Visitor bans, no background checks, “parachuting” in staff: how are providers in other countries tackling the coronavirus and the challenges of delivering care?

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On Wednesday, the Federal Government moved to restrict visits to aged care facilities across the country – limiting residents to two visitors once per day – in an effort to combat the spread of the virus.

But Australia is well behind other countries where the virus has spread further.

So, what has been the experience of aged care providers around the world – and what can Australia learn?

I spoke to our Director of Industry Engagement Judy Martin (pictured right) – who is also the Chair of the Global Ageing Network (GAN), which represents retirement living and aged care operators in 50 countries – about what actions other countries are taking to tackle the crisis.

She has provided feedback from a number of countries that points to a range of key issues including:

  • Ensuring adequate staffing
  • Supporting current staff
  • Adequate supply of PPE and testing
  • Bureaucratic spaghetti holding up resourcing
  • Residents becoming socially isolated
  • The need to manage families’ expectations
  • Impacts on admissions of new residents and respite care

See the full analysis below:

Ontario, Canada

As of Wednesday, Ontario, Canada (from where Dr Veronique Boscart gave evidence at Tuesday’s Royal Commission workshop) has declared a state of emergency and issued orders for the closure of all schools, day cares, sporting and athletic venues, theatres, religious venues, restaurants and bars with the exception of take-out/delivery.

All mass gatherings larger than 50 people are banned and all shared living settings – including aged care homes – are restricted to essential visitors only.

The country is already facing staff shortages. A previous order for all people returning from overseas to self-isolate for 14 days has been altered to allow health care and long-term care workers to self-monitor instead.

The Government has announced $300 million to tackle the crisis including:

  • More PPE: masks, gowns, gloves, ventilators
  • 24/7 health screening for long-term care
  • Funding for additional staffing and increased infection control measures in long-term care (similar to the measures announced by the Australian Government last week)

Within Ontario, stakeholders including the aged care peak bodies are being updated daily on the number of tests, results pending, the status of each diagnosed case, and measures implemented each day, but these numbers are changing hourly.

To this end, Ontario has stopped all regular placements into long-term care in the expectation of hospitals transferring people next week – providers are also looking for other potential sources of accommodation.

Two of the peak bodies, the Ontario Long Term Care Association and AdvantAge Ontario, are pushing for significant regulatory relief to free up staffing.

Ontario’s long-term care legislation was introduced following the outbreaks of SaRS and H1N1 and the peaks say that its over-prescriptiveness and the compliance culture it has fostered has created significant risks.

To give an example, the peaks do not have a number on what Personal Protective Equipment (PPE) inventory is available in homes – because operators are concerned stock will be taken away or they will be issued with a non-compliance order for not having enough inventory.

In terms of staffing, the peaks are also advocating for relief to allow greater flexibility in who can do tasks in homes – because the current legislation prescribes what tasks nurses and personal care workers can do, creating further risk.

Some homes are entirely reliant on agency staff that are shared with hospitals and home care and it is expected that hospitals will require these staff to pick a single site to prevent spread – which would have a devastating impact on the availability of staff.

To head this off, the peak bodies are now looking at redeploying workers from other sectors who are now unemployed to perform non-clinical tasks such as cleaning, serving meals and making beds.

England

While the British Government has not yet banned non-essential visits, most homes have banned visits from family and friends and are keeping residents indoors.

Care Forum Wales, which represents more than 450 care and nursing homes, has warned visitors to stay away and is calling for red tape to be cut so older people who no longer need hospital care could be transferred to aged care homes and free up hospital beds.

Some providers have announced that they are “cocooning” – placing residents in preventive isolation – for two weeks.

iPads are being used to allow residents to communicate with family and friends.

Routine inspections by the UK’s Care Quality Commission were also suspended on Monday, with its resources now being dedicated to “remote methods” of monitoring and extending extra support to care managers.

There has also been discussion around how to deal with the numbers of staff and volunteers potentially becoming sick or self-isolating.

The Department of Health and Social Care has asked providers whether the system of obligatory background checks for workers who have close physical contact with vulnerable people could hold up emergency plans being implemented.

People who have recently retired or left care work may be drafted back in to fill projected workforce shortfalls.

The Government is also reportedly looking at the possibility of parachuting care workers into coronavirus ‘hotspots’ if extra staff are needed – but workers have told The Guardian most people will not want to go into the danger zones.

There are also concerns that some staff could come into work sick because they need the money. Prime Minister Boris Johnson has announced statutory sick pay for workers who need to self-isolate, but staff who work at multiple homes don’t always meet the minimum requirement for sick leave.

The Government has also moved to close schools indefinitely and cancel exams – schools will however stay open for the supervision of thousands of children of NHS workers and other frontline staff such as police and supermarket delivery drivers who need to go to work to tackle the virus as well as vulnerable children.

Lombardy, Italy

One of the epicentres of the outbreak.

There has reportedly been a spike in the number of deaths in aged care homes in Italy since the start of March but it is currently unknown how many deaths are from coronavirus because only patients admitted to hospital with severe symptoms are now being tested.

One facility reported 18 deaths in one day from respiratory problems, but the lack of testing means they have not been marked as coronavirus deaths.

This is despite homes in northern Italy cutting off access to visitors on 21 February after the virus emerged.

One peak body reported there had been seven deaths in one day at a 36-bed facility. They launched an appeal for more PPE for staff in early March but hospitals were given priority given the shortages of supplies. They also say staff are also not undergoing testing.

Local health authorities say homes should have medical staff on hand to care for residents – but staff say they are overwhelmed and unable to organise hospital transfers because of the lack of hospital beds.

This is backed by the European Ageing Network who say (as of Tuesday) that both GPs and long-term care facilities have been “left alone”, especially in the procurement of PPE.

In most facilities, PPE are limited to use with positive people with managers forced to adopt a daily supply system.

In some facilities – despite it being against the health guidelines – staff are being asked to wear FFP2/3 masks for longer, combined with a standard surgical mask, which has led to protests by workers afraid of contagion.

The Lombardy region also established that staff who came into contact with a positive case were also not deemed to be a “contact” and not tested – instead, they were monitored daily and if they showed no symptoms, were allowed to keep working with the use of a surgical mask.

If a staff member did record a fever and a temperature higher than 37.5C, they were then tested as quickly as possible so they could be cleared to return to work.

When cases did test positive, isolation rooms were organised but this was not always possible in all home because of the distribution of residents in single and double rooms.

It was only after two weeks of increasing government restrictions, the admission of new residents, group activities, training and voluntary work was banned and family and friends barred from visiting.

The United States

The US has recorded a number of cases of the virus in aged care homes, including 35 deaths at the Life Care Center in Kirkland, Seattle (pictured at the top) – with staff members who worked sick now being blamed for that outbreak.

Subsequently, there have been a range of measures implemented including bans on visitors, no communal dining and deliveries being left on the loading docks.

Like other countries, access to PPE is limited and a significant concern for operators. In some cases, nursing homes have refused admissions from hospitals because they don’t have enough PPE to effectively care for another resident.

Because each state determines their own distribution system for PPE, the peak aged care body LeadingAge is lobbying for homes to be a priority.

Group and some individual therapy have stopped, but the use of telehealth and technology to keep residents connected with family and friends is increasing.

Surveys of nursing homes have also been paused, except where there is concern about infection control procedures.

The US faces a challenge in that its assisted living homes are regulated at the state level – and because they are not considered “health care”, they don’t have the same infection control and prevention protocols in place despite serving a high number of older people.

It is expected that any new restrictions announced by the Government will focus on this sector.

The other major concern now is adequate staffing – US school closures are impacting on the number of available staff.

LeadingAge is also advocating for an Older Adult Services Workforce Emergency Fund to pay enhanced wages and attract workers laid off from other professions to jobs in the sector, but acknowledge this will require effort to convince people that working in aged care services is “safe”.

They are also pushing for the states to cut red tape on workers, for example, licenses to work in the sector, so staff can more easily plug gaps.

Australia staring down a similar situation

The experience overseas points to a long road ahead for Australian operators.

Adequate staffing:

Ensuring there are enough staff on the floor will be critical.

School closures may mean staff stay home to care for children – the Government may need to take the lead from the UK and keep some schools open for health and aged care workers.

Relying on agency staff has proved problematic in other countries as nurses are deployed to hospitals.

The sector here has already raised the idea of students and overseas workers being used to fill gaps. Will background checks and other documentation need to be waived to get staff on the floor?

Supporting staff:

Keeping current staff coming to work could prove challenging, especially if testing is not immediately available.

Picture this: a facility has 100 beds and 70 staff. An outbreak occurs and 35 staff don’t show up for work the next day. Where do you find 35 staff?

Earle Haven showed what can happen when staff suddenly leave.

Adequate supply of PPE:

While the Government has said it is sourcing more PPE, there is a question mark over whether aged care will be prioritised at the same level as hospitals and GPs.

Will staff want to work if they don’t have enough equipment?

‘Bureaucratic spaghetti’:

Legal requirements have slowed the roll out of many measures in other countries that could provide more staff and resources.

Will the Government be willing to cut through the red tape to ensure facilities have what they need?

Social isolation of aged care residents:

GAN is raising concerns about the effect that lockdowns will have on the wellbeing of residents.

Keeping residents connected to the outside world through technology and providing ‘touch’ will be key.

Managing families’ expectations:

Families will be understandably tense about the health of their relatives and requiring regular information and communication.

Admissions of new residents and respite care:

The overseas experience suggests there could be a hold on new residents coming in and on the availability of respite care, impacting on occupancy levels and correspondingly RADs.

Challenging times ahead.

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