INTERNATIONAL REPORTS

Responses to 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 (Sources: https://www.health.gov.au/committees-and-groups/australian-health-protection-principal-committee-ahppc; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

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: https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Barriers/facilitators:

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 recommend 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 (https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

Last updated: September 8th, 2021


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 (Sources: https://www.health.gov.au/committees-and-groups/australian-health-protection-principal-committee-ahppc; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 8th, 2021


Canada (British Columbia)

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. The 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. EOC was useful and effective in coordinating responses in health authority owned and operated (public) LTC facilities but not privately owned or affiliate facilities. While responses addressed the LTC sector, there is no evidence of TLC specific expertise being brought to these response teams (Source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

 

Last updated: September 8th, 2021


Canada (British Columbia)

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: September 8th, 2021


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 (Source: https://journal.ilpnetwork.org/articles/10.31389/jltc.72/).

Last updated: September 8th, 2021


Denmark

The Danish Health Authority is chairing a “COVID-19 Intensive Task Force”, with representatives from national authorities and the Danish regions. The task force is responsible for coordinating the regional capacity of intensive care units and staff. The Danish Health Authority has published a status document with assessment of the need for ICU and ventilator capacity (Source: https://www.sst.dk/-/media/Nyheder/2020/ITA_COVID_19_220320.ashx?la=da&hash=633349284353F4D8559B231CDA64169D327F1227). Once a week, Danish Regions publish statistics on the stocks of masks, disinfectants and gloves (Source: https://www.regioner.dk/sundhed/coronaviruscovid-19).

Lessons learned

Given the high level of integration of the health and social sectors and their clear communication structures with municipalities, the pandemic response was able to efficiently focus on the wide range of LTC services during the pandemic (Source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: September 8th, 2021


Denmark

The Danish Health Authority is chairing a “COVID-19 Intensive Task Force”, with representatives from national authorities and the Danish regions. The task force is responsible for coordinating the regional capacity of intensive care units and staff. The Danish Health Authority has published a status document with an assessment of the need for intensive care units and ventilator capacity (Source: https://www.sst.dk/-/media/Nyheder/2020/ITA_COVID_19_220320.ashx?la=da&hash=633349284353F4D8559B231CDA64169D327F1227). Once a week, Danish Regions publish statistics on the stocks of masks, disinfectants, and gloves (Source: https://www.regioner.dk/sundhed/coronaviruscovid-19).

Last updated: September 8th, 2021


England (UK)

Guidance on Infection Prevention and Control for care homes was updated numerous times during the pandemic. Some of the relevant guidance was issued in policy documents from the Department of Health and Social Care, and some from Public Health England. Initial guidance on February 25, 2020, advised that it was unlikely that people receiving care would be infected (at the time there had been no known transmission within the UK). It was not until April that the guidance documents in England took into account the possibility of pre-symptomatic or asymptomatic transmission both with regards to testing and isolation policies.

Last updated: September 8th, 2021


Finland

Finland announced a state of emergency on March 16, 2020, after reaching its pandemic threshold of 156 cases on March 15 (Source https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view (p. 15)). The Ministry of Social Affairs and Health (MSAH) is responsible for the planning of the national pandemic response with the help of The Finnish Institute for Health and Welfare (THL), an independent national health research institute. Any national directive (i.e. care measures for infected LTC home residents) is then implemented by local municipalities (Source: https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620-1.pdf).

Decision-making has primarily fallen on the shoulders of the Finnish Health and Welfare research institute (THL), employed by the Ministry of Social Affairs and Health. Expertise at the municipality level is slightly unclear, although agents at the local level are clearly instrumental in bridging the gap between local need/services and nationwide policies/standards (Source: https://www.covid19healthsystem.org/countries/finland/livinghit.aspx?Section=5.%20Governance&Type=Chapter).

On the other hand, municipalities appear to have a large degree of freedom in decision making around LTC. National operators have developed guidelines for residential and domiciliary care. These guidelines were updated over time. However, most guidelines provided at the national level (including LTC guidance) were not binding for municipalities. This led to a situation that in some municipalities visiting bans were introduced ahead of the Government guideline, while others did not follow this. Other municipalities, on the other hand had implemented additional measures, such as support with shopping for older people. Regional variation of the spread of COVID-19 could have been another reason for the different application of guidelines (Source: https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620-1.pdf)

Last updated: September 8th, 2021


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.

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 demanded 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: September 8th, 2021


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


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

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: https://ourworldindata.org/grapher/covid-stringency-index?tab=chart&stackMode=absolute&time=2020-01-22..latest&country=~ISR&region=World).

LTC facilities in Israel are supervised by the Ministry of Health and/or the Ministry of Labor, Social Affairs and Social Services, while the National Insurance Institute carries responsibility for LTC services in the community.

Early in the pandemic the vulnerability of people with LTC needs was recognised. This led to the establishment of the ‘Fathers and Mothers Shield taskforce’. This task force was made up from representatives of all relevant government ministries, the Israeli army, Israeli intelligence organizations, and public sector organizations. Measures implemented by the taskforce 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’.

Last updated: September 8th, 2021


Israel

The Israeli Ministry of Health was charged with leading the government’s pandemic response, with both weekly and daily press releases published starting January 24, 2020. Lockdown measures were implemented the second week of March, which proved effective in terms of minimizing 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 (current) second wave, the index measures at 85 (with a significant drop to a score of 40 and a reopening of society in November 2020) (Source: https://ourworldindata.org/grapher/covid-stringency-index?tab=chart&stackMode=absolute&time=2020-01-22..latest&country=~ISR&region=World).

Last updated: September 8th, 2021


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


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). Hierarchically organised government agencies whose sole missions are elderly care, plus 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


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, which was similar at regional level. The governance of the pandemic in relation to the LTC sector 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 (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 8th, 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


Sweden

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 (NBHW). 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). In order to increase intensive care unit capacity, the government instructed the NBHW to function as a national coordinator to ensure expansion occurred to meet needs (Source: https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812).

Last updated: September 8th, 2021


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


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 3rd, 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 (https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf).

Last updated: March 23rd, 2021