INTERNATIONAL REPORTS

Responses to 3.07.03. Care homes: visiting and unpaid carer policies


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: September 8th, 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: 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: September 8th, 2021


Australia

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

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.

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


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


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


Canada (British Columbia)

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: September 8th, 2021


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: September 8th, 2021   Contributors: Gemma Drou-Roget  |  


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


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 (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”) askedthe 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” (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: September 8th, 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 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).

Last updated: September 8th, 2021


England (UK)

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 (https://www.bbc.co.uk/news/52674073). 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 22 July, linking the visiting policy to local levels of risk of transmission and advising that visits were limited to a “single constant visitor” (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus/update-on-policies-for-visiting-arrangements-in-care-homes).

On October 1, 2020, the Department of Health and Social Care (DHSC) announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, which includes enabling safe visiting of care homes (https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2).

On October 13, 2020, 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 (https://committees.parliament.uk/oralevidence/1032/pdf/; https://www.bbc.co.uk/news/uk-politics-54528021).

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 (https://www.laingbuissonnews.com/care-markets-content/news/organisations-call-for-care-home-visits-to-continue/). In response to the ongoing restrictions, a high court judge ruled on November 3, 2020, that visits to care homes were legal (https://www.theguardian.com/society/2020/nov/03/judge-says-care-home-residents-in-england-are-legally-allowed-visitors?fbclid=IwAR1EHVzBhTUH1E7IFqzu9eYzCN7nMnkpT8MIxhwoygL7tHQgl_glve2cok4). Following this, government guidance on visiting arrangements were updated on November 5, 2020, advising directors of public health and providers to facilitate visiting where possible in a “risk-managed way” (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus/update-on-policies-for-visiting-arrangements-in-care-homes). 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, 2020, 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 (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus).

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 (https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-care-homes).

On March 12, 2021, 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 (https://www.nuffieldtrust.org.uk/news-item/social-care-reform-running-out-of-time-and-money).

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 (https://www.laingbuissonnews.com/care-markets-content/news/adult-social-care-to-receive-extra-funds/).

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) (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

The most recent guidance (August 2021) removes the advice on the number of ‘named visitors’ and does not limit the number of visitors a resident can have in a single day. The essential caregiver should be able to visit even if the home is in outbreak (except where carer or resident are Covid-positive), or if the caregiver is not fully vaccinated.

Last updated: September 8th, 2021


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: September 8th, 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: September 8th, 2021


Germany

On 10 February 2020 the Federal Government noted that in some care and nursing homes staff and residents have already received the second vaccine. In addition, there has been a joint effort to undertake rapid tests in residential care settings. The Government asks federal states to develop concepts to expanded visiting rules following full vaccination. The armed forces can support rapid testing (https://www.bundesregierung.de/resource/blob/975226/1852514/508d851535b4a599c27cf320d8ab69e0/2021-02-10-mpk-data.pdf?download=1).

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: September 8th, 2021


Hong Kong

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: September 8th, 2021


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


Israel

Visiting policies in care homes were found to be very inconsistent early on, causing confusion for LTCF staff, residents and families (https://www.calcalist.co.il/local/articles/0,7340,L-3800102,00.html). 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. “To date, there has been no reported cases of COVID-19 infections in LTCFs arising from a family visit (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

Last updated: September 8th, 2021


Italy

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.

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


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: September 8th, 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 Minister of Health closed all care and nursing home to visitors on 20 March 2020. Families were only allowed to visit when their relatives were dying. Older people at home were not considered as vulnerable as people in nursing home, so the rule did not apply to them. Closing care homes created significant resistance and some nursing homes took drastic actions to prevent relatives from visiting (e.g. employing a security service, create fences) there were different views among relatives about the priorities of protecting people in care homes (https://www.sciencedirect.com/science/article/pii/S1525861020308318). The legality of the ban became contested. Older people became reluctant to move to nursing homes because of the ban. Nursing homes (which usually have a waiting list) do now have empty beds for which there is no demand. Key actors of the care sector agreed a protocol to gradually open homes on 8th May. This bottom up initiative was endorsed by the Ministry of Health (https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

However, others report that the ban provided discretion to nursing homes to allow visits from close families and friends as part of end of life care (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf). Visiting policies were relaxed and localised during the second wave, delegating responsibility and decision-making to local actors and care homes, it was recognised that residents should be able to see at least one family member or next of kin. While decisions were localised the central healthcare inspectorate retained the authority to monitor the situation (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 study of the decision to allow visitors back in nursing homes (https://www.sciencedirect.com/science/article/abs/pii/S1525861020305260). A study of changes to behaviour during the crisis of people in nursing homes (https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1857695). According to the LTC report new legislation requires care homes to enable visits at all levels of the pandemic and even if there are COVID-19 cases in the care home. Care homes have enabled this by creating COVID-19 wards or blocking visitors from specific wards with ongoing infections (https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf).

Government guidance states that if 80% of nursing home residents have been fully vaccinated, then a resident can receive a maximum of two visitors per day (https://www.rijksoverheid.nl/onderwerpen/coronavirus-covid-19/gezondheid-en-zorg/verpleegtehuizen#:~:text=Basisregels%3A%20iedereen%20houdt%201%2C5,bezoeker%20per%20bewoner%20per%20dag). If less than 80% of residents have been fully vaccinated, then a resident can receive a maximum of one visitor per day. Basic rules such as social distancing and using face masks still apply. Individual nursing homes have some discretionary space to set their own rules (https://kennisbank.patientenfederatie.nl/app/answers/detail/a_id/3050/~/regels-m.b.t.-cli%E3%ABnten-en-pati%E3%ABnten-in-verzorgings–of-verpleeghuizen).

The “client councils” in care homes have the right to participate in decisions that affect their daily lives and need to be consulted about organisational issues and have a right to consent to decisions that affect the residents’ daily lives. It is expected that they would advise on visiting restrictions (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181203/; 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).

Visiting arrangements from 10 June 2021: Residents in nursing homes may receive as many visitors as people at home (when 80% of the residents have been vaccinated) (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 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

Visitors are not tested and do not need to show a negative test before the visit (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).

Last updated: September 8th, 2021


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 have been asked to make appointments so that nursing homes can 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).

In response to the national situation, visiting guidelines are regularly updated. When there are increased cases in the community, guidelines are adjusted and updated, lowering the number of visitors that a resident can receive from two to one per day. Outings are not permitted for residents following an inpatient hospital stay. As of June 2021, there is currently no mandate for visitors to be vaccinated (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


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

As of July 2021, care home residents are currently 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.

Last updated: September 8th, 2021


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


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