LTCcovid Country Profiles

Responses to 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