LTCcovid Country Profiles

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

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.

 

About this question

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.

 

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

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

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  |  

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

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

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  |  

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

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

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

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. Blue plans were activated on 6th March, however a support cell for care homes was only set up on 31st march, which included (source): 

  • Permanent access to a geriatrician 
  • Mobile geriatric teams 
  • Direct admission route to hospitals supported by multi-disciplinary teams 
  • Embedding hospital at home measures 
  • Support around palliative care. 

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: October 23rd, 2024   Contributors: Camille Oung  |  Alis Sopadzhiyan  |  

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

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

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

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  |  

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  |  

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

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 BMJ Open 2021;11:e053235. doi: 10.1136/bmjopen-2021-053235

Last updated: January 6th, 2022   Contributors: Lisa van Tol  |  

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’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  |  

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  |  

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

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  |  

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  |  

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica Breuer, Jorge Browne Salas, Jenni Burton, William Byrd, Sara Charlesworth, Adelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin Hämel, Nina 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’Donovan, Camille 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. Schmidt, Agnieszka 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.