce shortages are prominent in countries included in this report, and OECD as well as EU data indicate that most countries around the world are facing LTC staff shortages, although some (e.g. Eastern and Southern European region) more severely than others (e.g.  Nordic countries in Europe). Moreover, at the current pace of an ageing population, it is estimated that the need for LTC workers will need to increase by 40 – 100% just to maintain the current staff ratios, which are already often considered to be insufficient (OECD, 2020).

Migrant care workforce

An explorative comparative study into the situation of migrant carers and COVID-19 health workforce policies in selected EU countries (Kuhlmann et al., 2020) revealed that undersupply of carers coupled with cash-benefits and a culture of family responsibility may result in high inflows of migrant carers, who are channelled in low-level positions or the informal care sector. The sending countries are characterised by very low expenditure and density of LTC care together with strong family subsidiarity and a marginal role of LTC in the wider healthcare system. Consequently, the LTC workforce is poorly developed precisely in those countries, showing the strongest outflows of carers. Inter-governmental labour market arrangements on LTC migrant care may often reduce costs in high income countries, but they are threatening the aim of universal healthcare coverage in the sending countries and hamper the development of a sustainable LTC sector (copied from Kuhlmann et a., 2020).

Covid-19 made the fragile labour market arrangements of migrant carers visible, which may create new health risks for both the individual carer and the population. Country case studies further illustrate the new threats and challenges (examples below copied from Kuhlmann et al., 2020). The pandemic increases the risk of infection for the individual carer if travelling in times of lockdown, coupled with the risk of losing one’s job and income if travel is not permitted. It threatens the healthcare systems of the sending country, which is losing carers in a situation of a pandemic, when they are needed the most; and it threatens the provision of care in the destination country, as access and quality of care may worsen if borders are closed and the mobile carers have left. The pandemic has enhanced a debate over problematic global ‘production chains’ based on cheap labour and a lack of sustainability in European countries, especially in relation to medical protection material. However, very little attention has been paid so far to the ‘global care chains’ and the human resources for health involved in these chains. Finally, from a public health and system perspective, enhancing the mobility of carers through cross-border arrangements during a pandemic is highly problematic and may increase health risks and new outbreaks.

Two important policy recommendations are emerging:

  • – to include LTC migrant carers more systematically in public health and health workforce research and
  • – to develop European health workforce governance which connects health system needs, health labour markets and the needs of the individual migrant carers.
References:

Kuhlmann E, Falkenbach M, Klasa K, Pavolini E, Ungureanu M. Migrant carers in Europe in times of Covid-19: a call to action for public health-informed European health workforce governance, European Journal of Public Health, 2020;30(Suppl. 4):iv22-iv27; DOI:10.1093/eurpub/ckaa126

OECD (2020), Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/92c0ef68-en.

International reports and sources

There are a number of useful reports that discuss LTC workforce in different countries, including the following:

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

OECD Library_LTC workers

WHO 2019. Integrated Delivery of Long-Term Care

2021 Long-term care in the 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: February 15th, 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 (Leichsenring et al. 2021; Leiblfinger, M. at al. 2020).

References: 

Leichsenring, K., Schmidt, A.,  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,  pp. 33–42. DOI: https://doi.org/10.31389/jltc.54

Leiblfinger, M. at al. (2020) ‘Impact of COVID-19 Policy Responses on Live-In Care Workers in Austria, Germany, and Switzerland’ Journal of
Long-Term Care, (2020), pp. 144–150. DOI: https://doi.org/10.31389/jltc.51

Last updated: February 2nd, 2022

Belgium

In Belgium, the Wallonia region allows personal care workers to perform nursing tasks when no other care options are available (OECD, 2020).

References:

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

Last updated: February 3rd, 2022

Bulgaria

Bulgaria established excellence programmes in LTC for nurses (OECD, 2020). However, the country, alongside other Eastern European countries, experiences so called  “care drain’ where many LTC workers moved to work in other EU countries, mostly because of better salaries and better working conditions (European Commission, 2021).

References:

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

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

Last updated: February 3rd, 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: February 11th, 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 (Badone, 2021).

References:

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: February 11th, 2022   Contributors: William Byrd  |  

Denmark

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

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

Last updated: June 28th, 2023

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. 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 (Forma et al., 2020).

References:

Forma, L., Aaltonen, M., Pulkki, J. (2020). ‘COVID-19 and clients of long-term care in Finland- impact and measures to control the virus’, LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 12 June 2020. Retrieved from: Finland: ltccovid.org

Last updated: February 10th, 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

Pay

The average gross salary of LTC workers per month in Germany (in 2019) ranged between €2146-3032. Average income depended on the level of qualification and sector. Wage rates among those providing home care, on average, appeared to be slightly lower (€2039-2721) than among those working in residential care (€2182- 3099).

Even though salaries in the sector have increased by 28% since 2021, in comparison to the median salary of hospital nurses, LTC workers earn considerably less (Milstein, Mueller & Lorenzoni, 2021). Rothgang, Müller and Preuß (2020) investigated LTC workers’ income satisfaction. They found that 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 in care, 53% report having difficulty to live off their income. Among LTC workers, 52% think that their retirement pay will not be sufficient.

Employment conditions

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 (Lückenbach et al., 2021).

A study found that in comparison with other jobs psychological burden of LTC workers was higher in a number the aspects compared. The report also showed that while the majority of care workers felt their job was important, only 53% of care workers reported that they felt their work was socially recognized (Rothgang, Müller & Preuß, 2020).

Qualification levels

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 (Bundesministerium für Gesundheit, 2020; Medizinischer Dienst, 2020).

Shortages

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 (Lückenbach et al., 2021). In response to this shortage, the Care Staff Strengthening Act created posts for 13,000 additional care workers in residential care. Furthermore, the framework of the ‘Act to Improve Healthcare and Nursing’ secured funding for 20,000 additional nursing assistant positions (European Commission 2021). In addition, efforts to co-operate with countries, especially Mexico, the Philippines and Kosovo, have been made around improving vocational training and recruiting LTC workers (European Commission, 2021).

However, the creation of these additional 13,000 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 was prepared in 2018 and came into effect in large parts in 2019 (VDEK, 2021).

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 (Rothgang, Müller & Preuß, 2020)..

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-Württemberg do not expect to experience the same challenges (Hackmann et al., 2016).

Policies to address these issues

On 2 June 2021 the German government passed a new care reform (Pflegereform 2021) that sets out that all LTC workers in care homes need to pay their staff according to a 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 (Bundesministerium für Gesundheit (Bundesministerium für Gesundheit, 2021).

References

European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu) (Accessed 4 February 2022).

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Milstein, R., Mueller, M. & Lorenzoni, L. (2021) Case study – Germany. In WHO Centre for Health Development (?Kobe, Japan)?, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (?2021)?. Pricing long-term care for older persons. World Health Organization. https://apps.who.int/iris/handle/10665/344505. License: CC BY-NC-SA 3.0 IGO

Rothgang,H. Müller, R. & Preuß, B. (2020) Barmer Pflegereport 2020 – Belastungen der Pflegekräfte und ihre Folgen. BARMER: Berlin. Available at: https://www.barmer.de/blob/283280/6b0313d72f48b2bf136d92113ee56374/data/barmer-pflegereport-2020-band-26-bifg.pdf (Accessed 2 February 2022).

VDEK (2021) Gesetzgebungsverfahren der deutschen Gesundheitspolitik: 2017-2021. Aavailable at: https://www.vdek.com/politik/gesetze/wahlperiode_19.html#ppsg (Accessed 2 February 2022).

Last updated: March 11th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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 (2021) 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
  • The care worker/person 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 nurses. 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, but it is estimated that only 40% are employed under a regular employment contracts. The trend to rely on home-based migrant carers has been supported by different policy measures (at local, regional and national level), including training and accreditation programmes for informal and migrant carers, regular contracts for the latter have also been promoted by policy makers  (Barbarella et al. 2018).

References:

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

Barbarella F, Casanova G, Chiatti C and Lamura G (2018), ‘Italy: emerging policy developments in the long-term care sector’. CEQUA LTC network report. Retrieved from Italy Country 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: February 4th, 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 (Curry et al, 2018; https://ageingasia.org/).

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 (Ikegami, 2007).

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

References:

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Ikegami, N. (2007). ‘Rationale, Design and Sustainability of Long-Term Care Insurance in Japan – In Retrospect’ Social Policy and Society 6(03):423 – 434

Last updated: February 10th, 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: European Commission: 2021 Long-term care in the EU.

Last updated: February 10th, 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 country has developed stress management/coaching programmes on healthier work environment and prevention of work-place accidents for LTC centres to help decrease absenteeism (OECD, 2020).

References:

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

Last updated: February 1st, 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: OECD: Who Cares? Attracting and Retaining Care Workers for the Elderly).

Last updated: February 10th, 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: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 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: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 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, which constitutes less than half the EU-27 average. Care provided by family members is 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, non-tertiary education. Non-standard employment is not very widespread e.g. the share of temporary employment is less than 10 %, whilst shift work is less than 40 %, far below the EU-27 average (European Commission, 2021).

References:

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

Last updated: February 4th, 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, for example, the monthly cost per LTC employee is 67% of the average wage 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 (Zalakain et al. 2020).

A mostly female and migrant workforce

In 2020 there were 684,949 people working in social care (based on data from the EPA survey), representing 3.7% of the total number of employed persons in Spain. 66.3% of social care workers were employed in private households, either as home carers (17.7%) or as domestic workers (82.3%). Carers working in care homes represented 19.9% of the total care workforce (most them  employed as nursing assistants), and carers in social services without accommodation (mostly home help services, usually referred to as SAD) represent 13.9% of the care workforce.

In all occupations women exceed 90% of the workforce, specially among domestic services, where 98.3% are female. Migrant workers represent 62.2% of domestic workers, 49.2% of home carers and 25.6% of nursing assistants (Roca et al., 2021).

Improving the working conditions of female workers is essential to ensure the quality of care. This is no a homogenous sector since it is very different to work in a care home, in a Home Help Service [SAD], or as a home and care worker (Martínez-Buján, 2011; Moré, 2015; Roca, 2017). But there are some common characteristics among care workers since they all share precarious working conditions. They also share that they are feminized and poorly qualified jobs, converted into a labour niche for foreign migrants with little recognition. Domestic workers have the worst working conditions and suffer from an evident lack of rights (Comas-d’Argemir and Martínez-Buján, 2021).

Female care workers face various obstacles to professionalization. One of them is related to the persistence of a family model of care that links care to the home (preference to grow old at home), where an individualizing logic predominates and where the figure of the family caregiver extends into that of the paid caregiver (Moreno-Colom et al., 2016). The other obstacle is that little or no qualifications are required to do this job, based on the naturalisation of expertise considered unique to women, which justifies the low salaries (Recio Cáceres et al., 2015). That weakens the capacity for collective action and increases the insecurity and vulnerability of these workers (Cañada, 2021). Job insecurity is the enemy of quality care. Low wages, part-time work and temporary employment generate a high turnover of female workers, especially the youngest, who can access more qualified qualifications and easily leave the sector searching for better-paid jobs. Or they go to the health sector, where there are better salaries. The lack of specific training to treat certain pathologies also affects the quality of care (Comas-d’Argemir and Martínez-Buján, 2021). The dichotomy is clear: either the costs of care are assumed socially so that it is carried out in decent conditions, or women continue to be exploited, either as unpaid family caregivers or as cheap labour. That is the current model in the Spanish context (Comas-d’Argemir and Martínez-Buján, 2021).

References:

Cañada, Ernest (2021) Cuidadoras. Historias de trabajadoras del hogar, del servicio de atención domiciliaria y de residencias, Barcelona, Icaria.

Comas-d’Argemir, Dolors y Martínez-Buján, Raquel (2021), Hacia un modelo alternativo de cuidados, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Martínez-Buján, Raquel (2011) La reorganización de los cuidados familiares en un contexto de migración internacional, Cuadernos de Relaciones Laborales, 29, 1, 93–123.

Moré, Paloma (2015) Cuidados a personas mayores en Madrid y París: la trastienda de la investigación, Sociología del Trabajo, 84, 85-105.

Moreno-Colom, Sara; Recio Cáceres, Carolina; Borràs Català, Vincent y Torns Martín, Teresa (2016) Significados e imaginarios de los cuidados de larga duración en España. Una aproximación cualitativa desde el discurso de las cuidadoras, Papeles del CEIC, 145, 1-28.

Roca, Mireia (2017): Tensiones y ambivalencias durante el trabajo de cuidados. Estudio de caso de un Servicio de Ayuda a Domicilio en la provincia de Barcelona, Cuadernos de Relaciones Laborales, 35, 2, 371-391.

Roca, Mireia, Bañéz, Tomasa y Hernández, Ana Lucía (2021), Trabajadoras en servicios de cuidado. Servicios sociales básicos, centros de día, asistencia domiciliaria y asistencia personal, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas.www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Recio Cáceres, Carolina; Moreno-Colom, Sara; Borràs Català, Vincent y Torns Martín, Teresa (2015) La profesionalización del sector de los cuidados, Zerbitzuan, 60, 179-193.

Zalakain, J. Davey, V. & Suárez-González, A. (2020). ‘The COVID-19 on users of Long-Term Care services in Spain’. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

Last updated: March 10th, 2022   Contributors: Joanna Marczak  |  Carlos Chirinos  |  

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

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

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

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

References

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

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

 

 

Last updated: February 13th, 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)

Overview

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 (Source: Build Back Better: Our Plan for Health and Social Care).

Social care vacancies

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 (Skill for Care, 2021). Overall, data indicate that the staff vacancy rate in social care in  2020/21 was much higher compared to 2014/15 and that pay could be a factor, as although pay has increased in the same period of time, the increase has not kept pace with other sectors (Bottery et al., 2022).

Working conditions and pay

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 (Bottery et al., 2022).

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 (Dayan et al., 2019).  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 (Source: UK points-based immigration system: further details statement). 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 (Skills for Care, 2021). To release the recruitment pressures, in December 2021, the government  announced that care workers, care assistants and home care workers will be added to the Shortage Occupation List as part of the health and care visa to make it quicker, cheaper and easier for social care employers to recruit eligible workers to fill employment gaps (see section 3.06 of this report for more details).

References: 

Bottery, S., Ward, D. (2022). Social Care 360. The King’s Fund. https://www.kingsfund.org.uk/publications/social-care-360

Dayan, M., Palmer, B. (2019). Stopping the staff we need? Migration choices in the 2019 general election. Nuffield Trust Election briefing

Skills for Care (2021). The state of the adult social care sector and workforce in England 2021.

Last updated: March 8th, 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: March 10th, 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: February 11th, 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. Role of unpaid carers and policies to support them

Overview

Introduction

Informal and unpaid care has attracted significant policy attention worldwide, partly driven by a recognition that unpaid carers play a critical role in ensuring the sustainability of the long-term care system.  For example, carers provide  as much as 80% of all care across the European Union (Eurocarers, 2017), although there are differences within Europe, where 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 (The 2021 Ageing Report).  The numbers of carers have also increased in the Europe between 2007 and 2021 from 1 in 3 to 1 in 2 (Ilinca and Simmons, 2022). Unpaid carers also provide a lion’s share of care in Sub-Saharan Africa, US, or Israel (see country reports in this section).

Gender care gap

Unpaidc care tends to be gendered i.e. women  tend to provide more informal care than men. For example, in  Austria women 60% provide unpaid care and  48% of men. In Spain the figure is  66% for women vs.
54% for men. Moreover, women tend to report more perceived pressure to provide unpaid care than men: in the EU in 2021 65.7% of women and 49.8 % of men reported feeling obliged to provide unpaid care  (Ilinca and Simmons, 2022).

Policies to support unpaid carers

Policy measures that aim to support unpaid carers can be divided into those directly addressed to carers and those addressed at people with needs which nonetheless can support carers (e.g. homecare). Policies directly aimed at supporting carers include compensation measures such as carers’ allowance, social security transfers, tax reliefs, and these tend to be implemented in many countries (e.g. in England, Austria, Italy, Sweden, Poland). Supportive measures such as training, support groups, carers’ assessment, respite care, are also common although in some countries (e.g. Austria, England, Finland, France, Germany, and Sweden) these are more prevalent that in others (e.g. Bulgaria, Latvia, Poland, Italy or Spain). Reconciliation measures aiming at facilitating work with care (e.g. paid or unpaid leaves that unpaid carers can take are less popular although also present in some countries (e.g. Austria, Germany, Italy).

Research evidence on the impact of caring

Evidence indicates that caring has a negative  impact on psychological health, such as depression, anxiety,  stress and burden (Gilhooly et al., 2016). There is also some evidence on the impact of caring on physical health. Intensity of caring as well as duration of care provision is significantly associated with poorer health (Bauer and Sousa-Poza, 2015; Brimblecombe et al., 2018).

Research evidence on the effectiveness of policy interventions to support carers

Reviews indicate  positive effects of various educational, psychosocial interventions and support groups on carers’ outcomes.  For example Thomas et al. (2017) meta-review found education, training and information for carers were highly effective in supporting unpaid carers.

The evidence on the impact of respite care on carers’ outcomes is mixed: some evidence suggests that although caregivers may be  satisfied with respite care, they experienced small or none improvements in burden, physical or mental health (Lopez-Hartmann et al., 2012; Maayan et al., 2014; Mason et al., 2007; Shaw et al., 2009).

Reviews also indicate that supporting unpaid carers through e.g. counselling, educational strategies, education and training, can delay institutionalisation of older people with needs e.g. those with dementia or Alzheimer’s disease (Gilhooly et al., 2016; Thinnes and Padilla, 2011; Mittelman et al., 2006).

Research highlights that it may be that a combination of various interventions that are most effective and that the type of support needed will depend on the carer’s (and the care recipient) broader circumstances (Dickinson et al., 2017; Gilhooly et al., 2016;  Thomas et al., 2017; Vandepitte et al., 2016)

References:

Brimblecombe, N., Fernandez, J., Knapp, M., Rehill, A., & Wittenberg, R. (2018). Review of the international evidence on support for unpaid carers. Journal of Long-term Care, 25-40 (ilpnetwork.org)

Dickinson, C., Dow, J., Gibson, G., Hayes, L., Robalino, S., & Robinson, L. (2017). Psychosocial intervention for carers of people with dementia: What components are most effective and when? A systematic review of systematic reviews. Int Psychogeriatr, 29(1), 31-43. doi:10.1017/S1041610216001447

Eurocarers. (2017). Overview of carers’ needs and existing support measure across Europe: Eurocarers

Ilinca, S, Simmons, C. (2022) The time to care about care: Responding to changing attitudes, expectations and preferences on long-term care in Europe. InCARE Policy brief No. 2 

Gilhooly, K., Gilhooly, M., Sullivan, M., McIntyre, A., Wilson, L., Harding, E., Crutch, S. (2016). A meta-review of stress, coping and interventions in dementia and dementia caregiving  BMC geriatrics, 16(1), 106.

Lopez-Hartmann, M., Wens, J., Verhoeven, V., & Remmen, R. (2012). The effect of caregiver support interventions for informal caregivers of community-dwelling frail elderly: a systematic review. Int J Integr Care, 12(5), 133. doi: 10.5334/ijic.845.

Mason, A., Weatherly, H., Spilsbury, K., Golder, S., Arksey, H., Adamson, J., & Drummond, M. (2007). The effectiveness and cost-effectiveness of respite for caregivers of frail older people. Journal of the American Geriatrics Society, 55(2), 290-299. doi: 10.1111/j.1532-5415.2006.01037.x.

Thinnes, A., & Padilla, R. (2011). Effect of educational and supportive strategies on the ability of caregivers of people with dementia to maintain participation in that role. American Journal of Occupational Therapy, 65(5), 541-549. doi: 10.5014/ajot.2011.002634.

Vandepitte, S., Van Den Noortgate, N., Putman, K., Verhaeghe, S., Faes, K., & Annemans, L. (2016). Effectiveness of supporting informal caregivers of people with dementia: a systematic review of randomized and non-randomized controlled trials. Journal of Alzheimer’s Disease, 52(3), 929-965. doi: 10.3233/JAD-151011.

International reports and sources

2021 EU Long-term care report. Trends, challenges and opportunities in an ageing society, Volume 2. Provides an overview of the situation of unpaid carers in a number of European Countries

Eurocarers website provide information, facts and publications about unpaid carers in European countries.

The CEQUA project provides an overview of policies on unpaid carers in 11 European countries including England, France, Germany, Spain, Sweden, Finland, Austria, Poland, Latvia, Bulgaria, Czech Republic and Italy  (https://www.cequa.org/).

For Sub-Saharan Africa, see WHO series on long-term care on healthy ageing. 

Australia

Informal carers play an important role in Australian society.  In 2018, around one in nine Australians provided unpaid care to an elderly person or somebody with disability  (Australian Bureau of Statistics, 2019).

References: 

Australian Bureau of Statistics (2019). Disability, ageing and carers Australia: Summary of findings, Australian Bureau of Statistics: Canberra, ACT, Australia

Last updated: March 4th, 2022

Austria

Unpaid carers have been receiving  greater recognition and benefits in Austria over the years. For example, since  2009, the federal Government pays old-age for informal carers themselves (prior to 2009, unpaid carers had an option to pay  health and pension insurance voluntarily from their own pockets).
Carers are also entitled to an extra allowance to pay for respite care. Since 2014, carers who are in paid employment may take a paid care leave or part-time care leave to care for dependent relatives for up to three months, the compensation amount is income-related (Rodrigues et al. 2017).

References: 

Rodrigues, R., Bauer, G., Leichsenring, K. (2017). ‘A decade of piecemeal changes in Austria’. CEQUA LTC Network report 

Last updated: February 15th, 2022

Belgium

Unpaid carers including family members provide an important share of Long-Term Care in Belgium (EC, 2021). 

References:

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Last updated: February 16th, 2022

Bulgaria

Care for older and disabled people has historically been the responsibility of family members in Bulgaria, although there is little information on actual numbers. Informal carers are supported by a range of measures which include leaves of absence from work to care for a dependent person. Carers are entitled to a paid leave of up to ten days per calendar year to providing care to a sick, adult, family member  which may include accompanying them for medical procedures. Unpaid leave may also be requested for longer periods, however whether its granted is subject to employer’s approval (Salchev, 2017).

Since 2019, informal carers may be also selected by the person with needs to act as personal assistants,  by approval from  the municipality, assistants can receive training by the municipalities. In line with the Social Services Act (SSA) informal family members who provide informal care for people with permanent disabilities may  receive free support and training services.  The SSA also established the right to respite care for informal carers (EC, 2021).

References: 

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Salchev, P. (2017). Bulgaria: Emerging policy developments in long-term care. CEQUA LTC Network 

Last updated: February 16th, 2022

British Columbia (Canada)

Unpaid carers 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 caregivers when liaising with the health and social sector (source: https://www.familycaregiversbc.ca/).

Last updated: March 3rd, 2022

Czech Republic

Unpaid carers represented 4.6 % of the population in 2020: 6.2 % among women and 2.9 % among men. One third of unpaid carers provide care for more than 20 hours per week. Around two-thirds of unpaid carers in social services are female aged between 35-65 years old (EC, 2021). Unpaid care plays an important role in the sustainability of LTC as other options are often not available. There is a growing emphasis to support carers, particularly through improving the availability of respite services and counselling although availability of support is very limited. A care allowance for dependent people who receive unpaid care is also aimed at supporting unpaid carers (Sowa-Kofta et al., 2017; EC, 2021).

References:

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Sowa-Kofta, A., Wija, P. (2017). Czech Republic: Emerging policy developments in long-term care. CEQUA country report.

Last updated: February 16th, 2022

Denmark

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

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

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

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

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

References: 

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

Last updated: May 24th, 2023

Finland

Although Finland assigns its municipalities a legal responsibility to provide care services, unpaid carers still play a major role in care provision. It is argued that reforms of the care system in the past 30 years have resulted in increased reliance on families, who have been provided with support through cash-for care schemes  Municipal support requires a contract between the municipality and the caregiver (Ylinen et al., 2021).

References:

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021. http://dx.doi.org/10.20350/digitalCSIC/13692

Last updated: February 15th, 2022

France

France is a country with a strong family tradition, where unpaid informal carers have always played an essential role. There were 4.8 million carers recorded in France in 2011. Support for carers 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 (Le Bihan et al. 2017).

References: 

Le Bihan, B., Sopadzhiyan, A. (2017). France Country report. CEQUA LTC Network 

Last updated: February 15th, 2022

Germany

In 2019, there were about 4.13 million people with long-term care needs and around 80% of them received care and support at home (80%). Of those, more than 60% were supported by informal carers only, almost 30% use care and support from both unpaid and domiciliary carers or domiciliary carers only  (source: https://www.destatis.de/DE). the German LTC system provides  cash benefits that could be used as payment for informal care arrangements and financial support for unpaid carers through household transfers for beneficiaries remains strong in the German LTC system. Family carers in paid employment are entitled to financial support if they reduce working hours to care for a close family relation: wage compensation can be granted by employers for reduced employment of a minimum of 15 hours for up to 24 months. Moreover,  the Care Leave Act of 2015 introduced a wage compensation for acute care leave of up to ten days, usually 90% of net earnings; a leave of up to three months is also available for those individuals who support family members at the end of life (Frisina-Doetter et al. 2017).

References: 

Frisina-Doetter, L., Rothgang, H. (2017). The German LTC policy landscape. CEQUA LTC Network report 

Last updated: February 15th, 2022

Ireland

Most long-term care in Ireland is provided by unpaid carers supplemented by home care services (Pierce, et al. 2020). Income support is often targeted at carers (rather than people with LTC needs), in the form of carer’s allowance/benefit. In order to qualify for carers’ allowance one needs to be in a position to provide full-time care to a person with needs.  Ireland also has a home carer’s tax credit for married couples or civil partners where one partner carers for a dependent person (rather than being in paid employment). The Carer’s Leave Act 2001 entitles employees to leave work temporarily to provide full-time care for someone who requires full-time care (as signed off by a GP).  To be eligible, the carer must have been in the continuous employment for at least 12 months. The leave can be taken for a period ranging from 13 weeks up to a maximum of 104 weeks. The leave can be taken either as a continuous period or for a number of separate periods not exceeding the maximum number of 104 weeks. The leave is unpaid, however it offers job protection and the person may be eligible for carer’s benefits (EC, 2021).

References: 

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Pierce M, Keogh F and O’Shea E (2020). ‘The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures’. Country report available at LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 13 May 2020.

Last updated: February 16th, 2022

Israel

Israel heavily relies on unpaid carers: an estimated million and a half Israelis, mostly women,  serve as primary caregivers and typically provide 21 hours of caregiving a week (Nissim et al. 2016).  In April 2018, as part of the LTC reform, the National Insurance Institute launched a program to entitle home-based unpaid caregivers to long-term care benefits. Made a national policy in August 2019, family members can be paid as caregivers under certain conditions; statistics on the implementation of the policy are unavailable (source: https://adva.org/wp-content/uploads/2019/03/Care-Deficit-EN.pdf).

References: 

Nissim, B. D. et al. (2016). A Method for Estimating the Participation Rate of Elder Care. Theoretical Economics Letters. 6 (3). Retrieved from: A Method for Estimating the Participation Rate of Elder Care

Last updated: February 15th, 2022

Italy

Italy has a strong family-based approach to LTC and unpaid carers represent the bulk of  provision. No precise figures are available, however, the number of family carers among the population in working age (15–64) who care for an adult, has been estimated at over 3.3 million. Carers have access to a number of provisions, including: help in performing care tasks (e.g. training); provision for carers but also for people with needs (e.g. respite care); ‘indirect specific’ services which aim to improve conditions for unpaid carers (e.g. measures to help carers combine caring with paid work); ‘indirect non-specific’ provisions:  directed at care
recipients however carers may also benefit from them. Migrant domestic carers constitute an important part of care provision in the country (Barbabella et al. 2017).

References:

Barbabella, F., Casanova, G., Chiatti, C., Lamura, G. (2017). ‘Italy: emerging policy developments in the long-term care sector’ CEQUA Report 

Last updated: February 15th, 2022

Japan

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. Although in-kind benefits are generous, but may not cover all needs. Moreover, there is also a 10% co-payment on accessing care, therefore poorer people may need to avoid using formal care and rely on unpaid carers instead (Curry et al. 2018).

References: 

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Last updated: February 15th, 2022

Latvia

Informal care is common in Latvia. Some services for people with LTC needs, which may also benefit carers, are provided by municipalities (e.g. homecare, meals on wheals etc). The Law on Social Services and Assistance indicates that local government has to offer counselling, psychological support as well as training to family caregivers, in some circumstances they may also provide material support  (EC, 2021s). Overall however, services for informal carers have been historically scarce and underdeveloped (Calite-Bordane, 2017).

References:

Calite-Bordane, D. (2017). ‘Latvia: Emerging policy developments in long-term care’. Retrieved from: CEQUA Latvia Country report

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Last updated: February 16th, 2022

Poland

Prevalence and characteristics of unpaid carers

Families are primarily responsible for care provision in Poland, and it is estimated that between 80% to over 95% of LTC is provided by unpaid carers. Typically, carers are women, who tend to be older themselves, often resigning from work and taking early retirement to provide care.

Cash benefits

Informal carers are mostly supported through cash benefits provided either to the carer or to the person with care needs, and benefits tend to be low. Most cash benefits cannot be combined with care, and overall there is little support to allow carers combine paid work with caring (Golinowska et al. 2017).

In-kind services

Such services as respite care, trainings and psychological help as scarce, and if they exist they tend to be provided by charities. A programme to introduce and develop respite care was launched in Poland in 2019 (EC, 2021).

References: 

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Golinowska, S., Sowa-Kofta, A. (2017). The Polish policy landscape. CEQUA Report 

Last updated: February 16th, 2022   Contributors: Joanna Marczak  |  

Spain

In Spain, the family continues to be an essential resource in care provision. Despite numerous public and private care resources that make up a complex care system, the family continues to be assigned by society the task of caring for its members. Virtually no family caregivers carry out care activities entirely alone (Soronellas & Jabbaz, 2021). Family care is carried out progressively, fitting together different resources provided by the care diamond agents: family, state, market, and community (Razavi, 2007). We will refer to this with the expression: mosaic of care resources, that is, the set of aids and services that are used to care for people in long-term care situations (Soronellas and Comas-d’Argemir, 2017). In Spain, the weakness of public policies and the lack of incorporation of men, fragments care among the different provider agents, overloads women and makes it difficult for families to manage care for people with care needs.

In the analysis of the mosaic of care, we must consider the factors that condition access to formal care resources that we will mention: (1) Having a certain degree of dependency. (2) Have the economic capacity to finance the private outsourcing of care. (3) Living in an urban area with a great diversity of institutional resources or low public and private resources in a rural area. (4) Be willing to accept the possibility of sharing care (Soronellas & Jabbaz, 2021).

Prevalence

The Spanish LTC system is family-based often relying on women.  In 2016, 13.3 % of women and  9.5 % of men provided unpaid care. Moreover, over 50% of informal carers provided more than 20 hours of care weekly (EC, 2021).

Impact of caring

A recent paper shows that informal carers experience significant problems due to their caring responsibilities, although the impact is greater on women than men.  It has been estimated that informal care duties pose significant obstacles for female carers’ participation in the paid workforce, as well as reporting less time for social activities and to care for themselves. Both men and female carers’ face financial difficulties due to their caring (Peña-Longobardo, et al. 2021).

To facilitate taking care of disabled people or people with care needs, many women abandon their careers. They consequently not only lose the opportunity to develop as a person, but  also as a worker who contributes to the labour market. They also lose the right to accrue possible benefits from the Social Security System, as it would be impossible to comply with the requirements of the system’s contributory benefits.

Measures to support unpaid carers

The Dependency Law, via a series of measures designed for non-professional caregivers (who are largely women), includes a measure that allows them to accrue social security benefits while caring for family members. This is financed by the Spanish General State Administration (AGE) and requires that non-professional caregivers of people with care needs sign an agreement to prevent them incurring any economic cost. Essentially, this allows non-professional carers to accrue benefits for retirement and if they find themselves suffering from permanent disability.

As of 31st January 2022, there are a total of 67,249 special agreements signed by non-professional caregivers (88.6% of which are women). The payment of the special agreements for non-professional carers by the AGE has meant a total expense of €1,639,881,600.61 since the Dependency Law came into force (although it must be taken into consideration that this measure was on hold between 2012 and April 2019).

Overall, services for informal carers are considered to be scarce and vary between the autonomous communities (EC, 2021). The law however promotes support for unpaid carers, such as training programmes, information and respite care. Carers may also pay social security on a voluntary basis (Guillen et al. 2017).

 

References:

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Peña-Longobardo, L.M.; Río-Lozano, M.D.; Oliva-Moreno, J.; Larrañaga-Padilla, I.; García- Calvente, M. (2021). Health, Work, and Social Problems in Spanish Informal Caregivers: Does Gender Matter? Int. J. Environ. Res. Public Health 2021, 18,7332. https://doi.org/10.3390/ijerph18147332

Guillen, M. et al. (2017). Spain. Country Report. CEQUA LTC Network 

Razavi, Shahra (2007): The political and social economy of care in a development context. Conceptual issues, research questions and policy options, United Nations Institute for Social Development, Enlace.

Soronellas, Montserrat y Jabbaz, Marcela (2021), Cuidadoras familiares, antes y depues de la pandemia, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Soronellas, Montserrat y Comas-d’Argemir, Dolors (2017): Hombres cuidadores de personas adultas dependientes. ¿Estrategias ante la crisis o nuevos agentes de cuidado?, en María Rosa Herrera y German Jaraiz (eds.), Pactar el Futuro. Debates para un nuevo consenso en torno al bienestar, Sevilla, Universidad Pablo de Olavide, 2221-2239.

Last updated: June 27th, 2022   Contributors: Joanna Marczak  |  Carlos Chirinos  |  Sara Ulla Díez  |  

sub-Saharan Africa

Families provide most of care in sub-Saharan Africa, often without any  support. Particularly women are often expected to forego education or employment to provide care for older people (source: WHO series on long-term care on healthy ageing).

Last updated: February 17th, 2022

Sweden

Although the general principle behind LTC policy in Sweden is to provide government-financed care, unpaid caregivers provide around two-thirds of the care received by those living in the community. Unpaid carers can claim time off work and compensation from national social insurance. Carers may receive cash benefits from municipalities, which are provided at the discretion of the municipality, or carers’ allowance, whereby a family carer is employed by the municipality to provide care (notably, this is not payable to those over 65 years old). Direct in-kind support for carers is provided by all municipalities as a general service and not based on needs assessment, it can be in the form of information and advice, counselling, support groups, respite care. The intensity, content and quality of the provided support can, however, vary between the municipalities (Johansson et al. 2017).

References: 

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

Last updated: February 15th, 2022

England (UK)

Prevalence

It has been estimated that around 5 million carers provide informal support to older people in England (Brimblecombe et al., 2016, Wittenberg, 2017). Considering the population ageing and increasing numbers of people with LTC needs, it has been projected that by 2035 the country will need additional 2.3 million of unpaid carers (Brimblecombe et al., 2016).

Policies to support unpaid carers

A number of policy changes have been introduced over the last decade that aim to support carers, and which focus on supporting carers directly (e.g. recognition of carers assessment, cash for carers, pension rules) as well as supporting people with needs, and thus carers indirectly. Perhaps the most important law for the last sixty years reforming the social care system, including carers’ related policies, was The Care Act 2014.  The statute  enhanced recognition of legal status of carers, it provided carers with new rights to receive needs assessment regardless of the eligibility to public support by the person they care for, and regardless of the intensity of the care provided. It also  clarified their entitlements to public support. The Care Act highlighted that  local authorities must promote carers’ wellbeing , they must provide information and advice to carers as well as support carers if they want to remain in employment (Marczak et al. 2017; Marczak et al. 2021).

Services for carers

The Care Act 2014,  specified that English local authorities have a legal duty to provide support to meet carers’ eligible needs (HM Government, 2014). Indeed, a recent King’s Fund report illustrated that more carers have received support in 2020/21 relative to 2015/16, although most carers receive information, advice or such universal services as signposting, conversely in the same period fewer carers received paid support such as personal budgets.

Cash benefits

Unpaid carers in England are eligible to claim cash benefits such as Carers Allowance, which is  not means-tested, eligibility depends on various criteria, including a that the carer provides at least 35 hours of care per week. As of February 2022, the allowance was £67.60 weekly.  Informal carers in receipt of Carer’s Allowance automatically get National Insurance credits which can help them to build towards their state pension (source: Carer’s Allowance – GOV.UK).

References: 

Brimblecombe, N. Fernandez, JL, Knapp, M., Rehill A. Wittenberg, R. (2016) Unpaid Care in England: Future Patterns and Potential Support Strategies. PSSRU Discussion Paper. London: EShCRU at LSE.

Marczak, J. Fernandez, JL, Wittenberg, R. (2017). The English policy landscape. CEQUA LTC Network

Marczak, J. Fernandez. JL, Manthorpe, J. Brimblecombe, N. Moriarty, J.  Knapp,M, Snell, T. (2021) How have the Care Act 2014 ambitions to support carers translated into local practice? Findings from a process evaluation study of local stakeholders’ perceptions of Care Act implementation. Health and Social Care in the Community https://doi.org/10.1111/hsc.13599 

Wittenberg, R. (2017) Long-term care for older people in England. In: MASIERO, S. & CARRARO, U. (eds.) Rehabilitation Medicine for Elderly Patients | SpringerLink

Last updated: March 3rd, 2022   Contributors: Joanna Marczak  |  

United States

The US 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 (Upadhyay and Weiner, 2019). 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 (van Houtven et al. 2020).

References:

Upadhyay P. and Weiner J. (2019) Long-Term Care financing in the United States. Leonard Davis Institute of Health Economics, Issue Brief 23(1). University of Pennsylvania.

Van Houtven, CH., Boucher NA, Dawson, WD. (2020). The Impact of COVID-19 Outbreak on Long Term Care in the United States. Country report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24th April 2020. Retrieved from: Article from ltccovid.org

 

Last updated: February 16th, 2022

1.12. Personalisation, 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

My Aged Care is the single point of entry for government subsidised care in Australia, operating through a phone line and website. It provides information about the different types of care available, an assessment of needs, provides referrals and support to find service providers and information on the fees people are likely to face.

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.

The Royal Commission report found that users of aged-care found the experience of seeking services to be “time-consuming, overwhelming, frightening and intimidating” (Royal Commission 2021, p. 65) and argues that the current My Aged Care system does not provide the personalised information and support that is required for people to be able to make decisions about their own care.

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: February 11th, 2022   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: February 11th, 2022

Ontario (Canada)

Focussing on Ontario, an article by Bardone (2021) 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 ageing, disability, and death that make possible the abandonment of frail older people.

References:

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: February 11th, 2022   Contributors: William Byrd  |  

Denmark

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

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

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

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

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

References:

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

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

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

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

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

Last updated: June 28th, 2023

Choice

People who use LTC at home have choice in the 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 Charter emphasises people’s choice regarding where to live, care and support and their daily routine as well as financial and legal aspects (Der paritätische Gesamtverband, 2018; PKV, n.d.).

In Baden-Württemberg, the task force on LTC recognises the importance of self-determination among people with LTC needs during COVID-19 (Task Force Langzeitpflege und Eingliederungshilfe, n.d.).

References

Der paritätische Gesamtverband (2018) Workshop: Recht auf Selbstbestimmung – auch in Abhängigkeitsverhältnissen. Selbstbestimmung ermöglichen – Was heißt das für Träger in der Pflege? Available at: https://www.der-paritaetische.de/fileadmin/user_upload/Schwerpunkte/Mensch-du-hast-recht/doc/VT2018_WS-Selbstbestimmung-Pflege_ThorstenMittag.pdf (Accessed 31 January 2022).

PKV (n.d.) So funktioniert die Pflegeversicherung. Available at: https://www.pkv.de/wissen/pflegeversicherung/so-funktioniert-die-pflegeversicherung/ (Accessed 31 January 2022).

Task Force Langzeitpflege und Eingliederungshilfe (n.d.) Positionspapier der Task Force Langzeitpflege und Eingliederungshilfe „Selbstbestimmung und soziale Teilhabe trotz Corona gewährleisten“  Available at: https://sozialministerium.baden-wuerttemberg.de/fileadmin/redaktion/m-sm/intern/downloads/Downloads_Gesundheitsschutz/Corona_Positionspapier-TF-Langzeitpflege-EGH_Selbstbestimmung-Teilhabe_20201204.pdf (Accessed 31 January 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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: February 11th, 2022

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 (Bolcato et al., 2021).

With regards choice, for people whose application for access to services to the Local Health Authority is successful, 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 (European Commission, 2021).

References: 

Bolcato M, Trabucco Aurilio M, Di Mizio G, Piccioni A, Feola A, Bonsignore A, Tettamanti C, Ciliberti R, Rodriguez D, Aprile A. (2021) 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 in the EU’ Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG Empl). Retrieved from: Publications catalogue – Employment, Social Affairs & Inclusion

Last updated: February 4th, 2022   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 (Curry et al. 2018).

References:

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Last updated: February 10th, 2022

Netherlands

In the Dutch long-term care system, the rights of clients have been strengthened by legislation. The ‘Participation by clients of Care Institutions Act (WMCZ)’ mandated every care organization to have a client advisory council: whose members are recruited from the users of the care organization and who will represent them. Care organisations assist client councils by providing resources such as office space, meeting rooms, budget, etc. More specifically, client councils have the legal rights to have meetings with management about organisations’ policy, to receive information, to request an investigation into mismanagement, to be consulted, and to consent. The right to be consulted permits client councils to give their advice regarding issues on changing the aim and policy of the organisation, merger with another organisation, and financial matters, but the management can disregard the advice provided by councils. The right to consent means that client councils have to approve plans concerning issues that affect the daily living of clients (e.g. in relation to diet, safety, recreation and leisure, hygiene, the quality of healthcare for clients, changes to the complaints procedure. The care organisation management cannot perform changes regarding these issues without approval from a relevant client council (Zuidgeest et al. 2011).  In 2019 the earlier WMCZ act was replaced by the act ‘WMCZ 2018’, which aimed to expand the rights for client councils to truly participate in organisational decisions regarding matters that influence the clients’ daily lives. Client councils have the right to consent to these decisions as well as the right to provide solicited and unsolicited advice (Kruse et al 2020).

References: 

Zuidgeest, M. et al. (2011). Legal rights of client councils and their role in policy of long-term care organisations in the Netherlands. BMC Health Service Research  doi: 10.1186/1472-6963-11-215

Kruse, F., van Tol, Vrinzen, C., van der Woerd, O., Jeurissen, P. (2020). The impact of COVID-19 on long-term care in the Netherlands: the second wave. LTCcovid report 

Last updated: January 6th, 2023

Sweden

LTC Quality and Choice

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

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

Predictors of Patient Satisfaction

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

References:

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

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

Last updated: February 12th, 2022

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: February 10th, 2022   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  |  

1.13. Equity and Long-Term Care

Overview

Unmet care need in international context

Overall, there is a considerable difference in care demand across countries. For example, in Norway,  23,2% of the population 65+ report care needs; this figure is  45,6% in the UK and Spain, and over 50% in Italy, Hungary and Estonia. Potential factors that might contribute to these differences might be differences in life-expectancy or cultural differences in terms of perceptions of care need. In terms of unmet need (i.e. the gap between people who report needing care and those who report receiving it), there are substantial cross-national disparities. For example, one of the highest unmet need is reported in Estonia and Hungary (over 80% of people who report care need, do not receive any services), as well as in Spain, UK and Italy (over 60%), while Norway has a relatively small care gap (16%) (Grages and Pfau-Effinger, 2022).

Social groups particularly affected by (unmet) care needs

Overall, data indicate that the risk of needing care increases with age and with decreasing  income across different countries. Women also tend to be at a higher risk of needing care than men. Moreover, there is a likely increase in the risk of care needs if a person combines several of the attributes mentioned above (e.g. an older woman, on low income will have a higher risk of care need than a woman on higher income). Consequently, in countries with less generous care provision, women aged 65+ with a low  income have a particularly high risk of developing care needs, including unmet care needs (Grages and Pfau-Effinger, 2022).

References:

Grages, C. and Pfau-Effinger, B. (2022) Gaps in the provision of long-term care across Europe. EUROSHIP Working Paper No. 14 

Denmark

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

References: 

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

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

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

Last updated: May 24th, 2023

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: February 11th, 2022

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 (Curry et al. 2018).

References:

Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

Last updated: February 10th, 2022

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  |  

1.14. 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).

 

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 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 to 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 LTC facilities: Nursing Homes (NH) and Assisted Living Communities (ALCs) in Florida, following hurricane Irma in 2017. The findings showed that despite federal disaster preparedness regulations and experience with disasters like hurricanes, NHs and ALCs in Florida experienced issues that highlighted response gaps, highlighting that adequate preparedness goes beyond simply putting in place regulations. The study highlights the importance of lLTC organisations building and maintaining connections with those who can provide support, including relationships with emergency managers and 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: February 11th, 2022   Contributors: Daisy Pharoah  |  Joanna Marczak  |  

Australia

In a study analysing pandemic preparedness in the context of the 2009 influenza pandemic, 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 (Itzwerth et al., 2018).

Another study found that residential care staff reported issues with infection prevention and control strategies. It identified 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 (Huhtinen et al., 2019)

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%). Interviews carried out for the Royal Commission found that, in hindsight, providers who experienced COVID-19 outbreaks did not think their previous self-assessments of preparedness were accurate (Royal Commission, 2020).

References:

Huhtinen E., Quinn E., Hess et al. (2018) Brief Report. Understanding barriers to effective management of influenza outbreaks in residential care facilities. Australasian Journal on Ageing 38(1):60-63. doi: 10.1111/ajag.12595

Itzwerth R, Moa A, MacIntyre C.R. (2018) Australia’s influenza pandemic preparedness plans: an analysis. J Public Health Pol 38:111-124. https://doi.org/10.1057/s41271-017-0109-5

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: February 11th, 2022

Belgium

In a 2020 report, MSF describe the situation in a nursing home in Belgium as a ‘real humanitarian crisis’. The organisation launched an emergency intervention in March 2020 in care homes in the capital city, and later in two other locations (Wallonia and Flanders). The intervention involved an initial inspection of the facilities, followed by recommendations tailored for each care home’s specific circumstances. Continued support was provided subsequently, for example through follow-up visits to train staff, if needed.

During the initial visits, a general lack of preparedness for this kind of emergency was reported by MSF: there was a lack of knowledge and understanding among staff of basic hygiene rules and protocols concerning the use of PPE and testing. Many care homes were expected to perform the duties of hospitals, but lacked the resources to do it – for example, many did not have ample masks and aprons. The reason for this poor preparedness, according to the report, was due to the complex health and social system in Belgium that is structurally underfunded and increasingly privatised. MSF reported that after their intervention, the country was in a better position to face subsequent waves of the pandemic (MSF, 2020).

Last updated: February 11th, 2022   Contributors: Daisy Pharoah  |  

Canada

A published practice paper presenting the chronology of events in Quebec leading to excess mortality in long-term care facilities (LTCFs) highlighted 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 (Beaulieu et al. 2021).

References:

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: February 11th, 2022   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 (source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: February 11th, 2022

Denmark

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

References: 

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

Last updated: February 11th, 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 (Ylilnen et al., 2021).

References:

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L., Ylinen, S. (2021). ‘Finland: Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future’. MC Covid Working Paper, Retrieved at: CSIC_covid_FINLANDIA.pdf

Last updated: February 11th, 2022

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

Germany

Roles & responsibilities

Each of the 16 Länder carries responsibility for pandemic preparedness in their area. At the national level, the Robert Koch-Institute (RKI) takes a key role in infectious disease monitoring and prevention. The Institute also provides pandemic plans. A second federal authority with the task to reduce health related risks is the Federal Office for Civil Protection and Disaster Assistance.

Warnings

As early as in 2013, the Federal Office for Civil Protection and Disaster Assistance already warned of the risk of a pandemic through a virus of the ‘virus family Coronaviridae’.

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 Personal Protection Equipment (PPE) stockpiling, vaccination and training of staff. This plan has been amended to respond to the COVID-19 pandemic in March 2020.

Limitations

Despite this systemic preparedness, in practice there has been divergence in handling and applying infection prevention and control plans, the experience has shown that not all LTC settings had developed specific plans or not developed them in sufficient detail and that not all care workers, especially care assistants, had been sufficiently trained, and there has also been a shortage of PPE. The existing shortage in the care workforce posed additional challenges to the response during the pandemic (Lückenbach et al., 2021).

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 (Kricheldorff, 2020).

A survey conducted among care providers in April/May 2020 found that almost two thirds of care home staff 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 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 (Wolf-Ostermann et al., 2020).

References

Kricheldorff, C. (2020) ‚Gesundheitsversorgung und Pflege für ältere Menschen in der Zukunft – Erkenntnisse aus der Corona-Pandemie’, Zeitschrift fur Gerontologie und Geriatrie53(8), 742–748. https://doi.org/10.1007/s00391-020-01809-z

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Wolf-Ostermann, K, Rothgang, H., Domhoff, D., Friedrich, A.-C., Heinze, F., Preuß, B., Schmidt, A.,  Seibert, K. & Stolle (2020) Zur Situation der Langzeitpflege in Deutschland während der Corona-Pandemie Ergebnisse einer Online-Befragung in Einrichtungen der (teil)stationären und ambulanten Langzeitpflege. Available at: https://media.suub.uni-bremen.de/bitstream/elib/4331/4/Ergebnisbericht%20Coronabefragung%20Uni-Bremen.pdf (Accessed 5 February 2022).

Last updated: February 13th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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 (Lum et al., 2020)

References:

Lum T., Shi C., Wong G. and Wong K. (2020) COVID-19 and Long-Term Care Policy for Older People in Hong Kong, Journal of Aging & Social Policy, 32:4-5, 373-379, DOI: 10.1080/08959420.2020.1773192

Last updated: February 11th, 2022

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 (Tsadok-Rosenbluth et al. 2020).

References: 

Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G and Brammli-Greenberg S (2020). The impact of COVID-19 on people using and providing Long-Term Care in Israel. Report available at LTCcovid.org, International Long- Term Care Policy Network, CPEC-LSE, 4 May 2020. Retrieved from Article from ltccovid.org

Last updated: February 11th, 2022   Contributors: LIAT AYALON  |  

Italy

Italy had formally updated the 2006 National Pandemic Plan for Influenza, only in late February 2020; leading to major shortcomings in the overall management of the COVID-19 outbreak.  The LTC sector was poorly prepared for 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, such as lack 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 (Notarnicola et al., 2021).

There are indications of a 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 adequate protection. The Lombardy Region had the highest mortality rate due to COVID-19 in nursing homes in Europe. Researchers argued that the negative impact of COVID-19 results from the poor development of LTC policy and from the marginality of residential institutions within the healthcare system (Arlotti et al., 2021).

References:

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: February 4th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  William Byrd  |  

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 (Estevez-Abe and Ide, 2021)

References:

Estévez-Abe M. and Ide H. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

 

Last updated: February 11th, 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 (Bruquetas-Callejo and Böcker, 2021). Most Dutch Long-Term Care organisations have an Infection Prevention and Control committee (van Tol et al., 2021).

References:

Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021

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: February 11th, 2022

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

Singapore

Singapore took the threat of COVID-19 seriously early on and was able to draw on an already existing Disease Outbreak Response System framework, which had been refined based on the experiences from the Severe Acute Respiratory Syndrome (SARS) of 2003 and the H1N1 influenza pandemic of 2009 (Graham and Wong, 2020).

Following the 2003 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 (Kuguyo et al., 2020).

Nursing homes in Singapore started to prepare for COVID-19 early. A case study of a large charitable nursing home’s measures shows that, as soon as news were reported from China, in January, the Nursing home’s Nursing Director and Infection Control Nurse started to work with staff to establish a command centre, setting up a screening counter, reviewing national pandemic guidelines and liaising with the Ministry of Health and the Agency for Integrated Care, and coordinating mask-fitting for all 400 staff (Goh et al., 2022)

References:

Goh, H.S.; Tan, V.; Lee, C.-N.; Zhang, H.; Devi, M.K. (2022) Nursing Home’s Measures during the COVID-19 Pandemic: A Critical Reflection. Int. J. Environ. Res. Public Health 19, 75. https://doi.org/10.3390/ijerph19010075

Graham, WCK, Wong, CH. (2020) Responding to COVID-19 in Residential Care: The Singapore Experience. LTCcovid country report, International Long-Term Care Policy Network, CPEC-LSE, 27 July 2020.

Kuguyo O., Kengne A.P., and Dandara C. (2020) Singapore COVID-19 Pandemic Response as a Successful Model Framework for Low-Resource Health Care Settings in Africa OMICS: A Journal of Integrative Biology.Aug 2020.470-478. https://doi.org/10.1089/omi.2020.0077

Last updated: February 11th, 2022

Spain

At the beginning of the COVID-19 pandemic, the protection of care home residents was a global priority. This included preparing clear and efficient action protocols, especially in the face of worsening scenarios.

However, in a study of the institutional and organisational management of the COVID-19 pandemic in Spanish care homes, Del Pino and colleagues identify lack of preparedness, as well as lack of protection resources, as key factors in the slow response. Consequently, the pandemic had especially serious and tragic effects for residents of nursing homes, especially during the first wave.

Prior to COVID-19, the Spanish Ministry of Health had developed a plan in response 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 these 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 infrastructure”, as most people living in these centres have no other housing alternative.

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. This was compounded by the experience of having “over-prepared” for flu pandemics in the past. There was a lack of recognition of the increased risk COVID-19 posed to care home residents in particular, despite awareness of the impact of flu among the older population (source: DIGITAL.CSIC).

On December 2, 2020, the final report of the COVID-19 and residences working group was released. The report compiled the lessons learned in the field of residential care during the first wave of the pandemic, along with some of the work carried out in previous months in conjunction with the autonomous communities. These included:

  • A common framework for the application in the field of social services of the Early Response Plan (Annex I).
  • A common checklist for contingency plans (Annex II).
  • A compilation and systematization of the measures adopted to ensure socio-health coordination in the different autonomous territories (ANNEX III).
  • Proposal for the systematization of information and adaptation to the European Centre for Disease Prevention and Control (ECDC) (Annex IV).

The report highlighted the factors that helped increase the impact of Covid-19 in residential centres:

  • The pathogen SARS-CoV-2 and the disease COVID-19.
  • The residents of residential centres and their characteristics.
  • Infrastructure, activity and access to means of protection.
  • Care staff and human resources of residential centres.
  • The policies and strategies of isolation and confinement.
  • Intersectoral governance between different administrations.
  • Ageism, ethical dilemmas and legal problems.

The report also provided a table of available evidence, lessons learned and possible measures to help contain, mitigate or annul the above factors. This was compiled through the examination of action plans developed by all the autonomous communities. Many of these measures, if not all, had been adopted by the release of the report.

Improving the response to the pandemic in care homes, involves deciding where there is capacity to act immediately and in the medium term. This is combined with clearly identifying tasks, resources, timings and responsibilities.

It is crucial to learn from what happened in care homes in the first wave of the pandemic, and to implementing improvements. The resulting measures should be adopted in care homes and maintained in the long term, regardless of the efficacy of vaccines.

Last updated: July 4th, 2022   Contributors: Sara Ulla Díez  |  

Sweden

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

Last updated: February 10th, 2022

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

Hong Kong (China)

After a relatively successful start of the COVID-19 pandemic, it appeared that Hong Kong’s strict zero-COVID policy had succeeded in protecting the population (including people living in care homes and relying on care from others) from COVID-19. However this situation has changed during the Omicron wave (see question 2.02). Perhaps due to this early success, the vaccination rates among older people are very low, even among the care home population.

Last updated: March 23rd, 2022

Spain

In Spain, the covid crisis has revealed the fragility of the long-term care system and has had a significant impact on the men and women who provide care, both in families (unpaid) and paid. In the social care sector, carers include family caregivers, care service workers and domestic workers. In all these cases, there is a strong predominance of women, many of whom have experienced the effects of the pandemic with great vulnerability and precariousness (Comas-d’Argemir et al., 2021).

The social care sector was practically ignored at the beginning of the pandemic until the extreme situation in care homes triggered a new crisis within the health emergency. This neglect had severe consequences for older people and people with disabilities and carers. The delay in supplying protective equipment to the workers facilitated contagion between the staff and the residents. There was also a strong impact of covid in care homes in other European countries, but Spain is one of those that suffered it most virulently (see the LTCcovid compilation of data here). Social, political, and cultural factors that give little value to social care, older people and people with disabilities, explain this neglect and the deficits of the social care system (Daly, 2020). The underfunding of the dependency care system also had an impact: historical lack of investment, setbacks in applying the Dependency Law, insufficient staff in the services, and precarious working conditions (Costa-Font et al., 2021; Navarro and Pazos, 2020). The coronavirus crisis has highlighted all of these problems and, at the same time, has given visibility to the importance and essential role of care in maintaining life and for the functioning of the economy and society (Bahn et al., 2020).

In part due to the urgency of the pandemic, the role of women in health crises has tended to be ignored (Smith, 2019), and this has also happened in Spain with the coronavirus pandemic. While the government assumed the health part of the pandemic, it placed the rest of the responsibility to fight the pandemic with households. The confinement and the measures adopted with the declaration of the state of alarm, which lasted for months, led to an increase in care tasks at home and required an extraordinary effort, especially from women (Comas-d’Argemir and Bofill -Poch, 2021). The family has been the pillar of the response to the pandemic, without this being explicitly acknowledged. The pandemic has redistributed social functions (due to the closure of day centres, educational centres, a saturation of health services, etc.) which have been assumed fundamentally by the women of the family. In parallel, the impact of covid on health and social care personnel, who have had to work without adequate protection materials and in unsafe working conditions, has also been cause for concern. The pandemic has confronted workers with unprecedented, high-tension situations that are emotionally difficult to deal with (related to illness and death, fear, isolation…), which in many cases have left profound consequences on their physical and psychological health. Women have been working on the front lines of the pandemic, and although the health sector has received social recognition for its work, this has not been the case with nursing home or care service workers (Comas-d’Argemir et al., 2021).

Video accounts of the experience of providing care in Spain during the pandemic (in Spanish)

These videos were made for the project CUMADE: El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19 (Comas-d’Argemir y Bofill-Poch, 2021).

Conxita and Rafael: family carers

 

Participants: Rafael Hervás (Castellon), who is carer to his wife and Conxita Vallès (Barcelona), who is a carer to her mother.

Iñaki: functional diversity support

 

Participant: Iñaki Martínez (Barcelona), who is a personal assistant and President of the Asociación Profesional de Asistencia Personal.

Ruth and Janire: Care professionals in care homes

Participants: Ruth González (L’Ametlla del Vallès), who is a geriatric assistant at the Fundació Antònia Roura care home, and Janire Diaz (Bilbao) who is a trade unionist, responsible for the socio-health area of Gipuzkoa in the Syndicate Eusko Langileen Alkartasuna- Solidarity of Basque Workers (ELA).

Patricia and Carolina: home care workers

Participants: Carolina Elías (Madrid), President of the association Servicio Doméstico Activo (SEDOAC) and Patricia Zapata (L’Hospitalet de Llobregat), Domestic and care worker, member of the association Mujeres Unidas entre Tierras (MUET)

Marina: Community initiatives

Participant: Marina García (Granada) Promoter of the Albaicín Town Hall Care Group, Granada

 

Caring in the pandemic (ALL PARTICIPANTS)
References

Bahn, Kate; Cohen, Jennifer y Van del Meulen Rodgers, Yana (2020): “A feminist perspective on COVID-19 and the value of care work globally”, Gender Work Organization, 27, 695-699.

Comas -d’Argemir, Dolors y Bofill-Poch, Sílvia (2021): “Entrevista a María Ángeles Durán ‘Pandemia y Cuidados’”, en Dolors Comas-d’Argemir y Sílvia Bofill-Poch (eds.), El cuidado de mayores y dependientes. Avanzando hacia la igualdad de género y la justicia social, Barcelona, Icaria, 35-54.

Comas-d’Argemir, Dolors; Legarreta, Matxalen y García Sainz, Cristina (2021), “Residencias, las grandes olvidadas”, en en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Costa-Font, Joan; Jiménez Martin, Sergi y Viola, Analía (2012): “Fatal underfunding? Explaining COVID-19 mortality in Spanish nursing homes”, Journal of Aging and Health, 33, 7-8, 607-617.

Daly, Mary (2020): “COVID?19 and care homes in England: What happened and why?”, Social Policy & Administration, 54, 7, 985-998.

Navarro, Vicenç y Pazos, María (2020): El cuarto pilar del Estado del Bienestar. Propuesta para cubrir necesidades esenciales de cuidado, crear empleo y avanzar hacia la igualdad de género. Propuestas presentadas en el Grupo de Trabajo de Políticas Sociales y Sistema de Cuidados de la Comisión para la Reconstrucción social y económica del Congreso de los Diputados (15 de junio), Enlace.

Last updated: March 21st, 2022   Contributors: Carlos Chirinos  |  

Turkey

In Turkey, older people (over 65s) and children under 20 were subject to a strict curfew between March and June 2020 (Akkan, 2020).

Case Study of a Care Home in Istanbul (Özten et al, 2021)

A recent report describes successful pandemic response measures in a nursing home in Istanbul. This nursing home (which is one of the biggest nursing homes in the country, with 679 residents) managed to avoid COVID-19 cases altogether (for both residents and employees) during the first year of the pandemic by using a working plan to successfully prevent cross-contamination.

Within the first month of the global outbreak, this nursing home had introduced the use of protective equipment and temperature checks for all employees (including face-shields and disposable clothing), the announcement of a COVID-19 protocol – including preventative measures and an algorithm for positive cases – and temporary suspension of new admissions and visitors, among other measures. In the eleven months to follow, further safety measures were implemented such as regular PCR testing for all staff, restricted access for staff to different areas of the building, and an assigned quarantine ward for residents with suspicious symptoms.

Psychosocial support was given to residents, to mitigate fears of death and abandonment: exercise activities were carried out periodically, and the message “we are with you, you are not alone and unattended” was repeatedly communicated to residents. Psychosocial support was also offered to staff, whose levels of stress increased due to the newly implemented 15-day shift patterns. Group communication therapies were offered, and various solutions were offered to mitigate feelings of anxiety from being separated from family (Özten et al, 2021).

References:

Akkan B and Canbazer C (2020) The Long-Term Care response to COVID-19 in Turkey. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 10 June 2020.

Özten O, Aytekin Akta? T, Süer H, Do?an H, Üner A, Özp?nar S, Ayy?ld?z Y, Bekta? H, Saka B. 2021. A 15-day Working Shift Prevent the Cross-contamination of Coronavirus Disease-2019 in a Nursing Home in Turkey. Eur J Geriatr Gerontol 2021;3(3):131-133

Last updated: January 26th, 2022   Contributors: Daisy Pharoah  |  

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

Overview

Between January 2020 and July 2021 there were just over 30,000 COVID cases in Australia with 910 deaths (58% of the deaths were in people over 85 years of age). Most of the COVID cases during this period were concentrated in two major waves of COVID in Australia interspersed with periods of low or zero community transmission with occasional localised COVID outbreaks. During this time, Australia states were either for the suppression and/or elimination of COVID control achieved by tight border restrictions, hotel quarantine, lockdowns, density limits in venues, mask wearing (in 2021), high levels PCR testing, contact tracing and isolation. Between November 2020 and July 2021 Australia had largely eliminated community transmission of COVID with the exception of localised outbreaks.

A third wave started in July 2021 in NSW which spread to Victoria.

From November/December 2021, following a vaccination program with targets of at least 80% vaccination for adults, the national focus changed from suppression/elimination to “living with COVID” and managing it like any other disease. This resulted state governments lifting most restrictions in most states (excluding Western Australia) including border restrictions and hotel quarantine and reducing contact tracing and isolation requirements for both COVID positive people and their close and casual contacts.

In late November the Omicron strain was sequenced in Australia. In December 2021 and January 2022 there was a rapid acceleration of COVID cases in all states in Australia (except Western Australia), with NSW and Victoria most affected.

As of the 23rd March 2022 there have been 3,868,171 confirmed COVID-19 infections in Australia, and 5,789 deaths, according to the Australian Department of Health. There are currently 402,837 estimated active cases in Australia. So far, deaths amount to 223 per 1 million population.

Although case numbers declined in January and early-mid February in NSW, Victoria, ACT, the Northern Territory, South Australia and Tasmania case numbers have started during late February to early March in all states except for the Northern Territory. From the beginning of February cases began rising in Western Australia which, as a result of strict internal and external borders and quarantine policy, has been largely free of community transmission of COVID. Both international and interstate borders were lifted on the 3rd of March 2022.

More details about the spread of COVID in Australia are given below.

The first wave

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.

The second wave

The second wave was limited mostly to Victoria (June – October) and was managed with a strict lockdown.

Localised COVID outbreaks

Despite Australia’s suppression/elimination strategy, there were some leaks out of hotel quarantine.  Australian states used contact tracing and “snap lockdowns” to halt community transmission of the virus during smaller outbreaks.

Third wave (Delta strain)

In July 2021, an outbreak of the Delta strain started in Sydney resulting in a third wave of COVID infections. NSW implemented a strict lockdown. The outbreak spread to Victoria where a lockdown was also implemented. The case numbers decreased substantially through November and early December.

Omicron and “living with COVID”

From mid-December 2021 and early January 2022 introduction of the Omicron strain of the virus, the concomitant easing of restrictions in most states and a change in policy directions which focus on “living with COVID” there has been rapid acceleration of COVID infections.  Limitations on PCR testing capacity, extensive delays for PCR testing and lack of access to rapid antigen tests in the community has meant that the available case data is likely to be an underrepresentation of the number of active cases.

Hospitalisation rates and death among recipients of aged care services have been lower during 2021 than in the 2020 waves.

Last updated: March 23rd, 2022   Contributors: Erica Breuer  |  

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

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

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

References:

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

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

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

Last updated: May 25th, 2023   Contributors: Joanna Marczak  |  

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

Latest numbers

As of 4th February 2022, there have been 10,671,602 confirmed COVID-19 infections in Germany, and 118,504 deaths attributed to COVID-19, according to the RKI (Robert Koch Institut, 2022a, 2022b).

Impact of the different waves

The first wave of COVID-19 infections was relatively mild in Germany, however, the second wave (experienced mostly between December 2020 and January 2021) and the third wave (March to April 2021) were much more severe. The fourth wave has had the highest number of infections so far and it gradually eased at the end of 2021. Due to the fast spread of the Omicron variant, the fifth wave is expected to be the strongest in terms of infection figures (ZDF 2022, Schilling et al., 2021, RKI 2022). The death toll was highest in the second wave, followed by the fourth wave (RKI, 2022).

References

Robert Koch Institut (2022) Wöchentlicher Lagebericht des RKI zur Coronavirus-Krankheit-2019 (COVID-19)  – 06.01.2022 – AKTUALISIERTER STAND FÜR DEUTSCHLAND. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Wochenbericht/Wochenbericht_2022-01-06.pdf?__blob=publicationFile

Robert Koch Institut (2022a) Situation reports from Monday to Friday. Available at: https://www.rki.de/EN/Content/infections/epidemiology/outbreaks/COVID-19/Situationsberichte_Tab.html (Accessed 5 February 2022).

Robert Koch Institut (2022b) Coronavirus Disease 2019 (COVID-19) Daily Situation Report by the Robert Koch Institute 04/02/2022- CURRENT STATUS FOR GERMANY. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Feb_2022/2022-02-04-en.pdf?__blob=publicationFile (Accessed 5 February 2022).

Schilling, J., Tolksdorf, K., Marquis, A., Faber, M., Pfoch, T., Buda, S., Haas, W., Schuler, E., Altmann, D., Grote, U., Diercke, M & RKI COVID-19 Study Group (2021) ‘Die verschiedenen Phasen der COVID-19-Pandemie in Deutschland: Eine deskriptive Analyse von Januar 2020 bis Februar 2021’ Bumdesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz, 64, pp.1093-1106. Available at: https://link.springer.com/article/10.1007/s00103-021-03394-x

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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  |  

Hong Kong (China)

As of April 8, 2022, more than 1.17 million people have contracted the virus since the onset of the fifth wave of COVID-19 (starting from 31 Dec 2021), involving 8,430 deaths. About 96% of the deaths were people aged 60 years and over, while over 70% are those aged 80 years and over. The latest data on the epidemic situation of the 5th wave in Hong Kong can be found on the Government’s news site.

 

Last updated: April 11th, 2022   Contributors: Cheng Shi  |  

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  |  

Malaysia

The first COVID-19 case in Malaysia was reported on 24th January 2020, and the number of cases began to increase two months later, in March (Jamaluddin et al., 2022). As of February 2022, the total number of COVID-19 cases in Malaysia is just under 3.1 million, and there have been 32,180 deaths. The greatest increase in the number of cases was seen in the second half of 2021, with the peak in infections seen in August 2021 (as a result of the Delta variant) (source: Worldometres).

Since the end of August 2021, the majority of deaths have been in the over 60 age-group (source: Malaysia MOH). Between 24 February and 14 September 2021, the median age of people who died from COVID-19 was 61 years old, and most deaths occurred in the 60-69 age group. Higher mortality rates were observed in the population who were unvaccinated (Abdul Taib et al., 2022).

Although the pandemic affected all of Malaysian society, vulnerable communities and low-income groups were affected in particular. It is thought that just over half a million households that were in the middle 40% income group fell to the bottom 40% group as a result of the pandemic (source: Yeo, 2021).

References:

Abdul Taib, N. A., Baha Raja, D., Teo, A. K. J., Kamarulzaman, A., William, T., HS, A. S., Mokhtar, S. A., Ting, C. Y., Yap, W. A., Kim, M. C. Y., & Edwin Amir, L. (2022). Characterisation of COVID-19 deaths by vaccination types and status in Malaysia between February and September 2021. The Lancet Regional Health – Western Pacific, 18, 100354. https://doi.org/10.1016/J.LANWPC.2021.100354/ATTACHMENT/96E09F81-FB57-495F-9CE7-DFDA52281B3C/MMC1.DOCX

Jamaluddin, F., Sheikh Dawood, S. R., Ramli, M. W., & Mohd Som, S. H. (2022). Bouncing back from the pandemic? A psychosocial analysis of older adults in urban areas of Malaysia. Http://Www.Editorialmanager.Com/Cogenthumanities, 9(1). https://doi.org/10.1080/23311983.2021.1996045

 

Last updated: February 16th, 2022   Contributors: Daisy Pharoah  |  

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

Pakistan

Official sources report that as of January 2022, the total number of confirmed COVID-19 cases is around 1.4 million, and deaths around 29,000. However, this is likely to be a substantial underestimate of the real levels of COVID-19 cases and mortality due to limited testing capabilities (Ahmed, 2021 and Our World in Data).

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

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

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

 

Last updated: February 22nd, 2022

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: March 8th, 2022   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

Overview

People who use long-term care services and rely on care and support from others have been at increased risk of the severe impacts of COVID-19, particularly those living in group settings such as care homes.

Due to the alarm cause by the large number of deaths among care home residents some countries started reporting data on the numbers of COVID-19 infections and associated deaths among care home residents (Comas-Herrera et al., 2021). Very few countries publish data of COVID-10-related deaths among people who use  community-based care.

For an international overview please visit:

International data on deaths attributed to COVID-19 among people living in care homes

There is a growing literature analysing factors associated with higher mortality of care home residents. A Rapid Review by the McMaster University National Collaborating Centre for Methods and Tools (NCCMT, 2020) published in December 2020 (before vaccinations) found that:

  • – The strongest association with COVID infections in care homes is the incidence of infections in the surrounding community (moderate certainty of evidence).
  • – Some characteristics of the residents: old age, racial/ethnic minority status, male sex where linked to increased risk of infections and mortality (low certain of evidence).
  • – With regards characteristics of care homes, high staffing by registered nurses was associated with lower risks of infections and mortality, for-profit status, facility size/density and movement of staff between facilities was found to increase risk of COVID-19 infections (low certainty of evidence).
References:

Comas-Herrera A, Zalakain J, Lemmon E, Henderson D, Litwin C, Hsu AT, Schmidt AE, Arling G, Kruse F and Fernandez J-L (2021) Mortality associated with COVID-19 in care homes: international evidence. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 1st February 2021.

National Collaborating Centre for Methods and Tools. (2020). What risk factors are associated with COVID-19 outbreaks and mortality in long-term care facilities and what strategies mitigate risk? Update 1. https://www.nccmt.ca/knowledge-repositories/covid-19- rapid-evidence-service

Australia

As of the 18th March 2022 there were 360 active outbreaks in residential aged care in Australia, with 1,613 residents and 1,542 staff affected.

As of 18th March 2022, there have been 20,154 confirmed cases of COVID-19 among subsidized residents in aged care facilities. There have been 1,879 deaths so far. Among people who use government-subsidized home care, there have been 192 confirmed cases of COVID-19 and 13 deaths. As of 18th March 2022 there have been 5,736 deaths among the whole population suggesting that 32.8% 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. 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 0.90% of this population (source: AIHW).

A weekly report publishes data on the number of outbreaks and staff infected in care homes. As of 18th March 2022, there have been 24,216 cases of staff with COVID-19 infections.

About the data:

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.

Last updated: March 23rd, 2022   Contributors: Erica Breuer  |  

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, including 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. Deaths in nursing homes are notified by the regional authorities with a 2 day delay, and are classified according to the date of death.

As of April 22nd, 2022, there have been 31,319 deaths linked to COVID-19 in Belgium. Of these 14,216 were residents in care homes and 10,261 occurred in the institutions themselves (source: Sciensano).  Belgium has an estimated 125,000 people aged 65 and over living in care homes. The number of deaths in care homes linked to COVID-19 so far would represent 11.37% of this population (source: KCE).

Last updated: May 3rd, 2022   Contributors: Daisy Pharoah  |  Disha Patel  |  

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  |  

Canada

The National Institute on Ageing Long-Term COVID-19 Tracker Open Data Working Group collects information on confirmed and presumptive positive, resident and staff cases and death in long-term care settings in Canada from multiple sources including public health units, government reports, media,  information posted bu homes publicly and shared with their staff, residents and family. Given this, all cases reported cannot be guaranteed to be laboratory confirmed. This data is updated twice a week.

In Wave 1 (up to September, 2020) NIA data shows there were 7,310 deaths, across 1,171 LTC facilities with outbreaks, making up 74% of total deaths from COVID-19 in Canada for that wave. In Wave 2 (still ongoing at the publishing of this data on February 15, 2021) there were a further 7,016 deaths across, 1,389 LTC facilities with outbreaks. At this time resident deaths across both waves represented 67% of total deaths from COVID-19 in Canada.

As of April 25, 2022, there have been 16,780 COVID-attributed deaths in care home residents. As of the 2016 census Canada had 425,755 residents living across 6029 LTC facilities. Thus, the number of COVID-19 related deaths of LTC residents represents 3.94% of the estimated population in care homes.

Last updated: May 3rd, 2022   Contributors: Disha Patel  |  

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

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

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

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

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

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

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

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

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

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

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

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

In the third phase, the infection rate rose in the nursing homes and more and more nursing homes introduced lockdowns. There were increasing concerns that the government’s response to the pandemic such as the lockdowns was inflexible and not tailored to individuals’ circumstances (rather, it was based on ‘one size fits all’ rules). Combined with the late ease of restrictions, it had a negative long-term impact on older people’s mental and physical health and concerns were raised that the government should have done more to respect basic individuals’ freedoms (Source: https://www.djoef.dk/presse). Over Christmas, the visiting ban was lifted, and it was also allowed to gather up to 50 residents for celebration, the latter which receives criticism from the interviewed experts in the VIVE evaluation – who are also in general agreement that the national lockdown came too late in order to protect the nursing home sector (Kjellberg, 2022b).

References:

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

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

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

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

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

Last updated: May 25th, 2023   Contributors: William Byrd  |  Disha Patel  |  Joanna Marczak  |  

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 from COVID-19 are recorded where either the death of a confirmed case or a death attributed to COVID-19 by the physician in the medical certificate of death.

Data published by the Ministry of Health on April 1, 2021 (Wave 1 & Wave 2), 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.

As of January 26th 2022, further data published by the Ministry of Health reported a total of 129,747 COVID-19 related deaths, of which 44,253 (34.1%) were care home residents. Of these, 27,403 died within a care home setting. 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 7.31% of all the available beds (Source: https://www.insee.fr/fr/statistiques/3676717?sommaire=3696937).

Last updated: February 7th, 2022   Contributors: William Byrd  |  Disha Patel  |  

Germany

About the data:

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%).

Deaths linked to COVID-19 in residential care

According to Germany’s Robert Koch-Institute, 25,789 residents of residential long-term care facilities (aged 60 and above) died in association with a SARS-CoV-2 infection during the course of the pandemic until week 4 of 2022 (Robert Koch Institut, 2022a). This figure may include a small proportion of staff and visitors in addition to residents, as attribution is not always clear. Thus, out of 118,504 death associated with the Covid pandemic in total, deaths associated with care homes constitute 21.76 % (Robert Koch Institut, 2022b).

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 were residents, 3.15% of all care home residents would have died due to COVID-19 (Source: Statista).

Deaths linked to COVID-19 among people who use care in the community

The number of users of community care or persons who are being cared for without the assistance of professional services in the community is unclear. The last data on this group was published on 16 July 2021 when the number of deaths was reported as 195 persons (Robert Koch Institut, 2021). However, the validity of this figure is questionable as data collection does not account for persons in need of care in a standardizes way.

References

Robert Koch Institut (2021) Täglicher Lagebericht des RKI zur Coronavirus-Krankheit-2019 (COVID-19) 16.07.2021 – AKTUALISIERTER STAND FÜR DEUTSCHLAND. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Jul_2021/2021-07-16-de.pdf?__blob=publicationFile (Accessed 5 February).

Robert Koch Institut (2022a) Wöchentlicher Lagebericht des RKI zur Coronavirus-Krankheit-2019 (COVID-19) 03.02.2022 – AKTUALISIERTER STAND FÜR DEUTSCHLAND. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Wochenbericht/Wochenbericht_2022-02-03.pdf?__blob=publicationFile (Accessed 5 February 2022).

Robert Koch Institut (2022b) Coronavirus Disease 2019 (COVID-19) Daily Situation Report by the Robert Koch Institute 04/02/2022- CURRENT STATUS FOR GERMANY. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Feb_2022/2022-02-04-en.pdf?__blob=publicationFile (Accessed 5 February 2022).

 

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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)

Data availability

There is no regularly published official data on the number of deaths of care home residents in Hong Kong, so this section reports data from credible media sources.

Early part of the pandemic

In Hong Kong, until 2022, the strategy of zero-COVID was successful in limiting infections in care homes. As of December 2020, there had been 20 care homes with outbreaks. This resulted in 124 residents and 29 staff members testing positive for COVID-19. Of these 124 residents, 32 had died, accounting for 19% of all COVID-19 related deaths in Hong Kong.

Omicron wave

The situation has been very different since the arrival of the Omicron wave. Since March 2022 there have been major outbreaks in care homes and large number of deaths. The media reported, on March 23 2022, that, of the just over 6000 deaths in the whole population to that date, 60% were care home residents. In addition, a total of 33,758 care home residents (45% of the total) were infected at that time in 776 care homes.

This high impact of the Omicron variant has been attributed to low vaccination rates among older people and lack of isolating facilities within care homes.

Size of care home population

In June 2020 there were 76,091 care home places in Hong Kong. Therefore, the number of deaths of care home residents linked to COVID-19 so far would represent 2.3% of this population.

Last updated: April 11th, 2022   Contributors: Cheng Shi  |  

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. A weekly report detailing mortality by place of death and as linked to outbreaks is published by the HSPC.

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%.

As of April 16th 2022, there have been a total of 6,964 deaths due to COVID-19 in Ireland, of which, 2,543 are linked to outbreaks in nursing homes and 2,240 occurred within residential institutions (including community hospital/long stay unit, homeless facility, mental health facility and nursing homes) themselves. Thus deaths linked to nursing home outbreaks represent 36.5% of all deaths from COVID-19. There are an estimated 30,000 people living in nursing homes. Therefore, 8.47% of all nursing home care residents would have died because of COVID-19 as of April 2022.

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

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 January 24, 2022, there have been 7,782  COVID-19 related deaths (defined as the number of deaths for which COVID-19 was identified as the primary cause of death by physicians on the death certificate), of which 415 were wards of social care institutions (5.3%) (Source: Ministry of Social Security and Labor of the Republic of Lithuania and the European Centre for Disease Prevention and Control). There are 13,100 residents in social care institutions in Lithuania. Therefore, the total number of COVID-19 related deaths in social care institutions represents 3.17% of all residents.

Last updated: February 7th, 2022   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 had been 8,446 COVID-19 related deaths of care home residents. Accounting for 51% of the total COVID-19 deaths in the Netherlands. 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.

As of April 25, 2022, there are 10,867 COVID-19 related deaths of care home residents and 22,227 deaths in the Netherlands overall (Source:https://coronadashboard.rijksoverheid.nl/landelijk). Thus care home residents account for 48.8% of the total COVID-19 deaths. The Netherlands has approximately 125,000 care home residents, so the deaths represent 8.7% of residents.

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 has been 9.9% excess mortality (observed-expected/expected) among long-term care users since the start of the pandemic to the end of January, 2022, compared to 8.5% excess mortality among the wider population (outside long-term care).

Last updated: May 3rd, 2022   Contributors: Adelina Comas-Herrera  |  Disha Patel  |  

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

Data on the numbers of deaths linked to COVID-19  is reported in a regular briefing document provided by the Central Disease Control Headquarters. While the report is released daily, specific data on deaths of people who use Long-Term Care is reported sporadically. The most recent data is from 23rd October 2021.

Of the 2,745 COVID-19 deaths in the whole population by 23rd October 2021, 465 (16.9%) have been attributed to those in long-term care hospitals, while 253 (9.2%) have been attributed to long-term care facilities, or nursing homes. Another 97 (3.5%) deaths were attributed to other community-based LTC providers such as adult day care centres and senior welfare centres.

As for place of death, vast majority of deaths (92.2%) occurred in the hospital inpatient setting. The remaining 4% occurred in the ER, 3.2% at home, and 0.6% other (overseas, in transport, etc.)

In 2019, according to OECD data, there were 210,284. Therefore, 0.12% of this population are estimated to have died from COVID-19. There were 483,433 patients hospitalized in the 1,560 long-term care hospitals in 2018. Therefore, 0.1% of this population would have died from COVID-19.

Last updated: February 20th, 2022   Contributors: Hongsoo Kim  |  

Singapore

In August 2021 there had only been 42 COVID-19 related deaths in Singapore, with a small share of those in care homes. When there was a smaller number of deaths and individual reporting of cases, it was possible to identify deaths of people who lived in care homes. However, since Singapore pivoted to an endemic COVID-19 strategy, once a high (over 80%) vaccination rate had been achieved, the number of deaths has increased rapidly, with many outbreaks in care homes. No separate data is published for care homes (Feng Tan and Feng Tan, 2021).

The Ministry of Health’s dashboard reports that there have been 882 deaths linked to COVID-19 on 11th February 2022.

References:

Feng Tan L. and Feng Tan M. (2021) Pandemic to endemic: New strategies needed to limit the impact of COVID-19 in long-term care facilities. Journal of the American Geriatrics Society.  70(1): 72-73. https://doi.org/10.1111/jgs.17556

Last updated: February 11th, 2022

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).

Cumulative estimated number of deaths linked to COVID-19 among care home residents:

So far, the total number of deaths linked to COVID-19 among care home residents (until the 6th of February 2022) is 32,639. The total number of deaths in the whole population (confirmed through testing) is 95,163 up to 9th February, 2022. Adding the suspected cases among care home residents in the first wave (10,546, see above) would bring this to 105,531. The estimated share of all deaths (confirmed and suspected) linked to COVID-19 who were care home residents in the whole period would be 30.9%. Comparing the number of deaths with the estimated number of residents in 2019, 333,920 (estimate by Envejecimiento en Red) suggests that the number of deaths linked to COVID so far represents 9.77% of the number of care home residents at the beginning of the pandemic.

First wave: difficulties estimating the number of deaths linked to COVID-19

Due to lack of testing at the beginning of the pandemic, there is some uncertainly about the number of people who had a COVID-19 infection and died in that period. IMSERSO estimates that, until 22nd June 2020, there were 27,411 deaths from all causes among care home residents. Of these, 9,753 had COVID infections confirmed through testing, and 10,546 had symptoms compatible with COVID. So the total number of care home residents who died with either a COVID-19 infection or compatible symptoms (suspected COVID) were 20,299. In the total population, official data shows that, during the same period, the total number of people who died with confirmed COVID infections was 29,692, there is no national estimate of the numbers of people who died with suspected COVID in the population. To estimate the total number of people who died linked to COVID in Spain during the first wave (up to 22nd June) we can add the number of suspected COVID deaths among care home residents to the total number of official deaths in the population, resulting in an estimate of 40,238 COVID-related deaths. Based on this, the share of COVID deaths that would have been care home residents would be 50.4% in the first wave.

2020: Estimated number of deaths linked to COVID-19 among care home residents

In total in the year 2020 there were 26,335 deaths among care home residents linked to COVID-19 (confirmed and suspected).

2021: Estimated number of deaths linked to COVID-19 among care home residents

During 2021 there were 5,205 deaths of care home residents who had tested positive for COVID-19, of these, 3,686 took place before the 1st of March, the date when the initial COVID-19 vaccination of care home residents was completed. There were 1,519 deaths in the period post-vaccination until the end of year.

2022 so far: Estimated number of deaths linked to COVID-19 among care home residents

As of the 6th February there have been 1,099 deaths of care home residents who had tested positive for COVID-19.

Excess mortality among people registered with the public LTC system:

IMSERSO also publishes a monthly report on excess mortality among people registered with the Spanish System for Autonomy and Dependency Support (SAAD). Between March 2020 and December 2021 there 71,539 excess deaths (compared to average in previous five years) among people in the SAAD register (19.7% more than expected), affecting 3.77% of people registered with the system. 78.9% of those whose death is counted as “in excess” were aged 80 and over (56,411 people).

Excess mortality was much higher among people who receive their SAAD benefits through residential care, amounting to 29,435 (11.8% of all recipients), among those receiving benefits for community or home-based care there were 44,977 excess deaths, representing 5.2% of recipients.

Last updated: February 14th, 2022

Sweden

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

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

As of April 5, 2021, there were 12,598 deaths in Sweden where COVID-19 was mentioned on the death certificate, of which 5,446 (43%) were among care home residents, and 3,277 among people who use care services in their own home (26%). Of the deaths of care home residents, 4,887 happened in the care home (90%). The regional differences at this time were strong in Sweden. In the Stockholm region, 7 % of care home residents had died, while there were hardly any COVID-19 deaths in care homes in several other regions (Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

 

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

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)

COVID-attributed deaths among care home residents

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

In wave 1 (up to September 2020), ONS  data shows that there were 19,783 registered deaths attributed to COVID-19 among care home residents in England, and 20,388 in wave 2 (from 12 September 2020 to 2 April 2021). Due to constraints in testing during the first wave, the ONS data shows that during wave 1 there around 26,087 more deaths in the period of the first wave compared to the average number of deaths observed on the same dates in the previous five years. In contrast, during the second wave, when care homes had much better access to testing, excess deaths amounted to 1,145. It is important, as ONS point out, to interpret excess deaths with caution, particularly in wave 2, as occupation rates in care homes were lower and the population that survived wave 1 is likely to be younger and healthier.

Between 3rd April 2021 and 14th April 2022, based on data from the ONS, we calculate that there were 4,658 COVID-attributed deaths registered among care home residents in England. This brings the cumulative number of deaths of care home residents registered as attributed to COVID since the beginning of the pandemic to 44,829. This figure does not include deaths that may have been due to COVID but not identified as such (particularly at the beginning of the pandemic when care homes had little access to tests). The total number of registered deaths attributed to COVID-19 in England IS 176,004 (Source: ONS).

According to ONS estimates, between 2019 and 2020 there were 391,027 people living in care homes in England. Therefore, the number of COVID-19 related deaths of care home residents represents 11.25% of the population in care homes when the pandemic started.

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.

COVID-attributed deaths among people who use home care

Data on people who use home care is available through the ONS for the period up to 2nd April, by then the deaths of 2,226 people who used home care had been linked to COVID-19.

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 (Williamson et al., 2021).

Deaths linked to COVID-19 among people living with dementia

According to ONS estimates, around half of all COVID-19-attributed deaths among care-home residents in England and Wales between March 2020 and April 2021 (waves 1 and 2), were people who were known to have with dementia.

References:

Williamson, et al, (2021). OpenSAFELY: Risks of COVID-19 hospital admission and death for people with learning disabilities – a cohort study. BMJ doi: https://doi.org/10.1101/2021.03.08.21253112 

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

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.

As of March 5, 2021, there had been 2,839 COVID-19 related deaths, with 762 of these occurring in care homes (27%). Furthermore, there had been 997 COVID-19 related deaths of care home residents. Therefore as of Wave 2 care home residents accounted for 35% of all COVID-19 related deaths in Northern Ireland.

As of April 15, 2022, there have been 4,519 deaths COVID-19 related deaths of which 1,270 (28%) were care home residents. 968 deaths have occurred within care homes. There are 14,935 care home residents in Northern Ireland. Therefore, the number of COVID-19 related deaths of care home residents represents 8.5% of this population.

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

Scotland (UK)

Since May 25, 2020, the Care Inspectorate Scotland (CIS) has reported weekly data on notifications of deaths of care home residents. Care homes are required to note whether COVID-19 was noted as confirmed or suspected on the death certificate.

As of April 24, 2022, the Scottish Government has reported 14,332 deaths where COVID-19 was mentioned on the death certificate. As of the same date, CIS has reported 4,726 deaths of care residents of suspected or probable COVID-19, accounting for 33% of total deaths. 4,151 deaths were reported to have occurred within care homes. Assuming that the number of adult care home residents has remained stable since 2017 (based on Care Home Census for Scotland, 35,898 adults receiving care in care homes in March 2017) the number of COVID-19 related deaths of care home residents represents 13.17% 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) (Henderson A. et al. 2021).

References: 

Henderson, A. et al. (2021) COVID-19 infection and outcomes in a population-based cohort of 17,173 adults with intellectual disabilities compared with the general population. BMJ doi: https://doi.org/10.1101/2021.02.08.21250525

Last updated: May 3rd, 2022   Contributors: Chris Hatton  |  Disha Patel  |  Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Wales (UK)

The Welsh Government publishes data collated by the Care Inspectorate Wales (CIW) at the Local Authority level of the number of notifications of deaths of adult care home residents by cause and location of death.

As of April 8, 2022, data published by the UK Health Security Agency there have been 10,797 deaths with COVID-19 on the death certificate. As of the same date, the CIW reported 2,163 Covid-19 related deaths (both confirmed and suspected) of care home residents in Wales. Therefore, care home resident deaths account for 25.6% of COVID-19 related deaths in Wales. Of these care home resident deaths, 1,477 (68%) occurred within care homes. There are 24,178 care home residents in Wales. Therefore, the number of COVID-19 related deaths of care home residents represents 8.95% of this population.

Data published by the Office of National Statistics showed that as of March 12, 2021, there had been 7,717 COVID-19 related deaths, with 1,650 of these occurring in care homes (21%). As of the same date, according to CIW data, there had 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 at this point during Wave 2. (Source: https://gov.wales/notifications-care-inspectorate-wales).

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) (Watkins, 2021).

References:

Watkins, A. (2021). COVID-19-related deaths in Wales amongst People with Learning Disabilities from 1st March to 19th November 2020.  Improvement Cymru

Last updated: May 3rd, 2022   Contributors: William Byrd  |  Chris Hatton  |  Adelina Comas-Herrera  |  Disha Patel  |  

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

Overview

What is long COVID?

There is no universally agreed definition of long COVID and different studies use varying definitions. Indeed, the World Health Organisation (WHO) highlights that “over the course of the pandemic, various terminology including long COVID, long-haul COVID or the WHO-recommended post COVID-19 condition have been proposed” (WHO 2021). Still, a globally standardized clinical case definition of this condition remains lacking. In the UK the National Institute for Health and Care Excellence (NICE) uses the following set of definitions to distinguish 3 phases following infection consistent with COVID-19, and to define the term ‘long COVID’:

Acute COVID-19 Signs and symptoms of COVID-19 for up to 4 weeks.

Ongoing symptomatic COVID-19 Signs and symptoms of COVID-19 from 4 weeks up to 12 weeks.

Post-COVID-19 syndrome Signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis. (NICE, 2022).

The term ‘long COVID’ is commonly used to describe signs and symptoms that continue or develop after acute COVID-19. It includes both ongoing symptomatic COVID-19 (from 4 to 12 weeks) and post-COVID-19 syndrome (12 weeks or more) (NICE, 2022). The majority of studies conducted on long COVID are based on either children or adults under the age of 69 as this is known to be the population with the most reported prevalence of long COVID symptoms.

We are not aware of any work that has been conducted on long COVID with regards to pathways, support or management of symptoms with residents in long term care homes or among people receive care and support from others in the community.

References:

NICE (2002) guidance  https://www.nice.org.uk/guidance/ng188/resources/COVID19-rapid-guideline-managing-the-longterm-effects-of-COVID19-pdf-51035515742 version 1.13 published on 01.02.2022 accessed 08/02/2022

WHO (2021) https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1 6/10/21 accessed 08/02/2022

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).

References:

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: February 16th, 2022   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: March 23rd, 2022

United Kingdom

It is reported from a survey conducted by the Office of National Statistics (ONS) that about 1.3 million people in the UK have “long COVID” symptoms lasting more than four weeks after an initial infection (ONS, 2022). Of those, 892,000 (70%) first caught the virus at least 12 weeks ago and 506,000 (40%) at least a year ago (ONS, 2022). Some caution is needed as the estimates relate to self-reported symptoms via a survey rather than a clinical diagnosis although for some respondents this might be the case and included only those living in private households and would not include any individuals living in any type of long-term care home setting.

In the UK, there are now established pathways and centres, some 89, for referring patients who are diagnosed as experiencing long-COVID symptoms (NHS, 2021). However, it is unclear if any care home residents are referred to these services since the majority of services are often located in urban settings linked to existing services and are often not easily accessible for those requiring ongoing support needs, such as a carer present. A plethora of studies has been undertaken on numerous aspects of the pandemic on care homes settings (see, LTCcovid database for details). However, we are not aware of studies directly relating to the management of resident symptoms, referral or access to the rehabilitation pathways or if indeed residents are recognised as having long COVID symptoms. This needs to be addressed. We are aware of current work been undertaken, led by Gordon et al., (2022), that is exploring the current rehabilitation pathways which will be considering the pathways for all patients including those living in care home settings.

References:

Gordon, A. et., al. (2022) Protocol: Long-COVID syndrome: understanding how rurality influences design and development of pathways for delivery of sustainable care. Exploratory study in one geographic region.

Office of National Statistics (ONS) (2022) Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK : 3 February 2022

NHS (2021)  Long COVID: the NHS plan for 2021/22 . Accessed 08/02/2022

NICE (2022). COVID-19 rapid guideline: managing the long-term effects of COVID-19.  Version 1.14 accessed 11/03/2022

Royal College of Nursing (RCN) (2021). Long COVID: what do we know? Retrieved from: https://www.rcn.org.uk/magazines accessed 11/03/2022

Last updated: March 11th, 2022   Contributors: Dr Kathryn Hinsliff-Smith  |  

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.

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 (Rocard et al., 2021).

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).

People who need care and support from others and live in the community also experienced reduced access to both health and social care services, some of this may be due to supply constraints, but an important factor was also reluctance to use services due to fear of contracting COVID-19 (see for example Merrilees et al. (2022).

Omicron wave:

The rapidly developing Omicron wave resulted in staffing shortages in long-term care provision in many countries, see for example the situation in England where there were reports of care being rationed.

References:

Merrilees J., Robinson-Teran J. Allawala M., et al. (2022). Responding to the needs of persons living with dementia and their caregivers during the COVID-19 pandemic: Lessons from the Care Ecosystem, Innovation in Aging, 2022;, igac007, https://doi.org/10.1093/geroni/igac007

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

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

Denmark

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

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

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

Reference:

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

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

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

 

Last updated: May 25th, 2023   Contributors: Joanna Marczak  |  

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 25th, 2022

Germany

Access to care for people living in the community

A survey among family carers of older people in April/Mai 2020 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 (Eggert et al., 2020).

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 (Wolf-Ostermann et al., 2020).

Access to care provided by migrant workers

In Germany, many people with care needs who still live in their own homes receive support from Eastern European migrant workers. The border closure around Easter 2020 left many people without their usual support (Lückenbach et al., 2021).

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:

Eggert, S., Teubner, C., Budnick, A., Gellert, P. & Kuhlmey, A. (2020) Pflegende Angehörige in der COVID-19-Krise: Ergebnisse einer bundesweiten Befragung. Available at: https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf (Accessed 31 January 2022)

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

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Wolf-Ostermann, K, Rothgang, H., Domhoff, D., Friedrich, A.-C., Heinze, F., Preuß, B., Schmidt, A.,  Seibert, K. & Stolle (2020) Zur Situation der Langzeitpflege in Deutschland während der Corona-Pandemie Ergebnisse einer Online-Befragung in Einrichtungen der (teil)stationären und ambulanten Langzeitpflege. Available at: https://media.suub.uni-bremen.de/bitstream/elib/4331/4/Ergebnisbericht%20Coronabefragung%20Uni-Bremen.pdf (Accessed 5 February 2022).

 

Last updated: February 13th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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

Impact of the pandemic on health and long-term care system

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%.

Impact on access to health care for care home residents

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 to 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).

Impact on availability of care and support for people living in the community

Italian data from a survey 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 (Eurocarers/IRCCs, 2021).

A qualitative study found that although alternative forms of support and interaction with services were introduced, they did not compenssate for the loss of in person support experienced by people with dementia and their family carers (Chirico et al., 2022).

References:

Chirico, I.Ottoboni, G.Giebel, C.Pappadà, A.Valente, M.Degli Esposti, V.Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in ItalyHealth & Social Care in the Community001– 10https://doi.org/10.1111/hsc.13758

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: February 22nd, 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: March 8th, 2022   Contributors: Chris Hatton  |  

England (UK)

Omicron wave: workforce shortages

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. A survey of members of the National Care Forum (the largest body representing not-for-profit care providers) 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.

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 care for people with dementia

In the earlier part of the pandemic there were reports of people living with dementia who had COVID being refused hospital treatment based on their dementia diagnosis and not their ability to benefit from treatment, and of people with dementia living in care homes being pressured into signing “Do Not Attempt Ressusciation” (DNAR), prompting the Alzheimer’s Society and 4 leading charities to send an open letter to the health secretary (Suarez-Gonzalez et al., 2020).

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 (Flynn et al., 2021).

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.

References:

Flynn, S., Hayden, N., Clarke, L., Caton, S., Hatton, C., Hastings, R. P., Abbott, D., Beyer, S., Bradshaw, J., Gillooly, A., Gore, N., Heslop, P., Jahoda, A., Maguire, R., Marriott, A., Oloidi, E., Paris, A., Mulhall, P., Scior, K., Taggart, L., & Todd, S. (2021). Coronavirus and people with learning disabilities study Wave 3 Results: September 2021 (Full Report). Coventry, UK: University of Warwick. ISBN: 978-1-871501-37-7

Suarez-Gonzalez A., Livingston G., Comas-Herrera A. (2020) Report: The impact of the COVID-19 pandemic on people living with dementia in UK, 3rd May 2020. https://ltccovid.org/2020/05/03/report-the-impact-of-the-covid-19-pandemic-on-people-living-with-dementia-in-uk/ 

Last updated: March 6th, 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: March 8th, 2022   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 (The Scottish Parliament, 2020).

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.

References:

The Scottish Parliament, (2020). How has Covid-19 impacted on care and support at home in Scotland?

Last updated: March 8th, 2022   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: March 8th, 2022   Contributors: Chris Hatton  |  

United States

Reductions in access to care for people living in the community

Qualitative interviews with professionals supporting people living with dementia and their family carers in four US states showed that, during the shelter-in-place periods in March to May 2020, fear of contracting COVID-19 led to reluctance in using medical care and respite care services. Concerns about restrictions to visiting and inability to provide care also led to reluctance to consider moving to care homes. When carers did seek services, they found that these were less available (or in the case of day care services, not at all). Carers also reported shortages of key supplies, including incontinence products and groceries. However, this study also showed how existing staff in Care Ecosystem programmes adapted their ways of working to provide additional support, including helping family carers learn how to use technology, practical in-home activity ideas, and help them navigate access to information and resources (Merrilees et al., 2022).

References:

Merrilees J., Robinson-Teran J. Allawala M., et al. (2022). Responding to the needs of persons living with dementia and their caregivers during the COVID-19 pandemic: Lessons from the Care Ecosystem, Innovation in Aging, 2022;, igac007, https://doi.org/10.1093/geroni/igac007

Last updated: March 3rd, 2022   Contributors: Adelina Comas-Herrera  |  

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.

People living in care homes
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; Giebel et al., 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). A study exploring the views of care home practitioners in the Netherlands about the relationship between changes in stimulation due to the pandemic restrictions and behavioural and psychological symptoms of different groups of residents suggests that residents with advanced dementia and psychotic or agitation symptoms had benefitted from the reduction in unplanned stimuli (such as noise in corridors) during the pandemic, whereas the general reduction in stimuli had affected negatively people without dementia and with depressive and apathetic behaviour (Knippenberg et al., 2022).

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).

As described above, Knippenberg et al (2022) found that different groups of residents had different responses to the reduction in stimuli produced by the pandemic restrictions, recommending more targeted approaches to the different needs for stimulation of different groups or residents (for example those with severe dementia compared to those without dementia and with depressive symptoms).

People using care in the community

A qualitative study in Italy found that carers of people with dementia reported accelerated decline in cognitive and functional abilities and increased behavioural and psychological symptoms (Chirico et al., 2022).

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.

Chirico, I.Ottoboni, G.Giebel, C.Pappadà, A.Valente, M.Degli Esposti, V.Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in ItalyHealth & Social Care in the Community001– 10https://doi.org/10.1111/hsc.13758

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

Giebel CHanna, K.Marlow, P.Cannon, J.Tetlow, H.Shenton, J.Faulkner, T.Rajagopal, M.Mason, S. & Gabbay, M. (2022). Guilt, tears and burnout—Impact of UK care home restrictions on the mental well-being of staff, families and residentsJournal of Advanced Nursing001– 12https://doi.org/10.1111/jan.15181

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

Knippenberg, I.A.H., Leontjevas, R., Nijsten, J.M.H. et al. Stimuli changes and challenging behavior in nursing homes during the COVID-19 pandemic. BMC Geriatr 22, 142 (2022). https://doi.org/10.1186/s12877-022-02824-y

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

Austria

A qualitative study by Pfabigan et al., (2022) indicated that older people with light and moderate care needs living alone in Austria had to adjust their activities of daily living as well as other activities such as practising faith or pastimes. However, it was in particular their autonomy that had to be negotiated e.g. those who used to do shopping on their own were no longer able to do so, and had to rely on others such as neighbours. Overall the study found that the management of everyday life and support was challenging for this group of people.

References:

Pfabigan, J., Wosko, P., Pichler, B., Reitinger, E. and Pleschberger, S. (2022) Under reconstruction: the impact of COVID-19 policies on the lives and support networks of older people living alone, 6(1-2): 211–228, International Journal of Care and Caring, DOI: 10.1332/239788221X16308602886127

Last updated: March 4th, 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: March 4th, 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 national research center VIVE has a part of a national evaluation conducted 29 interviews with relatives and users of long-term care. Some relatives note in the VIVE evaluation that the service cancellations may have had a negative impact on the cognitive and physical functional ability, especially among older people with dementia. Of concern has also been the changing members of staff as this may increase the risk of infection. However, the informants in general support the restrictions and saw it as a sad period that would nevertheless pass (Martin et al, 2022).

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

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

Reference:

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

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

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

Last updated: May 25th, 2023

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: February 1st, 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 so far that systematically measures the impact of COVID-19 on the health and wellbeing of people with LTC needs.

Mental health

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 (Zeit online, 2021; Aerzteblatt.,de, 2018).

A study by Seethaler et al (2021) investigated the impact of the COVID-19 pandemic on mental health and perceived psychosocial support for older 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:

Aerzteblatt.,de (2018) Wissenschaftler: Depressionen bei Heimbewohner seltener behandelt.Available at: https://www.aerzteblatt.de/nachrichten/98943/Wissenschaftler-Depression-bei-Heimbewohnern-seltener-behandelt(Accessed 6 February 2022).

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

Zeit online (2021) Treffs gegen Depressionen in Alters- und Pfelgeheimen. Available at: https://www.zeit.de/amp/news/2021-02/26/treffs-gegen-depressionen-in-alters-und-pflegeheimen (Accessed 6 February 2022).

 

Last updated: February 13th, 2022   Contributors: William Byrd  |  Adelina Comas-Herrera  |  Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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.

A qualitative study asked family carers of people living with dementia in the community about the impacts they perceived on their relatives with dementia. The carers reported acceleration decline of both cognitive and physical abilities, increased behavioural and psychological symptoms and difficulties meeting care needs due to reduction in formal care and support (Chirico et all, 2022).

References:

Chirico, I.Ottoboni, G.Giebel, C.Pappadà, A.Valente, M.Degli Esposti, V.Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in ItalyHealth & Social Care in the Community001– 10https://doi.org/10.1111/hsc.13758

Last updated: February 21st, 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 in a survey of 199 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). A further analysis of that data explore the views of practitioners on the effects of reductions in stimuli on behaviour. The study distinguished between targeted stimuli (such as planned recreational activities) and unplanned stimuli (for example spontaneous noise in corridors). Practitioners reported that, for residents with advanced dementia and those with psychotic and agitated behaviours reductions in untargueted stimuli were beneficial, as well as the the adjustments made to daily activities. In contrast, for people without dementia and those with depressive and apathetic behaviour the reduction in stimuli was considered to have had negative effects. The study concludes that it is important to adopt approaches more tailored to the needs of individual residents in terms of the right balance between stimuli and tranquility. Practitioners supported the the idea of creating separate environments within care homes with different levels of stimulation for residents with different needs (Knippenberg et al., 2022).

Impact of physical distancing on vulnerable people needing care

A study by de Vries et al. (2022) on the impact of physical distancing on vulnerable people (including people with learning disabilities, mental health problems, older people with care needs living in the community and in residential care, as well as carers) noted a range of experiences,  from relative calmness to loneliness and loss of perspective. For those with small social networks, the loss of  care professionals and informal carers in their daily life during the pandemic meant the loss of a vital part of their social networks. Overall, the loss of social contact for a longer time was linked to low quality of life or motivation for life.

References:

Knippenberg, I.A.H., Leontjevas, R., Nijsten, J.M.H. et al. Stimuli changes and challenging behavior in nursing homes during the COVID-19 pandemic. BMC Geriatr 22, 142 (2022). https://doi.org/10.1186/s12877-022-02824-y

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

de Vries, D., Pols, A., M’charek, A. and van Weert, J. (2022) The impact of physical distancing on socially vulnerable people needing care during the COVID-19
Pandemic in the Netherlands, 6(1-2): 123–140, International Journal of Care and Caring, DOI: 10.1332/239788221X16216113385146

Last updated: March 4th, 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.

A qualitative study by Mackowiak et al., (2021), indicated that people with dementia living at home experienced a burden resulting from limited interactions with social contacts. Uncertainty around the pandemic, has increased their perception of loss of control and overall decreased well-being of people with dementia. Moreover, the lack of stimulation that resulted from restrictions accelerated emotional and cognitive decline.

References:

Mackowiak, M.; Senczyszyn, A.; Lion, K.; Trypka, E.; Malecka, M.; Ciulkowicz, M.; Mazurek, J.; Swiderska, R.; Giebel, C.; Gabbay, M.; et al. (2021). The Experiences of
People with Dementia and Informal Carers Related to the Closure of Social and Medical Services in Poland during the COVID-19 Pandemic – A Qualitative Study. Healthcare. https://doi.org/10.3390/ healthcare9121677

Last updated: March 7th, 2022   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: March 21st, 2022   Contributors: Adelina Comas-Herrera  |  Carlos Chirinos  |  

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 (over 65s) and children under 20 were subject to a strict curfew between March and June 2020 (Akkan, 2020).  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:

Akkan B and Canbazer C (2020) The Long-Term Care response to COVID-19 in Turkey. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 10 June 2020.

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 26th, 2022

United Kingdom

Impacts on people living in care homes

A longitudinal qualitative study conducted in October and November 2020 and March 2021 found that family members and staff reported that residents were upset at the lack of visiting and deteriorating mental wellbeing and changes in behaviour. However, there was also an observation by staff that some residents appeared to be more settled without visits and with fewer social activities (Giebel et al., 2022).

Impacts on adults with learning disabilities

UK-wide interviews with approximately 500 adults with learning disabilities across the UK (Flynn et al. 2021) 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.

References:

Flynn, S., Hayden, N., Clarke, L., Caton, S., Hatton, C., Hastings, R. P., Abbott, D., Beyer, S., Bradshaw, J., Gillooly, A., Gore, N., Heslop, P., Jahoda, A., Maguire, R., Marriott, A., Oloidi, E., Paris, A., Mulhall, P., Scior, K., Taggart, L., & Todd, S. (2021). Coronavirus and people with learning disabilities study Wave 3 Results: September 2021 (Full Report). Coventry, UK: University of Warwick. ISBN:978-1-871501-37-7

Giebel, C.Hanna, K.Marlow, P.Cannon, J.Tetlow, H.Shenton, J.Faulkner, T.Rajagopal, M.Mason, S. & Gabbay, M. (2022). Guilt, tears and burnout—Impact of UK care home restrictions on the mental well-being of staff, families and residentsJournal of Advanced Nursing001– 12https://doi.org/10.1111/jan.15181

Last updated: February 21st, 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 by 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.

A study of changes in prescription in two specialist psychiatric services for people with intellectual disabilities in London (urban setting) and Cornwall (rural setting) found that, in the urban setting, there had been an 11% increase in psychotropic prescribing during the lockdown, compared the pre-lockdown period. The authors consider whether the rural setting and fewer restrictions in Cornwall may be mitigated some of the stress linked to lockdown. Another possible explanation for the difference between settings may be the composition of clinical support (psychiatrist in London compared to a multidisciplinary team in Cornwall) (Naqvi et al, 2021).

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

Naqvi D., Perera B., Mitchell S., Sheehan R. and Shankar R. (2021). COVID-19 pandemic impact on psychotropic prescribing for adults with intellectual disability: an observational study in English specialist community services. BJPsych Open. 8. 10.1192/bjo.2021.1064.

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: March 8th, 2022   Contributors: William Byrd  |  Chris Hatton  |  Stacey Rand  |  

Northern Ireland (UK)

Impact 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.

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: March 8th, 2022   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 (The Scottish Parliament, 2020).

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 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.

References:

The Scottish Parliament, (2020). How has Covid-19 impacted on care and support at home in Scotland?

 

Last updated: March 8th, 2022   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).

Impact 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.

References: 

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: March 8th, 2022   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

Pakistan

There is little available information on the impacts of the pandemic on care sector in Pakistan, in part because the care sector itself is not well-developed. However, there are suggestions that the economic insecurity that the pandemic has given rise to has especially affected older people who were previously working informally and in small businesses, on which their livelihoods depend on (Ayesha, 2021). This is true especially as only around 20 per cent of people aged 60 or more in Pakistan receive any form of pension (Qureshi, 2021).

References:

Ayesha, A. (2021). Be age-friendly during COVID -19 Pandemic. https://en.dailypakistan.com.pk/11- May-2020/be-age-friendly-during-covid-19-pandemic

W. Qureshi (2021). Four pension reforms that could improve older people’s life in Pakistan. https://www. helpage.org/blogs/waqas-qureshi-19658/four- pension-reforms-that-could-improve-older-peoples-lifein-pakistan-1078/

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

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 (Flynn et al., 2021).

No systematic information is available concerning the impact of the COVID-19 pandemic on autistic people without intellectual disabilities in England.

People with impaired mental capacity living in care homes and human rights

There have been concerns about the impact of the pandemic on the human rights of people with impaired mental capacity living in care homes, with research showing that the key legal mechanisms to protect the human rights of care home residents did not operate well, with confusion among professionals as to whether the public health and infection control guidance should supersede, or not, the legal framework that protects the rights of exceptionally vulnerable residents (Kuylen et al. 2022).

References:

Flynn, S., Hayden, N., Clarke, L., Caton, S., Hatton, C., Hastings, R. P., Abbott, D., Beyer, S., Bradshaw, J., Gillooly, A., Gore, N., Heslop, P., Jahoda, A., Maguire, R., Marriott, A., Oloidi, E., Paris, A., Mulhall, P., Scior, K., Taggart, L., & Todd, S. (2021). Coronavirus and people with learning disabilities study Wave 3 Results: September 2021 (Full Report). Coventry, UK: University of Warwick. ISBN: 978-1-871501-37-7

Kuylen M., Wyliie A., Bhatt V., Fitton E., Michalowski S., Martin W. (2022) COVID-19 and the Mental Capacity Act in care homes: Perspectives from capacity professionals. Health and Social Care in the Community. https://doi.org/10.1111/hsc.13747

Last updated: March 7th, 2022   Contributors: Chris Hatton  |  Adelina Comas-Herrera  |  

Northern Ireland (UK)

Adults 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: March 8th, 2022   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: March 8th, 2022   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: March 8th, 2022   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
Impacts on care partners/family carers of people living with dementia

A systematic review of the psychological consequences of the pandemic on care partners of people with dementia and people with dementia suggests that the psychological and physical burden experienced during COVID-19 has increased greatly and that the clinical condition of the persons with dementia has worsened. The increase in perceived burden appears to be higher for those caring for people with more severe dementia (Carbone et al, 2021).

Exacerbation of gender inequalities in caring

A Spanish study examined gender differences in the experiences of unpaid carers during the pandemic and found that female carers experienced a bigger increase in caregiving intensity and burden and a stronger deterioration in self-perceived health than male carers. This appeared to be linked to men experiencing fewer reductions in informal support. However, men who provided high intensity care experienced deteriorations in health similar to female carers (Del Rio et al., 2022). Similarly, Carbone et al (2021) also report that female gender was a risk factor for worse psychological outcomes for unpaid carers of people living with dementia.

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:

Carbone, E. A., de Filippis, R., Roberti, R., Rania, M., Destefano, L., Russo, E., De Sarro, G., Segura-Garcia, C., & De Fazio, P. (2021). The Mental Health of Caregivers and Their Patients With Dementia During the COVID-19 Pandemic: A Systematic Review. Frontiers in psychology, 12, 782833. https://doi.org/10.3389/fpsyg.2021.782833

Del Río-Lozano M, García-Calvente M, Elizalde-Sagardia B, Maroto-Navarro G. (2022) Caregiving and Caregiver Health 1 Year into the COVID-19 Pandemic (CUIDAR-SE Study): A Gender Analysis. International Journal of Environmental Research and Public Health;19(3). https://doi.org/10.3390/ijerph19031653

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

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

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:

Carbone, E. A., de Filippis, R., Roberti, R., Rania, M., Destefano, L., Russo, E., De Sarro, G., Segura-Garcia, C., & De Fazio, P. (2021). The Mental Health of Caregivers and Their Patients With Dementia During the COVID-19 Pandemic: A Systematic Review. Frontiers in psychology, 12, 782833. https://doi.org/10.3389/fpsyg.2021.782833

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).

A six-wave longitudinal study by Abbasi-Shavazi et al., (2022) also illustrated that COVID19 had a more sever impact on carers relative to non-carers in terms of life satisfaction and psychological distress. However, the study also noted that free childcare was important to carers’ wellbeing (more than to non-carers) as the additional burden of caring for young children and older person/person with disability may have explained the greater deterioration of life satisfaction and psychological distress of carers.

Positive impacts for unpaid carers of people living dementia

A study by Tulloch et al., (2021) sought to identify positive impacts of the pandemic for unpaid carers 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:

Abbasi-Shavazi, A., Biddle, N., Edwards, B. and Jahromi, M. (2022) Observed effects of the COVID-19 pandemic on the life satisfaction, psychological distress and loneliness of Australian carers and non-carers, 6(1-2): 179–209, International Journal of Care and Caring, DOI: 10.1332/239788221X16323394592678

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: March 4th, 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

Denmark

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

Reference:

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

Last updated: May 25th, 2023

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: February 1st, 2022

France

A qualitative study by Giraud et al., (2022) reported that the reduction or suspension of medico-social service worsened the situation of family carers who receive cash for care payments in France. Family carers reported higher levels of fatigue and tensions. Most carers were left on their own with the reorganisation of the care systems and very few received support or guidance from the administration.

References:

Giraud, O., Petiau, A., Touahria-Gaillard, A., Rist, B. and Trenta, A. (2022). Tensions and polarities in the autonomy of family carers in the context of the COVID-19 pandemic in France, 6(1-2): 141–156, International Journal of Care and Caring, DOI: 10.1332/239788221X16316514499801

Last updated: March 8th, 2022

Germany

Greater responsibility and less support

A survey among family carers of older people in April/May 2020 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) (Eggert et al., 2020).

References

Eggert, S., Teubner, C., Budnick, A., Gellert, P. & Kuhlmey, A. (2020) Pflegende Angehörige in der COVID-19-Krise: Ergebnisse einer bundesweiten Befragung. Available at: https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf (Accessed 31 January 2022).

Last updated: February 12th, 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. This was atttirbuted to the impact of restrictive measures, fear of contagion and feeling abandoned by the usual services and other forms of support that were disrupte by the pandemic (Cagnin et al., 2020 and Chirico et al. 2022).

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

Chirico, I.Ottoboni, G.Giebel, C.Pappadà, A.Valente, M.Degli Esposti, V.Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in ItalyHealth & Social Care in the Community001– 10https://doi.org/10.1111/hsc.13758

Last updated: March 7th, 2022   Contributors: Klara Lorenz-Dant  |  Adelina Comas-Herrera  |  

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

Poland

A qualitative study among informal carers of people with dementia, indicated that increased caring responsibilities during pandemic (e.g. due to closures of social and medical services) have led to lower mental and physical well-being for carers, leading to  causing sleep disturbances, depression or anxiety as well as increasing carer burnout (Mackowiak et al. 2021).

References:

Mackowiak, M.; Senczyszyn, A.; Lion, K.; Trypka, E.; Malecka, M.; Ciulkowicz, M.; Mazurek, J.; Swiderska, R.; Giebel, C.; Gabbay, M.; et al. The Experiences of
People with Dementia and Informal Carers Related to the Closure of Social and Medical Services in Poland during the COVID-19 Pandemic – A Qualitative Study. Healthcare. https://doi.org/10.3390/ healthcare9121677

Last updated: March 7th, 2022   Contributors: Joanna Marczak  |  

Spain

The impact on families and, specifically on women, has been intense and, in some cases, devastating due to the loss of support and essential social networks for care, disrupting the process of extension and externalization of care. This has caused the reorganization of care and a change in the mosaic of care (Soronellas and Comas-d’Argemir, 2017). The closure of day centres, the crisis in residences, the reduction of Home Help Service (SAD), the loss of some paid workers, the fear of contagion and the strict home confinement of older people have transferred care responsibilities to households. As a result, care has been refamiliarised, and, with it, women have absorbed much of the impact of the pandemic (Soronellas and Jabbaz, 2021).

The pandemic removed the option of residential care and day centres, with extended family networks and the community needing to take more care on. While some day centres carried out home visits, this was not enough to replace the support they used to provide, particularly in terms of physiotherapy and other therapeutic inputs (Soronellas and Jabbaz, 2021).

Family carers of medium and high socio-economic groups have suffered the economic consequences of the pandemic to a lesser extent. They have been able to hire paid carers to absorb the work overload caused by the closure or reduction of services. In contrast, care has been entirely within the family among carers from lower socioeconomic groups (Soronellas and Jabbaz, 2021).

A study by Del Rio-Lozano et al (2022), consisting of a cross-sectional survey carried out in two regions in Spain, found that the pandemic has exacerbated gender differences in unpaid care provision. They found that male unpaid carers experienced fewer reductions in informal support during the pandemic. Linked to this, female unpaid carers were more likely to have experienced increases in caring intensity and burden and deterioration of self-perceived health, compared to male unpaid carers. These differences in self-perceived health, however did not hold for men who provide high intensity of care.

References:

Del Río-Lozano M, García-Calvente M, Elizalde-Sagardia B, Maroto-Navarro G. (2022) Caregiving and Caregiver Health 1 Year into the COVID-19 Pandemic (CUIDAR-SE Study): A Gender Analysis. International Journal of Environmental Research and Public Health;19(3). https://doi.org/10.3390/ijerph19031653

Soronellas, Montserrat y Comas-d’Argemir, Dolors (2017): “Hombres cuidadores de personas adultas dependientes. ¿Estrategias ante la crisis o nuevos agentes de cuidado?”, en María Rosa Herrera y German Jaraiz (eds.), Pactar el Futuro. Debates para un nuevo consenso en torno al bienestar, Sevilla, Universidad Pablo de Olavide, 2221-2239.

Soronellas, Montserrat y Jabbaz, Marcela (2021), “Cuidadoras familiares, antes y depues de la pandemia”, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

 

Last updated: March 21st, 2022   Contributors: Adelina Comas-Herrera  |  Carlos Chirinos  |  

United Kingdom

Impact on family carers of care home residents

A longitudinal qualitative study carried out in the UK in Autumn 2020 and March 2021 found that family carers of people living in care homes expressed increasing anger and distress about lack of safe visiting, which included negative emotions and some resentment toward care home staff, and lack of trust towards both care homes and the government. Carers also reported feelings of guilt for what their relatives were experiencing and some reported that this was exacerbated by visits with physical barriers such as windows and screens (Giebel et al., 2022).

References:

Giebel, C.Hanna, K.Marlow, P.Cannon, J.Tetlow, H.Shenton, J.Faulkner, T.Rajagopal, M.Mason, S. & Gabbay, M. (2022). Guilt, tears and burnout—Impact of UK care home restrictions on the mental well-being of staff, families and residentsJournal of Advanced Nursing001– 12https://doi.org/10.1111/jan.15181

 

Last updated: March 11th, 2022

Wales (UK)

In a qualitative study based on co-resident family carers in Wales, interviewed carers stated the negative impact that staying at home (in response to government directives) during the lockdown had an overall negative impact on their subjective wellbeing, including increased depression and low mood. Social distancing measures were also said to strain personal relationships. Unpaid carers also experience lack of access to support services both for themselves and the person they cared for, which in turn  led to increased intensification of care responsibilities for co-resident carers (Cheshire-Allen, et al. 20022).

References: 

Cheshire-Allen, M. and Calder, G. (2022) ‘No one was clapping for us’: care, social justice and family carer wellbeing during the COVID-19 pandemic in
Wales, 6(1-2): 49–66, International Journal of Care and Caring, DOI: 10.1332/239788221X16316408646247

Last updated: March 4th, 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 (2020) 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 by Bennett et al. (2020) 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). (Bennett et al., 2020).

Impact 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:

Bennett, M., Zhang , Y., Yeandle, S. CARING and COVID-19 Hunger and mental wellbeing. University of Sheffield

Carers UK (2020). Caring behind closed doors: six months on. Retried from carersuk.org on 11/03/2022

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: March 11th, 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 can be attributed to poor pay and conditions, as well as lack of professional prestige of the sector (see for example Van Houtven et al. 2021).

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. This section is aims to provide an overview of the evidence of these impacts so far, building on a systematic review by Gray et al (2021) that covers evidence up to March 2021.

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 and Wales, 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).

Poor working conditions:

The challenge of having to implement measures to reduce risks of infections that were upsetting (and sometimes harmful) for care home residents, particularly those living with dementia, has been highlighted by some studies, for example Leontjevas et al, 2021 and Giebel et al., 2022), with staff experiencing increased challenging behaviour from residents and sometimes from family and relatives who were upset with the visiting restrictions.

Wellbeing and 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.

Mental health impacts:

Quantitative studies identified by a systematic review showed a high prevalence of mental health systems including anxiety, depression, PTSD and secondary traumatic stress, similar impacts were described in the qualitative studies, as well as exhaustion and burnout (Gray et al., 2021).

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 and mood disturbance moral. Many staff also reported that they were not able to cope with work demands (Brady et al., 2021).

A longitudinal qualitative study in the UK found that staff working in care homes reported increased workloads and burnout, worsening mental health, and experiences of conflict and relationship breakdown with family carers. They also reported difficulties linked to having to try to communicate with residents while wearing face coverings (Giebel et al, 2022).

Factors affecting or moderating mental health impacts:

The review by Gray et al (2021) identified these factors as affecting between mental health outcomes and working/pandemic conditions:

  • – Availability of Personal Protection Equipment (PPE)
  • – Lack and delays in testing
  • – Working conditions: shift working, staffing levels, workload and redeployment
  • – Conflicting and unclear guidance, poor communication
  • – Contact with ‘at risk’ or positive residents, fear of contagion
  • – Death and bereavement
  • – Feeling undervalued and abandoned
  • – Degree of support from colleagues, management and psychologists
Moral injury

Many of the measures that staff were asked to implement to prevent or control COVID infections resulted in staff feeling conflicted due to the impacts of the measures on the wellbeing and health of care home residents and their families. Brady et al, (2021) and Iaboni et al (2022) report high levels of moral injury or distress among care home staff.

Positive impacts:

The systematic review by Gray et al (2021) found that two studies reported positives from the pandemic: peer-support networks to communicate with other homes (Spilsbury et al, 2021) and increased teamwork and cooperation (White et al., 2021).

Evidence on what works to improve outcomes for care home staff during the pandemic:

The systematic review by Gray et al. (2021) identified a mixed-methods evaluation of a training intervention to provide rapid guidance and learning Extension for Community Health Outcomes (ECHO). The study found a high level of satisfaction with the training, an increase in participant’s comfort levels in work ing with people who had COVID or were at high risk and reports of increased confidence (Lingum 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

Giebel, C.Hanna, K.Marlow, P.Cannon, J.Tetlow, H.Shenton, J.Faulkner, T.Rajagopal, M.Mason, S. & Gabbay, M. (2022). Guilt, tears and burnout—Impact of UK care home restrictions on the mental well-being of staff, families and residentsJournal of Advanced Nursing001– 12https://doi.org/10.1111/jan.15181

Gray K.L., Birtles H., Reichelt K. and James I.A. (2021) The experiences of care home staff during the COVID-19 pandemic: A systematic review, Aging & Mental Health, DOI: 10.1080/13607863.2021.2013433

Iaboni, A., Quirt, H., Engell, K. et al. Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 22, 74 (2022). https://doi.org/10.1186/s12877-022-02759-4

Leontjevas, R., Knippenberg, I. A. H., Smalbrugge, M., Plouvier, A. O. A., Teunisse, S., Bakker, C., Koopmans, R. T. C. M., & Gerritsen, D. L. (2021). Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands. Aging & Mental Health, 25(7), 13141319. 

Lingum, N. R., Sokoloff, L. G., Meyer, R. M., Gingrich, S., Sodums, D. J., Santiago, A. T., Feldman, S., Guy, S., Moser, A., Shaikh, S., Grief, C. J., & Conn, D. K. (2021). Building long-term care staff capacity during COVID-19 through just-in-time learning: Evaluation of a modified ECHO model. Journal of the American Medical Directors Association, 22(2), 238244. https://doi.org/10.1016/j.jamda.2020.10.039 

Spilsbury, K., Devi, R., Griffiths, A., Akrill, C., Astle, A., Goodman, C., Gordon, A., Hanratty, B., Hodkinson, P., Marshall, F., Meyer, J., & Thompson, C. (2021). SEeking AnsweRs for Care Homes during the COVID-19 pandemic (COVID SEARCH). Age and Ageing, 50(2), 335340. https://doi.org/10.1093/ageing/afaa201 

Van Houtven, C., Miller, K., Gorges, R., et al. (2021) State Policy Responses to COVID-19 in Nursing Homes. Journal of Long-Term Care, (2021), pp.264–282. DOI: http://doi.org/10.31389/jltc.81

White, E. M., Wetle, T. F., Reddy, A., & Baier, R. R. (2021). Front-line nursing home staff experiences during the COVID-19 pandemic. Journal of the American Medical Directors Association, 22(1), 199203. https://doi.org/10.1016/j.jamda.2020.11.022 

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

International reports and sources

Systematic review of the experiences of care home staff during the pandemic (covering evidence from March 2020 to March 2021):

Gray K.L., Birtles H., Reichelt K. and James I.A. (2021) The experiences of care home staff during the COVID-19 pandemic: A systematic review, Aging & Mental Health, DOI: 10.1080/13607863.2021.2013433

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  |  

Ontario (Canada)

A survey of care home staff in Ontario by Iaboni and colleagues (2022) found that staff experienced high level of moral distress about the impact of measures such as isolation on residents’ quality of life, and fear about the reaction of residents to the measures.

References:

Iaboni, A., Quirt, H., Engell, K. et al. (2022) Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 22, 74. https://doi.org/10.1186/s12877-022-02759-4

Last updated: February 6th, 2022   Contributors: Andrea Iaboni  |  

Denmark

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

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

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

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

 

Reference:

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

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

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

Last updated: May 25th, 2023

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).

Evidence on the impact of COVID on working conditions in public and private sectors

A study by Mercille et al., (2022) illustrated that nearly 39% of care workers worked more hours during the pandemic compared to pre-pandemic times, while 16.5 % worked fewer hours. Those employed by private providers were more likely to experience increased working hours relative to those employed by public providers.  Moreover, care workers reported that they had to work when they were affected by the pandemic because of the derogations. Nearly 70% of care workers in reported receiving little or no COVID-19 training. Moreover, those employed by public sector providers received somewhat better conditions relative to those employed by private providers, e.g. the former were more likely to receive sick pay when they were either sick themselves or had close contacts of positive cases. Public providers were also more likely to inform their staff of contact with positive cases. However, the study showed no significant difference between private and public providers in terms of availability of PPE, testing or the use of derogations.

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

Mercille, J., Edwards, J. and O’Neill, N. (2022) Home care professionals’ views on working conditions during the COVID-19 pandemic: the case of Ireland, 6(1-2): 85–102, International Journal of Care and Caring, DOI: 10.1332/239788221X16345464319417

 

Last updated: March 4th, 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:

  • Additional 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).

Another qualitative study with care workers in care facilities highlighted a number of moral challenges faced by care professionals. These challenges were related to  to the visitor ban policy, residents’ loneliness and despair, as well as deaths. Moral challenges triggered different responses from care workers from acceptance  to deviating from protocols and ‘acts of rebellion’ as well as leading to clashes between care workers and with superiors. Overall, the paper noted that care workers experienced a degree of moral distress (van der Geugten et al., 2022).

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 der Geugten, W., Jacobs, G. and Goossensen, A. (2022) The struggle for good care: moral challenges during the COVID-19 lockdown of Dutch elderly care
facilities, 6(1-2): 157–177, International Journal of Care and Caring, DOI: 10.1332/239788221X16311375958540

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: March 7th, 2022

Pakistan

Perceptions and experiences of care home staff 

A study by Bilal and colleagues (published in August 2020) explores the experiences and perceptions of staff providing care to elderly residents across three care homes in Karachi. The results of the study highlighted the constant levels of fear and anxiety that care home staff experienced throughout the first few months of the pandemic, although this was alleviated somewhat by the availability of protective gear and training. The study also highlighted discrimination felt by caregivers, which was due to an ignorant fear among the public that they might be spreading the infection because of their close contact with elderly people. One carer described a driver cancelling his delivery of food to their care home (Bilal et al., 2020).

References:

Bilal, A., Saeed, M. A., & Yousafzai, T. (2020). Elderly care in the time of coronavirus: Perceptions and experiences of care home staff in Pakistan. International Journal of Geriatric Psychiatry, 35(12), 1442–1448. https://doi.org/10.1002/GPS.5386

Last updated: January 29th, 2022   Contributors: Daisy Pharoah  |  

United Kingdom

Impact on wellbeing and quality of life

Emerging evidence suggests that, since the pandemic began, health and care workers have been at high risk for significant psychological distress. Greene et al. (2020) surveyed a convenience sample (n = 1194) of health and social care workers from across the UK in the summer of 2020, to identify predictors of clinically significant distress (PTSD, anxiety, and depression) during the early phase of COVID-19.  The study found that clinically significant distress was common: just under 60% of participants met the threshold for PTSD, anxiety, or depression. This was less likely in participants with higher incomes. Predictors for a clinically significant mental disorder were concerns about passing COVID-19 onto others, being unable to discuss concerns with managers, being stigmatised, and not having reliable access to PPE.

Respondents to a survey (n = 163) conducted in early 2020 across the UK by The Queen’s Nursing Institute reported feeling worse (42%) or much worse (15%) in terms in terms of their mental and physical health as a result of working in conditions induced by the pandemic. Contributing factors to this included poor management, undervalued work (especially as compared to hospital staff), a lack of support from government, poor working conditions (including feeling inadequately protected by PPE), an increased workload, and concerns about the care workforce.

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).

Impact on staff working in care homes

A longitudinal qualitative study found that staff were feeling overburdened and burned out, this was attributed to increased workloads, lack of support, and the emotional impacts of having to implement measures that were causing distress to residents and their family members (Giebel et al, 2022).

References:

Giebel, C.Hanna, K.Marlow, P.Cannon, J.Tetlow, H.Shenton, J.Faulkner, T.Rajagopal, M.Mason, S. & Gabbay, M. (2022). Guilt, tears and burnout—Impact of UK care home restrictions on the mental well-being of staff, families and residentsJournal of Advanced Nursing001– 12https://doi.org/10.1111/jan.15181

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

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C. R., Bloomfield, M. A., & Billings, J. (2020). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. MedRxiv, 2020.10.21.20216804. https://doi.org/10.1101/2020.10.21.20216804

Queen’s Nursing Institute. (2020). The Experience of Care Home Staff During Covid-19. A Survey Report by The QNI International Community Nursing Observatory. July. https://www.qni.org.uk/wp-content/uploads/2020/08/The-Experience-of-Care-Home-Staff-During-Covid-19-2.pdf [accessed 11/10/2020]

Last updated: March 8th, 2022   Contributors: Daisy Pharoah  |  

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 COVID-related mortality

Data from the Office for National Statistics show that, between 9 March 2020 and 31 December 2021, there were 1,131 deaths of social care workers aged 20 to 64 attributed to COVID-19 in England. 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 203 deaths per 100,000 (compared to 77 for the general population and 78 for health care workers in the same age groups) and 93 deaths for 100,000 for females, compared to 43 for the general population and 36 for women working in healthcare.

Mental and physical health impacts

Emerging evidence suggests that, since the pandemic began, health and care workers have been at high risk for significant psychological distress (Greene et al., 2020). A study by Nyashanu et al. (2020) explored some of the triggers of mental health problems among healthcare workers during the first phase of the COVID-19 pandemic in early 2020. Semi-structured interviews with forty healthcare professionals from nursing homes and domiciliary care agencies in the English Midlands revealed various factors causing distress and anxiety. These included: a fear of infection and infecting others, lack of guidance from central government, death and loss of professionals and residents, unreliable testing and delayed or false results, staff shortages, and unsafe hospital discharges. Another important source of stress was the lack of recognition of care staff, which sat is stark contrast to the recognition showed to professionals in the NHS. Participants felt that they were not being adequately recognised as frontline healthcare workers, which negatively impacted their morale. This lack of recognition also caused delays in receiving PPE and testing; a further cause of stress.

Hussein (2020) reported findings from a survey of 296 frontline care workers that took place during July and August 2020. It 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 (Hussein 2020). 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:

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C. R., Bloomfield, M. A., & Billings, J. (2020). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. MedRxiv, 2020.10.21.20216804. https://doi.org/10.1101/2020.10.21.20216804

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

Hussein, S. (2020). The Impact of COVID-19 on social care workers’ workload, wellbeing and ability to provide care safely: Findings from the UK. PSSRU blog

Nyashanu, M., Pfende, F., & Ekpenyong, M. S. (2020). Triggers of mental health problems among frontline healthcare workers during the COVID-19 pandemic in private care homes and domiciliary care agencies: Lived experiences of care workers in the Midlands region, UK. Health & Social Care in the Community. https://doi.org/10.1111/HSC.13204

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

Last updated: March 8th, 2022   Contributors: Daisy Pharoah  |  

Northern Ireland (UK)

Mental Health Impacts

Emerging evidence suggests that, since the pandemic began, health and care workers have been at high risk for significant psychological distress. Greene et al. (2020) surveyed a convenience sample (n = 1194) of health and social care workers from across the UK in the summer of 2020, to identify predictors of clinically significant distress (PTSD, anxiety, and depression) during the early phase of COVID-19.  The study found that clinically significant distress was common: just under 60% of participants met the threshold for PTSD, anxiety, or depression. This was less likely in participants with higher incomes. Predictors for a clinically significant mental disorder were concerns about passing COVID-19 onto others, being unable to discuss concerns with managers, being stigmatised, and not having reliable access to PPE.

It is noted that the sample only included 14 participants from Northern Ireland, so it is possible that the results are not fully representative of the experience in this part of the UK.

References:

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C. R., Bloomfield, M. A., & Billings, J. (2020). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. MedRxiv, 2020.10.21.20216804. https://doi.org/10.1101/2020.10.21.20216804

Last updated: March 8th, 2022   Contributors: Daisy Pharoah  |  

Wales (UK)

Data from the Office for National Statistics show that, between 9 March 2020 and 31 December 2021, there were 56 deaths of social care workers aged 20 to 64 attributed to COVID-19 in Wales. People working social care had higher rates of death involving COVID-19 compared to people of similar age and sex. For women working in social care, there were 83 deaths per 100,000 (compared to 43 for the general population and 53 for health care workers in the same age groups), the rates for men cannot be compared meaningfully due very small numbers.

 

Last updated: February 3rd, 2022   Contributors: Adelina Comas-Herrera  |  

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

Overview

The pandemic has exacerbated the already precarious working and living conditions of migrant care workers, particularly those who provide live-in care.

The particular situation and experiences of live-in migrant carers

Kuhlmann et al (2020) explored the situation of migrant carers in Austria, Germany, Italy, Poland and Romania and developed a framework to gather empirical material on the LTC system, the LTC labour market, LTC care migration policies and COVID-19 specific regulation for LTC migrant carers. The study shows the importance of understanding the interactions between LTC policy and labour market and migration policies. COVID-19 has made the fragile labour market arrangements of migrant carers more visible and shown the importance of improving international care workforce governance.

An article by Giordano (2020) explores the position of migrant carers of older people at the intersection multiple systems of oppression that characterise their distinctive experiences, with being women, migrants, live-in carers, family breadwinners and their position as “quasi-family members” being key to understanding their dilemmas in relation to keeping their jobs and renouncing to their freedoms or leaving their employment.

References

Giordano C. (2020) Freedom or money? The dilemma of migrant live-in elderly carers in times of COVID-19. Feminist Frontiers 28(S1): 137-150. https://doi.org/10.1111/gwao.12509

Kuhlmann E, Falkenbach M, Klasa K, Pavolini E, Ungureanu MI. Migrant carers in Europe in times of COVID-19: a call to action for European health workforce governance and a public health approach. Eur J Public Health. 2020 Sep 1;30(Supplement_4):iv22-iv27. https://doi.org/10.1093/eurpub/ckaa126

 

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

Denmark

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

Last updated: June 5th, 2023

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  |  

Spain

The CUMADE project (Care matters. Gender impact on caregivers of elderly and dependent persons in times of COVID-19) carried out interviews with care workers, including those employed privately (often informally) in domestic settings, the majority of whom were migrant women).

A first consequence of the pandemic has been the dismissal of many female workers, accompanied by a drop in hiring. The reasons that explain the temporary or permanent suspension of jobs are diverse. However, apart from the deaths caused by the covid, the pandemic changes in the employment and economic situations of the employing families (teleworking, loss of jobs) temporarily dispensing with the worker and sometimes taking direct responsibility for the care of their family members. The pandemic also involves changes in the composition of households: older people with dependency moving in with their children, and children who move into their parents’ homes. These situations that can lead families to do without the worker. The fear of contagion and the perception of risk within households have also caused the temporary suspension of contracts or dismissals (Offenhenden and Bofill-Poch, 2021).

However, the impact varied according to the hiring regime of migrant caregivers. For example, the new conditions generated by the pandemic (economic precariousness, restricted mobility, restricted access to services) have increased the demand for live-in female workers. One of the characteristics that usually stands out in live-in work is the claim of the total availability of the worker’s time. In general terms, the increase in the working day has not been remunerated. Likewise, female workers have seen their mobility restricted, giving greater control to their employers and seeing their privacy and rest times reduced (Offenhenden and Bofill-Poch, 2021).

The labour changes caused by the pandemic and confinement have made it even more difficult for workers with family responsibilities to reconcile work and family. Strategies have ranged from delegating care to older sisters to quitting work. For some workers who have gone from the external to the internal (live-in) regime, confinement has meant not being able to attend to the care needs of their children. That has generated deep discomfort in the workers, who have not been able to care for their children at a challenging time due to home confinement (Offenhenden and Bofill-Poch, 2021).

On the other hand, those workers who did not have savings or alternative income, faced with the loss of employment or the drastic reduction of their working hours, have had to resort to mutual aid groups, social assistance entities and religious organisations to cover basic needs (accommodation and food). Moreover, the pandemic also affected the ability to send remittances and take care of his family’s costs from a distance. To send remittances (apart from the fact that the closing of call shops made it enormously difficult), women have reduced their daily expenses and prioritised costs in their countries of origin. In some cases, this leads to debts being generated in the families of origin due to the impossibility of sending money during confinement (Offenhenden and Bofill-Poch, 2021).

References

Offenhenden, María y Bofill-Poch, Sílvia (2021), “Trabajadoras de hogar y cuidados”, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Last updated: March 21st, 2022   Contributors: Carlos Chirinos  |  

England (UK)

Visa Relaxation for Migrant Care Workers

In in December 2021 , addressing unprecedented challenges prompted by the pandemic, the government announced a temporary relaxation of immigration rules for overseas care workers in an attempt to recruit and retain care staff. Care assistants and home and social care workers are to be added to the Shortage Occupation List (SOL) in early 2022 and will be eligible for a 12-month health and care visa; allowing migrants to fill gaps in workforces. It is proposed that these measures will be in place for at least 12 months (DHSC, 2021; BBC News).

References:

DHSC, (2021). Biggest visa boost for social care as Health and Care Visa scheme expanded. DHSC Press Release, Retrieved from: www.gov.uk on 11/03/2022

Last updated: March 11th, 2022   Contributors: Daisy Pharoah  |  

2.09. Impact of the pandemic on workforce shortages in the Long-Term Care sector

Overview

Staff shortages in the Long-Term Care sector pre-dated the start of the pandemic in many countries (see Rocard et al. 2021), and these have been exacerbated by the enormous impacts of the pandemic on the people working in the care sectors.

This situation has worsened over time and, during the Omicron wave in January 2022, a survey of the Federation of European Social Employers found that 85% of respondents had staff shortages, with almost 30% reporting that they had more than 10% of vacancies unfilled. Nurses and assistant nurses were the most affected job roles.

International reports and sources

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.

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

Austria

According to a recent report by The Federation of European Social Employers, Austria has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Belgium

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

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Bulgaria

According to a recent report (February 2022) by The Federation of European Social Employers, Bulgaria has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

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. Providers reported that the recent staffing shortages throughout the workforce have left the already troubled sector in further crisis (see section 2.04 of this report for more details on access to care).

Last updated: January 26th, 2022

Croatia

According to a recent report (February 2022) by The Federation of European Social Employers, Croatia has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Czech Republic

An OECD paper  as well as other sources indicated that Czech Republic faced  staff shortages during the pandemic, the country attempted to address those by providing financial help to LTC facilities to recruit unemployed or former LTC workers, as well as providing financial help to LTC facilities to recruit LTC students.

Last updated: January 26th, 2022

Denmark

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

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

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

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

Last updated: May 25th, 2023   Contributors: Daisy Pharoah  |  Tine Rostgaard  |  

Finland

According to a recent report (February 2022) by The Federation of European Social Employers, Finland has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

France

France recorded high levels of staff sickness, together with poor working conditions for staff entering the profession during the pandemic, and limited support during, led to chronic workforce shortages in LTC sector. Most staff were paid ‘Covid bonus’ of up to €1,500. However, staff shortages, in turn led to care staff taking on difficult tasks (e.g. end of life care) and also contributed to limited access to care.

According to a recent report (February 2022) by The Federation of European Social Employers, France has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Germany

Similar to other countries, Germany experienced workforce shortages during the pandemic. To address these, Germany supported the recruitment of LTC students through financial help to LTC facilities and increased/ lifted the maximum number of working hours (sources: Germany LTCcovid presentation; COVID-19 in long-term care: impact, policy responses and challenges).

According to a recent report (February 2022) by The Federation of European Social Employers, Germany has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Hungary

OECD report indicated that Hungary faced similar staff shortages during pandemic to other countries, there were efforts to recruit volunteers from the health sector to address the challenges (e.g. students, professionals in private sector).

Last updated: January 26th, 2022

Ireland

According to a recent report (February 2022) by The Federation of European Social Employers, Ireland has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Italy

During the first wave of the pandemic, a large share of nurses and doctors left long-term care (LTC) settings to enter the national health service, which was recruiting professionals to cope with the outbreaks in hospitals. Since then, the shortage of LTC personnel keeps growing, and as of December 2021 there were no plans to increase the LTC workforce (source: LTC system and the pandemic December 2021; Amnesty International Report 2021).  Conversely, an OECD paper indicated that in several Italian regions (e.g. Apulia, Lombardy, Piedmont, Veneto), an important hiring effort was implemented during the first wave of pandemic attracting many professional care workers thanks to public sector contractual conditions (generally better contracts applied in private nursing homes).

According to a recent report (February 2022) by The Federation of European Social Employers, Italy has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Netherlands

An OECD paper and other sources indicated that the Netherlands has experienced staff shortages during the various waves of pandemic. To address these, the country provided financial help to LTC facilities to recruit unemployed or former LTC workers, and provide financial help to LTC facilities to recruit students. LTC facilities also received financial support that they could use independently; including for stafff recruitment. Moreover, a pool of volunteers for emergencies was activated to boost staff at the start of the pandemic.

However, according to a recent report (February 2022) by The Federation of European Social Employers, The Netherlands has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Norway

Norway experienced staff shortages during the various waves of the pandemic. This was mostly due to increased staff sicknesses and inability to recruit new staff. In fact, a report (February 2022) by The Federation of European Social Employers, states that Norway has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

To address workforce shortages in LTC sector, Norway has taken several measures. For example, the maximum number of working hours allowed has been increased or lifted, visas for foreign workers in LTC facilities have been temporarily extended, and the country has provided financial help to LTC facilities to recruit unemployed or former LTC workers and to recruit LTC students (source: LTCcovid Norway presentation; COVID-19 in long-term care: impact, policy responses and challenges).

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Poland

During the pandemic, pre-existing workforce shortages were exacerbated (source Poland presentationLong-term care in Poland Nov 2021). According to a recent report (February 2022) by The Federation of European Social Employers, Poland has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Joanna Marczak  |  Daisy Pharoah  |  

Portugal

An OECD paper  notes that Portugal’s LTC facilities experiences staff shortages during the pandemic, exacerbated by high levels of sickness among staff, e.g. workers in LTC facilities accounted for about a third of COVID-19 related sick leave.

Last updated: February 1st, 2022

Romania

According to a recent report (February 2022) by The Federation of European Social Employers, Romania has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Spain

In December 2020, It was agreed by the Territorial Council of Social Services (TCSS) and the System for Autonomy and Care for Dependency (SAAD), that weekly IMERSO reports would be published for the duration of the pandemic. These reports contain information about how residential centres are coping during the pandemic.

The reports show that during the peak of each wave of the pandemic, the number of staff infected with Covid-19 was lower than the number of infected residents of the centres. This was not the case in the last weeks of December 2021 and first week of 2022, where the number of infected care home staff exceeded that of residents.

To guarantee services for people who rely on care from others during the pandemic, the TCSS and SAAD decided in March and October 2020 (and again in December 2021) that care home staff could be exempted from holding a professional qualification for the duration of the pandemic.

Survey data suggests that the number of long-term care (LTC) workers in Spain increased by 7% during the first wave of the pandemic. The increase was driven by the private sector recruiting female temporary staff; mostly part-time. Conversely, in Navarre, Spain, over 24% of workers in LTC facilities took at least one medical leave, and three-quarters of LTC facilities had at least one employee who took leave during the first wave.  Leave in context of staff shortages limited the capacity to respond effectively to the pandemic (Source: OECD paper). More recently, concerns have been voiced around staff shortages linked to the spread of the Omicron variant (Source: Territorial Council for Social Services, 2021).

According to a recent report (February 2022) by The Federation of European Social Employers, Spain has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

 

Last updated: June 29th, 2022   Contributors: Daisy Pharoah  |  Sara Ulla Díez  |  

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) (Source: CQC).

Workforce shortages: impact on mental health

Workforce shortages were reported as a key source of stress and anxiety in healthcare staff in a study by Nyashanu et al. (2020). Authors of this study collected data through interviews with forty healthcare workers from nursing homes (n = 20) and domiciliary care agencies (n = 20) in the English Midlands in the early phase of the pandemic (before May 2020) to explore triggers of mental health problems. Sickness rates increased and some had to use leave entitlements – this caused staff shortages and for the remaining staff to become increasingly mentally and physically drained. Participants reported feeling stressed and anxious in particular when shifts were being covered by agency staff who could have been exposed to the virus from working elsewhere.

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 demand (see section 2.04 of this report for more details on the impact on pandemic on access to care); these operators also reported an 18% vacancy rate and 14% absences as a result of Omicron, the vacancy rate was up from 9.4% in December 2021 (Skills for Care, 2021). Some providers reported having to close (some of their) care homes due to acute staff shortages, others report that care workers are under considerable pressures due to staff shortages  (see also section 3.06 of this report for more details on measures to ensure workforce availability).

References:

Nyashanu, M., Pfende, F., & Ekpenyong, M. S. (2020). Triggers of mental health problems among frontline healthcare workers during the COVID-19 pandemic in private care homes and domiciliary care agencies: Lived experiences of care workers in the Midlands region, UK. Health & Social Care in the Community. https://doi.org/10.1111/HSC.13204

Last updated: March 8th, 2022

United Kingdom

According to a recent report by The Federation of European Social Employers, The United Kingdom has experienced a strong increase of over 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Last updated: March 8th, 2022   Contributors: Daisy Pharoah  |  

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

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: March 11th, 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  |  

Sweden

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

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

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

References:

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

Last updated: February 13th, 2022

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

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

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

Lockdown

Denmark was one of the first countries worldwide to introduce a lockdown. This was announced on March 11th, and came into force March 13th, 2020. All persons working in non-essential functions in the public sector were ordered to stay at home for two weeks. Private employers were encouraged to ensure that their employees could work from home. All public institutions, including secondary education and universities, libraries and museums closed down. Exams were cancelled.

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

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

Test strategies

The general strategies for testing have changed a number of times in Denmark, leading to some criticism for lack of transparency or evidence-based practice. The initial test strategy, introduced in early March 2020, was aimed at preventing the disease from spreading, a so-called confinement strategy. This took place by testing persons who might have been exposed to the disease, even if they did not have symptoms.

As of March 15th, 2020, the strategy changed to a mitigation strategy, targeting test measures to alleviate the consequences of the disease. Now only persons with symptoms were tested and following a referral from the GP. This led to concerns being raised such as from the WHO, which generally advised a more aggressive testing strategy. Nationally it sparked a debate that the new test strategy was a pragmatic and not a health-based decision, mainly due to a lack of testing equipment. In the period of May 1st-May 12th, the number of daily tests was fluctuating between 4-15,000.

On May 12th, 2020, a new and more aggressive testing strategy was introduced, where persons without symptoms are also to be tested. The capacity was set to 20,000 persons on a daily basis and the ambition was to increase this number over time. This would make Denmark a country with one of the highest number of tests per inhabitants.

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

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

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

PPE

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

Vaccines

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

References:

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

Last updated: June 5th, 2023   Contributors: Tine Rostgaard  |  

Germany

General measures

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) (Lorenz-Dant, 2020; Die Bundesregierung, 2022).

Infection prevention bill

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 (Bundesministerium für Gesundheit, 2021).

References

Bundesministerium für Gesundheit (2021) Fragen und Antworten zum 4. Bevölkerungsschutzgesetz. Available at: https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/4-bevschg-faq.html(Accessed 6 February 2022).

Die Bundesregierung (2022) Corona-Regelungen: Das haben Bund und Länder vereinbart. Available at: https://www.bundesregierung.de/breg-de/themen/coronavirus/corona-regeln-und-einschrankungen-1734724 (Accessed 3 February 2022).

Die Bundesregierung (2021) Bund-Länder-Beschluss: Öffnungsperspektive in fünf Schritten. Available at: https://www.bundesregierung.de/breg-de/themen/coronavirus/fuenf-oeffnungsschritte-1872120 (Accessed 6 February 2022).

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Robert Koch Institut (2021b) Bericht zu Virusvarianten von SARS-CoV-2 in Deutschland, insbesondere zur Variant of Concern (VOC) B.1.1.7. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/DESH/Bericht_VOC_2021-03-31.pdf?__blob=publicationFile (Accessed 6 February 2022).

Last updated: February 12th, 2022

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

Malaysia

A comprehensive preparedness plan was developed by the Ministry of Health (MOH) in Malaysia during the very early days of the pandemic; before the first case in the nation had been identified. The main components of this plan included screening at ports of entry, designating hospitals and clinics as either treatment or sampling centres, and empowering the public health surveillance system (Hashim et al., 2021).

In March 2020, when the first community case was identified and cases in Malaysia subsequently began to increase, the Malaysian government introduced the Movement Control Order (MCO) in an attempt to mitigate spread of the virus. This order was extended and/or amended several times (e.g., the Recovery Movement Control Order) in the following months, until June 2021 when the National Recovery Plan (NRP) – a four-phase plan to steer the nation out of the pandemic – was put into effect (Jamaluddin et al., 2022). The MCOs involved the closing of local or community borders and strict enforcement of the prohibition of movement between areas, and its initial implementation was followed by a drop in the number of daily cases reported within two weeks (Ang et al., 2021).

Malaysia achieved successful delivery of medical services and COVID-19-related physical and digital infrastructure (such as mobile apps for track-and-trace) through a centralised coordination council which was made up of multiple ministries, to whom the Ministry of Health provided advice and updates on the pandemic, and collaborations with the general public, NGOs, and other states. Aside from the various national lockdowns, Malaysia adopted a targeted screening approach to monitor individuals who had been identified as high-risk (such as those who had travelled), and had hospital and non-hospital quarantine systems to manage active COVID-19 cases. These were organised according to the disease severity and risk of infection (Ang et al., 2021). The MOH distributed the National Guidelines on COVID-19 Management (aimed at assisting frontline staff and also available online) in every step of their management of COVID-19 cases. These guidelines were continuously updated throughout the trajectory of the pandemic (Hashim et al., 2021).

References:

Ang ZY, Cheah KY, Shakirah MS, Fun WH, Anis-Syakira J, Kong YL, Sararaks S. Malaysia’s Health Systems Response to COVID-19. Int J Environ Res Public Health. 2021 Oct 22;18(21):11109. doi: 10.3390/ijerph182111109. PMID: 34769629; PMCID: PMC8583455.

Hashim, J. H., Adman, M. A., Hashim, Z., Mohd Radi, M. F., & Kwan, S. C. (2021). COVID-19 Epidemic in Malaysia: Epidemic Progression, Challenges, and Response. Frontiers in Public Health, 9, 247. https://doi.org/10.3389/FPUBH.2021.560592/BIBTEX

Jamaluddin, F., Sheikh Dawood, S. R., Ramli, M. W., & Mohd Som, S. H. (2022). Bouncing back from the pandemic? A psychosocial analysis of older adults in urban areas of Malaysia. Http://Www.Editorialmanager.Com/Cogenthumanities, 9(1). https://doi.org/10.1080/23311983.2021.1996045

Last updated: February 17th, 2022   Contributors: Daisy Pharoah  |  

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

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

References

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

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

Last updated: February 13th, 2022

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

England (UK)

In response to the COVID-19, the Government have introduced various public health and economic measures in England to mitigate the impact of the pandemic.

The first wave and first lockdown (January -September 2020)

The first cases of COVID-19 were discovered in January 2020, as a result, in late January and February, the government issued advice for travellers coming from affected countries and contact tracing was introduced. As the COVID-19 spread across England, the government introduced further public restrictions, but it was not until 23rd of March 2020 when the first lockdown was announced, which lasted between March and April 2020. The Coronavirus Act 2020, came into force on the 25th of March 2020 and it granted the devolved governments (England, Wales, Scotland and Northern Ireland) emergency powers (e.g. to suspend public gatherings, order businesses to close, mandate social distancing, close educational institutions etc) and it gave powers to the police to enforce these measures.  Simultaneously, it was announced that economic support has been provided to businesses which suffered due to restrictions and to furlough employees to mitigate the economic impact of the lockdown. The national restrictions introduced during first lockdown were gradually lifted between April  and September 2020, and people were urged to go back to work in offices and restaurants; however regional measures (lockdowns) were introduced due to rises in Covid cases in specific regions (Source: Coronavirus (COVID-19): guidance and support – GOV.UK).

Further waves and lockdowns (October- January 2020)

By the end of September 2020 cases were drastically increasing and on 14 October 2020, the government introduced a three-tier approach to containing the virus across England. In the new approach, restrictions varied locally according to defined tiers (tier 1 restrictions were referred to as ‘Local COVID Alert Level Medium’,  tier 2 as ‘Local COVID Alert Level High’ and tier 3 ‘Local COVID Alert Level Very High’) (Source: Coronavirus, Local COVID-19 Alert Level). As cases continued to rise, a 4-week national lockdown was announced commencing on Nov 5, 2020 (Source: The UK needs a sustainable strategy for COVID-19). A new enhanced tier system was announced in November, which was to be applied following the end of the second lockdown on 2 December.  Following a discovery of a new COVID strain, England entered another national lockdown on the 5th of January 2021.

Vaccination and lifting of national lockdowns

The vaccination programme started in December 2020 and as it expanded, most restrictions were lifted in England on 19 July 2021. Following the discovery and spread of the Omicron variant, in December 2021, government advised people to work from home advice and mandatory face masks in certain settings were introduced.

Living with COVID- 19 (February 2022)

On the 21st February 2022 the government announced that all COVID regulations, including those that mandate lockdown and require people to self-isolate if they test positive, will be removed from the 24th of February, 2022. The plan is outlined in the “Living with Covid 19” report.  Although those who test positive and their close contacts (including those who are unvaccinated) will no longer be required by law to self-isolate, the advise still is to isolate for five days and avoid contact with vulnerable people. Financial support for people who are self-isolating will also come to an end, although statutory support due to illness will be available. From April 1, when the general public will no longer be able to access free COVID-19 tests (Source: Living with Covid 19).

Last updated: March 24th, 2022   Contributors: Joanna Marczak  |  

Scotland (UK)

First wave and lockdown

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.

Vaccination

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. By the 15th May, 66.6% of eligible Scots had received their first dose of the COVID-19 vaccination.

Second lockdown

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.

Level 0 and booster vaccinations

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: March 24th, 2022   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: March 3rd, 2022

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

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

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

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

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

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

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

References:

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

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

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

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

Last updated: May 25th, 2023

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.

Pandemic Governance: Perceptions of Care Home Managers

Authors of a study published in February 2021 interviewed 10 managers of care homes in the East Midlands of England, asking them about their experiences of the pandemic from a structured organisational perspective. Results highlighted that the care sector was placed in considerable jeopardy by the organised responses to the pandemic, in part because those responsible for pandemic response were insufficiently expert in the way that care is delivered in care homes. For example, when central and local government increased the formal reporting requirements placed on care homes (albeit to better understand their needs), efforts were duplicated for staff who were already overstretched – which risked compromised care for residents. Control over pandemic response was also taken away from care home managers – who were normally quite competent at managing the supply chain – when PPE supplies were centralised. Overall, participants in the study felt that care homes were not adequately considered by those making and delivering policy (Marshall et al., 2021).

Pandemic Governance: Experiences of Care Home Staff

Care home-specific guidance was scant during the early stages of the pandemic. This was highlighted in a study by Spilsbury et al. (2021), who analysed the contents of a WhatsApp group to capture the nature of uncertainties and organisational questions expressed by members. The self-formed WhatsApp group was comprised of 250 care home staff in the early stages of the pandemic to facilitate peer-support and information-sharing. Results of the study reveal that staff faced a range of uncertainties; in particular, uncertainties around symptoms and treatment, prevention and control, maintaining an effective workforce, and maintaining effective care. Importantly, just under a third of these (28%) were fact-based and could have been easily resolved through unambiguous and efficient signposting to guidance. The study illustrates that the basic information needs of care home staff were not satisfied in the early stages of the pandemic . This sits in contrast to the proliferation of – sometimes conflicting – guidance during the later stages of the pandemic (Hinsliff-Smith et al., 2020).

Pandemic Governance: Impact on Mental Health

Nyashanu et al. (2020) collected data through interviews with forty frontline healthcare workers from nursing homes (n = 20) and domiciliary care agencies (n = 20) in the English Midlands in the early phase of the pandemic to explore triggers of mental health problems. One of the key anxiety-inducing triggers that they found was a lack of guidance from central government. Participants felt that improved guidance was crucial, especially given the ever-changing information that was coming out about the virus.

References:

Hinsliff-Smith, K., Gordon, A., Devi, R., & Goodman, C. (2020). The COVID-19 Pandemic in UK Care Homes – Revealing the Cracks in the System. The Journal of Nursing Home Research, 6, 58–60. https://doi.org/10.14283/JNHRS.2020.17

Marshall, F., Gordon, A., Gladman, J. R. F., & Bishop, S. (2021). Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study. BMC Geriatrics, 21(1). https://doi.org/10.1186/S12877-021-02053-9

Nyashanu, M., Pfende, F., & Ekpenyong, M. S. (2020). Triggers of mental health problems among frontline healthcare workers during the COVID-19 pandemic in private care homes and domiciliary care agencies: Lived experiences of care workers in the Midlands region, UK. Health & Social Care in the Community. https://doi.org/10.1111/HSC.13204

Spilsbury, K., Devi, R., Griffiths, A., Akrill, C., Astle, A., Goodman, C., Gordon, A., Hanratty, B., Hodkinson, P., Marshall, F., Meyer, J., & Thompson, C. (2021). SEeking AnsweRs for Care Homes during the COVID-19 pandemic (COVID SEARCH). Age and Ageing, 50(2), 335–340. https://doi.org/10.1093/AGEING/AFAA201

Last updated: March 24th, 2022   Contributors: Daisy Pharoah  |  

Scotland (UK)

Health Protection Scotland (HPS) has published specific guidance for infection prevention and control in social or community care and residential settings for frail people and those with complex needs. In addition the Chief Medical Officer has published specific advice about visitors and admissions to care homes (Sources: GOV.SCOT; gov.scot.1; gov.scot.2gov.scot.3).

 

Last updated: March 29th, 2022   Contributors: Jenni Burton  |  Elizabeth Lemmon  |  David Henderson  |  David Bell  |  

United Kingdom

Governance: impact on mental health

Respondents across the UK of a survey in early 2020 by The Queen’s Nursing Institute (2020) reported feeling worse (42%) or much worse (15%) in terms in terms of their mental and physical health as a result of working in conditions instigated by the pandemic. A key contributing factor to this was a lack of government support or guidance.

References:

Queen’s Nursing Institute. (2020). The Experience of Care Home Staff During Covid-19. A Survey Report by The QNI International Community Nursing Observatory. July. https://www.qni.org.uk/wp-content/uploads/2020/08/The-Experience-of-Care-Home-Staff-During-Covid-19-2.pdf [accessed 11/10/2020]

Last updated: March 24th, 2022   Contributors: Daisy Pharoah  |  

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

Last updated: May 25th, 2023

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 long-term care largely falls under Länder authority. However, the State Secretary at the Federal Ministry of Health has in some cases sought a moderating role highlighting topics of importance (Die Bevollmächtigte der Bundesregierung für Pflege, n.d.). As the new government discontinued the role of the State Secretary for Care and Nursing, these initiatives have ended by the end of the year 2021. Federal agencies like the Robert Koch Institute have not established LTC-specific taskforces and responsibility for different aspects of long-term care is distributed across the agency.

References

Die Bevollmächtigte der Bundesregierung für Pflege (n.d.) Coronavirus. Available at: https://www.pflegebevollmaechtigte.de/nws-zum-Coronavirus.html (Accessed 11 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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

The National Board of Health and Welfare (NBHW) has gradually been assigned new tasks and roles that are handled by a special group that support the regions and municipalities in their work with COVID-19 (Johansson and Schon, 2020).

References

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

Last updated: February 12th, 2022

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 (DHSC, 2020). 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.

References:

DHSC (2020). Social Care Sector COVID-19 Support Taskforce: final report, advice and recommendations. Report, Retrieved from Social Care Sector COVID-19 Support Taskforce. Accessed on 15/03/2022

DHSC (2020). National action plan to further support adult social care sector. Press Release. Retrieved from https://www.gov.uk/government/news/national-action-plan-to-further-support-adult-social-care-sector. Accessed on 15/03/2022

DHSC (2021). Coronavirus (COVID-19): care home support package.  DHSC Guidance. Retrieved from https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-care-homes/coronavirus-covid-19-care-home-support-package

Last updated: March 15th, 2022   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: May 25th, 2023

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 system in the community) and the long-term care system, operate independently of each other. However, community care providers also provide medical care prescribed by family physicians. No formal coordination between the two systems 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 (Lorenz-Dant, 2020).

References

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  

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  |  

Malaysia

Throughout the pandemic, officials from the Department of Social Welfare and Ministry of Health have worked closely with academic, civil society groups, and care home representatives have worked together closely together to facilitate good care (Hasmuk et al., 2020).

References:

Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST (2020) The Long-Term Care COVID-19 Situation in Malaysia available at LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 2 October 2020.

Last updated: February 17th, 2022

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

There are examples of how, from the initial days of the pandemic, some hospitals who had existing arrangements to support local care homes organized teams to liaise and support them in dealing with COVID-19. For example Saez and Arredondo (2021) describe how a team formed by a geriatritian, two nurses, a registrar and a physiotherapist supported four care homes in their area during the first months of the pandemic, with support ranging from phone consultations to provision of training, medications, tests and Personal Protection Equipment.

References:

Sáez-López P, Arredondo-Provecho AB. (2021) Experiencia de colaboración entre hospital y centros sociosanitarios para la atención de pacientes con COVID-19. Rev Esp Salud Pública. 95: 14 de abril e202104053.

Last updated: February 22nd, 2022

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 (DHSC) (2020) 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.

References:

DHSC (2020). Novel coronavirus (COVID-19) standard operating procedure: running a medicines re-use scheme in a care home or hospice setting. Accessed on 15/03/2022

Hodgson, H. et al. (2020). Adult social care and COVID-19: Assessing the impact on social care users and staff in England so far. The Health Foundation briefing. Accessed on 15/03/2022

 

Last updated: March 15th, 2022   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).

Last updated: March 24th, 2022   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

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

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

Last updated: May 25th, 2023

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

On December 2, 2020, the Territorial Council of Social Services and the System for Autonomy and Dependency Care, agreed to prepare and publish weekly statistics and reports regarding the situation of residential centres during the Covid-19 pandemic.

The report is published on the Institute for the Elderly and Social Services (IMSERSO) website, and is prepared with each autonomous communities aggregate data concerning the situation of residential centres in their territory. The report includes information on residential centres for the elderly (R1), residential centres for people with disabilities (R2) and other permanent social services accommodation for both elderly and disabled people (R3).

The collection and systematization of statistics is conducted by IMSERSO, the Ministry of Health’s Coordination Centre for Health Alerts and Emergencies (CCAES) and the Ministry of Science and Innovation’s Institute of Health Carlos III (ISCIII). Data is submitted by ISCIII for weekly updates which can be found at https://covid19-country-overviews.ecdc.europa.eu/.

The data is always provisional and is updated weekly by the Autonomous Communities, and consequently, the structure of the report may vary. The report can be found on the IMSERSO website, and it is also possible to download the data that forms each weekly report.

The reports’ meet the parameters of the European Centre for Disease Prevention and Control’s (ECDC) protocol for epidemiological surveillance of residential centres in EU / EEA countries. The ECDC’s metadata has been implemented into the European Surveillance system (TESSy) since January 2021.

 

Last updated: July 4th, 2022   Contributors: Sara Ulla Díez  |  

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 (Hanratty et al. 2020). 

References:

Hanratty B. et al. (2020) Covid-19 and lack of linked datasets for care homes. BMJ 2020369 doi: https://doi.org/10.1136/bmj.m2463

Last updated: March 24th, 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: March 24th, 2022   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

Support with loss of income for residential care facilities

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 (Lorenz-Dant, 2020; Bundesministerium für Gesundheit, 2020).

Support for people where professional care was unavailable

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 (Lorenz-Dant, 2020).

Bonus payment for LTC workers & limitations

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  (Stolle et al., 2020).

Critique of limited focus on support for people with disabilities

In addition, there has been criticism regarding the limited focus of COVID-19 social protection packages on people with disabilities (Sozialverband VDK, 2020).

References

Bundesministerium für Gesundheit (2020) Bundesrat stimmt Gesetzespaketen zur Unterstützung des Gesundheitswesens bei der Bewältigung der Corona-Epidemie zu. Available at: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html (Accessed 3 February 2022).

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Sozialverband VDK (2020) Menschen mit Behinderung und Corona. Available at: https://www.vdk.de/deutschland/pages/presse/presse-statement/79041/behinderung_corona (Accessed 3 February 2022).

Stolle, C., Schmidt, A., Domhoff, D. et al. Bedarfe der Langzeitpflege in der COVID-19-Pandemie. Z Gerontol Geriat 53, 788–795 (2020). https://doi.org/10.1007/s00391-020-01801-7.

Last updated: February 13th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

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 Department of Health and Social Care (DHSC) (2020) published the action plan for social care, 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 (Rajan et al. 2020).

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, 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 published a blog post 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’ press release 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.

References:

DHSC (2020). COVID-19: Our Action Plan for Adult Social Care. Retrieved from: publishing.service.gov.uk; Accessed on 15/03/2022

Rajan, S, et al.. (2020). Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic? Journal of Long-Term Care, pp. 185–195. DOI: https://doi.org/10.31389/jltc.53

Oung, C. at al. (2020). What are carers in each of the four UK countries entitled to? Nuffield Trust blog post. Retrieved from: The Nuffield Trust ; Accessed on 15/03/2022

Additional sources: 

About the Adult Social Care Infection Control Fund – GOV.UK (www.gov.uk)

Support for care homes: letter from the Minister of State for Care (publishing.service.gov.uk)

Workforce Capacity Fund for adult social care – GOV.UK (www.gov.uk)

Last updated: March 15th, 2022   Contributors: William Byrd  |  

Vietnam

In response to the pandemic, the government introduced various policies to support the population. One of these, Resolution 42 (passed on 09-04-21) applied to people whose income decreased significantly or who could not maintain their minimum living standard due to the pandemic. However, there were reports that significant barriers were faced by many trying to access this support, including people with disabilities and their carers. Resolution 42 also applied to elderly people over the age of 80 (identified as part of the Social Protection beneficiaries). Few barriers were reported in terms of access for this group, mainly because their information is always available and accurate (source: careevaluations.org report).

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

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

Australia

The Australian Government’s Aged Care Quality and Safety Commission is responsible for providing COVID-19 information and recommendations to aged care providers and facilities. However, state and territory health agencies also have the ability to implement policies in the aged care sector. With both the federal, state, and territorial governments having some oversight over aged care providers, there is a fragmentation of power leading to ineffective and often confusing protocols (source: Aged Care and COVID-19 report).

Last updated: December 22nd, 2021

British Columbia (Canada)

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

Last updated: March 3rd, 2022

Denmark

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

Last updated: September 10th, 2021

Germany

LTC quality checks and necessary patient to staff ratios were temporarily suspended in March 2020 but supposed to resume in October 2020 (source: https://md-bund.de/aktuell/aktuelle-meldungen/corona-qualitaetspruefungen-in-pflegeeinrichtungen-ausgesetzt.html) Due to increased infection risk this date was finally pushed to March 2021 (Source: https://md-bund.de/aktuell/aktuelle-meldungen/regelpruefungen-und-persoenliche-pflegebegutachtungen-starten-im-maerz.html)  Quality checks were only undertaken if there was reason to suspect that quality of care was not maintained.

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

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Israel

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

Last updated: September 10th, 2021

Italy

LTC oversight and regulation is part of regional functions and did not changed during the pandemic. No specific intervention has been implemented during 2020 or 2021 and the governance model remained unchanged.

Last updated: December 3rd, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

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

Last updated: September 10th, 2021

Republic of Korea

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

Last updated: September 10th, 2021

Spain

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

Last updated: September 10th, 2021

Sweden

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

Last updated: November 30th, 2021

England (UK)

The Coronavirus Act (March 25 and renewed on September 30, 2020) included provision to relax the responsibilities of local authorities under the Care Act 2014 to streamline their services in case of workforce shortages or increased demand. The Act also enabled rapid discharge of patients from hospital by allowing assessments to be delayed. There was concern that the Care Act Easements included in the Coronavirus Act would be widely used to reduce care packages but only a small number of councils utilised them. As of November 2020, the Care Quality Commission (CQC) reported that no local authorities were currently using Care Act Easements.

The CQC interrupted routine inspections on March 16, 2020. In May 2020, the CQC began to implement an Emergency Support Framework setting out its approach to regulation during COVID-19. This involved suspending routine inspections of services and instead using and sharing information to target support where it’s needed and taking action to keep people safe and protect their human rights. The CQC are now starting to resume some inspections in 300 random homes in relation to management of the pandemic, examining four key areas; safe care and treatment; staffing arrangements; protection from abuse; assurance processes monitoring and risk management. Much will be conducted remotely and in person inspections will take place under exceptional circumstances only.

Published on November 3, 2021, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. During this period, the CQC will continue to apply a risk-based approach to inspection, using information from a range of sources, including from people using services and their families, to shape their inspection activity. Additionally, they will ensure that all inspections of care providers consider how well services are managing infection prevention and control, taking swift regulatory action where provider-level performance requires rapid improvement. This will include monitoring compliance with vaccinations as a condition of deployment within its inspection activity.

Additional Sources:

Dunn, P. et al. (2020). Adult social care and COVID-19: Assessing the policy response in England so far. Health Foundation briefing

Eight councils have triggered Care Act duty moratorium in month since emergency law came into force – Community Care

Joint statement on our regulatory approach during the coronavirus pandemic | Care Quality Commission (cqc.org.uk)

Routine inspections suspended in response to coronavirus outbreak | Care Quality Commission (cqc.org.uk)

Last updated: March 15th, 2022   Contributors: William Byrd  |  

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

Overview

People working in the long-term care sector, particularly in care homes, have had a very high exposure to COVID-19 infections, experiencing higher mortality than people working in other sectors, as well as severe impacts in terms of their mental health and wellbeing (see section 2.08). In response, countries have adopted measures to mitigate these impacts. The emphasis has been primarily in reducing their risk of infection and that they transmit the infection to the people they support, and to ensure that they can continue to work. There seems to have been much less emphasis (with some exceptions) in providing support to mitigate the negative impacts of the pandemic on the workers themselves.

An important context to this is that there were long-standing workforce shortages in the long-term care sector before the pandemic in many countries (see section 1.11). This has been identified as a factor that has severely hampered the ability of the sector to respond to the additional challenges posed by the pandemic and to maintain care standards (see for example Andersen et al.). In some occasions, when high numbers of staff became ill or needed to self-isolate, this has led to care failures, with examples of care homes that became completely overwhelmed and unable to function due to lack of staff.

This section provides examples of the strategies adopted in different countries to support care staff and ensure workforce availability throughout the pandemic. We distinguish between five main types of measures: measures that aim to reduce the risk of infection among care staff and support them in continuing to work, measures that aim to address stresses arising from the pandemic, measures to monitor the situation, measures to increase the pool of workers and measures to support providers experiencing acute workforce shortages.

Measures to reduce the risk of infection among care staff and support them in continuing to work
Reducing risk of infection in the workplace

Access to adequate Personal Protection Equipment, good Infection Prevention and Control practices, testing, single site working and ventilation are key to reduce risk of infection both for staff working in Long-Term Care and for people who use care services.

Reducing risk that staff acquire infections in the community and bring them into care settings

A number of countries requested that staff remain onsite in LTCFs for shifts lasting a few weeks and then quarantine for a week before returning to work (S.Korea, Turkey).

Measures to make it easier for staff to continue to work

Several countries rolled out support services for their care staff. Provisions for childcare prioritized for LTC staff were provided in Denmark, Finland, and Germany. Food services were provided to staff in Germany and Finland.

Measures that aim to address negative impacts from the pandemic on LTC staff
Supporting staff who have to quarantine

The precarious working conditions of care staff mean that in many countries they had no access to sick pay if they tested positive, or had to go without wages if they had to self-isolate due to being a close contact of someone who had tested positive. In Denmark COVID-19 has been recognised as a work-related injury, giving the person an entitlement to claim for compensation.

Additionally, accommodation for quarantine for care workers who did not want to quarantine with family was provided in Germany and S.Korea.

One-off “bonus” payments

There are several examples of countries offering one-off or intermittent “bonus” payments to encourage workers to stay in the sector (see for example Austria, Germany, Finland, Hong Kong and Canada, below) and compensate for the additional work and stress during the pandemic.

Measures to increase the pool of workers
Measures to make employment in the sector more attractive

Some countries have adopted longer-term measures to address pay and conditions (see section 4.05. for reforms to address LTC workforce recruitment, training, pay and conditions). In the United States pay for workers in nursing homes increased by 14.7% between February 2020 and October 2021.

In British Columbia, where care home workers were restricted to working in a single site, all employees received a common hourly wage regardless or their facility and employer.

Recruitment of staff who are new to the sector:

Several countries sought to recruit students (Australia – although tricky – given lack of training, Netherlands), retirees (Netherlands), people who were not able to work during lockdowns – flight attendants, restaurant workers (Sweden), voluntary sector (S.Korea, Israel). Some countries, like Australia, used online platforms to support the recruitment drive.

There have been concerns that staff recruited in this way did not have appropriate training and experience.

Increased involvement of family carers in formal care:

South Korea, for example, increased  support to family carers who were already very involved in care provision.

Re-deployment of staff from low infection areas to high infection areas

There are examples of this in S.Korea and among large care providers in Australia.

Relaxation of requirements in terms of qualifications, visa, etc.

For example in Germany and Turkey.

Information systems to monitor the staffing situation

Denmark and Sweden added the reporting of COVID-19 infections to the list of workplace injuries to better monitor the situation (Denmark, Sweden).

Several countries where Ministries of Health did not previously have oversight over the care sector increased their oversight to better document and understand who is working in LTC and where they are working (Canada).

Measures to support care providers facing acute staff shortages:

As well as financial support, in many countries there are rapid response teams or “strike teams” available to be deployed to care homes that are experiencing large outbreaks or severe workforce shortages (see section 3.06.01).

References:

Andersen L.E., Tripp L., Perz J.F., Stone N.D., Viall A.H., Ling S.M., Fleisher L.A. (2021) Protecting Nursing Home Residents from Covid-19: Federal Strike Team Findings and Lessons Learned. NEJM Catalyst. DOI: 10.1056/CAT.21.0144

Australia

Recruitment drives

In April 2020, the Australian government announced the use of an online platform, Mable, which recruits workers in nursing, allied health, personal care, domestic assistance, and social support service. While Mable generates additional staff in the event of staffing shortages, concerns were raised about the inexperience of surge staff and their ability to provide adequate care. International students were allowed to work for up to 40 hours. The maximum number of hours worked was increased in order to better supply the health care workforce (sources: Charlesworth and Low, 2020; DoH).

Due to surge of Omicron, is also stipulated that to the extent reasonably possible, personal care workers must not provide personal care to residents at more than one aged care facility  in South Australia.

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 19th, 2022

Austria

Austria implemented measures that required its hospitals to offer support to care homes in the form of personnel, expertise, and equipment (source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

In Austria almost 33,000 people with LTC needs receive support from 66,000 ‘personal’ migrant live-in carers. Closed borders at the beginning of the pandemic posed challenges. Two provinces charted flights to bring live-in carers from Eastern European countries back to Austria. Carers were quarantined for two weeks (without income and having to contribute to accommodation). Carers who decided to stay were offered a €500 bonus. A hotline helped to coordinate 24-hour care. Considerable efforts were made to maintain the live-in model. Care workers experienced challenges with complex paperwork (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

A panel survey of over 20,000 Austrian employees conducted in May 2020 found that 46% of care professionals reported their job to be ‘mentally stressful’, while this was only the case for 11% in other jobs. In addition, only 38% of carer workers think they will reach pension age in their sector (versus 61% of other professions). During the pandemic, one third of care workers reported ‘stress due to time pressure and changing labour processes’ (source: https://ltccovid.org/2020/11/27/the-second-wave-has-hit-austria-harder-also-in-care-homes/).

Last updated: January 6th, 2022

British Columbia (Canada)

A single site order was introduced on March 25, 2020, meaning that workers in British Columbia’s LTC and assisted-living facilities were limited to working in a single facility. On March 26, 2020, LTC operators were asked to provide personal and employment information, including name, contact information, and Social Insurance Numbers for all staff to the ministry to support decisions about the allocation of staff among facilities. On April 10, 2020, all employees within the scope of the Single Site Order would receive a common hourly wage regardless of their facility and employer. On April 15, 2020, Regional Health Boards were ordered to establish a working group to make recommendations to their Medical Health Officer about the assignment of staff because staffing shortages became a bigger issue following the Single Site Order (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: March 3rd, 2022

Denmark

There is ongoing work to try to collect statistics on the number of nursing home staff infected with COVID-19. In the meantime, the number of care staff reporting the disease as a work-related injury gives an indication of the situation. On April 24, 2020, a new guideline was published that underlined that COVID-19 would be regarded as a work-related injury if the person had been exposed to the disease and was tested positive. This gives the person an entitlement to claim for workers’ compensation. As of May 21, 242 people had reported COVID-19 as a work-related injury, and of these 42 people were employed in a nursing home. The majority of all cases relate specifically to the disease, while 9% relate to skin diseases caused by wearing Personal Protection Equipment (PPE) (Source: https://www.aes.dk/da/Temaer/COVID-19.aspx).

Regarding measures to increase or maintain the availability of health workers, emergency child care facilities are provided (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).  Denmark also provided financial help to LTC facilities to recruit unemployed or former LTC workers, as well as providing financial help to LTC facilities to recruit LTC students (Source: OECD paper).

Last updated: January 26th, 2022   Contributors: Joanna Marczak  |  

Finland

In Finland, retired staff and students that do not fall into high risk groups have been recruited to maintain staffing levels (Source: https://www.lse.ac.uk/lse-health/assets/documents/eurohealth/issues/eurohealth-v26n2.pdf).

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

France

High levels of staff sickness were experienced, and as a result, various platforms for redeployment of staff were put in place. Regional platforms put in place by the regional authorities (ARS) were largely more successful than the national platform, which only reached 62 care homes (Sources: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf; https://renfortrh.solidarites-sante.gouv.fr/).

Almost all local authorities gave domiciliary care workers a Covid bonus going up to 1,000€ in late 2020. Staff working in long-term care facilities were also entitled to a bonus of up to 1,500€.

More recently, the government has used ‘Intermediary Associations’ that are responsible for the reintegration of vulnerable people (out of work), to support social care workers, including in infection control and food preparation etc (Source: https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/crise-covid-19-le-gouvernement-soutient-les-associations-intermediaires-en).

Last updated: January 12th, 2022   Contributors: Camille Oung  |  Joanna Marczak  |  

Germany

Care strengthening bill

In January 2019, the care strengthening bill was enacted which means that there is active encouragement to increase the care workforce (Source: https://www.bundesgesundheitsministerium.de/sofortprogramm-pflege.html). This bill was developed in 2018 (Source: https://www.vdek.com/politik/gesetze/wahlperiode_19.html#ppsg). This does not solve the problem that there are not enough people available and willing to work in LTC.

Increase of minimum wage for care workers & ‘pandemic-bonus’

In April 2020, the German government announced a stepwise increase of the minimum wage for care workers as well as additional paid leave. In addition, care workers in Germany received a one-off ‘pandemic-bonus’ of up to €1,000 as part of their July 2020 pay. In some states the bonus was topped-up to €1,500 (Lorenz-Dant, 2020). In February 2021 the Federal Minister of Health announced a planned bonus for hospital staff. There are demands to also provide a bonus to LTC workers (Sources: https://www.aerztezeitung.de/Politik/Spahn-plant-weitere-Corona-Praemie-fuer-Klinikmitarbeiter-416931.html; https://www.aerzteblatt.de/nachrichten/121022/Deutscher-Pflegerat-will-Coronapraemie-fuer-alle-Pflegekraefte).

Emergency childcare for essential workers

While children of staff working in system relevant jobs (including health and LTC) could access emergency childcare, there have been demands to expand available childcare services to reflect the demands on care workers (Presseportal, 2021; Ministerium für Kultus, Jugend und Sport Baden-Württemberg, 2020).

Financial support towards catering costs

In Bavaria, the cost of catering for staff in health and LTC settings are financially supported (€6.50 per member of staff per day) as a sign of appreciation (Lorenz-Dant, 2020).

Access to regular testing

Following the national testing strategy, care workers should have access to regular testing. Rules vary between federal states, but LTC staff working in residential or domiciliary care settings should be tested regularly (BIVA Pflegeschutzbund, 2022)

Initiatives to recruit care workers

Earlier in the pandemic, the ‘care reserve’ initiative developed across federal states and separately in some federal states allowed people with a qualification to register. This provided an opportunity to recruit staff if there was a shortage due to infection. There have also been movements in some federal states to prioritise care-related professions when applying for permission to work in Germany and to financially incentivise training to become a care assistant (Pflegeassistenz) (Lorenz-Dant, 2020). In addition, some staffing rules and operational frameworks were relaxed (Langins et al., 2020).

References

BIVA Pflegeschutzbund (2022) Besuchseinschränkungen in Alten- und Pflegeheimen wegen Corona. Available at: https://www.biva.de/corona-im-pflegeheim/besuchseinschraenkungen-in-alten-und-pflegeheimen-wegen-corona/#bw

Langins, M., Curry, N., Lorenz-Dant, K., Comas-Herrera, A. & Rajan, S. (2020) ‘The COVID-19 Pandemic and Long-Term Care: What can we learn from the first wave about how to protect care homes?’ Eurohealth, 26(2). Available at: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Ministerium für Kultus, Jugend und Sport Baden-Württemberg (2020) Notbetreuung wird vom 27. April 2020 an erweitert. Available at: https://km-bw.de/,Lde/Startseite/Service/2020+04+20+Notbetreuung+wird+vom+27_+April+2020+an+erweitert (Accessed 3 February 2020).

Presseportal (2021) Pflegekräfte stärken bedeutet auch Kinderbetreuung sichern bpa fordert bessere Notbetreuungsangebote für Kinder von Pflegenden in Nordrhein-Westfalen. Available at: https://www.presseportal.de/pm/17920/4816116 (Accessed 3 February 2022)

Last updated: February 12th, 2022

Hong Kong (China)

A survey by the Hong Kong Social Workers and Employment Union in February 2020 showed that about 10% of care workers had to take unpaid leave or experienced pay deductions. The Social Welfare Department responded with a number of measures. These measures included a special allowance for workforce support. This means that subsidised residential and domiciliary care services receive a ‘one-off special allowance for workforce support’ and to ‘maintain daily operations in the event of COVID-19 related staff absences. Costs for this measure were about 130 million Hong Kong Dollars (HKD). In addition, social care providers have received a special allowance to pay the staff in 745 subsidised homes an additional 10% of their monthly salary (capped at 4,000 HKD) for at least 4 months. The additional salary was reserved for staff working during the epidemic. The cost of this measure amounts to approximately 208 million HKD (Source: https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 10th, 2021

Ireland

The Health Information and Quality Authority provided a ‘Regulatory Assessment Framework of the preparedness of designated centres for older people for a COVID-19 outbreak’ in mid-April 2020. This framework was supposed to help care settings to prepare for a potential COVID-19 outbreak and to develop contingency plans. In Ireland, an agreement was put in place that enabled the Health Services Executive (HSE) to redeploy HSE staff to private nursing homes on a voluntary basis. (source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Ireland launched recruitment campaigns to attract newcomers and former staff to the sector. Efforts were made to reduce staff working across different care settings. The HSE could support staff with alternative accommodation and transport to facilitate this (source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: January 6th, 2022

Israel

Reports of increased volunteerism to assist NGOs and care sector staff are available, although there is limited information on formal processes (source: Haaretz).

In Israel, the Ministry of Health made special teams available for periods of 7 to 14 days to support residential care settings that were acutely short-staffed, and a 24 hour call center was established to support LTC facility managers with medical and management advice (source: EuroHealth, 2020)

The Government also enacted emergency measures to ensure the availability of migrant home care workers in Israel. As of July 20th, 2021, the work permit of 3,000 migrant home care workers was extended to ensure continued care for older people during the pandemic (source: The Marker).

This regulatory ease did not solve the shortage of foreign workers in the field of LTC because this guideline does not apply to a foreign worker in case the care receiver named on the working permit dies. In this case, the work visa of the foreign worker is revoked, denying the legal frame to go work for another patient. At the same time, the state did not approve the entry of new foreign workers into the country, so the shortage of foreign workers (which existed before the epidemic) only worsened. The lack of thousands of foreign workers impacted the demanded wages of the caregivers, and families report wage demands that may reach as much as NIS 15,000 a month, which has made the care impossible for many families (source: The Marker).

Last updated: January 12th, 2022   Contributors: Shoshana Lauter  |  LIAT AYALON  |  Joanna Marczak  |  

Italy

During the first and second waves of the pandemic Long Term Care Facilities experienced a severe shortage of nurses due to both the effect of Covid-19 on the overall population and specific dynamics of LTC sector (high level of burnout, low commitment, preference to work in other care settings when possible). No support was provided in this respect to care providers from public authorities, and single institutions implemented corporate actions to try to guarantee care standards (i.e. transfer of care workers from one unit to another, transfer from different regions, collaboration with other care providers, relocation from care settings closed during lockdown).

With respect to measures addressed to staff in the LTC sector, it is noted that Regions have mainly focused on giving very operational and peremptory indications on the use of PPE, without giving space to training and emergency management preparation practices. There is variability between more general indications provided to the staff of the organisation (e.g. Piedmont) and cases in which the indications have been provided in detail for the individual professional figures (e.g. Tuscany). Once again, the issue of training of care workers and not of care homes has been delegated to the local level and managed by each structure or in conjunction with the healthcare companies. Also in this case, most attention was on the issues of isolation and containment of cases both by limiting movement and through the use of devices, without due attention to what the staff of the facilities could and should have done during the emergency or to any greater or different need for staff.

Generally speaking, this situation negatively impacted the wellbeing and job satisfaction of care workers. Moreover, in 2021, the Italian NHS and LTC sector in facing a massive shortage of care workers due to lack of vocational training and the absence of professionals (source: Amnesty International Italy, 2021).

Sources:

Amnesty International Italy (2021), Italy: Muzzled and unheard in the pandemic: Urgent need to address concerns of care and health workers in Italy

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

Japan

A recent study by the OECD, published in October 2021, reported that during the first wave of the Covid-19 pandemic, Japan not only prolonged LTC foreign workers’ contracts and visas, but it also offered them special rewards. Moreover, Japan assisted LTC workers’ mental well-being while providing them free services for psychological support.

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: November 24th, 2021

Netherlands

On March 16, 2020, the Dutch Youth and Health Care Inspectorate allowed nursing home managers to recruit personnel beyond their traditional pool of employees, enabling them to hire personnel such as medical students (Source: https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf). Several initiatives have been set up to increase the number of staff working in stretched LTC settings, including an IT platform “Extra Hands for Healthcare” to match existing healthcare staff with employers. This included a campaign to recruit healthcare personnel that had left the sector or retired (called “Duty calls”), and a rapid training scheme for those with no previous healthcare training (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: January 26th, 2022   Contributors: Joanna Marczak  |  

Norway

Since the start of Covid-19, Norway financially contributed to the recruitment not only of numerous LTC workers, but also of students, and former LTC workers. Moreover, Norway adopted additional emergency strategies as it prolonged LTC foreign workers’ visas and modified the allowance of working hours for LTC staff members within their facilities.

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.

Last updated: January 6th, 2022   Contributors: Elisa Aguzzoli  |  

Poland

During the pandemic, the central government increased the remuneration of medical and nursing staff in LTC sector, there was also an increase in sickness benefit of medical and care employees during quarantine and isolation in response to high infection risk they face in every-day work ( (source: Ageing policies – access to services in different EU Member States). To address workforce challenges which were brought to attention during the pandemic, experts recommended investment in the training and employment of nursing and care staff. For example, it was recommended that additional educational activities should be offered to trainees (e.g. trainee nurses in LTC), taking into account the apprenticeship of foreign workers. For current employees, it was recommended that training is provided regarding the application of new technologies in LTC sector, as well training to assure the necessary minimum knowledge in the field of psychology, public health (disease prevention), medicine and digitization. Recommendations were also issued to revise the standards, working conditions and increasing wages in LTC sector, to incentivise and address workforce shortages in LTC sector (source: Alert Zdrowotny 3).

In response to the pandemic, local authorities introduced regulations restricting employment of LTC staff to a single facility, and made efforts to enable isolation of staff and residents within the facility (source: ESPN Flash Report 2020/43).

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

Republic of Korea

There have been multiple measures to support care sector staff and ensure workforce availability in South Korea.

In order to minimize the risk of care workers to be infected with COVID-19, care workers who were considered to have been in close contact with cases were quarantined at home, whilst those who continued to work were temporally housed in a hotel, or voluntarily moved into the LTC facility. In some facilities a quarantine was upheld for 14 days during which nurses and nurse assistants voluntarily agreed to be quarantined in the LTC facility to continue resident care.

There were steps to address worker shortages by seeking volunteers and paying family carers, and, in areas of high outbreaks, healthcare workers were directed to sites with large clusters of infections, for example, an additional 2,400 health workers were recruited in Daegu alone.

A study by the OECD highlights that health workers in Korea were rewarded with a special bonus, and received a permanent increase in their salaries. LTC workers who showed mild Covid-19 symptoms also received paid leave which was often approved by the facility’s manager. Korea has defined and categorized Covid-19 as an occupational disease.

The Korean government does not appear to have offered a relief plan for workers who do not have employment insurance. They comprise 6.8 million people, and more than half are women, and allegedly many care workers belong to this group (Source: ).

Sources:

Last updated: November 25th, 2021   Contributors: Elisa Aguzzoli  |  

Singapore

Singapore recognised the limitations of their lean workforce in residential LTC and the need to protect it. ‘The implementation of split zones and full contact precautions’ protected facilities from acute staff shortages.

To ensure the functioning of split zones, housing was organised for LTC workers who shared accommodation with staff assigned to different zones, workers in different (health and LTC) care settings, or in dormitories that did not allow for safe distancing. Many care workers working in nursing homes lived in hotels and serviced apartments, others lived on-site (adhering to split zone arrangements) between April 7 and June 1, 2020, during the Circuit Break period. The government paid for meal delivery and dedicated transportation between home and work. Health and LTC workers that were moved into temporary accommodations received $500 to facilitate the transition.

In addition to public recognition, the workforces received care packages and message of support from care facilities and could access ‘professional counselling and emotional support services’ (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: January 6th, 2022

Slovenia

In Slovenia, medical teams were deployed to residential care settings if the regular staff became exhausted or overwhelmed (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: January 12th, 2022

Spain

In response to concerns about availability staffing linked to the spread of the Omicron variant, on the 30th December 2021 the Territorial Council for Social Services approved a provisional relaxation of the criteria required to recruit social care staff.

Last updated: January 13th, 2022   Contributors: Sara Ulla Díez  |  

Sweden

Staff shortages due to employees being on sick leave or in self-isolation led to a high use of casual workers, with little or no formal training.  Due to large numbers of temporary care staff with limited or no training in the sector, the government initiated a training program for 10,000 such workers. The state covers the expenses for the municipalities and the workers keep their ordinary pay while in training. To be eligible for the state subsidy, the municipalities have to offer a permanent position to workers who successfully have finished the course. In March 2020, the government abolished the requirement for a medical certificate when on sick leave for the first 14 days. In some municipalities, e.g. in Stockholm, flight attendants, restaurant staff, and other occupational groups who became unemployed due to the pandemic were quickly retrained as care assistants to help in municipal LTC and healthcare services (Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

The Government tasked the National Board of Health and Welfare with conducting an information initiative geared towards social services and municipal healthcare staff with the aim of reducing the spread of infection (Source: https://www.government.se/legal-documents/2020/10/dir.-202074/). The Corona Commission points out that an opportunity has been created for people who contracted COVID-19 when working in or being trained in healthcare facilities or in other handling of an infectious person to receive payments from work-related injury insurance (Source: https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf).

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

Turkey

Case Study of a Care Home in Istanbul (Özten et al, 2021)

A report describes successful pandemic response measures in a nursing home in Istanbul (one of the biggest in the country). Among other strict preventative measures to protect staff and residents, were the implementation of a 15-day shift plan, regular PCT testing and temperature checks, restricted access for staff to different areas of the building, and an assigned quarantine ward for any residents with suspicious symptoms.

Psychosocial support was also offered to staff, in order to mitigate stress and anxiety that may arise from being on-site and away from family for 15 day periods: for example, group communication therapies were offered, and staff were encouraged to use video calling technology to retain contact with their families (Özten et al, 2021)

References:

Özten O, Aytekin Akta? T, Süer H, Do?an H, Üner A, Özp?nar S, Ayy?ld?z Y, Bekta? H, Saka B. 2021. A 15-day Working Shift Prevent the Cross-contamination of Coronavirus Disease-2019 in a Nursing Home in Turkey. Eur J Geriatr Gerontol 2021;3(3):131-133

Last updated: January 26th, 2022   Contributors: Daisy Pharoah  |  

England (UK)

Overview: A Timeline

The social care action plan recognised the urgent need to increase the social care workforce during the pandemic “to cover for those who are not in work, and to relieve the pressure on those that are”. The action plan included an ‘ambition’ to attract 20,000 people into social care over 3 months.

On March 19, 2020, social care staff were designated as ‘key workers’ to enable them to continue to access childcare once schools were closed. On May 6, the government launched a dedicated CARE app to support the social care workforce during COVID-19, offering access to guidance, learning resources, discounts, and other support all in one place.

On May 11, the Department of Health and Social Care (DHSC) published guidance on maintaining the health and wellbeing of the adult social care workforce. This placed the responsibility on employers to check in on team members regularly, especially those who are working remotely. It stated that employers should encourage teams to create a wellness action plan so that employees can identify how to address what keeps individuals mentally well at work. This additionally suggested that employers should encourage those who are identified as being extremely clinically vulnerable to stay at home. Where this is not possible, they should be supported to work in roles or settings that have been assessed as lower risk.

On 15 May, the Government announced a new wellbeing package for social care staff delivered through the CARE app, including two new helplines, led by the Samaritans and Hospice UK. This is intended to help support care staff with their mental health and wellbeing, and support those who have experienced a traumatic death as part of their work.

On October 1, DHSC announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, in particular by helping to reduce the need for staff movements between sites. This includes ensuring that staff who are isolating in line with government guidance receive their normal wages, limiting all staff movement between settings unless necessary, limiting the number of different people from a home care agency visiting a particular individual, limiting or cohorting staff, supporting active recruitment of additional staff, and providing accommodation for staff who proactively choose to stay separate from their families.

On January 17, 2021, DHSC announced a £120 million Workforce Capacity Fund to help local authorities to boost staffing levels. The aim of this is to strengthen social care staff capacity so that safe and continuous care is achieved by all providers of adult social care. This additionally stated that providers should not be deploying people in care homes if these people are being deployed to provide care in other settings, unless in exceptional circumstances. This places the responsibility on local authorities for contacting private providers with excess capacity to redeploy these staff into other settings to best meet workforce demand. This fund can be used to pay overtime rates to encourage staff to work additional shifts, cover childcare costs to allow staff to take on hours they would usually be unable to work, and enable care providers to overstaff at pinch points to lessen the impact of any staff absences should they arise. Additionally, local authorities are responsible for considering whether there are trained individuals who have been made redundant from care providers which have exited the market and so would be able to transition quickly into a new care setting. There may be individuals without care experience who have recently been made redundant and may require support applying to the care sector and training.

On February 9, DHSC announced that the government was asking people to register their interest in taking up short-term paid work in the adult social care sector to meet urgent demand during winter.

On March 3, DHSC published guidance on restricting workforce movement between care settings. This stated that staffing requirements should be planned so that routine movement is not required to maintain safe staffing levels, with mitigations such as exclusivity contracts and block booking used to minimise staff movement where temporary staff are needed. Additionally, should a provider need to deploy an individual between two settings, they should ensure a 10-day interval between the individual attending the two settings. The individual must have a PCR negative test in the 7 days before starting the placement. Additionally, this states that providers should cohort staff to individual groups of residents and ensure staff movement is limited between these groups. Providers should take steps to limit the use of public transport by staff and discourage lift sharing arrangements.

In October 2021 the DHSC launched a national recruitment campaign highlighting the positive aspects of working in the social care sector. There are other measures in place to facilitate rapid recruitment to the sector, such as recruitment guidance and resources by Skill for Care (RecruitmentReady), and free rapid online induction and refresher training.

The Capacity Tracker, a web-based digital insight tool and the Adult Social Care Workforce Dataset are being used to monitor the situation. As of November 2021 the vacancy rate in social care was 9.2%

Published on November 3, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. This will provide £162.5 million through the workforce recruitment and retention fund to support local authorities and providers to recruit and retain sufficient staff over winter, and support growth in workforce capacity of the existing workforce, until 31 March 2022.

The DHSC has made available guidance and resources to support the wellbeing of people working in health and social care, including a collaboration with charities that provide mental health support, and a risk reduction framework for providers to reduce the risk of infection for staff working in social care.

To release the recruitment pressures (old and new pressures stemming from the new wave of Omicron), in December 2021, the government  announced that care workers, care assistants and home care workers will be added to the Shortage Occupation List as part of the health and care visa to make it quicker, cheaper and easier for social care employers to recruit eligible workers to fill employment gaps. The changes are planned to come into effect early 2022, initially for a period of 12 months. The inclusion on the Shortage Occupation List will stipulate an annual salary minimum of £20,480 for carers to qualify for the Health and Care visa and it will allow applicants and their dependents to benefit from fast-track processing, dedicated resources in processing applications and reduced visa fees.

Last updated: March 8th, 2022   Contributors: William Byrd  |  Joanna Marczak  |  Daisy Pharoah  |  

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 states that the government are supporting a national recruitment campaign with a focus on social media and a younger audience, and working to establish minimum terms and conditions for existing staff. A budget of £12 billion, an increase of £7 million on last year, is being provided to support the wellbeing of health and social care staff. This includes targeted support to the primary and community care and social care workforce of £2 million.

A workstream will be developed on the wellbeing of those working in social care/social work as part of the new National Wellbeing Programme to be implemented from autumn 2021. The Workforce Specialist Service, launched in February 2021, also provides tailored, confidential mental health support to regulated staff across the NHS and social care workforces.

Up to £48 million of funding will be made available to enable employers to update the hourly rate of Adult Social Care Staff offering direct care. The funding will enable an increase from at least £9.50 per hour to at least £10.02 per hour, which will take effect from December 1, 2021.

The Social Care Staff Support Fund has been extended to the end of March 2022 to continue to ensure that social care workers who are ill with COVID-19, or self-isolating in line with public health guidance, receive their normal income for that period.

Last updated: March 29th, 2022   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

United Kingdom

Results from a survey collected in early 2020 from 163 care staff across the UK illustrated concerns about workforce shortages and availability have been reported as a major factor for poor mental well-being and a general negative experience of working in care in the early stages of the pandemic. Another cause for stress and anxiety was the increased workload, which is likely to be due to extra measures taken to reduce the spread of the virus and increased staff absences (The Queen’s Nursing Institute, 2020).

References:

Queen’s Nursing Institute. (2020). The Experience of Care Home Staff During Covid-19. A Survey Report by The QNI International Community Nursing Observatory. July. https://www.qni.org.uk/wp-content/uploads/2020/08/The-Experience-of-Care-Home-Staff-During-Covid-19-2.pdf [accessed 11/10/2020]

Last updated: March 24th, 2022   Contributors: Daisy Pharoah  |  

United States

A survey of 11,920 nursing homes (NH) in May 2020 found that 15.9% reported shortages of licensed nurse staff, 18.4% of nurse aides, 2.5% of clinical staff and 9.8% of other staff. The study found that staff shortages were associated with COVID-19 related factors: NHs with any case of COVID-19 among residents or staff were more likely to experience staff shortages. NHs with more supplies of Personal Protection Equipment (PPE) were less likely to report staff shortages. Also, NHs with higher staffing levels (particularly higher ratios of registered nurses) were less likely to report shortages (Xu et al., 2020).

Increased wages

The KFF Health Systems Tracker 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. This is in the context ongoing declines in the numbers of people working in this sector, which accelerated during the pandemic.

References:

Xu, H., Intrator, O., & Bowblis, J. R. (2020). Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?. Journal of the American Medical Directors Association, 21(10), 1371–1377. https://doi.org/10.1016/j.jamda.2020.08.002)

Last updated: January 6th, 2022

3.06.01. Surge staffing and other measures to support care homes with outbreaks or critical staff shortages

Overview

Early in the pandemic there were examples of care homes where, due to a severe COVID-19 outbreak, staffing levels became too low for the care home to operate safely and be able to respond to the increased care needs linked to the outbreak. There is increasing alarm about the impact of the Omicron variant on staff availability in many countries.

Rapid response teams and surge staffing

In response to critical staff shortages, many countries deployed “rapid response” or “strike teams” that were mobilised to support these care homes. These range from medical teams deployed to deal with the health needs arising from an outbreak or technical support with Infection Prevention and Control, to more practical logistical support provided by the army or teams of people without prior care experience.

Increased involvement of family carers and volunteers in care provision in care homes

Another potential approach could involve an increased role for family carers of people living in care homes in the provision of care and support, or at least facilitating the levels of care by family members provided pre-pandemic, see section 3.07.03. on Visiting and unpaid carer policies in care homes.

There is evidence from before the pandemic that family and other unpaid carers and volunteers provided substantial care to people living in care homes. It can be argued that, if that family care is no longer available because visits are restricted (with no or only very brief, distanced visits allowed), this will result in either residents receiving less care, or in care home staff needing to take on additional care tasks.

A Dutch qualitative study found that family carers of people living with dementia in care homes reported that they were able to provide less care and felt felt sidelined when they were no longer able to continue providing care (Smaling et al., 2022).

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

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Australia

Surge staffing arrangements

To supply ‘surge’ staffing to residential aged care during COVID outbreaks, in early April 2020 the Australian government initially employed healthcare delivery provider Aspen Medical and care staff platform Mable to provide rapid response teams to residential and community care. As of 2 October 2020, significant surge workforce assistance had been provided by both state and National Aged Care Emergency Response (NACER) teams, with many workers deployed from interstate.

The Government’s National Aged Care Emergency Response (NACER) was introduced, during Victoria’s second wave, to mobilise experienced aged care workers from areas across Australia without community transmission of coronavirus (COVID-19) to help care for residents in care facilities that face staff shortages because of COVID-19. Staff recruited include registered nurses, enrolled nurses, personal care workers and cleaners. These workers can be deployed to care facilities for a four week period, followed by two weeks of quarantine and are supplied with uniforms and PPE, regular COVID-19 tests during their placement and have access to pastoral and mental health support.

Scale of use of surge staffing

By 14th January 2022 these labour hire firms had supplied staff for around 60,000 shifts in aged care services affected. This included 39,104 shifts through the Recruitment, Consulting and Staffing Association (RCSA). Aspen Medical had provided staff to fill 1,245 staff as clinical first responder deployments and Mable had filled 2,711 shifts.The State and NACER Teams have played a relatively small role (204 personnel were deployed).

How has this worked?

In evidence before the Royal Commission into Aged Care Quality & Safety, concerns were raised about the minimal experience many of the surge staff had in residential aged care.

An Independent Review COVID-19 outbreaks in Australian Residential Aged Care Facilities published in April 2021 found that, during the second wave in Victoria and staffing levels became depleted there was not enough supply of qualified and or experienced staff, the review found that some of the surge workforce did not have appropriate skills and experience, had not had sufficient training in Infection Prevention and Control, or did not speak English well enough, managers struggled to work with surge staff and many care homes preferred to avoid using workers they did not know.

This experience shows that organising and mobilising a surge workforce is a major logistical challenge that requires an extraordinary collaborative effort to deliver staff where they were needed. Some large providers with capacity to engage their own interstate
staff, also organised similar programs and incentives for staff to work in other states.

The Independent Review by Lilly and Gilbert also highlights that, in order to repond to the situation some care homes redesigned roles, so that staff without care skills and experience were deployed to roles such as helping residents communicate with their familes and updating families, and in some cases staff who were isolating at home would support remotely the surge workers, sharing their knowledge about the residents and their needs.

References:

Charlesworth, S and 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

Lilly A. and Gilbert L. (2021) Independent Review: COVID-19 outbreaks in Australian Residential Aged Care Facilities – No time for Complacency. https://www.health.gov.au/resources/publications/coronavirus-covid-19-independent-review-of-covid-19-outbreaks-in-australian-residential-aged-care-facilities

Last updated: February 18th, 2022   Contributors: Sara Charlesworth  |  Lee-Fay Low  |  

Finland

Preparations for possible future staff shortages began quite quickly, and a survey for a reserve of health professionals, including retired workers and students, began in early spring (https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: February 18th, 2022

France

Mobile geriatric and palliative care teams were deployed to care homes from 31st March 2020. The Assembly recommends these be embedded longer-term (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: February 18th, 2022

Germany

Measures varied between the States. The Ministry of Health in Bavaria introduced a long-term care group to support residential care settings in responding to COVID-19 cases in December 2020. The group includes experts in care, the authority monitoring quality of care for people with long-term care needs and disabilities and is called out as soon as one confirmed case has been established in a care home. The aim of this group is to prevent, advise and control infections and to support the task force infectious disease. Prior to the long-term care group (since March 2020), the Infectiology task force supported care homes in responding to outbreaks (https://www.stmgp.bayern.de/presse/neue-einsatzgruppe-unterstuetzt-pflege-einrichtungen-im-kampf-gegen-die-corona-pandemie/?output=pdfhttps://www.n-tv.de/regionales/bayern/Pflege-Einsatzgruppe-beraet-fast-200-Heime-article22297279.htmlhttps://www.stmgp.bayern.de/presse/huml-pflegeheime-brauchen-besonderen-schutz-vor-covid-19-handlungsanweisungen-des/?output=pdf).

In Lower Saxony care homes experiencing COVID-19 outbreaks could get support from qualified hygienists since May 2020. Health authorities can request support from these mobile teams through the Ministry of Social Affairs, Health and Equality in Lower Saxony (Niedersächisches Ministerium für Soziales, Gesundheit and Gleichstellung) (https://www.ms.niedersachsen.de/startseite/service_kontakt/presseinformationen/mobile-teams-zur-unterstutzung-von-pflegeheimen-bei-covid-19-ausbruchen-eingerichtet-kooperation-mit-medizinischem-dienst-der-krankenversicherung-188513.html).

A report from April/May 2020 showed that among residential care settings experiencing COVID-19 cases, 96.1% (n=749) receive support from a crisis team (https://www.uni-bremen.de/fileadmin/user_upload/fachbereiche/fb11/Aktuelles/Corona/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

Last updated: February 18th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Hungary

In April 2020 the army was deployed to provide desinfection tasks in care homes across Hungary.

Last updated: February 18th, 2022

Ireland

In Ireland, national and regional outbreak teams were set up to oversee, prevent and tackle COVID-19 clusters in residential LTC settings. Care home providers started to report COVID-19 outbreaks to the Health Information and Quality Authority (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: February 18th, 2022

Israel

The Israeli Army Home Front Command was called to assist in LTCF disinfection during three major facility outbreaks in mid-2020 (in a Jerusalem LTCF for older people, in a LTCF for older people in the South, and in a LTCF for disabled adults and children in central Israel) (Sharona Tsadok-Rosenbluth et al, 2020).

As the pandemic carried on, Israel’s army supplied critical response teams to support care homes and users, providing contract tracing, testing, medics, and vaccination support, and 29 quarantine locations nationwide (Nikkei AsiaThe Telegraph).

Last updated: February 18th, 2022

Italy

There were no no national or regional strategies to provide “squads” or rapid response teams to support care homes with outbreaks or staff shortages. When these teams were deployed, this was through local partnership and supported by private care providers.

Last updated: February 18th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Netherlands

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 that at times of high levels of staff absences due to COVID-19 infections and need to isolate, additional staff was brought in. These additional staff included  temporary workers, non-healthcare staff members and army medical staff. In some situations staff who needed to self-isolate were also provided with equipment to be able to work from home. (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: February 8th, 2022

Singapore

If a resident in a nursing home receives a positive COVID-19 test, a COVID-19 Incident Response Team (CIRT) is called in immediately by the AIC. These response teams consist of ‘representatives from the nursing home, the supporting regional hospital, the Ministry of Health, the Agency for Integrated Care, National Public Health Laboratory as well as the National Centre for Infectious Diseases. The response teams work on containing the number of positive cases, stepping up infection control, carrying out swabbing and testing operations, contact tracing, heightening vigilance (health monitoring of staff and residents), communicate with residents’ relatives and media, develop a service continuity plan and maintain adherence to the IPC measures, ensure workforce recovery after quarantine (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: February 18th, 2022

United States

Practical support for understaffed care homes:

During December 2021 the National Guard has been deployed to nursing homes across the United States to enable nursing homes with critically low numbers of staff to continue to operate. There is an acute shortage of staff in nursing homes across the country (a pre-pandemic problem).

In Minnesota 400 guard members with no previous experience in care have undergone rapid training before being sent to provide temporary support to nursing homes facing severe staffing shortages homes. The 75 hour training programme has been provided over 8 days, online and in person, by the Minnesota Department of Health and Minnesota National Guard medical staff, through sixteen Minnesota State community and technical colleges, the Guard members quality as emergency certified nursing assistants (CNA) and termporary nursing aides. This is in addition to an initiative to recruit, train and deploy at least 1,000 new certified nursing assistants for Long-Term Care Facilities in Minnesota by the end of January and an expansion of the emergency staffing pool so that short-term emergency temporary staff can be deployed to open up additional long-term care beds for people who are ready to be discharged from hosptial.

In October 2021 a provider survey found that 23,000 nursing home positions were unfilled in Minnesota, 8,000 more than in March of the same year.

Infection Prevention and Control strike teams:

In the United States a federal strike team initiative offered technical assistance and recommendations to facilities experiencing large outbreaks, with a focus on controlling the outbreak. The strike teams were deployed to nursing homes with outbreaks of 30 or more cases and typically included infection prevention specialists, epidemiologists and public health experts.

Analysis of the reports from the strike teams visits to 96 nursing homes in 30 states between July and November 2020,  had support from federal strike teams. These nursing homes faced challenges related to staffing, lack of Personal Protection Equipment (PPE), COVID-19 testing and implementation of COVID-19 Infection Prevention and Control (IPC).

The American Rescue Plan Act of 2021 has made available $500 million through the Centers for Disease Control and Prevention (CDC)’s  Epidemiology and Laboratory Capacity (ELC) Cooperative Agreement, for the Nursing Home & Long-Term Care Facility Strike Team and Infrastructure Project. The funds can be used on temporary staff and also to procure needed laboratory equipment, PPE, and technology to help reporting.

Virtual support:

In the United States there were also many examples of community health teams supporting nursing home staff, for example via telemedicine.

Last updated: February 18th, 2022

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

Overview

There were important national and within country differences in the capacity of both the development of guidance for the Long-Term Care sector, and in the ability of care providers to implement the guidance once this was available. As this section develops, we’ll consider both factors affecting guidance development and implementation.

Care home design and Infection Prevention and Control:

Emerging evidence suggests that the characteristics of care homes play an important role on the ability to implement guidance on, for example, isolation and cohorting.

There are emerging arguments about the need to consider quality of life together with infection control in architectural design models of nursing homes (Anderson et al., 2020; Szczerbi?ska, 2020, Inzitari et al., 2020).

A retrospective cohort study of nursing home residents in Ontario found a correlation between nursing home crowding (i.e. bedrooms shared between 2-4 residents) and Covid-19 infection and mortality. The study developed a crowding index equalling the mean number of residents sharing bedrooms and bathrooms (Brown et al., 2021). Larger nursing homes more likely to have outbreaks than smaller (among other factors) in a US study (Abrams et al., 2020).

Implementation of IPC measures in care homes and people with severe cognitive impairment

The implementation of restrictive measures, such us having to isolate in the bedroom or a defined space, or visitor restrictions, has been difficult for people with severe cognitive impairment. There is growing evidence of the difficulties that care home staff had when attempting to implement these measures, and the lack of specific guidance to support decision-making in these situations. This has resulted in approaches to implementation that range from finding “creative” solutions (such as sub-dividing living areas to enable people to leave their rooms for), to very strict adherence including the use of physical (and potentially pharmacological) restraints, to staff giving up and not enforcing isolation of people who had tested positive (see for example Kuylen et al., 2022).

The implementation of these restrictive measures and concern about their impact on the people experiencing them without being able to understand why this was happening has also been found to have caused moral injury among staff working in care homes (Brady et al., 2021, Iaboni et al., 2022)

References:

Abrams H.R., Loomer L., Gandhi A., Grabowski D.C. (2020) Characteristics of U.S. Nursing Homes with COVID-19 Cases. Journal of the American Geriatrics Society. https://doi.org/10.1111/jgs.16661 

Anderson, D. C., Grey, T., Kennelly, S., & O’Neill, D. (2020). Nursing Home Design and COVID-19: Balancing Infection Control, Quality of Life, and Resilience. Journal of the American Medical Directors Association, 21(11), 1519–1524. https://doi.org/10.1016/j.jamda.2020.09.005

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

Brown KA, Jones A, Daneman N, et al. Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada. JAMA Intern Med. 2021;181(2):229–236. doi:10.1001/jamainternmed.2020.6466

Iaboni, A., Quirt, H., Engell, K. et al. Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 22, 74 (2022). https://doi.org/10.1186/s12877-022-02759-4

Inzitari, M., Risco, E., Cesari, M. et al. Nursing Homes and Long Term Care After COVID-19: A New ERA?. J Nutr Health Aging 24, 1042–1046 (2020). https://doi.org/10.1007/s12603-020-1447-8

Kuylen M., Wyliie A., Bhatt V., Fitton E., Michalowski S., Martin W. (2022) COVID-19 and the Mental Capacity Act in care homes: Perspectives from capacity professionals. Health and Social Care in the Community. https://doi.org/10.1111/hsc.13747

Szczerbi?ska, K. (2020) Could we have done better with COVID-19 in nursing homes?. Eur Geriatr Med 11, 639–643. https://doi.org/10.1007/s41999-020-00362-7

 

International reports and sources

Narrative review of the experience of high-income Asian countries:

Calcaterra L, Cesari M, Lim WS (2022) Long-Term Care Facilities (LTCFs) During the COVID-19 Pandemic—Lessons From the Asian Approach: A Narrative Review, Journal of the American Medical Directors Association,
https://doi.org/10.1016/j.jamda.2022.01.049.

 

Australia

The Australian government provided over $1.5 billion to the aged care sector for COVID-19 support, a portion of which were to be used for IPC training. However, the Royal Commission into Aged Care Quality and Safety found that high-level infection control expertise was still lacking in the aged care sector and further systematic training is required. Additionally, they found that, while the Aged Care Quality and Safety Commission issued infection control self-assessment checklists, they did not conduct comprehensive on-site visits (sources: Care, Dignity and Respect 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

In Austria responsibility for the development of guidance in LTC settings, their implementation and monitoring has been given to newly established national task forces (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 9th, 2021

Belgium

MSF Intervention

Medicines Sans Frontiers (MSF) set up emergency interventions in nursing homes in Brussels, Wallonia and Flanders in early 2020. Part of the intervention was to train staff and provide learning tools – such as posters, webinars, and training courses – for care home staff on COVID-19. More than 3000 members of care home staff received support. The materials were also made available online so that facilities not receiving the intervention could also benefit (MSF, 2020).

Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

Canada

Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education programme

The capacity of long-term care (LTC) facilities in Canada was significantly affected by the pandemic. Project ECHO COE-LTC: COVID-19 is a case-based capacity-building online educational learning programme, developed for professionals working in LTC facilities. The program was developed in 2003, and attempts to bridge the gap between emerging best evidence its application: it was therefore a promising tool during the pandemic, which necessitated many changes in best practice and delivery of LTC. A study by Lingum et al. (2021) investigated whether the program was indeed effective at delivering just-in-time learning and best practices to support LTC residents and teams. The study found that participation in at least one weekly ECHO session led to increased confidence and comfort for workforce professionals working with residents who were either at risk, confirmed, or suspected of having the virus. Aside from this direct impact, study participants who attended sessions also reported an intention to share knowledge and change behaviour and resident care (Lingum et al., 2021).

References:

Lingum, N. R., Sokoloff, L. G., Meyer, R. M., Gingrich, S., Sodums, D. J., Santiago, A. T., Feldman, S., Guy, S., Moser, A., Shaikh, S., Grief, C. J., & Conn, D. K. (2021). Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model. Journal of the American Medical Directors Association, 22(2), 238-244.e1. https://doi.org/10.1016/J.JAMDA.2020.10.039

Last updated: March 3rd, 2022

British Columbia (Canada)

At the beginning of the pandemic, LTC providers did not feel confident with IPC and emergency management practices and felt unaware of emergency support resources that could be used such as IPC specialists and staffing support. Providers did not receive regular training and education on IPC, emergency management, and how to use PPE. When guidance about PPE was given, they were inconsistent and unclear. There was also a lack of guidance for community care providers and for residents with advanced dementia or behaviour and aggression challenges, who generally do not understand or comply with social distancing requirements.

These concerns have since been addressed by the BC Centre for Disease Control releasing frequently updated IPC guidelines for LTC facilities and assisted living (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf;  http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_HomeCommunityCareIPCGuidance.pdf; http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/long-term-care-facilities-assisted-living).

Last updated: November 6th, 2021

Ontario (Canada)

Restriction in staff mobility between nursing homes

From 22 April 2020, a public policy restricted staff from working at multiple homes. This policy was applied in Ontario later than in other provinces, such as British Columbia. The policy did not apply to temporary agency staff or other contracts staff; this ensured that nursing homes could have staff available to work in an emergency.

A study using GPS location data from mobile devices found that in the period prior to the restriction, 42.7% of nursing homes had a connection with at least one other nursing home. After the restrictions were  12.7% of nursing homes still had a connection with at least one other nursing home. In both periods, mobility between homes was higher in nursing homes in larger communities, with higher bed counts and those that were part of a large chain (Jones et al., 2021).

Workforce Training

Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education programme

The capacity of long-term care (LTC) facilities in Canada was significantly affected by the pandemic. Project ECHO COE-LTC: COVID-19 is a case-based capacity-building online educational learning programme, developed for professionals working in LTC facilities. The program was developed in 2003, and attempts to bridge the gap between emerging best evidence its application: it was therefore a promising tool during the pandemic, which necessitated many changes in best practice and delivery of LTC. A study by Lingum et al. (2021) investigated whether the program was indeed effective at delivering just-in-time learning and best practices to support LTC residents and teams. The study found that participation in at least one weekly ECHO session led to increased confidence and comfort for workforce professionals working with residents who were either at risk, confirmed, or suspected of having the virus. Aside from this direct impact, study participants who attended sessions also reported an intention to share knowledge and change behaviour and resident care (Lingum et al., 2021).

References:

Jones, A., Watts, A. G., Khan, S. U., Forsyth, J., Brown, K. A., Costa, A. P., Bogoch, I. I., & Stall, N. M. (2021). Impact of a Public Policy Restricting Staff Mobility Between Nursing Homes in Ontario, Canada During the COVID-19 Pandemic. Journal of the American Medical Directors Association, 22(3), 494–497. https://doi.org/10.1016/J.JAMDA.2021.01.068

Lingum, N. R., Sokoloff, L. G., Meyer, R. M., Gingrich, S., Sodums, D. J., Santiago, A. T., Feldman, S., Guy, S., Moser, A., Shaikh, S., Grief, C. J., & Conn, D. K. (2021). Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model. Journal of the American Medical Directors Association, 22(2), 238-244.e1. https://doi.org/10.1016/J.JAMDA.2020.10.039

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

Chile

Guidance for care homes on use of PPE, cleaning and disinfection, implementation of isolation areas and clean areas for staff, and actions to manage and mitigate suspected and confirmed COVID-19 cases was issued by the Ministry of Health (MoH), the National Service for Older People (Servicio Nacional de Personas Mayores, SENAMA) and the Chilean Geriatrics and Gerontology Society (SGGCh). Additionally, the SENAMA supported care homes with face-to-face technical support, supplies of PPE, staff replacement, testing and transfer of residents with COVID to isolation facilities. A survey of care homes staff showed that, in July 2020, the majority of managers had a high degree of knowledge of COVID-19 prevention and control and reported high degrees of agreement and support for the measures. Around 20% of managers reported PPE shortages, but there were reports of improvement in availability PPE over time. Half of all managers reported that the infrastructure of the homes was inadequate to implement measures, and lack of trained staff, support for staff and trust were identified as other barriers to the implementation of Infection Prevention and Control measures (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

There is a dedicated page on how to manage COVID-19 among older populations on the Danish Health Authority website. These are updated on a bi-weekly basis, or more frequently, if needed. On May 12th, 2020 an extensive publication providing new guidelines on how to organize visits in nursing homes was published by the Board of Health.

Last updated: May 25th, 2023

Finland

Guidance specific to LTC units and home care was relatively timely, with specific guidelines/mandates released in March and supplemented in April and May. Most of the municipalities have acted quickly to prevent the spread of the virus and followed the given instructions. Many municipalities have also introduced additional measures on their own initiative to address regional variations in the spread of the virus.  They can be seen summarized in a table on Page 9 of this report.

In 5.6 of LTC Covid Report for Finland (page 14) there is a summary of measures/dealings with people living with dementia.

Last updated: September 9th, 2021

France

Guidance specific to social care was much delayed compared to the health care sector, for example guidance on 20th Feb includes no reference to care homes at all. As a result, 9 large stakeholders wrote to the government and media on 9th March decrying the need for guidance for care homes. No guidance was published for domiciliary care until 2nd April (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). Guidance since the second wave has been more targeted to specific groups e.g. people with disabilities (https://www.cnsa.fr/documentation/covid-19_-_developpement_des_mesures_dhygiene_au_sein_des_essms.pdf), and require LTCFs to have protocols for infection control (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf).

Guidance has also been developed for infection control among specific groups, such as people with disabilities (https://solidarites-sante.gouv.fr/IMG/pdf/covid_protocole_ph.pdf) and some specific guidance has been published to support older people and protect carers (https://solidarites-sante.gouv.fr/IMG/pdf/plan_protection-personnes_agees_a_domicile-covid-19_1_.pdf ).

Last updated: November 2nd, 2021

Germany

Residential care

The RKI provides guidance on infection prevention and control in residential settings. These guidance documents have been regularly updated throughout the pandemic reflecting improved knowledge around virus transmission  https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Altenpflegeheime.html;https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Pflege/Dokumente.html;jsessionid=7230878758C5CAC3107EBB125EA8FB8B.internet051?nn=13490888; )

A working group of the German Society of Nursing Science have developed a guideline on care in care homes during the pandemic, which also seeks to minimise negative effects of infection control measures. The guideline is currently undergoing a major revision.

Domiciliary care

For domiciliary care, RKI only published a short notice online, last updated in November 2020.

A working group of the German Society of Nursing Science have developed a guideline on domiciliary care during the pandemic which also discusses some of the challenges around infection prevention and control guidance but also making suggestions of how these can be overcome.

Among the barriers identified to effective infection prevention and control in domiciliary care the expert group has identified that home care service providers are not being reimbursed for tasks that are not part of the long-term care insurance scheme. This means that for instance communication and coordination between different service providers or patient, family and carer education are not covered under the reimbursement agreements with the LTC insurance, even though these services could be particularly useful in a pandemic situation.

The document also highlights that domiciliary carers are guests in the home of the person with care needs and that any measures undertaken for infection prevention and control that affect the person with care needs and other people living in the household need to be agreed with them (e.g. isolating a person with COVID-19 in the home). Domiciliary care workers can advise and inform, however, implementing requires the consent of the residents. A domiciliary carer is entitled to protect themselves. The guidance emphasises the importance of consensus between clients and the domiciliary carers.

Suggestions provided in the document include: the development of pandemic plan that centers around the dignity of the person with care needs; the development of a continuity plan should domiciliary care have to stop; domiciliary care workers to receive training on measures for infection prevention; people with care needs to have a say on treatment and care should they develop a COVID-19 infection; infection control measures in the case of a COVID-19 infection; adherence to infection prevention protocols and guidance; adjusting of communication for people with visual, hearing and cognitive impairments; supporting the person with care needs in maintaining social contacts; enabling the person with care needs to maintain and promote mobility; support with nutrition; providing relevant information on pandemic measures to people with care needs and their family carers; in case of a COVID-19 infection there should be regular contact between domiciliary carers and the GP of the person with care needs; domiciliary carers should be able to recognise signs of maltreatment, neglect and abuse and where necessary take steps to protect the person with care needs.

The guideline has been updated once so far and is currently undergoing a major revision.

Day care

Day care and night care services were generally closed during the first phase of the pandemic. The states allowed these services to reopen in autumn in generally, given they had infection control measures in place. Depending on incidence rates, a reduction of the maximum number of users was mandated.

Last updated: February 12th, 2022

Hong Kong (China)

Early on in the pandemic care home resident were advised not to leave their rooms and to avoid contact with others. Instead they were encouraged to have their meals in their rooms and to use designated toilets. If they needed to leave the room, they were advised to wear a surgical mask. Hygiene protocols were supposed to clean the rooms on a daily basis and at least twice a day for areas that were frequently touched (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 9th, 2021

Ireland

In Ireland, a new Infection Prevention and Control Hub offered residential LTC settings guidance for outbreak preparation and management, information on infection prevention and control, and support with applying national advice. Some of this support is provided via telementoring interventions and webinars for nursing homes. In addition, the national membership organisation of home care providers developed a COVID-19-specific National Action Plan (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: November 2nd, 2021

Israel

Guidelines, procedures, and information for professional teams (e.g. public health system, justice system, medical staff, airports, food delivery systems) regarding COVID prevention and control are accessible on the Ministry of Health’s website. Guidance was timely; reports were first published in Spring 2020 and regularly updated. JDC-Eshel’s worked with the national  task force ‘TheFathers and Mothers Shield’ task forcewho are  primarily responsible for training and implementation of support of carers/people relying on care in the community. As already noted, specific regulations were developed for continuing care retirement communities, which have different characteristics from the traditional nursing homes or assisted living institutions.

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

Italy

At the beginning of the pandemic there was lack of ability to monitor and control the spread of the COVID-19 in nursing homes, and no testing of suspected cases among residents and care personnel. For several months (until Autumn 2020) procedures did not foresee testing residents in nursing homes, not even those presenting symptoms. This compromised data gathering on the actual number of COVID-19 related deaths among people living in nursing homes. From Autumn 2020, guidelines have been promoted by representative associations of care providers and the Istituto Superiore di Sanità concerning nursing homes internal procedures on Covid-19 management.

In relation to training, each region have then promoted specific measures on training on prevention and control measures. Moreover, guidelines published by the Ministry of Health required providers to ensure the COVID-related training of care workers.

Source:

Rapporto ISS COVID-19, n. 6/2021, Assistenza sociosanitaria residenziale agli anziani non autosufficienti: profili bioetici e biogiuridici

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

Japan

Early in the response, local LTCI officials had triggered well-established infection control measures put in place and regularly used for outbreaks of TB & influenza. A disease prevention manual was published; stricter hygiene practices put in place; and staff and visitor health screening and limited resident visitation (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf; https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: September 9th, 2021

Netherlands

On 20 March 2020 the National Institute for Health and the Environment (RIVM) issued their first Covid-19 guidelines to the LTC sector. These guidelines were regularly updated and new guidance was added. Some guidelines were difficult to follow, especially where there were shortages of Personal Protection Equipment and staff absent due to illness (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Experiences of Outbreak Teams in care homes

Long-Term Care organisations installed multidisciplinary Outbreak Teams, building on existing Infection Prevention and Control committees previously acting as focal points to lead and coordinate IPC activities. The Outbreak Teams also include management representatives, unlike the previous IPC committees.

Analysis of the minutes of 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). The data shows that most Outbreak Teams included management, medical staff, support services staff, policy advisors and communication specialists. Only in a few teams there was representation of nursing staff and residents.

The meetings mostly covered: crisis management, isolation of residents, PPE and hygiene, staff, residents’ well-being, visitor policies, testing and vaccination. The minutes reveal key challenges and dilemmas around testing, isolation of residents, PPE and staff and residents’ wellbeing.

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   Contributors: Lisa van Tol  |  

Singapore

A study conducted by Udod et al. (2021) (for which research was carried out in one nursing home in Singapore – so it is possible that this was not the experience of all LTC facilities in the state) reported that staff training and up-skilling – including competencies in pandemic management – was delivered by a nurse educator, who was also responsible for developing online training infrastructures in order for content to be available online.  Well-developed online training infrastructure and resources were then also made available to other nursing homes.

References:

Udod, S., Goh, H. S., Tan, V., Lee, C.-N., Zhang, H., & Devi, K. (2021). Nursing Home&rsquo;s Measures during the COVID-19 Pandemic: A Critical Reflection. International Journal of Environmental Research and Public Health 2022, Vol. 19, Page 75, 19(1), 75. https://doi.org/10.3390/IJERPH19010075

Last updated: January 11th, 2022   Contributors: Daisy Pharoah  |  

Spain

Care home experiences

According to a study of the experience of care home managers and local officials, lack of information and guidance at the beginning of the pandemic resulted in chaos and uncertainty and made it difficult to develop adequate responses. While some care homes were able to react quickly, others had not adopted any protocols until they had support from a primary health care centre in mid-April. Care homes were fearful of legal repercussions if they did not get things right. All care homes were required to develop contingency plans to fight the pandemic in June 2020 and were supported by the regional governments in developing these. However, numerous updates and changes proved to be a barrier to adoption: guidance was often difficult to implement because it did not reflect the reality of the care home environment: for example, the physical layout of care homes, staffing constraints, or the characteristics of residents. Early protocols did not account for the possibility of asymptomatic transmission. Care homes reported that they would have found it helpful to have some support with checking their plans, as well as the monitoring of implementation. Care homes found it very difficult to train staff to reflect changes in guidance, in part because many members of staff were new and had had little training or relevant experience (Del Pino et al., 2020).

There were examples of collaboration between hospitals and local care homes, for example Saez-Lopez and Arrendondo (2021) describe how a multidisciplinary team from a hospital supported four local care homes, not only through medical support, but also through training in Infection Prevention and Control (IPC) and implementation support, which included the hospital providing Personal Protection Equipment from their own stocks to the care homes.

Intervention by Medicines Sans Frontiers (MSF)

While supporting the public health system in Spain to overcome the most acute period of the COVID-19 outbreak in early 2020, MSF turned their attention to care homes in Spain to provide physical and emotional support to residents and staff. A key element of their intervention across over 500 care homes was to provide training (in person and remote) to enable staff to carry out their tasks safely. The organisation also set up a website with documents and videos on protocols, infection control, control tracing, and the use of PPE (source: MSF, 2020).

References:

Del Pino E., Moreno-Fuentes F.J., 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.

Sáez-López P, Arredondo-Provecho AB. (2021) Experiencia de colaboración entre hospital y centros sociosanitarios para la atención de pacientes con COVID-19. Rev Esp Salud Pública. 95: 14 de abril e202104053.

Last updated: February 22nd, 2022   Contributors: Daisy Pharoah  |  

Sweden

Guidance on measures to prevent infections in elderly care was delayed due to the fact that central government agencies responsible for providing recommendations and check-lists (i.e.: The Public Health Agency of Sweden and the National Board of Health and Welfare) did not have an adequate overview of the problems and deficiencies in municipal elderly care (https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf). Moreover, the  national authorities’ main recommendation to avoid spreading the virus in LTC was to follow the legislation on basic hygiene routines. A national e-training program  focusing on hygiene was developed early and, by July 2020 has been completed by more than  140,000 care workers. It was not until the 25th of June 2020 when the Public Health Agency recommended the use of shields and facemask in personal care of care recipients with suspected or confirmed COVID-19 (https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: September 9th, 2021

England (UK)

Overview of Government Guidance

Guidance for home care providers was provided relatively late in the pandemic. On April 27, 2020, Public Health England issued guidance on PPE use for care workers providing domiciliary care. The government published wider guidance for domiciliary care providers on May 22, 2020, much later than equivalent guidance for other long-term care settings was issued. This covered PPE, shielding of clinically vulnerable people, hospital discharge, and government and local authority support. The guidance has continued to be updated, including for providers to divide the people they care for into ‘care groups’ and allocate teams of staff to provide care specifically to those care groups.

Published on November 3, 2021, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. This will provide £388.3 million in further funding to support IPC, testing, and vaccination uptake in adult social care settings.

Updated on November 24, 2021, the UK IPC COVID-19 guidance for the winter period 2021 to 2022 supersedes the previous guidance for maintaining services within health and care settings. Recommendations for universal use of face masks for staff and face masks/coverings for all patients/visitors are to remain as an IPC measure within health and care settings over the winter period. This is likely to be until at least March/April 2022.

Guidance for Unpaid Carers

The government issued guidance for unpaid carers, which recommends that carers develop an emergency plan with the person they care for in case the carer becomes unable to continue to provide support, to follow hygiene rules, and to maintain their own health. Additionally it sets out how to react in case the person with care needs or the carer themselves develop symptoms of COVID-19.

Guidance for Carers Supporting People with Intellectual Disabilities

Guidance for unpaid carers of adults with intellectual disabilities and autistic adults is very similar to the general advice for unpaid care (published on April 24, 2020), and was last updated on 24 August 2021 to cover the lifting of restrictions and new guidance on self-isolation. There are, however, specific points raised around communication and coping with bereavement.

As of December 2021, government guidance for care staff supporting adults with intellectual disabilities and autistic adults was last updated on August 24, 2021, which links to a range of other relevant guidance and resources. This includes more detailed guidance from the Social Care Institute for Excellence on supporting autistic people and people with intellectual disabilities, including guidance for social workers and occupational therapists, guidance for care staff, and guidance for carers and family.

Guidance for People with Intellectual Disabilities

Government guidance has not always been accompanied by accessible versions for people with intellectual disabilities, autistic people, and family members, and several NGOs (including some financially supported by the government for this purpose) have been producing easy-read and other accessible information, resources and guidance guidance. Interviews with people with intellectual disabilities across the UK suggest that people are most likely to gain useful information about COVID-19 and associated restrictions from television news, with people rarely accessing government websites for guidance.

Implementing guidance: Experiences of Care Home Staff

The scant nature of care home-specific guidance during the early stages of the pandemic was highlighted in a study by Spilsbury et al. (2021), who analysed the contents of a WhatsApp group to capture the nature of uncertainties and organisational questions expressed by members. The self-formed WhatsApp group was comprised of 250 care home staff in the early stages of the pandemic to facilitate peer-support and information-sharing. Results of the study reveal that staff faced a wide range of uncertainties (n = 119) but the majority (n = 49) were about infection control and prevention, including uncertainties pertaining to PPE, isolation of residents, and zoning of residents and/or staff. More than one third (38%) of these questions or uncertainties could have been easily resolved through the availability of factsheets or targeted guidelines The study illustrates that the basic information needs of care home staff were not satisfied in the early stages of the pandemic. This sits in contrast to the proliferation of – sometimes conflicting – guidance during the later stages of the pandemic (Hinsliff-Smith et al., 2020).

Nyashanu et al. (2020) collected data through interviews with forty healthcare workers from nursing homes (n = 20) and domiciliary care agencies (n = 20) in the English Midlands to explore triggers of mental health problems, and found that a lack of guidance from central government was a key trigger of anxiety and stress for this workforce in the first phase of the pandemic. Other triggers included unsafe hospital discharges to care homes (of patients who then tested positive for COVID-19) and fear of infection and infecting others.

References:

Hinsliff-Smith, K., Gordon, A., Devi, R., & Goodman, C. (2020). The COVID-19 Pandemic in UK Care Homes – Revealing the Cracks in the System. The Journal of Nursing Home Research, 6, 58–60. https://doi.org/10.14283/JNHRS.2020.17

Nyashanu, M., Pfende, F., & Ekpenyong, M. S. (2020). Triggers of mental health problems among frontline healthcare workers during the COVID-19 pandemic in private care homes and domiciliary care agencies: Lived experiences of care workers in the Midlands region, UK. Health & Social Care in the Community. https://doi.org/10.1111/HSC.13204

Spilsbury, K., Devi, R., Griffiths, A., Akrill, C., Astle, A., Goodman, C., Gordon, A., Hanratty, B., Hodkinson, P., Marshall, F., Meyer, J., & Thompson, C. (2021). Seeking Answers for Care Homes during the COVID-19 pandemic (COVID SEARCH). Age and Ageing, 50(2), 335–340. https://doi.org/10.1093/AGEING/AFAA201

Last updated: March 24th, 2022   Contributors: William Byrd  |  Chris Hatton  |  Daisy Pharoah  |  

United States

Guidance

Guidance for LTCFs in the United States regarding COVID-19 infection prevention and control is regularly provided and updated by the Center for Disease Control and Prevention (CDC). The instructions (e.g. on PPE, distancing, quarantining) can be found here: CDC/Covid-19.

Technical support in managing outbreaks and Infection Prevention and Control (IPC)

In the United States a federal strike team initiative offers technical assistance and recommendations to Long-Term Care facilities experiencing large outbreaks, with a focus on controlling the outbreak. The strike teams were deployed to nursing homes with outbreaks of 30 or more cases and typically included infection prevention specialists, epidemiologists and public health experts.

Analysis of the reports from the strike teams visits to 96 nursing homes in 30 states between July and November 2020,  had support from federal strike teams. These nursing homes faced challenges related to staffing, lack of Personal Protection Equipment (PPE), COVID-19 testing and implementation of COVID-19 IPC. The study found evidence of improvement over time Key difficulties identified in relation implementation of IPC measures included:

  • Layout of the facilities and lack of space
  • Critical staff shortages and staff burnout, lack of staff trained in IPC
  • Delays in test results
  • PPE shortages
  • Rapidly changing guidance and lack of established lines of communications with agencies that issue guidance
Training in IPC

The Centres for Disease Control and Prevention and the Centers for Medicare & Medicaid Services (CMS) developed and made available a free online course: “Nursing Home Infection Preventionist Training Course” in March 2019 and in October 2020 launched project Firstline, a set of resources on IPC that includes short training videos for nursing homes.

In the first half of 2020, Médecins Sans Frontières (MSF) started working with nursing homes in Michigan by providing health education training on infection control measures to help prevent the spread of COVID-19 in these facilities. Feedback from the training was particularly positive from the non-medical staff (such as those working in the kitchen) who were less likely to have had any previous training on ways in which to protect themselves and the residents (source: MSF, 2020).

 

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

3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings

Australia

Approaches to hospital transfers vary depending on the state and individual aged care home. Some experts suggested not transferring COVID-19 positive residents to hospital unless it is the only solution to improve their survival rate and reduce risk of transmission. However, South Australia has an automatic transfer policy in which a resident who tests positive will immediately be transferred to a hospital. As of October 2020, the Communicable Diseases Network Australia (CDNA) has yet to introduce a specific recommendation on hospital transfers (source: Care, Dignity and Respect report).

Last updated: December 22nd, 2021

Austria

After 7 April 2020, which marked the peak use of capacity in hospitals during the first wave, patients were transferred from hospitals to care homes, ‘often without testing.’

By 16 April 2020, the Austrian government had announced that people discharged from hospital to care homes should be systematically tested (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

Last updated: September 9th, 2021

Belgium

There was never a blanket policy to refuse admission of nursing home residents in hospitals, the decisions to admit and discharge was left to the hospitals and healthcare professionals.  In the first few weeks of the pandemic there were no active measures in place to support nursing homes. Some hospitals took measures to support nursing homes in their area, mostly through sharing expertise in infection prevention and control and management skills, sharing staff and even PPE, equipment and medication. Nursing Homes who had an established functional relationship with a hospital were more likely to receive support.

Last updated: October 31st, 2021

British Columbia (Canada)

Temporary suspension of interfacility transfers, except for cases of intolerable risk to the patient. Facilities were required to notify the receiving facility if an outbreak occurred within a 14-day period of the transfer. The outbreak protocol states that residents transferred to acute care for treatment of COVID-19 or its complications, can return to facility when medically stable. July 15, 2020 – Notification that interfacility transfers may resume if precautions are taken. Services must follow regional MHO directions (including restricting transfers between facilities with active COVID-19 outbreaks). Precautions (e.g., 14-day isolation) for interfacility transfers will be at the direction of the MHO based on assessed regional risk (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: November 6th, 2021

Chile

According to a report published in July 2020, at the time there was no specific protocol for hospital discharges to nursing homes and due to the high pressure on health services, people were being discharged from hospital to nursing homes without the requirement of COVID-19 testing, but discharged residents were required to remain in an isolation area for 14 days (Browne et al., 2020).

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

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

Last updated: June 5th, 2023   Contributors: Tine Rostgaard  |  

Finland

A key LTC guideline, early on in the pandemic, was to avoid transfers between the care sites, such as between care homes and hospitals, whenever possible. Transfers were allowed only for medical reasons, and the new treatment site had to be notified on whether the person had had respiratory symptoms (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: September 9th, 2021

France

National Assembly report highlights that lack of support to the sector, especially in domiciliary care, meant that many services were reticent to taking on covid-positive service users, leading to discontinuity of care (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: September 9th, 2021

Germany

The Robert Koch Institute provides guidelines on infection prevention measures to be taken when transferring a person with a suspected/ confirmed COVID-19 infection between settings. However, actual measures taken has varied across the country.

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  

Staff in residential care settings were advised to monitor the health and body temperature of residents newly discharged from hospitals and to pay extra attention when providing personal care. Residents with respiratory symptoms must wear surgical masks and should continue isolating/cohorting. Furthermore, some nursing homes set up ‘temporary isolation wards’ for residents returning from hospital (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 9th, 2021

Israel

Different measures were introduced to minimize the transfer of LTCF residents between hospitals and facilities, including the opening of specialized COVID-19 wards within LTCFs and Geriatric Hospitals for those with mild or moderate cases. Required testing and potential quarantining following hospital visits and before returning to facilities was also introduced (source: Tsadok-Rosenbluth et al, 2021).

Magen David Adom is the state ambulance and emergency medical service, providing primary assistance for testing, vaccination and ambulatory transfers between hospitals, care homes, and communities (source: MDAIS).

It is important to note that coordinating the transfers and publishing directives to ensure successful and smooth transfers were one of the issues the task force managed.

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

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)

Source:

Rapporto ISS COVID-19, n. 6/2021, Assistenza sociosanitaria residenziale agli anziani non autosufficienti: profili bioetici e biogiuridici

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

Netherlands

Many people died in nursing homes and were not transferred to hospitals, therefore it was seen that nursing homes reduced pressure on hospital Intensive Care Units. It is customary to treat older people when they fall ill in the nursing home, perhaps explaining why few were referred to hospital (source: https://drive.google.com/file).

Last updated: November 30th, 2021

Singapore

As the DORSCON level reached orange in February 2020, elective surgical procedures and non-essential health/dental services were suspended. Hospitals continued to discharge residents to nursing homes throughout the Circuit Breaker period. The referrals were coordinated by the Agency for Integrated Care. At first, residents could be discharged if they did not have an acute respiratory infection and COVID-19 related symptoms. Those with an acute respiratory infection or pneumonia were required to provide a negative test. In May the policy changed as knowledge of asymptomatic COVID-19 increased. From then onwards, all patients discharged from hospital to nursing homes had to be tested (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 9th, 2021

Spain

In the early part of the pandemic residents returning to a care home, without a test, from a hospital stay for some other reason where suspected to be a main source of COVID-19 outbreaks. On the other hand, there were many instances where care homes were not able to access any health care support, from either primary care or hospitals. There were examples of hospitals that were systematically restricting admissions from care homes (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021

England (UK)

One of the most controversial policy decisions taken at an early stage in the management of the coronavirus crisis was the rapid discharge of older patients from hospitals to care homes around the country without testing for COVID-19. The British Medical Journal has referred to this as a ‘reckless policy’, a sentiment echoed by the Public Accounts Committee. On March 17, 2020, the Chief Executive of the NHS instructed managers to urgently discharge all hospital patients who were medically fit to leave in order to free up a substantial number of hospital beds. Discharges, including to care homes, may already have been taking place at this point in readiness for the expected surge in COVID-19 admissions.

Guidance issued on March 19, in support of hospital discharge arrangements, announced that the existing North of England Commissioning Support (NECS) care home tracker, designed to facilitate rapid searches for available capacity in care homes, would be expanded to cover all care homes across England. All care home providers were to sign up and use the tracker to identify vacancies from March 23. Even if the available care home was not their first choice, patients were to be moved to a care home as soon as possible and could be moved to their preferred care home afterwards. The guidance also outlined funding to provide care for people discharged from hospital into institutional care settings irrespective of whether a care assessment had been completed or where their ordinary residence was.

Care homes were to receive funding out of the NHS COVID-19 budget to expand their capacity to provide care. Funding to support people leaving hospital was renewed in August, with £588 million being allocated to the NHS to pay for additional support and rehabilitation for up to 6 weeks. At this time, testing capacity was limited and available primarily for patients in critical care and those requiring hospital admission with symptoms of pneumonia, acute respiratory stress syndrome, or flu like illness. The guidance published on April 2 was explicit that ‘Negative tests are not required prior to transfers / admissions into the care home’.

The National Audit Office (2020) estimated that around 25,000 people were discharged from hospitals to care homes between March 17 and April 15, 2020. Using an approach which also accounted for discharges for new as well as existing residents of care homes, the Health Foundation (Hodgson et al. 2020) estimated that, for the period of March 17 to April 30, 46,700 people had been discharged to care homes, 7,700 fewer than in previous years. However, the pattern of discharges differed between residential care and nursing homes. While residential care homes saw a decrease in discharges (with 12,400 discharges) compared to previous years, nursing homes saw an increase with 17,000 discharges.

National bodies representing care homes complained about homes being pressured to accept residents that had not been tested. The guidance published on April 2, stated that “patients can be safely cared for in a care home if this guidance is followed”. However,  clinicians noted in press reports that it was a “major error” to assume “that care homes could cope with isolating patients and infection control measures in the same way a hospital could”. Press also reported that the Care Quality Commission had been informed by care home managers that several hospitals discharged people to their care home despite suspecting, or even knowing, they were infected. NHS Providers, the membership organisation for NHS hospitals, has strongly rejected the suggestion that hospitals ‘knowingly’ transferred infected patients to care homes, but does acknowledge that some asymptomatic patients may have been transferred early, though “not in large numbers”. Evidence is lacking for any accurate assessment of the extent to which hospital discharges in this period led to transmission of infection into care homes and genomic analyses suggest multiple routes of ingress into care homes.

DHSC (2020) published the COVID-19 adult social care action plan on April 15, 2020, where the government declared that it was “mindful that some care providers are concerned about being able to effectively isolate COVID-19 positive residents”, and in this context set out a commitment to test all residents prior to their admission to care homes, including on discharge from hospital. In cases where the results of the test cannot be obtained in time for discharge, patients should be cared for in isolation as if they had tested positive for COVID-19. Asymptomatic patients who have tested negative should also be cared for in isolation for 14 days. The same was recommended for patients with COVID-19 symptoms and a positive test result where the patient needed to be discharged from acute NHS care within the 14-day period since the beginning of the symptoms. The action plan recognised that not all providers will be able to accommodate these individuals through appropriate isolation or cohorted care. This was supported by a survey of 43 English care home managers (Rajan et al. 2020). The action plan (DHSC, 2020) noted that in these circumstances the individual’s local authority will be asked to secure alternative appropriate accommodation and care for the remainder of the required isolation period. For admissions from the community, it is assumed they will be tested prior to admission, and in consultation with the family the care home can decide whether isolation is appropriate.

Published on November 3, 2021, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. A further £478 million to continue enhanced hospital discharge support until March 2022 will be provided (DHSC, 2021).

References:

DHSC (2020). COVID-19: Our Action Plan for Adult Social Care. Retrieved from: publishing.service.gov.uk; Accessed on 15/03/2022

DHSC (2021). Adult social care: COVID-19 winter plan 2021 to 2022. Retrieved from GOV.UK (www.gov.uk); Accessed on 15/03/2022

Hodgson, H. et al. (2020). Adult social care and COVID-19: Assessing the impact on social care users and staff in England so far. The Health Foundation briefing. Accessed on 15/03/2022

National Audit Office (2020). Readying the NHS and adult social care in England for COVID-19. NAO Report.

Rajan, S, et al.. (2020). Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic? Journal of Long-Term Care, pp. 185–195. DOI: https://doi.org/10.31389/jltc.53

Additional sources: 

Scally, G., Jacobson, B., & Abbasi, K. (2020). The UK’s public health response to covid-19. BMJ, 369. DOI:https://doi.org/10.1136/BMJ.M1932

Readying the NHS and social care for the COVID-19 peak – Public Accounts Committee – House of Commons (parliament.uk)

urgent-next-steps-on-nhs-response-to-covid-19-letter-simon-stevens.pdf (england.nhs.uk)

More than half a billion pounds to help people return home from hospital – GOV.UK (www.gov.uk)

‘Perfect storm’ say care homes told to accept people with coronavirus

Last updated: March 15th, 2022

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. Multi-disciplinary teams (MDTs) within health and social care will continue to play a critical role in keeping people well and independent and delivering the right care at home or in the community to prevent unnecessary hospital admission through accessing a range of health, social care and other community services. Extra funding will be provided to support the strengthening of Multi-Disciplinary Working across the health and social care system to support discharge from hospital and to ensure that people can be cared for as close to home as possible, reducing avoidable admissions to hospital. This includes up to £15 million for recruitment of support staff and £20 million to enhance MDTs this year and recurring (Source: www.gov.scot).

The plan includes funding of £40 million for 2021/22 to enable patients currently in hospital to move into care homes and other community settings, on an interim basis, to ensure they can complete their recovery in an appropriate setting. The Home First approach will be built on through the launch of an improvement programme (in collaboration with the Centre for Sustainable Delivery). The Discharge without Delay Programme will engage teams across the whole patient journey, aiming to ensure all delay is prevented where possible and placing a strong focus on discharge to assess. An additional £2.6 million has been shared between ten health boards so they can continue to develop Hospital at Home services to avoid admissions to hospital and we will work with Health Improvement Scotland (HIS) colleagues to monitor the progress of this work.

Last updated: March 24th, 2022

United States

In New York, following a hugely controversial directive from New York State’s Health Department on March 25, 2020, approximately 6,300 recovering coronavirus patients were transferred from hospitals into nursing homes throughout April (the peak of New York’s pandemic surge). The policy was defended by the Governor’s office, which argued that not only was this based on federal guidance, but that the devastation in nursing and long-term care facilities had more to do with the infection rates amongst staff. Regardless, the policy was overturned by mid-May and replaced with a new mandate such that patients could not enter nursing homes without a negative COVID test. News sources also counted over 2,700 “readmissions” of patients sent back from hospital to nursing homes they had previously lived in during that time. The executive board of The Society for Post-Acute and Long-Term Care Medicine (AMDA) estimated that 5,000 deaths in nursing homes and LTCFs are a direct result of that order (https://apnews.com/article/new-york-andrew-cuomo-us-news-coronavirus-pandemic-nursing-homes-512cae0abb55a55f375b3192f2cdd6b5; https://apnews.com/article/5ebc0ad45b73a899efa81f098330204c).

Last updated: September 9th, 2021

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

Overview

Key findings so far:

– There are different approaches to the isolation of people living in care homes who test positive with COVID-19 or who are potentially infected. These range from isolating people in their bedrooms, to cohorting them in separate sections of a facility, to being transferred to another care setting.

– There is relatively little evidence on this, with most of the published research so far being case studies and outbreak reports that do not establish whether one approach is better than the others.

– There is evidence that suggests that care homes with difficulties implementing isolation measures have had worse outcomes in terms of infections.

– There is concern about the well-being, physical, and mental health impacts of isolation measures (in particular confinement to a bedroom), especially for people living with dementia and other forms of cognitive impairment.

– Concerns about the impact on residents may result in staff not implementing isolation measures, and so it is important to develop compassionate approaches to isolation that take into account these concerns.

Introduction

Once there is a confirmed or suspected case of COVID-19 among residents in a care home, they are usually isolated from other residents in order to limit the risk of transmission. There is relatively little evidence on which approaches to isolation work best. This overview builds on the Cochrane rapid review of non-pharmacological measures in long-term care facilities by Stratil et al. (2021), complemented with articles identified as part of an update of an ongoing literature mapping review (see Byrd et al., 2021). Most of the evidence in this overview is from outbreak reports or case studies, which describe interventions undertaken, but are unable to provide an assessment of how effective these were in comparison to if no action had been taken.

Main approaches to isolation:

Sometimes, isolation has been combined with universal testing through point prevalence surveys, so that asymptomatic cases can also be identified and isolated (McBee et al., 2020; Shimotsu et al., 2020). However, as illustrated by Kim (2020), cohorting can occur in the absence of universal testing, where residents are divided into smaller units to try and limit the contacts between residents and therefore reduce the spread. In other cases, isolation has occurred in negative isolation spaces, either in individual rooms (Alawi, 2021), or in specific units (Miller et al., 2021).

More comprehensive strategies include cohorting, where the internal organisation of a care home is rearranged so that different groups of residents can be spatially isolated from each other. Sometimes, this cohorting separated positive and negative residents in different units (Shrader et al., 2020; Dora et al., 2021; Escobar et al., 2021). In addition, three-tiered cohorting was undertaken to separate positive, negative-exposed, and negative-unexposed residents, with the idea that negative-exposed residents may convert to positive, highlighting the importance of separating them from negative-unexposed (Collison et al., 2020; Eckardt et al., 2020). Cohorting often relied heavily on the availability of PCR testing to universally categorise residents for cohorting. Gonzalez de Villaumbrosia et al. (2020) suggested serology can be used to develop a three-tiered cohort when PCR testing is unavailable.

In some countries, for example Singapore, all residents who tested positive for COVID-19 were transferred to acute hospitals, as it was considered too risky to attempt isolation in nursing homes.

There have been some examples where care home staff have moved into care homes to avoid bringing in infections, in some countries this was voluntary and in others it was mandated. A study in France showed that the 17 care homes that implemented voluntary self-confinement of staff (in combination with other infection-control measures) had significantly lower levels of infection (Belmin et al., 2020).

These studies and examples are summarised below, by country.

Evidence on what works in relation to isolation in care homes:

Two studies that compared COVID-19 related outcomes in care homes with different abilities to isolate infected residents found that care homes that reported having difficulties with or were unable to isolate effectively had higher rates of outbreaks and larger outbreaks (Lombardo et al., 2021, Shallcross et al., 2021).

There are concerns about potential negative outcomes of isolation measures (impacts on physical and mental health) on the mental and physical health of care home residents, and in particular people who have cognitive impairment or dementia (see section 2.05. in this report for an overview of evidence). This has led, for example, to the development of a toolkit to support compassionate and effective isolation for people with dementia (Dementia Isolation Toolkit).

Concerns about the impacts of isolation may lead to staff feeling conflicted in implementing these measures. There are also significant constraints in the ability of care homes to implement isolation effectively, given physical and staffing constraints.

Iaboni et al (2022) found that most homes were not able to implement IPC measures effectively, with residents leaving isolation to circulate in common areas and not following hand hygiene or masking requests. Staff found it difficult to mitigate the impact on resident well-being, with mental health impacts, physical decline, and safety issues all reported.  Staff experienced high level of distress due to having to apply these measures. Around 1/3 respondents had used tools from the Dementia Isolation Toolkit, and of those, about half found the toolkit helpful at reducing their level of distress.

As illustrated by Collison et al. (2020), specific memory-care units within care homes can create their own isolation protocols, because off-unit isolation has the potential to do more harm than good for dementia patients. In Iceland a home-like isolation ward was used for older people with care needs with COVID-19 who did not require hospitalisation.

In the section below there are examples of isolation policies in different countries, as well as summaries of the studies identified in this overview.

References:

Alawi, M. M. S. (2021). Successful management of COVID-19 outbreak in a long-term care facility in Jeddah, Saudi Arabia: Epidemiology, challenges for prevention and adaptive management strategies. Journal of Infection and Public Health14(4), 521–526. https://doi.org/https://dx.doi.org/10.1016/j.jiph.2020.12.036

Belmin J, Um-Din N, Donadio C, et al. Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents. JAMA Netw Open. 2020;3(8):e2017533. doi:10.1001/jamanetworkopen.2020.17533

Byrd, W., Salcher-Konrad, M., Smith, S., & Comas-Herrera, A. (2021). What Long-Term Care Interventions and Policy Measures Have Been Studied During the Covid-19 Pandemic? Findings from a Rapid Mapping Review of the Scientific Evidence Published During 2020. Journal of Long-term Care, (2021), 423–437. DOI: http://doi.org/10.31389/jltc.97

Collison, M., Beiting, K. J., Walker, J., et al. (2020). Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care. Journal of the American Medical Directors Association21(11), 1560–1562. https://doi.org/10.1016/j.jamda.2020.09.001

Dora  V, A., Winnett, A., Fulcher, J. A., et al. (2021). Using Serologic Testing to Assess the Effectiveness of Outbreak Control Efforts, Serial Polymerase Chain Reaction Testing, and Cohorting of Positive Severe Acute Respiratory Syndrome Coronavirus 2 Patients in a Skilled Nursing Facility. CLINICAL INFECTIOUS DISEASES73(3), 545–548. https://doi.org/10.1093/cid/ciaa1286

Eckardt, P., Guran, R., Hennemyre, J., et al. (2020). Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control best practices. American Journal of Infection Controlhttps://doi.org/10.1016/j.ajic.2020.06.215

Escobar, D. J., Lanzi, M., Saberi, P., et al. (2021). Mitigation of a Coronavirus Disease 2019 Outbreak in a Nursing Home Through Serial Testing of Residents and Staff. Clinical Infectious Diseases72(9), E394–E396. https://doi.org/10.1093/cid/ciaa1021

Gonzalez de Villaumbrosia, C., Martinez Peromingo, J., Ortiz Imedio, J. et al. (2020). Implementation of an Algorithm of Cohort Classification to Prevent the Spread of COVID-19 in Nursing Homes. Journal of the American Medical Directors Association21(12), 1811–1814. https://doi.org/10.1016/j.jamda.2020.10.023

Iaboni, A., Quirt, H., Engell, K. et al. Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 22, 74 (2022). https://doi.org/10.1186/s12877-022-02759-4

Kim, T. (2020). Improving Preparedness for and Response to Coronavirus Disease 19 (COVID-19) in Long-Term Care Hospitals in the Korea. Infect Chemother.

Lombardo FL, Bacigalupo I, Salvi E, et al. The Italian national survey on coronavirus disease 2019 epidemic spread in nursing homes. International Journal of Geriatric Psychiatry 2021;36(6):873-82. https://doi.org/10.1002/gps.5487

McBee, S. M., Thomasson, E. D., Scott, M. A., Reed, C. L., Epstein, L., Atkins, A., & Slemp, C. C. (2020). Notes from the Field: Universal Statewide Laboratory Testing for SARS-CoV-2 in Nursing Homes – West Virginia, April 21-May 8, 2020. MMWR. Morbidity and Mortality Weekly Report69(34), 1177–1179. https://doi.org/10.15585/mmwr.mm6934a4

Miller, S. L., Mukherjee, D., Wilson, J., Clements, N., & Steiner, C. (2021). Implementing a negative pressure isolation space within a skilled nursing facility to control SARS-CoV-2 transmission. American Journal of Infection Control49(4), 438–446. https://doi.org/10.1016/j.ajic.2020.09.014

Shallcross L, Burke D, Abbott O, Donaldson A, Hallatt G, Hayward A, et al. Risk factors associated with SARS-CoV-2 infection and outbreaks in long term care facilities in England: a national survey. Lancet Healthy Longevity 2021;2(3):e129-e142. https://doi.org/10.1016/S2666-7568(20)30065-9

Shimotsu, S. T., Johnson, A. R. L., Berke, E. M., & Griffin, D. O. (2020). COVID-19 Infection Control Measures in Long-Term Care Facility, Pennsylvania, USA. Emerging Infectious Diseases27(2). https://doi.org/10.3201/eid2702.204265

Shrader, C. D., Assadzandi, S., Pilkerton, C. S., & Ashcraft, A. M. (2020). Responding to a COVID-19 Outbreak at a Long-Term Care Facility. Journal of Applied Gerontology?: The Official Journal of the Southern Gerontological Society, 733464820959163. https://doi.org/10.1177/0733464820959163

Stratil JM, Biallas RL, Burns J, et al. (2021). Non-pharmacological measures implemented in the setting of long-term care facilities to prevent SARS-CoV-2 infections and their consequences: a rapid review. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD015085. DOI: 10.1002/14651858.CD015085.pub2. Accessed 09 January 2022.

International reports and sources

Systematic review of non-pharmacologocial measures to prevent COVID infections in Long-Term Care facilities:

Stratil JM, Biallas RL, Burns J, et al. Non-pharmacological measures implemented in the setting of long-term care facilities to prevent SARS-CoV-2 infections and their consequences: a rapid review. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD015085. DOI: 10.1002/14651858.CD015085.pub2. Accessed 09 January 2022.

Australia

Guidance

If the COVID-19 positive person is a staff member, they must apply a surgical mask and leave the aged care facility by isolating at home. If the COVID-19 positive person is a resident, they must be moved to a single room, preferably with an en-suite, to isolate. The residential home may also be placed under lockdown for further testing. The local public health unit is responsible for contact tracing and the monitoring of residents (source: health.gov).

Dementia Support Australia provided guidance to support people with dementia during COVID-19. They suggested 1:1 residential support as the ideal way to help a resident isolate (source: Dementia Support Australia).

Last updated: January 12th, 2022

Austria

Implementation considerations

In care homes, isolation was used frequently, however, this was problematic in situation where more people shared rooms. (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/)

Last updated: January 12th, 2022

British Columbia (Canada)

Guidance

If a positive case is found in a LTC facility, the operator must close the affected floor/unit/ward or facility/residence to new admissions, re-admissions, or transfers, unless medically necessary and/or approved by a Medical Health Officer. COVID positive residents are not transferred to an external quarantine facility and are only transferred to acute medical care for COVID if necessary (http://www.bccdc.ca/Health-Info-Site/Documents/COVID19_LongTermCareAssistedLiving.pdf).

Last updated: January 12th, 2022

Ontario (Canada)

Evidence on barriers to implementing isolation

Iaboni et al (2022) surveyed staff working in care homes in Ontario, Canada, asking about their experiences with implementing infection control measures (IPC) in the first two waves, in the context of a preliminary evaluation of a toolkit to support compassionate and effective isolation for people with dementia (the Dementia Isolation Toolkit).  Their study found that most homes were not able to implement IPC measures effectively, with residents leaving isolation to circulate in common areas and not following hand hygiene or masking requests. Staff found it difficult to mitigate the impact on resident well-being, with mental health impacts, physical decline, and safety issues all reported.

Staff identified many barriers to isolating residents effectively- in particular, staff distress about the impact of isolation on residents’ quality of life (61%), and their fear about the reaction of residents when enforcing these measures (59%) were reported as important barriers to the effectiveness of isolation.  Moral distress around the implementation of these measures was high- one-third (33%) had large to extreme amounts of moral distress, 84% had an increase in moral distress since the start of the pandemic, and 40% reported a large impact of moral distress on their job satisfaction.  Around one third of respondents had used tools from the Dementia Isolation Toolkit, and of those, about half found the toolkit helpful at reducing their level of distress.

References:

Iaboni, A., Quirt, H., Engell, K. et al. Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 22, 74 (2022). https://doi.org/10.1186/s12877-022-02759-4

Last updated: February 6th, 2022   Contributors: Andrea Iaboni  |  

Denmark

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

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

 

Last updated: May 25th, 2023   Contributors: Tine Rostgaard  |  

Finland

National government guidelines to isolation have included LTC unit visiting bans, the provision of single rooms within LTC homes for symptomatic or exposed residents, restricted use of common areas in LTC units, and limited visitation of at-home care users. Some municipalities were quick to adhere to these policies, while others delayed implementation until the end of April (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: September 9th, 2021

France

Implementation experiences:

Many care homes had to individually isolate service users, especially at the beginning of the pandemic, due to lack of adequate PPE. The guidance published in April 2020 around testing would test the first symptomatic resident, who would then be taken care of either in strict isolation or in single rooms. If one care worker tested positive, all workers were required to be tested and isolate. This was noted as a struggle by the Assembly Commission as many care homes had shared rooms for residents (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). This was linked to severe health impacts (https://ltccovid.org/2020/05/05/summary-sars-cov-2-related-deaths-in-french-long-term-care-facilities-the-confinement-disease-is-probably-more-deleterious-than-the-covid-19-itself/).

Evidence: 

A study from France comparing mortality in nursing homes with staff confining with residents compared to national average showed that staff confining with residents was effective in preventing infection and reducing mortality (Belmin et al., 2020).

References:

Belmin J, Um-Din N, Donadio C, et al. Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents. JAMA Netw Open. 2020;3(8):e2017533. doi:10.1001/jamanetworkopen.2020.17533

Last updated: January 12th, 2022

Germany

Guidance:

Guidance to support people living in care homes stress the importance of human dignity and focus on the need to ensure social participation and quality of life of residents (https://www.awmf.org/uploads/tx_szleitlinien/184-001l_S1_Soz_Teilhabe_Lebensqualitaet_stat_Altenhilfe_Covid-19_2020-10_1.pdf). Guidance on approaches to isolation of confirmed/suspected cases in care homes are provided (and regularly updated following the latest evidence) by the Robert Koch Institute.

In some federal states (e.g. Bavaria) relevant ministries can also issue guidelines (https://www.stmgp.bayern.de/wp-content/uploads/2020/08/20200818_handlungsanweisungen.pdf).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  

Israel

Several LTC homes set up COVID wards and/or isolation areas within their institutions to limit the number of people in need of ambulatory transfer to hospitals. Medical geriatric centres were also asked to open at least one ward dedicated to mild or moderate COVID-19 cases; if cases became severe, patients were transferred to a general hospital. Due to lack of post-hospital geriatric support, many older people with COVID-19 remained in isolated recovery in hospital (Tsadok-Brosenbluth 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: January 12th, 2022   Contributors: Shoshana Lauter  |  

Italy

Guidelines have been issued by the Ministry of Health through the Italian Institute for Health (ISS), defining standards and procedures for isolation in nursing homes.

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

Japan

LTCFs used well-established infection control procedures and swiftly isolated affected residents and suspended visits and social events (as they are used to do in the case of influenza/TB outbreaks). Mask-wearing was also already common practice in the event of these outbreaks. Data suggests most cases were contained with few large outbreaks within facilities (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 9th, 2021

Netherlands

The association of geriatricians has issued guidelines for infection control in care homes (Verenso). The ability to control infection has increased substantially between the first and second wave. The publicly financed programme “Dignity and Pride on Location” has developed a “roadmap” to help providers to prepare for a new pandemic (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 9th, 2021

Republic of Korea

Evidence on experiences of cohorting to separate groups of residents (starting March 2020)

A study describes an emergency response to a COVID-19 outbreak in a long-term care hospital (LTCH) spread over floors 2 through 5 in a five-storey building in Bucheon, South Korea. As of March 12, 2020, there were 142 patients, with six to ten patients assigned to each room, and bed distance of less than one metre apart.

In response to an index case, all patients were considered contact persons. Patients in a dischargeable condition were isolated at home. Of the other patients, 73 were transferred to public hospitals and nearby private acute care hospitals. The remaining patients were in isolation cohorts after the beds were repositioned to maintain a bed distance of 2 metres or more. There were no more infected persons (Kim, 2020).

References:

Kim, T. (2020). Improving Preparedness for and Response to Coronavirus Disease 19 (COVID-19) in Long-Term Care Hospitals in the Korea. Infect Chemother. https://doi.org/10.3947/ic.2020.52.2.133

Last updated: January 14th, 2022   Contributors: William Byrd  |  

Saudi Arabia

Evidence from a case study on isolation of new admissions in a negative pressure room

A study describes the experience and outcomes of a COVID-19 outbreak in a long-term care facility in Jeddah, Saudi Arabia. This private long-term nursing centre (LTNC) comprised a 100-bed nursing home and a 6-bed intensive care and cardiovascular unit (ICVU).

On April 9, 2020, a new patient was admitted to the institution for long-term care. They were placed in an isolation room with negative air pressure and managed as a suspected case. On April 14, their test result came back positive. However, following a contact tracing investigation, no patient screened positive in the building. Tracing and screening were continued for more than 2 weeks following the identification of the index case, and yet no additional case has been detected so far (Alawi, 2021).

References:

Alawi, M. M. S. (2021). Successful management of COVID-19 outbreak in a long-term care facility in Jeddah, Saudi Arabia: Epidemiology, challenges for prevention and adaptive management strategies. Journal of Infection and Public Health, 14(4), 521–526. https://doi.org/https://dx.doi.org/10.1016/j.jiph.2020.12.036

Last updated: January 12th, 2022   Contributors: William Byrd  |  

Singapore

In comparison to other countries, there were only very few cases in nursing homes in Singapore. All of the residents with COVID-19 were transferred to acute hospitals.

Nursing homes introduced mandatory split zones to reduce the number of contacts for residents and staff. The zones cannot house more than 100 residents, a fixed set of staff and need to have dedicated entry and exist points. Communication between staff in different zones should take place remotely via text messages, phone or video conference. Shared spaces, such as pantries and lifts should have staggered access that allows for cleaning between the use from different zones. Medical staff needing to move across split zones are recorded for contact tracing and have to adhere to increased infection prevention and control measures (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 9th, 2021

Spain

Evidence on using a cohorting algorithm to separate infected, exposed, and unexposed residents

This study describes the implementation of a cohort classification algorithm to prevent the spread of COVID-19 in nursing homes in Spain. This algorithm helps to classify residents in order to separate them into three different areas. The approach was designed in the surge of the COVID-19 outbreak when PCR tests could not be performed for all nursing home residents.

The first step is to perform a chromatographic immunoassay to detect antibodies in all residents in the nursing home using rapid point-of-care test. Residents with a positive result would be placed in the ‘red zone’. Residents with a negative result would initially be located in the ‘green zone’. Early detection of cases of COVID-19 in this area must be performed either by identification of close contact to confirmed cases or through daily surveillance of symptoms. Residents considered suspicious of being infected should be immediately transferred to the ‘yellow zone’, where further study must be undertaken. The intervention was implemented on April 24, 2020, and it has been held in 17 nursing homes. The study reports that, after the intervention, 94% of nursing homes had made an improvement in sectorisation (Gonzalez de Villaumbrosia et al. 2020).

References:

Gonzalez de Villaumbrosia, C., Martinez Peromingo, J., Ortiz Imedio, J., Alvarez de Espejo Montiel, T., Garcia-Puente Suarez, L., Navas Clemente, I., Morales Cubo, S., Cotano Abad, L. E., Suarez Sanchez, Y., Torras Cortada, S., Onoro Algar, C., Palicio Martinez, C., Plaza Nohales, C., & Barba Martin, R. (2020). Implementation of an Algorithm of Cohort Classification to Prevent the Spread of COVID-19 in Nursing Homes. Journal of the American Medical Directors Association, 21(12), 1811–1814. https://doi.org/10.1016/j.jamda.2020.10.023

Last updated: January 12th, 2022   Contributors: William Byrd  |  

Sweden

Cohort care i.e. separating infected from non-infected care home residents within a care setting, was introduced; while some municipalities have used separate places for the care of people who have previously been hospitalized and infected with COVID-19. In many care homes new cleaning routines   organized, i.e. staff dedicated solely to care for people with suspected or established infection who live at home. In some care homes, COVID-19 teams have been combined with cohort care (https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Last updated: November 2nd, 2021

Turkey

Case Study of a Care Home in Istanbul (Özten et al, 2021)

A report describes successful pandemic response measures in a nursing home in Istanbul. This nursing home, which is one of the biggest in the country, managed to avoid COVID-19 cases for residents and staff altogether, as a result of strictly adhered-to regulations and implementation of preventative measures. This included the use of an assigned quarantine ward for any residents with suspicious symptoms. Residents sent to this ward were isolated, evaluated clinically, and followed up on by doctors and nurses. If indicated, they were transferred to hospital (Özten et al, 2021).

References:

Özten O, Aytekin Akta? T, Süer H, Do?an H, Üner A, Özp?nar S, Ayy?ld?z Y, Bekta? H, Saka B. 2021. A 15-day Working Shift Prevent the Cross-contamination of Coronavirus Disease-2019 in a Nursing Home in Turkey. Eur J Geriatr Gerontol 2021;3(3):131-133

Last updated: January 26th, 2022   Contributors: Daisy Pharoah  |  

England (UK)

Guidance

There have been two major difficulties in identifying and isolating infected individuals effectively in care homes in England. First, guidance issued to care homes focused only on people who were displaying symptoms (initial guidance only mentioned a persistent cough and fever as symptoms). It took a long time for official guidance to consistently recognize the potential for pre-symptomatic or asymptomatic transmission. Guidance on identifying residents and staff who may have been in contact with persons who had the virus and subsequent preventive isolation became available on April 2, 2020.

Ahead of the second wave, the government set up a scheme to prepare ‘designated settings’ that could provide safe isolation for people who were discharged from hospital while positive for COVID-19 and who needed to move to a care home. The settings had a to meet a set of standards to deliver safe care for COVID-19 positive residents.

Evidence on implementation difficulties

The ability of care homes to implement existing IPC guidance was hampered by a lack of access to testing (tests for asymptomatic residents and staff only started to be available after April 28, 2020) and PPE, staff shortages, and facilities that were not suitable for effective isolation or cohorting (Rajan et al., 2020). Where care homes are not able to implement adequate isolation or cohort policies, it is the responsibility of the local authority to secure alternative accommodation for the isolation period, drawing on the £1.3 billion discharge funding.

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), 185–195. DOI: http://doi.org/10.31389/jltc.53

House, S., Fewster, E. (2020). Asymptomatic and pre-symptomatic transmission in UK care homes – and infection, prevention and control (IPC) guidance – an update. Retrieved from:https://ltccovid.org/2020/06/12/

 

Last updated: March 24th, 2022   Contributors: William Byrd  |  

United States

Guidance:

The Centers for Disease Control guidelines encourage suspected and confirmed cases amongst new and returning residents of LTCFs to be placed in a designated, in-house COVID-care unit.

Evidence on isolation approaches:

Tiered cohorting to separate positive, exposed, and unexposed residents 

This study describes a rapidly deployed point-prevalence testing and 3-tiered cohorting in an urban skilled nursing facility (SNF) in Chicago with over 200 beds spread over 4 floors, including a memory-care unit floor. Three resident cohorts were created: positive (red), negative-cleared (green), and negative exposed (yellow).

On COVID-19 positive floors, sharing rooms was permitted, whereas on COVID-19 negative-exposed floors, residents were placed in their own rooms. The memory floor was separated into positive and negative cohorts, because off-floor relocation was believed to potentially cause more harm than benefit given the care needs of residents with dementia. Initial testing (n=120) identified 43 negative-exposed residents and 77 positive residents. Of those residents who were negative, testing performed 1 week later revealed 12 residents had converted to positive. Ten of the 12 who converted were on the memory-care unity (Collison et al., 2020)

Cohorting positive or exposed residents in specific units

A study by Dora et al. (2021) reported on the serology results following an outbreak in a skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System West Los Angeles (WLA) campus where residents were serially tested and positive residents were cohorted.

From 28 to 30 March 2020, symptom based testing identified 3 COVID-19 cases. In response, all remaining patients (n=96) underwent testing. Between 29 March and 6 April, 16 additional cases were identified. These 16 and the original 3 patients were transferred to the acute care hospital for treatment or a designated COVID-19 recovery unit (CRU) located within the SNF. No further cases were identified upon additional testing. An additional 9 patients from the community who were diagnosed with COVID-19 were transferred to the CRU by 5 June. When tested 46-76 days later, 24 of 26 positive residents available for testing were seropositive. None of the 124 negative residents had confirmed seropositivity.

Another study describes the interruption of a potential outbreak of COVID-19 in a 120 bed hospital affiliated long-term care facility in Florida using a point prevalence testing containment strategy. Universal prevalence testing was undertaken every 14 days for 6 weeks, starting on April 8, 2020. A cohort unit was established to avoid placing unexposed residents into a shared space with exposed residents. This included private rooms with a private bathroom. All positive confirmed cases were transferred to the hospital for complete medical evaluation and airborne isolation. The cohort unit did not see any conversions to positive. Over 6 weeks the spread of the disease was contained shown by the prevalence decreasing from 5.4% to 3.6% to 0.4%. From April 7 – May 6, a total of 9 patients were positive at the facility (Eckardt et al., 2020).

A case study on the response to an outbreak of COVID-19 in a long-term care facility (LTCF) in West Virginia. The facility is a free-standing structure with a 100-bed capacity, providing long-term care, skilled nursing, and hospice care. On March 22, 2020, an index case was identified. Within 36 hours, 21 of 98 residents initially tested were identified as positive. The facility has six separate units with four nursing stations. The designated isolation unit was chosen due to no shared common space with other units and a private nursing station. Each resident room had its own ventilation, recirculating air. As of August 20, 2020, the facility has had 52 residents test positive. The resident rate of infection (53%) and mortality (5%) are better than reported world averages for LTCFs (Shrader et al., 2020).

Isolation of positive residents in private rooms

A study conducted in 123 West Virginia in nursing homes in April 21 through May 8, 2020 reported on a universal testing strategy and isolation in private rooms. In nursing homes with active outbreaks, all persons received testing who had previously tested negative or had not been tested. All patients with positive test results were isolated in private rooms. Following universal testing, nursing homes screened residents daily and tested anyone with signs or symptoms of COVID-19. If additional cases were identified, testing was performed for close contacts. In total, 42 COVID-19 cases were identified in 28 nursing homes. Of these cases, 11 were residents. The 42 cases represented 20 single cases from 20 facilities and 22 outbreak associated cases, representing new outbreaks in eight facilities. In six of the eight nursing homes with newly identified outbreaks where cohorting of residents with positive test results was implemeneted, daily symptom screening of all residents and staff members for 28 days found that further transmission did not occur (McBee et al., 2020).

Isolation in negative pressure isolation spaces

A case study reports on the design, implementation, and validation of an isolation space at a skilled nursing facility (SNF) in Lancaster, Pennsylvania, with 114 beds. One hall was the subject of this study which consisted of 6 double occupancy rooms and one single occupancy room, all with single bathrooms.

The negative pressure isolation space was created on April 6, 2020, by modifying an existing HVAC system of the SNF. These modifications were not resource intensive and were rapidly established. As of June 23, 14 confirmed positive residents had been treated in the negative isolation space and the facility had utilised the isolation space for a total of 21 individuals. No transmission between residents isolated to the space occurred, not did any transmission to other residents occur (Miller et al., 2021).

References:

Collison, M., Beiting, K. J., Walker, J., Huisingh-Scheetz, M., Pisano, J., Chia, S., Marrs, R., Landon, E., Levine, S., & Gleason, L. J. (2020). Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care. Journal of the American Medical Directors Association, 21(11), 1560–1562. https://doi.org/10.1016/j.jamda.2020.09.001

Dora  V, A., Winnett, A., Fulcher, J. A., Sohn, L., Calub, F., Lee-Chang, I., Ghadishah, E., Schwartzman, W. A., Beenhouwer, D. O., Vallone, J., Graber, C. J., Goetz, M. B., & Bhattacharya, D. (2021). Using Serologic Testing to Assess the Effectiveness of Outbreak Control Efforts, Serial Polymerase Chain Reaction Testing, and Cohorting of Positive Severe Acute Respiratory Syndrome Coronavirus 2 Patients in a Skilled Nursing Facility. CLINICAL INFECTIOUS DISEASES, 73(3), 545–548. https://doi.org/10.1093/cid/ciaa1286

Eckardt, P., Guran, R., Hennemyre, J., Arikupurathu, R., Poveda, J., Miller, N., Katz, R., & Frum, J. (2020). Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control best practices. American Journal of Infection Control. https://doi.org/10.1016/j.ajic.2020.06.215

McBee, S. M., Thomasson, E. D., Scott, M. A., Reed, C. L., Epstein, L., Atkins, A., & Slemp, C. C. (2020). Notes from the Field: Universal Statewide Laboratory Testing for SARS-CoV-2 in Nursing Homes – West Virginia, April 21-May 8, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(34), 1177–1179. https://doi.org/10.15585/mmwr.mm6934a4

Miller, S. L., Mukherjee, D., Wilson, J., Clements, N., & Steiner, C. (2021). Implementing a negative pressure isolation space within a skilled nursing facility to control SARS-CoV-2 transmission. American Journal of Infection Control, 49(4), 438–446. https://doi.org/10.1016/j.ajic.2020.09.014

Shrader, C. D., Assadzandi, S., Pilkerton, C. S., & Ashcraft, A. M. (2020). Responding to a COVID-19 Outbreak at a Long-Term Care Facility. Journal of Applied Gerontology?: The Official Journal of the Southern Gerontological Society, 733464820959163. https://doi.org/10.1177/0733464820959163

Last updated: January 13th, 2022   Contributors: William Byrd  |  

3.07.03. Visiting and unpaid carer policies in care homes

Overview

Following the high mortality observed in care homes around the world in the initial waves of COVID-19, many countries closed their care homes to visitors. This had implications on residents and relatives’ wellbeing (see sections 2.05: Impact of the pandemic on the health and wellbeing of people who use long-term care, and 2.07. Impacts of the pandemic on unpaid carers). Most countries have adopted less draconian measures, allowing visits following strict hygiene protocols and in many cases identifying Essential Carers who are able to visit even during outbreaks.

Pre-pandemic evidence on the role of family carers and volunteers in care homes

There is evidence from before the pandemic that family and other unpaid carers and volunteers provided substantial care to people living in care homes. It can be argued that, if that family care is no longer available because visits are restricted (with no or only very brief, distanced visits allowed), this will result in either residents receiving less care, or in care home staff needing to take on additional care tasks.

Some family members, especially spouses, would be highly involved in the care of their relatives in care homes. The evidence shows that this involves “hands-on tasks” (provision of personal care and mealtime assistance), managerial roles (care coordination, taking the relative to appointments, providing food and supplies, helping with finances), social and emotional support, support to other care home residents (e.g. delivering food and drinks), and monitoring the health status of their relatives and detecting cases of abuse (Lindman Port, 2006 and Puurveen et al, 2018. Volunteers also played an important role in many care homes prior to the pandemic (Handley et al., 2021).

A study of the costs of dementia in England, which collected data on unpaid care provision in care homes, estimated that unpaid carers provided care to the value of £3,450 per person with dementia living in care home in England, per year (Wittenberg et al., 2019), about a third of unpaid carers were helping with eating and getting around both indoors and outdoors, transportation and food shopping, and 70% were providing help with finances.

A study in the United States using datas from the Health and Retirement Study and the Aging Trends Study also found that family members provide considerable care and support to people living in nursing homes and residential care facilities (Coe and Werner, 2021).

Evidence of decreased provision of unpaid care in care homes during the pandemic (and impacts)

A Dutch qualitative study found that family carers of people living with dementia in care homes reported being able provide less care and feeling sidelined when they were stopped from providing care (Smaling et al., 2022).

References:

Coe N.B. and Werner R.M. (2021) Informal caregivers provide considerable front-line support in residential care facilities and nursing homes. Health Affairs 41(1), 105-111. https://doi.org/10.1377/hlthaff.2021.01239

Handley M, Bunn F, Dunn V, Hill C, Goodman C. Effectiveness and sustainability of volunteering with older people living in care homes: A mixed methods systematic review. Health Soc Care Community. 2021 Sep 24. doi: 10.1111/hsc.13576. Epub ahead of print. PMID: 34558761.

Lindman Port C. Informal Caregiver Involvement and Illness Detection Among Cognitively Impaired Nursing Home Residents, The Journals of Gerontology: Series A. 2006, 61: 9, 970–974, https://doi.org/10.1093/gerona/61.9.970

Puurveen G, Baumbusch J, Gandhi P. From Family Involvement to Family Inclusion in Nursing Home Settings: A Critical Interpretive Synthesis, Journal of Family Nursing, 2018, 24(1):60–85. doi: 10.1177/1074840718754314.

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

Wittenberg R, Knapp M, Hu B, Comas-Herrera A, King D, Rehill A, et al. The costs of dementia in England. International Journal of Geriatric Psychiatry. 2019. DOI: 10.1002/gps.5113.

International reports and sources

International overview (January 2021):

Low L-F, Hinsliff-Smith K, Sinha S, Stall N, Verbeek H, Siette J, Dow B, Backhaus R, Spilsbury K, Brown J, Griffiths A, Bergman A, 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. https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf

November 2021 update covering care home visitor policies in Australia, Canada, Iceland, Israel, Norway and the Netherlands:

Rapid global scan of care home visitor policies in countries with high vaccination rates (November 2021)

Australia

First waves

The Australian government introduced visitor restrictions on March 18, 2020, which limited to two visitors at a time. Visits must be in private areas with no social activities. Children under 16, people who have travelled overseas, and people with COVID-19 symptoms were not allowed to visit. Individual state governments introduced their own visiting policies and restrictions. Queensland, Victoria, and NSW both implemented prolonged personal visitor bans and lockdowns. The Royal Commission into Aged Care Quality and Safety found that aged care residents were severely impacted by the loss of contact with loved ones and that the restrictions inside aged care facilities go beyond the restrictions for the general public (sources: Charlesworth and Low, 2020; Aged Care and COVID-19 report).

In June 2021 Australia was almost ‘back to normal’ in terms of social distancing requirements, except during outbreaks and lockdowns (which by Australia’s definition means almost any case of Covid-19 with incidence of community transmission).

During lockdowns, there are restrictions on visitors. In early August 2021, New South Wales (Greater Sydney and some parts of regional NSW), Victoria, and South East Queensland (Brisbane) are in short lockdowns due to the Delta variant outbreak. In Greater Sydney all visitors are excluded, except those providing essential caring functions and end of life visits, and masks need to be worn). Guidance is state/territory specific, with visitors still having to follow Covid-19 precautions, prohibiting those with Covid-19 symptoms or those who have recently returned from international travel.

Prior to the most recent lockdown, in NSW, Greater Sydney, all essential visits took place in residents’ rooms, with residents being provided with appropriate PPE and infection control advice if they needed to leave the facility for essential purposes. However, guidance now states that no visitors or non-essential staff are permitted, and residents should avoid leaving the facility, except for essential reasons. For all other facilities located in NSW, only two visitors are allowed each day and visits should take place in the residents’ rooms or another suitable location in the facility. Furthermore, according to guidance in NSW, from June 1 to September 30, 2021, visitors should not enter aged care facilities if they have not received a dose of the 2021 influenza vaccine, unless they meet the criteria under the exceptional and special circumstances.

In Victoria during the lockdown visitors are limited to 2 people and masks are mandatory. Previously there were no restrictions to number of visitors.

In South East Queensland, except for end of life care, no visitors are allowed. Residents are not allowed to leave except for healthcare, emergency or compassionate reasons.

In Western Australia, visitors must wear a mask, with two and four visitors allowed per resident per day respectively. In some states/territories, such as Australian Capital Territory, Northern Territory, and South Australia, care home visits are ‘back to normal’, with no restrictions to visitors. In Queensland the flu vaccine is required for visitors after May 31, 2021, whereas in Tasmania this is only strongly recommended.

The Omicron outbreak

Data released on the 8th January 2022 shows that nearly 500 aged care facilities are affected by COVID-19, with 1,370 infections among residents and 1,835 among staff, resulting in residents being placed in lockdown.

On December the 8th 2021, a Direction was issued under the Emergency Management Act 2004 to limit entry into residential aged care facilities (RACF) in South Australia, a person is not permitted to enter or remain on the premises unless they have received at least two doses of COVID-19 vaccine or, all dosages of a recognised COVID-19 vaccine in accordance with dosage schedule recommended by ATAGI for that vaccine. Some exemptions apply to children under the age of 12, and people who have exemptions from vaccinations for medical grounds.

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: January 18th, 2022

Austria

Following the first reports of cases and subsequent deaths in care homes in March 2020, some homes put in place visiting restrictions and bans, even before the general lockdown was implemented, but already by April 2020 some care homes worked towards enabling safe visits by creating ‘encounter zones’ that allowed families to meet residents at safe distance (in the garden/ divided by Plexiglas) and adhering to hygiene measures (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

In Austria, care home visiting has been possible again since May 2020 under a range of safety measures. Measures (‘visiting zone’, booth divided by plexiglass) varied between regions. The latest COVID-19 related measures issued by the government (8 February 2021) state that residents can be visited up to twice per week by up to two visitors per resident. Visitors must show a negative COVID-19 test and wear a FFP2 mask throughout their visit (https://www.sozialministerium.at/Informationen-zum-Coronavirus/Coronavirus—Aktuelle-Ma%C3%9Fnahmen.html).

It appears that Austrian visiting varied across Austria during the period from October to December 2020, when the country experienced a high number of cases. A paper reports on screening of visitors and restrictions of visits in public areas in Viennese care homes, as well as a ‘Corona traffic lights’ system in Lower Austria than put in place measures depending on local levels of infections (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

As of May 10, 2021, new legislation sets out provisions regarding opening from lockdown (https://www.ris.bka.gv.at/Dokumente/BgblAuth/BGBLA_2021_II_214/BGBLA_2021_II_214.html). A maximum of three visitors a day are allowed for nursing home residents. However, these restrictions do not apply for visits in the context of palliative and hospice care, pastoral care, and for accompaniment during critical life events. In addition, a maximum of two persons per resident in need of support may be admitted if they provide regular support and care tasks. Visitors must present proof of low epidemiological risk, such as evidence of a negative result of a SARS-CoV-2 antigen or molecular test, medical conformation of an infection with SARS-CoV-2 survived in the last six months, or proof of vaccination against Covid-19. Visitors must wear a mask of protection class FFP2 without an exhalation valve, unless there is a suitable protective device for spatial separation that ensures the same level of protection. The same rules apply for the admission of external service providers and patient advocates. Residents shall be offered a SARS-CoV-2 antigen or molecular test at least every week, or at least every three days if they have recently left the nursing home. There are no specific provisions in this legislation regarding outings for residents.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Belgium

The use of antigen rapid tests for visitors is done under the responsibility of and in consultation with the local medical authorities. The use is optional and depends on the epidemiological situation. Factors that may influence a decision include: an increased (local) prevalence; the circulation of more contagious variants; to protect residents and staff who have not (yet) been vaccinated or have not built up sufficient immunity (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Visits are allowed for all residents. The number of visitors is limited to four close contacts (hug contacts) who don’t have to wear a face mask. Additionally, they are allowed unlimited visitors with surgical face masks, although the number present at the same time is limited in accordance with precautionary measures, such as keeping distance and the number of people that can be present in a room at the same time. Visitors are not restricted by time (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: November 2nd, 2021

Brazil

The technical note No. 25/2020 (January 2021), issued by the Ministry of Health, recommended that family members only visit older residents when essential, maintaining the suspension of visits for the duration of the national public health emergency, a recommendation that was already issued by the Brazilian Society of Geriatrics and Gerontology and the ‘Frente Nacional de Fortalecimento à ILPI’ since March 2020. In April 2021, this was updated, allowing short visits to occur in ventilated common areas, using face masks, maintaining a safe distance, and other protective measures.

After significant reductions in the rates of new cases, hospitalizations, and deaths among residents of LTCF, some regions issued local policies regarding visiting and outings (e.g., the State of Ceará, cities of State of São Paulo and Belo Horizonte). Most of these recommendations suggest the adoption of plans to ease the visits and outings of residents progressively. They take into account the epidemiology of the infection in the community, the local hospital capacity, the level of vaccination of residents and workers, the physical infrastructure of the facilities, and the supplies of personal protective equipment and access to laboratory testing. During outbreaks and up to 14 days after a positive test of at least one resident, outings and visits are suspended, except for compassionate visits. In the phases of greater flexibility, exits considered essential (such as medical appointments) with return on the same day may dismiss laboratory testing or isolation. For outings lasting longer than 72 hours, most recommendations suggest the need for isolation for ten days and/or laboratory testing with Qt-PCR/antigen assays. Some guidance provided authorization for people’s entry to carry out academic and research activities and volunteer work, under local prerequisites. There is no national standardisation of protocols for outings for residents yet. The National Front suggests a plan with colours (red, orange, yellow and green) to guide an opening and progressive visit of the LTC facilities.

(Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/)

Last updated: September 8th, 2021

Canada

In Ontario, Canada, social outdoor visits were generally encouraged. From September 2020, family carers providing essential caregiving activities could enter the homes. As cases increase again, some areas limited social visits but enable family carers to continue to see their relatives. Family carers entering homes must get regular COVID-19 (bi-weekly/weekly in areas with high transmission) to be allowed to enter.

In Quebec, the government stated in November 2020 that care homes could not make the provision of a negative test a requirement for visitors (https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf).

Last updated: September 8th, 2021

British Columbia (Canada)

Visitor restrictions were put in place to only allow for essential visitors. March 19, 2020 – The definition of essential visitor was expanded and it was indicated that HAs would determine if a visit was essential. June 30, 2020 – Further amendment of the policy, stating that each facility must have a plan in place in accordance with BCCDC IPC (Infection Prevention and Control) guidance to indicate how social visits would be facilitated (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Visitor guidance for long-term care published March 30, 2021, stated that up to two adults and one child can visit a resident indoors without staff present, which may be increased when outdoors depending on current provincial guidelines (http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/long-term-care-facilities-assisted-living). There are no restrictions on the frequency and duration of visits, with physical touching allowed as long as masks are worn. Residents may leave nursing homes for non-essential reasons and are not required to isolate upon return.

Last updated: November 6th, 2021

Chile

Both enabling visiting in care homes and outings for residents are regulated in “plan paso a paso” (step by step). This regulates the number of personal visits and outings allowed based on the epidemiological status of each community. For “Fase 2” (step 2), the second step after lockdown, personal visits and outings are permitted. Isolation is not required following these activities (source: LTCCovid report).

Last updated: December 22nd, 2021

China

During the worst period of the pandemic, all the nursing homes were in lockdown, meaning that no one was allowed in or out, including nursing home staff. Administration staff were asked to work from home or take leave. Currently, nursing homes are not completely open, but in low risk areas visitors with a prior reservation can enter upon taking a temperature test and showing a green ‘health code’. This signifies their personal epidemiological status, which is related to where they have been and who they have recently come into sustained contact with. The same regulations are in place for staff who are working there. Visits that are not family related are stricter and depend on the specific regulations in each nursing home.

In June 2021 nursing homes were open to visitors with a prior reservation. When entering a nursing home, taking a temperature check, and showing a green ‘health code’ are required. The Health code is a QR code assigned by a color-coded system to each citizen according to their personal epidemiological status, which is related to their Covid-19 test results and whether they have visited non-low risk areas or have been in contact with infected persons recently. The same regulations are in place for staff who are working there. Voluntary activities are restricted in most areas, which depend on the specific regulations in each nursing home.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Hong Kong (China)

In the early part of the pandemic, visits of relatives and friends were suspended, ‘unless for compassionate reasons’. In some residential care settings remote/virtual meetings were organised to sustain contact with residents’ families. Visiting professional services were also delivered remotely, suspended or reduced in scale. Volunteers were not allowed to come into the homes (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

As of July 2021, visiting in care homes is allowed for individuals with prior reservation who are able to show a negative test result, which has been undertaken within the last three days. For family members who have had more than two weeks since being vaccinated, they can use the result of a self-administered Covid-19 test, instead of a standard lab test result.(https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/)

Last updated: November 23rd, 2021

Czech Republic

In July 2021, visits in care homes are allowed, with guidance stating that visitors are obliged to pass an antigen test, unless they have been vaccinated, have recovered from Covid-19 in the last 90 days before the visit, or have had a negative PCR test in the last two days (source: https://covid.gov.cz/opatreni/zdravotnicka-socialni-zarizeni/omezeni-navstev-v-zarizenich-socialni-pece). Regarding outings for residents, recently the Deputy Ombudsman (“Public Defender of Rights”) asked the Minister of Health to immediately lift the restrictions on the outing of clients of homes for the elderly and homes with special regimes. An extraordinary measure of the Ministry allows them to leave the facility only if they undergo two antigenic tests and subsequent isolation for several days. It is not possible to accept restrictions on these people in their fundamental rights” (source: https://www.ceskenoviny.cz/zpravy/simunkova-zada-zruseni-omezeni-vychazek-klientu-domovu-pro-seniory/2031948). Further conditions attached to outings for residents are specified in the same ‘extraordinary measure’.

Last updated: November 30th, 2021

Denmark

Measures were first introduced by the March 17, 2020, guidelines issued by the Board of Health, ’Håndtering af COVID-19: Besøg på institutioner hvor personer fra risikogrupper bor eller har langvarigt ophold’. These recommended that family members and friends should not visit nursing homes (or hospitals) unless strictly necessary, for instance if the person was terminally ill (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Individual institutions were asked to ensure that the visit could be conducted in a safe manner, for instance by ensuring that it was only a brief visit, that visitors did not sit in common areas and that they did not have physical contact or use common facilities. Institutions were required to inform visitors about the risk of spreading the disease and encouraging them to avoid visiting, through posters (for example a poster with the message ‘You best protect your loved ones by not visiting them’) and personal instruction. If family members had symptoms, they were not allowed to visit. Instead, it was recommended to stay in contact over the telephone, video or mail.

A formal ban of visiting was introduced temporarily on April 6, 2020, ‘Besøgsrestriktioner på plejehjem m.v. og sygehuse’. The guidelines also outlined that the manager should ensure that members of staff stayed at home if they showed signs of being infected, even with mild symptoms, and only returned after 48 hours of being symptom free. If a member of staff was suffering from respiratory diseases or the like they could be referred by the manager to take a COVID-19 test. Also, staff who had been in close contact with persons infected with COVID-19 were to be tested (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

On May 12, 2020, an extensive publication providing new guidelines on how to organize visits in nursing homes was published by the Board of Health. From the introduction, it was made clear that the Board of Health did not have the authority over who could visit, as this was the responsibility of the Board for Patient Safety, and thus underlining the general confusion over which authority was in charge (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/). It was recommended to limit the number of residents that each member of staff had access to and to avoid staff involvement in activities spread across the institution. Staff should receive instruction in the use of PPE and there should be a strong focus on hygiene and behaviour in all common rooms. It was acknowledged that residents were entitled to leave the institution but the manager and staff were encouraged to inform them about the increased risk and they should be supported in how to disinfect their hands upon returning. Staff were instructed in wearing work clothes and maintaining distance (1-2 m), regardless of whether the resident had any symptoms. Which centres have what kind of restrictions is posted here (https://stps.dk/~/media/07F68A96CC9C44B08BBDF33E1DF81C1C.ashx).

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

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

In June 2021 at most nursing homes things have returned to normal. There is again open access for relatives, volunteers and activities. Where there is an outbreak of COVID-19 at a nursing home or there is  comprehensive outbreak of COVID-19 in a municipality, the agency for patient security has the authority to issue a directive restricting access to nursing homes. In the following situations visits cannot be restricted: visits from close relatives to a critically ill person; close relatives visiting a grown adult with learning disabilities, to the degree that the person doesn’t have the ability to understand and accept the purpose of the restrictions, and by that reason has a special need to be visited; visits from the person’s guardian, personal representative or lawyer (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

References:

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

Last updated: May 25th, 2023

Finland

Visits to housing services for older people and at-risk groups in Finland were prohibited alongside the announcement of a nationwide state of emergency (https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

From mid-May 2020 onwards visits in care homes (e.g. outdoors/in meeting containers) became part of the national guidelines (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: November 2nd, 2021

France

Visits were suspended in care homes between 11th March and 20th April 2020 with a phased return to ‘normal’ by the summer (16th June). Care home managers criticised the approach of having to set up complex safe visiting protocols from almost one day to the next, and regretted not having been consulted on the proposals (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). The announcement of the second lockdown on 28th October 2020 was accompanied by a clear message that visiting in care homes would not be stopped (https://www.francetvinfo.fr/sante/maladie/coronavirus/confinement/confinement-pourquoi-les-visites-en-ehpad-vont-etre-autorisees_4160285.html), with a clear policy to ‘protect our elders without isolating them’ (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf).

From May 19, 2021, visiting restrictions have been further relaxed as a result of increasing vaccine coverage among older people (https://solidarites-sante.gouv.fr/IMG/pdf/allegement_post_vaccinal_des_mesures_de_gestion_ehpad_et_usld.pdf). The most recent protocol refers to the individual rights of social care users which are enshrined in law, including freedoms to see family and to “come and go”. On this basis visits to care homes (and other social care settings) must be guaranteed, transparent information must be given to residents and their families to allow them to make informed decisions. Visitors must be tested upon entry, except where vaccinated. They are unable to visit residents that have tested positive or that have been identified through contact tracing, except during end of life treatment or if they are ‘slipping away’. Residents undertaking outings must wear a surgical mask and be offered a PCR test upon return, and as far as possible they must limit their contact with other residents. Isolation of these residents upon return is not allowed. Restricting the movement in and out of care homes and other long-term care settings must be the final resort.

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

France

Visits were suspended in care homes between 11th March and 20th April 2020 with a phased return to ‘normal’ by the summer (16th June). Care home managers criticised the approach of having to set up complex safe visiting protocols from almost one day to the next, and regretted not having been consulted on the proposals (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). The announcement of the second lockdown on 28th October 2020 was accompanied by a clear message that visiting in care homes would not be stopped (https://www.francetvinfo.fr/sante/maladie/coronavirus/confinement/confinement-pourquoi-les-visites-en-ehpad-vont-etre-autorisees_4160285.html), with a clear policy to ‘protect our elders without isolating them’ (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf).

From May 19, 2021, visiting restrictions have been further relaxed as a result of increasing vaccine coverage among older people (https://solidarites-sante.gouv.fr/IMG/pdf/allegement_post_vaccinal_des_mesures_de_gestion_ehpad_et_usld.pdf). The most recent protocol refers to the individual rights of social care users which are enshrined in law, including freedoms to see family and to “come and go”. On this basis visits to care homes (and other social care settings) must be guaranteed, transparent information must be given to residents and their families to allow them to make informed decisions.

Visitors must be tested upon entry, except where vaccinated. They are unable to visit residents that have tested positive or that have been identified through contact tracing, except during end of life treatment or if they are ‘slipping away’. Residents undertaking outings must wear a surgical mask and be offered a PCR test upon return, and as far as possible they must limit their contact with other residents. Isolation of these residents upon return is not allowed.

Restricting the movement in and out of care homes and other long-term care settings must be the final resort.

Last updated: September 8th, 2021

Germany

In December 2020, the German ethics council issued recommendations on the minimum of social contacts for people receiving long-term care during the COVID-19 pandemic. The council emphasises quality of contacts over quantity, which emphasises the importance of enabling contact with people with whom they have a close and trusting relationship. The document also recognises the important of physical closeness. Where there are no relatives, volunteers should be considered to replace important social contact. Physical contact must be enabled if people with LTC needs express this wish. Programmes supporting social contact should be realised (potentially with help from volunteers) (https://www.ethikrat.org/fileadmin/Publikationen/Ad-hoc-Empfehlungen/deutsch/ad-hoc-empfehlung-langzeitpflege.pdf).

In addition, the authorised representative of the federal government for care has provided concepts to enable safe visiting during the COVID-19 pandemic (https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/C/Coronavirus/Handreichung-Besuchskonzepte_4.12.20.pdf).

The RKI continues to provide guidance around infection prevention measures around visiting arrangements in residential care settings (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile).

Visiting rules continue to vary somewhat between the federal states. Since the Ministers of Health have agreed on expanding visits in care home again visiting rules have become more similar, but there can be some variation in the number of visitors (in some areas tied to incidence rates), (rapid) testing, hygiene protocols (masks, disinfecting hand), provision of information for contact tracing. In case of an outbreak, care homes can suspect visits in consultation with health authority (https://www.biva.de/besuchseinschraenkungen-in-alten-und-pflegeheimen-wegen-corona/#bw).

On 22 March 2021 the Ministers of Health have agreed that residential care settings are allowed to expand visiting as well as group activities again two weeks after residents received the second vaccination and if there are no active COVID-19 cases in the institutions. There is no differentiation between residents who have received the vaccination and those who have not. New residents, who have not yet been vaccinated should be offered a vaccination appointment in a timely fashion. The federal government will continue to support testing. Länder regulations vary (https://pflegenetzwerk-deutschland.de/fileadmin/files/Corona/210316-Besuchsregelungen-Pflegeheime-Uebersicht.pdf).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Hungary

Restrictions on visiting in care homes were lifted in May 2021, once it was considered that the vaccination rate among care home residents was high enough.

Last updated: February 18th, 2022

Iceland

An interdisciplinary working group on care home issues relating to COVID-19 sets Iceland’s care home infection control measures, including visiting rules. Icelandic care homes set their own visiting rules but are encouraged to follow the guidelines from this working group. Most homes have restricted visiting hours, and ask visitors to wear a mask in common areas and practice good hand hygiene.

There are no policies or procedures in place to protect the rights of residents to have visitors.

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: December 5th, 2021   Contributors: Thordis Hulda Tomasdottir  |  

Indonesia

The Directorate of Social Rehabilitation for People with Disability under the Ministry of Social Affairs issued guidelineon health protection and psychosocial support for persons with disabilities during Covid-19 outbreaks in institutional care (https://kemensos.go.id/uploads/topics/15852709524796.pdf). In this document, it was mentioned that if visitations cannot take place, interactions through video calls are encouraged. In December 2020, the Ministry of Social Affairs released a report based on a study of several long-term care facilities in Indonesia (http://puslit.kemsos.go.id/upload/post/files/24d4dfb918f9d78c57f5f2fa0d0470aa.pdf). This report found that in general most facilities banned or limited visits, including from family members. Several implemented a ban on residents leaving the facilities. In some cases, residents returned to their family home based on advice from their facility to reduce the risk of them getting Covid-19. In general, the central government managed facilities had more resources to make these adjustments, whereas the private facilities were the ones that were struggling, because they largely rely on donations. The bans on visits impacted the mental health of the residents, reporting loneliness as a result.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Ireland

In early March, Nursing Homes Ireland announced visiting restrictions for care homes across Ireland. At that time, the Department of Health found that a blanket ban was not required. To mitigate the impact of social isolation, Nursing Homes Ireland conducted a survey of activities that could be put in place in nursing  homes to ensure that contact with families could be maintained. This was followed by the national initiative ‘Comfort Words’ that encouraged children to write to people living in nursing homes. It was anticipated that care home visiting should be reenabled as phase three of the Roadmap for Reopening Society and Businesses and to ‘return to normal’ in phase five. (https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: November 2nd, 2021

Israel

Visiting policies in care homes were found to be very inconsistent and restrictive early on, causing confusion for LTCF staff, residents and families. In Summer 2020, the national LTC pandemic taskforce, Shield of the Fathers and Mothers, issued a statement encouraging family visitation under social distancing guidelines, citing psychological health as the primary driver. Many LTCFs however adopted stricter policies and prohibited visitation altogether. The Ministry of Health maintained a pro-visitation policy for LTCFs in low-morbidity areas after the nationwide lockdown during the September second wave, arguing that “To date, there has been no reported cases of COVID-19 infections in LTCFs arising from a family visit”.

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

Italy

During the initial part of the pandemic, on 8th March 2020, the Italian government passed emergency legislation that, among other measures, restricted family and visitor access to Long-Term Care Facilities (LTCF), giving the administration of the LTCF the power to authorise visits, usually in end-of-life situations. Data from a care home survey showed that 88.8% if care homes interviewed had already restricted visits before the 9th March 2020.

A government circular in November 2020, recognised the importance of family and friends’ visits and provided guidance  to prevent the negative impacts of social and emotional isolation on the health, cognitive function and wellbeing of residents in LTCFs. The circular also included guidance to reduce the risk of transmission during visits. This document was the first time that the rights of care home residents to communication and social interaction had been recognised in an official document.

In May 2021, the Ministry of Health signed a new resolution that re-opened nursing homes to those relatives holding a “green certification”. This is a new national pass that asserts that the person either has been vaccinated, has already contracted and recovered from Covid-19 in the past, or has received a negative Covid-19 test within the previous 48 hours. Additionally, this resolution contains guidance on the procedures for residents going back to their houses.

From December 30th 2021 nursing home visitors need to have either a “super green pass” (two doses or a booster, or two doses and a negative test).

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

https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: December 29th, 2021   Contributors: Eleonora Perobelli  |  

Japan

Facilities implemented well-established policies to restrict visits, as used in times of influenza or TB outbreaks. These policies were triggered swiftly (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 8th, 2021

Kenya

As of June 2021 in Kenya, visiting care homes is highly discouraged, especially for individuals who have not undergone Covid-19 testing. The purpose of this guidance is to limit the exposure for residents. Covid-19 cases within care homes are quarantined in a well-ventilated room with a washroom. The Ministry of Health has provided guidelines to manage visitors for those in isolation due to suspected or confirmed Covid-19 infection. Visitors are limited to those providing care and support to those in isolation, with visitors having to wear masks and practice hand hygiene when they leave the isolation centre. Additionally, effort should be made to reduce the frequency of movement in and out of the isolation facility (Ministry of Health, 2020).

Sources: https://ltccovid.org/wp-content/uploads/2020/06/COVID-19-and-Long-Term-Care-in-Kenya-30-May-1.pdf and https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: November 2nd, 2021

Malaysia

In July 2021 the country was under its third lockdown. Intensive care units were full for the first time ever. The only visitors to care homes at the time were the vaccination teams. No other visitors were allowed and there were no plans to revise the ‘no visitor’ policy in Malaysian care homes.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Malta

In July 2021, despite all older persons who had wished to avail themselves of the vaccine having been able to do so, older persons were still not allowed outside the care homes.  Older persons have been confined in their respective care homes, at times also confined in their own rooms only, since March 2020.

With respect to visiting in care homes, (1) visits are currently allowed for 25 minutes 3x per week where 2 members of the same household are allowed time with the older person, (2) for older persons living with dementia, they will be allowed 15-minute visits every day with 2 members of the same household (3) for both instances, visits take place either behind Perspex or at a safe 2m distance within the care home’s common area as visitors are not allowed in the older person’s room.

Moreover, the Minister responsible for the older persons has indicated that vaccinated individuals will be given priority to visit their loved ones, when the care homes open ‘properly’ in the coming months.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Netherlands

The Netherlands was one of the first countries where, under strict conditions set by the Dutch government, the visiting ban in care homes was lifted and its impact was assessed scientifically (Verbeek et al., 2020). In October 2020, the Dutch Parliament accepted the Corona Act, a temporary legislation prohibiting complete lockdowns in care homes (Koopmans et al., 2021). The Act guarantees that each resident has the right to welcome at least one visitor in the case of COVID-19 outbreaks.

In October 2020, five months after the visiting ban in Dutch nursing homes had been lifted, there were still found to be consequences for residents, family members and staff. Although complete visiting bans are indeed prevented, not all nursing homes felt prepared for welcoming visitors in case of new COVID-19 infections (Backhaus et al., 2021).

Data collected in March and April 2021 showed that a high proportion of care homes had adjusted their visitor policies after vaccinations. Nevertheless, many restrictive rules were still often in place. For example, residents were not allowed to hug visitors, or visitors were not allowed to stay for dinner. Most nursing homes did not have concrete plans or protocols on how to further ease the protective measures and policies (Hamers, Koopmans, Gerritsen, & Verbeek, 2021).

References:

Backhaus, R., Verbeek, H., De Boer, B., Urlings, J. H. J., Gerritsen, D. L., Koopmans, R. T. C. M., & Hamers, J. P. H. (2021). From wave to wave: a Dutch national study on the long-term impact of COVID-19 on well-being and family visitation in nursing homes. BMC Geriatrics, 21(1). doi:10.1186/s12877-021-02530-1

Hamers, J., Koopmans, R., Gerritsen, D., & Verbeek, H. (2021). Gevaccineerd, en nu?

Koopmans, R. T. C. M., Verbeek, H., Bielderman, A., Janssen, M. M., Persoon, A., Lesman-Leegte, I., . . . Gerritsen, D. L. (2021). Reopening the doors of Dutch nursing homes during the COVID-19 crisis: results of an in-depth monitoring. International Psychogeriatrics, 1-8. doi:10.1017/s1041610221000296

Verbeek, H., Gerritsen, D. L., Backhaus, R., De Boer, B. S., Koopmans, R. T. C. M., & Hamers, J. P. H. (2020). Allowing Visitors Back in the Nursing Home During the COVID-19 Crisis: A Dutch National Study Into First Experiences and Impact on Well-Being. Journal of the American Medical Directors Association, 21(7), 900-904. doi:10.1016/j.jamda.2020.06.020

Last updated: November 29th, 2021

New Zealand

In New Zealand areas are grouped into different Alert Levels. At Alert Level 1 visits are possible following a set of hygiene rules and some providers may also put in place some additional precautions. At Alert Level 2 visits may only be possible for designated visitors and there may a limit on the number of visitors being in the building at the same time as well as limits to length of visit and places where visits can take place (https://covid19.govt.nz/everyday-life/parents-caregivers-and-whanau/visiting-an-aged-residential-care-facility/).

Last updated: September 8th, 2021

Norway

There are no national restrictions on receiving visitors in care homes. However, local authorities may re-introduce some restrictions if a local outbreak of infection takes place – as, indeed, a few municipalities have done since mid-November 2021, due to recent local outbreaks of COVID-19. For example, in Bergen, Norway’s second-largest city, both care home staff and visitors have been required to wear face masks since 22 November.

The Norwegian Directorate of Health has issued a statement declaring that residents in care homes have the right to receive visitors.

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

Poland

In the spring of 2020, the recommendations of the Ministry of Family, Labor and Social Policy included recommendations concerning the limitation of visits to and admission to Nursing Homes by unauthorized persons, as well as leaving the facilities by residents. In most local municipalities visiting bans had been introduced, in some areas visitors had been subjected to rapid testing before meeting residents or meetings were held only outdoors, with sanitary regimes applied. Due to the limitation of real contacts, care homes have been obliged to ensure the possibility of maintaining relationships with relatives via telephone or the Internet. However, in the face of the limited staff there were problems in ensuring contact. Ban on leaving institutions posed additional problems, and some local policy makers noted that there was no clear legal basis for restricting the rights of home residents to leave the premises (source: Domy-pomocy-spolecznej-w-dobie-pandemii-19-11.pdf (hfhr.pl).

Last updated: November 2nd, 2021   Contributors: Joanna Marczak  |  

Republic of Korea

Visiting policies for care homes have been fluctuating in line with the severity of cases. In March of 2021, the MoHW announced its plan to promote on-site visits for families after confirming negative for COVID19. However with the increase in community infections, no official policy was set forth regarding the visits. During the national holidays of Chuseok in September, family visits to LTCHs and LTCFs were made temporarily viable (9/13~9/26) for those whom both the resident and visitor were completely vaccinated.

As of December 2021, most facilities are carrying out remote visits through facetime and on-site visits are restricted.

Last updated: January 26th, 2022   Contributors: Hongsoo Kim  |  Jae Yoon Yi  |  

Singapore

In-person visits to nursing homes were suspended for just over two months during the Circuit Breaker Period (April to June 2020). In July 2020, nursing home residents could ‘receive one of two designated visitors for 30 minutes each day.’ Visitors were asked to make appointments so that nursing homes could manage the number of people present (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Following an increase in infection rates in September 2021 there has been a total ban on visiting in acute hospitals and care homes, with exceptions for critically ill residents. This ban was in place until 21st November 2021. Since then, visits are now only allowed when both the care home resident and the visitor are fully vaccinated (unless either of them is not medically eligible for vaccination). Only one designated visitor is allowed per visit and visits have to be under 30 minutes long. Visits are to be suspected when there is an active COVID-19 cluster in the home. Care homes are asked to continue to support alternative methods of communication.

Last updated: February 11th, 2022

Slovenia

In July 2021: Visits will take place in the premises of the centre for all residents, mostly from 09:00 to 18:00. One or two healthy people are allowed to visit together. The body temperature of the visitors is measured upon arrival. They must also sign a statement that they will follow the stated rules, that they have not been in contact with a Covid-19 infected person in the last 14 days, and that they will follow all instructions of competent institutions during the epidemic.

Visits are carried out outside or in the common areas of the home on the ground floor or at the reception. For the departure of residents to a home environment, they can talk individually with social services. At the time of the departure of the resident, the relatives are obliged to ensure that all preventive measures are strictly observed. At the same time, it is recommended that the resident does not come into contact with a large number of people in a home environment. In accordance with the recommendations of the medical profession, the essential preventive measures include limiting contact to a small number of people, maintaining appropriate distance, wearing a mask, and ventilation of the premises.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

South Africa

In June 2021, the country is at level 1 restriction, which eases restrictions on movements.  Residents are allowed to receive visitors, whilst maintaining Covid-19 safety protocols. Visits are undertaken in controlled isolated areas, mostly indoors, with no hugging allowed. If residents go home to their family, they are expected to isolate for ten days upon return. The extent to which care homes have ‘opened up’ varies from facility to facility. There is renewed fear of a third wave of Covid-19 infections, due to a 39% increase in cases over the last week, which would bring with it stricter controls on movement, especially in care homes.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

Spain

Visiting in care homes has been severely restricted between March 2020 and February 2021, although many care homes maintained very restrictive regimes for longer (Zunzunegui, 2022)

The recommendations from the Ministry of Health on care home visits have not been adopted uniformly in the different Autonomous Communities, with some being more restrictive. In practice care homes have developed and applied their own policies, as long as these were also more restrictive than the national or regional policy.

As of July 2021, in principle, care home residents are able to receive visitors and are able to themselves go on outings, always with appropriate protective measures. Before vaccination, visits were restricted. However, following vaccination there have been efforts to recover normal visitation schedules that have not been observed since before the pandemic. Both short and long outings are allowed.

References:

Zununegui M.V. (2022) COVID-19 en centros residenciales de personas mayores: la equidad sera necesaria para evitar nuevas catastrofes. Gaceta Sanitaria 36(1): 3-5 DOI: 10.1016/j.gaceta.2021.06.009

Last updated: January 21st, 2022

Catalonia (Spain)

In June 2021, care home residents are able to receive visitors and are able to themselves go on outings, always with appropriate protective measures. Before vaccination, visits were restricted. However, following vaccination there have been efforts to recover normal visitation schedules that have not been observed since before the pandemic. Both short and long outings are allowed (https://canalsalut.gencat.cat/web/.content/_A-Z/C/coronavirus-2019-ncov/material-divulgatiu/gestio-infeccio-coronavirus-ambit-residencial.pdf).

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

Sweden

Sweden implemented a ban of visiting care homes from 1 April 2020. These measures were lifted on 1 October but have been put in place again in some places in November 2020. The government provided Public Health Authority with the power to enact local bans (https://www.government.se/articles/2020/04/s-decisions-and-guidelines-in-the-ministry-of-health-and-social-affairs-policy-areas-to-limit-the-spread-of-the-covid-19-virusny-sida/; https://www.euronews.com/2020/11/25/serious-deficiencies-sweden-s-retirement-homes-under-fire-over-coronavirus-care; https://www.thelocal.se/20201120/sweden-brings-in-local-visit-bans-to-elderly-care-homes/). The Public Health Agency has initially advised against visiting care homes for older people. The Government subsequently introduced a corresponding ban by means of an ordinance (from April 1). However, no ban has been introduced on visiting residential accommodation for people with disabilities. Overall, government issued guidance for ‘special risk group’ including people over 70 and younger with underlying health conditions to limit their social contacts (https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf; https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

It has never been forbidden for care home residents to leave their care home, and from December 2020, a care home or a municipality cannot decide on imposing visitor restrictions visitors on their own. Instead, if there is a local outbreak, a care home that wants to restrict visitors has to prove that they have done what they can to arrange safe visits, and only thereafter can they ask for temporary permission from the national public health authority to restrict visitors. At the moment one municipality has restrictions (https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/covid-19/information-till-varden/personal-inom-aldreomsorg/lokala-besoksforbud-pa-aldreboenden/).

On 31 May 2021, the possibility for municipalities to request the Public Health Agency to temporarily ban visits to nursing homes came to an end. The repeal of the regulation is based on the improved epidemiological situation, the increasing vaccination coverage and the continued high compliance with other rules and recommendations (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021

Switzerland

During the first wave some nursing homes and care homes for older people took the radical step of shielding their residents entirely by not letting them see visitors or leave the home. This was strongly condemned by many stakeholders, especially the families of residents, residents themselves, and human rights advocates, who emphasised that people’s health and wellbeing should be regarded holistically and included people’s mental health and social wellbeing.

In Switzerland, canton governments have authority to devise visiting policies in care homes and some have delegated decisions about visiting policies to care homes. The Canton of Berne, for example, has since advised against any blanket bans on visiting. Individuals or groups of residents may be obliged to isolate or quarantine if there is a known infection, although it is always possible for relatives to stay if their relative is dying. Care homes also limit the number of visitors per day or make provisions for families and friends to meet outdoors or in larger spaces to reduce the risk of infection.

Source: https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/

Last updated: September 8th, 2021

England (UK)

Current policy

On the 27th January 2022 the Department of Health and Social Care (DHSC) announced that on the 31st January the limit on number of visitors allowed into care homes and also any limits on the number of visits would be lifted. Essential care givers will continue to be able to visit even if a care home has an outbreak.

The decision was announced on the same day that restrictions were listed for the general population. It was accompanied by the announcement of a reduction in the period of self-isolation for care home residents and a reduction in the period of outbreak management rules. Data on the very high share of care home residents who had a booster jab by that date (86.5%) and evidence showing that boosters are highly effective in preventing hospitalisations were cited to support this decision.

The guidance as updated on the 31st of January 2022 is available here.

Previous policies

The initial guidance in England published on March 13, 2020, advised against visits by people who had suspected COVID-19 or were feeling unwell. The main care home chains stopped non-essential visits around that time. Although no formal ban on visits to care homes was issued, the advice was not to visit except in exceptional (usually end of life) situations. The Prime Minister also announced on March 16 that the physical distancing measures should also apply to care homes. Guidance on family visits was issued on the July 22, linking the visiting policy to local levels of risk of transmission and advising that visits were limited to a ‘single constant visitor’.

On October 1, the DHSC announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, which includes enabling safe visiting of care homes.

On October 13, the Care Minister announced the government’s intention to pilot a care home visitor scheme, in which designated visitors would be recategorized as ‘key workers’ and given priority access to weekly rapid antigen tests and PPE.

Following the announcement of the second national lockdown, more than 60 care organisations collectively called on November 3, 2020, for safe visits to care homes to continue. A similar call was made by ADASS. In response to the ongoing restrictions, a high court judge ruled on November 3, that visits to care homes were legal. Following this, government guidance on visiting arrangements were updated on November 5, advising directors of public health and providers to facilitate visiting where possible in a ‘risk-managed way’. There is ongoing concern as to whether the arrangements are sufficiently flexible and sensitive to the needs of people in care homes and their families.

On December 1, DHSC released guidance on arrangements for visiting out of the care home, which was then updated on March 8, 2021. This stated that visits out of care homes should only be considered for care home residents of working age, and although regulations could technically allow residents to form a support bubble with another household, this is not recommended. This suggested that the assumption should be that visiting is allowed unless there is evidence to take a more restrictive approach, where the needs of the individual are balanced against a consideration of the risks to others in the home. For visits to take place, the residents and all members of the household must have had a negative result from a lateral flow device immediately preceding the visit. It is suggested that those involved in the visit should limit the number of people they meet for 2 weeks prior to the visit out. Upon returning to the care home, the resident should self-isolate for 14 days. In the event of an outbreak in a care home, all outward visiting should be immediately stopped.

On January 21, 2021, DHSC released guidance for care homes during the winter. This stated that visits to care homes could take place with arrangements such as substantial screens, visiting pods, or behind windows. This stipulated that end-of-life visits should always be supported.

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 in the form of the Rapid Testing Fund was crucial in enabling safe visits to occur in care homes, because it provided funding to allow every visitor to be tested. This support is due to expire at the end of March.

On March 18, LaingBuisson announced that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund.

Since May 17, every care home resident can nominate up to 5 named visitors who will be able to enter the care home for regular visits (and will be able to visit together or separately as preferred). Residents with higher care needs can choose to nominate an essential care giver who may visit the home to attend to essential care needs. The 5 named visitors may include an essential caregiver (where they have one) but excludes babies and preschool-aged children (as long as this does not breach national restrictions on indoor gatherings). To reduce the risk of infection, residents can have no more than 2 visitors at a time or over the course of one day (essential caregivers are exempt from this daily limit. In August, the guidance removed the advice on the number of ‘named visitors’ and did not limit the number of visitors a resident can have in a single day. The essential caregiver should be able to visit even if there is an outbreak in the home (except where carer or resident are COVID-19 positive), or if the caregiver is not fully vaccinated.

Updated guidance published on November 25, puts more emphasis on visits taking place wherever is most comfortable for the resident and that physical contact should be supported to help health and wellbeing. Visiting restrictions due to an outbreak should only be in place for 7 to 8 days following negative testing. Advice around flu and other transmissible viruses has also been added, along with guidance on how care homes can support residents on visits outside of the care home.

Last updated: March 24th, 2022   Contributors: William Byrd  |  Adelina Comas-Herrera  |  

United States

In the United States visitation guidelines fall into the decision-making power of the different states. States can decide whether they want to issue guidelines across the state or to provide them on an ‘individual facility basis’. A review found that most states leave care homes to make final decision on safe opening procedures (https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf).

CMS guidance on care home visiting from September 2020 can be found here: https://www.cms.gov/files/document/qso-20-39-nh.pdf. As of March 10, 2021, President Biden relaxed the federal guidelines (recommendations) on nursing and long-term care home visiting policies for the first time since September 2020 (https://www.nytimes.com/2021/03/10/us/politics/coronavirus-nursing-homes.html).

Last updated: September 8th, 2021

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

Australia

There has sufficient access to COVID-19 tests – testing has been available for all residents and staff in aged care facilities. Testing is typically only done if an individual shows symptoms or is suspected of having COVID-19. Regular testing for all staff and residents has not been introduced (source: DoH).

Last updated: December 22nd, 2021

Austria

By 16 April 2020, the Austrian government had announced plans that staff and residents in care homes should be systematically tested. A paper reports some reluctance in the implementation of testing in LTC services, especially in community care. However, it was also reported that residents ‘were scarcely tested’ up to January 2021 and that communication of test results did not always happen in good time (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

By November 2020, care home staff had to undergo compulsory testing on a weekly basis, but regulation allowed staff to continue working following a positive test if they do not show symptoms, their Ct value is above 30 and they ware an FFP2 mask (https://ltccovid.org/2020/11/27/the-second-wave-has-hit-austria-harder-also-in-care-homes/).

Last updated: September 8th, 2021

Belgium

For vaccinated residents with symptoms, only a PCR test can be used to detect a possible infection. An antigen rapid test can only be used for non-vaccinated symptomatic residents (symptom duration of maximum five days) and for residents with symptoms just after the first vaccination (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: November 2nd, 2021

British Columbia (Canada)

In care homes: Initially testing was only completed for symptomatic staff and patients, those experiencing “influenza-like illness (ILI) or respiratory symptoms, clients with fever without known cause, and clients experiencing other symptoms possibly due to COVID-19”. Contact tracing was completed by both public health authorities and the LTC facility itself. Residents who share rooms with the infected resident should be considered as exposed and should be monitored for symptoms at least twice a day for 14 days from last date of exposure (http://www.bccdc.ca/Health-Info-Site/Documents/COVID19_LongTermCareAssistedLiving.pdf). Staff wearing all appropriate PPE are not considered a close contact of a patient who tests positive (http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/testing-and-case-management-for-healthcare-workers).

Last updated: November 6th, 2021

Denmark

The general strategies for testing have changed a number of times in Denmark, leading to some criticism for lack of transparency or evidence-based practice. The initial test strategy, introduced in early March, was aimed at preventing the disease from spreading, a so-called confinement strategy. This took place by testing persons who might have been exposed to the disease, even if they did not have symptoms. These were typically persons who were exposed during travelling (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

As of March 15th, the strategy changed to a mitigation strategy, targeting test measures to alleviate the consequences of the disease. Now only persons with symptoms were tested and following a referral from the GP. This led to concerns being raised such as from the WHO, which generally advised a more aggressive testing strategy. Nationally it sparked a debate that the new test strategy was a pragmatic and not a health-based decision, mainly due to a lack of testing equipment (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Since 27 April 2020, residents and staff without symptoms could also be tested if there was an outbreak in the nursing home. Testing must take place at the nursing home and not in the regional test centres, which are set up in tents (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

On May 12th, a new and more aggressive testing strategy was introduced, where persons without symptoms were also tested. The capacity was set to 20,000 persons on a daily basis and the ambition was to increase this number over time. This would make Denmark a country with one of the highest number of tests per inhabitants. There were two tracks in the new strategy:

– A health track, which includes testing of persons with symptoms, as well as employees of hospitals and nursing homes and patients admitted to hospital, even if they do not have symptoms. The test took place at regional hospitals. The capacity for this track was 10,000 daily tests.

– A societal track, which included testing of persons without symptoms. Testing took place in 16 specially set-up tents around the country, some of them with a drive-in facility. The capacity was for an additional 10,000 daily tests. Initially, only those aged 18- 25 years old could asked to be tested. This included around 600,000 persons and 4,500 persons were tested during the first day. During the first week, other age groups were included and, as of 25th May, there were no age limitations. (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Staff, working in the health and elder sector and some parts of the social sector, should be tested twice a week if they are not fully vaccinated. It is essential to implement a systematic, regular solution, which is easily accessible for the staff to secure comprehensive support from the personnel. Fully vaccinated staff can refrain from being tested regularly. This also applies to staff working in nursing homes, assisted living facilities, respite care, and social institutions, and in hospitals and the home care sector. Unvaccinated staff should still be tested regularly (source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

In case of a discovery of a COVID-19 infection among a resident or an employee, all residents, if possible, should be tested within a day after contact with someone infected with COVID-19. The test is then repeated for the residents who are not fully vaccinated, every 7 days, until there are no more instances of COVID-19 at the institution. Personnel, including temporary staff and cleaning staff have to get tested even if they have no knowledge of being in contact with the person concerned and are fully vaccinated. The test must be taken as quickly as possible. Preferably within a day after they have received information, they must get tested. The test must be repeated every days for the personnel who are not fully vaccinated until there are no more outbreaks at the institution. It is a case of extra testing on the basis of caution, and the test does not require self-isolation for the staff member/s who can work while they wait on their test results (source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: May 25th, 2023

Finland

Access to testing in Finland was at first relatively restricted and has been steadily increasing. Nearly 3.2 million tests for COVID-19 have been conducted as of February 21st, 2021, but the increase in access to test only began in late July 2020 (https://experience.arcgis.com/experience/92e9bb33fac744c9a084381fc35aa3c7).

Last updated: September 8th, 2021

France

As with guidance, the sector decried that testing for care homes and in the community was made widely available too late – guidance published on 21st March 2020 limited tests only to symptomatic older people. Changes were made in April to grant priority access to testing for care home workers and residents, to test and isolate the first symptomatic care home worker (leading to isolation of all workers) and the first symptomatic older person, and the following three. On 20th April 2020 pressure was raised to extend tests beyond the first three residents as many asymptomatic cases were missed (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It was only from 6th May that all contacts of symptomatic cases were tested (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It is unclear how much testing was allowed for domiciliary care workers.

Last updated: September 8th, 2021

Germany

The German Federal Ministry of Health has put in place a national testing strategy. Testing is to be provided and paid for by the sickness funds for people with COVID-19 related symptoms, people without symptoms but close contact to a person infected with COVID-19, people in shared social  spaces (e.g. schools, day care centres, refugee centres, prisons) if a positive case has been recorded, staff, patients/residents in residential care settings/hospitals following an outbreak, patients/residents before (re)-entering residential or ambulatory care and staff of health and long-term care setting. Some groups/circumstances are only eligible for rapid tests. (https://www.bundesgesundheitsministerium.de/coronatest.html).

Rules vary between federal states, but LTC staff working in residential or domiciliary care settings have to be tested regularly (https://pflegenetzwerk-deutschland.de/fileadmin/files/Corona/210317-Uebersicht-Testfrequenzen-Laender.pdf).

Health authorities are responsible for contact tracing. Earlier in the pandemic teams were expanded to at least 5 people per 20,000 residents. In addition, affected areas received support from additional teams as well as the armed forces. An app was also been issued to facilitate contact tracing. However, rates have been consistently too high to ensure that contact tracing can be done consistently. It is estimated that all contacts can be traced again when a seven-day incidence of 50 new infections per 100,000 people or below is reached again. The federal government is supporting the individual states (https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1841048https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1744224 ). A new open-source software was due to be issued to local health authorities, however, so far this software does not offer all promised features and has not been consistently taken up by all health authorities. Other associated costs will be covered by the federal ministry of health (https://www.aerztezeitung.de/Politik/Warum-die-einheitliche-Corona-Kontaktnachverfolgung-holpert-416538.html).

Robert Koch Institute guidelines recommend that contact tracing in residential care settings should be prioritised. The guidelines outline the different levels of contacts and outline responsibilities of the health authority (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Kontaktperson/Management.htmhttps://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFilel).

Two-third of care homes surveyed as part of a study conducted in April/May had implemented clinical monitoring and found that it took on average between 3 and 4 days for care workers and people who use LTC to learn the results of their COVID-19 test (https://www.uni-bremen.de/fileadmin/user_upload/fachbereiche/fb11/Aktuelles/Corona/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

Last updated: September 8th, 2021

Ireland

From late March 2020, staff and residents of nursing homes were among the groups prioritised for testing. ‘Assessment and testing pathways’ for residents showing symptoms of COVID-19 in residential care settings were issues by the Health Service Executive. By early April, it was recommended that care home staff should be screened twice a day, and that staff should be prioritised for testing (https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: November 2nd, 2021

Israel

Access to testing in Israel was considered slow in Spring 2020, and ramped up by summer with the promise of 20 million tests by the end of 2020.

The national task force for managing the pandemic in the LTCFs (‘The Fathers and Mothers Shield’) changed the testing policy in early May 2020 from testing symptomatic staff and residents to regular screening regardless of known COVID-19 presence. Numbers gathered from these screenings were deemed key figures in determining potential outbreaks, and rates of illness decreased dramatically (and proportionally with the nationwide numbers) by early June 2020.

Last updated: December 5th, 2021   Contributors: Shoshana Lauter  |  

Italy

During the first wave in 2020, testing was not available for Long Term Care Facilities (LTCFs) and this has been considered as one of the main causes of the high mortality rate registered in LTCFs in the first months of 2020. From the second wave onwards, regional guidelines have been implemented that give LTCFs preferential access to testing.

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

Japan

Japan did not pursue a policy of mass testing, instead focusing on the 3Cs (closed space, crowded places, close contacts (https://www.mhlw.go.jp/content/3CS.pdf) and pursuing rigorous retrospective tracing) (https://thediplomat.com/2020/06/japans-pragmatic-approach-to-covid-19-testing/).

Last updated: September 8th, 2021

Netherlands

Access to testing was limited in the beginning of the pandemic and restrictive policies prevented access to testing for care homes. Testing capacity was limited and restrictions lasted until June. 2020. A new testing policy announced on 6th April 2020 allowed all healthcare workers (including LTC staff) to get tested when they developed symptoms (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf).

Criteria for testing have been broadened over time but testing capacity remained a challenge (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 8th, 2021

Republic of Korea

South Korea is notable for the speed of their drive to mass test, as early as February/March 2020. The government built hundreds of high-capacity screening clinics and worked closely with the private sector to ensure an adequate supply of tests. This enabled early testing of care home residents and staff. In March 2020, at one care home in Daegu, more than 70 patients and employees tested positive for the contagious disease, including 17 staff (https://world.kbs.co.kr/service/news_view.htm?lang=e&Seq_Code=152108). Diagnostic tests were conducted for 460 inpatients in LTCHs who were being treated for unknown pneumonia, as early as 5th March 2020. According to the Korean Convalescent (long-term care). In October authorities focused COVID-19 testing on all employees and patients of long-term care hospitals, mental health care providers and care homes located in the wider capital area, totalling around 160-thousand people (http://world.kbs.co.kr/service/news_view.htm?lang=e&id=Dm&Seq_Code=156889).

Regarding ‘healthcare workers’ operating across various settings including long-term care centres, there were clusters of outbreaks in Daegu within long term care centres. The government tasked health officials with conducting universal Covid-19 tests by RT-PCR for everyone in those facilities. Confirmed Covid-19 patients were transferred to a designated Covid-19 hospital or a community treatment centre. These centres with outbreaks were reinspected regularly. (https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0159).

The central and local governments respond to infected cases rapidly by tracing each case and isolating contacts. For the epidemiological survey, interviews are conducted with patients, families, and also healthcare workers, if necessary more objective data including medical records, mobile GPS, CCTV, credit card records, etc., may be collected and verified. Information about the travel routes of infected cases is provided on a website run by the government, in which no information that can identify a person is provided.” (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: September 8th, 2021

Singapore

In April 2020 Singapore started routine testing of residents who showed COVID-19 relevant symptoms. At the end of April 2020 routine testing of all staff and residents began. Testing and follow-up treatment for those with positive results identified through this surveillance mechanism were provided for free by the government.

In addition, the Ministry of Health and the Agency for Integrated Care have ‘worked with the regional hospitals to train nurses in care facilities and nurses in three home care providers in testing and to support the development of ‘mass swabbing workflows’. The Agency for Integrated Care took on the coordination of sending the samples to the National Public Health Laboratory (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: November 2nd, 2021

Sweden

The Corona Commission and other reports elaborate on shortcomings in testing strategy, particularly a scarcity of testing kits at the beginning of the pandemic. During the peak of the first wave in April, care home residents, homecare users and eldercare staff were not prioritized for testing. The Swedish Public Health Agency’s testing strategy was initially focused on active infection tracing, from mid-March patients who came to the hospital were tested first, followed by hospital employees, and those with community-leading occupations, followed by social care staff. Municipalities and social care providers could buy tests from private companies to test social care staff and service users. However, it was not until June 2020 when the government advocated increased testing activities and promised to cover the costs. The Swedish Public Health Agency was criticised for not giving clear signals earlier to the regions to increase the testing rate and although the agency pointed out that it did not want to overburden the healthcare system, it admitted that testing of, for example, staff in long-term care should have been started earlier. Overall, by the time of the second wave tests are widely available e.g. citizens can test themselves with home test kits delivered to their doors

Sources: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf;

https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf;

https://www.vilans.org/wp-content/uploads/2020/12/covid-19-in-long-term-care-until-october-31.pdf

Last updated: November 23rd, 2021

England (UK)

Limitations on testing capacity meant that the initial workforce testing strategy focused on NHS workers with symptoms. This was extended to social care workers (with symptoms) from April 15, 2020, and on April 28, a policy of one-off whole home testing was announced for all staff and residents of care homes with residents over 65 or with dementia. An online portal was launched on May 11 to help care homes arrange deliveries of test kits.

Although testing capacity was increasing, this was not without problems. The BBC reported that on April 22, 159 out of 210 care providers contacted about testing reported that none of their staff had received a test. On May 12, the Guardian reported that care home operators accused the government of “a complete system failure” regarding the promised testing in care homes. According to this article, only tens of thousands had been tested so far, leaving many vulnerable people at risk. Different government agencies were accused of passing responsibilities to each other. A survey of 43 English care home managers, which was conducted at the end of May and early June 2020, found that only 40% had accessed testing of asymptomatic residents and 50% of asymptomatic staff. At that time, only 36% of residents had been tested, with many describing a chaotic and poorly co-ordinated service, and only 10% of care homes surveyed had successfully tested all residents in their care home (Rajan et al. 2020).

On June 8, 2020, the Government announced that all remaining adult care homes would be able to access whole care home testing for all residents and asymptomatic staff through the digital portal, including adult care homes catering for adults with intellectual disabilities or mental health issues, physical disabilities, acquired brain injuries, and other categories for younger adults under 65 years old. It should be noted that these ‘whole care home’ testing arrangements do not apply to supported living settings, extra-care settings, and domiciliary care. In these situations, individual tests can be applied for through self-referral. From 3 July, care home staff were promised weekly testing, but domiciliary care staff were still only eligible for free testing if symptomatic, as the general population.

In light of advice from the Government’s Scientific Advisory Group for Emergencies (SAGE) and results from the Vivaldi 1 study, regular retesting of staff and residents in care homes for over 65s and those with dementia was announced to be implemented from early July. The Times reported that this had been delayed until September, with promises of new rapid point of care tests, although these had yet to be formally approved and questions remained about the most suitable and safe tests for such a vulnerable setting.

On December 23, the Department of Health and Social Care (DHSC) announced £149 million to support the rollout of Lateral Flow Device (LFD) testing in care homes. 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. Care homes currently have access to 3 tests per week for their staff, with daily testing for 7 days in the event of a positive case. Care homes will have additional LFDs to test individuals working in more than one setting before the start of every shift.

On February 16, 2021, DHSC published guidance announcing that weekly COVID-19 testing is to be made available to personal assistants working in adult social care in England. After testing positive, a person does not need to test again for 90 days unless they become symptomatic. This guidance gives personal assistants responsibility for informing their employers if they receive a positive result.

On January 17, 2021, DHSC announced a £120 million Workforce Capacity Fund to help local authorities to boost staffing levels, so that safe and continuous care is achieved by all providers of adult social care. If the specific way in which staff capacity is strengthened means that they do not have access to routine asymptomatic testing or LFD testing, then it is suggested that the local authority could use their allocation of LFD tests for routine testing.

On March 5, DHSC published guidance on LFD testing in adult social care settings. This stipulated that it is necessary to obtain consent before residents and staff are tested and their results shared. If a person receives a positive result from a LFD, then they will need to take a confirmatory PCR test and immediately self-isolate. With a negative test, the person can stop self-isolating but must continue to follow national and local rules and guidelines.

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 in the form of the Rapid Testing Fund was crucial in enabling safe visits to occur in care homes, which is due to expire at the end of March.

On March 18, LaingBuisson announced that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund.

Published on November 3, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. A further £388.3 million in further funding to support IPC, testing and vaccination uptake in adult social care settings will be provided. Regular asymptomatic COVID-19 testing will be maintained throughout winter for all staff and unpaid carers in adult social care, as well as more intense testing regimes in settings deemed higher risk, in line with clinical advice. Additionally, £126.3 million will be provided to continue to support the sector to deliver COVID-19 testing from October 2021 to the end of March 2022.

Access to testing: impact on mental health

Nyashanu et al. (2020) collected data through interviews with forty healthcare workers from nursing homes (n = 20) and domiciliary care agencies (n = 20) in the English Midlands in the early phase of the pandemic (before May 2020) to explore triggers of mental health problems. Participants reported experiencing distress and anxiety caused by unreliable testing and delayed or false results. Delayed results meant that healthcare workers who had been tested were delayed in their return to work, which led to further staff shortages – another cause of stress.

References:

Nyashanu, M., Pfende, F., & Ekpenyong, M. S. (2020). Triggers of mental health problems among frontline healthcare workers during the COVID-19 pandemic in private care homes and domiciliary care agencies: Lived experiences of care workers in the Midlands region, UK. Health & Social Care in the Community. https://doi.org/10.1111/HSC.13204

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

Last updated: March 24th, 2022   Contributors: William Byrd  |  Chris Hatton  |  Daisy Pharoah  |  

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

Overview

The OECD report on COVID-19 in Long-term care provides a good overview of international experiences in access to PPE. They found that access to Personal Protection Equipment (PPE) was a challenge in almost all countries at the beginning of the pandemic, although the situation improved over time. In many countries PPE had been prioritised for hospitals, leaving long-term care services facing severe difficulties. There some exceptions, such as Korea, where by early March 2020, the Central Disaster Management Headquarters had established a working group and IT system to distribute 5.46 million masks to long-term care providers.

In most countries providers of community or home based services had relatively little public sector support to obtain and pay for PPE.

Evidence from the United States   found that nursing homes with at least 1-week supply of PPE were less likely to have staff shortages during the pandemic (Xu et al., 2020).

References:

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

 

International reports and sources

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.

Australia

The Australian government worked with state and territory governments since the beginning of the pandemic to provide aged care facilities with PPE. As of October 2, 2020, 17 million masks, 4 million gowns, 11 million gloves and 4 million goggles and face shields had been provided to aged care facilities. But, even with this support, unions consistently reported PPE shortages within the facilities (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

British Columbia (Canada)

Health authority owned and operated facilities were supported in procuring PPE, managing staffing availability, and IPC education and training, whereas private and affiliate sites felt that they were left to manage independently unless an outbreak occurred. For example, one Health Authority provided PPE to private providers with 3 days notice, where others only provided supplies to health authority owned and operated facilities. Private LTC providers were left to source PPE through local community initiatives or unauthorized distributors, which often did not meet proper IPC requirements. Two policies were introduced regarding PPE: Emergency Prioritization in a Pandemic Equipment (PPE) Allocation Framework March 25, 2020 and Personal Protective Equipment (PPE) Supply, Assessment, Testing and Distribution Protocol May 1, 2020 (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: November 9th, 2021

Denmark

The shortage of PPE (and a decision to prioritize PPE for the hospitals) has influenced the recommendations for how to handle the disease in the nursing homes. Initially, physical distance was considered sufficient but later (when the supply of PPE seemed sufficient), wearing PPE was considered essential and regardless of whether there were symptoms of the disease. The reason for the shortage of PPE in the municipalities was that early in the outbreak (March 10th, 2020), the Danish Medicines Agency approached the providers of PPE and asked them to prioritize delivery to the regions and therefore for hospitals. The municipalities therefore needed to find other providers and this led to a shortage of PPE in the municipalities (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: May 25th, 2023

Finland

Access to PPE was an issue for Finland early on. In late March, the Ministry of Social Affairs and Health (MSAH) requested that the National Emergency Supply Agency release and distribute its stockpile to university hospital districts and municipalities. After expressed concern over lack of PPE in social care services/spaces, MSAH conducted a survey of municipalities that revealed 67% of respondents felt it impossible to follow the pandemic regulations, mainly because of a lack of protective equipment. For that reason, on May 13th the ministry mandated that the use of protective equipment was obligatory.

Source:

https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view, page 27.

Last updated: November 23rd, 2021

France

Access to PPE was delayed across the social care sector and is considered by the Senate as the key explanation behind the high level of Covid-19 infection in care homes (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). Until the end of April 2020 there were large insufficiencies in the provision of PPE despite a communication on 13th March stating care homes would have access where need was identified, and central/local conflicts, for example with the state requisitioning regional circuits to social care settings. Domiciliary care settings were hardest hit by PPE crisis, for example with guidance to local pharmacies holding masks to limit use to domiciliary care workers. Some domiciliary care agencies estimate the PPE received covered only 40% of their needs. Even where masks were allocated additional PPE including glasses and FFP2 masks and gowns were not accessible (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). One inspection authority followed employment regulation and condemned a domiciliary care agency for not having provided adequate PPE to employees (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Last updated: November 9th, 2021

Germany

Across Germany people need to wear surgical or FFP2-masks in public transports and shops since 19 January 2021.

Occupational Health and Safety Regulations stipulate that staff in care homes (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-stationaer_Download.pdf?__blob=publicationFile) and in home care (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-ambulant_Download.pdf?__blob=publicationFile) have to wear FFP-2 masks. In addition, full PPE has to be worn in high risk situations.

At risk groups (people aged 60 and older), people with specific medical risks and people with limited means (recipients of benefits) in Germany receive FFP2 masks for free (https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/schutzmv.html?fbclid=IwAR1ZsHTuu5cNRkbvqnAlRul821iBgJfopUoqu00ygGcODkuAG3ZalNltbXk).

The Federal Government has increased its stock of PPE and increased distribution as infection rates were rising in Winter 2020. The Federal Ministry of Health has also purchased rapid tests to facilitate opening up social life again (https://www.covid19healthsystem.org/countries/germany/livinghit.aspx?Section=2.1%20Physical%20infrastructure&Type=Section). However, rapid tests promised to the German population free by the Federal Minister of Health of charge from 1 March 2021 have been delayed. According to figures for the ECDC Germany is 22nd out of 27 countries in terms of testing (https://www.zdf.de/nachrichten/politik/corona-spahn-schnelltests-verschoben-100.html).

At the beginning of the pandemic federal states have taken different routes to support care providers with protective equipment. A detailed overview can be found here: Lorenz-Dant, 2020).

A study conducted among LTC workers between April and May 2020 showed that respondents found procurement of PPE was quite laborious. Respondents would have preferred a centralised storage and distribution system. Respondents also requested systematic and regular COVID-19 tests as well as rapid tests and improved communication of test results (https://link.springer.com/article/10.1007/s00391-020-01801-7 ).

Already in February 2020, Germany was involved in plans to procure protective equipment for medical staff through a joint European initiative.  In early March 2020, Germany prohibited the export of protective equipment to other countries and the Federal Ministry of Health took responsibility to procure protective equipment for doctors’ surgeries, hospitals and federal authorities (https://www.bundesgesundheitsministerium.de/coronavirus/chronik-coronavirus.html).

References

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  

Hong Kong (China)

Following a survey by the Hong Kong Social Workers and Welfare Employee Union in February 2020 that showed more than one quarter of respondents did not receive adequate PPE from their organisations, the Social Welfare Department gave 3 rounds of special allowances to procure PPE and sanitising items (total costs HK$34 million) to residential care homes for older people, community care providers and others. In additional, all residential care units were informed that they would receive 1 million face masks (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: November 9th, 2021

Israel

Israel faced limited PPE alongside most of the globe during its first lockdown in March/April. Equipment was scarce, especially in hospitals and other health providers treating patients. In April 2020, the LTCF Association submitted an ‘urgent petition’ to the Israeli Supreme Court, which included an emergency budget for protective gear. The petition was rejected but became one of the main objectives of the national task force that organized central purchase of PPE for all LTC institutions and also surpervised the management of the PPE stock in all LTC facilities. (Tsadok-Rosenbluth et al, 2021). Little has been reported on the matter since, except for some coverage in September that indicated a shortage of gloves and robes/protective suits headed into the second wave (source: Times of Israel).

Last updated: December 5th, 2021

Italy

Another relevant issue in Italy was the lack of Personal Protective Equipment (PPE) for Long Term Care services, including care home workers. Italy faced an enormous shortage of masks, tests, gowns, which deeply affected the social care and healthcare personnel. New PPE supplies were primarily directed to hospitals and nursing homes were left struggling to find the adequate equipment to protect their workers and residents. In the Lombardy Region, the first supply of masks for nursing homes arrived on the 12th of March 2020 but proved to be insufficient to cover their actual needs. In the national ISS survey, respondents stated that some of the major problems encountered during the crisis were related to the weak guidelines given to limit the spread of the disease, the lack of medical supplies, the absence of care workers, and the difficulty to promptly transfer positive patients into hospitals. All of these factors were considered to have allowed the virus to spread in LTC facilities, resulting in an incredibly high number of infected residents and care personnel, together with high mortality.

In 2021 PPE shortages are no longer an issue, but acquisition of the materials needed is still the responsibility of care providers.

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

Japan

Last updated: November 9th, 2021

Republic of Korea

By early March 2020 Korea had a strategic plan to distribute supplies of PPE: the Central Disaster Management Headquarters established a working group and IT system to distribute 5.46 million masks to long-term care providers.

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: November 25th, 2021   Contributors: Elisa Aguzzoli  |  

Netherlands

PPE was scarce in the early months of the pandemic and hospitals were given priority in government efforts to alleviate the problem. This was reinforced by regional networks of emergency care (ROAZ) being given responsibly for distributing PPE, which disadvantaged LTC. During the first wave, 90% of masks went to hospitals and only 10% to nursing homes. Care homes were asked to make their equipment available to hospitals (https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

During the first wave it was reported that the use of PPE was strictly regulated due to shortage, could only be used under specific circumstances. Only those LTC personnel that were at risk received PPE. The Dutch Health and Youth Inspectorate inquired whether the LTC providers have sufficient PPE (24th April 2020) (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf).

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 that there were still PPE shortages at that stage and costs were high. This resulted in Outbreak Teams considering the sterilisation and reuse of PPE (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

Pakistan

Speaking to authors of a recent report in May 2020, the owner of an old age home indicated that the government had not issued any particular Standard Operating Procedures for old age homes. They also had not yet been contacted for masks or safety kits – it was therefore left to the old age home to purchase overpriced masks to keep residents and staff safe. The owner of the home added that a health advisory was issued by the government to some shelter homes, even though the residents of such homes are more capable of looking after themselves than those in old age homes, where risks are doubled due to a reliance on receiving care (The Global Platform Reader).

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

Poland

Lack of PPE in care homes has been a challenge, partly addressed by donations from private companies, NGOs and individuals donors. Lack of procedures for coordinated/joint purchases of PPE equipment for several care homes made it harder for individual care home facilities to get adequate PPE supplies (sources: Domy-pomocy-spolecznej-w-dobie-pandemii-19-11.pdfLong-term care report – Publications Office of the EU).

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

Singapore

Already in 2018, Singapore introduced National Infection Prevention and Control Guidelines for Long Term Care Facilities. In addition, the Agency for Integrated Care provided webinars to review practices outlined with care providers and to provide up-to-date guidelines. In addition, the Ministry of Health issues current advisories.

The Agency for Integrated Care also drew on the national stockpile to ensure that all nursing homes, irrespective of provider, had sufficient levels of PPE. The supply of PPE was provided based on ‘the facilities’ staff size and level of precaution required of specific care services’.

Source:

https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf.

Last updated: November 23rd, 2021

Spain

TheReport of the Covid 19 and residences working group ” highlighted the difficulties care homes encountered sourcing effective PPE for their staff during the first wave of the Covid-19 pandemic; especially between March and mid-April 2020. During the first wave, care homes that did not purchase PPE in January or early February at the latest, were unable to obtain PPE afterwards. At the time, there were reports of plastic bags being used instead and of the sharing of masks between staff (Del Pino et al., 2020). The lack of supply from abroad was due to the global lack of resources.

However, there are examples of hospitals providing some of their own PPE to local care homes in the early part of the pandemic (Saez-Lopez, 2021).

While massive global demand for PPE is difficult to manage, especially if sufficient stock has not already been procured, the report recommends that an essential part of contingency planning is to ensure a sufficient stock of PPE that should last at least one month. This includes PPE for residents, care home staff and family members in the event of an outbreak that affects large numbers of residents.

The report also recommends offering training about COVID-19 and its transmission to all care home care home staff, as well as training in the use of PPE. The report also states that it is especially important for care home staff to be provided with PPE when treating infected residents

References:

Del Pino E., Moreno-Fuentes F.J., et al. (2020) Informe Gestion Institucional y Organizativa de las Residencias de Personas Mayores y COVID-19: dificultades y aprendizajes. Instituto de Politicas y Bienes Publicos (IPP-CSIC) Madrid.

Sáez-López P, Arredondo-Provecho AB. (2021) Experiencia de colaboración entre hospital y centros sociosanitarios para la atención de pacientes con COVID-19. Rev Esp Salud Pública. 95: 14 de abril e202104053.

Last updated: June 29th, 2022   Contributors: Sara Ulla Díez  |  

Sweden

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

On February 2020, Sweden signed an agreement to enable joint EU-wide procurement of medical counter-measures, including PPE. Companies that produce PPE and medical devices expanded their production where possible. There was no national mechanism to assess the stocks of PPE, as the regions and municipalities were responsible for managing their own medical stocks including PPE. Many municipalities did not have sufficient stocks of PPE and rationed what was available, prioritising hospitals (Johansson and Scho?n, 2020 and Szebehely, 2020).

References:

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

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

Last updated: February 13th, 2022

England (UK)

Overview

The government has faced criticism and legal challenges for failures in the availability and distribution of PPE, particularly in the early phase of the pandemic. There was a significant shortage of PPE (face masks, aprons, gloves and visors). Furthermore, the central stockpile was designed for a flu pandemic. According to editorial published in British Medical Journal (Scally et al. 2020) , the government “failed to protect staff in the NHS and social care by not delivering sufficient amounts of personal protective equipment (PPE) of the right specification, again deviating from WHO advice”. Directors in the social care sector specifically claimed that “a critical lack of PPE and testing of social care staff and service users is putting them at unnecessary risk of exposure”. Resentment about prioritisation of the NHS for distribution of PPE has been expressed.

Policy Measures

Initial steps announced on March 18, 2020, included the distribution of PPE to every care home and care home provider to ensure that they had at least 300 fluid repellent face masks for immediate needs, followed by a further tranche of items of PPE in early April. However, the government did acknowledge PPE supply shortages and published a PPE plan on April 15 with the goal that “everyone should get the personal protective equipment (PPE) they need”.

In the social care sector, providers have traditionally organised the PPE they required through the market. The adult social care action plan announced that the government was now stepping in with arrangements to support the supply and distribution of PPE. A parallel supply chain has been established for emergency PPE provision, involving new logistics networks and support from the army and including a national supply disruption response (NSDR) system to respond to emergency PPE requests, and a 24/7 helpline for providers who have an urgent requirement.

On September 30, the government announced that they were extending existing infection control funding with an additional £388.3 million. The funding is intended to help providers with PPE costs, amongst other needs.

Published on November 3, 2021, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. This set out that free PPE for COVID-19 needed to the adult social care sector would continue to be provided until the end of March 2022, with sufficient stock to cope throughout winter. Following a consultation on extending free PPE to the health and care sector after the current end date of 31 March 2022, on 13th January 2022 the government announced that free PPE will continue to be provided to health and care providers until 31st March 2023 or until infection control measures are withdrawn.

Issues with PPE

The need for appropriate PPE in care homes is of critical importance for the safety of residents and staff, particularly in light of the fact that care homes were accepting hospital discharges who were positive for COVID-19.  A survey launched by The Queen’s Nursing Institute (2020) in the early weeks to the pandemic found that 21% of respondents (from across the UK) had accepted COVID-19 positive patients into their facilities. 43% reported accepting people whose COVID-19 status was unknown. Although most respondents (74%) reported that PPE was made available by their employers, some were not provided with PPE and had to improvise by obtaining it themselves or making it. Furthermore, even for those who were provided with PPE, there was fear and anxiety around whether it was adequate to mitigate the spread of COVID-19 and keep them and their residents safe.

Announcements by the government about the number of items of PPE being delivered have been questioned. According to the BBC, over half of the 1.2 billion items of PPE the Department of Health announced on May 10 for health and social care providers in England were surgical gloves, with gloves individually counted rather than in pairs and faulty equipment subsequently being recalled. It is not clear how the protective equipment delivered was divided between health and social care and there have been suggestions that delivery systems have been failing to provide to care homes, requiring them to secure their own supplies individually. One example reported was that of a care provider who was provided with 400 face masks while requiring over 35,000 masks a week. In a survey of English care homes at the end of May and early June, 70% of care home managers reported insufficient PPE supplies, with 34% of providers purchasing supplies directly from abroad.

In addition to being captured in the media, dissatisfaction with PPE provision and policy has come through in some academic literature. A qualitative study published in February 2021 obtained results through interviews with ten care home managers in the East Midlands of England. Participants felt that control over pandemic response was taken away from care home managers – who were normally quite competent at managing the supply chain – when PPE supplies were centralised. This occurred in spite of the fact that they were responsible for making high stake decisions in circumstances defined by multiple and sometimes conflicting sources of information (Marshall et al., 2021).

References:

Scally, G. et al. (2020). The UK’s public health response to covid-19. BMJ 2020369 doi: https://doi.org/10.1136/bmj.m1932

Marshall, F., Gordon, A., Gladman, J. R. F., & Bishop, S. (2021). Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study. BMC Geriatrics, 21(1). https://doi.org/10.1186/S12877-021-02053-9

Queen’s Nursing Institute. (2020). The Experience of Care Home Staff During Covid-19. A Survey Report by The QNI International Community Nursing Observatory. July. https://www.qni.org.uk/wp-content/uploads/2020/08/The-Experience-of-Care-Home-Staff-During-Covid-19-2.pdf [accessed 11/10/2020]

Last updated: March 24th, 2022   Contributors: William Byrd  |  Nina Hemmings  |  Adelina Comas-Herrera  |  Daisy Pharoah  |  

Northern Ireland (UK)

Issues with PPE provision has come through in some recent academic literature. For example, a study by Greene et al. (2020), which found that lack of reliable access to PPE in the first phase of the pandemic (before July 2020) was a robust predictor of clinically significant mental distress in health and care workers across the UK. This highlights that the impacts of unreliable access to PPE go beyond compromising physical health of this workforce.

References:

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C. R., Bloomfield, M. A., & Billings, J. (2020). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. MedRxiv, https://pubmed.ncbi.nlm.nih.gov/33968317/

Last updated: March 24th, 2022   Contributors: Daisy Pharoah  |  

Scotland (UK)

The Adult Social Care – Winter Preparedness Plan: 2021-22 set out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. Following a review of the existing PPE support arrangements, it has been confirmed that the PPE Hubs and PPE Support Centre, which provide free PPE to providers across the sector where supply routes fail, and to unpaid carers who are unable to access PPE through their normal routes, will continue to operate until end March 2022. For care providers, payments for PPE over and above usual amounts as a result of the pandemic have also been extended to end March 2022 as part of the Financial Support for Adult Social Care Providers (see also Extending PPE access to all social care providers).

 

Last updated: March 29th, 2022   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

United Kingdom

Availability of PPE: impact on mental health

The need for appropriate PPE in care homes is of critical importance for the safety of residents and staff, particularly in light of the fact that care homes were accepting hospital discharges who were positive for COVID-19. However, issues with PPE provision has also come through in some recent literature. A survey launched by The Queen’s Nursing Institute (2020) in the early weeks to the pandemic found that 21% of respondents from across the UK had accepted COVID-19 positive patients into their facilities. 43% reported accepting people whose COVID-19 status was unknown. Although most respondents (74%) reported that PPE was made available by their employers, some were not provided with PPE and had to improvise by obtaining it themselves or making it. Furthermore, even for those who were provided with PPE, there was fear and anxiety around whether it was adequate to mitigate the spread of COVID-19 and keep them and their residents safe. Results from this survey were collected in early 2020 from 163 care staff across the UK.

A study by Greene et al (2020) found that lack of reliable access to PPE in the first phase of the pandemic (before July 2020) was a robust predictor of clinically significant mental distress in health and care workers across the UK. This highlights that the impacts of unreliable access to PPE go beyond compromising physical health of this workforce.

References:

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C. R., Bloomfield, M. A., & Billings, J. (2020). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. MedRxiv, 2020.10.21.20216804. https://doi.org/10.1101/2020.10.21.20216804

Queen’s Nursing Institute. (2020). The Experience of Care Home Staff During Covid-19. A Survey Report by The QNI International Community Nursing Observatory. July. https://www.qni.org.uk/wp-content/uploads/2020/08/The-Experience-of-Care-Home-Staff-During-Covid-19-2.pdf [accessed 11/10/2020]

Last updated: March 24th, 2022   Contributors: Daisy Pharoah  |  

United States

An electronic survey of 152 nursing home staff from 32 states, including direct care staff and administrators carried out from the 11th May to the 4th June 2020 showed that by then availability of PPE had improved compared to the earlier part of the pandemic. However, there were still shortages, resulting in extended reuse of PPE and supplementation with homemade PPE.  Staff in management roles spending large amounts of time (and money) to obtain sufficient supplies of PPE, having to rely on unconventional suppliers.

Last updated: January 2nd, 2022

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

Overview

Evidence on how technology has been used to maintain social contacts or to deliver care remotely is beginning to emerge.

Use of technology maintain social contacts during the pandemic

Loneliness and isolation in LTC facilities are salient issues, which were amplified during COVID-19 as facilities were largely inadequately prepared to support the socioemotional needs of their residents during the mandated lockdowns. Information and communication technologies (ICTs) can be a useful tool to enhance social connectedness for residents by facilitating communication with family and friends.

There are descriptions of increased use of technology to support communication, particularly for people living in care homes that were not able to have face to face contact with their family and friends due to visiting restrictions. The evidence so far shows that a large proportion of residents in care homes were not able to use technology for communication, for example a study in the US found that only 42% of residents were able to do so (Schuster and Cotten, 2022). People with dementia or other conditions accompanied by cognitive impairment have more difficulties with technology, appearing to face more difficulties in recognising virtual conversation partners (Lorenz-Dant and Comas-Herrera, 2021) and in some cases having negative emotional reactions (Leontjevas et al., 2021). Other researchers, suggest that, with the right kind of tools, some of these barriers can be overcome (Hung and Mann, 2020).

There are also examples, from Belgium and the Netherlands (see below), of the use of robots in care homes to facilitate video calls between the residents and their families (Getson and Nejat, 2021)

Telemedicine

While there has been much enthusiasm about the potential role of telemedicine, in many cases there have been substantial organisational and even financing barriers. The organisational readiness to adopt telemedicine has been identified as being particularly important (Seifert et al., 2020).

A study of the views of nursing home staff in the Netherlands suggests while psychologists, physicians and nurse practitioners thought it would be good to continue to do part of their work remotely after the pandemic, more than half staff of activity coordinators did not feel their tasks could be done remotely (Leontjevas et al, 2021).

Adapting therapeutic interventions to virtual delivery

An international collaboration piloted a 14-session virtual Cognitive Stimulation Therapy (vCST) programme for people living with dementia, as a result of services needing to move online during the pandemic. The protocol was field tested in Brazil, China (Hong Kong), India, Ireland and the UK, using the feedback to improve the protocol. The pilot showed that vCST is a feasible intervention for many people living with dementia and maybe useful for people who cannot attend in person groups beyond the pandemic (Perkins et al., 2022).

A qualitative study in Italy describes examples of using technology (personalised pre-recorded videos) to provide remote access to people with dementia to music therapy and low-impact exercise, as well as to group activities such as cognitive stimulation, physical activities and support groups (Chirico et al., 2022).

Digital inclusion and access to information for people with Intellectual Disabilities

A rapid review and international bricolage of evidence regarding the digital experiences of people with Intellectual Disabilities (ID) during the pandemic covering literature up to June 2021 found that, internationally, people with ID had inadequate support for digital access and accessible information on COVID-19 and how to keep safe. Existing barriers to digital inclusion have persisted, but there were positive impacts from digital solutions for those who could access them and had adequate support, for example in service provision, education and therapeutic services. NGOs had an important role in providing direct support for digital inclusion and COVID-19 information, whereas Governmental and crisis organisations were often found to be unprepared (Chadwick et al., 2021).

References:

Chadwick, D., Ågren, K.A., Caton, S., et al. (2022). Digital inclusion and participation of people with intellectual disabilities during COVID-19: A rapid review and international bricolage. Journal of Policy andPractice in Intellectual Disabilities,115. https://doi.org/10.1111/jppi.12410

Chirico, I.Ottoboni, G.Giebel, C.Pappadà, A.Valente, M.Degli Esposti, V.Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in ItalyHealth & Social Care in the Community001– 10https://doi.org/10.1111/hsc.13758

Getson C, Nejat G. (2021) Socially Assistive Robots Helping Older Adults through the Pandemic and Life after COVID-19. Robotics; 10(3):106.  https://doi.org/10.3390/robotics10030106

Hung, L. and Mann, J. (2020) ‘Virtual special issue – Using touchscreen tablets for virtual connection’, Dementia, 19(5), pp. 1346–1348. doi: 10.1177/1471301220924578.

Leontjevas, R., Knippenberg, I., Bakker, C., Koopmans, R., & Gerritsen, D. (2021). Telehealth and telecommunication in nursing homes during COVID-19 antiepidemic measures in the Netherlands. International Psychogeriatrics, 33(8), 835-836. https://doi.org/10.1017/S1041610221000685

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

Perkins L, Fisher E, Felstead C, Rooney C, Wong GHY, Dai R, Vaitheswaran S, Natarajan N, Mograbi DC, Ferri CP, Stott J, Spector A. Delivering Cognitive Stimulation Therapy (CST) Virtually: Developing and Field-Testing a New Framework. Clin Interv Aging. 2022;17:97-116
https://doi.org/10.2147/CIA.S348906

Schuster, A. M., & Cotten, S. R. (2022). COVID-19’s Influence on Information and Communication Technologies in Long-Term Care: Results From a Web-Based Survey With Long-Term Care Administrators. JMIR Aging 2022;5(1):E32442 Https://Aging.Jmir.Org/2022/1/E32442, 5(1), e32442. https://doi.org/10.2196/32442

Seifert A, Batsis JA and Smith AC (2020) Telemedicine in Long-Term Care Facilities During and Beyond COVID-19: Challenges Caused by the Digital Divide. Front. Public Health 8:601595. doi: 10.3389/fpubh.2020.601595

Australia

The government of Australia announced over $1.5 billion AUD in funding for the aged care sector during the pandemic. A portion of this amount has gone towards telehealth development for people over the age of 70. The Department of Health also recommends that older people opt for telehealth appointments instead of in person appointments (source: DoH).

Last updated: December 22nd, 2021

Belgium

In Belgium the James robot (by ZoraBot) was deployed to help in nursing homes during COVID lockdowns to help residents keep in contact with their family through video calls, using only voice commands (Getson and Nejat, 2021). The robot is able to measure body temperature, count people in a room, check if people are wearing masks properly and can be operated for disinfection duties (Raje et al., 2021).

References:

Getson C, Nejat G. (2021) Socially Assistive Robots Helping Older Adults through the Pandemic and Life after COVID-19. Robotics; 10(3):106.  https://doi.org/10.3390/robotics10030106

Raje S., Reddy N., Jerbi H. et al. (2021) Applications of Healthcare Robots in Combating the COVID-19 Pandemic. Applied Bionics and Biomechanics. https://doi.org/10.1155/2021/7099510

Last updated: February 11th, 2022

Canada

A study among unpaid carers in Canada using remote services reported some advantages but also disadvantages and some reported technical barriers (Lorenz-Dant & Comas-Herrera, 2021).  A report recommends the use of technology to ensure care in place for people in residential care settings (https://www.ic.gc.ca/eic/site/063.nsf/eng/h_98049.html).

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: https:// doi.org/10.31389/jltc.76

Last updated: February 11th, 2022

British Columbia (Canada)

Telemedicine and telehealth are covered under the Medical Services Plan. Individuals seeking care may also contact the non-emergency medical support phone line by dialing 811.

Last updated: November 6th, 2021

Denmark

The National Association for Older People organizes supports for using technology to access friends, social networks and health services (https://www.aeldresagen.dk/om-aeldresagen/lige-nu/corona/faa-gode-raad/saadan-ser-du-den-du-taler-med?scrollto=start; Kommunale nyskabelser under covid-19-krisen – VIVE).

Last updated: May 25th, 2023

France

Investment of 6bn euros across the health and social care system – for renovations and technology upgrades (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf0).

Telephone support lines were rolled out with some success for support, and according to the DGCS France has performed third worldwide after the US and China in the number of teleconsultations performed over the pandemic, especially in care homes (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: September 8th, 2021

Germany

A study among unpaid carers in Germany found that a considerable proportion of respondents started using technology for social contacts (https://www.socium.uni-bremen.de/uploads/Schnellbericht_Befragung_pflegender_Angehoriger_-_print.pdf).

Last updated: September 8th, 2021

Hong Kong (China)

NGOs in Hong Kong have provided older people with tablet computers that provided them with access to home sports videos, cognitive training games and equipment to monitor their help. The system would inform relevant persons (medical teams/family) if the health monitor registered abnormality. Other NGOs offers videos for sensory stimulating activities anti-epidemic exercise or remote activities and counselling for people with mild to moderate dementia (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 8th, 2021

Israel

The Administration of Disabilities at the Ministry of Welfare and Social Affairs provides services for people with intellectual developmental disabilities and other cognitive disabilities, individuals with autism, and individuals with sensory and motor disabilities. The initial action plan for COVID-19 included a transition to virtual education and community-building programs, the upstart of a food distribution program, and technology (e.g. tablet) distribution.

JDC Eshel in collaboration with the Ministry for Social Equality and Digital Israel have put forth the development of digital technology among people over the age of 60 as one of their goals, especially during the pandemic.

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

Italy

To compensate for limited access to visiting in nursing homes for difficulties in meeting families and caregivers, care providers have used tools such video calls, dedicated apps and telemonitoring.

A qualitative study found that in May 2020 family carers of people living with dementia began to have access to remote support from community-based services, through mobile smartphones, tablets and personal computers, using existing applications such as Whatsapp, Skype, Google Duo, and Meet. There were examples of the use of personalised pre-recorded videos to continue activities previously done face to face such as music therapy and low-impact expercise and videoconferencing to deliver group activities such as support groups, physical activities and cognitive stimulation. These were perceived to be helpful in reducing feelings of isolation and loneliness and maintaining relationships with therapists (Chirico, 2022).

References:

Chirico, I.Ottoboni, G.Giebel, C.Pappadà, A.Valente, M.Degli Esposti, V.Gabbay, M., & Chattat, R. (2022). COVID-19 and community-based care services: Experiences of people living with dementia and their informal carers in ItalyHealth & Social Care in the Community001– 10https://doi.org/10.1111/hsc.13758

Last updated: February 22nd, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

A study of the implementation of infection control measures in a nursing home in rural Japan includes a description of the use of Information and Communication Technology (ICT) using a system called Mame-net established by the local government. This system enabled the nursing home to share information regarding the health condition of the residents with the local clinic, and, if there were immediate concerns, there was direct phone communication between the care home staff and the clinic. The system is also used to share information about the residents’ condition with their family members (Ochta et al., 2021).

References

Ohta R, Ryu Y, Sano C. (2021) Effects of Implementation of Infection Control Measures against COVID-19 on the Condition of Japanese Rural Nursing Homes. International Journal of Environmental Research and Public Health. 18(11):5805. https://doi.org/10.3390/ijerph18115805

Last updated: February 17th, 2022

Netherlands

In the Netherlands the SARA robot, developed as part of EIT Digital, was offered to care homes to support the residents in communicating with their family and friends. The company offered care homes to have the robot for one month.

A survey of 175 nursing home staff found that practitioners thought there was value in continuing to use telecommunication between residents and their loved ones, in addition to the preferred face to face contact. However there were challenges in using telecommunication with residents with advanced dementia, with reports of negative emotional responses. With regards telehealth, some practitioners (particularly psychologists, physicians and nurse practitioners) would like to continue working partly remotely after the pandemic, whereas more than half activity coordinators reported that this would not be possible for their tasks (Leontjevas et al., 2021).

References:

Leontjevas, R., Knippenberg, I., Bakker, C., Koopmans, R., & Gerritsen, D. (2021). Telehealth and telecommunication in nursing homes during COVID-19 antiepidemic measures in the Netherlands. International Psychogeriatrics, 33(8), 835-836. https://doi.org/10.1017/S1041610221000685

 

Last updated: February 24th, 2022

Poland

The government introduced online or telephone medical consultations when feasible to compensate for lack of face to face consultations as well as to contain spread of infections (source: Ageing policies – access to services in different EU Member States).

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

Sweden

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

Last updated: November 30th, 2021

England (UK)

A considerable proportion of unpaid carers in the UK reported to have used technology for social contacts, a smaller proportion for health and long-term care services. The use of technology for remote support received mixed feedback. A report by Age UK (2021) has found that there was no significant change in the use of digital engagement during the first few months of the pandemic. The main barrier reported for peopled aged 75 and older was ‘lack of digital skills’.

A press release by the Department of Health and Social Care (DHSC) on April 24, 2020, announced that they, together with the Ministry for Housing Communities and Local Government, had awarded up to £25,000 to 18 innovative digital solutions as part of the TechForce19 challenge. Among these, one app that received funding aims to ‘help carers identify health risks and deterioration within elderly communities’.

Research by Lariviere et al. (2020) accompanying the virtual cuppa project, which offered unpaid carers the possibility to connect virtually for half an hour on weekdays with others in similar situations, facilitated by a professional carer coach, found that over time, carers developed friendships with other members participating in the project, shared resources and experience, and that the virtual cuppa group became “a resource in its own right to develop individual resilience” (p.22).

The digital lifeline initiative during the COVID-19 crisis, funded by the Department for Digital, Culture, Media and Sport (DCMS), 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 (Mackey et al. 2022).

Published on November 3, 2021, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. This sets out continued support for care providers to make best use of technology to support remote monitoring, enable secure online communications, and enable people within care homes to remain connected with friends and families. NHSX, a joint unit of DHSC and NHS England, will provide a package of support over the winter to help care providers make the best use of digital tools, safely and securely. A new ring-fenced care provider Digitising Social Care fund of up to £8 million will be available. Additionally, there will be implementation funding support to all 7 NHSEI regions to significantly increase levels of technology-enabled remote monitoring within care homes. Plans have been agreed for over 100,000 people living in a care home to receive digitally enabled support by March 2022.

References: 

Age UK (2021). Digital inclusion and older people – how have things changed in a Covid-19 world? Age UK briefing paper, Retrieved from: ageuk.org.uk briefing papers. Accessed on 24/03/2022

Mackay, J. et al. (2022). Digital Lifeline: A Qualitative Evaluation , Full evaluation report. Retrieved from: DCMS Digital Lifeline Fund: Evaluation Report Accessed on 24/03/2022

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., Hanna, K., Cannon, J., Eley, R., Tetlow, H., Gaughan, A., Komuravelli, A., Shenton, J., Rogers, C., Butchard, S., Callaghan, S., Limbert, S., Rajagopal, M., Ward, K., Shaw, L., Whittington, R., Hughes, M., & Gabbay, M. (2020). Decision-making for receiving paid home care for dementia in the time of COVID-19: A qualitative study. BMC Geriatrics, 20(1), 1–8. DOI:https://doi.org/10.1186/S12877-020-01719-0/TABLES/2

Lariviere, M et al. (2020). Caring during lockdown: Challenges and opportunities for digitally supporting carers. Research report, Retrieved from: 007_Aspect-Virtual-Cuppa-Report-4-compressed.pdf (shef.ac.uk); Accessed on 24/03/2022

Last updated: March 24th, 2022   Contributors: William Byrd  |  

United States

A recent study by Schuster and Cotten (2022) explored the use of ICTs across 70 LTC facilities (12 nursing homes and 58 assisted living facilities) in South Carolina during the pandemic. 61% of the LTC facility administrators surveyed reported an increase in technology spending at their facility, although the main method of purchase was through facility funds (with only 45% reporting funding through Medicaid or Medicare services). Roughly 42% of residents used the technology provided by facilities and a quarter were unable to use the ICTs (owing to health or other impairments). Overall, the study found that the key benefit of ICTs was promoting feelings of connectedness to family, friends, and other residents. Barriers to ICT use by residents included a shortage of staff to assist with ICT use and technology that didn’t work.

References:

Schuster, A. M., & Cotten, S. R. (2022). COVID-19’s Influence on Information and Communication Technologies in Long-Term Care: Results From a Web-Based Survey With Long-Term Care Administrators. JMIR Aging 2022;5(1):E32442 Https://Aging.Jmir.Org/2022/1/E32442, 5(1), e32442. https://doi.org/10.2196/32442

Last updated: February 17th, 2022

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

Overview

Most high-income countries gave priority for COVID-19 vaccinations to people who are old and or have disabilities, or live in communal establishments, as well as staff working in the LTC sector (often after healthcare staff).

With increasing evidence that the effectiveness of the COVID-19 vaccines wanes over time and the rapid spread of the Omicron variant many countries are offering vaccine boosters or third doses.

There have been concerns in many countries about resistance to vaccination among staff working in LTC, prompting a debate on whether vaccinations should be mandatory for people working in the LTC sector, with a few countries introducing this measure. This has generated concerns that this measure could aggravate existing staff shortages. There are other measures that can also be explored to encourage vaccination uptake in this sector.

Evidence on measures to increase COVID-19 uptake among long-term care staff:

A comparative study of measures adopted by different nursing homes in the United States during February/March 2021 showed that nursing homes with medium or higher vaccination coverage were significantly more likely to have designated frontline staff champions and to have set vaccination goals. Nursing homes with high coverage were more likely to have given non-monetary rewards such as T-shirts. The use of multiple strategies was associated with greater likelihood of having medium or high vaccination coverage (Berry et al., 2022).

An evidence summary prepared in May 2021 reviewed strategies to encourage vaccine take-up and reduce hesitancy, beside making vaccination mandatory. The strategies identified included targeted communication, increasing the convenience of vaccinations, and time and opportunities to discuss concerns with peers, managers and trusted professionals (Hemmings et al., 2021).

References:

Berry SD, Baier RR, Syme M, et al. (2022). Strategies associated with COVID-19 vaccine coverage among nursing home staff. J Am Geriatr Soc.  Jan;70(1):19-28. doi: 10.1111/jgs.17559

Hemmings, N., Oung, C., Ettelt, S., Salcher-Konrad, M., Curry N. and Comas-Herrera, A. (2021) Evidence summary: Strategies to support uptake of Covid-19 vaccination among staff working in social care settings. LTCcovid.org evidence summary. https://ltccovid.org/2021/05/25/evidence-summary-strategies-to-support-uptake-of-covid-19-vaccinations-among-staff-working-in-social-care-settings/

International reports and sources

Evidence summary: Strategies to support uptake of Covid-19 vaccinations among staff working in social care settings

Hemmings, N., Oung, C., Ettelt, S., Salcher-Konrad, M., Curry N. and Comas-Herrera, A. (2021) Evidence summary: Strategies to support uptake of Covid-19 vaccination among staff working in social care settings. LTCcovid.org evidence summary. https://ltccovid.org/2021/05/25/evidence-summary-strategies-to-support-uptake-of-covid-19-vaccinations-among-staff-working-in-social-care-settings/

Australia

Vaccination rollout:

COVID-19 vaccination in Australia began in late February 2021 with people living in care homes and staff working in health and aged care included in phase 1a of the national rollout strategy. From 17th September 2021, residential and community-based aged care workers were required to be vaccinated against COVID-19 as a condition of employment (source: DoH). By this date, 95.8% of residential aged care workers had received their first dose, and 76.9% had received both doses (source: health.gov). As of 6th January 2022 99.4% of staff were double vaccinated. Approximately 85.9% of care home residents had received two doses, and 89.3% had received one dose.

At 9th January 2022 92.0% of the population aged over 16 and 74.04% of 12-15 year olds were double vaccinated. 3,565,888 people aged 16 and over had had more than two doses. The rates of vaccination for aboriginal and Torres Strait Islander peoples are lower, with 71.8% of people aged 16 and over having had two doses and 59.9% of people aged 12-15 having had at least one dose.

Booster/third doses:

The booster program for residential care began on 8th November 2021, with in-reach teams visiting care homes which have been prioritised in each rollout. Booster data are not being routinely reported (source: health.gov). As of 7th January 2022, a total of 425,273 vaccine doses had been administered to care home residents.

Impact of the COVID-19 vaccination on care home infections and deaths:

There have been no formal studies of the impact of vaccination on care home deaths. From official government data, up until 17th December 2021, 206 residents had passed away from 1,601 infections. This contrasts sharply with data from 2020, when – as of 20th November – there had been 678 deaths and 2027 COVID infections in residential care homes (source: DoH). This could be attributed to better healthcare and vaccinations. However, it seems that there is a similar rate of death per infection in residential aged care, despite lower numbers of deaths: as of 21st November 2021, the total Australian death rate was 0.46% against the total number of residential aged care bed across the country. By comparison, this figure was around 0.37% in November 2020.

Mandatory vaccinations for care home staff:

All states and territories have mandated COVID-19 vaccinations for staff in residential aged care through public health orders.

Visiting in care homes and vaccination requirements:

In relation to mandatory vaccination for long-term care facility visitors, advice from the Quality and Safety Commission is given. This does not mandate vaccination, but heavily encourages it. In the advice, Industry Code is mentioned, whereby level of risk is used to provide or deny access to visitors.

 

Last updated: January 19th, 2022   Contributors: Lee-Fay Low  |  Sara Charlesworth  |  

Austria

On 26 December 2020 the Federal Ministry of Social Affairs, Health, Care and consumer protection published their COVID-19 vaccine prioritization recommendations. In the first phase, the highest priority group included residents and staff in care and nursing home, staff in health care sector with high risk of exposure and people aged 80 years and older. The second phase included people with existing illnesses (including dementia) and their closes contacts (especially of those living in residential care settings), domiciliary care workers, people aged 75 to 79 years. Since the end of December, 1,053,599 people have been vaccinated (appx. 275,000 of whom have received both doses). Starting March 2021, those 65 and older are eligible for vaccination, indicating successfully high rates of vaccination amongst the top two priority groups (https://info.gesundheitsministerium.at/en/).

Currently there is only a recommendation to get vaccinated in place for care staff, but no obligation. An obligatory regulation is also not foreseen in the near future. However, there is a law (Epidemiegesetz 1950) that could make this possible.

It is possible, however, when hiring new staff, that employers ask for tighter tests in the hospital or care sector (e.g. for measles, hepatitis, not influenza). Only in one region (Styria) there are some legal possibilities to oblige staff to have specific vaccinations done. In general, across Austria care personnel that are still undergoing training might not be accepted if no tighter tests are provided. Care homes deviate in their views on how to handle the situation (whether or not to make vaccinations obligatory).

Information in German on COVID-19 vaccinations for care personnel: https://www.sozialministerium.at/Themen/Gesundheit/Impfen/Impfempfehlungen-Allgemein/Empfehlung-f%C3%BCr-Gesundheitspersonal.html

Last updated: September 7th, 2021

Belgium

After an initial pilot in care homes, the official COVID-19 vaccination campaign started on 5th January 2020. By 31stMarch 2021, 1,868,577 doses had been administered, by that date, 73% of people aged 85 or more had had at least one dose and 26% had both doses. Care home residents and staff were prioritized for vaccination (https://covid-19.sciensano.be/sites/default/files/Covid19/COVID-19_Weekly_report_FR.pdf). On the 23rd March 2021 it was reported that 95% of care home residents in Flanders had been vaccinated, as well as 87% of staff (https://www.rtbf.be/info/dossier/epidemie-de-coronavirus/detail_coronavirus-95-des-residents-des-maisons-de-repos-de-flandre-vaccines?id=10725504). On the 5th March that 94% of all care home residents in Brussels and 92% in Vallonia had been vaccinated (https://www.rtbf.be/info/dossier/epidemie-de-coronavirus/detail_derriere-les-chiffres-9-residents-sur-10-vaccines-en-maisons-de-repos-les-deces-en-chute-libre?id=10712029).

In long-term care, management may not simply ask if someone has been vaccinated. For many people, vaccination does appear in a medical record (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 7th, 2021

Brazil

From 3 January 2020 to 20 December 2021, there have been 22.204.941 confirmed cases of COVID-19 with 617.395 deaths, as reported to WHO. The first vaccination date was 17 January 2021. Once supplies become available, despite the political crisis, vaccination coverage skyrocketed in the second semester of 2021. So far, Brazil has administered at least 325.593.485 doses of COVID-19 vaccines (approximately 151.80 doses/100 people). Assuming every person needs 2 doses (the number of people who received single-dose vaccines was low in the country), that’s enough to have vaccinated about 77.1% of the country’s population, at least 66% of them fully vaccinated. About 23.33 million booster doses were administered (10.90/100 people).

However, the inequity of these doses distribution in a continental country means that while some states have more than 76.7% of their population fully immunized (12.8% of these having already received the booster dose), others have only 38.8% fully vaccinated.

As the decision to prioritize population groups is currently under the responsibility of municipal and state administrations, there are not enough national data to estimate the coverage of the booster dose in the resident population and workers of LTCFs.

Higher vaccination coverage among Brazilian older adults was associated with substantial declines in relative mortality (when compared to younger individuals, with the two vaccines primarily distributed in the country until then, namely, CoronaVac and AstraZeneca, in a setting where the gamma variant predominates) (Victora CG et al., 2021).

Unfortunately, again, there are no national data to assess the effectiveness of immunization only in the population that depends on long-term care.

The country has not adopted mandatory vaccination policies for LTC staff, nor did it require visitors to present proof of their vaccination status when visits to the facilities were allowed. The current vaccination rates of staff (and the booster rollout in older residents) remain largely unknown.

Recently, researchers from the ‘Frente Nacional de Fortalecimento à ILPI’ published a study estimating the number of LTCF in the country in 7029 facilities, noting that 64% of the 5 570 Brazilian municipalities do not have LTCF for older adults. (Lacerda TTB et al., 2021)

Last updated: December 21st, 2021   Contributors: Patrick Alexander Wachholz  |  

Canada

COVID-19 vaccination policies are created by each of the thirteen provinces or territories. As a result, significant variation exists across the country. People who live in Long-Term Care Facilities (LTCFs), staff working there and, in some provinces, essential family caregivers (EFCs) were prioritised for vaccination. This resulted in a rapid reduction in COVID-19 infections and deaths in LTCFs during 2021. Vaccination take up among LTCF residents has been very high, but there has been some hesitancy among staff, which has led to several provinces introducing vaccination mandates for their LTC staff. Also, British Columbia and Nova Scotia also require that all visitors, including EFCs are fully vaccinated before visiting.

Booster shots for residents in LTCFs were recommended on 28th September 2021 by the National Advisory Community on Immunization (NACI). This recommendation is supported by increasing evidence from studies in nursing homes and assisted living facilities (see, for example, Zhang et al. 2021).

References:

Zhang, A. et al. (2021). ‘Antibody Responses to 3rd Dose mRNA Vaccines in Nursing Home and Assisted Living Residents’. doi.org/10.1101/2021.12.17.21267996. Retrieved from:  Ontario study (pre-print)

 

Last updated: February 11th, 2022

British Columbia (Canada)

Phase 1 prioritized LTC: residents and staff of LTC facilities, individuals assessed and waiting for LTC, residents and staff of assisted living residences, essential visitors to LTC and AL facilities (https://www2.gov.bc.ca/gov/content/safety/emergency-preparedness-response-recovery/covid-19-provincial-support/vaccines). Distribution depends on the province/territory jurisdiction – distribution difficult in northern areas, Moderna vaccine may easier to deliver than Pfizer (https://ltccovid.org/2021/01/25/the-rollout-of-the-covid-19-vaccines-in-care-homes-in-canada/). Pfizer’s discontinuation of shipment for week of Jan 25 sets back vaccination schedule (https://ltccovid.org/2021/01/25/the-rollout-of-the-covid-19-vaccines-in-care-homes-in-canada/). All LTC facility residents and the people who care for them have been offered vaccine in all health authorities around the province, as of February 9. Uptake is quite high, 87% of long-term care residents have received their 1st dose (https://bc.ctvnews.ca/all-residents-and-staff-of-b-c-s-long-term-care-homes-have-been-offered-vaccines-top-doctor-1.5288511).

Covid-19 vaccinations are not mandatory for long-term staff or any sector. As of April 30, 2021, 142,000 healthcare, assisted-living and long-term care staff in British Columbia (B.C.) had received vaccinations but the percentage of vaccinated staff in the province is unknown because not all provincial health authorities report total number of registered staff. 82.9 per cent of Vancouver Coastal Health’s eligible staff had received a first dose of COVID-19 vaccine, leaving more than 4,200 workers unvaccinated (https://www.cbc.ca/news/canada/british-columbia/bc-health-care-worker-vaccination-1.6008486).

The Ministry of Health is taking an educational approach, informing staff working in Long-Term Care instead of making vaccines compulsory (https://vancouversun.com/news/covid-19-high-rate-of-vaccinations-among-care-home-staff-dispels-anti-vax-fears).

Last updated: November 6th, 2021

Chile

Long-Term Care residents were prioritized and mass vaccination started in January 2021 using an extramural vaccination strategy. This primary scheme used Coronavac – Sinovac (96%) and Pfizer/BioNTech (4%). Later in, August 2021, a booster mass vaccination strategy was carried out reaching 83% of the residents who had been vaccinated with the primary scheme. The booster scheme used the Oxford – AstraZeneca vaccine except for those with known thromboembolic disease (eg. Myocardial Infarction, deep vein thrombosis).

Long-Term Care staff have been also identified as a prioritized group and where vaccinated using extramural strategies in their place of work. Furthermore, booster doses were given simultaneously to residents. Vaccination remains optional, no governmental compulsory policies have been implemented.

Data available: SAS Report

Last updated: December 22nd, 2021   Contributors: Jorge Browne  |  

China

The Chinese Government announced that over 215.2 million people aged 60 and over have been vaccinated in mainland China by the 29th November, with the remaining 50 million (20%) older people not vaccinated. The National Health Commission of the PRC requires local authorities to promote the vaccination rate among older people based on their health conditions and provide follow-up observation service in the community-level after being vaccinated. Currently, some areas also have set up a vaccination “Green Channel” for older people or provide mobile vaccinating services (e.g., mobile medical vans) to reduce their waiting time.

In Mainland China, long-term care staff have been identified as the priority group to receive COVID-19 vaccination in national level. For now, there is no sign that Covid-19 vaccination will be mandated in law for long term care staff, however, in practice, local government and care providers have made vaccination compulsory already without passing any regulation. Care staff and care institutions have very high willingness be vaccinated.

Other vaccinations such as flu are not compulsory.

Last updated: December 6th, 2021   Contributors: Cheng Shi  |  

Czech Republic

Covid-19 vaccination is not compulsory for anyone. However, care home workers were among the first groups, together with health care workers, who were offered vaccination. The Czech Association of Social Services Providers published several surveys on progress in vaccination in social services –the findings have been published online (in Czech only).

There has been no specific vaccination campaign at national level targeting long-term care staff, nevertheless they are prioritized group, and were among the first groups who got vaccinated. There has been a more general campaign to promote vaccination among vulnerable groups and prioritized group of workers.

(Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/).

Last updated: November 30th, 2021

Denmark

Denmark was one of the first countries to reach near full-vaccination of people living in care homes, concluding the first round of vaccinations by mid-February 2021, and by mid-March for older people who receive long-term care.

In November 2020 new legislation was proposed which would give the Danish Health Authority the power to “define groups of people who must be vaccinated in order to contain and eliminate a dangerous disease”. The proposal applied to diseases posing threats to public health; diseases which the global community are seeking to eradicate; diseases with a high mortality rate; or in instances where a person is deemed to be a danger to themselves or others. In January 2021 the proposed legislation was not passed due to concerns about the use of coercion and physical detainment to control the disease. Any proposed future interventions will instead be on a case by case basis, requiring a parliamentary vote. The Health Minister noted: “we believe that information and openness are better for the vaccination case than threats and force”.

In early September 2021 the vaccination rate among care home residents was 96% and it was announced that all care home residents will be offered a third those, following an increase in infections in care home during August 2021. Among those receiving home care, the rate is 97.9% and 98.4% among staff working in LTC.

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

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

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

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

Data sources:

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

Last updated: May 25th, 2023   Contributors: Tine Rostgaard  |  

Finland

The vaccination rollout in Finland, determined by the THL and their vaccine expert taskforce (KRAR), prioritized older people (70+) and healthcare personnel. Finland receives its vaccines through the EU joint procurement plan (https://stm.fi/en/coronavirus-vaccines). Rates of vaccination by age can be found at (https://www.thl.fi/episeuranta/rokotukset/koronarokotusten_edistyminen.html).

Last updated: November 23rd, 2021

France

In late 2020 priority for vaccination was given to older people residing in collective housing and vulnerable people working there – following recommendations from the High Health authority. Vaccination is free. The 2nd phase addressed those over 75, then 65-74, then health professionals in health and social care over 50, and/or with comorbidities.

To accelerate coverage, a “health pass” was introduced for all people over 17 from July 2021, and for all people over 12 from September 2021. The health pass is required for access to cultural spaces, bars and restaurants, cinemas, and transport, as well as for access to health and social care facilities. The pass is valid if a person has a full vaccination cycle according to the French government (n.b. in France, this includes people with antibodies and a single dose) or a negative test of less than 24 hours. As of 15 December 2021, the “health pass” for those over 65 will not be valid without a booster dose. This will apply for those aged 18-65 from 15 January 2022. In January 2022 Ministers will vote on a law to make the “health pass” into a “vaccine pass”, where negative tests would no longer be accepted as sufficient. The possibility of making the “vaccine pass” a requirement in work and businesses is currently being debated, although unions are strongly opposed to this.

Covid-19 vaccination is mandatory for health and social care staff since 15th September 2021. This follows a precedent from 2005/6, where legislation was passed mandating a number of other vaccines for health and social care staff. An amendment to the Public Health code of 2016 introduced a condition that health and social care professionals should be vaccinated if it presents a risk to those they care for.

Most recent visiting guidance places the ethical responsibility for vaccination on care staff and highlights that full ‘return to normal’ is not possible without high vaccination rates among staff. Where staff are not vaccinated, they must be ‘very frequently’ tested. 92.9% of staff in care homes have also had at least one dose of vaccine, and approximately 92.2% have had a ‘full’ vaccination cycle. 36.4% have had their booster dose. In September 2021, estimates suggested around 5% of domiciliary care staff had not been vaccinated, but data are limited.

As of 20 December 2021, 92.9% of residents in care homes and long-term care facilities have received a full dose cycle of vaccination, and 64.8% have received their booster dose. The booster campaign in long-term care facilities has been underway since August 2021 and was seen to be more straightforward than the previous campaigns with a high uptake from residents, however fewer staff have been available to facilitate roll-out. Numbers presented by the Minister for Care are higher, claiming that more than 80% of care home residents have received  their booster dose.

A study by the French Directorate of Research and Statistics (DREES) published in November 2021 has looked at the impact of vaccination on infection rates in care homes. They found that a 10 percentage point increase in vaccine coverage among care home residents has led to a reduction of around 20% in the number of confirmed COVID-19 cases. A similar impact has been observed for single-dose vaccinated residents, however the reduction in number of cases is around 10 times smaller. In France, the uptake of the vaccine among residents was much higher in early 2021 than among staff and the authors posit this has made a difference: the number of infection episodes where only staff have been infected has increased from 15% in June 2020 to 60% in June 2021. It is worth noting other factors may have impacted on these results, including restrictions on visiting in early 2021, turnover in residents, and local infection rates.

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

Germany

COVID-19 vaccination rollout:

Germany’s vaccination strategy has been described here (Lorenz-Dant, 2020). As of 21 December 2021, it is estimated that 70.5% of the general population had received their basic immunisation against COVID-19 and 33.8% had also received a booster (Impfdashboard.de, 2022).

Progress has been relatively slow, but most people living in residential care setting had received the first dose by mid-February 2021 (Lorenz-Dant & Ettelt, 2021). Ongoing progress is reported through the vaccination dashboard (Impfdashboard.de, 2022). However, the dashboard only reports estimates, as a reliable monitoring system is not in place in Germany.

Systematic monitoring of vaccination in residential care facilities was only introduced in October 2021, based on a nationwide sample of care homes and Bavarian monitoring data (n = 1003 facilities). A first report indicates that in October 2021 on average 89.3 % of all residents in care homes and nursing homes had received their basic immunisation and 48.7% had received a booster. However, large variations between different residential care facilities were also reported with individual rates ranging between 28% -100% for the basic immunisation and 0% to 100% for booster vaccinations (Robert Koch Institut, 2021).

According to the same report, on average 81.1% (range: 20% – 100%) of staff in residential care facilities had received their basic immunisation in October and 23.4% (range: 0% – 100%) had received a booster (Robert Koch Institut, 2021).

Unlike in the earlier phases of the vaccination rollout, older persons or residents of residential care facilities are not prioritised to receive booster immunisations. While vaccinations to residential care facilities are still usually organised by the respective state or municipal authorities, persons cared for in their own homes have to rely on their primary care physicians to prioritise them or compete for appointments at vaccination centres in those Länder where they still exist.

Even during the initial rollout, persons cared for in their own homes had to visit a vaccination centre or their personal primary care physician for their immunisation in many Länder, as mobile teams were only deployed to these individuals in some Länder (such as Berlin). This is the case even if a home care service is employed, as Registered Nurses in Germany are not allowed to administer vaccinations independent from a physician. Restricted mobility as well as impaired social, cognitive and financial resources can impede access to the vaccination centres or arrangement of appointments with the individual’s physician. Home care services can be reimbursed for some limited assistance in these cases in some Länder. Support for this user group varies between the Länder.

Many people with disabilities have been isolating since March 2020. The focus of the vaccination on older people, people living in residential care setting and health care workers meant that many people with disabilities living independently had long waiting times for access to vaccines as they fell into Group 2 or lower. There has been criticism that people with disabilities, many of which are at high risk, do not have the same lobby power as older people (Deutschlandfunk.de, 2021).

Mandatory vaccination for Long-Term Care staff

Early in 2021, there was some debate about introducing mandatory vaccination for health and LTC workers, but the Government had then decided against it. With the fourth wave of the COVID-19 pandemic in Autumn 2021 that also led to a resurgence of cases and fatalities in residential care facilities and a growing debate around low vaccination rates among employees in residential care facilities, the debate resurfaced. The newly elected Federal Parliament on 10 December  2021 introduced mandatory COVID-19 vaccinations for all employees at hospitals, residential care facilities and providers of community care services coming into effect on 15 March 2022.

On 10 December 2021 the Federal Parliament also limited access to public transport to persons who are vaccinated or who have recovered from COVID-19 or who can provide a current negative lateral flow test. The same applies to all work places where employers have to provide lateral flow tests to employees. Some states have also limited access to restaurants, retail, gyms and other venues to persons who can provide proof of vaccination or recovery from COVID-19.

References

Deutschlandfunk.de (2021) Coronavirus – Menschen mit Behinderung fühlen sich im Stich gelassen. Available at: https://www.deutschlandfunk.de/coronavirus-menschen-mit-behinderung-fuehlen-sich-im-stich-100.html (Accesse 11 February 2022).

Impfdashboard.de (2022) Wie ist der Fortschritt der COVID-19-Impfung? Aktueller Impfstatus. Available at: https://impfdashboard.de/ (Accessed 11 February 2022).

Lorenz-Dant (2020) A brief overview of the current German Covid-19 vaccination strategy. Available at: https://ltccovid.org/2020/12/18/a-brief-overview-of-the-current-german-covid-19-vaccination-strategy/ (Accessed 11 February 2022).

Lorenz-Dant & Ettelt (2021) Roll-out of Sars-CoV-2 vaccination in Germany: how it started, how it is going. Available at: https://ltccovid.org/2021/02/09/roll-out-of-sars-cov-2-vaccination-in-germany-how-it-started-how-it-is-going/(Accessed: 11 February 2022).

Robert Koch Institut (2021) Monitoring von COVID-19 und der Impfsituation in Langzeitpflegeeinrichtungen STAND DER ERHEBUNG SEPTEMBER BIS OKTOBER 2021 Durchgeführt vom Robert Koch-Institut (RKI) Bericht vom 15.12.2021. Available at: https://www.rki.de/DE/Content/Infekt/Impfen/ImpfungenAZ/COVID-19/Bericht1_Monitoring_COVID-19_Langzeitpflegeeinrichtungen.pdf?__blob=publicationFile (Accessed 11 February 2022)

Last updated: February 12th, 2022   Contributors: Thomas Fischer  |  

Hong Kong (China)

COVID-19 vaccine and booster doses roll-out

On the 8th April 2022, the Hong Kong Government announced that persons aged 60 or above who have received three doses vaccine may receive the fourth vaccine dose at least three months after their last dose. This additional dose is recommended for older people living in the community as well as those living residential care settings.

Measures to increase COVID-19 vaccination uptake among people using and providing Long-Term Care 
Providing at home vaccination for people who are house-bound

Since the 31st March 2022, the Hong Kong Government have started home vaccination trial to provide a door-to-door COVID-19 vaccination service for citizens aged 70 or above who have not yet been vaccinated and people who are unable to leave home for vaccination due to illness or physical disability.

Considerations of making COVID-19 vaccinations mandatory among LTC staff and residents

On the 1st May 2021, following discussions with the governments of Philippines and Indonesia, and in light of concerns raised by  labour groups, the government abandoned their proposal to make Covid-19 vaccination mandatory for foreign-born domestic care workers (many of whom provide domestic services to older people in their own homes). The proposal required foreign-born domestic workers to demonstrate they had received two doses as condition of approval or renewal of work visas. Covid-19 vaccination therefore remains voluntary in Hong Kong.

The Hospital Authority usually check all their new nurses for vaccination records and will “highly recommend” them to get vaccinated before starting employment. We are unsure about the current practice in Nursing Homes. The Hong Kong government has not published any data about the adoption of vaccination among healthcare workers.

Under the Residential Care Home Vaccination Programme administered by the Department of Health, it provides free Seasonal Influenza Vaccination and Covid-19 Vaccination for all residents and staff at residential care homes. Residents and staff who wish to receive vaccination would need to provide consent. Enrolled doctors, i.e. Visiting Medical Officers (VMOs), would administer vaccinations at residential care homes https://www.chp.gov.hk/en/features/21702.html. Besides, residents and staff can also arrange their own appointments to receive Covid-19 Vaccination in Community Vaccination Centres, private hospitals or clinics. Staff who have completed two doses of vaccination are exempted from the regular compulsory testing of Covid-19 https://www.covidvaccine.gov.hk/pdf/RVP_DoctorsGuide.pdf.

Mandatory vaccination for people moving into care homes

The Hong Kong Government announced on the 4th February 2022, that from the 14th March onwards, all persons newly admitted to the care homes must have received at least the first dose of a COVID-19 vaccine, unless COVID-19 Vaccination Medical Exemption Certificates is issued by doctors.

Last updated: April 11th, 2022   Contributors: Cheng Shi  |  

Iceland

As of 23 November 2021, 621,821 doses of vaccine have been given in Iceland. This represents double vaccination of 79% of the entire population, or 89% of Icelanders aged 12 years and older. In addition, 31% have received a third dose.

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

India

India’s vaccination programme for those 60 and older, and those deemed 45+ and high risk, began on March 1st, 2021. This coincided with the opening of a partially private market (e.g. vaccination out of pocket): approximately 10,000 government centres nationwide are offering free vaccinations, and 20,000 private hospitals charge the state-fixed rate of 250 rupees ($4.57). Over 12 million health, long term, and frontline workers have already been vaccinated through the state-funded program

(Sources: https://www.bloomberg.com/news/articles/2021-02-24/india-to-start-giving-covid-19-shots-to-the-elderly-at-a-costhttps://www.straitstimes.com/asia/south-asia/indias-covid-19-vaccination-for-senior-citizens-launches-to-relief-and-confusion).

Last updated: September 7th, 2021

Ireland

Family carers are not currently included on the Vaccine Prioritisation Programme in Ireland, this led Care Alliance Ireland to publish a position paper calling for vaccine prioritisation for Ireland’s family carers (https://www.carealliance.ie/userfiles/files/CAI-C19Vaccine_Position_Paper.pdf).

In Ireland, an international review of policies relating to mandatory vaccination for health care professionals was undertaken by the Health Information and Quality Authority (HIQA) in April 2021 (https://www.hiqa.ie/sites/default/files/2021-04/International_review-HCPs_who_do_not_avail_of_vaccination.pdf).

A report outlining advice to the National Public Health Emergency Team (NPHET)  by HIQA relating to this issue was also produced in April 2021. In this report, the evidence from the literature and input from the COVID-19 Expert Advisory Group was considered (https://www.hiqa.ie/sites/default/files/2021-04/Advice-to-NPHET_HCPs-who-do-not-avail-of-vaccination.pdf). The report states that, among the Covid-19 Expert Advisory Group, ‘there was a general consensus that mandating Covid-19 vaccination may not be appropriate at this time as this may act as a deterrent. Additionally, such a measure may be perceived as being overly harsh on a workforce that have had a particularly traumatic year. If all lesser restrictive measures have been exhausted and there is still low uptake, consideration may be given to mandatory vaccination in the future. However, caution was expressed with regards to how far one should go to ensure high levels of vaccination, and the potential creation of a negative work environment’. The advice given to NPHET by HIQA is to maintain a ‘support and encourage’ model, whereby staff are facilitated to make the decision to become vaccinated in a supportive environment’. According to the report, anecdotally, uptake and demand for COVID-19 vaccine among healthcare workers are currently high.

Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/

Last updated: September 7th, 2021

Israel

Israel has been globally recognized for its vaccination rollout. By early February 2021, over 90% of individuals aged 60 years and older had received their first vaccine; by end of March some reports said that almost all nursing home patients have received both doses. According to Ran Balicer, Chief Innovation Officer of Clalit Health Service and Chair of the Ministry of Health’s COVID-19 National Experts Team, much of the success of the scheme was due to its simplicity of prioritization categories.

Some studies of how successfully the vaccination program is within residents of LTCF and geriatric hospitals as well as the LTC workforce have been published and some are underway. A recent study showed evidence of the high effectiveness of the BNT162b2 COVID-19 vaccine (Biontech/Pfizer) in preventing the acquisition of SARS-CoV-2 infection within the LTCF workfoce. The researchers conclude that the rapid deployment of Covid-19 vaccines among the LTCF workforce and residents of LTCFs should be a high priority globally to reduce fatalities and transmissions of the virus. Another recent study highlighted the key role that Israel’s emergency ambulatory services, Magen David Adom, had in coordinating paramedic-led teams that were focused almost exclusively on vaccinating geriatric hospitals.

By February 2nd, 2021, Magen David Adom, the national emergency services system in charge of the vaccination rollout in LTCFs, announced it had completed its vaccination of all residents and employees of LTCFs (sheltered housing and nursing homes in Israel) – the first country in the world to do so.

The Green Passport gives vaccinated people access to most places in society and is seen as an incentive towards vaccination. There was some discussion of mandatory vaccination but this has not been taken forward.

At the end of July 2021 it was announced that Israel would start offering a third dose of the vaccine to the whole population aged 60 or over. As already noted, currently, 4,056,586 people have received  the third jab.

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

Italy

On December 12th, 2020 the Ministry of Health published the Italian strategic plan for the vaccination against Covid-19. The plan identified three priority groups for the vaccination: 1) Front-line health and LTC personnel, 2) Nursing homes’ residents, 3) People aged 80 or above. These three categories accounted for 6,416,372 people, almost 11% of the Italian population. There was also criticism that older citizens have not been prioritized in practice as they were in the original plans (only 30% of vaccination doses have been given to those over 70). The government made a major push to accelerate vaccination rates up to 600,000 per day in March 2021.

In March 2021, Covid-19 vaccination became mandatory for health professionals working in health and in LTC settings, including GPs, nurses and pharmacists who are deployed in social care settings. Mandatory vaccination concerned only clinical staff. Those who refuse cannot have their employment terminated. The employer is responsible for either transferring the employee to another job where the risk of spreading infections is lower (without affecting salary), or enforcing unpaid leave, with suspension of pay until December 31, 2021.

There are no administrative data over the vaccination rate among LTC staff and users, but a recent study from the Ministry of Health on a sample of LTC facilities shows a sharp decrease in the number of new cases and of deaths after the launch of the vaccination campaign.

At present, 85% of people aged 12 and more have received two doses from the vaccine, and the Government is pushing the booster rollout.

Mandatory vaccination policies for staff and visitors 

In October 2021 mandatory vaccination also extended to care and administrative staff working in LTC settings, although there is lack of clarity over who is responsible for to monitoring compliance.

From December 30th 2021 nursing home visitors need to have either a “super green pass” (two doses or a booster, or two doses and a negative test).

Last updated: February 1st, 2022   Contributors: Elisabetta Notarnicola  |  Eleonora Perobelli  |  

Japan

Japan has been relatively slow to roll out vaccines. Vaccination started in April 2021 for all people aged 65 and over, followed by care home staff from June but it faces issues with high levels of vaccine hesitancy (https://www.theguardian.com/world/2021/jan/28/japan-faces-olympian-task-slow-start-covid-vaccinations). Japan also faces logistical difficulties in roll out of the Pfizer vaccine in that it lacks sufficient syringes to deliver it (https://www.theguardian.com/world/2021/feb/10/japan-pfizer-vaccine-doses-wrong-syringes). There do not appear to be plans to prioritise people who live in care homes.

Last updated: September 7th, 2021

Kenya

The Ministry of Health in Kenya prioritized the use of COVID-19 vaccine based on the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Roadmap and targeted high priority groups (at higher risk of exposure) (Africa Medical and Research Foundation (AMREF) https://amref.org/coronavirus/vaccine/) such as health care workers, other front-line workers, individuals above 50 years as well as adults with underlying conditions. Although the Ministry of Health urged eligible populations to receive the vaccines due to the high transmission rates (10-11%), it is not yet mandatory and an individual may decide not to be vaccinated. Whilst receiving the vaccine is very important for all Kenyans, the government is only able to use a phased approach to provide vaccines to different populations in order to reduce the risk of social injustice in case there is inadequate supply of vaccines.

(Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Malaysia

Vaccination overview

Vaccines were rolled out during the Ministry of Health’s National COVID-19 Immunization Plan; a framework describing three phases with an aim to vaccinate 80% of the population and achieve herd immunity by February 2022. In the first phase of vaccination, priority was given to frontline staff, followed by vulnerable and high-risk groups – including elderly people (Hashim et al., 2021).

Vaccination rollout in care homes and the LTC community

Information on the vaccination rollout in Malaysia has not been made publicly available. Due to the delay in vaccination at care homes, most care home residents had received their vaccines through a separate individual vaccination route through vaccination centres, facilitated either by family members or care home staff. It is impossible to tell, therefore, how many care home residents eventually had been vaccinated as these would not be recorded as care home residents. The vaccination rate is high in Malaysia with 97.6% of all its adult population reported to be fully vaccinated by 28 December 2021.

Booster/third doses:

As care homes were not prioritized for initial vaccines, the policy of only boosting at 6 months meant that care homes residents who received vaccines at their homes would not yet be due their booster shots (as of December 2021). However, the many who took matters into their own hands and received their vaccines through individual efforts during Phase 2 of the national vaccination programme in May and June 2021 would now have been offered their booster shots. Empirical reports have suggested poorer uptake for booster shots.

Impact of the COVID-19 vaccination on care home infections and deaths:

There is no available data on the impact of the vaccination on care home infections and deaths. Although the number of deaths from care homes have almost certainly seen a significant reduction since August 2021 (when the number of cases nationally also started coming down), this has been largely attributed to high vaccination uptake. The initial delay in vaccine roll out was attributed to a lack of vaccine availability.

Policy in relation to mandatory vaccination for LTC Staff and visitors to care homes

There is no mandatory vaccination policy for users or providers of LTC. However, there is a mandatory vaccination policy for civil servants, with those who do not comply being asked to resign from their posts. With this severe policy, it is likely that care home owners and managers are likely to have a similar approach to their staff.

With thanks to Professor Tan Maw Pin

References:

Hashim, J. H., Adman, M. A., Hashim, Z., Mohd Radi, M. F., & Kwan, S. C. (2021). COVID-19 Epidemic in Malaysia: Epidemic Progression, Challenges, and Response. Frontiers in Public Health, 9, 247. https://doi.org/10.3389/FPUBH.2021.560592/BIBTEX

Last updated: February 17th, 2022

Netherlands

National COVID-19 vaccination coverage and booster rollout

As of 2nd January 2022, 86.0% of people over the age of 18 have completed the basic vaccination for COVID-19 in the Netherlands, while 89.1% have had at least one dose. With regard to people over the age of 12, 87.4% have had at least one dose, while 84.4% are fully vaccinated. With regards boosters/third doses, according to the RIVM (national institute for public health and environment), Dutch inhabitants are invited by the Municipal Health Service (in dutch ‘GGD’) for their booster vaccine in order of birth year (oldest first). By the 2nd January 2022, 32.0% of all over 18 y/o have received a booster dose.

The website of national organisation for 25 national Municipal health services (GGD’s) and Medical Aid Organizations (GHOR’s) in the regions announces that by the 4th of January 2022, all 18y/o or older, who have been vaccinated or got COVID-19 at least 3 months ago, can now plan an appointment to receive a booster vaccine within the coming weeks.

Vaccination among people living in care homes and staff

In the Netherlands, as in many other countries, care home residents and staff were among the first to be vaccinated against COVID-19. The first residents were vaccinated on 18 January 2021. After residents had been fully vaccinated, COVID-outbreaks and deaths in care homes declined.

According to the website of professional association for carers and nurses ‘V&VN’, the booster vaccination for healthcare workers was to start on the 19th November 2021. This had been planned for December but, due to high rates of COVID-19 related absences for nurses and carers, the Ministry of Health, Welfare and Sports decided to start earlier.

Hospitals vaccinate their own employes, ambulance staff, employees of rehabilitation institutions and categorical institutions (such as asthma clincs, orthopedic clinics), general practitioners and their employees.

Employees in the other care sectors, after invitation from RIVM, can visit the GGD (municipal health service) locations to receive their booster vaccine. Healthcare institutions can also choose to provide the booster to their employees themselves.

Measures to increase vaccination uptake among staff working in the long-term care sector

Vaccinations are voluntary, according to guidelines of the ministry of Health Welfare and Sports. This statement is supported by all professional associations in the long-term care sector. In accordance with the General Data Protection Regulation (GDPR) by the European Union (EU), it is not mandatory for employees to inform their employer of their vaccination status. Among politicians and within the media, debate about making vaccinations for long-term care staff compulsory has been limited. There has been some discussion about the legal grounds on which an employer could change the terms of employment for employees who work with vulnerable people and refuse to be vaccinated.

In December 2020, before the vaccination program was rolled out, some polls found that vaccine hesitancy among healthcare personnel (in long-term care and other healthcare sub-sectors) was about 30%. Currently this hesitancy has decreased over time. However, there are no hard figures for vaccination coverage in healthcare, because the standards for privacy protection applicable in the Netherlands also apply to nurses and carers.

This factsheet (in Dutch) provides an overview of the strategies that long-term care organisations have used to improve the willingness of staff to take up COVID-19 vaccinations.

Last updated: January 6th, 2022   Contributors: Lisa van Tol  |  

New Zealand

In NZ vaccinations are offered to LTC staff but not mandatory. Uptake has been high for staff. Currently vaccinations are being rolled out to Aged Residential Care facilities, and the process has been variable regionally. (Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/)

Last updated: September 7th, 2021

Norway

As of 23 November, Norway’s single vaccination rate for people aged 18 and over is 91.7%, while the double vaccination rate is 87.6% (Norwegian Institute of Public Health, 2021).

Care home residents were the first to be vaccinated in Norway, followed by healthcare staff in direct contact with patients. Presently, persons 65+ and people in a vulnerable health condition are receiving their third dose, aimed to be completed by the end of 2021.

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   Contributors: Elisa Aguzzoli  |  

Pakistan

Although older people are a priority group for vaccination, progress to date has been relatively slow. By May 2021, only 1.7 per cent of the population had received at least one dose. To date (January 2022), 52% of the eligible population has been vaccinated (Ministry of National Health Services and covid.gov.pk).

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

Poland

Vaccination priority was given to older people, residents of long-term care facilities, medical and care personnel, and groups facing the risk of severe development of the disease due to the existence of other health risks (e.g. cancer). By mid-June 2021, over 60% of the people age 60 + received at least one dose of the vaccine, a higher share of people aged 70-79 were vaccinated (about 78%) than those aged 80+ (just under 60%) (source: Ageing policies – access to services in different EU Member States; Szczepienie przeciwko COVID-19 Gov.pl).

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

Republic of Korea

COVID-19 vaccine rollout in care homes

By the 13th September 2021 approximately 99.9% of those eligible for the vaccine in Long-Term Care Hospitals (LTCHs) had received the first dose and 90.0% the second dose. In Long-Term Care Facilities (LTCFs), 99.9% had received the first dose and 91.8% the second dose (Central Disease Control Headquarters data).

Booster rollout in care homes

The Central Disease Control Headquarters announced that the rapid rollout of booster shots for LTCF staff and residents would be a priority. Currently 466,648 people are eligible for the booster shot in LTCF and LTCHs and as of the 26th November 2021, 285,909 have received a third dose of COVID-19 vaccination.

This vaccination effort has been supported by personnel from the Ministry of Defence (60 military nurses) to carry out the booster shot vaccinations in LTCHs and LTCFs.

There are no published statistics allow to separate numbers of staff and residents who have been vaccinated.

Impact of COVID-19 vaccination on mortality in care homes

The Central Disease Control Headquarters analysed vaccination, infection, and severity data from seven mass infections in high-risk facilities (LTCH, LTCF, adult day care) to identify associated factors. They found that the severity of infection was higher among non-vaccinated people compared to those who were vaccinated. Analytic results suggest a 75% protective effect of vaccination on severity.

Last updated: January 26th, 2022   Contributors: Hongsoo Kim  |  Jae Yoon Yi  |  

Singapore

Covid-19 Vaccinations have been voluntary for the whole healthcare sector (and country), but Care Providers proactively educate their staff and regularly report vaccination rates.  As of Mid-February, already 73% of healthcare workers had been vaccinated with at least 1 dose (the vaccination campaign started around Mid-Jan, so the coverage is likely much higher now) (https://www.moh.gov.sg/news-highlights/details/progress-of-covid-19-vaccination-programme/).

On the 3rd September 2021, the Expert Committee on Covid-19 Vaccination recommended that people aged 60 and over, as well as those who live in aged care facilities, should receive a booster dose of an mRNA vaccine six to nine months after the completion of vaccination with two doses.

The Agency for Integrated Care supports people who are housebound and need to be vaccinated at home or who need escorting or transported to vaccination centres.

Last updated: December 17th, 2021

South Africa

Covid-19 vaccinations are completely voluntary in South Africa.  The Constitution protects individuals’ rights to decide for themselves, without due influence.  Care homes strongly encourage vaccination of staff (flu and Covid-19) but cannot make it compulsory or preclude staff from coming to work (this would become a labour law issue).  The phase 2 of vaccination (general population – beyond health care workers) started during May 2020 and, at least the in Western Cape (if not the whole country) people in Long-Term Care Facilities and people aged 60 or over were being prioritized.

Source: https://ltccovid.org/2021/05/25/national-discussions-on-mandatory-vaccination-among-long-term-care-staff-in-23-countries-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19-no-1-may/

Last updated: September 7th, 2021

Spain

Spain’s vaccination programme began in early January 2021, with nursing home and long-term care facility residents in the highest prioritization group alongside frontline healthcare workers. Vaccination campaign responsibilities fall to the individual regions.

In Spain, like with any other vaccine, vaccination for COVID-19 is voluntary for all the citizens, including workers from the health sector and the long-term care sector. Workers from the health and the long-term care sector have been prioritized groups in the COVID-19 vaccination strategy, but vaccination is not compulsory (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion6_EstrategiaVacunacion.pdf).

Last updated: September 7th, 2021

Sweden

Vaccination started on 27th December 2020, after the approval of Pfizer/BioNTech vaccine by the European Union commission (Sweden is part of an EU cooperation on a joint agreement for the purchase of Covid-19 vaccines). Vaccination against Covid-19 is free of charge for everyone. The national plan for Covid-19 vaccination has been drawn up by the Public Health Agency of Sweden, the National Board of Health and Welfare, the Swedish Civil Contingencies Agency (MSB), the Swedish Association of Local Authorities and Regions (SKR), the national coordinator for Covid-19 vaccine, and infectious disease doctors and representatives from the regions. Vaccine availability will determine how quickly the vaccine can be offered to more people. The order of priority for vaccines is divided by 4 phases: Phase 1: Individuals who live in residential care homes for older people or who use home care services under the Social Services Act. Healthcare personnel working with this risk group. Adults who live with someone in this risk group. Phase 2 Other individuals aged 70 years or older. The oldest will be vaccinated first. Individuals aged 18 years and older who receive help under the Act concerning Support and Service for Persons with Certain Functional Impairments (LSS). This also applies to individuals aged 18 years and older who have been granted assistance allowance under the Swedish Social Insurance Code. Medical and care service professionals, including LSS, who work closely with patients and recipients of care (https://www.krisinformation.se/en/hazards-and-risks/disasters-and-incidents/2020/official-information-on-the-new-coronavirus/vaccine-medicine-and-treatment).

No vaccination is compulsory in Sweden and, comparatively, there is very high acceptance of all kinds of vaccines.  A survey from March 2021 showed that 91% of the population intended to take the COVID-19 vaccine when offered. There was some discussion (at the local level) that staff who refused vaccination would not be allowed to work directly with residents in care homes, but more recently that does not seem to be on the agenda (probably due to the clear evidence of the rapidly declining number of cases among residents once they have been vaccinated). From the beginning, care home staff were in the first priority group together with care home residents, but when there were problems with the amount of doses arriving, the vaccination of care home staff stopped and instead the recommendation is to prioritise only according to age (once care home residents and home care users have got their first dose).

As of June 2021, the vaccination rate of people living in LTC or receiving home care (priority group number 1 in Sweden) is 94% at least one dose, 89% fully vaccinated (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 7th, 2021

England (UK)

Latest data on COVID vaccinations among people using and providing social care in England

Detailed data on COVID vaccinations is published weekly by NHS England. By December 16 2021, it was reported that 95% of all eligible residents and 94.2% of staff in all care homes had been given a second COVID-19 vaccine dose. 77.9% of residents and 33.6% of care home staff had had a booster.

Among social care staff working for registered providers in other settings, including domiciliary care, 81.2% had two vaccine doses and 23.1% had had a booster.

For the 8.5 million people aged 16 to 64 who are identified as “at risk” or as carers, 83.6% had had two doses and 50.1% had had a booster. This group includes people with intellectual disabilities.

Vaccination rollout and social care

On November 27, 2020, Public Health England (PHE) published their COVID-19 vaccine guidance for health and social care workers. On December 7, NHS England (NHSE) published a standard operating procedure on vaccine deployment for care home staff. This gave care home providers the responsibility to inform their staff, organise logistics, and encourage vaccine uptake.

On December 20, NHSE published information stating that a roving model to deliver the vaccine in care home settings was to be deployed as soon as possible. On December 30, NHSE announced that vaccines should still be offered to older adults in care homes which have cases, although for those who are acutely unwell or within four weeks of the onset of COVID-19 symptoms, this should be temporarily deferred.

On December 30, the Department of Health and Social Care (DHSC) published information on vaccination priority groups. Previous publications by the Joint Committee on Vaccination and Immunisation (JCVI) had stated that the first priority group for receiving COVID-19 vaccinations were residents in care homes for older adults and their carers. Frontline social care workers, including those who work in hospice care, are to be included in the second priority group. Carers of those with an underlying health condition should be offered vaccines alongside these groups, which is group six unless the person they are caring for is in a higher group.

On January 7, 2021, NHSE published additional operational guidance, further to the guidance from December 30, 2020. This stated that by mid-January, NHS Trusts would be established as hospital hubs, which were the default provider of COVID-19 vaccinations for all healthcare and social care workers. On January 11, DHSC published an update to their vaccine delivery plan. This aimed to have offered a first vaccine to everyone in the top 4 priority groups by 15 February. This stated that local vaccination services had a responsibility to coordinate and deliver vaccination to people who were unable to attend a vaccination site, such as the homes of housebound individuals, and residential settings for people with intellectual disabilities or autism.

On January 13, NHSE published information regarding the next stage of the vaccine rollout in older adult care homes. The addition of the Oxford/AstraZeneca vaccine to the schedule from the w/c January 4 meant that smaller care homes could be vaccinated. First doses were expected to be administered to care home residents and staff by January 17, and by January 24 at the latest. This was to occur 8am to 8pm, 7 days a week. It was suggested that primary care networks (PCNs) had a responsibility to provide mutual aid to other PCNs to ensure that all care homes had been vaccinated by the end of the w/c January 18. On January 14, NHSE published an update outlining the next steps for eligible social care worker vaccination.

On January 26, the National Care Forum (NCF) published the results of a snapshot survey across 750 care homes for older people in England between January 25 and 26. Of these 750, 715 had achieved whole home vaccination, representing 95% vaccine take up. Whilst most organisations who responded noted that 50% or more of staff had been vaccinated, only 27% reported vaccination over 70% for their staff. The NHSE target to vaccinate all residents and staff by January 24 has been missed, and the next goal is the government objective of getting all those in JCVI groups 1-4 vaccinated by February 15. On February 15, the BBC reported the announcement from the Health Secretary that a third of social care staff in England had not had the COVID-19 vaccine. Everyone in the top four groups had been offered the COVID-19 vaccine.

On February 24, PHE reported that the JCVI had advised that all people on the GP Learning Disability Register were to be invited for vaccination as part of the JVCI group 6 (people with Down’s syndrome are included in group 4). On March 8, NHSE published an operating procedure relating to COVID-19 vaccine deployment for unpaid carers who will now be part of the JCVI cohort 6. Where the person they care for is part of the JCVI vaccine cohort 6, then they are able to receive their vaccination at the same time.

On March 10, Nuffield Trust released some analysis. This showed that by the end of February, fewer than 3 in 4 staff working in care homes for older adults had received their first dose. This showed regional variation, with rates highest in the North East and Yorkshire and lowest in London. Rates for other social care staff are even lower with fewer than 3 in 5 having had their first dose.

By August 29, it was reported that 95% of all eligible residents and 82% of staff in older adult (65+) care homes had been given a second COVID-19 vaccine dose. In England, 78.7% of all care homes had at least 80% staff and 90% residents vaccinated with at least one dose. Among younger adults living in care homes, 88.9% had been given a second dose.

From September 16, 2021, the government began rolling out booster vaccinations to those in JCVI cohorts 1 to 9 who received their second dose more than 6 months ago, and boosters are now being delivered and administered to older adult care home residents and staff within their homes.

Policy on mandatory vaccinations:

On March 22, The Telegraph reported that leaked details of a paper, ‘Vaccination as a condition of deployment in adult social care and health settings’, submitted to the COVID-19 Operations Cabinet sub-committee showed that the Prime Minister and the Health Secretary had requested that vaccinations become a legal requirement for care home workers. The legal change would be likely to affect England only, with health policy the remit of the devolved administrations in Wales, Northern Ireland, and Scotland. Only around a quarter of care homes in London, and half in other parts of England, have reached the level of vaccination among staff and residents deemed safe by government scientists, which SAGE set at 80% vaccination among staff and 90% among residents of a care home.

On August 4, it was announced that full COVID-19 vaccination would be mandatory for staff working in care homes by November 11, despite it being reported by the Guardian that there were concerns from providers that this may worsen existing staff shortages. Analysis of data reported by the Department of Health and Social care indicated that as of 26th October 2021, 39% of agency staff and 10% of directly employed staff deployed in care home settings had not yet received two doses of a covid-19 vaccine (Skills for Care, 2021).

Published on November 3, 2021, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. This will provide £388.3 million in further funding to support IPC, testing, and vaccination uptake in adult social care settings. Following consultation, the government announced on November 9, 2021, that all frontline NHS and care staff, including volunteers, will also be required to be fully vaccinated against COVID-19 from April 1, 2022. From November 11, 2021, being fully vaccinated against COVID-19 will be a condition of deployment for people working or volunteering in care homes, unless they are exempt. These requirements will apply to all CQC-registered care homes in England that provide accommodation for persons who require nursing or personal care.

On the 31st January 2022, the Health and Social Care Secretary announced that the legal requirement for health and social care staff to be double vaccinated to work would be removed, subject to consultation and approval by Parliament. The announcement justifies this changed based on high levels of vaccination and boosters in the population and lower levels of hospitalisations and mortality. Health and social care professionals are still urged to get vaccinated and boosted but it is no longer mandatory. The care home sector has estimated that mandatory vaccinations contributed to over 30,000 care workers leaving the sector, at a time of acute workforce shortages (see section on workforce shortages during the pandemic).

References:

Skills for Care, (2020). The state of the adult social care sector and workforce in England. Retrieved from: skillsforcare.org.uk. Accessed on 24/03/2022

Last updated: March 24th, 2022   Contributors: William Byrd  |  Nina Hemmings  |  Chris Hatton  |  Adelina Comas-Herrera  |  

Scotland (UK)

COVID-19 vaccination rollout in the long-term care sector

Care home residents were prioritised for boosters, with teams going in to care homes to vaccinate residents and available staff. Thereafter staff were invited to attend other locations in the community to receive their booster vaccination.

By the 29th December 2021, Public Health Scotland estimated that 89.4% of all care home residents in Scotland had received a booster or 3rd dose and 95.1% had had at least two doses. 63.6% of staff had had the booster (or 3rd dose) and 88.6% had had two doses.

Calculating the share of care home residents who have received vaccinations is difficult as there is no complete method to identify all people who live in care homes in Scotland using routine data sources, or staff working in care homes.

Policy on mandatory vaccination for long-term care staff

The UK Government has mandated that all care home staff in England are required to be fully vaccinated. Scottish Care released a statement in June 2021 to say that this mandate had little relevance in Scotland since Public Health Scotland figures released up until 15th June 2021 showed that a very high percentage of care home staff had already been fully vaccinated. It is not Scottish Government policy to make vaccination mandatory for care home staff.

Last updated: March 24th, 2022   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

United States

The United States’ federal effort to get nursing and long-term care home residents vaccinated, known as the Pharmacy Partnership for Long-Term Care Program, partnered with pharmacies such as Walgreens and CVS to set up vaccination clinics in and around LTCFs. The federal program used a statistical formula that has significantly overestimated how many doses would be needed for long-term care facilities, leading some states such as Oklahoma and Maine to redistribute the federally-provided vaccinations to those 65 and older living at home. A map containing the number of doses distributed from this Long-Term Care Program specifically was shared on the CDC website.

On March 11th 2021, President Biden’s administration announced an updated timeline for vaccination across the country, making all adults eligible for vaccination by May 1st due to the success of vaccination rates of the highest priority groups.

On 18th August 2021, President Biden announced that the week of 20th September booster shots would start being administered to individuals who had had the second dose eight months before, the first citizens that will be eligible will be healthcare providers, residents in nursing homes and other older people. The President also announced that COVID-19 vaccinations would be mandatory for all Long-Term Care workers for Medicare and Medicaid services.

Due to the raising infections and deaths in nursing home facilities in Omicron wave in the US, there has been a renewed push to get more residents and staff members vaccinated and boosted. In December 2021, a federal appeals court revived in 26 U.S. states a COVID-19 mandate issued by President Biden’s administration requiring healthcare workers to get vaccinated if they work in facilities that receive federal funding.

Last updated: January 18th, 2022

Vietnam

In early 2021, the Vietnamese Ministry of Health set out a target of 150 million doses to vaccinate 75% of the population and achieve herd immunity by early 2022. A rollout plan was issued which included 16 priority groups. These groups included medical workers and those who participate in COVID-19 prevention and control work, people with chronic conditions, people aged 65 and older, poor people, and social policy beneficiaries. No mention is made of people who provide long term care (although notably these are mainly informal carers / family members of older people) (source: CCI France Vietnam).

For those who were unable to go to health facilities to receive the vaccine (for example, due to old age or disability) in some areas, vaccination medical teams did home visits (source: WHO).

To date (end of December 2021), almost 80% of the total population have received at least one dose of the vaccine and around 58% are fully vaccinated (source: Our World in Data). On December 24th 2021, the Ministry of Health declared that they aim to complete the administration of booster shots by the end of the first quarter of 2022 (source: Reuters).

There is no information available (in English) on the number of vaccines different segments of the population (for example, elderly people) have received.

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

3.12. Measures to support unpaid carers

Overview

As shown in Part 2 of this report, unpaid carers have experienced substantial negative impacts during the pandemic, affecting their mental, physical and financial health.

Across countries voluntary organisations have responded quickly trying to offer unpaid carers information and remote services. In several countries, Ministries and local authorities have also offered information. In some countries, policy makers have established dedicated support to support family carers (e.g. financial support, relaxation of existing policies, provision of PPE and other resources, paid care leave) while in others, carers may have benefited from general measures put in place to mitigate the financial impact of the pandemic.

Specific governmental measures to support unpaid carers have included:

  • – financial support, for example special care leave (Austria, Belgium, Luxemburg), the right to receive a care-giver allowance as a wage replacement benefit for an extended period of up to 20 working days (instead of 10 days) to provide or organise care in situations caused by the pandemic (Germany)
  • – targeted guidance on dealing with COVID-19 while providing care
  • – identification of unpaid carers as key workers,
  • – providing access to testing, telehealth, PPE and vaccinations.
  • – psychological support (Austria, Slovenia)
  • – toll-free number to receive advice and support (France)

A scoping review covering academic studies up to July 2021 found that support measures for unpaid carers were discussed in 12 studies, but only one of these was a Randomised Controlled Trial (RCT) of an intervention. The interventions described included informal neighbourhood support, social worker support, memory cafes and technology. The RCT was of an intervention consisting of videoconference coaching and access to a website with tailored to distance carers of people with cancer, which was found to be effective in reducing anxiety and distress for unpaid carers.

There is also evidence of how existing services and forms of support, such as the Care Ecosystem programme, in four states of the United States, adapted its activities to support unpaid carers of people with dementia during the pandemic (Merrilees et al., 2022).

References:

Merrilees J., Robinson-Teran J. Allawala M., et al. (2022). Responding to the needs of persons living with dementia and their caregivers during the COVID-19 pandemic: Lessons from the Care Ecosystem, Innovation in Aging, 2022;, igac007, https://doi.org/10.1093/geroni/igac007

International reports and sources

This rapid review (currently being updated), covered measures to support unpaid carers during the pandemic up to November 2020, as well as evidence on the impacts of the pandemic on carers: https://journal.ilpnetwork.org/articles/10.31389/jltc.76/

This report from June 2020 covered measures to support unpaid carers in the early part of the pandemic (https://ltccovid.org/wp-content/uploads/2020/06/International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-17-June.pdf).

This scoping review also covers measures adopted to support unpaid carers:

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

Some information on support measures for unpaid carers during the pandemic in the European Union can be found in a 2021 EU report on LTC (Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Australia

Carers Australia have published resources and guides to help informal carers throughout the pandemic. The government has not introduced specific funding support for unpaid carers, however, unpaid carers are eligible for the Australian Government’s Coronavirus Supplement.

Funding for the My Aged Care website and phone services was boosted through an extra $12.3m to support. The Carer Gateway website also provides information for family carers.

Most unpaid carers are eligible for COVID-19 vaccines as part of the phase 1b of the vaccination rollout (which started in March 2021).

Last updated: December 22nd, 2021

Austria

Austria has supported carers through telephone hotlines (for psychological counselling, self-help, guidance, resources). An online course for unpaid carers is being provided by the Austrian Red cross. The national dementia strategy and the Austrian carers association provide links to NGO support. (https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Austria-13-July-1.pdf). An article by Leichsenring and colleagues published in the Journal of Long-Term Care highlights the limited support available for unpaid carers.

Last updated: September 7th, 2021

Brazil

In Brazil a number of organisations have developed technical and educational guidelines. The Ministry of Women, Family and Human Rights established a website to provide family carers and people with long-term care needs with information around the COVID-19 pandemic. Some organisations have also established psychosocial activities (https://ltccovid.org/wp-content/uploads/2020/05/COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf).

Last updated: September 7th, 2021

British Columbia (Canada)

The Canada Emergency Response Benefit (CERB) was offered between March 15, 2020 and September 26, 2020. Individuals were eligible if they stopped working due to taking care of a family member with COVID-19, having a disability with usual care not available because of COVID-19, or a child because schools are closed. CERB has now been discontinued; however, unpaid carers are eligible for the Canada Recovery Care Benefit (CRCB). CRCB provides income support to employed and self-employed individuals who are unable to work because they must care for their child under 12 years old or a family member who needs supervised care (https://www.canada.ca/en/services/benefits/ei/cerb-application.html#eligible; https://www.canada.ca/en/revenue-agency/services/benefits/recovery-caregiving-benefit.html).

As part of British Columbia’s emergency COVID-19 response plan, BC doubled 2020 funding for Family Caregivers of British Columbia to $1 million CAD. Family Caregivers of British Columbia is a non-for-profit organization that provides support for over 1 million unpaid carers (https://news.gov.bc.ca/releases/2020HLTH0141-000763).

Last updated: November 6th, 2021

Denmark

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

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

Last updated: September 16th, 2021

Finland

Section 5.5 of the LTC Covid Report (page 12) provides a review of the work of Carers Finland, an organization that during the pandemic has collected information and testimonials from informal carers. Key themes from their research include heightened loneliness and isolation; decreased physical and mental functioning; emotional and logistical struggles in accessing external services; inadequate means of support (e.g. internet calls) (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Formal measures for support remain unclear.  As in other countries, NGO services, such as the member associations of Carers Finland provided remote services over the phone or through virtual meetings (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: September 7th, 2021

Germany

The Federal Government has issued support measures for unpaid carers during the COVID-19 pandemic (so far valid until 31 March 2021). These include ‘Care Support Payment’, which covers carers pay for up to 20 working days when they need to cover care during the pandemic or if they need to provide care that cannot be replaced by someone else. Working carers can also take ‘family care time’ if they have not used the maximum number of days. Family carers can request an interest free loan or to get loss of income during the pandemic recognised in repayment scheduling (Bundesministerium für Familie, Senioren, Frauen und Jugend, 2021).

The German Society of Nursing Science has developed new guidance on how domiciliary carers can support unpaid carers, this includes offering training on hygiene measures for family carers; informing family carers about available support structures and services; family carers to receive psychosocial support or to be provided with information about psychosocial support (https://www.awmf.org/uploads/tx_szleitlinien/184-002l_S1_Haeusliche-Versorgung-soziale-Teilhabe-Lebensqualitaet-bei-Menschen-mit-Pflegebedarf-COVID19-Pandemie_2020-12.pdf).

In Bavaria unpaid carers receive three FFP2 masks for free through their local government (Pflegeberatung.de, 2022).

References

Bundesministerium für Familie, Senioren, Frauen und Jugend (2021) Informationen für pflegende Angehörige. Available at: https://www.bmfsfj.de/bmfsfj/themen/corona-pandemie/informationen-fuer-pflegende-angehoerige (Accessed 11 February 2022).

Pflegeberatung.de (2022) Aktuelle Regelungen in der Pflege im Kontext von Corona. Available at: https://www.pflegeberatung.de/corona (Accessed 11 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

India

Organisations in India provide COVID-19 information for people with disabilities/LTC needs and their family carers. One organisation has developed an app to enable family carers to access expert advice. The Ministry of Health and Family Welfare provided online medication, yoga videos, advice on mental health support and a psychosocial behavioural helpline. Some states have set up dedicated services (helplines) and organisations have implemented virtual interventions. Guidelines by the Ministry of Social Justice and Empowerment state that family carers should be issued with travel passes (https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID-situation-in-India-30th-May.pdf).

Last updated: September 7th, 2021

Indonesia

Some social assistance programme were put in place during the COVID-19 pandemic, from which unpaid carers may have benefited. The Ministry of Social Affairs plans to increase the number of social security beneficiary programmes for older people (https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19-Long-Term-Care-situation-in-Indonesia-30-May-1.pdf).

Last updated: September 7th, 2021

Ireland

A number of organisations in Ireland developed material, helplines and remote interventions to support family carers during the pandemic. Those qualifying for Carers Allowance will receive payments. Those who have lost their jobs can receive the Pandemic Unemployment Payment in addition to their Carers Allowance (https://ltccovid.org/wp-content/uploads/2020/06/International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-17-June.pdf).

Last updated: September 7th, 2021

Israel

Information on support to unpaid (family) carers is unclear beyond the stipend received by all citizens and increased accessibility of unemployment benefits; an updated January 2021 guidelines document is available, which lists counseling services and call centers as primary measures for support.

The Ministry of Health also provided a guide for carers of people with dementia.

Last updated: December 5th, 2021

Japan

Japan has offered payments to all citizens as part of their economic stimulus packages, which may help offset some of the economic burden of care (AHWIN, 2020 in https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: September 7th, 2021

Netherlands

The Dutch government issued guidelines for informal carers. These guidelines include advice on hygiene standards and guidelines on how a caregiver should act if the person they provide care to develops symptoms of COVID-19 (https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long-Term-Care-situation-in-the-Netherlands-25-May-2020-1.pdf).

All family care caregivers that experience symptoms of COVID-19 have been able to get tested since 18 May 2020. In addition, family carers could access free PPE from 19 May 2020 if they support vulnerable people (70 years and older, with chronic conditions) who experience symptoms of COVID-19 and where personal care (with less than 1.5 metres distance) is required (https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long-Term-Care-situation-in-the-Netherlands-25-May-2020-1.pdf).

Municipalities have set up support desks to help distressed informal carers and the role of the General Practitioner (GP) to support has been emphasised (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).

Guidelines advise that GPs play an important role in supporting unpaid carers.

Last updated: September 7th, 2021

New Zealand

Unpaid carers in New Zealand can get a carer support subsidy from the Ministry of Health. The funding guidelines were relaxed to support carers during Alert levels 2-4, this included expanding the guidelines of what could be purchased, allowing a resident family member to be paid and support with finding a support worker (https://ltccovid.org/wp-content/uploads/2020/08/The-LTC-COVID-situation-in-New-Zealand-9-August-2020.pdf).

Last updated: September 7th, 2021

Republic of Korea

Family members were paid to provide the necessary care to older adults care at the same wage as professional caregivers after they receive two hours of training (https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: September 7th, 2021

Spain

The Mecudia plan (initiated 18 March 2020) enables people with work and care responsibilities to request an adjustment or reduction of their working arrangement to support the person with care needs. In addition, people who are financially vulnerable, including unpaid carers who experience a substantial loss of income can apply for a mortgage debt moratorium. Some municipal governments have also produced information material, helplines or phone counselling. NGOs have also provided information and support (https://ltccovid.org/wp-content/uploads/2020/10/LTCcovid-Spain-country-report-28-May-1.pdf). In addition, resources to support unpaid carers have been developed (https://ltccovid.org/wp-content/uploads/2020/06/International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-17-June.pdf).

Last updated: September 7th, 2021

Sweden

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

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

Last updated: September 7th, 2021

England (UK)

Very few measures were initially announced to support unpaid carers. These increased over time and included specific guidance for unpaid carers, enabling those experiencing symptoms to be tested and providing guidance related to the unpaid carer role (Source: DHSC: Guidance for unpaid carers). Additionally, the government provided funding for the Carers UK helpline.

A major source of support for many working unpaid carers was the furlough scheme, which enabled them to maintain up to 80% of their income (Lorenz-Dant, 2020). During the vaccine rollout, unpaid carers were included in priority group 6 (Source: DHSC: Priority groups for coronavirus vaccination).

References:

Lorenz-Dant, K. (2020) International examples of measures to support unpaid carers during the COVID-19 pandemic. Report on LTCcovid.org 

Last updated: March 10th, 2022   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 an additional £400,000 into the Time to Live Fund to provide micro-grants to give unpaid carers a break. Local delivery will be supported by funding and working with partners including the Carer Centre Manager Network and Scottish Young Carer Services Alliance. Additionally, £1.4million is being provided to deliver the ScotSpirit Holiday Voucher Scheme which will help low income families, unpaid carers, and disadvantaged young people to enjoy a break over the winter (Source: gov.scot).

Last updated: March 24th, 2022   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

United States

Policy measures:

During the pandemic Medicaid allowed more people with care needs to hire family members as paid carers.

Home-based tele-health has been expanded and the Care Act requires a caregiver to be registered within people’s health records.

Some US guidance includes unpaid carers in the vaccination priority list.

Care Ecosystem programmes: adapting to support unpaid carers and people with dementia

Qualitative interviews with professionals supporting people living with dementia and their family carers in four US states with established Care Ecoystem programmes showed that, during the shelter-in-place periods in March to May 2020, fear of contracting COVID-19 led to reluctance in using medical care and respite care services. Concerns about restrictions to visiting and inability to provide care also led to reluctance to consider moving to care homes. When carers did seek services, they found that these were less available (or in the case of day care services, not at all). Carers also reported shortages of key supplies, including incontinence products and groceries. Staff from the existing However, this study also showed how existing staff  (mainly Care Team Navigators) adapted their ways of working to provide additional support, including helping family carers learn how to use technology, practical in-home activity ideas, and help them navigate access to information and resources (Merrilees et al., 2022).

References:

Merrilees J., Robinson-Teran J. Allawala M., et al. (2022). Responding to the needs of persons living with dementia and their caregivers during the COVID-19 pandemic: Lessons from the Care Ecosystem, Innovation in Aging, 2022;, igac007, https://doi.org/10.1093/geroni/igac007

Last updated: March 3rd, 2022

PART 4.
Reforms that aim to address structural weaknesses of Long-Term Care systems and to improve preparedness for future pandemics and other emergencies

4.00. Overview of new Long-Term Care reforms (adopted or under consideration)

Denmark

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

Last updated: May 25th, 2023   Contributors: Tine Rostgaard  |  

Italy

Currently (December 2021) no reform has been implemented with regard to LTC and LTCF. In the National Plan for Recovery and Resilience, strategic objectives concerning integration of care, social housing, home care, have been included but no action was taken until today.

Sources:

AAVV, 2021, PIANO NAZIONALE DI RIPRESA E RESILIENZA MISSIONE SALUTE, Monitor, Anno II, Numero 45

Last updated: December 11th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

4.01. Reforms to address Long-Term Care governance

Overview

Some reforms in LTC governance have been implemented in EU Member States (source: EU report 2021).

International reports and sources

Some information on recent reforms related to governance in LTC sector can be found in EU report 2021.

Finland

An EU report notes that Finland has launched programme for health and social services centres for the future, which will be implemented in 2020-2022 and where patients will have access to various services in one place (e.g. primary healthcare, local social work, and homecare services). Moreover, the responsibility for organising health and social will be transferred from the municipalities to 22 regional authorities to provide better access to LTC. Finland also took steps in 2018 to improve the sharing of individual social welfare information in the national archive with care institutions at county level, to improve care management.

Last updated: November 24th, 2021

France

A fifth pillar of social security is being created around long-term care insurance. Social care policy (termed policy of ‘independence’) will be steered between the Caisse nationale de solidarite pour l’autonomie (CNSA, which becomes a true insurance fund), and local authorities (the decentralised level). There are plans over  2020-2022 to improve and modernise local regional authorities for the disabled (Maison Departementale des Personnes Handicapees) and local regional authorities for independence (Maison Departementale de l’Autonomie), which help people who draw on care access care and support by providing services such as information, care assessments and planning, follow-up, and medication. The centres are made up of multi-disciplinary teams including doctors, nurses, occupational therapists, care workers, and inclusion specialists.

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

Mexico

There is evidence of the need to formally develop a National Care System that provides support to those in need of care and their families, and that includes LTCFs. In view of the challenges due to the lack of information and competencies in infection prevention and control at LTCFs, a group of experts, in collaboration with different public institutions, joined efforts with the purpose to update the guidelines in order to allow LTCFs face the pandemic and to contribute to the generation of a National Care System.

Source:

Mena-Madrazo, J. A., Sosa-Tinoco, E., Flores-Castro, M., López-Ortega, M., & Gutiérrez-Robledo, L. M. (2021). COVID-19 and long-term care facilities in Mexico: a debt that cannot be postponed. COVID-19 e instituciones de cuidados a largo plazo en México: una deuda impostergable. Gaceta medica de Mexico157(1), 94–96. https://doi.org/10.24875/GMM.20000549

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

4.02. Reforms to the Long-term care financing system

Overview

Belgium, Germany, Estonia, Poland, Romania, and Slovakia introduced changes in the sources, or the conditions for LTC financing. Additionally, a number of countries including France, Austria, Finland, and Germany have announced plans for financing reforms (source: https://ec.europa.eu).

A reform to the social care funding system in England was also announced in September 2021.

International reports and sources

An EU report (2021) highlights recent reforms related to financing and coverage of LTC in Member States.

Austria

Since 2017 Austrian federal provinces can no longer use assets of people in residential care, (or assets of their relatives, heirs or gift-recipients) to cover the costs of care. In January 2020, a yearly indexation of long-term care cash benefits was established (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 8th, 2021

Belgium

An EU report (2021) noted that the federated region of Wallonia recently reformed the financing mechanism for residential care facilities and established a regulation for the daily fee.

Last updated: November 23rd, 2021

Czech Republic

In 2019 the personal care allowance for the most dependent groups of beneficiaries (apart from people in residential care) has been increased by 45 % (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 8th, 2021

France

An EU report (2021) noted that France has announced a reform plan in response to the COVID-19 crisis  which proposes numerous measures regarding long-term care which include (among other things): establishing a new financing mix for the supply of LTC (e.g. combining healthcare and social care expenditure in residential care to decrease the remaining amount payable by residents); changing the existing financial support system (e.g. a new cash benefit for homecare); and increasing resources to support informal carers. Additionally, the 2020 law on social debt and autonomy created a fifth sector of the National Health System, dedicated to the loss of autonomy of older people and people with disabilities, with EUR 1 billion funding.

Following the Segur de la sante (wide stakeholder engagement in 2020 to recover and build resilience in health and care), a national investment strategy was adopted and is devolved from national to regional level. This gives greater decision-making power to regional structures (ARS) to enable them to be closer to local needs and reduce complexity/length of allocation and increase clarity/transparency around decision-making.

Author: Alis Sopadzhiyan (LTC Covid profile pending)

Last updated: December 3rd, 2021

Germany

Expansion of entitlement to LTC benefits

From 2017 the legal entitlement to LTC benefits and the categories of beneficiaries have been extended (particularly to people with dementia) by recognising cognitive and mental capacity as part of the instrument used to assess people’s care level. The assessment encompasses the six areas: mobility, cognitive and communication abilities, behavioural and mental difficulties, self-care, ability to cope and independently manage health or therapy related needs and burden, organising everyday life and social contacts; in addition, the amount of benefits have increased substantially for most through the reorganisation of support entitlements into five care grades. No person already receiving support should have been worse off following the reform.

Co-payments for people living in residential care settings no longer depend on a person’s care grade. All people in living in a nursing now pay the same care-related co-payment (the amount differs between residential homes). In addition, people in full- or part residential care settings receive a legal entitlement for additional offers of care.

Increasing contributions to LTC insurance

As part of this ‘second care strengthening bill’ (zweites Pflegestärkungsgesetz) contribution rates to the mandatory long-term care insurance increased by 0.2 percentage points (to 2.55 per cent for people with children and 2.8 per cent for people without children).

Income cap on co-payments for children of beneficiaries

Children of people with care needs can be exempt from the obligation to cover the cost of care for their parent that is not provided for as part of the LTC insurance. Since 2019 this exemption has been put in place for children of people with care needs earning less than EUR 100,000 (annual gross income) (European Commission, 2021).

Cap on co-payments for people living in residential care settings over longer time periods

In June 2021 a new care reform was passed. The reform seeks to relieve people living in residential care settings for longer periods of time from some of the co-payments. For example, the reform seeks to reduce co-payments of people living in residential care for more than 12 months by 25 per cent (on average €228 per month based on average contributions of €911). This reduction increases with time spent in residential care. For people living in residential care settings for more than 36 months, the reduction will amount to 70 per cent (on average €638 per month based on average contributions of €911).

The reform is planned to be financed by a federal grant (1 billion per year) and an increase in the long-term care insurance of 0.1 per cent for childless people (Bundesministerium für Gesundheit, 2021).

Reference

Bundesministerium für Gesundheit (2017) Die Pflegestärkungsgesetze – Das Wichtigste im Überblick. Available at: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Broschueren/PSG_Das_Wichtigste_im_Ueberblick.pdf(Accessed 1 February 2022)

European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu) (Accessed 4 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Malta

The country reinforced homecare by introducing a cash benefit for people employing a fulltime carer (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: September 8th, 2021

Poland

In 2018, Poland implemented a programme that finances care services in rural areas and smaller towns, which are particularly prone to depopulation and ageing due to migration processes. Under the programme, local authorities may be granted a subsidy to enable homecare services.  In 2019 a cash benefit was introduced for adults who are unable to live independently. A definition of ‘inability to live independently’ was established, together with new assessment rules (source: Employment, Social Affairs & Inclusion – European Commission).

Last updated: November 24th, 2021

Romania

An EU report noted that in 2020 the country adopted new cost standards for all social services, including residential and homecare services for both public and private service-providers.

Last updated: September 7th, 2021

Slovakia

An EU report (2021) noted that financial contribution from state to social service providers has been significantly increased in Slovakia, which is estimated to have increased the supply of long-term care services and has made these services more affordable.

Last updated: September 7th, 2021

Spain

On January 15th 2021, a Shock Plan was approved by the Territorial Council of Social Services and the System for Autonomy and Care for Dependency (SAAD). The aim of the Shock Plan is to ensure adequate working conditions for people who work in the SAAD, along with improvements in services and benefits to guarantee adequate care for dependents.

The plan includes a series of objectives and measures regarding the development and management of the SAAD. The issues that are addressed by the plan include the need to carry out an evaluation of the SAAD, the reduction of administrative obstacles, the simplification of the procedures for awarding benefits, the reduction of waiting lists, and the recognition of telecare as a subjective right.

Improving the financing of SAAD is one of the main aims of the Shock Plan, and is achieved by an increase in contributions from the General State Administration (AGE). The two areas that have seen increase are in the minimum levels of protection and the agreed level of protection.

In 2021 and 2022 the funding for both areas increased significantly. The increase in minimum levels of protection have been enshrined in the General State Budgets for the year 2022, and can be seen in the table below:

Degree Previous amounts (€/month) New amounts (€/month) Increase
Grade III Large Dependency €235.00 €250.00 6.38%
Grade II Severe Dependence €94.00 €125.00 32.98%
Grade I Moderate Dependence €60.00 €67.00 11.67%

The agreed levels of protection increased from €283,197,420 in 2021 to €483,197,420 in 2022. In 2021 the overall financing of the SAAD increased by 40.53% to €563 million and is expected to increase significantly in 2022.

 

 

Last updated: June 30th, 2022   Contributors: Sara Ulla Díez  |  

England (UK)

On September 7th, 2021, the Prime Minister announced a social care reform plan to cap the costs of social care, with the aim of protecting people against catastrophic costs of care. This is to be funded through a new UK-wide 1.25 per cent Health and Social Care Levy that will be ring-fenced for health and social care, based on National Insurance contributions. This levy will be applied to all working adults, including those over state pension age. Of the £36bn that will be raised through this mechanism, £5.4bn will be for social care (spread over 3 years).

The new cap on social care has been set at £86,000 in care costs over the course of a person’s lifetime (estimates vary but it would take someone in residential care around 4 years to reach the cap and around 6 years for someone receiving home care). So far it seems that the cap will start from October 2023 and that costs up to that point will not be taken into account. The cap will only cover ‘personal care’ costs, such as dressing, washing, and eating, amongst others. Accommodation, food, and other ‘hotel costs’ that are included in care home fees and costs of other forms of social care support (such as activities to enable social participation) will not count towards the cap.

An important measure included in this reform will be an increase to the means-test, changing the ‘floor’ above which individuals are able to access any public funding for social care, which will change from £23,350 to £100,000. People with assets below £20,000 will not be asked to contribute to the costs of their care from their assets.

In summary, people with assets over £100,000 will be ‘self-funders’ until the amount they have spent on ‘eligible care costs’ reaches the cap of £86,000. People with assets between £100,000 and £20,000 will contribute to the costs of their care from their assets and income until they have either reached the cap or have less than £20,000 left in assets and savings. People with assets below £20,000 will only be asked to make contributions from their income. The financing of long-term social care for working-age adults has not been considered. An article by Curry (2021) provides an initial analysis of the changes.

An amendment to the Health and Care Bill has excluded means-tested council support payments from the new £86,000 lifetime limit on costs.

The government published its long-awaited white paper for social care reform on 1st December 2021. In it, it restated its plans to raise additional funding for social care via a health and social care levy (as previously announced on 7th September 2021) and that, beyond the three year spending cycle, there is an intention for a greater share of the revenue to be allocated to social care (at present, only £5.4bn of the total £36bn raised is set to flow to social care in England). The majority of that extra funding will go towards the new cap on costs and the more generous means test. In addition, it is intended to fund fairer fees for providers of social care, better staff training and investment in innovative care models, housing and digital and technological initiatives. On launch, the document was met with scepticism that the funding envelope would be adequate to achieve the vision that it set out (see for example: Adass press release Local Government Association; The Nuffield Trust press release).

References:

Curry, N. (2021). The health and care levy—is social care fixed now? The BMJ Opinion.  Retrieved from: the BMJ Accessed on 28/03/2022

Last updated: March 28th, 2022   Contributors: William Byrd  |  Adelina Comas-Herrera  |  Natasha Curry  |  

4.03. Reforms to develop or improve Long-Term Care data and information systems

France

As part of the reforms following the Segur de la sante, 2 billion euros have been invested into digital infrastructure, including 600 million euros for care and nursing homes. These investments will enable the creation of an online health and care portal including a shared health and care records, shared messaging system, records and information relative to hospital discharge, etc. (l’Espace numerique de sante).

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

Germany

Funding for digital and technical innovations

The LTC insurance funds can provide home care and residential care providers between 2019 and 2021 with partial funding (up to €12,000) to support the purchasing of technical tools aimed at improving working conditions and reducing bureaucratic load (European Commission; 2021; Bundesministerium für Gesundheit, 2021).

References

Bundesministerium fuer Gesundheit (2021) Sofortprogramm Pflege. Available at: https://www.bundesgesundheitsministerium.de/sofortprogramm-pflege.html (Accessed 4 February 2022).

European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu) (Accessed 4 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

England (UK)

The primary national-level strategy for forward looking long term care data policy in England is outlined in the UK Government’s Data Saves Lives (DSL): reshaping health and social care with data (DHSC, 2021). DSL aims to bring a coherent data strategy to a large and diverse range of stakeholders across both health and care sectors, traditionally sectors with different data needs, different data practices and different levels of digital maturity. DSL was launched in June 2021 and aims to feed into primary legislation through the Health and Social Care Bill, and also influence secondary legislation. The strategy is being run by NHS England & Improvement following the merger of NHSE&I with NHS X and NHS Digital in November 2021 (Source: DHSC).

Much of the strategy is given over to building on what it perceives as  momentum gained during the pandemic in health data. Specifically the linkage, integration, interoperability of data within health systems and between health and social care systems for the purposes of informing decisions with population health data and creating efficiencies in the aggregation and use of health data by researchers.

One chapter of seven is given over to long term care, Chapter 4 Improving data for adult social care. General commitments are made to addressing the following issues: access to basic information for providers of adult social care; addressing gaps in data collected by local authorities (for instance, all those they don’t fund);  integration of health and social care data; expanding the use of care technologies. The problems are discussed at a high level and financial costings, committed budgets and delivery dates are not included and have been absent from subsequent policy announcements on social care planning and spending (O’Donovan, 2021).

A survey and consultation on the strategy ran throughout the summer of 2021 and attracted submissions from a broad set of stakeholder organisations such as health and care think tanks and data specialists such as the Information Commissioners Office, The National Data Guardian and the UK Pandemic Ethics Accelerator.

A webinar hosted by LTCcovid on 18th October 2021 brought together a panel of leading practitioners and academics from different parts of social care and across the UK. They identified seven data issues for policy makers working on digital transformation in the sector:

  • Lessons about social data use during the pandemic are not agreed by everyone. For instance, data infrastructure such as the adult social care capacity tracker has had unforeseen consequences such as increased burdens on staff. These are often unacknowledged in plans for future data policy.
  • The continued lack of data on people who pay for their own care or do not receive services from local authorities remains a priority issue across social care.
  • Tensions between conflicting desires for private data, more data, minimal data and no data must be addressed in future policy plans if trust in public social care data is to be built.
  • New tensions have arisen due to decisions that are being made with the data today that were not agreed with the providers from the start.
  • At the same time, robust data infrastructures are a prior condition of wider reform across UK social care, critical for anticipatory appraisal, ongoing monitoring and evaluation of innovation in services and practices.
  • Opportunities for optimism include building social care data that is designed around the wellbeing of people in communities – such data would go beyond the existing principles and values of population data in health to report on the relationships and values that matter for care.
  • For this, new measures with which to assess data quality and new ways of assessing and improving data operations within councils will be needed.
References:

DHSC (2021). Data saves lives: reshaping health and social care with data.  Department of Health and Social Care Policy Paper. Retrieved from: Data saves lives Accessed on 28/03/2022

O’Donovan, C. (2021). Getting the basics right in digital social care transformations. The BMJ Opinion. 

Last updated: March 28th, 2022   Contributors: Cian O'Donovan  |  

4.04. Reforms to improve care coordination

Overview

A number of reforms in EU Member States have been introduced or are planned (2021) focusing on integrated delivery of care and to set up coordination structures (source: EU report).

International reports and sources

EU report on LTC (2021) highlights recent reforms related to care coordination in Member States.

Some information regarding reforms in Canada related to, among other things, care coordination could be found online.

Belgium

An EU report shows that in 2017 the federated region of Flanders was divided into ‘primary care zones’ to improve the governance of homecare services. These zones are responsible for coordinating the different primary and social care partners within the zone, and are central mechanism for coordinating homecare among different stakeholders. Moreover, a federal programme has been implemented to improve care for people with chronic diseases, including older people. Since 2018, 12 projects have been set up at local level, testing a series of measures to improve care integration.

During the crisis, setting up a strong collaboration model and integrated care between nursing homes and hospitals has enabled nursing homes to manage specific and complex care in their own environment. A published report shows that integrated care is possible and that both the hospital and the nursing homes benefit from such a system. They suggested that investments in people, resources, training and guidance concerning transitional care, and knowledge exchange between hospitals and nursing homes, are necessary to guarantee a more efficient and robust approach to (pandemic) crises in nursing homes.

Source:

Deschacht, M., Malfait, S., & Eeckloo, K. (2021, May 1). Integrated care for older adults during the COVID-19 pandemic in Belgium: Lessons learned the hard way. International Journal of Older People Nursing. John Wiley and Sons Inc. https://doi.org/10.1111/opn.12366

Last updated: March 3rd, 2022   Contributors: William Byrd  |  

Estonia

An EU report noted that in 2021 Estonia is planning an overarching reform of the LTC system, establishing an integrated LTC framework to ensure the cross-sectoral supply, availability, and quality of services.

Last updated: November 23rd, 2021

Slovakia

An EU report notes that a proposal for a comprehensive reform is underway (2021), focusing on long-term and palliative care. The main aim is to strengthen the integration of social care and healthcare.

Last updated: November 23rd, 2021

Slovenia

An EU report noted that a draft long-term care act (2021) aims to facilitate and ensure the implementation of long-term care as the new pillar of social security which will take the form of integrated activities.

Last updated: September 7th, 2021

Bulgaria

An EU report (2021) noted that a new model for high-quality integrated social services was established in 2020. The reform is aimed at establishing an integrated network of homecare services for people with disabilities and older people.

Last updated: November 24th, 2021

Canada

As of March 2021, Canada has announced a number of LTC reforms, including reforms intended at improving coordination of LTC services across the health system, and particularly integration at the level of local community services (source: Long-Term Care Services – HSO Health Standards Organization). 

Last updated: February 11th, 2022

Germany

An EU report (2021) notes that care-support bases offering advice and support are being set up in Germany, providing relevant information, application forms, and practical assistance (European Commission, 2021).

References

European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu) (Accessed 4 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Greece

An EU report notes that a programme to establish 150 integrated care centres for older people was implemented in 2018.  The centres provide information and support to homecare services provided exclusively to older people, and co-ordinate the existing care services such as the open protection centres for older people, daycare centres, and the ‘help at home’ programme.

Last updated: November 24th, 2021

Netherlands

An EU report noted that several programmes were set up in 2017 with an aim to improve integrated delivery of care and the matching of care to needs.

Last updated: November 24th, 2021

England (UK)

The Health and Care Bill contains provisions to enable integrated health care systems to play a greater role. There are two forms of integration underpinned by the legislation: integration within the NHS and greater collaboration between the NHS and local government. Measures will also be brought forward for statutory integrated care systems (ICSs). These will be comprised of an ICS Health and Care Partnership, bringing together the NHS, local government and partners, and an ICS NHS Body. The ICS NHS body will be responsible for the day to day running of the ICS, while the ICS Health and Care Partnership will bring together systems to support integration and develop a plan to address the health, public health, and social care needs of the system (DHSC, 2021; 2022).

In parallel with the Health and Social Care Bill, the government is also developing an integration white paper, which is seeking to establish greater integration between health and social care services. The contents of the white paper are unclear at present but media reports in the trade press suggest that the proposals will seek to facilitate integration through the pooling of budgets and establishing a single line of accountability. The plans have raised concerns amongst experts. The exact date of publication is unknown, but it is expected in late 2021/early 2022 (Edwards, 2021).

The government plan for social care, Build Back Better (DHSC, 2022), contains provisions for improving the integration of health and social care. This will be shaped by three principles:

  1. Outcomes focussed – The government will work with systems to identify a single set of system-based health and care outcomes that local systems (including ICSs and Local Authorities) will be asked to deliver.
  2. Empowering local leaders – Local leaders will be given the freedom to align incentives and structures in order to deliver these outcomes in the way that is best for their communities.
  3. Wider system reforms – There will be Care Quality Commission (CQC) oversight of commissioning of adult social care by Local Authorities, which will be introduced through the Health and Care Bill, and a role for the CQC in assessing the overall quality of ICSs.
References: 

DHSC (2021). Integration and innovation: working together to improve health and social care for all. Department of Health and Social Care Policy Paper. Retrieved from: https://www.gov.uk/government/publications. Accessed on 28/03/2022

DHSC. (2022). Build Back Better: Our Plan for Health and Social Care. Department of Health and Social Care Policy Paper. Retrieved from:https://www.gov.uk/government/publications. Accessed on 28/03/2022

Edwards, N. (2021). Pooling NHS and social care budgets needs more thought. HSJ. Retrieved from: Health Service Journal. Accessed on 28/03/2022

Last updated: March 28th, 2022   Contributors: William Byrd  |  Natasha Curry  |  

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

Overview

Several countries have embarked on reforms to address working conditions, wages as well as improve attractiveness of the sector (source: EU report; Fixing Long-Term Care Act, 2021;New Legislation To Reform Ontario’s Long-Term Care Sector).

International reports and sources

EU report on LTC (2021) highlights recent reforms related to LTC workforce in Member States.

Bulgaria

An EU report (2021) noted that a new social services law in Bulgaria established the right to training for LTC workers and the right to supervision.

Last updated: September 13th, 2021

Ontario (Canada)

To improve staffing levels, in November 2020, the Ontario government announced funding to increase the average daily direct care from a nurse or personal support worker  per long-term care resident to four hours a day by 2025. The Act proposes to enshrine this commitment in legislation, and to increase care provided by allied health care professionals to an average of 36 minutes per resident per day by March 31, 2023. The proposed Act provides that higher (but not lower) targets of average care may be established by regulation (source: Fixing Long-Term Care Act, 2021;New Legislation To Reform Ontario’s Long-Term Care Sector).

Last updated: December 10th, 2021

Croatia

An EU report noted that Croatian government launched a programme in 2017 to encourage the employment of disadvantaged women (especially 50 years old+) to provide support and care for older people, the programme was serving around 30,000 people, and employed 6,000 women in 2020.

Last updated: September 13th, 2021

Czech Republic

An EU report (2021) noted that the Czech government has continually and significantly increased the wages of employees in LTC sector since 2014 which is likely to have made the profession more attractive.

Last updated: September 13th, 2021

Denmark

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

References:

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

Last updated: May 25th, 2023

France

The transformation funds from the Segur de la Sante will also invest into developing digital tools around ageing and disability, for instance by developing digital integrated care records.

Following the Segur de la Sante, which was a consultation of all medical and social care stakeholders over 2020 to contribute to recovery of the health and care sectors and build resilience, a number of measures were taken to revalorise health and care staff.

To increase the attractiveness of the care home sector as a route of employment, care worker pay was reviewed in 2020 and increased by 183€ per month.

Increased salary rates for domiciliary care workers in the public sector will start from October 1st 2021 and will represent a 13-15% increase in pay.

An 2,330 additional training places for nurses were also created.

Author: Alis Sopadzhiyan (LTC Covid profile pending)

Last updated: December 3rd, 2021   Contributors: Adelina Comas-Herrera  |  Camille Oung  |  

Malta

An EU report (2021) noted that jobs in the LTC sector are being made more attractive through new training opportunities at tertiary level, with the launch of certified training programmes for potential carers.

Last updated: September 13th, 2021

Netherlands

An EU report (2021) noted that the Netherlands implemented numerous measures in 2017, including: improved working conditions; better protected contracts (e.g. open-ended contracts, flexible working time, leave); better matching of supply and demand. The government programmes also focus on improving the attractiveness of the sector via image campaigns as well as other measures improving working conditions and training.

Last updated: December 2nd, 2021

Sweden

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

Last updated: November 30th, 2021

England (UK)

A Health and Social Care Levy was announced by the government on September 9, 2021. As part of this £36 billion investment to reform the NHS and social care, at least £500 million will be allocated for funding the care workforce across three years. It is reported that it represents a five-fold increase in public spending on the skills and training of care workers and registered managers. The government have committed to providing additional support for the continuous professional development of the workforce, including training places and certifications for care workers. The funding will also be directed to mental health wellbeing resources and to provide access to occupational health funding (DHSC, 2021a).

The government announced that this would be accompanied on November 3, 2021, with a new recruitment campaign to encourage people to apply for roles in the adult social care sector. ‘Made with Care’ will launch across broadcast and social media for five months and will highlight vacancies in the sector as well as showcasing the work care workers do. However, many organisations and sector leaders have raised concerns that the existing funding and measures in place are not sufficient to mitigate a deepening workforce crisis ahead of a difficult winter.

The government published its White Paper on social care reform on 1st December 2021 (DHSC, 2021b). In it were a suite of initiatives for strengthening the skills and training of the social care workforce. These include the establishment of a Knowledge and Skills Framework, portable care certificates, and support for mental health and wellbeing. However, it stopped short of enhancing pay and no new money beyond the previously announced (£500m over three years from the health and social care levy) and the £162.5m for the winter of 2021/22 was allocated to workforce initiatives (Source: Workforce Recruitment and Retention Fund for adult social care).

Visa Relaxation for Migrant Care Workers

In December 2021 , addressing unprecedented challenges prompted by the pandemic, the government announced a temporary relaxation of immigration rules for overseas care workers in an attempt to recruit and retain care staff. Care assistants and home and social care workers are to be added to the Shortage Occupation List (SOL) in early 2022 and will be eligible for a 12-month health and care visa; allowing migrants to fill gaps in workforces. It is proposed that these measures will be in place for at least 12 months (Sources: BBC News and gov.uk).

References:

DHSC (2021a). Health and Social Care Levy. Department of Health and Social Care Policy Paper. Retrieved from: Health and Social Care Levy. Accessed on 28/03/2022

DHSC (2021b). People at the Heart of Care: adult social care reform white paper. Department of Health and Social Care Policy Paper. Retrieved from: ASC Reform White Paper.  Accessed on 28/03/2022

Last updated: March 28th, 2022   Contributors: William Byrd  |  Nina Hemmings  |  Natasha Curry  |  Daisy Pharoah  |  

Northern Ireland (UK)

The ‘Social Care – Making a Difference’ campaign has been developed by the Northern Ireland Social Care Council (NISCC) on behalf of the Department of Health as part of its ongoing work to reform Adult Social Care. The campaign highlights that social care staff are an integral and valued part of the health and social workforce and their work is critical to the sustainable provision of social care services now and in the future. This campaign went live on May 10, 2021 and is centred on local social care workers, whose stories are told through video and photography while highlighting the diversity, impact and importance of social care and the positive difference it makes in people’s lives (Source: Adult social care recruitment campaign launched).

 

Last updated: March 28th, 2022

Scotland (UK)

In April 2020, the Scottish Government announced an immediate 3.3% pay increase for all social care staff in recognition of the vital work they carried out during the pandemic.

Last updated: March 28th, 2022   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

4.06. Reforms to improve support for unpaid carers

Overview

Between 2017 and 2020, most European Union Member States have implemented numerous measures to improve the situation of informal carers. These include introducing or raising carer’s allowances, more favourable social protection conditions, work-life balance measures as well as training, psychological support and respite services. In 2019 the EU introduced a directive on work-life balance, aiming to improve access to family leave and flexible work arrangements for carers -Member States have three years to implement the directive (source: https://eur-lex.europa.eu). Several EU Member States (Austria, Belgium, Czech Republic, Estonia, Croatia, Portugal and Spain) introduced a carer’s leave in line with the work-life balance Directive. A carer’s allowance has also been introduced in Czech Republic, France, Poland, Portugal, Slovakia (source:https://ec.europa.eu).

International reports and sources

EU report on LTC (2021) highlights recent reforms which aim to support unpaid carers in Member States.

Austria

In 2019, Austria introduced a legal entitlement to care leave, which applies in companies with more than five employees; where previously the employer had to agree to it which impacted the uptake (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 23rd, 2021

Belgium

An EU report noted that from 2019 the country has provided extended leave for workers to provide informal care under specific conditions (including provision of at least 50 hours care per month or 600 hours per year).

Last updated: November 23rd, 2021

Czech Republic

In 2018 the Czech Republic, introduced a ‘long-term care-giver’s allowance’ for employed or self-employed carers who can be compensated for the loss of income from work due to taking care of a family member discharged from hospital and requiring at least 30 days of further care up to a maximum of 90 days (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 23rd, 2021

Finland

In 2016 Finland increased the number of holidays for informal carers who enter into a care agreement with the municipality to at least two or three days off per month; informal carers have the right to coaching and training organised by the municipality (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 23rd, 2021

France

In 2019 the country introduced an allowance for people entitled to carer’s leave to encourage carers to make use of the leave, which, at that point, had a low take up (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 23rd, 2021

Germany

Replacement care

The care strengthening bills ensure that when unpaid carers are temporarily unable to provide care (e.g. holidays, illness) for people with care level 2 or higher, the long-term care insurance covers the costs of up to six weeks replacement (up to €1,612) care per calendar year. This can also support other household members/unpaid carers taking on the replacement care. This replacement care can also be taken up on an hourly basis. (erste pflegestarkungsgesetz). In addition, replacement care can be combined with 50per cent of the support for short-term care (Kurzzeitpflege) (Bundesministerium für Gesundheit, 2017b; Bundesministerium für Gesundheit,2021).

Retirement contribution & unemployment insurance

Following the care strengthening bills, unpaid carers in Germany providing community care for people at care level 2 or higher, providing 10 or more hours per of care and do not work more than 30 hours per week are entitled to retirement contributions through the long-term care insurance. In addition, protection through the unemployment insurance has been expanded for carers. This also remains when unpaid carers take holidays (Deutsche Rentenversicherung. 2022 ;Bundesministerium für Gesundheit, 2021).

Entitlement to qualified advice

The care strengthening bills also provided an entitlement to qualified advice from their care fund. This can help unpaid carers to organise and coordinate care arrangements (Bundesministerium für Gesundheit, 2017b).

Leave and reduced hours for working family carers

A bill to improve the compatibility of family, care and work enables employees to leave their job for up to six months to care for a close relative at home. In addition, employees can reduce their work hours for up to two year to up to 15 hours per week. To mitigate the loss of income, employees taking up this possibility can apply for an interest-free loan from a government agency (Bundesministerium für Gesundheit, 2017b).

In addition, working unpaid carers can take up to 10 days paid leave (paid by long-term care insurance – care support money) if they need to temporarily organise care for a close relative (Bundesministerium für Gesundheit, 2017b).

Improved access to rehabilitation

From 2019 unpaid carers receive improved access to rehabilitation. The changes include that unpaid carers can now access residential rehabilitation even if from a medical perspective ambulatory treatment would be sufficient. Unpaid carers are also entitled to have the person they care for looked after in the same residential setting where they receive medical rehabilitation (Bundesministerium für Gesundheit, 2018).

References

Bundesministerium für Gesundheit (2021) Verhinderungspflege (Urlaubs-/Krankheitsvertretung). Available at: https://www.bundesgesundheitsministerium.de/verhinderungspflege.html (Accessed 1 February 2022).

Bundesministerium für Gesundheit (2018) Neuregelungen im Jahr 2019 in Gesundheit und Pflege. Available at: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2018/4-quartal/neuregelungen-2019.html(Accessed: 1 February 2022)

Bundesministerium für Gesundheit (2017b) Die Pflegestärkungsgesetze – Das Wichtigste im Überblick. Available at: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Broschueren/PSG_Das_Wichtigste_im_Ueberblick.pdf(Accessed 1 February 2022)

Deutsche Rentenversicherung (2022) Pflege von Angehörigen lohnt sich auch für die Rente. Available at: https://www.deutsche-rentenversicherung.de/DRV/DE/Rente/Familie-und-Kinder/Angehoerige-pflegen/angehoerige-pflegen_node.html (Accessed 1 February 2022)

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Ireland

In 2017 Ireland implemented a programme of training and support for family carers which is funded from unused funds in dormant accounts in credit institutions and unclaimed life assurance policies (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 23rd, 2021

Poland

In 2019, a programme entitled ‘Respite care’ (Opieka wytchnieniowa) was started in Poland to provide help for informal carers (source: EU: Long-term care report).

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

Portugal

In 2019 Portugal introduced a major reform establishing a formal status for informal carers, with  the right for ‘principal carers’, who provide care on a permanent basis, to receive a carer’s allowance. This is conditional on: the carer being a family member and living in the same household as the care recipient; not receiving any remuneration (for instance from work, pension); and the household in which the principal carer lives having an income below a certain threshold. The law also introduced new rights for both principal and non-principal carers, including the right to: accumulate social security credits; receive training; receive information and psychological support; and respite periods. The new law also contains rules to facilitate the work-life balance of ‘non-principal informal carers’ (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 23rd, 2021

Slovakia

In 2019 Slovakia introduced a social benefit for long-term carers for a sick relative. This benefit will be implemented as of 2021; it allows people to care for relatives who leave hospital in bad health or in need of palliative care for a maximum of 90 days. Slovakia repeatedly increased the amount of the ‘attendance service benefit’, which in 2018 reached the level of the minimum wage (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 23rd, 2021

Spain

In 2019, Spain reinstated the payment of social protection credits by the state for informal carers who were recognised as care-givers in an individualised care plan (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

This means that, people who can prove they are a non-professional caregiver and meet the conditions necessary to receive a cash benefit for caring for a family member, will be able to apply for social security credits without incurring any financial penalty. Instead, it will be the General State Administration that will pick up the cost of paying for the benefits.

As of January 2022, 67,249 special agreements have been signed by non-professional caregivers (of which 88.6% correspond to women, and the remaining 11.4% to men). The total cost of special agreements for the General State Administration since the signing of the Dependency Law, is €1,639,881,600.61. However, this measure was suspended between 2012 and April 2019.

Last updated: July 4th, 2022   Contributors: Sara Ulla Díez  |  

4.07. Reforms to Long-term care regulatory and quality assurance systems

Overview

Fourteen EU Member States introduced reforms focusing on enhanced control and monitoring of LTC services. Some reforms have implemented new quality-assessment procedures or improved administrative procedures or were linked to investments in residential care facilities (source: https://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=8396&furtherPubs=yes).

International reports and sources

EU report on LTC (2021) highlights recent reforms related to care quality in Member States.

Canada

 Health Standards Organization (HSO) is developing (as of November 2021) a National Standard of Canada (NSC) for the co-design and delivery of integratedresident-and-family-centred LTC services across CanadaThe HSO National Long-Term Care Services Standard will provide LTC homes across Canada with evidence-informed practices that define how LTC homes and LTC teams can work collaboratively to keep people safe, provide safe, reliable, and high-quality care, and demonstrate positive, outcomes-focused change (source: Long-Term Care Services – HSO Health Standards Organization).

Last updated: February 11th, 2022

England (UK)

The government plans to establish an enhanced assurance framework for adult social care, working alongside the Care Quality Commission (CQC) and local authorities to improve adult social care oversight, access, and outcomes across England.

The Health and Care Bill introduces a new duty for the CQC to review and make an assessment of the delivery of adult social care duties by local authorities. Where they find a significant failure, the Secretary of State will act to secure improvement. The CQC will publish the findings of their reviews with the intentions of allowing people to see how their local authority is performing in the delivery of its adult social care duties.

On May 27, 2021, the CQC launched its new strategy outlining how it plans to change and transform to deliver more effective regulation. There are four key themes set out.

  1. People & communities – The CQC wants regulation to be driven by people’s needs and experiences, placing a focus on what’s important to people and communities as they access, use, and move between services. A key outcome for this is the development of a clear definition of quality and safety that is in line with people’s changing needs and expectations.
  2. Smarter regulation – The CQC wants to use smarter, more dynamic, and flexible regulation that provides up-to-date and high-quality information and ratings. In achieving this the CQC aims to move away from inspection-reliant regulation by placing more focus on data and feedback from people on their experiences of care.
  3. Safety through learning – The CQC wants to regulate for stronger safety cultures across the sector, prioritising learning and improvement, and collaboration.
  4. Accelerating improvement – The CQC aims to have accelerated improvements in the quality of care and encouraged and enabled safe innovation that benefits people or results in more effective and efficient services (Sources: https://www.gov.uk/government/health-and-care-bill-factsheets/health-and-care-bill-adult-social-care-assurance-and-support; https://www.ridout-law.com/cqcs-new-strategy-what-does-it-say-and-how-will-it-be-implemented/).

Last updated: March 28th, 2022   Contributors: William Byrd  |  

Wales (UK)

The Health and Social Care (Quality and Engagement) (Wales) Act became law on June 1, 2020. The Welsh Government is working to bring the Act into force in spring 2023. The Act will strengthen the existing duty of quality on NHS bodies and extend this to the Welsh Ministers in relation to their health service functions. This places an overarching duty of quality on the Welsh Ministers and reframes and broadens the existing duty on NHS bodies. Additionally, the duty seeks to strengthen governance arrangements by requiring the Welsh Ministers and NHS bodies to report annually on the steps they have taken to comply with the duty and assess the extent of any improvement in outcomes (Source: https://gov.wales/health-and-social-care-quality-and-engagement-wales-act-summary-html).

Last updated: March 28th, 2022

4.08. Reforms to strengthen community-based care

International reports and sources

EU report on LTC (2021) highlights some recent reforms in LTC in Member States.

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: December 10th, 2021

France

In domiciliary care, the Prime Minister announced in September 2021 the introduction of a minimum rate of €22 per hour for home care to stabilise the sector, with the potential to get an additional 3€ per hour for providers who demonstrate a commitment to improvements (e.g. around workforce training, investment in infrastructure, weekend delivery, complex care). The additional total spending for 2022 will be €240million. However, municipalities have estimated that the cost of these reforms is more in the region of €800 million.

Last updated: December 4th, 2021   Contributors: Camille Oung  |  

Germany

Financial support to adapt homes

People with LTC needs can receive up to €4,000 for changes to their home (for example, to widen doors) to enable people to remain in the community for longer (Bundesministerium für Gesundheit, 2017a, 2017b).

Financial support for shared accommodation for people with care need needs in the community

The care strengthening bills support people wishing to set up shared accommodation for people with LTC needs by providing financial support to set this up. People with care needs living in shared accommodations can also receive monthly financial support (Bundesministerium für Gesundheit, 2017a, 2017b).

Expansion of day and nigh care services

The first care strengthening bill expanded day and night care services. These services can be used without reducing people’s care allowance or entitlement to domiciliary care (Bundesministerium für Gesundheit, 2017b).

References

Bundesministerium für Gesundheit (2017a) Erstes Pflegestärkungsgesetz (PSG I). Available at: https://www.bundesgesundheitsministerium.de/service/begriffe-von-a-z/p/pflegestaerkungsgesetz-erstes-psg-i.html(Accessed 1 February 2022)

Bundesministerium für Gesundheit (2017b) Die Pflegestärkungsgesetze – Das Wichtigste im Überblick. Available at: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Broschueren/PSG_Das_Wichtigste_im_Ueberblick.pdf(Accessed 1 February 2022)

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

4.09. Reforms to improve care homes, including new standards and building regulations

Overview

Care home design and building regulations:
Evidence:

The pandemic has highlighted that the design of care homes has been an important factor in the risk of infections and deaths from COVID-19 experienced by care home residents. A study analysing associations between nursing home design and COVID-19 cases, deaths and transmissibility in 7,785 nursing homes the United States found that an increased share of private rooms, larger living area per bed and the presence of a ventilator-dependent unit were associated with fewer COVID-19 infections, deaths and transmissibility. (Zhu et al., 2021).

References:

Zhu X., Lee H., Sang H. et al. (2021) Nursing Home Design and COVID-19: Implications of Guidelines and Regulation. JAMDA in press https://doi.org/10.1016/j.jamda.2021.12.026

Ontario (Canada)

The Fixing Long-Term Care Act, announced in 2021, would permit the Minister of Long-Term Care to develop a policy outlining how many beds are needed in the province and where these beds are most needed (source: Bill 37, Providing More Care, Protecting Seniors, and Building More Beds Act, 2021).

Last updated: December 10th, 2021

Finland

The Finnish government is currently proposing reforms to the Social Welfare Act that aim to promote diverse and flexible housing and care solutions, including communal housing and housing with 24-hour care. The communal housing would offer accessible and safe homes where people can live in apartments where they can participate in activities have support with any care needs. Both communal housing and housing with 24-hour care would be provided in the same building complex, also including ordinary apartments, with the aim that clients can get the services they need at home without having to move when their care needs change.

Long-term institutional care for older people is to be abolished by the end 2027, with a transition period to introduce and adapt the services.

Last updated: December 10th, 2021

France

Improving infrastructure for older people, and in particular the social care sector, was a key pillar of the French government’s plan to “relaunch the economy and make it more resilient” and intends to build a resilient care sector over a journey of 20-25 years. For care homes, 2.1 billion euros have been allocated over 5 years to invest in the transformation, renovation works, and digital upgrading of care and nursing homes. Examples of how this will be used include the renovation of 65,000 care home beds to adapt estates to the futures: buildings allowing for smaller structures with more convivial living opportunities, more rooms adapted to cognitive impairments, and future-proofing estates against climate change. The funds will also build new care homes.

1.5 billion euros have been allocated over 4 years to transform models of care homes, into more human, locally connected and medicalised settings. In addition, 125 million euros have been allocated to finance daily needs, such as buying new equipment, small changes and construction works.

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

4.10. Reforms to improve Infection Prevention and Control standards and infection surveillance in the Long-Term Care sector

England (UK)

A leading nursing charity, the Queen’s Nursing Institute, has received government funding to develop a network of infection prevention and control (IPC) champions for the adult social care sector in England. This £35,000 grant will be used to cover both care home and domiciliary care services. The Department of Health and Social Care aim is to help maintain and continuously improve IPC standards across the care sector through this programme. The network, consisting of social care nurses and other professionals responsible for IPC, will share best practice through virtual meetings, a newsletter, and discussion forum (Source: Nursing time innovations).

 

Last updated: March 28th, 2022   Contributors: William Byrd  |  

4.11. Reforms to improve the pandemic and emergency preparedness of the Long-Term Care sector

Overview

Beliefs by LTC staff about improved pandemic preparedness

A study carried out in Sweden, Italy, Germany and the United Kingdom investigating LTC staff learning of new knowledge and skills during the pandemic and their beliefs for changes in the future showed that care staff reported significant learning, despite the disruptive nature of events. Staff also held a strong belief that digital technologies and clinical protocols for care would be increasingly used in the future, leading to improved care, but expressed concern about the poor public image of the sector and its inability to attract staff. They also reported low expectations about increased collaboration between professionals from different organisations (Malmgren Fänge et al, 2022).

References:

Malmgren Fänge A, Christensen J, Backhouse T, Kenkmann A, Killett A, Fisher O, Chiatti C, Lethin C. (2022) Care Home and Home Care Staff’s Learning during the COVID-19 Pandemic and Beliefs about Subsequent Changes in the Future: A Survey Study in Sweden, Italy, Germany and the United Kingdom. Healthcare; 10(2):306. https://doi.org/10.3390/healthcare10020306

International reports and sources

EU report on LTC (2021) highlights some recent reforms related to pandemic preparedness in Member States.

Denmark

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

Last updated: May 25th, 2023

Netherlands

The country aims to focus research on pandemic-related issues (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: November 9th, 2021

4.12. Reforms to strengthen and guarantee the rights and voice of people who use and provide care

Ontario (Canada)

The Fixing Long-Term Care Act, 2021 proposes an expanded Residents’ Bill of Rights which includes a right to ongoing and safe support by caregivers and a right to be provided with care and services based on a palliative care philosophy (source: Bill 37, Providing More Care, Protecting Seniors, and Building More Beds Act, 2021).

Last updated: December 10th, 2021

Italy

In November 30th 2020, an official document recognised, for the first time, the right to the social and emotional support from family and friends for people who live in care homes.

Source:

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

Last updated: November 23rd, 2021   Contributors: Adelina Comas-Herrera  |  

Norway

The right of care home residents to receive residents has been formally recognised by the Norwegian Directorate of Health.

Last updated: November 29th, 2021

Wales (UK)

On June 1, 2020, The Health and Social Care (Quality and Engagement) (Wales) Act became law. The Welsh Government is now working to bring the Act into force in spring 2023. This Act will strengthen the voice of citizens, by replacing Community Health Councils with a new all-Wales Citizen Voice Body that will represent the interests of people across health and social care. The aims of this new body are to:

  1. Strengthen the citizen voice in Wales in matters related to both health and social services, ensuring that citizens have an effective mechanism for ensuring that their views are heard.
  2. Ensure that individuals are supported with advice and assistance when making a complaint in relation to their care. se the service user experience to drive forward improvement.
  3. Use the service user experience to drive forward improvement.

This new organisation will be established as a national body but it will be structured in such a way as to enable it to perform its functions at a national, regional and local level (Source: https://gov.wales/health-and-social-care-quality-and-engagement-wales-act-summary-html).

Last updated: March 28th, 2022

4.13. Any other relevant Long-Term Care reforms

Poland

Although in 2021 there are no major reforms planned to increase coherency of LTC sector, various efforts have been made over the past few years to strengthen LTC services in Poland. Since 2018, a programme ‘Care 75+’ (Opieka 75+) has been in place, supporting local authorities in rural areas and small towns financially to provide care services (rural areas and small towns are particularly prone to population ageing due to migration and have informal care deficits). In 2018, a complementary programme ‘Care services for people with  disabilities’ (Uslugi opiekuncze dla osób niepelnosprawnych), targeting people with disabilities under the age of 75 was introduced. Moreover, in 2019 a cash benefit was introduced for adults incapable of living independently. The benefit of PLN 500 (around EUR 119) is targeted at individuals with lower incomes, as a support measure in need for LTC. A definition of incapability to live independently with a new assessment for this purpose was implemented. Local governments have also also planning  to organise meals on wheels for older people or targeted social assistance benefits for acquiring meals (Posilek w domu i w szkole na lata 2019–2023) (source: Long-term care report – Publications Office of the EU (europa.eu).

Moreover, in the aftermath of pandemic, the promotion of digital technologies has become one of the priority areas of the Activity+ programme, which was established in 2021 and is aimed at stimulating the social participation of older people (source: Ageing policies – access to services in different Member States (europa.eu).

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

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica BreuerJorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.