Care homes have become the focus of the COVID-19 debate across Europe.
People who reside in care homes are vulnerable due to their health status and the fact that they live in close proximity to others. Although the numbers of deaths from COVID-19 in care homes varies between and within countries, the percentage of COVID-related deaths in care homes worldwide are thought to range from 24% to 82%.[i] This policy snapshot looks at what countries have done to protect care homes during the COVID-19 crisis, including providing guidance, strengthening medical support, efforts to prevent the spread of the virus and minimise infection, testing for residents and staff, and other supportive measures.
We have examined what measures different countries have taken to protecting care homes using evidence gathered from the COVID-19 Health Systems Response Monitor (HSRM) (up to 25 May 2020). Although data is still limited, it is important to begin to build a picture of how varied the initial approaches were and to draw out learning for future waves of infection. We summarise the main strategies deployed and highlight key divergences or similarities in approaches between countries. The absence of mention of a particular country does not necessarily mean that measures were not taken in that country, only that that information is not available in the HSRM.
Countries have provided national guidance with implementation and enforcement delegated to local levels
Approaches to organising a response in the care sector have varied between countries. While all countries report some degree of national guidance for the sector, implementation and enforcement has often been delegated to more local administrations. In England, implementing the response has been the responsibility of individual care homes or the local authorities with oversight for long-term care. Germany’s states have exercised a high degree of autonomy and have diverged in the timing and type of guidance issued. In some countries, the COVID-19 outbreak has shifted governance structures to enable centralised procurement of equipment (Estonia, Germany, Iceland, Malta) and to establish long-term care task forces (Hungary, Iceland, Germany, Greece). In a small number of countries examined (notably Hungary and Ireland), care homes have been required to appoint a COVID lead in order to define clear accountability in the event of an outbreak. Further research is required to understand the relative benefits of different approaches to governance during the outbreak.
There has also been divergence in the reporting and monitoring of infection rates and deaths within care homes. Ireland is notable in that its mortality data included care home deaths from the outset. Many other countries began to report deaths in care homes later in the crisis (e.g. France and Hungary from early April; Finland from mid-April and England from late-April). Norway to date has not published a national overview of deaths in care homes. Iceland and Israel include care home deaths but do not separate them from deaths in other settings (although in Iceland, death from COVID number only 10 in total).
New measures to quarantine and provide clinical treatments have been introduced for positive or suspected cases
Where a care home has identified a positive case of COVID-19 or has a resident with suspected COVID, the general approach has been to try to isolate and quarantine the affected person. In England, where a home is unable to implement effective quarantine or cohorting, it has been the local authority’s responsibility to find suitable alternative accommodation and to move the affected person. Similarly, in Israel, residents with mild symptoms have been transferred to hotels where cases cannot be accommodated within homes. Ireland also worked with hotels to accommodate people being discharged from hospitals back to long-term care facilities so as to ensure that facilities were prepared and patients were found to be COVID-negative. Homes in Israel have been required to establish COVID care units and in the Czech Republic, long-term care facilities have been required to reserve 10% of their capacity to accommodate suspected or infected cases.
Medical support to care homes has been strengthened
One factor that has surfaced in a number of countries is the lack of medical provision within care homes, and that has created particular difficulties in places where transfer to hospital has been explicitly discouraged (e.g. England, France, Italy, Norway, the Netherlands). To address this, support has been deployed to homes in some countries to avoid admission to hospital. Italyand Luxembourg have required homes to have a 24/7 medical presence to follow up unwell residents and France is now encouraging physician visits and offering greater remuneration after having told homes to minimise such visits initially. Austria requires its hospitals to offer support to care homes in the form of personnel, expertise and equipment.
Most countries have banned visits to homes to prevent infection
One of the key approaches to reducing the risk of community infection across the countries looked at was to ban visits to care homes, other than essential ones or those in exceptional circumstances (e.g. at the end of life). However, the point in the crisis for issuing such a ban varied between countries. The Czech Republic and Iceland acted most swiftly (on 2nd and 6th March respectively), the Czech Republic acting just the day after its first case of COVID-19 in the country. Finland, France, Israel and Norway followed suit in mid-March. Sweden imposed a ban on 30th Mach and England, Hungary and Greece did not impose a similar ban until early April. However, in England it is known that some care homes implemented their own ban on visitors several weeks before the government advice which came into force on 2nd April.
For some countries it became clear that physical distancing for people in long-term care facilities could be detrimental to their wellbeing and therefore guidance and rules have since been amended to allow some contact with families and friends. In Austria, single visitors can make appointments preferably to meet in an area outside the home and a mask (with mouth-nose protection) is obligatory. In France, visits to relatives in nursing homes have been allowed again since 20th April, albeit under stringent conditions. In Germany and the Netherlands, care homes have created ways for residents to see and speak with relatives by using virus-proof containers, garden sheds, telephone boxes or other solutions.
Efforts are underway to minimise infection by managing the workforce
While some countries reported providing additional training for staff (e.g. Belgium and France), the focus of most workforce strategies was to increase the supply of staff (Belgium, Canada, Germany, Ireland, Israel, Switzerland). Iceland took special measures to quarantine all long-term care staff in affected facilities and bring in replacement staff from other areas of the country. Several countries (e.g. Austria, Germany, Iceland, Switzerland) have deployed armed forces to provide anything from care to delivering meals to testing or procuring equipment (see also the related policy snapshot on What is the role of the military in the COVID-19 response?).
In the face of pre-existing and widespread staff shortages, some countries have made efforts to boost staffing levels through recruitment and retention. England launched a recruitment campaign to attract newcomers and return former staff to the sector; France has brought in auxiliary staff and volunteers; Israel is deploying student nurses and unemployed doctors in homes; Norway banned health and care staff from leaving the country; and Germany has offered staff a bonus.
Some countries have made efforts to prevent staff moving between homes (Canada, Cyprus, Germany, Israel). In Israel, staff can only work in one facility for regular 12-hour shifts with the same personnel. Ireland has also sought to minimise the movement of staff across different facilities.
Estonia recommended staff stay in the facility 24 hours a day for the duration of a five-day shift. In the absence of official guidance, some homes in England have chosen to implement a similar shift pattern where staff to sleep in the home for a period of time.
Some countries are centralizing procurement for PPE
Almost all countries which reported, have experienced shortages in PPE for their long-term care facilities, or difficulties in procurement (e.g. Belgium, Finland, Germany, Ireland, Malta, the United Kingdom). Several countries have reported managing this challenge by centralizing procurement of PPE for regions (e.g. the Czech Republic, Denmark, Estonia, Finland, Germany, Greece, Malta) while others (e.g. England) have left individual homes or localities to source it. Still others have emphasized the need to streamline procurement for all private and public long-term care facilities with the procurement for health services (Estonia, Italy).
Testing of residents has expended over time
Testing programmes in care homes have been expanded as the crisis has unfolded but many countries have struggled with either logistical or capacity issues (or both) so rolling out testing has been slow in many places. Several countries began with a relatively focused approach, only testing those with symptoms or, in the case of France initially, only those with symptoms and underlying conditions. The Netherlands and England began testing only the first 2-5 cases with symptoms in a care home.
As time has gone on and it has become clear that COVID-19 can be spread while a person is asymptomatic, efforts have been made to expand testing including for those in homes without symptoms. Denmark began testing all residents, regardless of symptoms from 27th April and England has also pledged to offer testing to all but has run into logistical issues and a lack of clarity over which organisation is responsible for oversight. Spain and Switzerland also require post-mortem testing whether COVID-19 is suspected or not. In the Czech Republic and now in England, all new residents are required to be tested before moving into homes. In England, people were discharged from hospital into homes after a testing positive for COVID-19 or while awaiting a test and homes were advised to quarantine those individuals. There is some debate as to whether the policy of discharging residents who had tested positive for COVID-19 directly into care homes aided the spread of the virus.
Testing of staff varies
Similar to testing for residents, the policy on staff testing has evolved during the crisis period and varies between countries. For instance, in England, testing for care staff was not introduced until 24th April, before which staff with symptoms were ordered to self-isolate. Since 3rd May, testing for all staff (including those who are asymptomatic) has been available albeit with certain logistical and capacity challenges. The Czech Republic and Denmark have stressed the need for repeat testing for asymptomatic staff, or those with a negative test, being retested at regular intervals (7 – 14 days). In Ireland, staff are screened for symptoms twice a day.
Financial support for care homes has been available in some countries
In recognition that care homes are facing increased costs (e.g. from extra PPE, staff sickness, and a reduction in new residents), financial support has been given in some countries: in Ireland, some of this was given directly to homes, in the case of England and Sweden, money was given to local authorities and it has been up to them to allocate it as they see fit. In England, that has led to concerns that the homes, and other care providers, have received no direct financial support. Germany has sought to compensate providers for low occupancy in some facilities but extra costs of PPE and so on are largely covered by long-term care insurance. In the Netherlands, a package of financial support for the sector is expected later in June.
Care homes remain vulnerable as lockdowns are eased
Although overall infection rates in Europe appear to be on a downward trajectory and many countries are now easing lockdown arrangements, there is still concern that care homes may not follow this downward trajectory if measures are not taken to understand the full impact of COVID-19 in these settings. It is difficult at this stage in the crisis, without further detailed data, to ascertain which measures to protect care homes have been successful and to what extent underlying contextual factors (e.g. pre-existing workforce shortages, funding issues and integration with health care) contributed to success or otherwise. The organisation, administration and funding of care homes is hugely variable across countries and examining those contexts will be crucial in identifying learning for the future.
Natasha Curry, Margrieta Langins
[i] Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N and Fernández J-L (2020) Mortality associated with COVID19 outbreaks in care homes: early international evidence. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 21 May 2020. https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-21-May-6.pdf