Preventing and managing COVID-19 across long-term care services: policy brief, 24 July 2020

Policy brief Preventing and managing COVID-19 across long-term care services 24 July 2020

Preventing and managing COVID-19 across long-term care services Policy brief 24 July 2020 WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/) Suggested citation. Preventing and managing COVID-19 across long-term care services : policy brief. Geneva: World Health Organization; 2020 (WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Inis Communication Contents Acknowledgements iv Executive summary v Part 1. Overview 1 1.1 Aim of the document 1 1.2 Impact of COVID-19 on long-term care: what the evidence tells us 2 1.3 The case for action: leaving no one behind 3 Part 2. Responding to the COVID-19 pandemic in long-term care 5 2.1 Include long-term care in all phases of the national response to the COVID-19 pandemic 7 2.2 Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic 9 2.3 Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses 11 2.4 Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services 14 2.5 Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation 17 2.6 Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases 19 2.7 Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services 22 2.8 Provide support for family and voluntary caregivers 24 2.9 Prioritize the psychological well-being of people receiving and providing long-term care services 27 2.10 Ensure a smooth transition to the recovery phase 30 2.11 Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services 32 References 33 Annex 1. Methods 41 Acknowledgements This policy brief was developed by WHO through new analysis, expert consensus and reference to existing WHO guidance. Coordinating departments Department of Integrated Health Services (Shannon Barkley, Edward Kelley) Department of Maternal, Newborn, Child and Adolescent Health and Ageing (Zee-A Han, Anshu Banerjee) Principal writers World Health Organization: Zee-A Han (responsible officer), Shannon Barkley, Yuka Sumi London School of Economics and Political Science: Adelina Comas-Herrera, Klara Lorenz-Dant, Maximilian Salcher-Konrad Other contributors and reviewers WHO Steering Committee: Ageing and Health; Clinical Services and Systems; Gender, Equity and Human Rights; Integrated Health Services; Maternal, Newborn, Child and Adolescent Health and Ageing; Mental Health and Substance Use; Sensory Functions, Disability and Rehabilitation; Infection Prevention and Control Hub and Task Force; WHO Kobe Centre, and regional offices (Benedetta Allegranzi, Jotheeswaran Amuthavalli Thiyagarajan, Sarah Louise Barber, Anjana Bhushan, Alessandro Cassini, Alarcos Cieza, Theresa Diaz, Stefanie Freel, Manfred Huber, Anne Johansen, Theadora Koller, Margrieta Langins, Madison Moon, Paul Ong, Ritu Sadana, Nicoline Schiess, Katrin Seeher, Enrique Vega). The following individuals contributed to or reviewed the document. Confidentiality agreements were signed and declarations of interest were collected and reviewed. Non-WHO experts: WHO Global Network on Long-term Care for Older People (Liat Ayalon, Pablo Villalobos Dintrans, Walter Frontera, Muthoni Gichu, Sandhya Gupta, Hanadi Khamis Al Hamad, Arvind Mathur, Reshma A. Merchant, Stephen O’Connor, Vinod Shah, Lieve Van den Block) and Rachel Albone, Sean Cannone, Leon Geffen, Terry Fulmer, Richard Humphries, Caitlin Littleton, Terry Lum, Saniya Sabzwari, David Stewart. WHO continues to monitor the situation closely for any changes that may affect this policy brief. Should any factors change, WHO will issue a further update. WHO gratefully acknowledges the kind support of the Government of the Republic of Korea, Ministry of Health and Welfare. iv Preventing and managing COVID-19 across long-term care services Executive summary The COVID-19 pandemic has affected older people disproportionately, especially those living in long-term care facilities. In many countries, evidence shows that more than 40% of COVID-19 related deaths have been linked to long-term care facilities, with figures being as high as 80% in some high-income countries. Furthermore, in long-term care facilities, the case fatality for residents with COVID-19 may be higher than in the population of the same age living outside long-term care facilities. Residents of long-term care facilities often face high risk, low preventive measures and inadequate resources to recover from COVID-19, as well as reduced access to essential health services in a context where health systems are experiencing constraints during the COVID-19 surge. The impact of COVID-19 has additionally been high in providers of long-term care services, within long- term facilities and in other settings. A 2020 study by the United Kingdom Office for National Statistics of deaths by occupation found that the social care workforce had a significantly raised death rate associated with COVID-19. So far, COVID-19 has disproportionately affected long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community-based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. The response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries. Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19. This policy brief provides 11 policy objectives and key action points to prevent and manage COVID-19 across long-term care. Its intended audience is policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on currently available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and to mitigate impact across long-term care services, including care providers. While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized because they have experienced extremely high COVID-19 incidence, morbidity and mortality. Furthermore, the policy brief addresses long-standing problems in long-term care systems, including underfunding, lack of accountability, fragmentation between health and long-term care and an undervalued workforce. The brief suggests ways to transform health and long-term care services so that long-term care services are readily integrated and provided as part of the continuum of care that includes health promotion, prevention, treatment, rehabilitation and palliation. It is only through these measures that people in need of long-term care can receive quality, equitable and sustainable care that allows them to live in a manner respecting their basic rights, fundamental freedoms and human dignity. v Preventing and managing COVID-19 across long-term care services vi Preventing and managing COVID-19 across long-term care services Part 1. Overview 1.1 Aim of the document The COVID-19 pandemic has revealed weaknesses in emergency response where long-term care services has been underprioritized, resulting in the devastating impact seen across long-term care services globally. These events have highlighted long-standing problems in the long-term care systems in most countries: underfunding, lack of accountability, fragmentation, poor coordination between health and long-term care, and an undervalued workforce (1–3). This policy brief provides policy objectives and key action points to prevent and manage COVID-19 across long-term care for policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on current available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and its impact on those who use long-term care and care providers (including paid staff and family and other voluntary caregivers). It also expands on the technical working guidance on preventing and managing the COVID-19 pandemic across long-term care services in the World Health Organization (WHO) European Region to provide global perspectives and country examples across all WHO regions (4). While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized as they have experienced extremely high incidence, morbidity and mortality due to COVID-19. However, although long-term care facilities are an integral part of long-term care, it must be highlighted that community-based services are the key to promoting ageing in place, reducing institutionalization, and supporting deinstitutionalization, so that people can live in a manner consistent with their basic rights, fundamental freedoms and human dignity. Box 1 presents definitions of the terminology used in this document. Box 1. Working terminology: definitions of terms used Long-term care systems National systems that ensure integrated long-term care that is appropriate, affordable, accessible and upholds the rights of people and caregivers alike (1). Long-term care Services to ensure that people with or at risk of significant loss of physical and mental capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity (1). These services typically involve care and assistance with everyday tasks (including dressing, bathing, shopping, cooking and cleaning), support with social participation, and management of advanced chronic conditions through community nursing, rehabilitation and end-of-life care. Services are provided by both unpaid caregivers (typically family but also volunteers) and paid care staff. Throughout the document, the use of the term “long- term care services” covers care at home, in the community and in facilities (residential long-term care facilities, nursing homes or other group living facilities), unless otherwise specified. Long-term care facilities Long-term care facilities may vary by country. Nursing homes, skilled nursing facilities, assisted living facilities, residential facilities and residential long-term care facilities are collectively known as long-term care facilities that provide a variety of services, including medical and assistive care, to people who are unable to live independently in the community. Throughout the document, the use of the term “long-term care facilities” does not include home-based long-term care, community centres, adult day care facilities or respite care. Caregiver A person who provides care and support to someone else. Caregivers may include family members, friends, neighbours, volunteers, care workers and health professionals (1). UN SP LA SH / JE RE M Y ST EN UI T 1 Preventing and managing COVID-19 across long-term care services 1.2 Impact of COVID-19 on long-term care: what the evidence tells us Evidence from a systematic review (5) and compiled reports on the COVID-19 situation in long-term care facilities (Annex 1) shows that, while there is little evidence of the impact of COVID-19 on people who use and provide long-term care services in the community, the pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities. In countries with large numbers of deaths from COVID-19, about half of all those deaths have been among residents of long-term care facilities. The methods for the systematic review and other reviewing carried out for this report are described in more detail in Annex 1. Early evidence shows that the extent of COVID-19 infections in long-term care facilities has varied widely, between and within countries: some countries (such as Jordan) have had no infections reported in long-term care facilities so far, whereas in Sweden, for example, by the end of April, 25% of long-term care facilities in the whole country had COVID-19 outbreaks, with 67% of long-term care facilities in Stockholm affected. Data from 21 high-income countries show that while some countries have had no or very few deaths among residents in long-term care facilities, other countries report that on average nearly half of all deaths linked to COVID-19 in the country were of long-term care facility residents (ranging from 24% in Hungary to as high as 82% in Canada). In some countries, the share of deaths among all residents of long- term care facilities linked to COVID-19 has been as high as 3% to 6% of all residents (6). Disaggregated data by age and gender are not available for many countries. The evidence also shows that once COVID-19 infection is present in long-term care facilities it is difficult to control, in part due to the large number of people living close together in facilities designed for communal living and the fact that personal care requires close proximity. Although case reports from the Republic of Korea, demonstrated successful mitigation of further infections in long-term care facilities after a member of staff had tested positive (7–8), case studies in several other countries demonstrate how difficult it is to contain the infection in these settings. For example, studies in the United Kingdom of Great Britain and Northern Ireland and the United States of America have shown incidence rates between 40% and 72% among residents (9–14), with infection rates among staff between 1.5% and 5.9% when all staff members at outbreak facilities were tested (7–8, 15–18). There is also evidence from one study that staff working across more than one home may have been the source of transmission (19). An analysis of deaths by occupation in the United Kingdom showed that men and women working in social care had significantly raised rates of deaths involving COVID-19 (23.4 per 100 000 males compared to 9.9 for males aged 20–64 years, and 9.6 per 100 000 females compared to 5.2 for females aged 20–64 years) (20). Six studies describing measures to prevent (China and Singapore) and contain or manage (Canada and the Republic of Korea) outbreaks in long-term care facilities reported some success, although these studies did not have a control group (7–8, 22–23). There is increasing evidence of potential transmission from presymptomatic or asymptomatic people who have COVID-19 and people presenting with “atypical symptoms” in long-term care facilities. Studies of outbreaks show that 7% to 75% of residents and 50% to 100% of staff who tested positive are presymptomatic or asymptomatic (11–13, 15, 17, 19, 24). Between 57% and 89% of asymptomatic positive residents develop symptoms later (11, 19). Systematic nationwide testing of residents and staff in Belgium showed that 74% of cases among residents and 76% of cases among staff were asymptomatic at the time of testing (25). “Men and women working in social care have significantly raised rates of deaths involving COVID-19.” “The pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities.” 2 Preventing and managing COVID-19 across long-term care services Once people living in long-term care facilities have COVID-19, the case fatality for residents may be higher than in the population of the same age outside long-term care facilities. For example, the incidence rate of COVID-19 deaths among residents of long-term care facilities in Ontario, Canada, was 13 times higher compared to community-dwelling cases aged 70 years or older (26), and the risk for severe disease, including death, was 2.5 times higher for Israeli nursing home residents with COVID-19 compared to other cases over 65 years of age (27). No studies report on the detrimental health sequelae of either the infection itself or the measures taken to prevent infection in long-term care facilities, although many editorials and commentary articles mention potential impacts on both mental and physical health (for example, distress, depression, anorexia, loss of physical condition due to lack of exercise, and consequences of increased chemical and physical restraints). This has raised concerns for increased direct and indirect morbidity and mortality (28–29). There is limited evidence on the impact of the COVID-19 pandemic on people who use and provide community-based long-term care, including home help, day care facilities and unpaid caregivers. Some public health and infection prevention measures (including movement restrictions, physical distancing and curfews) may resulted in restriction of the usual sources of care and support that many people with care needs rely on. Evidence from the United Kingdom found that people with disabilities experienced widening inequalities during the COVID-19 pandemic. People with disabilities reported difficulty in accessing food and medication and delays in the benefit system, with some experiencing food insecurity and poverty. Many people with disabilities reported feeling isolated and, for some, lack of Internet access meant that they could not access virtual replacement services. Furthermore, reduction of ongoing support structures left people reliant on family and neighbours (30). It is also likely that people living with existing health conditions experience difficulties in accessing essential health care services, including rehabilitation, which further increases care needs. Furthermore, discontinuity of health care services can result in heightened need for care (31–32). It is increasingly recognized that in many countries the initial plans to contain the pandemic did not include long-term care facilities; it was only when media reports of large numbers of deaths started to emerge that resources were mobilized. In some countries, the army and other emergency response units had to be deployed to support long-term care facilities that had been overwhelmed by large numbers of deaths and insufficient staff (33). In many countries, long-term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred (34). 1.3 The case for action: leaving no one behind Health systems have a responsibility to offer safe, accessible, affordable and quality health care, including assistive and palliative care, for all people, without discrimination. However, as the evidence shows, residents of long-term care facilities are often facing higher risk, lower preventive measures and inadequate resources to manage COVID-19, as well as reduced access to essential health services, as health systems experience constraints in the context of a COVID-19 surge (35). Older people, particularly those with underlying conditions who are more likely to develop severe COVID-19, make up a large proportion of those using long-term care services, including those living in long-term care facilities (36). Immediate action is required to prevent infection and mitigate the impact of the COVID-19 pandemic among this population and to ensure that essential health and assistive care services are provided. “In many countries, long- term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred.” 3 Preventing and managing COVID-19 across long-term care services Furthermore, women, especially older women, represent the highest share of people who use care services, dominate the long-term care workforce, and are the main providers of family care (1, 37). In addition, long- term care services often depend heavily on migrant workers and workers from ethnic groups, who may be at higher risk (1, 38–40). The response to the pandemic must include long-term care to ensure that ethnic, age and gender groups are not marginalized. Concerns about human rights have also been expressed, both in the potential neglect of the population relying on (and providing) long-term care, and in measures adopted in an attempt to reduce the risk of infection (for example, a ban on visitation and forbidding outside physical activity). It is mandatory that the response to the pandemic is inclusive of long-term care, so that appropriate and tailored measures are implemented and issues specific to long-term care are addressed. So far, COVID-19 has disproportionately affected people living in long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community- based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. Considering the magnitude of the impact of COVID-19 on long-term care, response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries (4). Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19 (41). 4 Preventing and managing COVID-19 across long-term care services Part 2. Responding to the COVID-19 pandemic in long-term care While the pandemic has brought public attention to the immediate impacts of the pandemic, and the need to be prepared for present contingencies and possible future waves, it has also shown that there are major structural challenges that need to be addressed to improve the safety and resilience of long-term care systems. So far, most countries have struggled to develop coherent systems to ensure access to person-centred, quality, long-term care services that meet the growing health and assistive care needs and that are consistent with basic rights, fundamental freedoms and human dignity (1, 42–45). Even in high-income countries, a review by the Organisation for Economic Co-operation and Development (OECD) concluded that “there is a history in many countries of long-term care policies being developed in a piecemeal manner, responding to immediate political or financial problems, rather than being constructed in a sustainable, transparent manner” (43). This section looks into the unique challenges that have affected the ability of long-term care systems to respond to the COVID-19 pandemic and proposes policy objectives and key actions to address these challenges in the short and longer term. Informed by the available evidence and international experience thus far, the 11 policy objectives presented on the next page will be key to addressing COVID-19 in long-term care systems. The following subsections address each of these policy objectives in turn. UN SP LA SH / A P X 90 5 Preventing and managing COVID-19 across long-term care services Eleven policy objectives to mitigate the impact of COVID-19 across long-term care 1. Include long-term care in all phases of the national response to the COVID-19 pandemic. 2. Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic. 3. Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses. 4. Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services. 5. Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation. 6. Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases. 7. Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services. 8. Provide support for family and voluntary caregivers. 9. Prioritize the psychosocial well-being of people receiving and providing long-term care services. 10. Ensure a smooth transition to the recovery phase. 11. Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services. 6 Preventing and managing COVID-19 across long-term care services 2.1 INCLUDE LONG-TERM CARE IN ALL PHASES OF THE NATIONAL RESPONSE TO THE COVID-19 PANDEMIC 2.1.1 The challenge Long-term care has low political priority compared to health and other policy areas Long-term care tends to have low political priority and is often referred to as “the Cinderella of the welfare state”, where political attention to its importance is often transient and secondary to health care (46). This lack of political attention to long-term care may be one of the reasons why the initial policy responses to the pandemic in many countries did not include the long-term care sector (4). Governance of the long-term care system often involves multiple sectors, different ministries and different levels of government, making coordination difficult In most countries, long-term care falls between different ministries, typically health care and social affairs, development, or social protection. Long-term care services and health care systems are often poorly coordinated or integrated, and tend to have separate (and often complex) arrangements for financing, regulation, information systems, and the training and procurement of staff (1, 43). This has created several difficulties during the COVID-19 crisis. For example, back-up staffing models to meet the surge in COVID-19 patients in hospitals were not flexible enough to meet demand surges in the long-term care sector. It was also difficult for appropriate staff to move flexibly across the system as needed. Similarly, the long-term care sector, and especially long-term care facilities, struggled to access testing and PPE, as this had been prioritized for hospitals (47). In addition, countries frequently distribute responsibility for long-term care vertically across national, regional and local actors, creating difficulties in coordination of services and effective oversight (48). For example, in Spain and Italy, the same person may be receiving long-term care services that are organized or funded by up to three different levels of government (49–50). Long-term care services consist of a mixture of public, private for-profit and private not-for-profit service providers, in addition to family caregivers Long-term care services are also characterized by a mix of public, private for-profit and private not- for-profit service providers (51). In some countries, most long-term care facilities are operated by private for-profit providers and, particularly in low- and middle-income countries, these are often unregulated (52–53). Particularly in low- and middle-income countries, nongovernmental organizations (NGOs) play an important role in the provision of long-term care services and are often the sole source of support for unpaid caregivers. However, where NGOs are non-existent, the care responsibility often falls entirely on the families themselves. This unpaid care is rarely recognized within a formal system and so is not included in any governance processes or mechanisms beyond those of the NGOs that support the work. These structures can result in a lack of ownership, diffused accountability, and fragmentation of responsibilities, causing problems with coordination and quality of care and leading to underdeveloped information systems (43, 54). 7 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 May impede inclusion of long-term care in pandemic national response May impede planning, oversight and accountability during the pandemic May impede coordinated response between long-term care and health care sectors in responding to the pandemic May impede effective resource allocation 2.1.2 Key actions Whole sector Ensure a focal point to manage long-term care (with a special focus on long-term care users and providers) in the overarching COVID-19 governing body. Establish joint steering committees and information- and data-sharing systems between sectors and subnational policy levels to ensure a coordinated response. Establish a mechanism to support unregulated providers, focusing on cooperative support rather than punitive measures. Long-term care facilities If long-term care facilities are expanding their health care role during the pandemic, establish triggers or thresholds that activate a phased reallocation of routine comprehensive health service capacity, including direct health care staff. Country examples In Singapore, the Agency for Integrated Care and the Ministry of Health, together with long-term care service providers, have jointly developed a number of measures to respond to the COVID-19 pandemic. These include infection control and prevention measures, access to PPE, distancing and zoning measures, suspension of visitors, alternative accommodation for long-term care workers, and testing to monitor people with long-term care needs and care workers. The Agency for Integrated Care also set up an incident response team to support long-term care providers in responding to COVID-19 infections. The Silver Generation Office, which is an outreach arm of the Agency for Integrated Care, has supported older people with contact, information and the provision of services during the COVID-19 pandemic (55–56). In Israel, a governing team has been appointed to manage COVID-19 outbreaks in long-term care facilities across the country. This team has provided a national plan under the Fathers and Mothers Shield project, including establishment of a headquarters from which government efforts can be coordinated. In addition, the Home Front Command has been assisting long-term care facilities throughout the pandemic with managing visitor access, disinfection, and food and equipment delivery, and has been offering training and guidance on protective and preventive measures (57). In Malta, the Social Care Standards Authority, the regulatory body for long-term care, defined the residential care settings as being high risk with regard to COVID-19 in early March. Immediately, the Social Care Standards Authority issued the directives mapped out in its COVID-19 brief (2020). There was immediate cooperation between the Public Health Authority and the Social Care Standards Authority, which proved to be the primary catalyst towards safeguarding older persons within the facilities (58). 8 Preventing and managing COVID-19 across long-term care services 2.2 MOBILIZE ADEQUATE FUNDING FOR LONG-TERM CARE TO RESPOND TO AND RECOVER FROM THE COVID-19 PANDEMIC 2.2.1 The challenge Limited public funding allocated for long-term care Average public expenditure on long-term care is very low, less than 1% of GDP globally. Such public underfunding jeopardizes access to long-term care (42). This is even more pronounced in low- and middle-income countries, many of which lack dedicated sources of public financing for long-term care. Public benefit schemes for long-term care are usually needs based and means tested, and often require co-payments, leaving large parts of the population outside the public system In most countries, public benefit schemes for long-term care support are needs based and means tested, and often require co-payments. Those with greater needs often receive more support, but some countries also set limits on the amount that can be covered through public resources. While some countries protect the most vulnerable from additional costs, considerable out-of-pocket expenses are common across countries for most people receiving long-term care services (43, 59–60). Also, due to the large share of care provided by unpaid caregivers, in practice a large share of the costs of long-term care fall on families, through a combination of the opportunity costs of providing care and out-of-pocket payments. Few countries have financing mechanisms that protect the whole population from catastrophic long- term care costs (1). Reduced income for long-term care sector and higher costs of care Increasing PPE and workforce costs mean that service providers are facing substantial additional costs. At the same time, providers are experiencing decreases in revenues due to lower occupancy in long- term care facilities (resulting from both a decrease in admissions and the higher-than-usual numbers of deaths) and the closure of community-based services such as day care centres. Several countries have already provided emergency funds to support the long-term care sector during this crisis. However, the provision and distribution of resources may be easier in countries with more developed and regulated long-term care systems. The provision of resources and support to the unregistered long-term care sector poses additional challenges. Such unique challenges in the financing of long-term care have made it difficult for the long-term care system to react and respond to the additional costs that may be incurred due to preparing for and responding to COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of adequate funding for the additional costs linked to the COVID-19 response may endanger the safety of long-term care users and providers The increase in the costs of care due to the pandemic results in increased out-of-pocket payments for care users 9 Preventing and managing COVID-19 across long-term care services 2.2.2 Key actions Whole sector Consider injecting extra ring-fenced funds for long-term care to cover the additional costs linked to the pandemic (for example, additional staff costs, infection prevention and control (IPC) training, and materials such as PPE and sanitizers). Consider how to reduce regulatory and other costs to providers for the duration of the pandemic (such as staffing requirements). Provide flexibility in the use of emergency funds allocated to long-term care providers as well as users. Long-term care facilities Provide funding to compensate for lower occupancy rates and ensure provision of quality essential health and care services. Provide funding to support providers of long-term care facilities with the additional costs incurred in ensuring the safety of their residents and staff, including additional IPC measures and testing for COVID-19. Community-based care Support providers (particularly not-for-profit) that are experiencing loss of revenue if they have to close some services, such as day care and community centres, during the pandemic. Enable flexibility in the use of personal budgets and other cash benefits, for example by allowing them to be used to employ a family member or neighbour if community centres are not available. Caregivers Support caregivers who may need to take on additional care responsibilities to compensate for the unavailability of usual care, and may need to give up employment to do so. Country examples In the United States, the US$ 3 trillion COVID-19 stimulus package (under the Coronavirus Aid, Relief, and Economic Security (CARES) Act) provides some funding for the long-term care sector. Out of the US$ 100 billion funding allocated to health care providers under the CARES Act, US$ 50 billion is being distributed to hospitals and long-term care providers, including providers of home health (61). As of 3 June 2020, US$ 4.9 billion had been targeted to skilled nursing facilities (62). In the Republic of Korea, the Ministry of Health and Welfare and the Korean National Health Insurance Service have issued temporary reimbursement guidelines for the long-term care sector. The guidelines take into consideration the need for COVID-19-related physical distancing measures and staff shortages. In addition, service providers operating in special disaster zones will not be facing payment cuts if they cannot adhere to staffing requirements during the pandemic (63). In China, subsidized long-term care providers were allocated a special one-off allowance to support staffing (for example, hiring and redeploying workers and reimbursing overtime) to ensure the continued provision of long-term care services. It is estimated that this support will amount to a total of around US$ 1.6 million (64–66). 10 Preventing and managing COVID-19 across long-term care services 2.3 ENSURE EFFECTIVE MONITORING AND EVALUATION OF THE IMPACT OF COVID-19 ON LONG-TERM CARE AND ENSURE EFFICIENT INFORMATION CHANNELLING BETWEEN HEALTH AND LONG-TERM CARE SYSTEMS TO OPTIMIZE RESPONSES 2.3.1 The challenge Few countries have information and monitoring systems for long-term care systems Relatively few countries have information and monitoring systems that include individual-level data about the characteristics, needs and outcomes of people who use formal long-term care services, and about the type and quality of care that they are receiving. This reflects the overall situation of limited data sources about older people (who are often long-term care users) and lack of age- and gender- disaggregated data (67). Where individual-level data are available, quite often they only cover people who use publicly funded long-term care or provide services. Furthermore, health and social care data are usually collected under separate systems, leading to difficulties linking data for the same individual. There are reports of unregulated long-term care facilities being “discovered” as a result of the COVID-19 pandemic (68). Lack of individual-level data about the characteristics of the residents of long-term care facilities has been identified as a barrier to response planning for the COVID-19 pandemic (69–70). This has meant, for example, that mathematical models that have informed planning for the pandemic have not accounted for residents in long-term care facilities separately from surrounding populations in their calculations (71). Data on the pandemic were initially only collected on people who had been tested and died in hospitals Very few countries publish data on the numbers of residents of long-term care facilities who have been infected or died from confirmed or suspected COVID-19. Because residents of long-term care facilities have been less likely to be tested or admitted to hospital than people living in private households, it is likely that countries that do not include deaths outside hospital are underestimating the death toll of COVID-19. An international initiative to track data on deaths of residents of long-term care facilities only found publicly available data for 21 countries in May 2020 (6). Without data on the impact of the infection on long-term care facilities and on people who rely on care and live in the community, there is a risk that the resources needed to prevent and mitigate the impact of COVID-19 in the long-term care sector (funds, workforce, tests, PPE and other equipment) may not be provided adequately and in a timely manner. There are few data available on associated health impacts of the pandemic Many people who rely on assistive care, particularly community-based care, will have had disruptions in their usual access to care, which can potentially put them at risk (for example due to malnutrition, undetected infections or other health complications). Data to identify people who may be at higher risk are needed to identify gaps and reconfigure services as needed. 11 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 Difficult to monitor the impact of COVID-19 across long-term care services Difficult to develop tailored response plans for long-term care to mitigate impact Difficult to include long-term care populations in modelling projections Difficult to monitor health impact of COVID-19 on long-term care users and long-term care workforce Fragmentation of information between long-term care facilities and health facilities 2.3.2 Key actions Whole sector Find effective ways to make use of existing long-term care management data where they are available (for example, MDS 3.0 in the United States, and the interRAI assessment systems of Canada and New Zealand) to model the impact of COVID-19 on health (including mental health) and the functioning of older people in long-term care. For countries without these systems, consider establishing such management data systems as actions for the longer term. Encourage research on the impact, and measures to mitigate the impact, of COVID-19 on long-term care to identify gaps and prepare for future pandemics. Long-term care facilities Establish a surveillance system that captures people who have COVID-19 and deaths that occur in long- term care facilities (probable and confirmed, disaggregated by age, gender, disability and existing health condition), and ensure that these are integrated with existing surveillance systems. Establish the necessary legal mechanisms to secure and transmit information relating to COVID-19 on a regular and frequent basis to and from long-term care facilities, health facilities, public health authorities and the public. Set up a mechanism to ensure that these data are analysed regularly and the findings used to refine government policy on the COVID-19 response. Community-based care Establish mechanisms to report the number of people who have COVID-19 among those receiving and providing long-term care in the community and in homes to public bodies responsible for commissioning services. 12 Preventing and managing COVID-19 across long-term care services Examples In South Africa, managers of long-term care facilities have to inform the Department of Social Development if a COVID-19 case has been confirmed (72). In the European Union, the European Centre for Disease Prevention and Control (an agency of the European Union) has included long-term care facilities in its strategy for COVID-19 surveillance at national and European Union/European Economic Area levels and is collecting data from Member States covering mitigation action, infection rates and mortality (73). In Argentina, in La Plata, an NGO co-developed a website for monitoring and sharing information about both registered and informal long-term care facilities. This platform was used to survey the COVID-19 preparation of the long-term care facilities and resulted in the local government ensuring that testing was provided to all employees of long-term care facilities (53). 13 Preventing and managing COVID-19 across long-term care services 2.4 SECURE STAFF AND RESOURCES, INCLUDING ADEQUATE HEALTH WORKFORCE AND HEALTH PRODUCTS, TO RESPOND TO THE COVID-19 PANDEMIC AND DELIVER QUALITY LONG- TERM CARE SERVICES 2.4.1 The challenge Pre-existing workforce shortages, poor pay and working conditions Before the COVID-19 pandemic, workforce shortages, poor pay and working conditions, and low proportions of professionally qualified staff were already a major concern in long-term care systems (2–3, 73). The workforce supporting people with long-term care needs is predominantly female (90%) (37), and in many countries migrant care workers make up a large proportion of the long-term care workforce (74). It is common for care workers to have zero-hour contracts and to work for multiple facilities or agencies (75). Long-term care staff shortages during pandemic In many countries, long-term care services, particularly long-term care facilities, have experienced acute staff shortages during the COVID-19 pandemic when their staff had to isolate due to suspected or confirmed infection with COVID-19 (49–50, 76–77). This has happened at a time when family and other unpaid caregivers, due to visiting and movement restrictions, have been less able to provide support (even in long-term care facilities, family and volunteer caregivers make an important care contribution). On some occasions countries had to rely on extreme measures such as calling on the military or other emergency services when long-term care facilities became overwhelmed and understaffed (49). In some countries, long-term care workers and caregivers were not initially considered key workers and lockdown measures and curfews meant they were not able to travel to work (or continue to provide care to people in other households) (78–79). Using public transport or living in crammed accommodation may have increased the risk for care staff to be exposed to the virus. Difficulties adapting to increased health care needs in long-term care facilities While some long-term care facilities employ nurses and other health care staff, this is not the case in all facilities, and there are reports of the difficulties faced by non-medically trained staff in long-term care facilities needing to provide care to people with COVID-19 infections or to those who need palliative care without health care staff support or oversight by qualified health professionals such as physicians and nurses. Administrative barriers to transferring staff and medical supplies from the health service to long-term care facilities led, in the case of a region of Spain, to all long-term care facilities being put under the control of the Department of Health during the pandemic (49). Long-term care providers and caregivers not able to obtain PPE Difficulties faced by long-term care providers and caregivers in accessing PPE and other resources (such as hand sanitizer and disinfectant) have emerged in many countries, due to global shortages and the prioritization of hospitals and other health care settings. Long-term care providers reported having to buy PPE at inflated prices as a result. 14 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 A vast workforce shortage for long-term care When compensating for workforce shortage, high staff turnover can impede continuity of care and consistency in important IPC measures Decreased integrity of the work and value of a workforce dominated by women and migrant workers Increased financial pressures to work while ill due to poor working conditions, such as lack of compensation for sick leave Occupational safety of long-term care workforce not taken into careful consideration Substantial lack of PPE for long-term care facilities, long-term care workforce (including caregivers) and recipients of care Lack of essential medical supplies and health workforce in long-term care facilities Lack oversight by qualified health professionals in providing essential services in long-term care facilitie 2.4.2 Key actions Whole sector Estimate surge capacity needed to support long-term care services in coordination with the focal point on long-term care. Set up links between health and social care procurement chains to ensure a continuous and non- conflicting supply during COVID-19. Recruit additional staff and develop rapid training programmes (for example, recruit retirees, students from health and long-term care training programmes, and volunteers) on IPC measures. Address contractual and related issues and put in place policies and measures that keep staff safe but allow them to work in a flexible manner and move from health care services into long-term care services as needed. Establish rosters and secure staff from health systems who can be repurposed if needed to support staff in long-term care settings. Implement measures to prevent policies from impeding delivery of important home, community and facility-delivered care through the long-term care workforce. Implement measures to monitor staff working in multiple locations, with increased risk of transmission, and consider facilitating transport and accommodation of staff to minimize the risk of infection during local outbreaks. Provide financial payment for care staff to incentivize them to stay in their jobs during the epidemic and compensate them for additional workload and stress. Long-term care facilities Ensure adequate supply of PPE in long-term care facilities to protect care staff from infection. Provide adequate training guidance and enforce routine training of staff and family caregivers on IPC measures in long-term care facilities so they can continue providing care in those facilities. Facilitate flexible arrangements whereby palliative care teams and other relevant health and care professionals work with staff in long-term care facilities to ensure access to palliative care as needed. 15 Preventing and managing COVID-19 across long-term care services Ensure adequate oversight by appropriately trained personnel to deliver essential services in long-term care facilities. Ensure provision of PPE to home care workers, particularly those providing care in close proximity. Provide adequate training guidance and enforce routine training of community-based care providers. Family and other voluntary caregivers Ensure provision of PPE to caregivers providing care in close proximity. Provide adequate guidance and offer training for family and other voluntary caregivers. Country examples In Austria, staffing and licensing regulations for care workers have been eased substantially during the COVID-19 pandemic. This enables people who have done national service (those who opted for civilian duties) to provide basic care. People in the national service have contributed to managing the logistics of the pandemic. Their employment as care workers can be enforced by the government. In addition, people undertaking training in relevant areas and interested people who are currently unemployed can also step in (76). In Ireland, Nursing Homes Ireland started a recruitment campaign for nursing homes (private and NGO operated) in March 2020. Furthermore, the Health Service Executive agreed to redeploy staff (on a voluntary basis) to private nursing homes (77). In India, some long-term care facilities support their in-house staff with incentives, such as free food. In addition, some long-term care facilities are working to promote the mental health of their staff through regular check-ins and counselling (78). If long-term care facilities in Israel experience a shortage of staff, the Ministry of Health will send a special team for 7–14 days to support the provision of care for the acute period (57). In the Netherlands, since 19 May 2020 PPE has been available free of charge for care workers providing care activities that require close proximity (less than 1.5 metres) to persons with long-term care needs (80). In Spain, care staff from community care centres have been supporting the provision of home care, for example through phone calls. In addition, the long-term care sector can hire non-qualified staff in instances of absenteeism of their usual staff (49). In Australia, residential care workers will receive a retention bonus for two quarters of up to 800 Australian dollars after tax. The government has employed health care delivery providers to form rapid response teams in the long-term care sector where needed in each state. Visa rules were relaxed to enable staff to work more hours (81). In parts of the United Kingdom, care workers have had their wages increased and have been offered a special one-off payment for staff working during the COVID-19 pandemic (82). 16 Preventing and managing COVID-19 across long-term care services 2.5 ENSURE THE CONTINUUM AND CONTINUITY OF ESSENTIAL SERVICES FOR PEOPLE RECEIVING LONG-TERM CARE, INCLUDING PROMOTION, PREVENTION, TREATMENT, REHABILITATION AND PALLIATION 2.5.1 The challenge Requirement for continuous, complex care with high levels of physical and emotional contact People with long-term care needs often require continuous, complex and personalized support structures. Assistive care for personal tasks in particular requires high levels of physical and emotional contact. People who are receiving this care, and who are dependent on this support, benefit enormously from continuity of care (1). In many countries, the majority of residents of long-term care facilities have dementia (83–85). Variability in health care provision in long-term care facilities Long-term care facilities are very diverse, and while some may be specialized in providing medical care, such as long-term care hospitals or some nursing facilities, others, typically residential homes or supported accommodation, may not have any health care trained staff members. Long-term care facilities in many countries have experienced difficulties providing health care support and resources for essential health services, in addition to responding to the new burden of COVID-19 (including in the areas of rehabilitative and palliative care). Potential for discriminatory triage practices in hospital admissions There have been reports that residents of long-term care facilities have not been able to access health care in hospitals (49–50), and have had limited access to primary care. It has also been reported that advance care directives have sometimes been put in place without adhering to the usual person- centred standards (86). Countries have responded by emphasizing the importance of equitable access to health and palliative care for older adults and people with existing conditions during the COVID-19 pandemic (36–37). IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities in many countries have experienced difficulties providing health care support and resources to continue essential health services and to provide assistive care services for the new challenge of COVID-19 Residents of long-term care facilities have sometimes been denied hospital care based on irrelevant or discriminatory criteria, such as age, under the presumption that they are too frail to survive 17 Preventing and managing COVID-19 across long-term care services 2.5.2 Key actions Whole sector Consider developing clear COVID-19 care pathways, inclusive of long-term care facilities and home- and community-based care, for transfers to primary, secondary and tertiary care for people with COVID-19 and non-COVID-19 symptoms (87–89). Consider appropriate tele-health and virtual technologies for consultations, taking account of the views of older people, and provide any support necessary to use this technology effectively. Ensure that all palliative care plans and advanced care directives are up to date and applied through a person-centred approach. Ensure that national and regional policies, programmes and guidelines are in place to support the provision of palliative care in long-term care facilities and long-term care services (including physical, psychological, social and spiritual support). Long-term care facilities Consider involving the residents of long-term care facilities in the development of protocols for referral and access to essential health services. Ensure there is no selection based on age or disease in such protocols, but that people’s needs and preferences determine care decisions. Ensure that all long-term care facilities are supported by a primary care service. Establish rapid response teams, preferably with geriatric and palliative care training, for long-term care facilities for older people, to reduce avoidable hospitalizations and ensure optimal person-centred communication and decision-making. Ensure that staff are trained in providing palliative care and know how to communicate about death, dying and end-of-life decisions (35). Country examples In the United States, the use of home-based tele-health has been expanded as remote patient monitoring can now be reimbursed. Since March 2020, Medicare beneficiaries have been able to receive behavioural or substance use disorder interventions. For people with severe symptoms of COVID-19, post-acute tele-health visits are now possible. This enables social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists to perform remote evaluations and therapy. This may also support people with long-term care needs living in the community (61). In Italy, special palliative care teams were able to reorganize themselves rapidly in order to respond to demand quickly and flexibly. For example, they created networks of hospice care services by shifting staff from hospice inpatient to home care services. The experiences also highlighted the important need for case conferences and similar team collaborations to be able to decide quickly where to prioritize resources (for example, by deciding who will get support after hospital discharge) (50, 90). In Austria, the National Association for Palliative Care has issued a position paper on palliative care during the COVID-19 pandemic and has provided guidance on ensuring access to palliative care for people who will not receive the intensive care that normally is provided. The association has also published guidelines for family caregivers and long-term care workers. Furthermore, multidisciplinary guidance provided by the government is available to support people with COVID-19 who are reaching the end of life. There are also clinical guidelines and resources on how to facilitate social support and on bereavement for family carers and care workers supporting a person who reaches the end of life during the COVID-19 pandemic (76). In Slovenia, medical teams are ready to be sent to residential long-term care facilities to support regular staff if they become exhausted or overwhelmed (91). 18 Preventing and managing COVID-19 across long-term care services 2.6 ENSURE THAT INFECTION PREVENTION AND CONTROL STANDARDS ARE IMPLEMENTED AND ADHERED TO IN ALL LONG-TERM CARE SETTINGS TO PREVENT AND SAFELY MANAGE COVID-19 CASES 2.6.1 The challenge Lack of mandatory implementation of IPC guidance for long-term care Guidance on IPC for long-term care providers has been developed relatively late in the pandemic in many countries, and many of the guidelines have been slow to incorporate evidence of asymptomatic transmission and atypical symptoms of COVID-19. In many countries, guidance has only been developed for long-term care facilities, with no guidance available for providers of community-based care and for family caregivers. Finally, there is a lack of mechanisms to ensure implementation of these guidelines and to monitor their implementation. Lack of IPC experience and training in long-term care and resultant implementation difficulties In many countries, long-term care providers have weak IPC systems and training in place, resulting in many staff being unfamiliar with IPC and the correct use of PPE. This is a particular challenge for long-term care facilities that make high use of temporary or agency staff. Even where guidance and training are available, implementing some of the measures can be challenging due to the need for personal assistive care to be provided in close proximity. Lack of availability of testing and PPE, shortages of staff, difficulties in implementing physical distancing (given the design of traditional long-term care facilities), and a lack of alternative isolation facilities have been reported in countries that have struggled to contain infections in long-term care facilities. Across countries, guidelines have identified the importance of isolating residents exhibiting COVID-19- related symptoms, as well as those who have been in contact with people who are suspected of having or confirmed to have COVID-19. While in some countries residents in long-term care facilities live in single rooms with their own wet rooms, this is not the case in others. The specific structure of buildings in which long-term care facilities are housed may also pose barriers to the establishment of effective quarantine zones. Managers of long-term care facilities need to be supported in assessing the capacity of facilities to enable effective isolation policies and to provide additional quarantine spaces should the care setting not lend itself to effective isolation strategies. Countries that had experienced severe acute respiratory syndrome and Middle East respiratory syndrome had recently strengthened their IPC systems in long-term care facilities and community-based settings and have tended to systematically transfer people who are suspected or confirmed to have COVID-19 to isolation facilities, which appears to have been successful in controlling outbreaks (63). However, evidence on the impact of these measures on the mental and physical well-being of residents is not yet available. In some countries, there are large numbers of unregistered and therefore unregulated long-term care facilities. It is essential to support these facilities to ensure that they can keep their residents safe (53). Similarly, community-based care services are less often subject to direct regulatory control than residential long-term care facilities, and there are even fewer well developed information and monitoring systems that would enable the gathering of timely information on how the pandemic is affecting, directly or indirectly, people who rely on community-based care. Home care providers typically visit people with care 19 Preventing and managing COVID-19 across long-term care services needs in their own home. This means that care workers need to travel between homes and often visit multiple people with care needs. There is evidence that families have stopped using home care support to reduce the risk of infection for the person with care needs; however, this may create other risks (77, 81). IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of mechanisms to ensure implementation of IPC guidelines and monitor and assess implementation Lack of training of long-term care workforce on IPC measures High staff turnover impedes continuity of care and consistency of IPC measures Physical distancing is difficult to achieve for long-term care services Care workers cannot adequately access information on limiting transmission in the context of COVID-19 2.6.2 Key actions Whole sector Establish a coordinating body to develop, adjust and update IPC guidance and protocols during the COVID-19 pandemic for long-term care, based on the best available evidence (87-88, 92-93). Ensure implementation of the IPC guidance across long-term care services (for all settings). Establish a mechanism to plan, prioritize support for, and monitor implementation of measures to protect staff and people receiving long-term care from infection or spread of COVID-19. Establish early recognition, surveillance thresholds and escalation strategies for outbreaks of COVID-19 across long-term care. Consider how to ensure that providers of long-term care who may be operating outside the system (unregulated or illegal providers) can be supported to ensure the safety of the people living in their facilities or using their services. Ensure that everyone involved in direct delivery of care (staff and family caregivers), in long-term care facilities or in home care services, has access to IPC training (including use of PPE, hand hygiene, cleaning and disinfection of environments and waste management). This should be carried out regardless of their role, and especially for those having direct contact with older people with underlying health conditions (93). Consider developing and circulating standard operating procedures that give direction on how and when to rapidly isolate people receiving long-term care services, using the most up-to-date COVID-19 guidance. Implement extended IPC precautions for people discharged from hospital, based ideally on an agreed protocol for testing to determine individual needs for isolation and PPE required. Translate any strategies for standard operating procedures into clear referral systems that are made available to all staff delivering long-term care services. Long-term care facilities Ensure implementation of IPC guidance in long-term care facilities with reference to the WHO IPC guidance for long-term care facilities in the context of COVID-19 (92). Implement administrative controls, including syndromic surveillance upon entrance to a facility, for all staff and visitors. 20 Preventing and managing COVID-19 across long-term care services Ensure that staff in long-term care facilities have working conditions and arrangements that minimize their movement between settings and people receiving long-term care services, and that sick pay enables them to stay at home if they are unwell. Ensure that long-term care facilities have access to the resources needed to implement IPC (such as PPE, hand sanitizers and disinfectant). Develop the necessary IPC protocols and guidance and ensure that they are made available for visitors and are clearly visible in easy-to-understand formats (94). Develop guidance and ensure implementation of IPC protocol for staff and ensure educational resources are provided alongside continuous training. Ensure that long-term care facilities have an IPC focal point to lead and coordinate IPC activities, ideally supported by an IPC team with delegated responsibilities and advised by a multidisciplinary committee. Community-based care and caregivers Increase training and decision-making support for the long-term care workforce in the community to effectively manage COVID-19, including family caregivers, keeping in mind constraints, especially gender- related constraints, that family caregivers may face (87–88). Country examples In Jamaica, a temporary employment programme was created for regular cleaning of public sector long- term care facilities, and spaces were set aside in those facilities for isolation of symptomatic residents. Also, a multisectoral exercise between multiple State and private sector agencies facilitated deep sanitization of public long-term care facilities (79). In Indonesia, prevention measures in long-term care facilities include knowledge-sharing on hygiene principles with care workers and residents, regular disinfection and ventilation, and abstaining from sharing personal medical equipment. Residential long-term care facilities have put in place a registration system and do not allow visitors with symptoms of COVID-19 to enter the premises (95). In one region of China, after the severe acute respiratory syndrome epidemic, the regional authorities published the first guidelines on prevention of communicable diseases in residential long-term care facilities for the elderly in 2004, and required all operators of long-term care facilities to designate an infection control officer to coordinate and implement infection control measures within the facility, according to the guidelines (65). In Germany, the Robert Koch Institute recommends that domiciliary care workers wear face masks when providing care and that they regularly monitor their health. Additional equipment should be made available if the person they care for shows COVID-19-related symptoms (96). In the Netherlands, some home care workers are organized into special “Corona teams”. These teams look after people with COVID-19, while other teams care for people without infection (80). 21 Preventing and managing COVID-19 across long-term care services 2.7 PRIORITIZE TESTING, CONTACT TRACING AND MONITORING OF THE SPREAD OF COVID-19 AMONG PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.7.1 The challenge Many countries have experienced shortages in testing capacity as hospital services were prioritized In many countries there have been shortages of testing capacity as initially the available capacity was used mostly in hospitals, leaving providers of long-term residential and community services with difficulties in detecting people who had COVID-19. This approach is increasingly understood to have been a major problem, given the high rates of pre-symptomatic or asymptomatic people who have COVID-19 and could be spreading infection. Effective contact tracing in long-term care settings requires coordination and collaboration between long-term care providers and the relevant health authorities Effective testing, tracing and monitoring of COVID-19 in long-term care require coordination and collaboration between long-term care providers and the relevant health authorities. However, due to challenges in governance, such coordination has been difficult in the initial phases of the response. A growing number of countries are now including contact tracing in guidance for the long-term care sector and are developing apps and other systems to support contact tracing. Lack of systematic monitoring of the health status of people receiving and providing care Regular monitoring enables staff to detect changes in people’s health status, including the development of atypical symptoms (13), and to respond faster if a person with care needs or staff develop symptoms of COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities have become a blind spot for priority testing, tracing and monitoring of COVID-19 High rates of asymptomatic people who have COVID-19 have made early recognition and subsequent appropriate steps difficult 2.7.2 Key actions Whole sector Ensure testing data are aggregated and shared with local and national public health agencies so that the pandemic is managed at both the population and individual levels. Ensure contact tracing and isolation based on national guidance, with reference to WHO guidance on contact tracing in the context of COVID-19 (36, 97). Trace any clusters of infections or deaths of people in long-term care facilities or amongst those receiving home care services. 22 Preventing and managing COVID-19 across long-term care services Do not rely on symptoms alone, particularly “typical” cough and fever symptoms, when screening for COVID-19, and ensure that staff are trained in identifying other atypical symptoms, especially in older persons (36). Ensure that the health of people receiving and providing long-term care is monitored so that the development of symptoms (including atypical symptoms) can be detected quickly. Long-term care facilities In areas with ongoing or suspected community transmission, rigorous testing of both residents (including new admissions) and staff and tracing of close contacts are essential to develop isolation policies. Community-based care Ensure that people providing and receiving care in the community as well as their household members have access to testing and contact tracing, and have support if they need to isolate (87–88). Include household members of people with care needs in symptom monitoring. Examples In Denmark, both symptomatic and asymptomatic residents and staff in long-term care facilities can access testing at regional hospitals (since 12 May 2020). Even before that date, residents and staff were tested if there was an outbreak in a residential long-term care facility. If one resident shows symptoms, all residents and staff are tested within 24 hours and retested after seven days. If a staff member tests positive, all residents in the same area are also tested (98). In the Netherlands, all family caregivers that experience symptoms of COVID-19 can get tested (since 18 May 2020). In addition, family carers have been able to access free PPE since 19 May 2020 if they support vulnerable people (aged 70 years and older, with chronic conditions) who experience symptoms of COVID-19 and where personal assistive care (with less than 1.5 metres distance) is required (80). In Malaysia, all registered and unregistered long-term care facilities have undergone testing for COVID-19 (99). In the European Union, the European Centre for Disease Prevention and Control guidance recommends testing strategies that distinguish between “affected local areas” (random testing of residents and staff) and “unaffected areas”. Affected areas are those with actual or presumed continuing community transmission (73). 23 Preventing and managing COVID-19 across long-term care services 2.8 PROVIDE SUPPORT FOR FAMILY AND VOLUNTARY CAREGIVERS 2.8.1 The challenge Family caregivers provide an important share of care, but support such as respite care, training or care leave schemes remain limited and without compensation An important share of long-term care across countries is provided by family caregivers who provide care directly, and also help coordinate and complement formal services. In countries without established formal long-term care services, family caregivers provide almost all long-term care. Caregivers usually do not have access to any training for their role. Some countries recognize the impact of caregiving and offer support such as paid care leave, flexible work arrangements, respite care, training and psychological interventions, as well as cash benefits to mitigate negative impacts (29). However, access to these support structures remains limited in most countries and caregivers traditionally provide support without compensation, training or support (1). Even though caregivers’ important contribution is increasingly recognized, available support structures and financial support were already limited before the COVID-19 pandemic (100). The provision of intense levels of care has generally been associated with lower income and ultimately higher poverty rates, as well as poor mental health The largest share of this care is provided by women (61%), though the share of male caregivers increases with age (74). There are also many young (including children) and older caregivers who support family members with long-term care needs. The provision of intense levels of care has generally been associated with reduced labour force attachment (for those of working age), lower income and ultimately higher poverty rates (101). In addition, reduced income and lack of pension contributions exacerbate the risk of vulnerability and poverty in old age. Caregivers also have a higher prevalence of mental health problems (101). The COVID-19 pandemic has meant that some caregivers have had to adjust or give up their jobs to provide care or to avoid exposing the person they support to the risk of a COVID-19 infection. Caregivers working in the informal economy may also have experienced reduced working opportunities due to restrictions, posing a risk to their income. Caregivers also require support for the financial impact of the pandemic (102). The discontinuation of residential care options has left many family caregivers with increased responsibilities and without their usual support structures The COVID-19 pandemic has led to the closure of many day and respite care options, including community-based or short-term care, leaving many caregivers with additional responsibilities and without their established support structures. It is important to understand the issues caregivers face during this pandemic and how they can best be supported (102). Caregivers need to be able to get to the person with care needs, have access to information, PPE and testing, and be supported in developing contingency plans In many countries, government and NGOs have responded to this need by providing guidance and resource documents on hygiene measures to prevent infection and how to respond if the person with care needs or the caregivers themselves develop symptoms. Issues that have emerged during the pandemic include the need for caregivers to have permission to travel due to their care responsibility (78–79), supporting caregivers with access to testing and PPE (80), and developing contingency plans in case they can no longer continue to provide care (77). 24 Preventing and managing COVID-19 across long-term care services Changes in care needs and violence or abuse towards the caregiver Many caregivers are coping with changes in the needs of the person for whom they care (which may be due to infection or to the impact of the restrictive measures). Also, disruption to the normal routine may cause anxiety and stress in people with care needs, increasing pressure on caregivers (29). The COVID-19 pandemic has brought domestic violence and abuse to the surface (38). Family caregivers may also experience violence and abuse in their care relationship and require support (103). IMPLICATIONS IN THE CONTEXT OF COVID-19 Many caregivers have additional responsibilities without established support structures (such as day and respite care options) Social and physical distancing measures across countries are having negative health impacts on caregivers Even though caregivers’ important contribution is increasingly recognized, available financial support remains limited Caregivers experience difficulties in getting the necessary supplies, as they cannot easily leave the person they support alone Access to PPE and testing has largely been absent for family and voluntary caregivers Prolonged isolation, care responsibility without breaks, concerns about the person with care needs, worries about contingency care in case the caregiver becomes incapacitated, as well as violence or abuse towards the caregiver, have implications for caregivers’ mental health 2.8.2 Key actions Whole sector Record the main caregiver in health and long-term care records so that they become recognized as an important source of information and support. Long-term care facilities Enable family caregivers who provide psychological and practical support for people living in long-term care facilities to continue such roles through supportive measures that ensure the safety of the caregivers. Caregivers Provide information, training, support and, if possible, respite care at national level to caregivers, particularly those caring for older people living with dementia, including information on how to manage increased caregiving responsibilities and stress. Consider establishing a telephone helpline or online portal to offer advice, information and support (104). Consider rolling out an assessment to monitor family caregiver needs. Develop clear guidance for family caregivers on when and how to self-isolate. Increase vigilance and monitoring of domestic violence and support for family caregivers. Ensure access to PPE (without family caregivers bearing the inflated cost) and to equipment and medications. Explore new ways of providing support services to caregivers through technology, and support caregivers in accessing relevant technologies. Introduce or expand financial and psychosocial support for family caregivers. Provide bereavement support and ensure careful communication on decision-making with family. 25 Preventing and managing COVID-19 across long-term care services Country examples In Brazil, NGOs (such as the Brazilian Society of Geriatrics and Gerontology and the Brazilian Alzheimer’s Association) have published technical and educational caregiver guidance documents. A booklet has been prepared by FioCruz and other health-related organizations to educate caregivers of older people on preventive and protective measures for COVID-19. There is also a website by the Ministry of Women, Family and Human Rights dedicated to the provision of information for people with rare conditions and disabilities and their caregivers. A collaboration between the Ministry of Health and the Pan American Health Organization has developed a video campaign to support the mental health of people in Brazil who struggle with feelings of isolation, loneliness and distress. NGOs, such as the Alzheimer’s Association, provide helplines and online forums. Other groups have organized psychosocial activities (105). In India, guidelines issued by the Indian Ministry of Social Justice and Empowerment on 27 March 2020 recognized the importance of caregivers being able to get to the people they support. It was recommended that caregivers should be issued with passes that enable them to travel during the period of movement restrictions. Also, NGOs (such as the Alzheimer’s and Related Disorders Society of India, Nightingales Medical Trust and Silver Innings) and specialist services (National Institute of Mental Health and Neuro-Sciences, Cognitive Disorders Clinic) offer information and resources for caregivers of people living with dementia. The Nightingales Medical Trust provides the DemKonnect app, which offers expert advice to caregivers. The Ministry of Health and Family Welfare offers a psychosocial and behavioural helpline. In addition, it has provided videos (including on meditation and yoga) for stress management and mental health tips for different age groups on its website (78). In Ireland, the Dementia Services Information and Development Centre has provided resources for caregivers, including suggested activities for people living with dementia to mitigate the impact of social isolation. The Alzheimer Society of Ireland also offers relevant resources for support and information. Caregivers in receipt of the means-tested carer’s allowance continue to receive payments during the COVID-19 pandemic. In addition, working caregivers in receipt of the carer’s allowance who have lost their jobs due to the pandemic can also access the new pandemic unemployment payment of 350 euros. Similarly, Family Carers Ireland has developed guidance for the development of an emergency plan for caregivers (77). In Germany, the period for receiving long-term care allowance (Pflegeunterstützungsgeld) to respond to an emergency care situation in the family or to organize care arrangements has been doubled in response to the COVID-19 pandemic from 10 to 20 days (until 30 September 2020). The right to stay away from work to respond to an acute care situation has also been extended to 20 days. People who usually receive in-kind services that have become unavailable during the COVID-19 pandemic (such as day care) can be reimbursed to finance replacement care (96). 26 Preventing and managing COVID-19 across long-term care services 2.9 PRIORITIZE THE PSYCHOLOGICAL WELL-BEING OF PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.9.1 The challenge Many people with care needs experience a change to their routines and prolonged periods of isolation Many people, particularly older adults, with long-term care needs have been isolated in homes or facilities for many weeks, leading to reduced social contact and disrupted and changed routines. Some people with long-term care needs, such as people living with dementia, experience changes in their physical and cognitive status. Rapid changes to their routine may also increase their vulnerability to pre-existing conditions (84, 104). Specifically, in long-term care facilities, residents have struggled with not being able to socialize with fellow residents or to receive visits from their family and friends. Families are also extremely distressed that they are not able to visit and oversee the resident’s care. Long-term care facilities have recognized the importance of supporting residents with social contacts and have introduced innovative solutions, such as technical tools that enable virtual contact with their families and friends. Sharp increase in the risk of violence against older people Violence against older people, who are already bearing the brunt of this pandemic, has risen sharply since the beginning of the COVID-19 pandemic and imposition of restrictive stay-at-home measures. Violence is occurring in homes, in institutions such as long-term care facilities, and online, with a surge in scams directed at older people (106). Long-term care workers experience substantial pressure on their mental health during the COVID-19 pandemic Long-term care workers (compensated through pay) have experienced sustained pressure to provide care to vulnerable groups during the COVID-19 pandemic, and have worked hard to prevent the spread of COVID-19 to the people they assist. Many will have experienced traumatic situations and multiple bereavements. This leads to substantial pressure on their mental health. In the Netherlands, a survey by the Dutch Nurses’ Association (V&VN) found that 69% of community carers have felt greater pressure on their mental health during the COVID-19 pandemic. Among the 3325 respondents, 28% reported that there was no mental health support provided by their employer (80). Specific interventions to support the well-being of care workers are largely lacking. Some countries have recognized the mental health toll that the COVID-19 situation in long-term care facilities has taken on their staff and have put in place interventions to support the mental health of staff. In the United Kingdom, efforts have been made through support services to enhance the well- being of care workers. Migrant carers, particularly those who were commuting to provide care in other countries, may have found themselves either unable to return home after their shifts or unable to go to work (and therefore be paid) as countries closed their borders, leading to considerable hardship (76, 107). 27 Preventing and managing COVID-19 across long-term care services Family and voluntary caregivers experience great care responsibility and isolation, while their usual support services have largely been suspended Many family caregivers have been isolating with the person they care for to protect them from a COVID-19 infection. This has left them feeling disconnected from their social networks. In addition, their usual support structures (such as day care, home care, other family caregivers and carer support groups) have been reduced in frequency or suspended, leaving family caregivers without important social contacts and sources of practical support. In some countries, helplines, virtual counselling and carer support groups have been established to support caregivers’ psychosocial well-being during the COVID-19 pandemic. IMPLICATIONS IN THE CONTEXT OF COVID-19 There has been a significant impact on the mental health of the staff of long-term care facilities, family and voluntary caregivers, and people with assistive care needs Many residents of long-term care facilities have struggled with not being able to socialize with fellow residents, to participate in regular social activities, or to receive visits from their family and friends Specific interventions to support the well-being of people providing and receiving care are largely lacking 2.9.2 Key actions Whole sector Establish an intersectoral working group to monitor long-term care staff stress and burn-out, and assess and implement strategies to provide mental health and psychosocial support to staff delivering long- term care. Establish a dedicated helpline for mental health and psychological support for anyone who requests it. Consider providing guidance on training care staff and volunteers to improve communication skills on sensitive issues such as end-of-life decisions, death, dying and bereavement. Encourage long-term care providers on the use of screening tools, review staffing procedures (such as flexible schedules and work breaks) to better manage the burden of care, and seek to reduce the use of physical restraints. Ensure mental and emotional support is available from mental health professionals and family caregiver networks, using digital media when required to support recipients and providers of care. Support the monitoring of violence towards older people. Long-term care facilities Establish clear visiting policies that provide balance between IPC measures and the need for people to maintain their psychological well-being (enable residents to have visitors while minimizing the risk of COVID-19 entering long-term care facilities). Facilitate residents’ contact with family and friends by phone, the Internet or written messages if access is restricted. Increase recruitment of volunteers to help with providing social interaction for isolated residents. 28 Preventing and managing COVID-19 across long-term care services Community-based care Ensure access to and scale-up of resources for migrant live-in care workers. Encourage and enhance psychosocial support structures for family caregivers. Consider introducing mental health first aid training for volunteers and community members. Country examples In Chile, the National Service for Older Persons and the Society of Geriatrics and Gerontology have issued videos and graphics to support older people and family caregivers to cope with the COVID-19 situation. This material includes information on the use of PPE, distancing and mental health recommendations (108). It also offers templates to support the organization of community support for people needing help with the basic activities of daily living (109). In Mexico, the Ministry of Health implemented a mental health support campaign, which includes a rapid telephone assessment, to provide support strategies and to make referrals for specific support. Part of the strategy includes a campaign targeted at health care workers (110). In Kenya, some NGOs have moved to virtual peer support. However, poor connectivity in some areas, the cost of purchasing Internet bundles, and online fatigue pose challenges to efforts to support family carers. The Ministry of Labour and Social Protection published guidance for long-term care facilities, which explicitly states that staff should ensure that residents can maintain regular communication (through mobile calls or online chats) with their families and social networks, and should promote the well-being of residents by establishing regular routines and reducing interruptions to those (111). In Malaysia, staff of day care centres continue to look after the people they support through video calls, as well as sharing activities and exercise videos (99). In the United Kingdom, the COVID Trauma Response Working Group has developed guidance for managers and service planners concerned with looking after staff of long-term care facilities who may have experienced trauma (112). 29 Preventing and managing COVID-19 across long-term care services 2.10 ENSURE A SMOOTH TRANSITION TO THE RECOVERY PHASE 2.10.1 The challenge Loss in public confidence in long-term care facilities The COVID-19 pandemic has disproportionately affected people who live in long-term care facilities, and the share of deaths in those facilities appears to increase with the number of people affected in the community. This suggests that as long as there is community transmission of COVID-19 locally, long- term care facilities are at high risk of infection and large numbers of deaths. There are concerns in many countries about the loss in public confidence in long-term care facilities, and the possible negative impacts that might result if people who would benefit from living in a long- term care facility fail to do so because of fear. This may have negative consequences for these persons, for their families, and also for the financial viability of providers of long-term care facilities. Movement restrictions and other shielding measures in long-term care facilities One of the first measures adopted in almost all countries has been restricting visitors to long-term care facilities. While this measure is relatively easy to implement, it is increasingly recognized that it has an enormous impact on the well-being of both the residents of long-term care facilities and their families, and that, particularly where the resident has dementia, a lack of understanding of why the visits have stopped may generate additional distress. Concerns have also been expressed that many family members provide care in their regular (sometimes daily) visits, and that not allowing them to visit at a time when the staff of long-term care facilities may already be overburdened due to increased complexity of care and lower staffing ratios may compound staffing problems. Difficulties in monitoring quality of services in long-term care facilities Another concern is that family member visits have stopped at a time when many countries have suspended inspections. Families may be concerned about the quality of care the residents are receiving, and not being allowed to visit may exacerbate their fears. Ensuring safe visiting is increasingly recognized as a key step in rebuilding trust in long-term care facilities. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of exit strategy on restrictive measures applied to long-term care facilities Lack of monitoring quality of care within long-term care facilities when movement restrictions are implemented for those facilities 30 Preventing and managing COVID-19 across long-term care services 2.10.2 Key actions Long-term care facilities Make available surveillance mechanisms to monitor the quality of care within long-term care facilities during implementation of public health and social measures. Make available guidance on thresholds as to when and how to phase in or out isolation of residents and loosen restrictions on visitors. Establish clear criteria on when and how people living in long-term care facilities can move to and from hospitals to protect both staff and other residents. Ensure that the needs of long-term care residents are considered in providing acute, primary and community health services, and that pre-COVID-19 levels of support from primary care and community nursing are reinstated as early as possible. Community-based care Ensure that protocols are being developed so that people receiving community care (for example, day care) can access these services again. Country examples In Malta, day care services started again on a rotational basis on 1 June 2020. People with care needs receiving no services were given priority. Strict hygiene procedures and distancing measures were put in place. For example, staff and people with care needs keep shoes at the day care facility and change when they leave. People with care needs have to wear masks and visors while attending the centre. Staff also wear visors throughout the working day. In addition, people receiving and providing care have their temperature monitored (58). In Denmark, people could continue to visit residents receiving end-of-life care while adhering to hygiene protocols. Since 24 April 2020, residents in long-term care facilities can receive visitors in the outdoor areas (98). In Germany, restrictions around visitors started to be relaxed again in May 2020. While specific rules on the number of people visiting and the frequency and lengths of their visits vary between federal states, all states require that long-term care facilities put clear infection prevention measures in place. Visitors also have to register so that they can be identified for contact tracing if this becomes necessary (96). 31 Preventing and managing COVID-19 across long-term care services 2.11 INITIATE STEPS FOR TRANSFORMATION OF HEALTH AND LONG-TERM CARE SYSTEMS TO APPROPRIATELY INTEGRATE AND ENSURE CONTINUOUS, EFFECTIVE GOVERNANCE OF LONG-TERM CARE SERVICES The COVID-19 pandemic has highlighted fragmentation between long-term care services within health care systems. This fragmentation, along with inherent weaknesses in the current overarching governance structure for long-term care, has led to devastating consequences for long-term care facilities during the COVID-19 pandemic. It is with urgency that we need to transform health and long-term care systems so that long-term care services are readily integrated and provided alongside the traditional continuum of care: promotion, prevention, treatment, rehabilitation and palliation. It must be emphasized that assistive care, defined in this document as assistance provided to help a person perform a particular task to maintain functional ability and preserve independence, is considered an essential service that helps to promote ageing in place and ensure that a person can continue to do what they have reason to value even after significant declines in physical and mental capacity. The WHO Global Strategy and Action Plan on Ageing and Health, adopted in 2016, states that “Every country should have a sustainable and equitable system of long-term care” (44). The Decade of Healthy Ageing (2020–2030) also emphasizes access to long-term care for older people who need it (113). Although long-term care is not just for older people and includes a diverse range of users, the fundamentals are the same: providing services to those that are in need of long-term care in order to ensure a life consistent with their basic rights, fundamental freedoms and human dignity. The following actions reflect the lessons we are learning from the COVID-19 pandemic to realize sustainable and equitable long-term care for all. Key actions Ensure legislation and establish national strategy and frameworks on long-term care. Strengthen relationships between different levels of government involved in long-term care and health care and develop concrete vertical and intersectoral coordination mechanisms. Integrate regular national data collection of health and long-term care systems to enable systemwide evaluation and monitoring. Ensure sustainable and equitable financing mechanisms for long-term care that protect people from catastrophic costs of care. Ensure integrated person-centred care pathways spanning the health and long-term care continuum to enable people with long-term care needs to receive comprehensive care. Ensure continuous training and improved working conditions for the long-term care workforce. Introduce and expand financial and in-kind support for family and voluntary caregivers. Identify mechanisms to ensure quality services in the unregulated long-term care sector and strengthen accreditation. Ensure health sector oversight of long-term care facilities to prepare for future pandemics. Promote research building on lessons learned from the COVID-19 pandemic to address weaknesses in the health and long-term care system. 32 Preventing and managing COVID-19 across long-term care services References 1. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ handle/10665/186463). 2. Care work and care jobs for the future of decent work. Geneva: International Labour Organization; 2018 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/documents/publication/ wcms_633135.pdf, accessed 21 June 2020). 3. Who cares? Attracting and retaining care workers for the elderly. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd.org/publications/who-cares-attracting-and- retaining-elderly-care-workers-92c0ef68-en.htm, accessed 23 June 2020). 4. Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region: strengthening the health systems response to COVID-19. Technical Working Guidance No. 6. WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health-topics/Health-systems/ health-services-delivery/publications/2020/strengthening-the-health-systems-response-to-covid-19- technical-guidance-6,-21-may-2020, accessed 21 June 2020). 5. Salcher-Konrad M, Jhass A, Naci H, Tan M, El-Tawil Y, Comas-Herrera A. COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence. medRxiv. 2020. doi:10.1101/2020.06.09.20125237. 6. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N, Fernández J-L. Mortality associated with COVID-19 outbreaks in LTCFs: early international evidence. International Long-Term Care Policy Network; 2020 (https:// ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in-care-homes-early-international- evidence/, accessed 21 June 2020). 7. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 8. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 9. American Geriatrics Society. American Geriatrics Society (AGS) policy brief: CCOVID-19 and assisted living facilities. Journal of the American Geriatrics Society. May 2020:jgs.16510. doi:10.1111/jgs.16510. 10. American Geriatrics Society. American Geriatrics Society policy brief: COVID-19 and nursing homes. Journal of the American Geriatrics Society. 2020;68(5):908–11. doi:10.1111/jgs.16477. 11. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. New England Journal of Medicine. 2020;382:2081– 90. doi:10.1056/nejmoa2008457. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. UN SP LA SH / AR NE L HA SA NO VI C 33 Preventing and managing COVID-19 across long-term care services 13. Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A et al. SARS-CoV-2 infection: clinical features and outcome of COVID-19 in United Kingdom nursing homes. Journal of Infection. 2020;5:38. doi:10.1016/j. jinf.2020.05.073. 14. Goldberg SA, Pu CT, Thompson RW, Mark E, Sequist TD, Grabowski DC. Asymptomatic spread of COVID-19 in 97 patients at a skilled nursing facility. Journal of the American Medical Directors Association. 2020. doi:10.1016/j.jamda.2020.05.040. 15. Guery R, Cécile D, Noëlle B, Nael V, Castain L, Raffi F et al. Limited effectiveness of systematic screening by nasopharyngeal RT-PCR of medicalized nursing home staff after a first case of COVID-19 in a resident. Médecine et Maladies Infectieuses. May 2020. doi:10.1016/j.medmal.2020.04.020. 16. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A et al. Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults: Seattle, Washington, 2020. Morbidity and Mortality Weekly Report. 2020;69(14):416–8. doi:10.15585/mmwr. mm6914e2. 17. Grabenhorst U, Stiels-Prechtel R, Niemann M, Weckbecker K. COVID-19 in the nursing home: a case report. MMW-Fortschritte der Medizin. 2020;162(9):60–2. doi:10.1007/s15006–020–0481–0. 18. Dora AV, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans: Los Angeles, California, 2020. Morbidity and Mortality Weekly Report. 2020;69(21):651–5. doi:10.15585/mmwr.mm6921e1. 19. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. 2020;382(21):2005– 11. doi:10.1056/NEJMoa2005412. 20. Coronavirus (COVID-19) related deaths by occupation, England and Wales. Office for National Statistics; 2020 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/ bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistereduptoandinc luding20april2020#:~:text=A%20total%20of%20131%20deaths,100%2C000%20females%20(86%20 deaths), accessed 21 June 2020). 21. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 22. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherapy. May 2020. 23. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 24. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 25. COVID-19. Sciensano (https://epistat.wiv-isp.be/covid, accessed 21 June 2020). 26. Fisman D, Lapointe-Shaw L, Bogoch I, McCready J, Tuite A. Failing our most vulnerable: COVID-19 and long- term care facilities in Ontario. medRxiv. doi:10.1101/2020.04.14.20065557. 27. Yanover C, Mizrahi B, Kalkstein N, Marcus K. What factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization. medRxiv. 2020. doi:10.1101/ 2020.05.07.20091652. 28. Dawson WD, Ashcroft E, Lorenz-Dant K, Comas-Herrera A. Impact of the COVID-19 outbreak on community- based care services: a review of initial international policy responses. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Community-Based-Care-Report-19- May.pdf, accessed 21 June 2020). 29. Lorenz-Dant K. International examples of measures to support unpaid carers during the COVID-19 pandemic. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ 34 Preventing and managing COVID-19 across long-term care services International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-20.05.20-complete-2. pdf, accessed 21 June 2020). 30. COVID-19 supercharges existing inequalities faced by Glasgow’s 150,000 disabled people. Glasgow Disability Alliance; 2020 (http://gda.scot/our-community/news/2020/4/28/covid-19-supercharges-existing- inequalities-faced-by-glasgows-150–000-disabled-people, accessed 21 June 2020). 31. Noncommunicable diseases and COVID-19. Geneva: World Health Organization (https://www.who.int/ teams/ncds/covid-19, accessed 21 June 2020). 32. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–332240, accessed 21 June 2020). 33. Coronavirus: Spanish army finds care home residents “dead and abandoned”. BBC News, 24 March 2020 (https://www.bbc.co.uk/news/world-europe-52014023, accessed 21 June 2020). 34. 31 Senioren in Kanada tot: Pfleger kamen aus Angst vor Corona nicht [31 seniors dead in Canada: carers did not come for fear of Corona]. MSN, 18 April 2020 (https://www.msn.com/de-at/news/other/31-senioren- in-kanada-tot-pfleger-kamen-aus-angst-vor-corona-nicht/ar-BB12QiDh#image=1, accessed 21 June 2020). 35. Bauer A, Dixon J. The challenges of providing end-of-life support in LTCFs during the COVID-19 pandemic, and opportunities for the future: an international perspective. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Challenges-of-providing-end-of-life-support-in- care-homes-during-the-COVID-19-pandemic-1.pdf, accessed 21 June 2020). 36. Clinical management of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https:// www.who.int/publications-detail/clinical-management-of-covid-19, accessed 21 June 2020). 37. Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions. In: Gender equality. Paris: Organisation for Economic Co-operation and Development; 2019 (https://www.oecd.org/gender/data/womenare-well-represented-in-health-and-long-term-care- professions-but-often-in-jobs-with-poor-workingconditions.ht, accessed 21 June 2020). 38. COVID-19 and violence against women: what the health sector/system can do. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/331699. 39. Shippee T, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao M et al. COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging and Social Policy. June 2020. doi:10.1080/08959420.2020.1772004. 40. Long-term care for older people: a new global gender priority. New York; UN Women; 2017. 41. Policy brief: the impact of COVID-19 on older persons. New York: United Nations; 2020. 42. Scheil-Adlung X. Global estimates of deficits in long-term care protection for older persons. Extension of Social Security Series, No. 50. Geneva: International Labour Organization; 2015. 43. Help wanted? Providing and paying for long-term care. Paris: Organisation for Economic Co-operation and Development; 2011. 44. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. Report by the Secretariat. Sixty-ninth World Health Assembly, April 2016. Geneva: World Health Organization; 2016 (https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17-en.pdf?ua=1, accessed 21 June 2020). 45. Accelerating global actions for a world without poverty: United Nations System-wide Plan of Action for the Third United Nations Decade for the Eradication of Poverty (2018–2027). New York: United Nations; 2018 (https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/03/SWAP-Poverty- Booklet-Digital-Feb27.pdf, accessed 21 June 2020). 46. Barr N. Long-term care: a suitable case for social insurance. Social Policy and Administration. 2010;44(4):359– 74. doi:10.1111/j.1467–9515.2010.00718.x. 47. Protective equipment being diverted from LTCFs to hospitals, say bosses. The Guardian, 30 March 2020 (https://www.theguardian.com/world/2020/mar/30/protective-equipment-being-diverted-from-care- homes-to-hospitals-say-bosses, accessed 21 June 2020). 35 Preventing and managing COVID-19 across long-term care services 48. Spasova S, Baeten R, Coster S, Ghailani D, Pena-Casas R, Vanhercke B. Challenges in long-term care in Europe: a study of national policies. Brussels: European Commission; 2018. 49. Zalakain J, Davey V, Suárez-González A. The COVID-19 on users of long-term care services in Spain. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTCcovid-Spain-country-report-28-May-1.pdf, accessed 21 June 2020). 50. Berloto S, Notarnicola E, Perobelli E, Rotolo A. Italy and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID19- situation-in-Italy-30-April-2020.pdf, accessed 21 June 2020). 51. King D, Zigante V. Quality assurance practices in long-term care in Europe: emerging evidence on care market management. Brussels: Publications Office of the European Union; 2020. 52. Lloyd-Sherlock P, Neto J, Comas-Herrera A, Redondo N. Re: Covid-19: why we need a national health and social care service. BMJ. 2020;369. doi:10.1136/bmj.m1465. 53. Lloyd-Sherlock P, Bastos J, Geffen L, Giacomin K, Redondo N, Sasat S et al. An emergency strategy for managing COVID-19 in LTCFs in LMICs: the CIAT Framework. 2020 (https://www.corona-older.com/post/ an-emergency-strategy-for-managing-covid-19-in-care-homes-in-lmics-the-ciat-framework-version-1, accessed 21 June 2020). 54. Country assessment framework for the integrated delivery of long-term care. Copenhagen: WHO Regional Office for Europe; 2019. 55. COVID-19: Singapore to house nursing home staff in hotels to protect the elderly. Channel News Asia, 8 May 2020 (https://www.facebook.com/ChannelNewsAsia/videos/1098221953890384/, accessed 21 June 2020). 56. Covid-19 testing completed for nursing home residents and staff; no new cases found apart from 5 earlier ones. The Straits Times, 31 May 2020 (https://www.straitstimes.com/singapore/health/covid-19-testing- completed-for-all-nursing-home-residents-and-staff, accessed 21 June 2020). 57. Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G, Brammli-Greenberg S. The impact of COVID-19 on people using and providing long-term care in Israel. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4- May.pdf, accessed 21 May 2020). 58. Fenech MA, Vella M, Calleja N. The COVID-19 long-term care situation in Malta and Gozo. International Long-Term Care Policy Network; 2020. 59. Cès S, Coster S. Mapping long-term care quality assurance practices in the EU: summary report. Brussels: European Commission; 2019. 60. Hashiguchi T, Llena-Nozal A. The effectiveness of social protection for long-term care in old age: is social protection reducing the risk of poverty associated with care needs? OECD Health Working Papers. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd-ilibrary.org/social- issues-migration-health/the-effectiveness-of-social-protection-for-long-term-care-in-old-age_2592f06e-en, accessed 21 June 2020). 61. Van Houtven CH, Boucher NA, Dawson WD. The impact of COVID-19 outbreak on long term care in the United States. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf, accessed 21 June 2020). 62. HHS Provider Relief Fund. Centers for Disease Control and Prevention; 2020 (https://data.cdc.gov/ Administrative/HHS-Provider-Relief-Fund/kh8y-3es6, accessed 21 June 2020). 63. Kim H. The impact of COVID-19 on long-term care in South Korea and measures to address it. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term- Care-COVID19-situation-in-South-Korea-7-May-2020.pdf, accessed 21 June 2020). 64. Lum T, Shi C, Wong G, Wong K. COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging and Social Policy. 2020. doi:10.1080/08959420.2020.1773192. 36 Preventing and managing COVID-19 across long-term care services 65. Wong K, Lum T, Wong G. The COVID-19 long-term care situation in Hong Kong: impact and measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/ Hong-Kong-COVID-19-Long-term-Care-situation-27-April-2020–1.pdf, accessed 21 June 2020). 66. Shi C, Hu B, Feng M, Wong G. Report from mainland China: policies to support long-term care during the COVID-19 outbreak. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/Report-from-Mainland-China-18-April-final.pdf, accessed 21 June 2020). 67. Statistics Commission endorses new Titchfield City Group on Ageing. New York: United Nations Department of Economic and Social Affairs; 16 March 2018 (https://www.un.org/development/desa/ageing/ news/2018/03/title-statistics-commission-endorses-new-titchfield-city-group-on-ageing/, accessed 21 June 2020). 68. Descubren una residencia ilegal en La Laguna por las pruebas del Covid-19 [They discover an illegal residence in La Laguna by the tests of Covid-19]. La Provincia, 4 April 2020 (https://www.laprovincia.es/ sociedad/2020/04/04/descubren-residencia-ilegal-laguna-pruebas/1271776.html, accessed 21 June 2020). 69. Burton A, Goodman C, Quinn T. The invisibility of the UK care home population: UK care homes and a minimum dataset. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/ the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/, accessed 21 June 2020). 70. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 71. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.9540. 72. Jacobs R, Ashwell A, Docrat S, Schneider M. The impact of COVID-19 on long-term care in South Africa. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/ COVID-19-Long-Term-Care-Situation-in-South-Africa.docx, accessed 21 June 2020). 73. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. European Centre for Disease Prevention and Control; 2020 (https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term- care-facilities-EU-EEA, accessed 21 June 2020). 74. Rodrigues R, Huber M, Lamura G. Facts and figures on healthy ageing and long-term care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research; 2012. 75. Van Houtven CH, DePasquale N, Coe NB. Essential long-term care workers commonly hold second jobs and double- or triple-duty caregiving roles. Journal of the American Geriatrics Society. 2020. doi:10.1111/ jgs.16509. 76. Schmidt AE, Leichsenring K, Staflinger H, Litwin C, Bauer A. The impact of COVID-19 on users and providers of long-term care services in Austria. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/ wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Austria-15-May.pdf, accessed 22 June 2020). 77. Pierce M, Keogh F, O’Shea E. The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf, accessed 22 June 2020). 78. Rajagopalan J, Huzruk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTC-COVID-situation-in-India-30th-May.pdf, accessed 22 June 2020). 79. Amour R, Robinson JN, Govia I. The COVID-19 long-term care situation in Jamaica. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term- Care-situation-in-Jamaica-25-May-2020–1.pdf, accessed 22 June 2020). 37 Preventing and managing COVID-19 across long-term care services 80. Kruse F, Abma I, Jeurissen P. The impact of COVID-19 on long-term care in the Netherlands. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long- Term-Care-situation-in-the-Netherlands-25-May-2020–1.pdf, accessed 22 June 2020). 81. Low L-F. The long-term care COVID-19 situation in Australia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Australia-LTC-COVID19-situation-24-April-2020. pdf, accessed 22 June 2020). 82. Extra payment for unpaid carers. Scottish Government, 6 May 2020 (https://www.gov.scot/news/extra- payment-for-unpaid-carers/, accessed 22 June 2020). 83. Global action plan on the public health response to dementia 2017–2025. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259615). 84. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo J et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190–1. 85. Suarez-Gonzalez A, Livingston G, Comas-Herrera. Report: the impact of the COVID-19 pandemic on people living with dementia in UK. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/2020/05/03/report-the-impact-of-the-covid-19-pandemic-on-people-living-with-dementia-in-uk/, accessed 22 June 2020). 86. Joint statement on advance care planning. Care Quality Commission; 2020 (https://www.who.int/ publications/i/item/WHO-2019-nCoV-Comm_health_care-2020.1). 87. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ WHO-2019-nCoV-Comm_health_care-2020.1 accessed 22 June 2020). 88. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms- and-management-of-contacts, accessed 22 June 2020). 89. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 90. Bauer A. COVID19: providing palliative care for the many. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/03/31/covid19-proving-palliative-care-for-the-many/, accessed 22 June 2020). 91. Oven A. COVID-19 and long-term care in Slovenia: impact, measures and lessons learnt. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/COVID19-and- Long-Term-Care-in-Slovenia-impact-measures-and-lessons-learnt-21-April-2020.pdf, accessed 22 June 2020). 92. Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO- 2019-nCoV-Comm_health_care-2020.1, accessed 22 June 2020). 93. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. Geneva: World Health Organization; 2020 (https://www. who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-of- health-workers-including-key-considerations-for-occupational-safety-and-health, accessed 22 June 2020). 94. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–331495, accessed 22 June 2020). 95. Sani TP, Tan M, Rustandi KK, Turana Y. COVID-19 long-term care situation in Indonesia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19- Long-Term-Care-situation-in-Indonesia-30-May-1.pdf, accessed 22 June 2020). 96. Lorenz-Dant K. Germany and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19–26-May-2020. pdf, accessed 22 June 2020). 38 Preventing and managing COVID-19 across long-term care services 97. Contact tracing in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who. int/publications/i/item/contact-tracing-in-the-context-of-covid-19, accessed 22 June 2020). 98. Rostgaard T. The COVID-19 long-term care situation in Denmark. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care- situation-in-Denmark-29-May-2020.pdf, accessed 22 June 2020). 99. Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST. The long term care COVID-19 situation in Malaysia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/05/Malaysia-LTC-COVID-situation-report-30-May.pdf, accessed 22 June 2020). 100. Health at a glance 2019: OECD indicators. Paris: Organisation for Economic Co-operation and Development; 2019 (http://www.oecd.org/health/health-systems/health-at-aglance-19991312.htm, accessed 22 June 2020). 101. Brimblecombe N, Fernandez J-L, Knapp M, Rehill A, Wittenberg R. Unpaid care in England: future patterns and potential support strategies. London: London School of Economics; 2018. 102. Caring behind closed doors: forgotten families in the coronavirus outbreak. London: Carers UK; 2020 (https:// www.carersuk.org/for-professionals/policy/policy-library/caring-behind-closed-doors-report, accessed 22 June 2020). 103. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? Journal of Gerontological Social Work. 2014;57(5):460–77. doi:10.1080/01634372.2014.882466. 104. Mental health and psychosocial considerations during the COVID-19 outbreak: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/mental-health-and- psychosocial-considerations-during-the-covid-19-outbreak, accessed 22 June 2020). 105. Da Mata F, Oliveira D. COVID-19 and long-term care in Brazil: impact, measures and lessons learned. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf, accessed 22 June 2020). 106. COVID-19 and violence against older people. Geneva: World Health Organization; 2020 (https://www.who. int/publications/m/item/covid-19-and-violence-against-older-people, accessed 22 June 2020). 107. Leiblfinger M, Prieler V, Schwiter K, Steiner J, Benazha A, Lutz H. Impact of the COVID-19 pandemic on live-in care workers in Germany, Austria and Switzerland. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/impact-of-the-covid-19-pandemic-on-live-in-care-workers-in-germany- austria-and-switzerland/, accessed 22 June 2020). 108. Coronavirus Plan of Action. Chile: Senama (http://www.senama.gob.cl/protocolos-covid-19, accessed 22 June 2020). 109. Cuenta con migo [count on me]. Government of Chile (https://www.gob.cl/cuentaconmigo/, accessed 22 June 2020). 110. López-Ortega M, Sosa-Tinoco E. COVID-19 and long-term care in Mexico: questions, challenges, and the way forward. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/06/LTC-Covid-19-situation-in-Mexico-8-June.pdf, accessed 22 June 2020). 111. Musyimi C, Mutunga E, Ndetei D. COVID-19 and long-term care in Kenya. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/06/02/new-country-report-the-covid-19-long-term-care- situation-in-kenya/, accessed 22 June 2020). 112. COVID Trauma Response Working Group (https://www.traumagroup.org/, accessed 22 June 2020). 113. Decade of Healthy Ageing 2020–2030. Geneva: World Health Organization; 2020 (https://www.who.int/ docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en. pdf?sfvrsn=b4b75ebc_3, accessed 22 June 2020). 114. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 39 Preventing and managing COVID-19 across long-term care services 40 Preventing and managing COVID-19 across long-term care services Annex 1. Methods Living systematic review A living systematic review was undertaken, aiming to synthesize early international evidence on mortality rates and incidence of COVID-19 among people who use and provide long-term care. The review was registered with Prospero (CRD42020183557) and includes studies identified through database searches conducted on 15 May 2020 and updated up to 5 June 2020. The methods and findings have been published in full in medRxiv. Seven databases were searched (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv) to identify all studies reporting primary data on COVID-19-related mortality and incidence of disease among long-term care users and staff. In addition, evidence on country-level mortality rates was identified from LTCcovid.org, an international network of long- term care experts. Studies not focusing on long-term care were excluded. Included primary studies were critically appraised and results on number of deaths and COVID-19-related mortality rates, case fatality rates, and excess deaths (co-primary outcomes), as well as incidence of disease, hospitalizations, and intensive care unit admissions, were synthesized narratively. Title and abstract screening, and a full text review, were undertaken by three reviewers and records reporting on the same study or outbreak were combined. A standardized template was used to extract data at the study level, including information on study design; care setting (institutional versus community); how COVID-19 was diagnosed and confirmed; baseline characteristics of participants; absolute number of deaths and mortality rates from confirmed and suspected COVID-19 cases; case fatality rates; excess deaths; absolute numbers and rates of confirmed and suspected COVID-19; and rates of hospitalization and intensive care unit admissions among confirmed and suspected COVID-19 cases. All study participant characteristics and outcome data were extracted separately for long-term care users and staff. Information was also extracted on the proportion of asymptomatic cases at time of testing, and findings of studies comparing outcomes in long-term care users to others. Due to heterogeneity in the definitions of numerators, denominators, and follow-up times across included studies, data were not pooled. Instead, results were summarized narratively and presented in tables, including information on sample characteristics, follow-up time, and case definitions, as appropriate. Where studies reported on overlapping populations, preference was given to those with larger sample sizes and longer follow-up times. The quality of included primary studies reporting figures relating to mortality rates, case fatality rates, or disease incidence were assessed using the Joanna Briggs Institute critical appraisal tool for prevalence studies. Risk of bias across studies was not assessed. A total of 33 study reports for 30 unique primary studies or outbreak reports were included (Figure A1.1). UN SP LA SH / R IZ AL H IL M AN 41 Preventing and managing COVID-19 across long-term care services MEDLINE: n=673 Embase: n=43 CINAHL Plus: n=221 Web of Science: n= 184 Global Health: n=7 WHO COVID-19 Research Database n=202 medRxiv: n=3454 LTCcovid.org: n=22 Total included: n=33 (30 unique, original studies) Updated database searches: n=418 Database searches: n=4806 Included in first review: n=30 (27 unique, original studies) After deduplication: n=418 Full text review: n=33 Newly included: n=4 After deduplication: n=4457 Full text review: n=247 Excluded after title and abstract screening: n=4210 Excluded after full text review Not focused on LTC: n=75 Review article: n=52 No mortality or infection data: n=56 Opinion piece: n=25 Full text not accessible: n=7 Modelling study: n=3 Not focused on COVID-19: n=3 Duplicate: n=3 Excluded after title and abstract screening: n=385 Excluded after full text review Review article: n=8 Opinion piece: n=6 No mortality or infection data: n=4 Not focused on LTC: n=3 Not focused on COVID-19: n=2 Duplicate: n=1 Full text not accessible: n=0 Modelling study: n=0 Excluded: 1 previously included study (withdrawn by author) Records identified through other sources: n=3 Figure A1.1 Flow chart for selection of included primary studies 42 Preventing and managing COVID-19 across long-term care services Pilot of a systematic review of effectiveness of interventions to mitigate the impact of COVID-19 on people who use and provide long-term care A systematic review on the effectiveness of interventions to manage the impact of COVID-19 on people who use and provide long-term care is under development. While piloting the search strategy across seven databases (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv), 21 studies were identified that described responses to the COVID-19 pandemic and provided some sort of evaluation of effectiveness or aimed to assess characteristics of long-term care services associated with COVID-19 infection rates and associated mortality. There were five reports from the United States, three from Italy, two each from Canada, China, the Republic of Korea and Spain, and one report each from Belgium, France, Ireland, Singapore and the United Kingdom. The interventions identified and target groups varied. Three of the studies related to pharmacological therapies in care homes (1–3), additional studies described the implementation of measures to prevent (China and Singapore) and contain (Canada, China, the Republic of Korea and the United States of America) outbreaks in care homes (1, 4–8), one study reported about prevention measures for community-based care in the United States (9), four reported on multifaceted organizational changes to deal with COVID-19 in long-term care settings, including multidisciplinary collaboration and coordination (6, 10–12), three were pilot studies for detecting COVID-19 through rapid point-of-care testing, pooled testing, and bedside chest ultrasonography (13–15), and one adapted an existing cognitive stimulation intervention for people with dementia to provide information and support in relation to COVID-19 (16). These studies were mostly descriptive and, lacking a control group, were not designed to rigorously evaluate the effectiveness of implemented measures. Nevertheless, the prevention and outbreak management interventions described in the papers from China, the Republic of Korea and Singapore all reported successes in preventing or containing outbreaks. Another three studies assessed the association between different characteristics of care homes and COVID-19 outbreaks and outcomes. Stall et al. found that for-profit status of nursing homes in Ontario, Canada, was associated with both the size of a nursing home outbreak and the number of resident deaths (17). However, for-profit status was not associated with a higher likelihood of an outbreak. Romero-Ortuño and Kennelly found moderate, statistically significant association between crude number of deaths and maximum occupancy in Irish care homes, but no statistically significant association was found for quality of care homes (18). Similarly, Abrams et al. did not find a statistically significant association between the reporting of at least one COVID-19 case in United States nursing homes and traditional quality criteria (19). However, a statistically significant association was found for larger facility size, urban location, percentage of African-American residents, non-chain status, and state. Finally, two studies analysed the association between regional characteristics, including features of the long- term care system such as the proportion of private versus public long-term care beds and the availability of nursing home beds, and spread of COVID-19 in Italian regions (20–21). Country reports on the COVID-19 long-term care situation Country reports published on the LTCcovid website (an initiative of the International Long-Term Care Policy Network) were reviewed. The reports were produced by experts in long-term care, usually academics. The reports aimed to document the impact of COVID-19 on people who use and provide long-term care in each country, and the measures adopted to mitigate the impacts of the pandemic on this population. Information from these reports informed the examples of measures adopted by different countries. 43 Preventing and managing COVID-19 across long-term care services References 1. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 2. Ahmad I, Alam M, Saadi R, Mahmud S, Saadi E. Doxycycline and hydroxychloroquine as treatment for high- risk COVID-19 patients: experience from case series of 54 patients in long-term care facilities. medRxiv. May 2020. doi:10.1101/2020.05.18.20066902. 3. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 4. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherarpy. May 2020. 5. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 6. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 7. Munanga A. Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing. 2020;46(6):3–5. doi:10.3928/00989134–20200511–03. 8. Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M et al. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. Journal of Intellectual Disability Research. 2020. doi:10.1111/jir.12740. 9. Archbald-Pannone LR, Harris DA, Albero K, Steele RL, Pannone AF, Mutter JB. COVID-19 collaborative model for an academic hospital and long-term care facilities. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.044. 10. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 11. Koeberle S, Tannou T, Bouiller K, Becoulet N, Outrey J, Chirouze C et al. COVID 19 outbreak: organisation of a geriatric assessment and coordination unit – a French example. Age and Ageing. May 2020. doi:10.1093/ ageing/afaa092. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Cabrera JJ, Rey S, Perez S, Martinez-Lamas L, Cores-Calvo O, Torres J et al. Pooling for SARS-CoV-2 control in care institutions. medRxiv. June 2020. doi:10.1101/2020.05.30.20108597. 14. Nouvenne A, Ticinesi A, Parise A, Prati B, Esposito M, Cocchi V et al. Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.050. 15. Goodman-Casanova JM, Dura-Perez E, Guzman-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study. Journal of Medical Internet Research. 2020;22(5):e19434. doi:10.2196/19434. 16. Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit nursing homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada. Medrxiv. 2020. doi:10.1101/2020.05.25.20112664. 44 Preventing and managing COVID-19 across long-term care services 17. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 18. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16661. 19. Buja A, Paganini M, Cocchio S, Scioni M, Rebba V, Baldo V. Demographic and socio-economic factors, and healthcare resource indicators associated with the rapid spread of COVID-19 in northern Italy: an ecological study. medRxiv. 2020. doi:10.1101/2020.04.25.20078311. 20. Liotta G, Marazzi MC, Orlando S, Palombi L. Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox. PLoS One. 2020;15(5):e0233329. doi:10.1371/journal. pone.0233329. 45 Preventing and managing COVID-19 across long-term care services World Health Organization Avenue Appia 20 1202 Geneva, Switzerland

Policy brief Preventing and managing COVID-19 across long-term care services 24 July 2020

Preventing and managing COVID-19 across long-term care services Policy brief 24 July 2020 WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/) Suggested citation. Preventing and managing COVID-19 across long-term care services : policy brief. Geneva: World Health Organization; 2020 (WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Inis Communication Contents Acknowledgements iv Executive summary v Part 1. Overview 1 1.1 Aim of the document 1 1.2 Impact of COVID-19 on long-term care: what the evidence tells us 2 1.3 The case for action: leaving no one behind 3 Part 2. Responding to the COVID-19 pandemic in long-term care 5 2.1 Include long-term care in all phases of the national response to the COVID-19 pandemic 7 2.2 Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic 9 2.3 Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses 11 2.4 Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services 14 2.5 Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation 17 2.6 Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases 19 2.7 Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services 22 2.8 Provide support for family and voluntary caregivers 24 2.9 Prioritize the psychological well-being of people receiving and providing long-term care services 27 2.10 Ensure a smooth transition to the recovery phase 30 2.11 Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services 32 References 33 Annex 1. Methods 41 Web Annex: Key objectives and actions to prevent and manage COVID-19 in long-term care facilities https://apps.who.int/iris/bitstream/handle/10665/334020/WHO-2019-nCoV-Policy_Brief-Long-term_ Care-Web_Annex-2020.1-eng.pdf iii Acknowledgements This policy brief was developed by WHO through new analysis, expert consensus and reference to existing WHO guidance. Coordinating departments Department of Integrated Health Services (Shannon Barkley, Edward Kelley) Department of Maternal, Newborn, Child and Adolescent Health and Ageing (Zee-A Han, Anshu Banerjee) Principal writers World Health Organization: Zee-A Han (responsible officer), Shannon Barkley, Yuka Sumi London School of Economics and Political Science: Adelina Comas-Herrera, Klara Lorenz-Dant, Maximilian Salcher-Konrad Other contributors and reviewers WHO Steering Committee: Ageing and Health; Clinical Services and Systems; Gender, Equity and Human Rights; Integrated Health Services; Maternal, Newborn, Child and Adolescent Health and Ageing; Mental Health and Substance Use; Sensory Functions, Disability and Rehabilitation; Infection Prevention and Control Hub and Task Force; WHO Kobe Centre, and regional offices (Benedetta Allegranzi, Jotheeswaran Amuthavalli Thiyagarajan, Sarah Louise Barber, Anjana Bhushan, Alessandro Cassini, Alarcos Cieza, Theresa Diaz, Stefanie Freel, Manfred Huber, Anne Johansen, Theadora Koller, Margrieta Langins, Madison Moon, Paul Ong, Ritu Sadana, Nicoline Schiess, Katrin Seeher, Enrique Vega). The following individuals contributed to or reviewed the document. Confidentiality agreements were signed and declarations of interest were collected and reviewed. Non-WHO experts: WHO Global Network on Long-term Care for Older People (Liat Ayalon, Pablo Villalobos Dintrans, Walter Frontera, Muthoni Gichu, Sandhya Gupta, Hanadi Khamis Al Hamad, Arvind Mathur, Reshma A. Merchant, Stephen O’Connor, Vinod Shah, Lieve Van den Block) and Rachel Albone, Sean Cannone, Leon Geffen, Terry Fulmer, Richard Humphries, Caitlin Littleton, Terry Lum, Saniya Sabzwari, David Stewart. WHO continues to monitor the situation closely for any changes that may affect this policy brief. Should any factors change, WHO will issue a further update. WHO gratefully acknowledges the kind support of the Government of the Republic of Korea, Ministry of Health and Welfare. iv Preventing and managing COVID-19 across long-term care services Executive summary The COVID-19 pandemic has affected older people disproportionately, especially those living in long-term care facilities. In many countries, evidence shows that more than 40% of COVID-19 related deaths have been linked to long-term care facilities, with figures being as high as 80% in some high-income countries. Furthermore, in long-term care facilities, the case fatality for residents with COVID-19 may be higher than in the population of the same age living outside long-term care facilities. Residents of long-term care facilities often face high risk, low preventive measures and inadequate resources to recover from COVID-19, as well as reduced access to essential health services in a context where health systems are experiencing constraints during the COVID-19 surge. The impact of COVID-19 has additionally been high in providers of long-term care services, within long- term facilities and in other settings. A 2020 study by the United Kingdom Office for National Statistics of deaths by occupation found that the social care workforce had a significantly raised death rate associated with COVID-19. So far, COVID-19 has disproportionately affected long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community-based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. The response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries. Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19. This policy brief provides 11 policy objectives and key action points to prevent and manage COVID-19 across long-term care. Its intended audience is policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on currently available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and to mitigate impact across long-term care services, including care providers. While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized because they have experienced extremely high COVID-19 incidence, morbidity and mortality. Furthermore, the policy brief addresses long-standing problems in long-term care systems, including underfunding, lack of accountability, fragmentation between health and long-term care and an undervalued workforce. The brief suggests ways to transform health and long-term care services so that long-term care services are readily integrated and provided as part of the continuum of care that includes health promotion, prevention, treatment, rehabilitation and palliation. It is only through these measures that people in need of long-term care can receive quality, equitable and sustainable care that allows them to live in a manner respecting their basic rights, fundamental freedoms and human dignity. v Preventing and managing COVID-19 across long-term care services vi Preventing and managing COVID-19 across long-term care services Part 1. Overview 1.1 Aim of the document The COVID-19 pandemic has revealed weaknesses in emergency response where long-term care services has been underprioritized, resulting in the devastating impact seen across long-term care services globally. These events have highlighted long-standing problems in the long-term care systems in most countries: underfunding, lack of accountability, fragmentation, poor coordination between health and long-term care, and an undervalued workforce (1–3). This policy brief provides policy objectives and key action points to prevent and manage COVID-19 across long-term care for policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on current available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and its impact on those who use long-term care and care providers (including paid staff and family and other voluntary caregivers). It also expands on the technical working guidance on preventing and managing the COVID-19 pandemic across long-term care services in the World Health Organization (WHO) European Region to provide global perspectives and country examples across all WHO regions (4). While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized as they have experienced extremely high incidence, morbidity and mortality due to COVID-19. However, although long-term care facilities are an integral part of long-term care, it must be highlighted that community-based services are the key to promoting ageing in place, reducing institutionalization, and supporting deinstitutionalization, so that people can live in a manner consistent with their basic rights, fundamental freedoms and human dignity. Box 1 presents definitions of the terminology used in this document. Box 1. Working terminology: definitions of terms used Long-term care systems National systems that ensure integrated long-term care that is appropriate, affordable, accessible and upholds the rights of people and caregivers alike (1). Long-term care Services to ensure that people with or at risk of significant loss of physical and mental capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity (1). These services typically involve care and assistance with everyday tasks (including dressing, bathing, shopping, cooking and cleaning), support with social participation, and management of advanced chronic conditions through community nursing, rehabilitation and end-of-life care. Services are provided by both unpaid caregivers (typically family but also volunteers) and paid care staff. Throughout the document, the use of the term “long- term care services” covers care at home, in the community and in facilities (residential long-term care facilities, nursing homes or other group living facilities), unless otherwise specified. Long-term care facilities Long-term care facilities may vary by country. Nursing homes, skilled nursing facilities, assisted living facilities, residential facilities and residential long-term care facilities are collectively known as long-term care facilities that provide a variety of services, including medical and assistive care, to people who are unable to live independently in the community. Throughout the document, the use of the term “long-term care facilities” does not include home-based long-term care, community centres, adult day care facilities or respite care. Caregiver A person who provides care and support to someone else. Caregivers may include family members, friends, neighbours, volunteers, care workers and health professionals (1). UN SP LA SH / JE RE M Y ST EN UI T 1 Preventing and managing COVID-19 across long-term care services 1.2 Impact of COVID-19 on long-term care: what the evidence tells us Evidence from a systematic review (5) and compiled reports on the COVID-19 situation in long-term care facilities (Annex 1) shows that, while there is little evidence of the impact of COVID-19 on people who use and provide long-term care services in the community, the pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities. In countries with large numbers of deaths from COVID-19, about half of all those deaths have been among residents of long-term care facilities. The methods for the systematic review and other reviewing carried out for this report are described in more detail in Annex 1. Early evidence shows that the extent of COVID-19 infections in long-term care facilities has varied widely, between and within countries: some countries (such as Jordan) have had no infections reported in long-term care facilities so far, whereas in Sweden, for example, by the end of April, 25% of long-term care facilities in the whole country had COVID-19 outbreaks, with 67% of long-term care facilities in Stockholm affected. Data from 21 high-income countries show that while some countries have had no or very few deaths among residents in long-term care facilities, other countries report that on average nearly half of all deaths linked to COVID-19 in the country were of long-term care facility residents (ranging from 24% in Hungary to as high as 82% in Canada). In some countries, the share of deaths among all residents of long- term care facilities linked to COVID-19 has been as high as 3% to 6% of all residents (6). Disaggregated data by age and gender are not available for many countries. The evidence also shows that once COVID-19 infection is present in long-term care facilities it is difficult to control, in part due to the large number of people living close together in facilities designed for communal living and the fact that personal care requires close proximity. Although case reports from the Republic of Korea, demonstrated successful mitigation of further infections in long-term care facilities after a member of staff had tested positive (7–8), case studies in several other countries demonstrate how difficult it is to contain the infection in these settings. For example, studies in the United Kingdom of Great Britain and Northern Ireland and the United States of America have shown incidence rates between 40% and 72% among residents (9–14), with infection rates among staff between 1.5% and 5.9% when all staff members at outbreak facilities were tested (7–8, 15–18). There is also evidence from one study that staff working across more than one home may have been the source of transmission (19). An analysis of deaths by occupation in the United Kingdom showed that men and women working in social care had significantly raised rates of deaths involving COVID-19 (23.4 per 100 000 males compared to 9.9 for males aged 20–64 years, and 9.6 per 100 000 females compared to 5.2 for females aged 20–64 years) (20). Six studies describing measures to prevent (China and Singapore) and contain or manage (Canada and the Republic of Korea) outbreaks in long-term care facilities reported some success, although these studies did not have a control group (7–8, 22–23). There is increasing evidence of potential transmission from presymptomatic or asymptomatic people who have COVID-19 and people presenting with “atypical symptoms” in long-term care facilities. Studies of outbreaks show that 7% to 75% of residents and 50% to 100% of staff who tested positive are presymptomatic or asymptomatic (11–13, 15, 17, 19, 24). Between 57% and 89% of asymptomatic positive residents develop symptoms later (11, 19). Systematic nationwide testing of residents and staff in Belgium showed that 74% of cases among residents and 76% of cases among staff were asymptomatic at the time of testing (25). “Men and women working in social care have significantly raised rates of deaths involving COVID-19.” “The pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities.” 2 Preventing and managing COVID-19 across long-term care services Once people living in long-term care facilities have COVID-19, the case fatality for residents may be higher than in the population of the same age outside long-term care facilities. For example, the incidence rate of COVID-19 deaths among residents of long-term care facilities in Ontario, Canada, was 13 times higher compared to community-dwelling cases aged 70 years or older (26), and the risk for severe disease, including death, was 2.5 times higher for Israeli nursing home residents with COVID-19 compared to other cases over 65 years of age (27). No studies report on the detrimental health sequelae of either the infection itself or the measures taken to prevent infection in long-term care facilities, although many editorials and commentary articles mention potential impacts on both mental and physical health (for example, distress, depression, anorexia, loss of physical condition due to lack of exercise, and consequences of increased chemical and physical restraints). This has raised concerns for increased direct and indirect morbidity and mortality (28–29). There is limited evidence on the impact of the COVID-19 pandemic on people who use and provide community-based long-term care, including home help, day care facilities and unpaid caregivers. Some public health and infection prevention measures (including movement restrictions, physical distancing and curfews) may resulted in restriction of the usual sources of care and support that many people with care needs rely on. Evidence from the United Kingdom found that people with disabilities experienced widening inequalities during the COVID-19 pandemic. People with disabilities reported difficulty in accessing food and medication and delays in the benefit system, with some experiencing food insecurity and poverty. Many people with disabilities reported feeling isolated and, for some, lack of Internet access meant that they could not access virtual replacement services. Furthermore, reduction of ongoing support structures left people reliant on family and neighbours (30). It is also likely that people living with existing health conditions experience difficulties in accessing essential health care services, including rehabilitation, which further increases care needs. Furthermore, discontinuity of health care services can result in heightened need for care (31–32). It is increasingly recognized that in many countries the initial plans to contain the pandemic did not include long-term care facilities; it was only when media reports of large numbers of deaths started to emerge that resources were mobilized. In some countries, the army and other emergency response units had to be deployed to support long-term care facilities that had been overwhelmed by large numbers of deaths and insufficient staff (33). In many countries, long-term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred (34). 1.3 The case for action: leaving no one behind Health systems have a responsibility to offer safe, accessible, affordable and quality health care, including assistive and palliative care, for all people, without discrimination. However, as the evidence shows, residents of long-term care facilities are often facing higher risk, lower preventive measures and inadequate resources to manage COVID-19, as well as reduced access to essential health services, as health systems experience constraints in the context of a COVID-19 surge (35). Older people, particularly those with underlying conditions who are more likely to develop severe COVID-19, make up a large proportion of those using long-term care services, including those living in long-term care facilities (36). Immediate action is required to prevent infection and mitigate the impact of the COVID-19 pandemic among this population and to ensure that essential health and assistive care services are provided. “In many countries, long- term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred.” 3 Preventing and managing COVID-19 across long-term care services Furthermore, women, especially older women, represent the highest share of people who use care services, dominate the long-term care workforce, and are the main providers of family care (1, 37). In addition, long- term care services often depend heavily on migrant workers and workers from ethnic groups, who may be at higher risk (1, 38–40). The response to the pandemic must include long-term care to ensure that ethnic, age and gender groups are not marginalized. Concerns about human rights have also been expressed, both in the potential neglect of the population relying on (and providing) long-term care, and in measures adopted in an attempt to reduce the risk of infection (for example, a ban on visitation and forbidding outside physical activity). It is mandatory that the response to the pandemic is inclusive of long-term care, so that appropriate and tailored measures are implemented and issues specific to long-term care are addressed. So far, COVID-19 has disproportionately affected people living in long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community- based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. Considering the magnitude of the impact of COVID-19 on long-term care, response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries (4). Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19 (41). 4 Preventing and managing COVID-19 across long-term care services Part 2. Responding to the COVID-19 pandemic in long-term care While the pandemic has brought public attention to the immediate impacts of the pandemic, and the need to be prepared for present contingencies and possible future waves, it has also shown that there are major structural challenges that need to be addressed to improve the safety and resilience of long-term care systems. So far, most countries have struggled to develop coherent systems to ensure access to person-centred, quality, long-term care services that meet the growing health and assistive care needs and that are consistent with basic rights, fundamental freedoms and human dignity (1, 42–45). Even in high-income countries, a review by the Organisation for Economic Co-operation and Development (OECD) concluded that “there is a history in many countries of long-term care policies being developed in a piecemeal manner, responding to immediate political or financial problems, rather than being constructed in a sustainable, transparent manner” (43). This section looks into the unique challenges that have affected the ability of long-term care systems to respond to the COVID-19 pandemic and proposes policy objectives and key actions to address these challenges in the short and longer term. Informed by the available evidence and international experience thus far, the 11 policy objectives presented on the next page will be key to addressing COVID-19 in long-term care systems. The following subsections address each of these policy objectives in turn. UN SP LA SH / A P X 90 5 Preventing and managing COVID-19 across long-term care services Eleven policy objectives to mitigate the impact of COVID-19 across long-term care 1. Include long-term care in all phases of the national response to the COVID-19 pandemic. 2. Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic. 3. Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses. 4. Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services. 5. Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation. 6. Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases. 7. Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services. 8. Provide support for family and voluntary caregivers. 9. Prioritize the psychosocial well-being of people receiving and providing long-term care services. 10. Ensure a smooth transition to the recovery phase. 11. Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services. 6 Preventing and managing COVID-19 across long-term care services 2.1 INCLUDE LONG-TERM CARE IN ALL PHASES OF THE NATIONAL RESPONSE TO THE COVID-19 PANDEMIC 2.1.1 The challenge Long-term care has low political priority compared to health and other policy areas Long-term care tends to have low political priority and is often referred to as “the Cinderella of the welfare state”, where political attention to its importance is often transient and secondary to health care (46). This lack of political attention to long-term care may be one of the reasons why the initial policy responses to the pandemic in many countries did not include the long-term care sector (4). Governance of the long-term care system often involves multiple sectors, different ministries and different levels of government, making coordination difficult In most countries, long-term care falls between different ministries, typically health care and social affairs, development, or social protection. Long-term care services and health care systems are often poorly coordinated or integrated, and tend to have separate (and often complex) arrangements for financing, regulation, information systems, and the training and procurement of staff (1, 43). This has created several difficulties during the COVID-19 crisis. For example, back-up staffing models to meet the surge in COVID-19 patients in hospitals were not flexible enough to meet demand surges in the long-term care sector. It was also difficult for appropriate staff to move flexibly across the system as needed. Similarly, the long-term care sector, and especially long-term care facilities, struggled to access testing and PPE, as this had been prioritized for hospitals (47). In addition, countries frequently distribute responsibility for long-term care vertically across national, regional and local actors, creating difficulties in coordination of services and effective oversight (48). For example, in Spain and Italy, the same person may be receiving long-term care services that are organized or funded by up to three different levels of government (49–50). Long-term care services consist of a mixture of public, private for-profit and private not-for-profit service providers, in addition to family caregivers Long-term care services are also characterized by a mix of public, private for-profit and private not- for-profit service providers (51). In some countries, most long-term care facilities are operated by private for-profit providers and, particularly in low- and middle-income countries, these are often unregulated (52–53). Particularly in low- and middle-income countries, nongovernmental organizations (NGOs) play an important role in the provision of long-term care services and are often the sole source of support for unpaid caregivers. However, where NGOs are non-existent, the care responsibility often falls entirely on the families themselves. This unpaid care is rarely recognized within a formal system and so is not included in any governance processes or mechanisms beyond those of the NGOs that support the work. These structures can result in a lack of ownership, diffused accountability, and fragmentation of responsibilities, causing problems with coordination and quality of care and leading to underdeveloped information systems (43, 54). 7 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 May impede inclusion of long-term care in pandemic national response May impede planning, oversight and accountability during the pandemic May impede coordinated response between long-term care and health care sectors in responding to the pandemic May impede effective resource allocation 2.1.2 Key actions Whole sector Ensure a focal point to manage long-term care (with a special focus on long-term care users and providers) in the overarching COVID-19 governing body. Establish joint steering committees and information- and data-sharing systems between sectors and subnational policy levels to ensure a coordinated response. Establish a mechanism to support unregulated providers, focusing on cooperative support rather than punitive measures. Long-term care facilities If long-term care facilities are expanding their health care role during the pandemic, establish triggers or thresholds that activate a phased reallocation of routine comprehensive health service capacity, including direct health care staff. Country examples In Singapore, the Agency for Integrated Care and the Ministry of Health, together with long-term care service providers, have jointly developed a number of measures to respond to the COVID-19 pandemic. These include infection control and prevention measures, access to PPE, distancing and zoning measures, suspension of visitors, alternative accommodation for long-term care workers, and testing to monitor people with long-term care needs and care workers. The Agency for Integrated Care also set up an incident response team to support long-term care providers in responding to COVID-19 infections. The Silver Generation Office, which is an outreach arm of the Agency for Integrated Care, has supported older people with contact, information and the provision of services during the COVID-19 pandemic (55–56). In Israel, a governing team has been appointed to manage COVID-19 outbreaks in long-term care facilities across the country. This team has provided a national plan under the Fathers and Mothers Shield project, including establishment of a headquarters from which government efforts can be coordinated. In addition, the Home Front Command has been assisting long-term care facilities throughout the pandemic with managing visitor access, disinfection, and food and equipment delivery, and has been offering training and guidance on protective and preventive measures (57). In Malta, the Social Care Standards Authority, the regulatory body for long-term care, defined the residential care settings as being high risk with regard to COVID-19 in early March. Immediately, the Social Care Standards Authority issued the directives mapped out in its COVID-19 brief (2020). There was immediate cooperation between the Public Health Authority and the Social Care Standards Authority, which proved to be the primary catalyst towards safeguarding older persons within the facilities (58). 8 Preventing and managing COVID-19 across long-term care services 2.2 MOBILIZE ADEQUATE FUNDING FOR LONG-TERM CARE TO RESPOND TO AND RECOVER FROM THE COVID-19 PANDEMIC 2.2.1 The challenge Limited public funding allocated for long-term care Average public expenditure on long-term care is very low, less than 1% of GDP globally. Such public underfunding jeopardizes access to long-term care (42). This is even more pronounced in low- and middle-income countries, many of which lack dedicated sources of public financing for long-term care. Public benefit schemes for long-term care are usually needs based and means tested, and often require co-payments, leaving large parts of the population outside the public system In most countries, public benefit schemes for long-term care support are needs based and means tested, and often require co-payments. Those with greater needs often receive more support, but some countries also set limits on the amount that can be covered through public resources. While some countries protect the most vulnerable from additional costs, considerable out-of-pocket expenses are common across countries for most people receiving long-term care services (43, 59–60). Also, due to the large share of care provided by unpaid caregivers, in practice a large share of the costs of long-term care fall on families, through a combination of the opportunity costs of providing care and out-of-pocket payments. Few countries have financing mechanisms that protect the whole population from catastrophic long- term care costs (1). Reduced income for long-term care sector and higher costs of care Increasing PPE and workforce costs mean that service providers are facing substantial additional costs. At the same time, providers are experiencing decreases in revenues due to lower occupancy in long- term care facilities (resulting from both a decrease in admissions and the higher-than-usual numbers of deaths) and the closure of community-based services such as day care centres. Several countries have already provided emergency funds to support the long-term care sector during this crisis. However, the provision and distribution of resources may be easier in countries with more developed and regulated long-term care systems. The provision of resources and support to the unregistered long-term care sector poses additional challenges. Such unique challenges in the financing of long-term care have made it difficult for the long-term care system to react and respond to the additional costs that may be incurred due to preparing for and responding to COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of adequate funding for the additional costs linked to the COVID-19 response may endanger the safety of long-term care users and providers The increase in the costs of care due to the pandemic results in increased out-of-pocket payments for care users 9 Preventing and managing COVID-19 across long-term care services 2.2.2 Key actions Whole sector Consider injecting extra ring-fenced funds for long-term care to cover the additional costs linked to the pandemic (for example, additional staff costs, infection prevention and control (IPC) training, and materials such as PPE and sanitizers). Consider how to reduce regulatory and other costs to providers for the duration of the pandemic (such as staffing requirements). Provide flexibility in the use of emergency funds allocated to long-term care providers as well as users. Long-term care facilities Provide funding to compensate for lower occupancy rates and ensure provision of quality essential health and care services. Provide funding to support providers of long-term care facilities with the additional costs incurred in ensuring the safety of their residents and staff, including additional IPC measures and testing for COVID-19. Community-based care Support providers (particularly not-for-profit) that are experiencing loss of revenue if they have to close some services, such as day care and community centres, during the pandemic. Enable flexibility in the use of personal budgets and other cash benefits, for example by allowing them to be used to employ a family member or neighbour if community centres are not available. Caregivers Support caregivers who may need to take on additional care responsibilities to compensate for the unavailability of usual care, and may need to give up employment to do so. Country examples In the United States, the US$ 3 trillion COVID-19 stimulus package (under the Coronavirus Aid, Relief, and Economic Security (CARES) Act) provides some funding for the long-term care sector. Out of the US$ 100 billion funding allocated to health care providers under the CARES Act, US$ 50 billion is being distributed to hospitals and long-term care providers, including providers of home health (61). As of 3 June 2020, US$ 4.9 billion had been targeted to skilled nursing facilities (62). In the Republic of Korea, the Ministry of Health and Welfare and the Korean National Health Insurance Service have issued temporary reimbursement guidelines for the long-term care sector. The guidelines take into consideration the need for COVID-19-related physical distancing measures and staff shortages. In addition, service providers operating in special disaster zones will not be facing payment cuts if they cannot adhere to staffing requirements during the pandemic (63). In China, subsidized long-term care providers were allocated a special one-off allowance to support staffing (for example, hiring and redeploying workers and reimbursing overtime) to ensure the continued provision of long-term care services. It is estimated that this support will amount to a total of around US$ 1.6 million (64–66). 10 Preventing and managing COVID-19 across long-term care services 2.3 ENSURE EFFECTIVE MONITORING AND EVALUATION OF THE IMPACT OF COVID-19 ON LONG-TERM CARE AND ENSURE EFFICIENT INFORMATION CHANNELLING BETWEEN HEALTH AND LONG-TERM CARE SYSTEMS TO OPTIMIZE RESPONSES 2.3.1 The challenge Few countries have information and monitoring systems for long-term care systems Relatively few countries have information and monitoring systems that include individual-level data about the characteristics, needs and outcomes of people who use formal long-term care services, and about the type and quality of care that they are receiving. This reflects the overall situation of limited data sources about older people (who are often long-term care users) and lack of age- and gender- disaggregated data (67). Where individual-level data are available, quite often they only cover people who use publicly funded long-term care or provide services. Furthermore, health and social care data are usually collected under separate systems, leading to difficulties linking data for the same individual. There are reports of unregulated long-term care facilities being “discovered” as a result of the COVID-19 pandemic (68). Lack of individual-level data about the characteristics of the residents of long-term care facilities has been identified as a barrier to response planning for the COVID-19 pandemic (69–70). This has meant, for example, that mathematical models that have informed planning for the pandemic have not accounted for residents in long-term care facilities separately from surrounding populations in their calculations (71). Data on the pandemic were initially only collected on people who had been tested and died in hospitals Very few countries publish data on the numbers of residents of long-term care facilities who have been infected or died from confirmed or suspected COVID-19. Because residents of long-term care facilities have been less likely to be tested or admitted to hospital than people living in private households, it is likely that countries that do not include deaths outside hospital are underestimating the death toll of COVID-19. An international initiative to track data on deaths of residents of long-term care facilities only found publicly available data for 21 countries in May 2020 (6). Without data on the impact of the infection on long-term care facilities and on people who rely on care and live in the community, there is a risk that the resources needed to prevent and mitigate the impact of COVID-19 in the long-term care sector (funds, workforce, tests, PPE and other equipment) may not be provided adequately and in a timely manner. There are few data available on associated health impacts of the pandemic Many people who rely on assistive care, particularly community-based care, will have had disruptions in their usual access to care, which can potentially put them at risk (for example due to malnutrition, undetected infections or other health complications). Data to identify people who may be at higher risk are needed to identify gaps and reconfigure services as needed. 11 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 Difficult to monitor the impact of COVID-19 across long-term care services Difficult to develop tailored response plans for long-term care to mitigate impact Difficult to include long-term care populations in modelling projections Difficult to monitor health impact of COVID-19 on long-term care users and long-term care workforce Fragmentation of information between long-term care facilities and health facilities 2.3.2 Key actions Whole sector Find effective ways to make use of existing long-term care management data where they are available (for example, MDS 3.0 in the United States, and the interRAI assessment systems of Canada and New Zealand) to model the impact of COVID-19 on health (including mental health) and the functioning of older people in long-term care. For countries without these systems, consider establishing such management data systems as actions for the longer term. Encourage research on the impact, and measures to mitigate the impact, of COVID-19 on long-term care to identify gaps and prepare for future pandemics. Long-term care facilities Establish a surveillance system that captures people who have COVID-19 and deaths that occur in long- term care facilities (probable and confirmed, disaggregated by age, gender, disability and existing health condition), and ensure that these are integrated with existing surveillance systems. Establish the necessary legal mechanisms to secure and transmit information relating to COVID-19 on a regular and frequent basis to and from long-term care facilities, health facilities, public health authorities and the public. Set up a mechanism to ensure that these data are analysed regularly and the findings used to refine government policy on the COVID-19 response. Community-based care Establish mechanisms to report the number of people who have COVID-19 among those receiving and providing long-term care in the community and in homes to public bodies responsible for commissioning services. 12 Preventing and managing COVID-19 across long-term care services Examples In South Africa, managers of long-term care facilities have to inform the Department of Social Development if a COVID-19 case has been confirmed (72). In the European Union, the European Centre for Disease Prevention and Control (an agency of the European Union) has included long-term care facilities in its strategy for COVID-19 surveillance at national and European Union/European Economic Area levels and is collecting data from Member States covering mitigation action, infection rates and mortality (73). In Argentina, in La Plata, an NGO co-developed a website for monitoring and sharing information about both registered and informal long-term care facilities. This platform was used to survey the COVID-19 preparation of the long-term care facilities and resulted in the local government ensuring that testing was provided to all employees of long-term care facilities (53). 13 Preventing and managing COVID-19 across long-term care services 2.4 SECURE STAFF AND RESOURCES, INCLUDING ADEQUATE HEALTH WORKFORCE AND HEALTH PRODUCTS, TO RESPOND TO THE COVID-19 PANDEMIC AND DELIVER QUALITY LONG- TERM CARE SERVICES 2.4.1 The challenge Pre-existing workforce shortages, poor pay and working conditions Before the COVID-19 pandemic, workforce shortages, poor pay and working conditions, and low proportions of professionally qualified staff were already a major concern in long-term care systems (2–3, 73). The workforce supporting people with long-term care needs is predominantly female (90%) (37), and in many countries migrant care workers make up a large proportion of the long-term care workforce (74). It is common for care workers to have zero-hour contracts and to work for multiple facilities or agencies (75). Long-term care staff shortages during pandemic In many countries, long-term care services, particularly long-term care facilities, have experienced acute staff shortages during the COVID-19 pandemic when their staff had to isolate due to suspected or confirmed infection with COVID-19 (49–50, 76–77). This has happened at a time when family and other unpaid caregivers, due to visiting and movement restrictions, have been less able to provide support (even in long-term care facilities, family and volunteer caregivers make an important care contribution). On some occasions countries had to rely on extreme measures such as calling on the military or other emergency services when long-term care facilities became overwhelmed and understaffed (49). In some countries, long-term care workers and caregivers were not initially considered key workers and lockdown measures and curfews meant they were not able to travel to work (or continue to provide care to people in other households) (78–79). Using public transport or living in crammed accommodation may have increased the risk for care staff to be exposed to the virus. Difficulties adapting to increased health care needs in long-term care facilities While some long-term care facilities employ nurses and other health care staff, this is not the case in all facilities, and there are reports of the difficulties faced by non-medically trained staff in long-term care facilities needing to provide care to people with COVID-19 infections or to those who need palliative care without health care staff support or oversight by qualified health professionals such as physicians and nurses. Administrative barriers to transferring staff and medical supplies from the health service to long-term care facilities led, in the case of a region of Spain, to all long-term care facilities being put under the control of the Department of Health during the pandemic (49). Long-term care providers and caregivers not able to obtain PPE Difficulties faced by long-term care providers and caregivers in accessing PPE and other resources (such as hand sanitizer and disinfectant) have emerged in many countries, due to global shortages and the prioritization of hospitals and other health care settings. Long-term care providers reported having to buy PPE at inflated prices as a result. 14 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 A vast workforce shortage for long-term care When compensating for workforce shortage, high staff turnover can impede continuity of care and consistency in important IPC measures Decreased integrity of the work and value of a workforce dominated by women and migrant workers Increased financial pressures to work while ill due to poor working conditions, such as lack of compensation for sick leave Occupational safety of long-term care workforce not taken into careful consideration Substantial lack of PPE for long-term care facilities, long-term care workforce (including caregivers) and recipients of care Lack of essential medical supplies and health workforce in long-term care facilities Lack oversight by qualified health professionals in providing essential services in long-term care facilitie 2.4.2 Key actions Whole sector Estimate surge capacity needed to support long-term care services in coordination with the focal point on long-term care. Set up links between health and social care procurement chains to ensure a continuous and non- conflicting supply during COVID-19. Recruit additional staff and develop rapid training programmes (for example, recruit retirees, students from health and long-term care training programmes, and volunteers) on IPC measures. Address contractual and related issues and put in place policies and measures that keep staff safe but allow them to work in a flexible manner and move from health care services into long-term care services as needed. Establish rosters and secure staff from health systems who can be repurposed if needed to support staff in long-term care settings. Implement measures to prevent policies from impeding delivery of important home, community and facility-delivered care through the long-term care workforce. Implement measures to monitor staff working in multiple locations, with increased risk of transmission, and consider facilitating transport and accommodation of staff to minimize the risk of infection during local outbreaks. Provide financial payment for care staff to incentivize them to stay in their jobs during the epidemic and compensate them for additional workload and stress. Long-term care facilities Ensure adequate supply of PPE in long-term care facilities to protect care staff from infection. Provide adequate training guidance and enforce routine training of staff and family caregivers on IPC measures in long-term care facilities so they can continue providing care in those facilities. Facilitate flexible arrangements whereby palliative care teams and other relevant health and care professionals work with staff in long-term care facilities to ensure access to palliative care as needed. 15 Preventing and managing COVID-19 across long-term care services Ensure adequate oversight by appropriately trained personnel to deliver essential services in long-term care facilities. Ensure provision of PPE to home care workers, particularly those providing care in close proximity. Provide adequate training guidance and enforce routine training of community-based care providers. Family and other voluntary caregivers Ensure provision of PPE to caregivers providing care in close proximity. Provide adequate guidance and offer training for family and other voluntary caregivers. Country examples In Austria, staffing and licensing regulations for care workers have been eased substantially during the COVID-19 pandemic. This enables people who have done national service (those who opted for civilian duties) to provide basic care. People in the national service have contributed to managing the logistics of the pandemic. Their employment as care workers can be enforced by the government. In addition, people undertaking training in relevant areas and interested people who are currently unemployed can also step in (76). In Ireland, Nursing Homes Ireland started a recruitment campaign for nursing homes (private and NGO operated) in March 2020. Furthermore, the Health Service Executive agreed to redeploy staff (on a voluntary basis) to private nursing homes (77). In India, some long-term care facilities support their in-house staff with incentives, such as free food. In addition, some long-term care facilities are working to promote the mental health of their staff through regular check-ins and counselling (78). If long-term care facilities in Israel experience a shortage of staff, the Ministry of Health will send a special team for 7–14 days to support the provision of care for the acute period (57). In the Netherlands, since 19 May 2020 PPE has been available free of charge for care workers providing care activities that require close proximity (less than 1.5 metres) to persons with long-term care needs (80). In Spain, care staff from community care centres have been supporting the provision of home care, for example through phone calls. In addition, the long-term care sector can hire non-qualified staff in instances of absenteeism of their usual staff (49). In Australia, residential care workers will receive a retention bonus for two quarters of up to 800 Australian dollars after tax. The government has employed health care delivery providers to form rapid response teams in the long-term care sector where needed in each state. Visa rules were relaxed to enable staff to work more hours (81). In parts of the United Kingdom, care workers have had their wages increased and have been offered a special one-off payment for staff working during the COVID-19 pandemic (82). 16 Preventing and managing COVID-19 across long-term care services 2.5 ENSURE THE CONTINUUM AND CONTINUITY OF ESSENTIAL SERVICES FOR PEOPLE RECEIVING LONG-TERM CARE, INCLUDING PROMOTION, PREVENTION, TREATMENT, REHABILITATION AND PALLIATION 2.5.1 The challenge Requirement for continuous, complex care with high levels of physical and emotional contact People with long-term care needs often require continuous, complex and personalized support structures. Assistive care for personal tasks in particular requires high levels of physical and emotional contact. People who are receiving this care, and who are dependent on this support, benefit enormously from continuity of care (1). In many countries, the majority of residents of long-term care facilities have dementia (83–85). Variability in health care provision in long-term care facilities Long-term care facilities are very diverse, and while some may be specialized in providing medical care, such as long-term care hospitals or some nursing facilities, others, typically residential homes or supported accommodation, may not have any health care trained staff members. Long-term care facilities in many countries have experienced difficulties providing health care support and resources for essential health services, in addition to responding to the new burden of COVID-19 (including in the areas of rehabilitative and palliative care). Potential for discriminatory triage practices in hospital admissions There have been reports that residents of long-term care facilities have not been able to access health care in hospitals (49–50), and have had limited access to primary care. It has also been reported that advance care directives have sometimes been put in place without adhering to the usual person- centred standards (86). Countries have responded by emphasizing the importance of equitable access to health and palliative care for older adults and people with existing conditions during the COVID-19 pandemic (36–37). IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities in many countries have experienced difficulties providing health care support and resources to continue essential health services and to provide assistive care services for the new challenge of COVID-19 Residents of long-term care facilities have sometimes been denied hospital care based on irrelevant or discriminatory criteria, such as age, under the presumption that they are too frail to survive 17 Preventing and managing COVID-19 across long-term care services 2.5.2 Key actions Whole sector Consider developing clear COVID-19 care pathways, inclusive of long-term care facilities and home- and community-based care, for transfers to primary, secondary and tertiary care for people with COVID-19 and non-COVID-19 symptoms (87–89). Consider appropriate tele-health and virtual technologies for consultations, taking account of the views of older people, and provide any support necessary to use this technology effectively. Ensure that all palliative care plans and advanced care directives are up to date and applied through a person-centred approach. Ensure that national and regional policies, programmes and guidelines are in place to support the provision of palliative care in long-term care facilities and long-term care services (including physical, psychological, social and spiritual support). Long-term care facilities Consider involving the residents of long-term care facilities in the development of protocols for referral and access to essential health services. Ensure there is no selection based on age or disease in such protocols, but that people’s needs and preferences determine care decisions. Ensure that all long-term care facilities are supported by a primary care service. Establish rapid response teams, preferably with geriatric and palliative care training, for long-term care facilities for older people, to reduce avoidable hospitalizations and ensure optimal person-centred communication and decision-making. Ensure that staff are trained in providing palliative care and know how to communicate about death, dying and end-of-life decisions (35). Country examples In the United States, the use of home-based tele-health has been expanded as remote patient monitoring can now be reimbursed. Since March 2020, Medicare beneficiaries have been able to receive behavioural or substance use disorder interventions. For people with severe symptoms of COVID-19, post-acute tele-health visits are now possible. This enables social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists to perform remote evaluations and therapy. This may also support people with long-term care needs living in the community (61). In Italy, special palliative care teams were able to reorganize themselves rapidly in order to respond to demand quickly and flexibly. For example, they created networks of hospice care services by shifting staff from hospice inpatient to home care services. The experiences also highlighted the important need for case conferences and similar team collaborations to be able to decide quickly where to prioritize resources (for example, by deciding who will get support after hospital discharge) (50, 90). In Austria, the National Association for Palliative Care has issued a position paper on palliative care during the COVID-19 pandemic and has provided guidance on ensuring access to palliative care for people who will not receive the intensive care that normally is provided. The association has also published guidelines for family caregivers and long-term care workers. Furthermore, multidisciplinary guidance provided by the government is available to support people with COVID-19 who are reaching the end of life. There are also clinical guidelines and resources on how to facilitate social support and on bereavement for family carers and care workers supporting a person who reaches the end of life during the COVID-19 pandemic (76). In Slovenia, medical teams are ready to be sent to residential long-term care facilities to support regular staff if they become exhausted or overwhelmed (91). 18 Preventing and managing COVID-19 across long-term care services 2.6 ENSURE THAT INFECTION PREVENTION AND CONTROL STANDARDS ARE IMPLEMENTED AND ADHERED TO IN ALL LONG-TERM CARE SETTINGS TO PREVENT AND SAFELY MANAGE COVID-19 CASES 2.6.1 The challenge Lack of mandatory implementation of IPC guidance for long-term care Guidance on IPC for long-term care providers has been developed relatively late in the pandemic in many countries, and many of the guidelines have been slow to incorporate evidence of asymptomatic transmission and atypical symptoms of COVID-19. In many countries, guidance has only been developed for long-term care facilities, with no guidance available for providers of community-based care and for family caregivers. Finally, there is a lack of mechanisms to ensure implementation of these guidelines and to monitor their implementation. Lack of IPC experience and training in long-term care and resultant implementation difficulties In many countries, long-term care providers have weak IPC systems and training in place, resulting in many staff being unfamiliar with IPC and the correct use of PPE. This is a particular challenge for long-term care facilities that make high use of temporary or agency staff. Even where guidance and training are available, implementing some of the measures can be challenging due to the need for personal assistive care to be provided in close proximity. Lack of availability of testing and PPE, shortages of staff, difficulties in implementing physical distancing (given the design of traditional long-term care facilities), and a lack of alternative isolation facilities have been reported in countries that have struggled to contain infections in long-term care facilities. Across countries, guidelines have identified the importance of isolating residents exhibiting COVID-19- related symptoms, as well as those who have been in contact with people who are suspected of having or confirmed to have COVID-19. While in some countries residents in long-term care facilities live in single rooms with their own wet rooms, this is not the case in others. The specific structure of buildings in which long-term care facilities are housed may also pose barriers to the establishment of effective quarantine zones. Managers of long-term care facilities need to be supported in assessing the capacity of facilities to enable effective isolation policies and to provide additional quarantine spaces should the care setting not lend itself to effective isolation strategies. Countries that had experienced severe acute respiratory syndrome and Middle East respiratory syndrome had recently strengthened their IPC systems in long-term care facilities and community-based settings and have tended to systematically transfer people who are suspected or confirmed to have COVID-19 to isolation facilities, which appears to have been successful in controlling outbreaks (63). However, evidence on the impact of these measures on the mental and physical well-being of residents is not yet available. In some countries, there are large numbers of unregistered and therefore unregulated long-term care facilities. It is essential to support these facilities to ensure that they can keep their residents safe (53). Similarly, community-based care services are less often subject to direct regulatory control than residential long-term care facilities, and there are even fewer well developed information and monitoring systems that would enable the gathering of timely information on how the pandemic is affecting, directly or indirectly, people who rely on community-based care. Home care providers typically visit people with care 19 Preventing and managing COVID-19 across long-term care services needs in their own home. This means that care workers need to travel between homes and often visit multiple people with care needs. There is evidence that families have stopped using home care support to reduce the risk of infection for the person with care needs; however, this may create other risks (77, 81). IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of mechanisms to ensure implementation of IPC guidelines and monitor and assess implementation Lack of training of long-term care workforce on IPC measures High staff turnover impedes continuity of care and consistency of IPC measures Physical distancing is difficult to achieve for long-term care services Care workers cannot adequately access information on limiting transmission in the context of COVID-19 2.6.2 Key actions Whole sector Establish a coordinating body to develop, adjust and update IPC guidance and protocols during the COVID-19 pandemic for long-term care, based on the best available evidence (87-88, 92-93). Ensure implementation of the IPC guidance across long-term care services (for all settings). Establish a mechanism to plan, prioritize support for, and monitor implementation of measures to protect staff and people receiving long-term care from infection or spread of COVID-19. Establish early recognition, surveillance thresholds and escalation strategies for outbreaks of COVID-19 across long-term care. Consider how to ensure that providers of long-term care who may be operating outside the system (unregulated or illegal providers) can be supported to ensure the safety of the people living in their facilities or using their services. Ensure that everyone involved in direct delivery of care (staff and family caregivers), in long-term care facilities or in home care services, has access to IPC training (including use of PPE, hand hygiene, cleaning and disinfection of environments and waste management). This should be carried out regardless of their role, and especially for those having direct contact with older people with underlying health conditions (93). Consider developing and circulating standard operating procedures that give direction on how and when to rapidly isolate people receiving long-term care services, using the most up-to-date COVID-19 guidance. Implement extended IPC precautions for people discharged from hospital, based ideally on an agreed protocol for testing to determine individual needs for isolation and PPE required. Translate any strategies for standard operating procedures into clear referral systems that are made available to all staff delivering long-term care services. Long-term care facilities Ensure implementation of IPC guidance in long-term care facilities with reference to the WHO IPC guidance for long-term care facilities in the context of COVID-19 (92). Implement administrative controls, including syndromic surveillance upon entrance to a facility, for all staff and visitors. 20 Preventing and managing COVID-19 across long-term care services Ensure that staff in long-term care facilities have working conditions and arrangements that minimize their movement between settings and people receiving long-term care services, and that sick pay enables them to stay at home if they are unwell. Ensure that long-term care facilities have access to the resources needed to implement IPC (such as PPE, hand sanitizers and disinfectant). Develop the necessary IPC protocols and guidance and ensure that they are made available for visitors and are clearly visible in easy-to-understand formats (94). Develop guidance and ensure implementation of IPC protocol for staff and ensure educational resources are provided alongside continuous training. Ensure that long-term care facilities have an IPC focal point to lead and coordinate IPC activities, ideally supported by an IPC team with delegated responsibilities and advised by a multidisciplinary committee. Community-based care and caregivers Increase training and decision-making support for the long-term care workforce in the community to effectively manage COVID-19, including family caregivers, keeping in mind constraints, especially gender- related constraints, that family caregivers may face (87–88). Country examples In Jamaica, a temporary employment programme was created for regular cleaning of public sector long- term care facilities, and spaces were set aside in those facilities for isolation of symptomatic residents. Also, a multisectoral exercise between multiple State and private sector agencies facilitated deep sanitization of public long-term care facilities (79). In Indonesia, prevention measures in long-term care facilities include knowledge-sharing on hygiene principles with care workers and residents, regular disinfection and ventilation, and abstaining from sharing personal medical equipment. Residential long-term care facilities have put in place a registration system and do not allow visitors with symptoms of COVID-19 to enter the premises (95). In one region of China, after the severe acute respiratory syndrome epidemic, the regional authorities published the first guidelines on prevention of communicable diseases in residential long-term care facilities for the elderly in 2004, and required all operators of long-term care facilities to designate an infection control officer to coordinate and implement infection control measures within the facility, according to the guidelines (65). In Germany, the Robert Koch Institute recommends that domiciliary care workers wear face masks when providing care and that they regularly monitor their health. Additional equipment should be made available if the person they care for shows COVID-19-related symptoms (96). In the Netherlands, some home care workers are organized into special “Corona teams”. These teams look after people with COVID-19, while other teams care for people without infection (80). 21 Preventing and managing COVID-19 across long-term care services 2.7 PRIORITIZE TESTING, CONTACT TRACING AND MONITORING OF THE SPREAD OF COVID-19 AMONG PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.7.1 The challenge Many countries have experienced shortages in testing capacity as hospital services were prioritized In many countries there have been shortages of testing capacity as initially the available capacity was used mostly in hospitals, leaving providers of long-term residential and community services with difficulties in detecting people who had COVID-19. This approach is increasingly understood to have been a major problem, given the high rates of pre-symptomatic or asymptomatic people who have COVID-19 and could be spreading infection. Effective contact tracing in long-term care settings requires coordination and collaboration between long-term care providers and the relevant health authorities Effective testing, tracing and monitoring of COVID-19 in long-term care require coordination and collaboration between long-term care providers and the relevant health authorities. However, due to challenges in governance, such coordination has been difficult in the initial phases of the response. A growing number of countries are now including contact tracing in guidance for the long-term care sector and are developing apps and other systems to support contact tracing. Lack of systematic monitoring of the health status of people receiving and providing care Regular monitoring enables staff to detect changes in people’s health status, including the development of atypical symptoms (13), and to respond faster if a person with care needs or staff develop symptoms of COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities have become a blind spot for priority testing, tracing and monitoring of COVID-19 High rates of asymptomatic people who have COVID-19 have made early recognition and subsequent appropriate steps difficult 2.7.2 Key actions Whole sector Ensure testing data are aggregated and shared with local and national public health agencies so that the pandemic is managed at both the population and individual levels. Ensure contact tracing and isolation based on national guidance, with reference to WHO guidance on contact tracing in the context of COVID-19 (36, 97). Trace any clusters of infections or deaths of people in long-term care facilities or amongst those receiving home care services. 22 Preventing and managing COVID-19 across long-term care services Do not rely on symptoms alone, particularly “typical” cough and fever symptoms, when screening for COVID-19, and ensure that staff are trained in identifying other atypical symptoms, especially in older persons (36). Ensure that the health of people receiving and providing long-term care is monitored so that the development of symptoms (including atypical symptoms) can be detected quickly. Long-term care facilities In areas with ongoing or suspected community transmission, rigorous testing of both residents (including new admissions) and staff and tracing of close contacts are essential to develop isolation policies. Community-based care Ensure that people providing and receiving care in the community as well as their household members have access to testing and contact tracing, and have support if they need to isolate (87–88). Include household members of people with care needs in symptom monitoring. Examples In Denmark, both symptomatic and asymptomatic residents and staff in long-term care facilities can access testing at regional hospitals (since 12 May 2020). Even before that date, residents and staff were tested if there was an outbreak in a residential long-term care facility. If one resident shows symptoms, all residents and staff are tested within 24 hours and retested after seven days. If a staff member tests positive, all residents in the same area are also tested (98). In the Netherlands, all family caregivers that experience symptoms of COVID-19 can get tested (since 18 May 2020). In addition, family carers have been able to access free PPE since 19 May 2020 if they support vulnerable people (aged 70 years and older, with chronic conditions) who experience symptoms of COVID-19 and where personal assistive care (with less than 1.5 metres distance) is required (80). In Malaysia, all registered and unregistered long-term care facilities have undergone testing for COVID-19 (99). In the European Union, the European Centre for Disease Prevention and Control guidance recommends testing strategies that distinguish between “affected local areas” (random testing of residents and staff) and “unaffected areas”. Affected areas are those with actual or presumed continuing community transmission (73). 23 Preventing and managing COVID-19 across long-term care services 2.8 PROVIDE SUPPORT FOR FAMILY AND VOLUNTARY CAREGIVERS 2.8.1 The challenge Family caregivers provide an important share of care, but support such as respite care, training or care leave schemes remain limited and without compensation An important share of long-term care across countries is provided by family caregivers who provide care directly, and also help coordinate and complement formal services. In countries without established formal long-term care services, family caregivers provide almost all long-term care. Caregivers usually do not have access to any training for their role. Some countries recognize the impact of caregiving and offer support such as paid care leave, flexible work arrangements, respite care, training and psychological interventions, as well as cash benefits to mitigate negative impacts (29). However, access to these support structures remains limited in most countries and caregivers traditionally provide support without compensation, training or support (1). Even though caregivers’ important contribution is increasingly recognized, available support structures and financial support were already limited before the COVID-19 pandemic (100). The provision of intense levels of care has generally been associated with lower income and ultimately higher poverty rates, as well as poor mental health The largest share of this care is provided by women (61%), though the share of male caregivers increases with age (74). There are also many young (including children) and older caregivers who support family members with long-term care needs. The provision of intense levels of care has generally been associated with reduced labour force attachment (for those of working age), lower income and ultimately higher poverty rates (101). In addition, reduced income and lack of pension contributions exacerbate the risk of vulnerability and poverty in old age. Caregivers also have a higher prevalence of mental health problems (101). The COVID-19 pandemic has meant that some caregivers have had to adjust or give up their jobs to provide care or to avoid exposing the person they support to the risk of a COVID-19 infection. Caregivers working in the informal economy may also have experienced reduced working opportunities due to restrictions, posing a risk to their income. Caregivers also require support for the financial impact of the pandemic (102). The discontinuation of residential care options has left many family caregivers with increased responsibilities and without their usual support structures The COVID-19 pandemic has led to the closure of many day and respite care options, including community-based or short-term care, leaving many caregivers with additional responsibilities and without their established support structures. It is important to understand the issues caregivers face during this pandemic and how they can best be supported (102). Caregivers need to be able to get to the person with care needs, have access to information, PPE and testing, and be supported in developing contingency plans In many countries, government and NGOs have responded to this need by providing guidance and resource documents on hygiene measures to prevent infection and how to respond if the person with care needs or the caregivers themselves develop symptoms. Issues that have emerged during the pandemic include the need for caregivers to have permission to travel due to their care responsibility (78–79), supporting caregivers with access to testing and PPE (80), and developing contingency plans in case they can no longer continue to provide care (77). 24 Preventing and managing COVID-19 across long-term care services Changes in care needs and violence or abuse towards the caregiver Many caregivers are coping with changes in the needs of the person for whom they care (which may be due to infection or to the impact of the restrictive measures). Also, disruption to the normal routine may cause anxiety and stress in people with care needs, increasing pressure on caregivers (29). The COVID-19 pandemic has brought domestic violence and abuse to the surface (38). Family caregivers may also experience violence and abuse in their care relationship and require support (103). IMPLICATIONS IN THE CONTEXT OF COVID-19 Many caregivers have additional responsibilities without established support structures (such as day and respite care options) Social and physical distancing measures across countries are having negative health impacts on caregivers Even though caregivers’ important contribution is increasingly recognized, available financial support remains limited Caregivers experience difficulties in getting the necessary supplies, as they cannot easily leave the person they support alone Access to PPE and testing has largely been absent for family and voluntary caregivers Prolonged isolation, care responsibility without breaks, concerns about the person with care needs, worries about contingency care in case the caregiver becomes incapacitated, as well as violence or abuse towards the caregiver, have implications for caregivers’ mental health 2.8.2 Key actions Whole sector Record the main caregiver in health and long-term care records so that they become recognized as an important source of information and support. Long-term care facilities Enable family caregivers who provide psychological and practical support for people living in long-term care facilities to continue such roles through supportive measures that ensure the safety of the caregivers. Caregivers Provide information, training, support and, if possible, respite care at national level to caregivers, particularly those caring for older people living with dementia, including information on how to manage increased caregiving responsibilities and stress. Consider establishing a telephone helpline or online portal to offer advice, information and support (104). Consider rolling out an assessment to monitor family caregiver needs. Develop clear guidance for family caregivers on when and how to self-isolate. Increase vigilance and monitoring of domestic violence and support for family caregivers. Ensure access to PPE (without family caregivers bearing the inflated cost) and to equipment and medications. Explore new ways of providing support services to caregivers through technology, and support caregivers in accessing relevant technologies. Introduce or expand financial and psychosocial support for family caregivers. Provide bereavement support and ensure careful communication on decision-making with family. 25 Preventing and managing COVID-19 across long-term care services Country examples In Brazil, NGOs (such as the Brazilian Society of Geriatrics and Gerontology and the Brazilian Alzheimer’s Association) have published technical and educational caregiver guidance documents. A booklet has been prepared by FioCruz and other health-related organizations to educate caregivers of older people on preventive and protective measures for COVID-19. There is also a website by the Ministry of Women, Family and Human Rights dedicated to the provision of information for people with rare conditions and disabilities and their caregivers. A collaboration between the Ministry of Health and the Pan American Health Organization has developed a video campaign to support the mental health of people in Brazil who struggle with feelings of isolation, loneliness and distress. NGOs, such as the Alzheimer’s Association, provide helplines and online forums. Other groups have organized psychosocial activities (105). In India, guidelines issued by the Indian Ministry of Social Justice and Empowerment on 27 March 2020 recognized the importance of caregivers being able to get to the people they support. It was recommended that caregivers should be issued with passes that enable them to travel during the period of movement restrictions. Also, NGOs (such as the Alzheimer’s and Related Disorders Society of India, Nightingales Medical Trust and Silver Innings) and specialist services (National Institute of Mental Health and Neuro-Sciences, Cognitive Disorders Clinic) offer information and resources for caregivers of people living with dementia. The Nightingales Medical Trust provides the DemKonnect app, which offers expert advice to caregivers. The Ministry of Health and Family Welfare offers a psychosocial and behavioural helpline. In addition, it has provided videos (including on meditation and yoga) for stress management and mental health tips for different age groups on its website (78). In Ireland, the Dementia Services Information and Development Centre has provided resources for caregivers, including suggested activities for people living with dementia to mitigate the impact of social isolation. The Alzheimer Society of Ireland also offers relevant resources for support and information. Caregivers in receipt of the means-tested carer’s allowance continue to receive payments during the COVID-19 pandemic. In addition, working caregivers in receipt of the carer’s allowance who have lost their jobs due to the pandemic can also access the new pandemic unemployment payment of 350 euros. Similarly, Family Carers Ireland has developed guidance for the development of an emergency plan for caregivers (77). In Germany, the period for receiving long-term care allowance (Pflegeunterstützungsgeld) to respond to an emergency care situation in the family or to organize care arrangements has been doubled in response to the COVID-19 pandemic from 10 to 20 days (until 30 September 2020). The right to stay away from work to respond to an acute care situation has also been extended to 20 days. People who usually receive in-kind services that have become unavailable during the COVID-19 pandemic (such as day care) can be reimbursed to finance replacement care (96). 26 Preventing and managing COVID-19 across long-term care services 2.9 PRIORITIZE THE PSYCHOLOGICAL WELL-BEING OF PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.9.1 The challenge Many people with care needs experience a change to their routines and prolonged periods of isolation Many people, particularly older adults, with long-term care needs have been isolated in homes or facilities for many weeks, leading to reduced social contact and disrupted and changed routines. Some people with long-term care needs, such as people living with dementia, experience changes in their physical and cognitive status. Rapid changes to their routine may also increase their vulnerability to pre-existing conditions (84, 104). Specifically, in long-term care facilities, residents have struggled with not being able to socialize with fellow residents or to receive visits from their family and friends. Families are also extremely distressed that they are not able to visit and oversee the resident’s care. Long-term care facilities have recognized the importance of supporting residents with social contacts and have introduced innovative solutions, such as technical tools that enable virtual contact with their families and friends. Sharp increase in the risk of violence against older people Violence against older people, who are already bearing the brunt of this pandemic, has risen sharply since the beginning of the COVID-19 pandemic and imposition of restrictive stay-at-home measures. Violence is occurring in homes, in institutions such as long-term care facilities, and online, with a surge in scams directed at older people (106). Long-term care workers experience substantial pressure on their mental health during the COVID-19 pandemic Long-term care workers (compensated through pay) have experienced sustained pressure to provide care to vulnerable groups during the COVID-19 pandemic, and have worked hard to prevent the spread of COVID-19 to the people they assist. Many will have experienced traumatic situations and multiple bereavements. This leads to substantial pressure on their mental health. In the Netherlands, a survey by the Dutch Nurses’ Association (V&VN) found that 69% of community carers have felt greater pressure on their mental health during the COVID-19 pandemic. Among the 3325 respondents, 28% reported that there was no mental health support provided by their employer (80). Specific interventions to support the well-being of care workers are largely lacking. Some countries have recognized the mental health toll that the COVID-19 situation in long-term care facilities has taken on their staff and have put in place interventions to support the mental health of staff. In the United Kingdom, efforts have been made through support services to enhance the well- being of care workers. Migrant carers, particularly those who were commuting to provide care in other countries, may have found themselves either unable to return home after their shifts or unable to go to work (and therefore be paid) as countries closed their borders, leading to considerable hardship (76, 107). 27 Preventing and managing COVID-19 across long-term care services Family and voluntary caregivers experience great care responsibility and isolation, while their usual support services have largely been suspended Many family caregivers have been isolating with the person they care for to protect them from a COVID-19 infection. This has left them feeling disconnected from their social networks. In addition, their usual support structures (such as day care, home care, other family caregivers and carer support groups) have been reduced in frequency or suspended, leaving family caregivers without important social contacts and sources of practical support. In some countries, helplines, virtual counselling and carer support groups have been established to support caregivers’ psychosocial well-being during the COVID-19 pandemic. IMPLICATIONS IN THE CONTEXT OF COVID-19 There has been a significant impact on the mental health of the staff of long-term care facilities, family and voluntary caregivers, and people with assistive care needs Many residents of long-term care facilities have struggled with not being able to socialize with fellow residents, to participate in regular social activities, or to receive visits from their family and friends Specific interventions to support the well-being of people providing and receiving care are largely lacking 2.9.2 Key actions Whole sector Establish an intersectoral working group to monitor long-term care staff stress and burn-out, and assess and implement strategies to provide mental health and psychosocial support to staff delivering long- term care. Establish a dedicated helpline for mental health and psychological support for anyone who requests it. Consider providing guidance on training care staff and volunteers to improve communication skills on sensitive issues such as end-of-life decisions, death, dying and bereavement. Encourage long-term care providers on the use of screening tools, review staffing procedures (such as flexible schedules and work breaks) to better manage the burden of care, and seek to reduce the use of physical restraints. Ensure mental and emotional support is available from mental health professionals and family caregiver networks, using digital media when required to support recipients and providers of care. Support the monitoring of violence towards older people. Long-term care facilities Establish clear visiting policies that provide balance between IPC measures and the need for people to maintain their psychological well-being (enable residents to have visitors while minimizing the risk of COVID-19 entering long-term care facilities). Facilitate residents’ contact with family and friends by phone, the Internet or written messages if access is restricted. Increase recruitment of volunteers to help with providing social interaction for isolated residents. 28 Preventing and managing COVID-19 across long-term care services Community-based care Ensure access to and scale-up of resources for migrant live-in care workers. Encourage and enhance psychosocial support structures for family caregivers. Consider introducing mental health first aid training for volunteers and community members. Country examples In Chile, the National Service for Older Persons and the Society of Geriatrics and Gerontology have issued videos and graphics to support older people and family caregivers to cope with the COVID-19 situation. This material includes information on the use of PPE, distancing and mental health recommendations (108). It also offers templates to support the organization of community support for people needing help with the basic activities of daily living (109). In Mexico, the Ministry of Health implemented a mental health support campaign, which includes a rapid telephone assessment, to provide support strategies and to make referrals for specific support. Part of the strategy includes a campaign targeted at health care workers (110). In Kenya, some NGOs have moved to virtual peer support. However, poor connectivity in some areas, the cost of purchasing Internet bundles, and online fatigue pose challenges to efforts to support family carers. The Ministry of Labour and Social Protection published guidance for long-term care facilities, which explicitly states that staff should ensure that residents can maintain regular communication (through mobile calls or online chats) with their families and social networks, and should promote the well-being of residents by establishing regular routines and reducing interruptions to those (111). In Malaysia, staff of day care centres continue to look after the people they support through video calls, as well as sharing activities and exercise videos (99). In the United Kingdom, the COVID Trauma Response Working Group has developed guidance for managers and service planners concerned with looking after staff of long-term care facilities who may have experienced trauma (112). 29 Preventing and managing COVID-19 across long-term care services 2.10 ENSURE A SMOOTH TRANSITION TO THE RECOVERY PHASE 2.10.1 The challenge Loss in public confidence in long-term care facilities The COVID-19 pandemic has disproportionately affected people who live in long-term care facilities, and the share of deaths in those facilities appears to increase with the number of people affected in the community. This suggests that as long as there is community transmission of COVID-19 locally, long- term care facilities are at high risk of infection and large numbers of deaths. There are concerns in many countries about the loss in public confidence in long-term care facilities, and the possible negative impacts that might result if people who would benefit from living in a long- term care facility fail to do so because of fear. This may have negative consequences for these persons, for their families, and also for the financial viability of providers of long-term care facilities. Movement restrictions and other shielding measures in long-term care facilities One of the first measures adopted in almost all countries has been restricting visitors to long-term care facilities. While this measure is relatively easy to implement, it is increasingly recognized that it has an enormous impact on the well-being of both the residents of long-term care facilities and their families, and that, particularly where the resident has dementia, a lack of understanding of why the visits have stopped may generate additional distress. Concerns have also been expressed that many family members provide care in their regular (sometimes daily) visits, and that not allowing them to visit at a time when the staff of long-term care facilities may already be overburdened due to increased complexity of care and lower staffing ratios may compound staffing problems. Difficulties in monitoring quality of services in long-term care facilities Another concern is that family member visits have stopped at a time when many countries have suspended inspections. Families may be concerned about the quality of care the residents are receiving, and not being allowed to visit may exacerbate their fears. Ensuring safe visiting is increasingly recognized as a key step in rebuilding trust in long-term care facilities. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of exit strategy on restrictive measures applied to long-term care facilities Lack of monitoring quality of care within long-term care facilities when movement restrictions are implemented for those facilities 30 Preventing and managing COVID-19 across long-term care services 2.10.2 Key actions Long-term care facilities Make available surveillance mechanisms to monitor the quality of care within long-term care facilities during implementation of public health and social measures. Make available guidance on thresholds as to when and how to phase in or out isolation of residents and loosen restrictions on visitors. Establish clear criteria on when and how people living in long-term care facilities can move to and from hospitals to protect both staff and other residents. Ensure that the needs of long-term care residents are considered in providing acute, primary and community health services, and that pre-COVID-19 levels of support from primary care and community nursing are reinstated as early as possible. Community-based care Ensure that protocols are being developed so that people receiving community care (for example, day care) can access these services again. Country examples In Malta, day care services started again on a rotational basis on 1 June 2020. People with care needs receiving no services were given priority. Strict hygiene procedures and distancing measures were put in place. For example, staff and people with care needs keep shoes at the day care facility and change when they leave. People with care needs have to wear masks and visors while attending the centre. Staff also wear visors throughout the working day. In addition, people receiving and providing care have their temperature monitored (58). In Denmark, people could continue to visit residents receiving end-of-life care while adhering to hygiene protocols. Since 24 April 2020, residents in long-term care facilities can receive visitors in the outdoor areas (98). In Germany, restrictions around visitors started to be relaxed again in May 2020. While specific rules on the number of people visiting and the frequency and lengths of their visits vary between federal states, all states require that long-term care facilities put clear infection prevention measures in place. Visitors also have to register so that they can be identified for contact tracing if this becomes necessary (96). 31 Preventing and managing COVID-19 across long-term care services 2.11 INITIATE STEPS FOR TRANSFORMATION OF HEALTH AND LONG-TERM CARE SYSTEMS TO APPROPRIATELY INTEGRATE AND ENSURE CONTINUOUS, EFFECTIVE GOVERNANCE OF LONG-TERM CARE SERVICES The COVID-19 pandemic has highlighted fragmentation between long-term care services within health care systems. This fragmentation, along with inherent weaknesses in the current overarching governance structure for long-term care, has led to devastating consequences for long-term care facilities during the COVID-19 pandemic. It is with urgency that we need to transform health and long-term care systems so that long-term care services are readily integrated and provided alongside the traditional continuum of care: promotion, prevention, treatment, rehabilitation and palliation. It must be emphasized that assistive care, defined in this document as assistance provided to help a person perform a particular task to maintain functional ability and preserve independence, is considered an essential service that helps to promote ageing in place and ensure that a person can continue to do what they have reason to value even after significant declines in physical and mental capacity. The WHO Global Strategy and Action Plan on Ageing and Health, adopted in 2016, states that “Every country should have a sustainable and equitable system of long-term care” (44). The Decade of Healthy Ageing (2020–2030) also emphasizes access to long-term care for older people who need it (113). Although long-term care is not just for older people and includes a diverse range of users, the fundamentals are the same: providing services to those that are in need of long-term care in order to ensure a life consistent with their basic rights, fundamental freedoms and human dignity. The following actions reflect the lessons we are learning from the COVID-19 pandemic to realize sustainable and equitable long-term care for all. Key actions Ensure legislation and establish national strategy and frameworks on long-term care. Strengthen relationships between different levels of government involved in long-term care and health care and develop concrete vertical and intersectoral coordination mechanisms. Integrate regular national data collection of health and long-term care systems to enable systemwide evaluation and monitoring. Ensure sustainable and equitable financing mechanisms for long-term care that protect people from catastrophic costs of care. Ensure integrated person-centred care pathways spanning the health and long-term care continuum to enable people with long-term care needs to receive comprehensive care. Ensure continuous training and improved working conditions for the long-term care workforce. Introduce and expand financial and in-kind support for family and voluntary caregivers. Identify mechanisms to ensure quality services in the unregulated long-term care sector and strengthen accreditation. Ensure health sector oversight of long-term care facilities to prepare for future pandemics. Promote research building on lessons learned from the COVID-19 pandemic to address weaknesses in the health and long-term care system. 32 Preventing and managing COVID-19 across long-term care services References 1. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ handle/10665/186463). 2. Care work and care jobs for the future of decent work. Geneva: International Labour Organization; 2018 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/documents/publication/ wcms_633135.pdf, accessed 21 June 2020). 3. Who cares? Attracting and retaining care workers for the elderly. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd.org/publications/who-cares-attracting-and- retaining-elderly-care-workers-92c0ef68-en.htm, accessed 23 June 2020). 4. Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region: strengthening the health systems response to COVID-19. Technical Working Guidance No. 6. WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health-topics/Health-systems/ health-services-delivery/publications/2020/strengthening-the-health-systems-response-to-covid-19- technical-guidance-6,-21-may-2020, accessed 21 June 2020). 5. Salcher-Konrad M, Jhass A, Naci H, Tan M, El-Tawil Y, Comas-Herrera A. COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence. medRxiv. 2020. doi:10.1101/2020.06.09.20125237. 6. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N, Fernández J-L. Mortality associated with COVID-19 outbreaks in LTCFs: early international evidence. International Long-Term Care Policy Network; 2020 (https:// ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in-care-homes-early-international- evidence/, accessed 21 June 2020). 7. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 8. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 9. American Geriatrics Society. American Geriatrics Society (AGS) policy brief: CCOVID-19 and assisted living facilities. Journal of the American Geriatrics Society. May 2020:jgs.16510. doi:10.1111/jgs.16510. 10. American Geriatrics Society. American Geriatrics Society policy brief: COVID-19 and nursing homes. Journal of the American Geriatrics Society. 2020;68(5):908–11. doi:10.1111/jgs.16477. 11. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. New England Journal of Medicine. 2020;382:2081– 90. doi:10.1056/nejmoa2008457. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. UN SP LA SH / AR NE L HA SA NO VI C 33 Preventing and managing COVID-19 across long-term care services 13. Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A et al. SARS-CoV-2 infection: clinical features and outcome of COVID-19 in United Kingdom nursing homes. Journal of Infection. 2020;5:38. doi:10.1016/j. jinf.2020.05.073. 14. Goldberg SA, Pu CT, Thompson RW, Mark E, Sequist TD, Grabowski DC. Asymptomatic spread of COVID-19 in 97 patients at a skilled nursing facility. Journal of the American Medical Directors Association. 2020. doi:10.1016/j.jamda.2020.05.040. 15. Guery R, Cécile D, Noëlle B, Nael V, Castain L, Raffi F et al. Limited effectiveness of systematic screening by nasopharyngeal RT-PCR of medicalized nursing home staff after a first case of COVID-19 in a resident. Médecine et Maladies Infectieuses. May 2020. doi:10.1016/j.medmal.2020.04.020. 16. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A et al. Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults: Seattle, Washington, 2020. Morbidity and Mortality Weekly Report. 2020;69(14):416–8. doi:10.15585/mmwr. mm6914e2. 17. Grabenhorst U, Stiels-Prechtel R, Niemann M, Weckbecker K. COVID-19 in the nursing home: a case report. MMW-Fortschritte der Medizin. 2020;162(9):60–2. doi:10.1007/s15006–020–0481–0. 18. Dora AV, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans: Los Angeles, California, 2020. Morbidity and Mortality Weekly Report. 2020;69(21):651–5. doi:10.15585/mmwr.mm6921e1. 19. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. 2020;382(21):2005– 11. doi:10.1056/NEJMoa2005412. 20. Coronavirus (COVID-19) related deaths by occupation, England and Wales. Office for National Statistics; 2020 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/ bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistereduptoandinc luding20april2020#:~:text=A%20total%20of%20131%20deaths,100%2C000%20females%20(86%20 deaths), accessed 21 June 2020). 21. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 22. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherapy. May 2020. 23. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 24. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 25. COVID-19. Sciensano (https://epistat.wiv-isp.be/covid, accessed 21 June 2020). 26. Fisman D, Lapointe-Shaw L, Bogoch I, McCready J, Tuite A. Failing our most vulnerable: COVID-19 and long- term care facilities in Ontario. medRxiv. doi:10.1101/2020.04.14.20065557. 27. Yanover C, Mizrahi B, Kalkstein N, Marcus K. What factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization. medRxiv. 2020. doi:10.1101/ 2020.05.07.20091652. 28. Dawson WD, Ashcroft E, Lorenz-Dant K, Comas-Herrera A. Impact of the COVID-19 outbreak on community- based care services: a review of initial international policy responses. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Community-Based-Care-Report-19- May.pdf, accessed 21 June 2020). 29. Lorenz-Dant K. International examples of measures to support unpaid carers during the COVID-19 pandemic. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ 34 Preventing and managing COVID-19 across long-term care services International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-20.05.20-complete-2. pdf, accessed 21 June 2020). 30. COVID-19 supercharges existing inequalities faced by Glasgow’s 150,000 disabled people. Glasgow Disability Alliance; 2020 (http://gda.scot/our-community/news/2020/4/28/covid-19-supercharges-existing- inequalities-faced-by-glasgows-150–000-disabled-people, accessed 21 June 2020). 31. Noncommunicable diseases and COVID-19. Geneva: World Health Organization (https://www.who.int/ teams/ncds/covid-19, accessed 21 June 2020). 32. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–332240, accessed 21 June 2020). 33. Coronavirus: Spanish army finds care home residents “dead and abandoned”. BBC News, 24 March 2020 (https://www.bbc.co.uk/news/world-europe-52014023, accessed 21 June 2020). 34. 31 Senioren in Kanada tot: Pfleger kamen aus Angst vor Corona nicht [31 seniors dead in Canada: carers did not come for fear of Corona]. MSN, 18 April 2020 (https://www.msn.com/de-at/news/other/31-senioren- in-kanada-tot-pfleger-kamen-aus-angst-vor-corona-nicht/ar-BB12QiDh#image=1, accessed 21 June 2020). 35. Bauer A, Dixon J. The challenges of providing end-of-life support in LTCFs during the COVID-19 pandemic, and opportunities for the future: an international perspective. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Challenges-of-providing-end-of-life-support-in- care-homes-during-the-COVID-19-pandemic-1.pdf, accessed 21 June 2020). 36. Clinical management of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https:// www.who.int/publications-detail/clinical-management-of-covid-19, accessed 21 June 2020). 37. Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions. In: Gender equality. Paris: Organisation for Economic Co-operation and Development; 2019 (https://www.oecd.org/gender/data/womenare-well-represented-in-health-and-long-term-care- professions-but-often-in-jobs-with-poor-workingconditions.ht, accessed 21 June 2020). 38. COVID-19 and violence against women: what the health sector/system can do. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/331699. 39. Shippee T, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao M et al. COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging and Social Policy. June 2020. doi:10.1080/08959420.2020.1772004. 40. Long-term care for older people: a new global gender priority. New York; UN Women; 2017. 41. Policy brief: the impact of COVID-19 on older persons. New York: United Nations; 2020. 42. Scheil-Adlung X. Global estimates of deficits in long-term care protection for older persons. Extension of Social Security Series, No. 50. Geneva: International Labour Organization; 2015. 43. Help wanted? Providing and paying for long-term care. Paris: Organisation for Economic Co-operation and Development; 2011. 44. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. Report by the Secretariat. Sixty-ninth World Health Assembly, April 2016. Geneva: World Health Organization; 2016 (https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17-en.pdf?ua=1, accessed 21 June 2020). 45. Accelerating global actions for a world without poverty: United Nations System-wide Plan of Action for the Third United Nations Decade for the Eradication of Poverty (2018–2027). New York: United Nations; 2018 (https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/03/SWAP-Poverty- Booklet-Digital-Feb27.pdf, accessed 21 June 2020). 46. Barr N. Long-term care: a suitable case for social insurance. Social Policy and Administration. 2010;44(4):359– 74. doi:10.1111/j.1467–9515.2010.00718.x. 47. Protective equipment being diverted from LTCFs to hospitals, say bosses. The Guardian, 30 March 2020 (https://www.theguardian.com/world/2020/mar/30/protective-equipment-being-diverted-from-care- homes-to-hospitals-say-bosses, accessed 21 June 2020). 35 Preventing and managing COVID-19 across long-term care services 48. Spasova S, Baeten R, Coster S, Ghailani D, Pena-Casas R, Vanhercke B. Challenges in long-term care in Europe: a study of national policies. Brussels: European Commission; 2018. 49. Zalakain J, Davey V, Suárez-González A. The COVID-19 on users of long-term care services in Spain. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTCcovid-Spain-country-report-28-May-1.pdf, accessed 21 June 2020). 50. Berloto S, Notarnicola E, Perobelli E, Rotolo A. Italy and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID19- situation-in-Italy-30-April-2020.pdf, accessed 21 June 2020). 51. King D, Zigante V. Quality assurance practices in long-term care in Europe: emerging evidence on care market management. Brussels: Publications Office of the European Union; 2020. 52. Lloyd-Sherlock P, Neto J, Comas-Herrera A, Redondo N. Re: Covid-19: why we need a national health and social care service. BMJ. 2020;369. doi:10.1136/bmj.m1465. 53. Lloyd-Sherlock P, Bastos J, Geffen L, Giacomin K, Redondo N, Sasat S et al. An emergency strategy for managing COVID-19 in LTCFs in LMICs: the CIAT Framework. 2020 (https://www.corona-older.com/post/ an-emergency-strategy-for-managing-covid-19-in-care-homes-in-lmics-the-ciat-framework-version-1, accessed 21 June 2020). 54. Country assessment framework for the integrated delivery of long-term care. Copenhagen: WHO Regional Office for Europe; 2019. 55. COVID-19: Singapore to house nursing home staff in hotels to protect the elderly. Channel News Asia, 8 May 2020 (https://www.facebook.com/ChannelNewsAsia/videos/1098221953890384/, accessed 21 June 2020). 56. Covid-19 testing completed for nursing home residents and staff; no new cases found apart from 5 earlier ones. The Straits Times, 31 May 2020 (https://www.straitstimes.com/singapore/health/covid-19-testing- completed-for-all-nursing-home-residents-and-staff, accessed 21 June 2020). 57. Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G, Brammli-Greenberg S. The impact of COVID-19 on people using and providing long-term care in Israel. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4- May.pdf, accessed 21 May 2020). 58. Fenech MA, Vella M, Calleja N. The COVID-19 long-term care situation in Malta and Gozo. International Long-Term Care Policy Network; 2020. 59. Cès S, Coster S. Mapping long-term care quality assurance practices in the EU: summary report. Brussels: European Commission; 2019. 60. Hashiguchi T, Llena-Nozal A. The effectiveness of social protection for long-term care in old age: is social protection reducing the risk of poverty associated with care needs? OECD Health Working Papers. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd-ilibrary.org/social- issues-migration-health/the-effectiveness-of-social-protection-for-long-term-care-in-old-age_2592f06e-en, accessed 21 June 2020). 61. Van Houtven CH, Boucher NA, Dawson WD. The impact of COVID-19 outbreak on long term care in the United States. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf, accessed 21 June 2020). 62. HHS Provider Relief Fund. Centers for Disease Control and Prevention; 2020 (https://data.cdc.gov/ Administrative/HHS-Provider-Relief-Fund/kh8y-3es6, accessed 21 June 2020). 63. Kim H. The impact of COVID-19 on long-term care in South Korea and measures to address it. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term- Care-COVID19-situation-in-South-Korea-7-May-2020.pdf, accessed 21 June 2020). 64. Lum T, Shi C, Wong G, Wong K. COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging and Social Policy. 2020. doi:10.1080/08959420.2020.1773192. 36 Preventing and managing COVID-19 across long-term care services 65. Wong K, Lum T, Wong G. The COVID-19 long-term care situation in Hong Kong: impact and measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/ Hong-Kong-COVID-19-Long-term-Care-situation-27-April-2020–1.pdf, accessed 21 June 2020). 66. Shi C, Hu B, Feng M, Wong G. Report from mainland China: policies to support long-term care during the COVID-19 outbreak. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/Report-from-Mainland-China-18-April-final.pdf, accessed 21 June 2020). 67. Statistics Commission endorses new Titchfield City Group on Ageing. New York: United Nations Department of Economic and Social Affairs; 16 March 2018 (https://www.un.org/development/desa/ageing/ news/2018/03/title-statistics-commission-endorses-new-titchfield-city-group-on-ageing/, accessed 21 June 2020). 68. Descubren una residencia ilegal en La Laguna por las pruebas del Covid-19 [They discover an illegal residence in La Laguna by the tests of Covid-19]. La Provincia, 4 April 2020 (https://www.laprovincia.es/ sociedad/2020/04/04/descubren-residencia-ilegal-laguna-pruebas/1271776.html, accessed 21 June 2020). 69. Burton A, Goodman C, Quinn T. The invisibility of the UK care home population: UK care homes and a minimum dataset. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/ the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/, accessed 21 June 2020). 70. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 71. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.9540. 72. Jacobs R, Ashwell A, Docrat S, Schneider M. The impact of COVID-19 on long-term care in South Africa. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/ COVID-19-Long-Term-Care-Situation-in-South-Africa.docx, accessed 21 June 2020). 73. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. European Centre for Disease Prevention and Control; 2020 (https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term- care-facilities-EU-EEA, accessed 21 June 2020). 74. Rodrigues R, Huber M, Lamura G. Facts and figures on healthy ageing and long-term care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research; 2012. 75. Van Houtven CH, DePasquale N, Coe NB. Essential long-term care workers commonly hold second jobs and double- or triple-duty caregiving roles. Journal of the American Geriatrics Society. 2020. doi:10.1111/ jgs.16509. 76. Schmidt AE, Leichsenring K, Staflinger H, Litwin C, Bauer A. The impact of COVID-19 on users and providers of long-term care services in Austria. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/ wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Austria-15-May.pdf, accessed 22 June 2020). 77. Pierce M, Keogh F, O’Shea E. The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf, accessed 22 June 2020). 78. Rajagopalan J, Huzruk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTC-COVID-situation-in-India-30th-May.pdf, accessed 22 June 2020). 79. Amour R, Robinson JN, Govia I. The COVID-19 long-term care situation in Jamaica. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term- Care-situation-in-Jamaica-25-May-2020–1.pdf, accessed 22 June 2020). 37 Preventing and managing COVID-19 across long-term care services 80. Kruse F, Abma I, Jeurissen P. The impact of COVID-19 on long-term care in the Netherlands. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long- Term-Care-situation-in-the-Netherlands-25-May-2020–1.pdf, accessed 22 June 2020). 81. Low L-F. The long-term care COVID-19 situation in Australia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Australia-LTC-COVID19-situation-24-April-2020. pdf, accessed 22 June 2020). 82. Extra payment for unpaid carers. Scottish Government, 6 May 2020 (https://www.gov.scot/news/extra- payment-for-unpaid-carers/, accessed 22 June 2020). 83. Global action plan on the public health response to dementia 2017–2025. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259615). 84. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo J et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190–1. 85. Suarez-Gonzalez A, Livingston G, Comas-Herrera. Report: the impact of the COVID-19 pandemic on people living with dementia in UK. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/2020/05/03/report-the-impact-of-the-covid-19-pandemic-on-people-living-with-dementia-in-uk/, accessed 22 June 2020). 86. Joint statement on advance care planning. Care Quality Commission; 2020 (https://www.who.int/ publications/i/item/WHO-2019-nCoV-Comm_health_care-2020.1). 87. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ WHO-2019-nCoV-Comm_health_care-2020.1 accessed 22 June 2020). 88. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms- and-management-of-contacts, accessed 22 June 2020). 89. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 90. Bauer A. COVID19: providing palliative care for the many. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/03/31/covid19-proving-palliative-care-for-the-many/, accessed 22 June 2020). 91. Oven A. COVID-19 and long-term care in Slovenia: impact, measures and lessons learnt. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/COVID19-and- Long-Term-Care-in-Slovenia-impact-measures-and-lessons-learnt-21-April-2020.pdf, accessed 22 June 2020). 92. Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO- 2019-nCoV-Comm_health_care-2020.1, accessed 22 June 2020). 93. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. Geneva: World Health Organization; 2020 (https://www. who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-of- health-workers-including-key-considerations-for-occupational-safety-and-health, accessed 22 June 2020). 94. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–331495, accessed 22 June 2020). 95. Sani TP, Tan M, Rustandi KK, Turana Y. COVID-19 long-term care situation in Indonesia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19- Long-Term-Care-situation-in-Indonesia-30-May-1.pdf, accessed 22 June 2020). 96. Lorenz-Dant K. Germany and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19–26-May-2020. pdf, accessed 22 June 2020). 38 Preventing and managing COVID-19 across long-term care services 97. Contact tracing in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who. int/publications/i/item/contact-tracing-in-the-context-of-covid-19, accessed 22 June 2020). 98. Rostgaard T. The COVID-19 long-term care situation in Denmark. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care- situation-in-Denmark-29-May-2020.pdf, accessed 22 June 2020). 99. Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST. The long term care COVID-19 situation in Malaysia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/05/Malaysia-LTC-COVID-situation-report-30-May.pdf, accessed 22 June 2020). 100. Health at a glance 2019: OECD indicators. Paris: Organisation for Economic Co-operation and Development; 2019 (http://www.oecd.org/health/health-systems/health-at-aglance-19991312.htm, accessed 22 June 2020). 101. Brimblecombe N, Fernandez J-L, Knapp M, Rehill A, Wittenberg R. Unpaid care in England: future patterns and potential support strategies. London: London School of Economics; 2018. 102. Caring behind closed doors: forgotten families in the coronavirus outbreak. London: Carers UK; 2020 (https:// www.carersuk.org/for-professionals/policy/policy-library/caring-behind-closed-doors-report, accessed 22 June 2020). 103. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? Journal of Gerontological Social Work. 2014;57(5):460–77. doi:10.1080/01634372.2014.882466. 104. Mental health and psychosocial considerations during the COVID-19 outbreak: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/mental-health-and- psychosocial-considerations-during-the-covid-19-outbreak, accessed 22 June 2020). 105. Da Mata F, Oliveira D. COVID-19 and long-term care in Brazil: impact, measures and lessons learned. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf, accessed 22 June 2020). 106. COVID-19 and violence against older people. Geneva: World Health Organization; 2020 (https://www.who. int/publications/m/item/covid-19-and-violence-against-older-people, accessed 22 June 2020). 107. Leiblfinger M, Prieler V, Schwiter K, Steiner J, Benazha A, Lutz H. Impact of the COVID-19 pandemic on live-in care workers in Germany, Austria and Switzerland. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/impact-of-the-covid-19-pandemic-on-live-in-care-workers-in-germany- austria-and-switzerland/, accessed 22 June 2020). 108. Coronavirus Plan of Action. Chile: Senama (http://www.senama.gob.cl/protocolos-covid-19, accessed 22 June 2020). 109. Cuenta con migo [count on me]. Government of Chile (https://www.gob.cl/cuentaconmigo/, accessed 22 June 2020). 110. López-Ortega M, Sosa-Tinoco E. COVID-19 and long-term care in Mexico: questions, challenges, and the way forward. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/06/LTC-Covid-19-situation-in-Mexico-8-June.pdf, accessed 22 June 2020). 111. Musyimi C, Mutunga E, Ndetei D. COVID-19 and long-term care in Kenya. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/06/02/new-country-report-the-covid-19-long-term-care- situation-in-kenya/, accessed 22 June 2020). 112. COVID Trauma Response Working Group (https://www.traumagroup.org/, accessed 22 June 2020). 113. Decade of Healthy Ageing 2020–2030. Geneva: World Health Organization; 2020 (https://www.who.int/ docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en. pdf?sfvrsn=b4b75ebc_3, accessed 22 June 2020). 114. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 39 Preventing and managing COVID-19 across long-term care services 40 Preventing and managing COVID-19 across long-term care services Annex 1. Methods Living systematic review A living systematic review was undertaken, aiming to synthesize early international evidence on mortality rates and incidence of COVID-19 among people who use and provide long-term care. The review was registered with Prospero (CRD42020183557) and includes studies identified through database searches conducted on 15 May 2020 and updated up to 5 June 2020. The methods and findings have been published in full in medRxiv. Seven databases were searched (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv) to identify all studies reporting primary data on COVID-19-related mortality and incidence of disease among long-term care users and staff. In addition, evidence on country-level mortality rates was identified from LTCcovid.org, an international network of long- term care experts. Studies not focusing on long-term care were excluded. Included primary studies were critically appraised and results on number of deaths and COVID-19-related mortality rates, case fatality rates, and excess deaths (co-primary outcomes), as well as incidence of disease, hospitalizations, and intensive care unit admissions, were synthesized narratively. Title and abstract screening, and a full text review, were undertaken by three reviewers and records reporting on the same study or outbreak were combined. A standardized template was used to extract data at the study level, including information on study design; care setting (institutional versus community); how COVID-19 was diagnosed and confirmed; baseline characteristics of participants; absolute number of deaths and mortality rates from confirmed and suspected COVID-19 cases; case fatality rates; excess deaths; absolute numbers and rates of confirmed and suspected COVID-19; and rates of hospitalization and intensive care unit admissions among confirmed and suspected COVID-19 cases. All study participant characteristics and outcome data were extracted separately for long-term care users and staff. Information was also extracted on the proportion of asymptomatic cases at time of testing, and findings of studies comparing outcomes in long-term care users to others. Due to heterogeneity in the definitions of numerators, denominators, and follow-up times across included studies, data were not pooled. Instead, results were summarized narratively and presented in tables, including information on sample characteristics, follow-up time, and case definitions, as appropriate. Where studies reported on overlapping populations, preference was given to those with larger sample sizes and longer follow-up times. The quality of included primary studies reporting figures relating to mortality rates, case fatality rates, or disease incidence were assessed using the Joanna Briggs Institute critical appraisal tool for prevalence studies. Risk of bias across studies was not assessed. A total of 33 study reports for 30 unique primary studies or outbreak reports were included (Figure A1.1). UN SP LA SH / R IZ AL H IL M AN 41 Preventing and managing COVID-19 across long-term care services MEDLINE: n=673 Embase: n=43 CINAHL Plus: n=221 Web of Science: n= 184 Global Health: n=7 WHO COVID-19 Research Database n=202 medRxiv: n=3454 LTCcovid.org: n=22 Total included: n=33 (30 unique, original studies) Updated database searches: n=418 Database searches: n=4806 Included in first review: n=30 (27 unique, original studies) After deduplication: n=418 Full text review: n=33 Newly included: n=4 After deduplication: n=4457 Full text review: n=247 Excluded after title and abstract screening: n=4210 Excluded after full text review Not focused on LTC: n=75 Review article: n=52 No mortality or infection data: n=56 Opinion piece: n=25 Full text not accessible: n=7 Modelling study: n=3 Not focused on COVID-19: n=3 Duplicate: n=3 Excluded after title and abstract screening: n=385 Excluded after full text review Review article: n=8 Opinion piece: n=6 No mortality or infection data: n=4 Not focused on LTC: n=3 Not focused on COVID-19: n=2 Duplicate: n=1 Full text not accessible: n=0 Modelling study: n=0 Excluded: 1 previously included study (withdrawn by author) Records identified through other sources: n=3 Figure A1.1 Flow chart for selection of included primary studies 42 Preventing and managing COVID-19 across long-term care services Pilot of a systematic review of effectiveness of interventions to mitigate the impact of COVID-19 on people who use and provide long-term care A systematic review on the effectiveness of interventions to manage the impact of COVID-19 on people who use and provide long-term care is under development. While piloting the search strategy across seven databases (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv), 21 studies were identified that described responses to the COVID-19 pandemic and provided some sort of evaluation of effectiveness or aimed to assess characteristics of long-term care services associated with COVID-19 infection rates and associated mortality. There were five reports from the United States, three from Italy, two each from Canada, China, the Republic of Korea and Spain, and one report each from Belgium, France, Ireland, Singapore and the United Kingdom. The interventions identified and target groups varied. Three of the studies related to pharmacological therapies in care homes (1–3), additional studies described the implementation of measures to prevent (China and Singapore) and contain (Canada, China, the Republic of Korea and the United States of America) outbreaks in care homes (1, 4–8), one study reported about prevention measures for community-based care in the United States (9), four reported on multifaceted organizational changes to deal with COVID-19 in long-term care settings, including multidisciplinary collaboration and coordination (6, 10–12), three were pilot studies for detecting COVID-19 through rapid point-of-care testing, pooled testing, and bedside chest ultrasonography (13–15), and one adapted an existing cognitive stimulation intervention for people with dementia to provide information and support in relation to COVID-19 (16). These studies were mostly descriptive and, lacking a control group, were not designed to rigorously evaluate the effectiveness of implemented measures. Nevertheless, the prevention and outbreak management interventions described in the papers from China, the Republic of Korea and Singapore all reported successes in preventing or containing outbreaks. Another three studies assessed the association between different characteristics of care homes and COVID-19 outbreaks and outcomes. Stall et al. found that for-profit status of nursing homes in Ontario, Canada, was associated with both the size of a nursing home outbreak and the number of resident deaths (17). However, for-profit status was not associated with a higher likelihood of an outbreak. Romero-Ortuño and Kennelly found moderate, statistically significant association between crude number of deaths and maximum occupancy in Irish care homes, but no statistically significant association was found for quality of care homes (18). Similarly, Abrams et al. did not find a statistically significant association between the reporting of at least one COVID-19 case in United States nursing homes and traditional quality criteria (19). However, a statistically significant association was found for larger facility size, urban location, percentage of African-American residents, non-chain status, and state. Finally, two studies analysed the association between regional characteristics, including features of the long- term care system such as the proportion of private versus public long-term care beds and the availability of nursing home beds, and spread of COVID-19 in Italian regions (20–21). Country reports on the COVID-19 long-term care situation Country reports published on the LTCcovid website (an initiative of the International Long-Term Care Policy Network) were reviewed. The reports were produced by experts in long-term care, usually academics. The reports aimed to document the impact of COVID-19 on people who use and provide long-term care in each country, and the measures adopted to mitigate the impacts of the pandemic on this population. Information from these reports informed the examples of measures adopted by different countries. 43 Preventing and managing COVID-19 across long-term care services References 1. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 2. Ahmad I, Alam M, Saadi R, Mahmud S, Saadi E. Doxycycline and hydroxychloroquine as treatment for high- risk COVID-19 patients: experience from case series of 54 patients in long-term care facilities. medRxiv. May 2020. doi:10.1101/2020.05.18.20066902. 3. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 4. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherarpy. May 2020. 5. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 6. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 7. Munanga A. Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing. 2020;46(6):3–5. doi:10.3928/00989134–20200511–03. 8. Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M et al. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. Journal of Intellectual Disability Research. 2020. doi:10.1111/jir.12740. 9. Archbald-Pannone LR, Harris DA, Albero K, Steele RL, Pannone AF, Mutter JB. COVID-19 collaborative model for an academic hospital and long-term care facilities. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.044. 10. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 11. Koeberle S, Tannou T, Bouiller K, Becoulet N, Outrey J, Chirouze C et al. COVID 19 outbreak: organisation of a geriatric assessment and coordination unit – a French example. Age and Ageing. May 2020. doi:10.1093/ ageing/afaa092. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Cabrera JJ, Rey S, Perez S, Martinez-Lamas L, Cores-Calvo O, Torres J et al. Pooling for SARS-CoV-2 control in care institutions. medRxiv. June 2020. doi:10.1101/2020.05.30.20108597. 14. Nouvenne A, Ticinesi A, Parise A, Prati B, Esposito M, Cocchi V et al. Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.050. 15. Goodman-Casanova JM, Dura-Perez E, Guzman-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study. Journal of Medical Internet Research. 2020;22(5):e19434. doi:10.2196/19434. 16. Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit nursing homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada. Medrxiv. 2020. doi:10.1101/2020.05.25.20112664. 44 Preventing and managing COVID-19 across long-term care services 17. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 18. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16661. 19. Buja A, Paganini M, Cocchio S, Scioni M, Rebba V, Baldo V. Demographic and socio-economic factors, and healthcare resource indicators associated with the rapid spread of COVID-19 in northern Italy: an ecological study. medRxiv. 2020. doi:10.1101/2020.04.25.20078311. 20. Liotta G, Marazzi MC, Orlando S, Palombi L. Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox. PLoS One. 2020;15(5):e0233329. doi:10.1371/journal. pone.0233329. 45 Preventing and managing COVID-19 across long-term care services World Health Organization Avenue Appia 20 1202 Geneva, Switzerland

Policy brief Preventing and managing COVID-19 across long-term care services 24 July 2020

Preventing and managing COVID-19 across long-term care services Policy brief 24 July 2020 WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/) Suggested citation. Preventing and managing COVID-19 across long-term care services : policy brief. Geneva: World Health Organization; 2020 (WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Inis Communication Contents Acknowledgements iv Executive summary v Part 1. Overview 1 1.1 Aim of the document 1 1.2 Impact of COVID-19 on long-term care: what the evidence tells us 2 1.3 The case for action: leaving no one behind 3 Part 2. Responding to the COVID-19 pandemic in long-term care 5 2.1 Include long-term care in all phases of the national response to the COVID-19 pandemic 7 2.2 Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic 9 2.3 Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses 11 2.4 Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services 14 2.5 Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation 17 2.6 Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases 19 2.7 Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services 22 2.8 Provide support for family and voluntary caregivers 24 2.9 Prioritize the psychological well-being of people receiving and providing long-term care services 27 2.10 Ensure a smooth transition to the recovery phase 30 2.11 Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services 32 References 33 Annex 1. Methods 41 Web Annex: Key objectives and actions to prevent and manage COVID-19 in long-term care facilities https://apps.who.int/iris/bitstream/handle/10665/334020/WHO-2019-nCoV-Policy_Brief-Long-term_ Care-Web_Annex-2020.1-eng.pdf iii Acknowledgements This policy brief was developed by WHO through new analysis, expert consensus and reference to existing WHO guidance. Coordinating departments Department of Integrated Health Services (Shannon Barkley, Edward Kelley) Department of Maternal, Newborn, Child and Adolescent Health and Ageing (Zee-A Han, Anshu Banerjee) Principal writers World Health Organization: Zee-A Han (responsible officer), Shannon Barkley, Yuka Sumi London School of Economics and Political Science: Adelina Comas-Herrera, Klara Lorenz-Dant, Maximilian Salcher-Konrad Other contributors and reviewers WHO Steering Committee: Ageing and Health; Clinical Services and Systems; Gender, Equity and Human Rights; Integrated Health Services; Maternal, Newborn, Child and Adolescent Health and Ageing; Mental Health and Substance Use; Sensory Functions, Disability and Rehabilitation; Infection Prevention and Control Hub and Task Force; WHO Kobe Centre, and regional offices (Benedetta Allegranzi, Jotheeswaran Amuthavalli Thiyagarajan, Sarah Louise Barber, Anjana Bhushan, Alessandro Cassini, Alarcos Cieza, Theresa Diaz, Stefanie Freel, Manfred Huber, Anne Johansen, Theadora Koller, Margrieta Langins, Madison Moon, Paul Ong, Ritu Sadana, Nicoline Schiess, Katrin Seeher, Enrique Vega). The following individuals contributed to or reviewed the document. Confidentiality agreements were signed and declarations of interest were collected and reviewed. Non-WHO experts: WHO Global Network on Long-term Care for Older People (Liat Ayalon, Pablo Villalobos Dintrans, Walter Frontera, Muthoni Gichu, Sandhya Gupta, Hanadi Khamis Al Hamad, Arvind Mathur, Reshma A. Merchant, Stephen O’Connor, Vinod Shah, Lieve Van den Block) and Rachel Albone, Sean Cannone, Leon Geffen, Terry Fulmer, Richard Humphries, Caitlin Littleton, Terry Lum, Saniya Sabzwari, David Stewart. WHO continues to monitor the situation closely for any changes that may affect this policy brief. Should any factors change, WHO will issue a further update. WHO gratefully acknowledges the kind support of the Government of the Republic of Korea, Ministry of Health and Welfare. iv Preventing and managing COVID-19 across long-term care services Executive summary The COVID-19 pandemic has affected older people disproportionately, especially those living in long-term care facilities. In many countries, evidence shows that more than 40% of COVID-19 related deaths have been linked to long-term care facilities, with figures being as high as 80% in some high-income countries. Furthermore, in long-term care facilities, the case fatality for residents with COVID-19 may be higher than in the population of the same age living outside long-term care facilities. Residents of long-term care facilities often face high risk, low preventive measures and inadequate resources to recover from COVID-19, as well as reduced access to essential health services in a context where health systems are experiencing constraints during the COVID-19 surge. The impact of COVID-19 has additionally been high in providers of long-term care services, within long- term facilities and in other settings. A 2020 study by the United Kingdom Office for National Statistics of deaths by occupation found that the social care workforce had a significantly raised death rate associated with COVID-19. So far, COVID-19 has disproportionately affected long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community-based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. The response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries. Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19. This policy brief provides 11 policy objectives and key action points to prevent and manage COVID-19 across long-term care. Its intended audience is policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on currently available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and to mitigate impact across long-term care services, including care providers. While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized because they have experienced extremely high COVID-19 incidence, morbidity and mortality. Furthermore, the policy brief addresses long-standing problems in long-term care systems, including underfunding, lack of accountability, fragmentation between health and long-term care and an undervalued workforce. The brief suggests ways to transform health and long-term care services so that long-term care services are readily integrated and provided as part of the continuum of care that includes health promotion, prevention, treatment, rehabilitation and palliation. It is only through these measures that people in need of long-term care can receive quality, equitable and sustainable care that allows them to live in a manner respecting their basic rights, fundamental freedoms and human dignity. v Preventing and managing COVID-19 across long-term care services vi Preventing and managing COVID-19 across long-term care services Part 1. Overview 1.1 Aim of the document The COVID-19 pandemic has revealed weaknesses in emergency response where long-term care services has been underprioritized, resulting in the devastating impact seen across long-term care services globally. These events have highlighted long-standing problems in the long-term care systems in most countries: underfunding, lack of accountability, fragmentation, poor coordination between health and long-term care, and an undervalued workforce (1–3). This policy brief provides policy objectives and key action points to prevent and manage COVID-19 across long-term care for policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on current available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and its impact on those who use long-term care and care providers (including paid staff and family and other voluntary caregivers). It also expands on the technical working guidance on preventing and managing the COVID-19 pandemic across long-term care services in the World Health Organization (WHO) European Region to provide global perspectives and country examples across all WHO regions (4). While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized as they have experienced extremely high incidence, morbidity and mortality due to COVID-19. However, although long-term care facilities are an integral part of long-term care, it must be highlighted that community-based services are the key to promoting ageing in place, reducing institutionalization, and supporting deinstitutionalization, so that people can live in a manner consistent with their basic rights, fundamental freedoms and human dignity. Box 1 presents definitions of the terminology used in this document. Box 1. Working terminology: definitions of terms used Long-term care systems National systems that ensure integrated long-term care that is appropriate, affordable, accessible and upholds the rights of people and caregivers alike (1). Long-term care Services to ensure that people with or at risk of significant loss of physical and mental capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity (1). These services typically involve care and assistance with everyday tasks (including dressing, bathing, shopping, cooking and cleaning), support with social participation, and management of advanced chronic conditions through community nursing, rehabilitation and end-of-life care. Services are provided by both unpaid caregivers (typically family but also volunteers) and paid care staff. Throughout the document, the use of the term “long- term care services” covers care at home, in the community and in facilities (residential long-term care facilities, nursing homes or other group living facilities), unless otherwise specified. Long-term care facilities Long-term care facilities may vary by country. Nursing homes, skilled nursing facilities, assisted living facilities, residential facilities and residential long-term care facilities are collectively known as long-term care facilities that provide a variety of services, including medical and assistive care, to people who are unable to live independently in the community. Throughout the document, the use of the term “long-term care facilities” does not include home-based long-term care, community centres, adult day care facilities or respite care. Caregiver A person who provides care and support to someone else. Caregivers may include family members, friends, neighbours, volunteers, care workers and health professionals (1). UN SP LA SH / JE RE M Y ST EN UI T 1 Preventing and managing COVID-19 across long-term care services 1.2 Impact of COVID-19 on long-term care: what the evidence tells us Evidence from a systematic review (5) and compiled reports on the COVID-19 situation in long-term care facilities (Annex 1) shows that, while there is little evidence of the impact of COVID-19 on people who use and provide long-term care services in the community, the pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities. In countries with large numbers of deaths from COVID-19, about half of all those deaths have been among residents of long-term care facilities. The methods for the systematic review and other reviewing carried out for this report are described in more detail in Annex 1. Early evidence shows that the extent of COVID-19 infections in long-term care facilities has varied widely, between and within countries: some countries (such as Jordan) have had no infections reported in long-term care facilities so far, whereas in Sweden, for example, by the end of April, 25% of long-term care facilities in the whole country had COVID-19 outbreaks, with 67% of long-term care facilities in Stockholm affected. Data from 21 high-income countries show that while some countries have had no or very few deaths among residents in long-term care facilities, other countries report that on average nearly half of all deaths linked to COVID-19 in the country were of long-term care facility residents (ranging from 24% in Hungary to as high as 82% in Canada). In some countries, the share of deaths among all residents of long- term care facilities linked to COVID-19 has been as high as 3% to 6% of all residents (6). Disaggregated data by age and gender are not available for many countries. The evidence also shows that once COVID-19 infection is present in long-term care facilities it is difficult to control, in part due to the large number of people living close together in facilities designed for communal living and the fact that personal care requires close proximity. Although case reports from the Republic of Korea, demonstrated successful mitigation of further infections in long-term care facilities after a member of staff had tested positive (7–8), case studies in several other countries demonstrate how difficult it is to contain the infection in these settings. For example, studies in the United Kingdom of Great Britain and Northern Ireland and the United States of America have shown incidence rates between 40% and 72% among residents (9–14), with infection rates among staff between 1.5% and 5.9% when all staff members at outbreak facilities were tested (7–8, 15–18). There is also evidence from one study that staff working across more than one home may have been the source of transmission (19). An analysis of deaths by occupation in the United Kingdom showed that men and women working in social care had significantly raised rates of deaths involving COVID-19 (23.4 per 100 000 males compared to 9.9 for males aged 20–64 years, and 9.6 per 100 000 females compared to 5.2 for females aged 20–64 years) (20). Six studies describing measures to prevent (China and Singapore) and contain or manage (Canada and the Republic of Korea) outbreaks in long-term care facilities reported some success, although these studies did not have a control group (7–8, 22–23). There is increasing evidence of potential transmission from presymptomatic or asymptomatic people who have COVID-19 and people presenting with “atypical symptoms” in long-term care facilities. Studies of outbreaks show that 7% to 75% of residents and 50% to 100% of staff who tested positive are presymptomatic or asymptomatic (11–13, 15, 17, 19, 24). Between 57% and 89% of asymptomatic positive residents develop symptoms later (11, 19). Systematic nationwide testing of residents and staff in Belgium showed that 74% of cases among residents and 76% of cases among staff were asymptomatic at the time of testing (25). “Men and women working in social care have significantly raised rates of deaths involving COVID-19.” “The pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities.” 2 Preventing and managing COVID-19 across long-term care services Once people living in long-term care facilities have COVID-19, the case fatality for residents may be higher than in the population of the same age outside long-term care facilities. For example, the incidence rate of COVID-19 deaths among residents of long-term care facilities in Ontario, Canada, was 13 times higher compared to community-dwelling cases aged 70 years or older (26), and the risk for severe disease, including death, was 2.5 times higher for Israeli nursing home residents with COVID-19 compared to other cases over 65 years of age (27). No studies report on the detrimental health sequelae of either the infection itself or the measures taken to prevent infection in long-term care facilities, although many editorials and commentary articles mention potential impacts on both mental and physical health (for example, distress, depression, anorexia, loss of physical condition due to lack of exercise, and consequences of increased chemical and physical restraints). This has raised concerns for increased direct and indirect morbidity and mortality (28–29). There is limited evidence on the impact of the COVID-19 pandemic on people who use and provide community-based long-term care, including home help, day care facilities and unpaid caregivers. Some public health and infection prevention measures (including movement restrictions, physical distancing and curfews) may resulted in restriction of the usual sources of care and support that many people with care needs rely on. Evidence from the United Kingdom found that people with disabilities experienced widening inequalities during the COVID-19 pandemic. People with disabilities reported difficulty in accessing food and medication and delays in the benefit system, with some experiencing food insecurity and poverty. Many people with disabilities reported feeling isolated and, for some, lack of Internet access meant that they could not access virtual replacement services. Furthermore, reduction of ongoing support structures left people reliant on family and neighbours (30). It is also likely that people living with existing health conditions experience difficulties in accessing essential health care services, including rehabilitation, which further increases care needs. Furthermore, discontinuity of health care services can result in heightened need for care (31–32). It is increasingly recognized that in many countries the initial plans to contain the pandemic did not include long-term care facilities; it was only when media reports of large numbers of deaths started to emerge that resources were mobilized. In some countries, the army and other emergency response units had to be deployed to support long-term care facilities that had been overwhelmed by large numbers of deaths and insufficient staff (33). In many countries, long-term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred (34). 1.3 The case for action: leaving no one behind Health systems have a responsibility to offer safe, accessible, affordable and quality health care, including assistive and palliative care, for all people, without discrimination. However, as the evidence shows, residents of long-term care facilities are often facing higher risk, lower preventive measures and inadequate resources to manage COVID-19, as well as reduced access to essential health services, as health systems experience constraints in the context of a COVID-19 surge (35). Older people, particularly those with underlying conditions who are more likely to develop severe COVID-19, make up a large proportion of those using long-term care services, including those living in long-term care facilities (36). Immediate action is required to prevent infection and mitigate the impact of the COVID-19 pandemic among this population and to ensure that essential health and assistive care services are provided. “In many countries, long- term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred.” 3 Preventing and managing COVID-19 across long-term care services Furthermore, women, especially older women, represent the highest share of people who use care services, dominate the long-term care workforce, and are the main providers of family care (1, 37). In addition, long- term care services often depend heavily on migrant workers and workers from ethnic groups, who may be at higher risk (1, 38–40). The response to the pandemic must include long-term care to ensure that ethnic, age and gender groups are not marginalized. Concerns about human rights have also been expressed, both in the potential neglect of the population relying on (and providing) long-term care, and in measures adopted in an attempt to reduce the risk of infection (for example, a ban on visitation and forbidding outside physical activity). It is mandatory that the response to the pandemic is inclusive of long-term care, so that appropriate and tailored measures are implemented and issues specific to long-term care are addressed. So far, COVID-19 has disproportionately affected people living in long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community- based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. Considering the magnitude of the impact of COVID-19 on long-term care, response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries (4). Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19 (41). 4 Preventing and managing COVID-19 across long-term care services Part 2. Responding to the COVID-19 pandemic in long-term care While the pandemic has brought public attention to the immediate impacts of the pandemic, and the need to be prepared for present contingencies and possible future waves, it has also shown that there are major structural challenges that need to be addressed to improve the safety and resilience of long-term care systems. So far, most countries have struggled to develop coherent systems to ensure access to person-centred, quality, long-term care services that meet the growing health and assistive care needs and that are consistent with basic rights, fundamental freedoms and human dignity (1, 42–45). Even in high-income countries, a review by the Organisation for Economic Co-operation and Development (OECD) concluded that “there is a history in many countries of long-term care policies being developed in a piecemeal manner, responding to immediate political or financial problems, rather than being constructed in a sustainable, transparent manner” (43). This section looks into the unique challenges that have affected the ability of long-term care systems to respond to the COVID-19 pandemic and proposes policy objectives and key actions to address these challenges in the short and longer term. Informed by the available evidence and international experience thus far, the 11 policy objectives presented on the next page will be key to addressing COVID-19 in long-term care systems. The following subsections address each of these policy objectives in turn. UN SP LA SH / A P X 90 5 Preventing and managing COVID-19 across long-term care services Eleven policy objectives to mitigate the impact of COVID-19 across long-term care 1. Include long-term care in all phases of the national response to the COVID-19 pandemic. 2. Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic. 3. Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses. 4. Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services. 5. Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation. 6. Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases. 7. Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services. 8. Provide support for family and voluntary caregivers. 9. Prioritize the psychosocial well-being of people receiving and providing long-term care services. 10. Ensure a smooth transition to the recovery phase. 11. Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services. 6 Preventing and managing COVID-19 across long-term care services 2.1 INCLUDE LONG-TERM CARE IN ALL PHASES OF THE NATIONAL RESPONSE TO THE COVID-19 PANDEMIC 2.1.1 The challenge Long-term care has low political priority compared to health and other policy areas Long-term care tends to have low political priority and is often referred to as “the Cinderella of the welfare state”, where political attention to its importance is often transient and secondary to health care (46). This lack of political attention to long-term care may be one of the reasons why the initial policy responses to the pandemic in many countries did not include the long-term care sector (4). Governance of the long-term care system often involves multiple sectors, different ministries and different levels of government, making coordination difficult In most countries, long-term care falls between different ministries, typically health care and social affairs, development, or social protection. Long-term care services and health care systems are often poorly coordinated or integrated, and tend to have separate (and often complex) arrangements for financing, regulation, information systems, and the training and procurement of staff (1, 43). This has created several difficulties during the COVID-19 crisis. For example, back-up staffing models to meet the surge in COVID-19 patients in hospitals were not flexible enough to meet demand surges in the long-term care sector. It was also difficult for appropriate staff to move flexibly across the system as needed. Similarly, the long-term care sector, and especially long-term care facilities, struggled to access testing and PPE, as this had been prioritized for hospitals (47). In addition, countries frequently distribute responsibility for long-term care vertically across national, regional and local actors, creating difficulties in coordination of services and effective oversight (48). For example, in Spain and Italy, the same person may be receiving long-term care services that are organized or funded by up to three different levels of government (49–50). Long-term care services consist of a mixture of public, private for-profit and private not-for-profit service providers, in addition to family caregivers Long-term care services are also characterized by a mix of public, private for-profit and private not- for-profit service providers (51). In some countries, most long-term care facilities are operated by private for-profit providers and, particularly in low- and middle-income countries, these are often unregulated (52–53). Particularly in low- and middle-income countries, nongovernmental organizations (NGOs) play an important role in the provision of long-term care services and are often the sole source of support for unpaid caregivers. However, where NGOs are non-existent, the care responsibility often falls entirely on the families themselves. This unpaid care is rarely recognized within a formal system and so is not included in any governance processes or mechanisms beyond those of the NGOs that support the work. These structures can result in a lack of ownership, diffused accountability, and fragmentation of responsibilities, causing problems with coordination and quality of care and leading to underdeveloped information systems (43, 54). 7 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 May impede inclusion of long-term care in pandemic national response May impede planning, oversight and accountability during the pandemic May impede coordinated response between long-term care and health care sectors in responding to the pandemic May impede effective resource allocation 2.1.2 Key actions Whole sector Ensure a focal point to manage long-term care (with a special focus on long-term care users and providers) in the overarching COVID-19 governing body. Establish joint steering committees and information- and data-sharing systems between sectors and subnational policy levels to ensure a coordinated response. Establish a mechanism to support unregulated providers, focusing on cooperative support rather than punitive measures. Long-term care facilities If long-term care facilities are expanding their health care role during the pandemic, establish triggers or thresholds that activate a phased reallocation of routine comprehensive health service capacity, including direct health care staff. Country examples In Singapore, the Agency for Integrated Care and the Ministry of Health, together with long-term care service providers, have jointly developed a number of measures to respond to the COVID-19 pandemic. These include infection control and prevention measures, access to PPE, distancing and zoning measures, suspension of visitors, alternative accommodation for long-term care workers, and testing to monitor people with long-term care needs and care workers. The Agency for Integrated Care also set up an incident response team to support long-term care providers in responding to COVID-19 infections. The Silver Generation Office, which is an outreach arm of the Agency for Integrated Care, has supported older people with contact, information and the provision of services during the COVID-19 pandemic (55–56). In Israel, a governing team has been appointed to manage COVID-19 outbreaks in long-term care facilities across the country. This team has provided a national plan under the Fathers and Mothers Shield project, including establishment of a headquarters from which government efforts can be coordinated. In addition, the Home Front Command has been assisting long-term care facilities throughout the pandemic with managing visitor access, disinfection, and food and equipment delivery, and has been offering training and guidance on protective and preventive measures (57). In Malta, the Social Care Standards Authority, the regulatory body for long-term care, defined the residential care settings as being high risk with regard to COVID-19 in early March. Immediately, the Social Care Standards Authority issued the directives mapped out in its COVID-19 brief (2020). There was immediate cooperation between the Public Health Authority and the Social Care Standards Authority, which proved to be the primary catalyst towards safeguarding older persons within the facilities (58). 8 Preventing and managing COVID-19 across long-term care services 2.2 MOBILIZE ADEQUATE FUNDING FOR LONG-TERM CARE TO RESPOND TO AND RECOVER FROM THE COVID-19 PANDEMIC 2.2.1 The challenge Limited public funding allocated for long-term care Average public expenditure on long-term care is very low, less than 1% of GDP globally. Such public underfunding jeopardizes access to long-term care (42). This is even more pronounced in low- and middle-income countries, many of which lack dedicated sources of public financing for long-term care. Public benefit schemes for long-term care are usually needs based and means tested, and often require co-payments, leaving large parts of the population outside the public system In most countries, public benefit schemes for long-term care support are needs based and means tested, and often require co-payments. Those with greater needs often receive more support, but some countries also set limits on the amount that can be covered through public resources. While some countries protect the most vulnerable from additional costs, considerable out-of-pocket expenses are common across countries for most people receiving long-term care services (43, 59–60). Also, due to the large share of care provided by unpaid caregivers, in practice a large share of the costs of long-term care fall on families, through a combination of the opportunity costs of providing care and out-of-pocket payments. Few countries have financing mechanisms that protect the whole population from catastrophic long- term care costs (1). Reduced income for long-term care sector and higher costs of care Increasing PPE and workforce costs mean that service providers are facing substantial additional costs. At the same time, providers are experiencing decreases in revenues due to lower occupancy in long- term care facilities (resulting from both a decrease in admissions and the higher-than-usual numbers of deaths) and the closure of community-based services such as day care centres. Several countries have already provided emergency funds to support the long-term care sector during this crisis. However, the provision and distribution of resources may be easier in countries with more developed and regulated long-term care systems. The provision of resources and support to the unregistered long-term care sector poses additional challenges. Such unique challenges in the financing of long-term care have made it difficult for the long-term care system to react and respond to the additional costs that may be incurred due to preparing for and responding to COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of adequate funding for the additional costs linked to the COVID-19 response may endanger the safety of long-term care users and providers The increase in the costs of care due to the pandemic results in increased out-of-pocket payments for care users 9 Preventing and managing COVID-19 across long-term care services 2.2.2 Key actions Whole sector Consider injecting extra ring-fenced funds for long-term care to cover the additional costs linked to the pandemic (for example, additional staff costs, infection prevention and control (IPC) training, and materials such as PPE and sanitizers). Consider how to reduce regulatory and other costs to providers for the duration of the pandemic (such as staffing requirements). Provide flexibility in the use of emergency funds allocated to long-term care providers as well as users. Long-term care facilities Provide funding to compensate for lower occupancy rates and ensure provision of quality essential health and care services. Provide funding to support providers of long-term care facilities with the additional costs incurred in ensuring the safety of their residents and staff, including additional IPC measures and testing for COVID-19. Community-based care Support providers (particularly not-for-profit) that are experiencing loss of revenue if they have to close some services, such as day care and community centres, during the pandemic. Enable flexibility in the use of personal budgets and other cash benefits, for example by allowing them to be used to employ a family member or neighbour if community centres are not available. Caregivers Support caregivers who may need to take on additional care responsibilities to compensate for the unavailability of usual care, and may need to give up employment to do so. Country examples In the United States, the US$ 3 trillion COVID-19 stimulus package (under the Coronavirus Aid, Relief, and Economic Security (CARES) Act) provides some funding for the long-term care sector. Out of the US$ 100 billion funding allocated to health care providers under the CARES Act, US$ 50 billion is being distributed to hospitals and long-term care providers, including providers of home health (61). As of 3 June 2020, US$ 4.9 billion had been targeted to skilled nursing facilities (62). In the Republic of Korea, the Ministry of Health and Welfare and the Korean National Health Insurance Service have issued temporary reimbursement guidelines for the long-term care sector. The guidelines take into consideration the need for COVID-19-related physical distancing measures and staff shortages. In addition, service providers operating in special disaster zones will not be facing payment cuts if they cannot adhere to staffing requirements during the pandemic (63). In China, subsidized long-term care providers were allocated a special one-off allowance to support staffing (for example, hiring and redeploying workers and reimbursing overtime) to ensure the continued provision of long-term care services. It is estimated that this support will amount to a total of around US$ 1.6 million (64–66). 10 Preventing and managing COVID-19 across long-term care services 2.3 ENSURE EFFECTIVE MONITORING AND EVALUATION OF THE IMPACT OF COVID-19 ON LONG-TERM CARE AND ENSURE EFFICIENT INFORMATION CHANNELLING BETWEEN HEALTH AND LONG-TERM CARE SYSTEMS TO OPTIMIZE RESPONSES 2.3.1 The challenge Few countries have information and monitoring systems for long-term care systems Relatively few countries have information and monitoring systems that include individual-level data about the characteristics, needs and outcomes of people who use formal long-term care services, and about the type and quality of care that they are receiving. This reflects the overall situation of limited data sources about older people (who are often long-term care users) and lack of age- and gender- disaggregated data (67). Where individual-level data are available, quite often they only cover people who use publicly funded long-term care or provide services. Furthermore, health and social care data are usually collected under separate systems, leading to difficulties linking data for the same individual. There are reports of unregulated long-term care facilities being “discovered” as a result of the COVID-19 pandemic (68). Lack of individual-level data about the characteristics of the residents of long-term care facilities has been identified as a barrier to response planning for the COVID-19 pandemic (69–70). This has meant, for example, that mathematical models that have informed planning for the pandemic have not accounted for residents in long-term care facilities separately from surrounding populations in their calculations (71). Data on the pandemic were initially only collected on people who had been tested and died in hospitals Very few countries publish data on the numbers of residents of long-term care facilities who have been infected or died from confirmed or suspected COVID-19. Because residents of long-term care facilities have been less likely to be tested or admitted to hospital than people living in private households, it is likely that countries that do not include deaths outside hospital are underestimating the death toll of COVID-19. An international initiative to track data on deaths of residents of long-term care facilities only found publicly available data for 21 countries in May 2020 (6). Without data on the impact of the infection on long-term care facilities and on people who rely on care and live in the community, there is a risk that the resources needed to prevent and mitigate the impact of COVID-19 in the long-term care sector (funds, workforce, tests, PPE and other equipment) may not be provided adequately and in a timely manner. There are few data available on associated health impacts of the pandemic Many people who rely on assistive care, particularly community-based care, will have had disruptions in their usual access to care, which can potentially put them at risk (for example due to malnutrition, undetected infections or other health complications). Data to identify people who may be at higher risk are needed to identify gaps and reconfigure services as needed. 11 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 Difficult to monitor the impact of COVID-19 across long-term care services Difficult to develop tailored response plans for long-term care to mitigate impact Difficult to include long-term care populations in modelling projections Difficult to monitor health impact of COVID-19 on long-term care users and long-term care workforce Fragmentation of information between long-term care facilities and health facilities 2.3.2 Key actions Whole sector Find effective ways to make use of existing long-term care management data where they are available (for example, MDS 3.0 in the United States, and the interRAI assessment systems of Canada and New Zealand) to model the impact of COVID-19 on health (including mental health) and the functioning of older people in long-term care. For countries without these systems, consider establishing such management data systems as actions for the longer term. Encourage research on the impact, and measures to mitigate the impact, of COVID-19 on long-term care to identify gaps and prepare for future pandemics. Long-term care facilities Establish a surveillance system that captures people who have COVID-19 and deaths that occur in long- term care facilities (probable and confirmed, disaggregated by age, gender, disability and existing health condition), and ensure that these are integrated with existing surveillance systems. Establish the necessary legal mechanisms to secure and transmit information relating to COVID-19 on a regular and frequent basis to and from long-term care facilities, health facilities, public health authorities and the public. Set up a mechanism to ensure that these data are analysed regularly and the findings used to refine government policy on the COVID-19 response. Community-based care Establish mechanisms to report the number of people who have COVID-19 among those receiving and providing long-term care in the community and in homes to public bodies responsible for commissioning services. 12 Preventing and managing COVID-19 across long-term care services Examples In South Africa, managers of long-term care facilities have to inform the Department of Social Development if a COVID-19 case has been confirmed (72). In the European Union, the European Centre for Disease Prevention and Control (an agency of the European Union) has included long-term care facilities in its strategy for COVID-19 surveillance at national and European Union/European Economic Area levels and is collecting data from Member States covering mitigation action, infection rates and mortality (73). In Argentina, in La Plata, an NGO co-developed a website for monitoring and sharing information about both registered and informal long-term care facilities. This platform was used to survey the COVID-19 preparation of the long-term care facilities and resulted in the local government ensuring that testing was provided to all employees of long-term care facilities (53). 13 Preventing and managing COVID-19 across long-term care services 2.4 SECURE STAFF AND RESOURCES, INCLUDING ADEQUATE HEALTH WORKFORCE AND HEALTH PRODUCTS, TO RESPOND TO THE COVID-19 PANDEMIC AND DELIVER QUALITY LONG- TERM CARE SERVICES 2.4.1 The challenge Pre-existing workforce shortages, poor pay and working conditions Before the COVID-19 pandemic, workforce shortages, poor pay and working conditions, and low proportions of professionally qualified staff were already a major concern in long-term care systems (2–3, 73). The workforce supporting people with long-term care needs is predominantly female (90%) (37), and in many countries migrant care workers make up a large proportion of the long-term care workforce (74). It is common for care workers to have zero-hour contracts and to work for multiple facilities or agencies (75). Long-term care staff shortages during pandemic In many countries, long-term care services, particularly long-term care facilities, have experienced acute staff shortages during the COVID-19 pandemic when their staff had to isolate due to suspected or confirmed infection with COVID-19 (49–50, 76–77). This has happened at a time when family and other unpaid caregivers, due to visiting and movement restrictions, have been less able to provide support (even in long-term care facilities, family and volunteer caregivers make an important care contribution). On some occasions countries had to rely on extreme measures such as calling on the military or other emergency services when long-term care facilities became overwhelmed and understaffed (49). In some countries, long-term care workers and caregivers were not initially considered key workers and lockdown measures and curfews meant they were not able to travel to work (or continue to provide care to people in other households) (78–79). Using public transport or living in crammed accommodation may have increased the risk for care staff to be exposed to the virus. Difficulties adapting to increased health care needs in long-term care facilities While some long-term care facilities employ nurses and other health care staff, this is not the case in all facilities, and there are reports of the difficulties faced by non-medically trained staff in long-term care facilities needing to provide care to people with COVID-19 infections or to those who need palliative care without health care staff support or oversight by qualified health professionals such as physicians and nurses. Administrative barriers to transferring staff and medical supplies from the health service to long-term care facilities led, in the case of a region of Spain, to all long-term care facilities being put under the control of the Department of Health during the pandemic (49). Long-term care providers and caregivers not able to obtain PPE Difficulties faced by long-term care providers and caregivers in accessing PPE and other resources (such as hand sanitizer and disinfectant) have emerged in many countries, due to global shortages and the prioritization of hospitals and other health care settings. Long-term care providers reported having to buy PPE at inflated prices as a result. 14 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 A vast workforce shortage for long-term care When compensating for workforce shortage, high staff turnover can impede continuity of care and consistency in important IPC measures Decreased integrity of the work and value of a workforce dominated by women and migrant workers Increased financial pressures to work while ill due to poor working conditions, such as lack of compensation for sick leave Occupational safety of long-term care workforce not taken into careful consideration Substantial lack of PPE for long-term care facilities, long-term care workforce (including caregivers) and recipients of care Lack of essential medical supplies and health workforce in long-term care facilities Lack oversight by qualified health professionals in providing essential services in long-term care facilitie 2.4.2 Key actions Whole sector Estimate surge capacity needed to support long-term care services in coordination with the focal point on long-term care. Set up links between health and social care procurement chains to ensure a continuous and non- conflicting supply during COVID-19. Recruit additional staff and develop rapid training programmes (for example, recruit retirees, students from health and long-term care training programmes, and volunteers) on IPC measures. Address contractual and related issues and put in place policies and measures that keep staff safe but allow them to work in a flexible manner and move from health care services into long-term care services as needed. Establish rosters and secure staff from health systems who can be repurposed if needed to support staff in long-term care settings. Implement measures to prevent policies from impeding delivery of important home, community and facility-delivered care through the long-term care workforce. Implement measures to monitor staff working in multiple locations, with increased risk of transmission, and consider facilitating transport and accommodation of staff to minimize the risk of infection during local outbreaks. Provide financial payment for care staff to incentivize them to stay in their jobs during the epidemic and compensate them for additional workload and stress. Long-term care facilities Ensure adequate supply of PPE in long-term care facilities to protect care staff from infection. Provide adequate training guidance and enforce routine training of staff and family caregivers on IPC measures in long-term care facilities so they can continue providing care in those facilities. Facilitate flexible arrangements whereby palliative care teams and other relevant health and care professionals work with staff in long-term care facilities to ensure access to palliative care as needed. 15 Preventing and managing COVID-19 across long-term care services Ensure adequate oversight by appropriately trained personnel to deliver essential services in long-term care facilities. Ensure provision of PPE to home care workers, particularly those providing care in close proximity. Provide adequate training guidance and enforce routine training of community-based care providers. Family and other voluntary caregivers Ensure provision of PPE to caregivers providing care in close proximity. Provide adequate guidance and offer training for family and other voluntary caregivers. Country examples In Austria, staffing and licensing regulations for care workers have been eased substantially during the COVID-19 pandemic. This enables people who have done national service (those who opted for civilian duties) to provide basic care. People in the national service have contributed to managing the logistics of the pandemic. Their employment as care workers can be enforced by the government. In addition, people undertaking training in relevant areas and interested people who are currently unemployed can also step in (76). In Ireland, Nursing Homes Ireland started a recruitment campaign for nursing homes (private and NGO operated) in March 2020. Furthermore, the Health Service Executive agreed to redeploy staff (on a voluntary basis) to private nursing homes (77). In India, some long-term care facilities support their in-house staff with incentives, such as free food. In addition, some long-term care facilities are working to promote the mental health of their staff through regular check-ins and counselling (78). If long-term care facilities in Israel experience a shortage of staff, the Ministry of Health will send a special team for 7–14 days to support the provision of care for the acute period (57). In the Netherlands, since 19 May 2020 PPE has been available free of charge for care workers providing care activities that require close proximity (less than 1.5 metres) to persons with long-term care needs (80). In Spain, care staff from community care centres have been supporting the provision of home care, for example through phone calls. In addition, the long-term care sector can hire non-qualified staff in instances of absenteeism of their usual staff (49). In Australia, residential care workers will receive a retention bonus for two quarters of up to 800 Australian dollars after tax. The government has employed health care delivery providers to form rapid response teams in the long-term care sector where needed in each state. Visa rules were relaxed to enable staff to work more hours (81). In parts of the United Kingdom, care workers have had their wages increased and have been offered a special one-off payment for staff working during the COVID-19 pandemic (82). 16 Preventing and managing COVID-19 across long-term care services 2.5 ENSURE THE CONTINUUM AND CONTINUITY OF ESSENTIAL SERVICES FOR PEOPLE RECEIVING LONG-TERM CARE, INCLUDING PROMOTION, PREVENTION, TREATMENT, REHABILITATION AND PALLIATION 2.5.1 The challenge Requirement for continuous, complex care with high levels of physical and emotional contact People with long-term care needs often require continuous, complex and personalized support structures. Assistive care for personal tasks in particular requires high levels of physical and emotional contact. People who are receiving this care, and who are dependent on this support, benefit enormously from continuity of care (1). In many countries, the majority of residents of long-term care facilities have dementia (83–85). Variability in health care provision in long-term care facilities Long-term care facilities are very diverse, and while some may be specialized in providing medical care, such as long-term care hospitals or some nursing facilities, others, typically residential homes or supported accommodation, may not have any health care trained staff members. Long-term care facilities in many countries have experienced difficulties providing health care support and resources for essential health services, in addition to responding to the new burden of COVID-19 (including in the areas of rehabilitative and palliative care). Potential for discriminatory triage practices in hospital admissions There have been reports that residents of long-term care facilities have not been able to access health care in hospitals (49–50), and have had limited access to primary care. It has also been reported that advance care directives have sometimes been put in place without adhering to the usual person- centred standards (86). Countries have responded by emphasizing the importance of equitable access to health and palliative care for older adults and people with existing conditions during the COVID-19 pandemic (36–37). IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities in many countries have experienced difficulties providing health care support and resources to continue essential health services and to provide assistive care services for the new challenge of COVID-19 Residents of long-term care facilities have sometimes been denied hospital care based on irrelevant or discriminatory criteria, such as age, under the presumption that they are too frail to survive 17 Preventing and managing COVID-19 across long-term care services 2.5.2 Key actions Whole sector Consider developing clear COVID-19 care pathways, inclusive of long-term care facilities and home- and community-based care, for transfers to primary, secondary and tertiary care for people with COVID-19 and non-COVID-19 symptoms (87–89). Consider appropriate tele-health and virtual technologies for consultations, taking account of the views of older people, and provide any support necessary to use this technology effectively. Ensure that all palliative care plans and advanced care directives are up to date and applied through a person-centred approach. Ensure that national and regional policies, programmes and guidelines are in place to support the provision of palliative care in long-term care facilities and long-term care services (including physical, psychological, social and spiritual support). Long-term care facilities Consider involving the residents of long-term care facilities in the development of protocols for referral and access to essential health services. Ensure there is no selection based on age or disease in such protocols, but that people’s needs and preferences determine care decisions. Ensure that all long-term care facilities are supported by a primary care service. Establish rapid response teams, preferably with geriatric and palliative care training, for long-term care facilities for older people, to reduce avoidable hospitalizations and ensure optimal person-centred communication and decision-making. Ensure that staff are trained in providing palliative care and know how to communicate about death, dying and end-of-life decisions (35). Country examples In the United States, the use of home-based tele-health has been expanded as remote patient monitoring can now be reimbursed. Since March 2020, Medicare beneficiaries have been able to receive behavioural or substance use disorder interventions. For people with severe symptoms of COVID-19, post-acute tele-health visits are now possible. This enables social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists to perform remote evaluations and therapy. This may also support people with long-term care needs living in the community (61). In Italy, special palliative care teams were able to reorganize themselves rapidly in order to respond to demand quickly and flexibly. For example, they created networks of hospice care services by shifting staff from hospice inpatient to home care services. The experiences also highlighted the important need for case conferences and similar team collaborations to be able to decide quickly where to prioritize resources (for example, by deciding who will get support after hospital discharge) (50, 90). In Austria, the National Association for Palliative Care has issued a position paper on palliative care during the COVID-19 pandemic and has provided guidance on ensuring access to palliative care for people who will not receive the intensive care that normally is provided. The association has also published guidelines for family caregivers and long-term care workers. Furthermore, multidisciplinary guidance provided by the government is available to support people with COVID-19 who are reaching the end of life. There are also clinical guidelines and resources on how to facilitate social support and on bereavement for family carers and care workers supporting a person who reaches the end of life during the COVID-19 pandemic (76). In Slovenia, medical teams are ready to be sent to residential long-term care facilities to support regular staff if they become exhausted or overwhelmed (91). 18 Preventing and managing COVID-19 across long-term care services 2.6 ENSURE THAT INFECTION PREVENTION AND CONTROL STANDARDS ARE IMPLEMENTED AND ADHERED TO IN ALL LONG-TERM CARE SETTINGS TO PREVENT AND SAFELY MANAGE COVID-19 CASES 2.6.1 The challenge Lack of mandatory implementation of IPC guidance for long-term care Guidance on IPC for long-term care providers has been developed relatively late in the pandemic in many countries, and many of the guidelines have been slow to incorporate evidence of asymptomatic transmission and atypical symptoms of COVID-19. In many countries, guidance has only been developed for long-term care facilities, with no guidance available for providers of community-based care and for family caregivers. Finally, there is a lack of mechanisms to ensure implementation of these guidelines and to monitor their implementation. Lack of IPC experience and training in long-term care and resultant implementation difficulties In many countries, long-term care providers have weak IPC systems and training in place, resulting in many staff being unfamiliar with IPC and the correct use of PPE. This is a particular challenge for long-term care facilities that make high use of temporary or agency staff. Even where guidance and training are available, implementing some of the measures can be challenging due to the need for personal assistive care to be provided in close proximity. Lack of availability of testing and PPE, shortages of staff, difficulties in implementing physical distancing (given the design of traditional long-term care facilities), and a lack of alternative isolation facilities have been reported in countries that have struggled to contain infections in long-term care facilities. Across countries, guidelines have identified the importance of isolating residents exhibiting COVID-19- related symptoms, as well as those who have been in contact with people who are suspected of having or confirmed to have COVID-19. While in some countries residents in long-term care facilities live in single rooms with their own wet rooms, this is not the case in others. The specific structure of buildings in which long-term care facilities are housed may also pose barriers to the establishment of effective quarantine zones. Managers of long-term care facilities need to be supported in assessing the capacity of facilities to enable effective isolation policies and to provide additional quarantine spaces should the care setting not lend itself to effective isolation strategies. Countries that had experienced severe acute respiratory syndrome and Middle East respiratory syndrome had recently strengthened their IPC systems in long-term care facilities and community-based settings and have tended to systematically transfer people who are suspected or confirmed to have COVID-19 to isolation facilities, which appears to have been successful in controlling outbreaks (63). However, evidence on the impact of these measures on the mental and physical well-being of residents is not yet available. In some countries, there are large numbers of unregistered and therefore unregulated long-term care facilities. It is essential to support these facilities to ensure that they can keep their residents safe (53). Similarly, community-based care services are less often subject to direct regulatory control than residential long-term care facilities, and there are even fewer well developed information and monitoring systems that would enable the gathering of timely information on how the pandemic is affecting, directly or indirectly, people who rely on community-based care. Home care providers typically visit people with care 19 Preventing and managing COVID-19 across long-term care services needs in their own home. This means that care workers need to travel between homes and often visit multiple people with care needs. There is evidence that families have stopped using home care support to reduce the risk of infection for the person with care needs; however, this may create other risks (77, 81). IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of mechanisms to ensure implementation of IPC guidelines and monitor and assess implementation Lack of training of long-term care workforce on IPC measures High staff turnover impedes continuity of care and consistency of IPC measures Physical distancing is difficult to achieve for long-term care services Care workers cannot adequately access information on limiting transmission in the context of COVID-19 2.6.2 Key actions Whole sector Establish a coordinating body to develop, adjust and update IPC guidance and protocols during the COVID-19 pandemic for long-term care, based on the best available evidence (87-88, 92-93). Ensure implementation of the IPC guidance across long-term care services (for all settings). Establish a mechanism to plan, prioritize support for, and monitor implementation of measures to protect staff and people receiving long-term care from infection or spread of COVID-19. Establish early recognition, surveillance thresholds and escalation strategies for outbreaks of COVID-19 across long-term care. Consider how to ensure that providers of long-term care who may be operating outside the system (unregulated or illegal providers) can be supported to ensure the safety of the people living in their facilities or using their services. Ensure that everyone involved in direct delivery of care (staff and family caregivers), in long-term care facilities or in home care services, has access to IPC training (including use of PPE, hand hygiene, cleaning and disinfection of environments and waste management). This should be carried out regardless of their role, and especially for those having direct contact with older people with underlying health conditions (93). Consider developing and circulating standard operating procedures that give direction on how and when to rapidly isolate people receiving long-term care services, using the most up-to-date COVID-19 guidance. Implement extended IPC precautions for people discharged from hospital, based ideally on an agreed protocol for testing to determine individual needs for isolation and PPE required. Translate any strategies for standard operating procedures into clear referral systems that are made available to all staff delivering long-term care services. Long-term care facilities Ensure implementation of IPC guidance in long-term care facilities with reference to the WHO IPC guidance for long-term care facilities in the context of COVID-19 (92). Implement administrative controls, including syndromic surveillance upon entrance to a facility, for all staff and visitors. 20 Preventing and managing COVID-19 across long-term care services Ensure that staff in long-term care facilities have working conditions and arrangements that minimize their movement between settings and people receiving long-term care services, and that sick pay enables them to stay at home if they are unwell. Ensure that long-term care facilities have access to the resources needed to implement IPC (such as PPE, hand sanitizers and disinfectant). Develop the necessary IPC protocols and guidance and ensure that they are made available for visitors and are clearly visible in easy-to-understand formats (94). Develop guidance and ensure implementation of IPC protocol for staff and ensure educational resources are provided alongside continuous training. Ensure that long-term care facilities have an IPC focal point to lead and coordinate IPC activities, ideally supported by an IPC team with delegated responsibilities and advised by a multidisciplinary committee. Community-based care and caregivers Increase training and decision-making support for the long-term care workforce in the community to effectively manage COVID-19, including family caregivers, keeping in mind constraints, especially gender- related constraints, that family caregivers may face (87–88). Country examples In Jamaica, a temporary employment programme was created for regular cleaning of public sector long- term care facilities, and spaces were set aside in those facilities for isolation of symptomatic residents. Also, a multisectoral exercise between multiple State and private sector agencies facilitated deep sanitization of public long-term care facilities (79). In Indonesia, prevention measures in long-term care facilities include knowledge-sharing on hygiene principles with care workers and residents, regular disinfection and ventilation, and abstaining from sharing personal medical equipment. Residential long-term care facilities have put in place a registration system and do not allow visitors with symptoms of COVID-19 to enter the premises (95). In one region of China, after the severe acute respiratory syndrome epidemic, the regional authorities published the first guidelines on prevention of communicable diseases in residential long-term care facilities for the elderly in 2004, and required all operators of long-term care facilities to designate an infection control officer to coordinate and implement infection control measures within the facility, according to the guidelines (65). In Germany, the Robert Koch Institute recommends that domiciliary care workers wear face masks when providing care and that they regularly monitor their health. Additional equipment should be made available if the person they care for shows COVID-19-related symptoms (96). In the Netherlands, some home care workers are organized into special “Corona teams”. These teams look after people with COVID-19, while other teams care for people without infection (80). 21 Preventing and managing COVID-19 across long-term care services 2.7 PRIORITIZE TESTING, CONTACT TRACING AND MONITORING OF THE SPREAD OF COVID-19 AMONG PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.7.1 The challenge Many countries have experienced shortages in testing capacity as hospital services were prioritized In many countries there have been shortages of testing capacity as initially the available capacity was used mostly in hospitals, leaving providers of long-term residential and community services with difficulties in detecting people who had COVID-19. This approach is increasingly understood to have been a major problem, given the high rates of pre-symptomatic or asymptomatic people who have COVID-19 and could be spreading infection. Effective contact tracing in long-term care settings requires coordination and collaboration between long-term care providers and the relevant health authorities Effective testing, tracing and monitoring of COVID-19 in long-term care require coordination and collaboration between long-term care providers and the relevant health authorities. However, due to challenges in governance, such coordination has been difficult in the initial phases of the response. A growing number of countries are now including contact tracing in guidance for the long-term care sector and are developing apps and other systems to support contact tracing. Lack of systematic monitoring of the health status of people receiving and providing care Regular monitoring enables staff to detect changes in people’s health status, including the development of atypical symptoms (13), and to respond faster if a person with care needs or staff develop symptoms of COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities have become a blind spot for priority testing, tracing and monitoring of COVID-19 High rates of asymptomatic people who have COVID-19 have made early recognition and subsequent appropriate steps difficult 2.7.2 Key actions Whole sector Ensure testing data are aggregated and shared with local and national public health agencies so that the pandemic is managed at both the population and individual levels. Ensure contact tracing and isolation based on national guidance, with reference to WHO guidance on contact tracing in the context of COVID-19 (36, 97). Trace any clusters of infections or deaths of people in long-term care facilities or amongst those receiving home care services. 22 Preventing and managing COVID-19 across long-term care services Do not rely on symptoms alone, particularly “typical” cough and fever symptoms, when screening for COVID-19, and ensure that staff are trained in identifying other atypical symptoms, especially in older persons (36). Ensure that the health of people receiving and providing long-term care is monitored so that the development of symptoms (including atypical symptoms) can be detected quickly. Long-term care facilities In areas with ongoing or suspected community transmission, rigorous testing of both residents (including new admissions) and staff and tracing of close contacts are essential to develop isolation policies. Community-based care Ensure that people providing and receiving care in the community as well as their household members have access to testing and contact tracing, and have support if they need to isolate (87–88). Include household members of people with care needs in symptom monitoring. Examples In Denmark, both symptomatic and asymptomatic residents and staff in long-term care facilities can access testing at regional hospitals (since 12 May 2020). Even before that date, residents and staff were tested if there was an outbreak in a residential long-term care facility. If one resident shows symptoms, all residents and staff are tested within 24 hours and retested after seven days. If a staff member tests positive, all residents in the same area are also tested (98). In the Netherlands, all family caregivers that experience symptoms of COVID-19 can get tested (since 18 May 2020). In addition, family carers have been able to access free PPE since 19 May 2020 if they support vulnerable people (aged 70 years and older, with chronic conditions) who experience symptoms of COVID-19 and where personal assistive care (with less than 1.5 metres distance) is required (80). In Malaysia, all registered and unregistered long-term care facilities have undergone testing for COVID-19 (99). In the European Union, the European Centre for Disease Prevention and Control guidance recommends testing strategies that distinguish between “affected local areas” (random testing of residents and staff) and “unaffected areas”. Affected areas are those with actual or presumed continuing community transmission (73). 23 Preventing and managing COVID-19 across long-term care services 2.8 PROVIDE SUPPORT FOR FAMILY AND VOLUNTARY CAREGIVERS 2.8.1 The challenge Family caregivers provide an important share of care, but support such as respite care, training or care leave schemes remain limited and without compensation An important share of long-term care across countries is provided by family caregivers who provide care directly, and also help coordinate and complement formal services. In countries without established formal long-term care services, family caregivers provide almost all long-term care. Caregivers usually do not have access to any training for their role. Some countries recognize the impact of caregiving and offer support such as paid care leave, flexible work arrangements, respite care, training and psychological interventions, as well as cash benefits to mitigate negative impacts (29). However, access to these support structures remains limited in most countries and caregivers traditionally provide support without compensation, training or support (1). Even though caregivers’ important contribution is increasingly recognized, available support structures and financial support were already limited before the COVID-19 pandemic (100). The provision of intense levels of care has generally been associated with lower income and ultimately higher poverty rates, as well as poor mental health The largest share of this care is provided by women (61%), though the share of male caregivers increases with age (74). There are also many young (including children) and older caregivers who support family members with long-term care needs. The provision of intense levels of care has generally been associated with reduced labour force attachment (for those of working age), lower income and ultimately higher poverty rates (101). In addition, reduced income and lack of pension contributions exacerbate the risk of vulnerability and poverty in old age. Caregivers also have a higher prevalence of mental health problems (101). The COVID-19 pandemic has meant that some caregivers have had to adjust or give up their jobs to provide care or to avoid exposing the person they support to the risk of a COVID-19 infection. Caregivers working in the informal economy may also have experienced reduced working opportunities due to restrictions, posing a risk to their income. Caregivers also require support for the financial impact of the pandemic (102). The discontinuation of residential care options has left many family caregivers with increased responsibilities and without their usual support structures The COVID-19 pandemic has led to the closure of many day and respite care options, including community-based or short-term care, leaving many caregivers with additional responsibilities and without their established support structures. It is important to understand the issues caregivers face during this pandemic and how they can best be supported (102). Caregivers need to be able to get to the person with care needs, have access to information, PPE and testing, and be supported in developing contingency plans In many countries, government and NGOs have responded to this need by providing guidance and resource documents on hygiene measures to prevent infection and how to respond if the person with care needs or the caregivers themselves develop symptoms. Issues that have emerged during the pandemic include the need for caregivers to have permission to travel due to their care responsibility (78–79), supporting caregivers with access to testing and PPE (80), and developing contingency plans in case they can no longer continue to provide care (77). 24 Preventing and managing COVID-19 across long-term care services Changes in care needs and violence or abuse towards the caregiver Many caregivers are coping with changes in the needs of the person for whom they care (which may be due to infection or to the impact of the restrictive measures). Also, disruption to the normal routine may cause anxiety and stress in people with care needs, increasing pressure on caregivers (29). The COVID-19 pandemic has brought domestic violence and abuse to the surface (38). Family caregivers may also experience violence and abuse in their care relationship and require support (103). IMPLICATIONS IN THE CONTEXT OF COVID-19 Many caregivers have additional responsibilities without established support structures (such as day and respite care options) Social and physical distancing measures across countries are having negative health impacts on caregivers Even though caregivers’ important contribution is increasingly recognized, available financial support remains limited Caregivers experience difficulties in getting the necessary supplies, as they cannot easily leave the person they support alone Access to PPE and testing has largely been absent for family and voluntary caregivers Prolonged isolation, care responsibility without breaks, concerns about the person with care needs, worries about contingency care in case the caregiver becomes incapacitated, as well as violence or abuse towards the caregiver, have implications for caregivers’ mental health 2.8.2 Key actions Whole sector Record the main caregiver in health and long-term care records so that they become recognized as an important source of information and support. Long-term care facilities Enable family caregivers who provide psychological and practical support for people living in long-term care facilities to continue such roles through supportive measures that ensure the safety of the caregivers. Caregivers Provide information, training, support and, if possible, respite care at national level to caregivers, particularly those caring for older people living with dementia, including information on how to manage increased caregiving responsibilities and stress. Consider establishing a telephone helpline or online portal to offer advice, information and support (104). Consider rolling out an assessment to monitor family caregiver needs. Develop clear guidance for family caregivers on when and how to self-isolate. Increase vigilance and monitoring of domestic violence and support for family caregivers. Ensure access to PPE (without family caregivers bearing the inflated cost) and to equipment and medications. Explore new ways of providing support services to caregivers through technology, and support caregivers in accessing relevant technologies. Introduce or expand financial and psychosocial support for family caregivers. Provide bereavement support and ensure careful communication on decision-making with family. 25 Preventing and managing COVID-19 across long-term care services Country examples In Brazil, NGOs (such as the Brazilian Society of Geriatrics and Gerontology and the Brazilian Alzheimer’s Association) have published technical and educational caregiver guidance documents. A booklet has been prepared by FioCruz and other health-related organizations to educate caregivers of older people on preventive and protective measures for COVID-19. There is also a website by the Ministry of Women, Family and Human Rights dedicated to the provision of information for people with rare conditions and disabilities and their caregivers. A collaboration between the Ministry of Health and the Pan American Health Organization has developed a video campaign to support the mental health of people in Brazil who struggle with feelings of isolation, loneliness and distress. NGOs, such as the Alzheimer’s Association, provide helplines and online forums. Other groups have organized psychosocial activities (105). In India, guidelines issued by the Indian Ministry of Social Justice and Empowerment on 27 March 2020 recognized the importance of caregivers being able to get to the people they support. It was recommended that caregivers should be issued with passes that enable them to travel during the period of movement restrictions. Also, NGOs (such as the Alzheimer’s and Related Disorders Society of India, Nightingales Medical Trust and Silver Innings) and specialist services (National Institute of Mental Health and Neuro-Sciences, Cognitive Disorders Clinic) offer information and resources for caregivers of people living with dementia. The Nightingales Medical Trust provides the DemKonnect app, which offers expert advice to caregivers. The Ministry of Health and Family Welfare offers a psychosocial and behavioural helpline. In addition, it has provided videos (including on meditation and yoga) for stress management and mental health tips for different age groups on its website (78). In Ireland, the Dementia Services Information and Development Centre has provided resources for caregivers, including suggested activities for people living with dementia to mitigate the impact of social isolation. The Alzheimer Society of Ireland also offers relevant resources for support and information. Caregivers in receipt of the means-tested carer’s allowance continue to receive payments during the COVID-19 pandemic. In addition, working caregivers in receipt of the carer’s allowance who have lost their jobs due to the pandemic can also access the new pandemic unemployment payment of 350 euros. Similarly, Family Carers Ireland has developed guidance for the development of an emergency plan for caregivers (77). In Germany, the period for receiving long-term care allowance (Pflegeunterstützungsgeld) to respond to an emergency care situation in the family or to organize care arrangements has been doubled in response to the COVID-19 pandemic from 10 to 20 days (until 30 September 2020). The right to stay away from work to respond to an acute care situation has also been extended to 20 days. People who usually receive in-kind services that have become unavailable during the COVID-19 pandemic (such as day care) can be reimbursed to finance replacement care (96). 26 Preventing and managing COVID-19 across long-term care services 2.9 PRIORITIZE THE PSYCHOLOGICAL WELL-BEING OF PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.9.1 The challenge Many people with care needs experience a change to their routines and prolonged periods of isolation Many people, particularly older adults, with long-term care needs have been isolated in homes or facilities for many weeks, leading to reduced social contact and disrupted and changed routines. Some people with long-term care needs, such as people living with dementia, experience changes in their physical and cognitive status. Rapid changes to their routine may also increase their vulnerability to pre-existing conditions (84, 104). Specifically, in long-term care facilities, residents have struggled with not being able to socialize with fellow residents or to receive visits from their family and friends. Families are also extremely distressed that they are not able to visit and oversee the resident’s care. Long-term care facilities have recognized the importance of supporting residents with social contacts and have introduced innovative solutions, such as technical tools that enable virtual contact with their families and friends. Sharp increase in the risk of violence against older people Violence against older people, who are already bearing the brunt of this pandemic, has risen sharply since the beginning of the COVID-19 pandemic and imposition of restrictive stay-at-home measures. Violence is occurring in homes, in institutions such as long-term care facilities, and online, with a surge in scams directed at older people (106). Long-term care workers experience substantial pressure on their mental health during the COVID-19 pandemic Long-term care workers (compensated through pay) have experienced sustained pressure to provide care to vulnerable groups during the COVID-19 pandemic, and have worked hard to prevent the spread of COVID-19 to the people they assist. Many will have experienced traumatic situations and multiple bereavements. This leads to substantial pressure on their mental health. In the Netherlands, a survey by the Dutch Nurses’ Association (V&VN) found that 69% of community carers have felt greater pressure on their mental health during the COVID-19 pandemic. Among the 3325 respondents, 28% reported that there was no mental health support provided by their employer (80). Specific interventions to support the well-being of care workers are largely lacking. Some countries have recognized the mental health toll that the COVID-19 situation in long-term care facilities has taken on their staff and have put in place interventions to support the mental health of staff. In the United Kingdom, efforts have been made through support services to enhance the well- being of care workers. Migrant carers, particularly those who were commuting to provide care in other countries, may have found themselves either unable to return home after their shifts or unable to go to work (and therefore be paid) as countries closed their borders, leading to considerable hardship (76, 107). 27 Preventing and managing COVID-19 across long-term care services Family and voluntary caregivers experience great care responsibility and isolation, while their usual support services have largely been suspended Many family caregivers have been isolating with the person they care for to protect them from a COVID-19 infection. This has left them feeling disconnected from their social networks. In addition, their usual support structures (such as day care, home care, other family caregivers and carer support groups) have been reduced in frequency or suspended, leaving family caregivers without important social contacts and sources of practical support. In some countries, helplines, virtual counselling and carer support groups have been established to support caregivers’ psychosocial well-being during the COVID-19 pandemic. IMPLICATIONS IN THE CONTEXT OF COVID-19 There has been a significant impact on the mental health of the staff of long-term care facilities, family and voluntary caregivers, and people with assistive care needs Many residents of long-term care facilities have struggled with not being able to socialize with fellow residents, to participate in regular social activities, or to receive visits from their family and friends Specific interventions to support the well-being of people providing and receiving care are largely lacking 2.9.2 Key actions Whole sector Establish an intersectoral working group to monitor long-term care staff stress and burn-out, and assess and implement strategies to provide mental health and psychosocial support to staff delivering long- term care. Establish a dedicated helpline for mental health and psychological support for anyone who requests it. Consider providing guidance on training care staff and volunteers to improve communication skills on sensitive issues such as end-of-life decisions, death, dying and bereavement. Encourage long-term care providers on the use of screening tools, review staffing procedures (such as flexible schedules and work breaks) to better manage the burden of care, and seek to reduce the use of physical restraints. Ensure mental and emotional support is available from mental health professionals and family caregiver networks, using digital media when required to support recipients and providers of care. Support the monitoring of violence towards older people. Long-term care facilities Establish clear visiting policies that provide balance between IPC measures and the need for people to maintain their psychological well-being (enable residents to have visitors while minimizing the risk of COVID-19 entering long-term care facilities). Facilitate residents’ contact with family and friends by phone, the Internet or written messages if access is restricted. Increase recruitment of volunteers to help with providing social interaction for isolated residents. 28 Preventing and managing COVID-19 across long-term care services Community-based care Ensure access to and scale-up of resources for migrant live-in care workers. Encourage and enhance psychosocial support structures for family caregivers. Consider introducing mental health first aid training for volunteers and community members. Country examples In Chile, the National Service for Older Persons and the Society of Geriatrics and Gerontology have issued videos and graphics to support older people and family caregivers to cope with the COVID-19 situation. This material includes information on the use of PPE, distancing and mental health recommendations (108). It also offers templates to support the organization of community support for people needing help with the basic activities of daily living (109). In Mexico, the Ministry of Health implemented a mental health support campaign, which includes a rapid telephone assessment, to provide support strategies and to make referrals for specific support. Part of the strategy includes a campaign targeted at health care workers (110). In Kenya, some NGOs have moved to virtual peer support. However, poor connectivity in some areas, the cost of purchasing Internet bundles, and online fatigue pose challenges to efforts to support family carers. The Ministry of Labour and Social Protection published guidance for long-term care facilities, which explicitly states that staff should ensure that residents can maintain regular communication (through mobile calls or online chats) with their families and social networks, and should promote the well-being of residents by establishing regular routines and reducing interruptions to those (111). In Malaysia, staff of day care centres continue to look after the people they support through video calls, as well as sharing activities and exercise videos (99). In the United Kingdom, the COVID Trauma Response Working Group has developed guidance for managers and service planners concerned with looking after staff of long-term care facilities who may have experienced trauma (112). 29 Preventing and managing COVID-19 across long-term care services 2.10 ENSURE A SMOOTH TRANSITION TO THE RECOVERY PHASE 2.10.1 The challenge Loss in public confidence in long-term care facilities The COVID-19 pandemic has disproportionately affected people who live in long-term care facilities, and the share of deaths in those facilities appears to increase with the number of people affected in the community. This suggests that as long as there is community transmission of COVID-19 locally, long- term care facilities are at high risk of infection and large numbers of deaths. There are concerns in many countries about the loss in public confidence in long-term care facilities, and the possible negative impacts that might result if people who would benefit from living in a long- term care facility fail to do so because of fear. This may have negative consequences for these persons, for their families, and also for the financial viability of providers of long-term care facilities. Movement restrictions and other shielding measures in long-term care facilities One of the first measures adopted in almost all countries has been restricting visitors to long-term care facilities. While this measure is relatively easy to implement, it is increasingly recognized that it has an enormous impact on the well-being of both the residents of long-term care facilities and their families, and that, particularly where the resident has dementia, a lack of understanding of why the visits have stopped may generate additional distress. Concerns have also been expressed that many family members provide care in their regular (sometimes daily) visits, and that not allowing them to visit at a time when the staff of long-term care facilities may already be overburdened due to increased complexity of care and lower staffing ratios may compound staffing problems. Difficulties in monitoring quality of services in long-term care facilities Another concern is that family member visits have stopped at a time when many countries have suspended inspections. Families may be concerned about the quality of care the residents are receiving, and not being allowed to visit may exacerbate their fears. Ensuring safe visiting is increasingly recognized as a key step in rebuilding trust in long-term care facilities. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of exit strategy on restrictive measures applied to long-term care facilities Lack of monitoring quality of care within long-term care facilities when movement restrictions are implemented for those facilities 30 Preventing and managing COVID-19 across long-term care services 2.10.2 Key actions Long-term care facilities Make available surveillance mechanisms to monitor the quality of care within long-term care facilities during implementation of public health and social measures. Make available guidance on thresholds as to when and how to phase in or out isolation of residents and loosen restrictions on visitors. Establish clear criteria on when and how people living in long-term care facilities can move to and from hospitals to protect both staff and other residents. Ensure that the needs of long-term care residents are considered in providing acute, primary and community health services, and that pre-COVID-19 levels of support from primary care and community nursing are reinstated as early as possible. Community-based care Ensure that protocols are being developed so that people receiving community care (for example, day care) can access these services again. Country examples In Malta, day care services started again on a rotational basis on 1 June 2020. People with care needs receiving no services were given priority. Strict hygiene procedures and distancing measures were put in place. For example, staff and people with care needs keep shoes at the day care facility and change when they leave. People with care needs have to wear masks and visors while attending the centre. Staff also wear visors throughout the working day. In addition, people receiving and providing care have their temperature monitored (58). In Denmark, people could continue to visit residents receiving end-of-life care while adhering to hygiene protocols. Since 24 April 2020, residents in long-term care facilities can receive visitors in the outdoor areas (98). In Germany, restrictions around visitors started to be relaxed again in May 2020. While specific rules on the number of people visiting and the frequency and lengths of their visits vary between federal states, all states require that long-term care facilities put clear infection prevention measures in place. Visitors also have to register so that they can be identified for contact tracing if this becomes necessary (96). 31 Preventing and managing COVID-19 across long-term care services 2.11 INITIATE STEPS FOR TRANSFORMATION OF HEALTH AND LONG-TERM CARE SYSTEMS TO APPROPRIATELY INTEGRATE AND ENSURE CONTINUOUS, EFFECTIVE GOVERNANCE OF LONG-TERM CARE SERVICES The COVID-19 pandemic has highlighted fragmentation between long-term care services within health care systems. This fragmentation, along with inherent weaknesses in the current overarching governance structure for long-term care, has led to devastating consequences for long-term care facilities during the COVID-19 pandemic. It is with urgency that we need to transform health and long-term care systems so that long-term care services are readily integrated and provided alongside the traditional continuum of care: promotion, prevention, treatment, rehabilitation and palliation. It must be emphasized that assistive care, defined in this document as assistance provided to help a person perform a particular task to maintain functional ability and preserve independence, is considered an essential service that helps to promote ageing in place and ensure that a person can continue to do what they have reason to value even after significant declines in physical and mental capacity. The WHO Global Strategy and Action Plan on Ageing and Health, adopted in 2016, states that “Every country should have a sustainable and equitable system of long-term care” (44). The Decade of Healthy Ageing (2020–2030) also emphasizes access to long-term care for older people who need it (113). Although long-term care is not just for older people and includes a diverse range of users, the fundamentals are the same: providing services to those that are in need of long-term care in order to ensure a life consistent with their basic rights, fundamental freedoms and human dignity. The following actions reflect the lessons we are learning from the COVID-19 pandemic to realize sustainable and equitable long-term care for all. Key actions Ensure legislation and establish national strategy and frameworks on long-term care. Strengthen relationships between different levels of government involved in long-term care and health care and develop concrete vertical and intersectoral coordination mechanisms. Integrate regular national data collection of health and long-term care systems to enable systemwide evaluation and monitoring. Ensure sustainable and equitable financing mechanisms for long-term care that protect people from catastrophic costs of care. Ensure integrated person-centred care pathways spanning the health and long-term care continuum to enable people with long-term care needs to receive comprehensive care. Ensure continuous training and improved working conditions for the long-term care workforce. Introduce and expand financial and in-kind support for family and voluntary caregivers. Identify mechanisms to ensure quality services in the unregulated long-term care sector and strengthen accreditation. Ensure health sector oversight of long-term care facilities to prepare for future pandemics. Promote research building on lessons learned from the COVID-19 pandemic to address weaknesses in the health and long-term care system. 32 Preventing and managing COVID-19 across long-term care services References 1. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ handle/10665/186463). 2. Care work and care jobs for the future of decent work. Geneva: International Labour Organization; 2018 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/documents/publication/ wcms_633135.pdf, accessed 21 June 2020). 3. Who cares? Attracting and retaining care workers for the elderly. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd.org/publications/who-cares-attracting-and- retaining-elderly-care-workers-92c0ef68-en.htm, accessed 23 June 2020). 4. Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region: strengthening the health systems response to COVID-19. Technical Working Guidance No. 6. WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health-topics/Health-systems/ health-services-delivery/publications/2020/strengthening-the-health-systems-response-to-covid-19- technical-guidance-6,-21-may-2020, accessed 21 June 2020). 5. Salcher-Konrad M, Jhass A, Naci H, Tan M, El-Tawil Y, Comas-Herrera A. COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence. medRxiv. 2020. doi:10.1101/2020.06.09.20125237. 6. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N, Fernández J-L. Mortality associated with COVID-19 outbreaks in LTCFs: early international evidence. International Long-Term Care Policy Network; 2020 (https:// ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in-care-homes-early-international- evidence/, accessed 21 June 2020). 7. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 8. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 9. American Geriatrics Society. American Geriatrics Society (AGS) policy brief: CCOVID-19 and assisted living facilities. Journal of the American Geriatrics Society. May 2020:jgs.16510. doi:10.1111/jgs.16510. 10. American Geriatrics Society. American Geriatrics Society policy brief: COVID-19 and nursing homes. Journal of the American Geriatrics Society. 2020;68(5):908–11. doi:10.1111/jgs.16477. 11. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. New England Journal of Medicine. 2020;382:2081– 90. doi:10.1056/nejmoa2008457. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. UN SP LA SH / AR NE L HA SA NO VI C 33 Preventing and managing COVID-19 across long-term care services 13. Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A et al. SARS-CoV-2 infection: clinical features and outcome of COVID-19 in United Kingdom nursing homes. Journal of Infection. 2020;5:38. doi:10.1016/j. jinf.2020.05.073. 14. Goldberg SA, Pu CT, Thompson RW, Mark E, Sequist TD, Grabowski DC. Asymptomatic spread of COVID-19 in 97 patients at a skilled nursing facility. Journal of the American Medical Directors Association. 2020. doi:10.1016/j.jamda.2020.05.040. 15. Guery R, Cécile D, Noëlle B, Nael V, Castain L, Raffi F et al. Limited effectiveness of systematic screening by nasopharyngeal RT-PCR of medicalized nursing home staff after a first case of COVID-19 in a resident. Médecine et Maladies Infectieuses. May 2020. doi:10.1016/j.medmal.2020.04.020. 16. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A et al. Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults: Seattle, Washington, 2020. Morbidity and Mortality Weekly Report. 2020;69(14):416–8. doi:10.15585/mmwr. mm6914e2. 17. Grabenhorst U, Stiels-Prechtel R, Niemann M, Weckbecker K. COVID-19 in the nursing home: a case report. MMW-Fortschritte der Medizin. 2020;162(9):60–2. doi:10.1007/s15006–020–0481–0. 18. Dora AV, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans: Los Angeles, California, 2020. Morbidity and Mortality Weekly Report. 2020;69(21):651–5. doi:10.15585/mmwr.mm6921e1. 19. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. 2020;382(21):2005– 11. doi:10.1056/NEJMoa2005412. 20. Coronavirus (COVID-19) related deaths by occupation, England and Wales. Office for National Statistics; 2020 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/ bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistereduptoandinc luding20april2020#:~:text=A%20total%20of%20131%20deaths,100%2C000%20females%20(86%20 deaths), accessed 21 June 2020). 21. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 22. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherapy. May 2020. 23. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 24. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 25. COVID-19. Sciensano (https://epistat.wiv-isp.be/covid, accessed 21 June 2020). 26. Fisman D, Lapointe-Shaw L, Bogoch I, McCready J, Tuite A. Failing our most vulnerable: COVID-19 and long- term care facilities in Ontario. medRxiv. doi:10.1101/2020.04.14.20065557. 27. Yanover C, Mizrahi B, Kalkstein N, Marcus K. What factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization. medRxiv. 2020. doi:10.1101/ 2020.05.07.20091652. 28. Dawson WD, Ashcroft E, Lorenz-Dant K, Comas-Herrera A. Impact of the COVID-19 outbreak on community- based care services: a review of initial international policy responses. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Community-Based-Care-Report-19- May.pdf, accessed 21 June 2020). 29. Lorenz-Dant K. International examples of measures to support unpaid carers during the COVID-19 pandemic. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ 34 Preventing and managing COVID-19 across long-term care services International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-20.05.20-complete-2. pdf, accessed 21 June 2020). 30. COVID-19 supercharges existing inequalities faced by Glasgow’s 150,000 disabled people. Glasgow Disability Alliance; 2020 (http://gda.scot/our-community/news/2020/4/28/covid-19-supercharges-existing- inequalities-faced-by-glasgows-150–000-disabled-people, accessed 21 June 2020). 31. Noncommunicable diseases and COVID-19. Geneva: World Health Organization (https://www.who.int/ teams/ncds/covid-19, accessed 21 June 2020). 32. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–332240, accessed 21 June 2020). 33. Coronavirus: Spanish army finds care home residents “dead and abandoned”. BBC News, 24 March 2020 (https://www.bbc.co.uk/news/world-europe-52014023, accessed 21 June 2020). 34. 31 Senioren in Kanada tot: Pfleger kamen aus Angst vor Corona nicht [31 seniors dead in Canada: carers did not come for fear of Corona]. MSN, 18 April 2020 (https://www.msn.com/de-at/news/other/31-senioren- in-kanada-tot-pfleger-kamen-aus-angst-vor-corona-nicht/ar-BB12QiDh#image=1, accessed 21 June 2020). 35. Bauer A, Dixon J. The challenges of providing end-of-life support in LTCFs during the COVID-19 pandemic, and opportunities for the future: an international perspective. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Challenges-of-providing-end-of-life-support-in- care-homes-during-the-COVID-19-pandemic-1.pdf, accessed 21 June 2020). 36. Clinical management of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https:// www.who.int/publications-detail/clinical-management-of-covid-19, accessed 21 June 2020). 37. Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions. In: Gender equality. Paris: Organisation for Economic Co-operation and Development; 2019 (https://www.oecd.org/gender/data/womenare-well-represented-in-health-and-long-term-care- professions-but-often-in-jobs-with-poor-workingconditions.ht, accessed 21 June 2020). 38. COVID-19 and violence against women: what the health sector/system can do. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/331699. 39. Shippee T, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao M et al. COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging and Social Policy. June 2020. doi:10.1080/08959420.2020.1772004. 40. Long-term care for older people: a new global gender priority. New York; UN Women; 2017. 41. Policy brief: the impact of COVID-19 on older persons. New York: United Nations; 2020. 42. Scheil-Adlung X. Global estimates of deficits in long-term care protection for older persons. Extension of Social Security Series, No. 50. Geneva: International Labour Organization; 2015. 43. Help wanted? Providing and paying for long-term care. Paris: Organisation for Economic Co-operation and Development; 2011. 44. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. Report by the Secretariat. Sixty-ninth World Health Assembly, April 2016. Geneva: World Health Organization; 2016 (https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17-en.pdf?ua=1, accessed 21 June 2020). 45. Accelerating global actions for a world without poverty: United Nations System-wide Plan of Action for the Third United Nations Decade for the Eradication of Poverty (2018–2027). New York: United Nations; 2018 (https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/03/SWAP-Poverty- Booklet-Digital-Feb27.pdf, accessed 21 June 2020). 46. Barr N. Long-term care: a suitable case for social insurance. Social Policy and Administration. 2010;44(4):359– 74. doi:10.1111/j.1467–9515.2010.00718.x. 47. Protective equipment being diverted from LTCFs to hospitals, say bosses. The Guardian, 30 March 2020 (https://www.theguardian.com/world/2020/mar/30/protective-equipment-being-diverted-from-care- homes-to-hospitals-say-bosses, accessed 21 June 2020). 35 Preventing and managing COVID-19 across long-term care services 48. Spasova S, Baeten R, Coster S, Ghailani D, Pena-Casas R, Vanhercke B. Challenges in long-term care in Europe: a study of national policies. Brussels: European Commission; 2018. 49. Zalakain J, Davey V, Suárez-González A. The COVID-19 on users of long-term care services in Spain. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTCcovid-Spain-country-report-28-May-1.pdf, accessed 21 June 2020). 50. Berloto S, Notarnicola E, Perobelli E, Rotolo A. Italy and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID19- situation-in-Italy-30-April-2020.pdf, accessed 21 June 2020). 51. King D, Zigante V. Quality assurance practices in long-term care in Europe: emerging evidence on care market management. Brussels: Publications Office of the European Union; 2020. 52. Lloyd-Sherlock P, Neto J, Comas-Herrera A, Redondo N. Re: Covid-19: why we need a national health and social care service. BMJ. 2020;369. doi:10.1136/bmj.m1465. 53. Lloyd-Sherlock P, Bastos J, Geffen L, Giacomin K, Redondo N, Sasat S et al. An emergency strategy for managing COVID-19 in LTCFs in LMICs: the CIAT Framework. 2020 (https://www.corona-older.com/post/ an-emergency-strategy-for-managing-covid-19-in-care-homes-in-lmics-the-ciat-framework-version-1, accessed 21 June 2020). 54. Country assessment framework for the integrated delivery of long-term care. Copenhagen: WHO Regional Office for Europe; 2019. 55. COVID-19: Singapore to house nursing home staff in hotels to protect the elderly. Channel News Asia, 8 May 2020 (https://www.facebook.com/ChannelNewsAsia/videos/1098221953890384/, accessed 21 June 2020). 56. Covid-19 testing completed for nursing home residents and staff; no new cases found apart from 5 earlier ones. The Straits Times, 31 May 2020 (https://www.straitstimes.com/singapore/health/covid-19-testing- completed-for-all-nursing-home-residents-and-staff, accessed 21 June 2020). 57. Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G, Brammli-Greenberg S. The impact of COVID-19 on people using and providing long-term care in Israel. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4- May.pdf, accessed 21 May 2020). 58. Fenech MA, Vella M, Calleja N. The COVID-19 long-term care situation in Malta and Gozo. International Long-Term Care Policy Network; 2020. 59. Cès S, Coster S. Mapping long-term care quality assurance practices in the EU: summary report. Brussels: European Commission; 2019. 60. Hashiguchi T, Llena-Nozal A. The effectiveness of social protection for long-term care in old age: is social protection reducing the risk of poverty associated with care needs? OECD Health Working Papers. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd-ilibrary.org/social- issues-migration-health/the-effectiveness-of-social-protection-for-long-term-care-in-old-age_2592f06e-en, accessed 21 June 2020). 61. Van Houtven CH, Boucher NA, Dawson WD. The impact of COVID-19 outbreak on long term care in the United States. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf, accessed 21 June 2020). 62. HHS Provider Relief Fund. Centers for Disease Control and Prevention; 2020 (https://data.cdc.gov/ Administrative/HHS-Provider-Relief-Fund/kh8y-3es6, accessed 21 June 2020). 63. Kim H. The impact of COVID-19 on long-term care in South Korea and measures to address it. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term- Care-COVID19-situation-in-South-Korea-7-May-2020.pdf, accessed 21 June 2020). 64. Lum T, Shi C, Wong G, Wong K. COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging and Social Policy. 2020. doi:10.1080/08959420.2020.1773192. 36 Preventing and managing COVID-19 across long-term care services 65. Wong K, Lum T, Wong G. The COVID-19 long-term care situation in Hong Kong: impact and measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/ Hong-Kong-COVID-19-Long-term-Care-situation-27-April-2020–1.pdf, accessed 21 June 2020). 66. Shi C, Hu B, Feng M, Wong G. Report from mainland China: policies to support long-term care during the COVID-19 outbreak. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/Report-from-Mainland-China-18-April-final.pdf, accessed 21 June 2020). 67. Statistics Commission endorses new Titchfield City Group on Ageing. New York: United Nations Department of Economic and Social Affairs; 16 March 2018 (https://www.un.org/development/desa/ageing/ news/2018/03/title-statistics-commission-endorses-new-titchfield-city-group-on-ageing/, accessed 21 June 2020). 68. Descubren una residencia ilegal en La Laguna por las pruebas del Covid-19 [They discover an illegal residence in La Laguna by the tests of Covid-19]. La Provincia, 4 April 2020 (https://www.laprovincia.es/ sociedad/2020/04/04/descubren-residencia-ilegal-laguna-pruebas/1271776.html, accessed 21 June 2020). 69. Burton A, Goodman C, Quinn T. The invisibility of the UK care home population: UK care homes and a minimum dataset. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/ the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/, accessed 21 June 2020). 70. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 71. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.9540. 72. Jacobs R, Ashwell A, Docrat S, Schneider M. The impact of COVID-19 on long-term care in South Africa. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/ COVID-19-Long-Term-Care-Situation-in-South-Africa.docx, accessed 21 June 2020). 73. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. European Centre for Disease Prevention and Control; 2020 (https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term- care-facilities-EU-EEA, accessed 21 June 2020). 74. Rodrigues R, Huber M, Lamura G. Facts and figures on healthy ageing and long-term care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research; 2012. 75. Van Houtven CH, DePasquale N, Coe NB. Essential long-term care workers commonly hold second jobs and double- or triple-duty caregiving roles. Journal of the American Geriatrics Society. 2020. doi:10.1111/ jgs.16509. 76. Schmidt AE, Leichsenring K, Staflinger H, Litwin C, Bauer A. The impact of COVID-19 on users and providers of long-term care services in Austria. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/ wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Austria-15-May.pdf, accessed 22 June 2020). 77. Pierce M, Keogh F, O’Shea E. The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf, accessed 22 June 2020). 78. Rajagopalan J, Huzruk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTC-COVID-situation-in-India-30th-May.pdf, accessed 22 June 2020). 79. Amour R, Robinson JN, Govia I. The COVID-19 long-term care situation in Jamaica. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term- Care-situation-in-Jamaica-25-May-2020–1.pdf, accessed 22 June 2020). 37 Preventing and managing COVID-19 across long-term care services 80. Kruse F, Abma I, Jeurissen P. The impact of COVID-19 on long-term care in the Netherlands. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long- Term-Care-situation-in-the-Netherlands-25-May-2020–1.pdf, accessed 22 June 2020). 81. Low L-F. The long-term care COVID-19 situation in Australia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Australia-LTC-COVID19-situation-24-April-2020. pdf, accessed 22 June 2020). 82. Extra payment for unpaid carers. Scottish Government, 6 May 2020 (https://www.gov.scot/news/extra- payment-for-unpaid-carers/, accessed 22 June 2020). 83. Global action plan on the public health response to dementia 2017–2025. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259615). 84. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo J et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190–1. 85. Suarez-Gonzalez A, Livingston G, Comas-Herrera. Report: the impact of the COVID-19 pandemic on people living with dementia in UK. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/2020/05/03/report-the-impact-of-the-covid-19-pandemic-on-people-living-with-dementia-in-uk/, accessed 22 June 2020). 86. Joint statement on advance care planning. Care Quality Commission; 2020 (https://www.who.int/ publications/i/item/WHO-2019-nCoV-Comm_health_care-2020.1). 87. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ WHO-2019-nCoV-Comm_health_care-2020.1 accessed 22 June 2020). 88. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms- and-management-of-contacts, accessed 22 June 2020). 89. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 90. Bauer A. COVID19: providing palliative care for the many. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/03/31/covid19-proving-palliative-care-for-the-many/, accessed 22 June 2020). 91. Oven A. COVID-19 and long-term care in Slovenia: impact, measures and lessons learnt. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/COVID19-and- Long-Term-Care-in-Slovenia-impact-measures-and-lessons-learnt-21-April-2020.pdf, accessed 22 June 2020). 92. Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO- 2019-nCoV-Comm_health_care-2020.1, accessed 22 June 2020). 93. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. Geneva: World Health Organization; 2020 (https://www. who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-of- health-workers-including-key-considerations-for-occupational-safety-and-health, accessed 22 June 2020). 94. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–331495, accessed 22 June 2020). 95. Sani TP, Tan M, Rustandi KK, Turana Y. COVID-19 long-term care situation in Indonesia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19- Long-Term-Care-situation-in-Indonesia-30-May-1.pdf, accessed 22 June 2020). 96. Lorenz-Dant K. Germany and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19–26-May-2020. pdf, accessed 22 June 2020). 38 Preventing and managing COVID-19 across long-term care services 97. Contact tracing in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who. int/publications/i/item/contact-tracing-in-the-context-of-covid-19, accessed 22 June 2020). 98. Rostgaard T. The COVID-19 long-term care situation in Denmark. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care- situation-in-Denmark-29-May-2020.pdf, accessed 22 June 2020). 99. Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST. The long term care COVID-19 situation in Malaysia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/05/Malaysia-LTC-COVID-situation-report-30-May.pdf, accessed 22 June 2020). 100. Health at a glance 2019: OECD indicators. Paris: Organisation for Economic Co-operation and Development; 2019 (http://www.oecd.org/health/health-systems/health-at-aglance-19991312.htm, accessed 22 June 2020). 101. Brimblecombe N, Fernandez J-L, Knapp M, Rehill A, Wittenberg R. Unpaid care in England: future patterns and potential support strategies. London: London School of Economics; 2018. 102. Caring behind closed doors: forgotten families in the coronavirus outbreak. London: Carers UK; 2020 (https:// www.carersuk.org/for-professionals/policy/policy-library/caring-behind-closed-doors-report, accessed 22 June 2020). 103. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? Journal of Gerontological Social Work. 2014;57(5):460–77. doi:10.1080/01634372.2014.882466. 104. Mental health and psychosocial considerations during the COVID-19 outbreak: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/mental-health-and- psychosocial-considerations-during-the-covid-19-outbreak, accessed 22 June 2020). 105. Da Mata F, Oliveira D. COVID-19 and long-term care in Brazil: impact, measures and lessons learned. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf, accessed 22 June 2020). 106. COVID-19 and violence against older people. Geneva: World Health Organization; 2020 (https://www.who. int/publications/m/item/covid-19-and-violence-against-older-people, accessed 22 June 2020). 107. Leiblfinger M, Prieler V, Schwiter K, Steiner J, Benazha A, Lutz H. Impact of the COVID-19 pandemic on live-in care workers in Germany, Austria and Switzerland. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/impact-of-the-covid-19-pandemic-on-live-in-care-workers-in-germany- austria-and-switzerland/, accessed 22 June 2020). 108. Coronavirus Plan of Action. Chile: Senama (http://www.senama.gob.cl/protocolos-covid-19, accessed 22 June 2020). 109. Cuenta con migo [count on me]. Government of Chile (https://www.gob.cl/cuentaconmigo/, accessed 22 June 2020). 110. López-Ortega M, Sosa-Tinoco E. COVID-19 and long-term care in Mexico: questions, challenges, and the way forward. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/06/LTC-Covid-19-situation-in-Mexico-8-June.pdf, accessed 22 June 2020). 111. Musyimi C, Mutunga E, Ndetei D. COVID-19 and long-term care in Kenya. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/06/02/new-country-report-the-covid-19-long-term-care- situation-in-kenya/, accessed 22 June 2020). 112. COVID Trauma Response Working Group (https://www.traumagroup.org/, accessed 22 June 2020). 113. Decade of Healthy Ageing 2020–2030. Geneva: World Health Organization; 2020 (https://www.who.int/ docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en. pdf?sfvrsn=b4b75ebc_3, accessed 22 June 2020). 114. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 39 Preventing and managing COVID-19 across long-term care services 40 Preventing and managing COVID-19 across long-term care services Annex 1. Methods Living systematic review A living systematic review was undertaken, aiming to synthesize early international evidence on mortality rates and incidence of COVID-19 among people who use and provide long-term care. The review was registered with Prospero (CRD42020183557) and includes studies identified through database searches conducted on 15 May 2020 and updated up to 5 June 2020. The methods and findings have been published in full in medRxiv. Seven databases were searched (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv) to identify all studies reporting primary data on COVID-19-related mortality and incidence of disease among long-term care users and staff. In addition, evidence on country-level mortality rates was identified from LTCcovid.org, an international network of long- term care experts. Studies not focusing on long-term care were excluded. Included primary studies were critically appraised and results on number of deaths and COVID-19-related mortality rates, case fatality rates, and excess deaths (co-primary outcomes), as well as incidence of disease, hospitalizations, and intensive care unit admissions, were synthesized narratively. Title and abstract screening, and a full text review, were undertaken by three reviewers and records reporting on the same study or outbreak were combined. A standardized template was used to extract data at the study level, including information on study design; care setting (institutional versus community); how COVID-19 was diagnosed and confirmed; baseline characteristics of participants; absolute number of deaths and mortality rates from confirmed and suspected COVID-19 cases; case fatality rates; excess deaths; absolute numbers and rates of confirmed and suspected COVID-19; and rates of hospitalization and intensive care unit admissions among confirmed and suspected COVID-19 cases. All study participant characteristics and outcome data were extracted separately for long-term care users and staff. Information was also extracted on the proportion of asymptomatic cases at time of testing, and findings of studies comparing outcomes in long-term care users to others. Due to heterogeneity in the definitions of numerators, denominators, and follow-up times across included studies, data were not pooled. Instead, results were summarized narratively and presented in tables, including information on sample characteristics, follow-up time, and case definitions, as appropriate. Where studies reported on overlapping populations, preference was given to those with larger sample sizes and longer follow-up times. The quality of included primary studies reporting figures relating to mortality rates, case fatality rates, or disease incidence were assessed using the Joanna Briggs Institute critical appraisal tool for prevalence studies. Risk of bias across studies was not assessed. A total of 33 study reports for 30 unique primary studies or outbreak reports were included (Figure A1.1). UN SP LA SH / R IZ AL H IL M AN 41 Preventing and managing COVID-19 across long-term care services MEDLINE: n=673 Embase: n=43 CINAHL Plus: n=221 Web of Science: n= 184 Global Health: n=7 WHO COVID-19 Research Database n=202 medRxiv: n=3454 LTCcovid.org: n=22 Total included: n=33 (30 unique, original studies) Updated database searches: n=418 Database searches: n=4806 Included in first review: n=30 (27 unique, original studies) After deduplication: n=418 Full text review: n=33 Newly included: n=4 After deduplication: n=4457 Full text review: n=247 Excluded after title and abstract screening: n=4210 Excluded after full text review Not focused on LTC: n=75 Review article: n=52 No mortality or infection data: n=56 Opinion piece: n=25 Full text not accessible: n=7 Modelling study: n=3 Not focused on COVID-19: n=3 Duplicate: n=3 Excluded after title and abstract screening: n=385 Excluded after full text review Review article: n=8 Opinion piece: n=6 No mortality or infection data: n=4 Not focused on LTC: n=3 Not focused on COVID-19: n=2 Duplicate: n=1 Full text not accessible: n=0 Modelling study: n=0 Excluded: 1 previously included study (withdrawn by author) Records identified through other sources: n=3 Figure A1.1 Flow chart for selection of included primary studies 42 Preventing and managing COVID-19 across long-term care services Pilot of a systematic review of effectiveness of interventions to mitigate the impact of COVID-19 on people who use and provide long-term care A systematic review on the effectiveness of interventions to manage the impact of COVID-19 on people who use and provide long-term care is under development. While piloting the search strategy across seven databases (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv), 21 studies were identified that described responses to the COVID-19 pandemic and provided some sort of evaluation of effectiveness or aimed to assess characteristics of long-term care services associated with COVID-19 infection rates and associated mortality. There were five reports from the United States, three from Italy, two each from Canada, China, the Republic of Korea and Spain, and one report each from Belgium, France, Ireland, Singapore and the United Kingdom. The interventions identified and target groups varied. Three of the studies related to pharmacological therapies in care homes (1–3), additional studies described the implementation of measures to prevent (China and Singapore) and contain (Canada, China, the Republic of Korea and the United States of America) outbreaks in care homes (1, 4–8), one study reported about prevention measures for community-based care in the United States (9), four reported on multifaceted organizational changes to deal with COVID-19 in long-term care settings, including multidisciplinary collaboration and coordination (6, 10–12), three were pilot studies for detecting COVID-19 through rapid point-of-care testing, pooled testing, and bedside chest ultrasonography (13–15), and one adapted an existing cognitive stimulation intervention for people with dementia to provide information and support in relation to COVID-19 (16). These studies were mostly descriptive and, lacking a control group, were not designed to rigorously evaluate the effectiveness of implemented measures. Nevertheless, the prevention and outbreak management interventions described in the papers from China, the Republic of Korea and Singapore all reported successes in preventing or containing outbreaks. Another three studies assessed the association between different characteristics of care homes and COVID-19 outbreaks and outcomes. Stall et al. found that for-profit status of nursing homes in Ontario, Canada, was associated with both the size of a nursing home outbreak and the number of resident deaths (17). However, for-profit status was not associated with a higher likelihood of an outbreak. Romero-Ortuño and Kennelly found moderate, statistically significant association between crude number of deaths and maximum occupancy in Irish care homes, but no statistically significant association was found for quality of care homes (18). Similarly, Abrams et al. did not find a statistically significant association between the reporting of at least one COVID-19 case in United States nursing homes and traditional quality criteria (19). However, a statistically significant association was found for larger facility size, urban location, percentage of African-American residents, non-chain status, and state. Finally, two studies analysed the association between regional characteristics, including features of the long- term care system such as the proportion of private versus public long-term care beds and the availability of nursing home beds, and spread of COVID-19 in Italian regions (20–21). Country reports on the COVID-19 long-term care situation Country reports published on the LTCcovid website (an initiative of the International Long-Term Care Policy Network) were reviewed. The reports were produced by experts in long-term care, usually academics. The reports aimed to document the impact of COVID-19 on people who use and provide long-term care in each country, and the measures adopted to mitigate the impacts of the pandemic on this population. Information from these reports informed the examples of measures adopted by different countries. 43 Preventing and managing COVID-19 across long-term care services References 1. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 2. Ahmad I, Alam M, Saadi R, Mahmud S, Saadi E. Doxycycline and hydroxychloroquine as treatment for high- risk COVID-19 patients: experience from case series of 54 patients in long-term care facilities. medRxiv. May 2020. doi:10.1101/2020.05.18.20066902. 3. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 4. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherarpy. May 2020. 5. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 6. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 7. Munanga A. Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing. 2020;46(6):3–5. doi:10.3928/00989134–20200511–03. 8. Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M et al. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. Journal of Intellectual Disability Research. 2020. doi:10.1111/jir.12740. 9. Archbald-Pannone LR, Harris DA, Albero K, Steele RL, Pannone AF, Mutter JB. COVID-19 collaborative model for an academic hospital and long-term care facilities. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.044. 10. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 11. Koeberle S, Tannou T, Bouiller K, Becoulet N, Outrey J, Chirouze C et al. COVID 19 outbreak: organisation of a geriatric assessment and coordination unit – a French example. Age and Ageing. May 2020. doi:10.1093/ ageing/afaa092. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Cabrera JJ, Rey S, Perez S, Martinez-Lamas L, Cores-Calvo O, Torres J et al. Pooling for SARS-CoV-2 control in care institutions. medRxiv. June 2020. doi:10.1101/2020.05.30.20108597. 14. Nouvenne A, Ticinesi A, Parise A, Prati B, Esposito M, Cocchi V et al. Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.050. 15. Goodman-Casanova JM, Dura-Perez E, Guzman-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study. Journal of Medical Internet Research. 2020;22(5):e19434. doi:10.2196/19434. 16. Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit nursing homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada. Medrxiv. 2020. doi:10.1101/2020.05.25.20112664. 44 Preventing and managing COVID-19 across long-term care services 17. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 18. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16661. 19. Buja A, Paganini M, Cocchio S, Scioni M, Rebba V, Baldo V. Demographic and socio-economic factors, and healthcare resource indicators associated with the rapid spread of COVID-19 in northern Italy: an ecological study. medRxiv. 2020. doi:10.1101/2020.04.25.20078311. 20. Liotta G, Marazzi MC, Orlando S, Palombi L. Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox. PLoS One. 2020;15(5):e0233329. doi:10.1371/journal. pone.0233329. 45 Preventing and managing COVID-19 across long-term care services World Health Organization Avenue Appia 20 1202 Geneva, Switzerland

Policy brief Preventing and managing COVID-19 across long-term care services 24 July 2020

Preventing and managing COVID-19 across long-term care services Policy brief 24 July 2020 WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/) Suggested citation. Preventing and managing COVID-19 across long-term care services : policy brief. Geneva: World Health Organization; 2020 (WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Inis Communication Contents Acknowledgements iv Executive summary v Part 1. Overview 1 1.1 Aim of the document 1 1.2 Impact of COVID-19 on long-term care: what the evidence tells us 2 1.3 The case for action: leaving no one behind 3 Part 2. Responding to the COVID-19 pandemic in long-term care 5 2.1 Include long-term care in all phases of the national response to the COVID-19 pandemic 7 2.2 Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic 9 2.3 Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses 11 2.4 Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services 14 2.5 Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation 17 2.6 Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases 19 2.7 Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services 22 2.8 Provide support for family and voluntary caregivers 24 2.9 Prioritize the psychological well-being of people receiving and providing long-term care services 27 2.10 Ensure a smooth transition to the recovery phase 30 2.11 Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services 32 References 33 Annex 1. Methods 41 Web Annex: Key objectives and actions to prevent and manage COVID-19 in long-term care facilities https://apps.who.int/iris/bitstream/handle/10665/334020/WHO-2019-nCoV-Policy_Brief-Long-term_ Care-Web_Annex-2020.1-eng.pdf iii Acknowledgements This policy brief was developed by WHO through new analysis, expert consensus and reference to existing WHO guidance. Coordinating departments Department of Integrated Health Services (Shannon Barkley, Edward Kelley) Department of Maternal, Newborn, Child and Adolescent Health and Ageing (Zee-A Han, Anshu Banerjee) Principal writers World Health Organization: Zee-A Han (responsible officer), Shannon Barkley, Yuka Sumi London School of Economics and Political Science: Adelina Comas-Herrera, Klara Lorenz-Dant, Maximilian Salcher-Konrad Other contributors and reviewers WHO Steering Committee: Ageing and Health; Clinical Services and Systems; Gender, Equity and Human Rights; Integrated Health Services; Maternal, Newborn, Child and Adolescent Health and Ageing; Mental Health and Substance Use; Sensory Functions, Disability and Rehabilitation; Infection Prevention and Control Hub and Task Force; WHO Kobe Centre, and regional offices (Benedetta Allegranzi, Jotheeswaran Amuthavalli Thiyagarajan, Sarah Louise Barber, Anjana Bhushan, Alessandro Cassini, Alarcos Cieza, Theresa Diaz, Stefanie Freel, Manfred Huber, Anne Johansen, Theadora Koller, Margrieta Langins, Madison Moon, Paul Ong, Ritu Sadana, Nicoline Schiess, Katrin Seeher, Enrique Vega). The following individuals contributed to or reviewed the document. Confidentiality agreements were signed and declarations of interest were collected and reviewed. Non-WHO experts: WHO Global Network on Long-term Care for Older People (Liat Ayalon, Pablo Villalobos Dintrans, Walter Frontera, Muthoni Gichu, Sandhya Gupta, Hanadi Khamis Al Hamad, Arvind Mathur, Reshma A. Merchant, Stephen O’Connor, Vinod Shah, Lieve Van den Block) and Rachel Albone, Sean Cannone, Leon Geffen, Terry Fulmer, Richard Humphries, Caitlin Littleton, Terry Lum, Saniya Sabzwari, David Stewart. WHO continues to monitor the situation closely for any changes that may affect this policy brief. Should any factors change, WHO will issue a further update. WHO gratefully acknowledges the kind support of the Government of the Republic of Korea, Ministry of Health and Welfare. iv Preventing and managing COVID-19 across long-term care services Executive summary The COVID-19 pandemic has affected older people disproportionately, especially those living in long-term care facilities. In many countries, evidence shows that more than 40% of COVID-19 related deaths have been linked to long-term care facilities, with figures being as high as 80% in some high-income countries. Furthermore, in long-term care facilities, the case fatality for residents with COVID-19 may be higher than in the population of the same age living outside long-term care facilities. Residents of long-term care facilities often face high risk, low preventive measures and inadequate resources to recover from COVID-19, as well as reduced access to essential health services in a context where health systems are experiencing constraints during the COVID-19 surge. The impact of COVID-19 has additionally been high in providers of long-term care services, within long- term facilities and in other settings. A 2020 study by the United Kingdom Office for National Statistics of deaths by occupation found that the social care workforce had a significantly raised death rate associated with COVID-19. So far, COVID-19 has disproportionately affected long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community-based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. The response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries. Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19. This policy brief provides 11 policy objectives and key action points to prevent and manage COVID-19 across long-term care. Its intended audience is policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on currently available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and to mitigate impact across long-term care services, including care providers. While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized because they have experienced extremely high COVID-19 incidence, morbidity and mortality. Furthermore, the policy brief addresses long-standing problems in long-term care systems, including underfunding, lack of accountability, fragmentation between health and long-term care and an undervalued workforce. The brief suggests ways to transform health and long-term care services so that long-term care services are readily integrated and provided as part of the continuum of care that includes health promotion, prevention, treatment, rehabilitation and palliation. It is only through these measures that people in need of long-term care can receive quality, equitable and sustainable care that allows them to live in a manner respecting their basic rights, fundamental freedoms and human dignity. v Preventing and managing COVID-19 across long-term care services vi Preventing and managing COVID-19 across long-term care services Part 1. Overview 1.1 Aim of the document The COVID-19 pandemic has revealed weaknesses in emergency response where long-term care services has been underprioritized, resulting in the devastating impact seen across long-term care services globally. These events have highlighted long-standing problems in the long-term care systems in most countries: underfunding, lack of accountability, fragmentation, poor coordination between health and long-term care, and an undervalued workforce (1–3). This policy brief provides policy objectives and key action points to prevent and manage COVID-19 across long-term care for policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on current available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and its impact on those who use long-term care and care providers (including paid staff and family and other voluntary caregivers). It also expands on the technical working guidance on preventing and managing the COVID-19 pandemic across long-term care services in the World Health Organization (WHO) European Region to provide global perspectives and country examples across all WHO regions (4). While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized as they have experienced extremely high incidence, morbidity and mortality due to COVID-19. However, although long-term care facilities are an integral part of long-term care, it must be highlighted that community-based services are the key to promoting ageing in place, reducing institutionalization, and supporting deinstitutionalization, so that people can live in a manner consistent with their basic rights, fundamental freedoms and human dignity. Box 1 presents definitions of the terminology used in this document. Box 1. Working terminology: definitions of terms used Long-term care systems National systems that ensure integrated long-term care that is appropriate, affordable, accessible and upholds the rights of people and caregivers alike (1). Long-term care Services to ensure that people with or at risk of significant loss of physical and mental capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity (1). These services typically involve care and assistance with everyday tasks (including dressing, bathing, shopping, cooking and cleaning), support with social participation, and management of advanced chronic conditions through community nursing, rehabilitation and end-of-life care. Services are provided by both unpaid caregivers (typically family but also volunteers) and paid care staff. Throughout the document, the use of the term “long- term care services” covers care at home, in the community and in facilities (residential long-term care facilities, nursing homes or other group living facilities), unless otherwise specified. Long-term care facilities Long-term care facilities may vary by country. Nursing homes, skilled nursing facilities, assisted living facilities, residential facilities and residential long-term care facilities are collectively known as long-term care facilities that provide a variety of services, including medical and assistive care, to people who are unable to live independently in the community. Throughout the document, the use of the term “long-term care facilities” does not include home-based long-term care, community centres, adult day care facilities or respite care. Caregiver A person who provides care and support to someone else. Caregivers may include family members, friends, neighbours, volunteers, care workers and health professionals (1). UN SP LA SH / JE RE M Y ST EN UI T 1 Preventing and managing COVID-19 across long-term care services 1.2 Impact of COVID-19 on long-term care: what the evidence tells us Evidence from a systematic review (5) and compiled reports on the COVID-19 situation in long-term care facilities (Annex 1) shows that, while there is little evidence of the impact of COVID-19 on people who use and provide long-term care services in the community, the pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities. In countries with large numbers of deaths from COVID-19, about half of all those deaths have been among residents of long-term care facilities. The methods for the systematic review and other reviewing carried out for this report are described in more detail in Annex 1. Early evidence shows that the extent of COVID-19 infections in long-term care facilities has varied widely, between and within countries: some countries (such as Jordan) have had no infections reported in long-term care facilities so far, whereas in Sweden, for example, by the end of April, 25% of long-term care facilities in the whole country had COVID-19 outbreaks, with 67% of long-term care facilities in Stockholm affected. Data from 21 high-income countries show that while some countries have had no or very few deaths among residents in long-term care facilities, other countries report that on average nearly half of all deaths linked to COVID-19 in the country were of long-term care facility residents (ranging from 24% in Hungary to as high as 82% in Canada). In some countries, the share of deaths among all residents of long- term care facilities linked to COVID-19 has been as high as 3% to 6% of all residents (6). Disaggregated data by age and gender are not available for many countries. The evidence also shows that once COVID-19 infection is present in long-term care facilities it is difficult to control, in part due to the large number of people living close together in facilities designed for communal living and the fact that personal care requires close proximity. Although case reports from the Republic of Korea, demonstrated successful mitigation of further infections in long-term care facilities after a member of staff had tested positive (7–8), case studies in several other countries demonstrate how difficult it is to contain the infection in these settings. For example, studies in the United Kingdom of Great Britain and Northern Ireland and the United States of America have shown incidence rates between 40% and 72% among residents (9–14), with infection rates among staff between 1.5% and 5.9% when all staff members at outbreak facilities were tested (7–8, 15–18). There is also evidence from one study that staff working across more than one home may have been the source of transmission (19). An analysis of deaths by occupation in the United Kingdom showed that men and women working in social care had significantly raised rates of deaths involving COVID-19 (23.4 per 100 000 males compared to 9.9 for males aged 20–64 years, and 9.6 per 100 000 females compared to 5.2 for females aged 20–64 years) (20). Six studies describing measures to prevent (China and Singapore) and contain or manage (Canada and the Republic of Korea) outbreaks in long-term care facilities reported some success, although these studies did not have a control group (7–8, 22–23). There is increasing evidence of potential transmission from presymptomatic or asymptomatic people who have COVID-19 and people presenting with “atypical symptoms” in long-term care facilities. Studies of outbreaks show that 7% to 75% of residents and 50% to 100% of staff who tested positive are presymptomatic or asymptomatic (11–13, 15, 17, 19, 24). Between 57% and 89% of asymptomatic positive residents develop symptoms later (11, 19). Systematic nationwide testing of residents and staff in Belgium showed that 74% of cases among residents and 76% of cases among staff were asymptomatic at the time of testing (25). “Men and women working in social care have significantly raised rates of deaths involving COVID-19.” “The pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities.” 2 Preventing and managing COVID-19 across long-term care services Once people living in long-term care facilities have COVID-19, the case fatality for residents may be higher than in the population of the same age outside long-term care facilities. For example, the incidence rate of COVID-19 deaths among residents of long-term care facilities in Ontario, Canada, was 13 times higher compared to community-dwelling cases aged 70 years or older (26), and the risk for severe disease, including death, was 2.5 times higher for Israeli nursing home residents with COVID-19 compared to other cases over 65 years of age (27). No studies report on the detrimental health sequelae of either the infection itself or the measures taken to prevent infection in long-term care facilities, although many editorials and commentary articles mention potential impacts on both mental and physical health (for example, distress, depression, anorexia, loss of physical condition due to lack of exercise, and consequences of increased chemical and physical restraints). This has raised concerns for increased direct and indirect morbidity and mortality (28–29). There is limited evidence on the impact of the COVID-19 pandemic on people who use and provide community-based long-term care, including home help, day care facilities and unpaid caregivers. Some public health and infection prevention measures (including movement restrictions, physical distancing and curfews) may resulted in restriction of the usual sources of care and support that many people with care needs rely on. Evidence from the United Kingdom found that people with disabilities experienced widening inequalities during the COVID-19 pandemic. People with disabilities reported difficulty in accessing food and medication and delays in the benefit system, with some experiencing food insecurity and poverty. Many people with disabilities reported feeling isolated and, for some, lack of Internet access meant that they could not access virtual replacement services. Furthermore, reduction of ongoing support structures left people reliant on family and neighbours (30). It is also likely that people living with existing health conditions experience difficulties in accessing essential health care services, including rehabilitation, which further increases care needs. Furthermore, discontinuity of health care services can result in heightened need for care (31–32). It is increasingly recognized that in many countries the initial plans to contain the pandemic did not include long-term care facilities; it was only when media reports of large numbers of deaths started to emerge that resources were mobilized. In some countries, the army and other emergency response units had to be deployed to support long-term care facilities that had been overwhelmed by large numbers of deaths and insufficient staff (33). In many countries, long-term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred (34). 1.3 The case for action: leaving no one behind Health systems have a responsibility to offer safe, accessible, affordable and quality health care, including assistive and palliative care, for all people, without discrimination. However, as the evidence shows, residents of long-term care facilities are often facing higher risk, lower preventive measures and inadequate resources to manage COVID-19, as well as reduced access to essential health services, as health systems experience constraints in the context of a COVID-19 surge (35). Older people, particularly those with underlying conditions who are more likely to develop severe COVID-19, make up a large proportion of those using long-term care services, including those living in long-term care facilities (36). Immediate action is required to prevent infection and mitigate the impact of the COVID-19 pandemic among this population and to ensure that essential health and assistive care services are provided. “In many countries, long- term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred.” 3 Preventing and managing COVID-19 across long-term care services Furthermore, women, especially older women, represent the highest share of people who use care services, dominate the long-term care workforce, and are the main providers of family care (1, 37). In addition, long- term care services often depend heavily on migrant workers and workers from ethnic groups, who may be at higher risk (1, 38–40). The response to the pandemic must include long-term care to ensure that ethnic, age and gender groups are not marginalized. Concerns about human rights have also been expressed, both in the potential neglect of the population relying on (and providing) long-term care, and in measures adopted in an attempt to reduce the risk of infection (for example, a ban on visitation and forbidding outside physical activity). It is mandatory that the response to the pandemic is inclusive of long-term care, so that appropriate and tailored measures are implemented and issues specific to long-term care are addressed. So far, COVID-19 has disproportionately affected people living in long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community- based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. Considering the magnitude of the impact of COVID-19 on long-term care, response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries (4). Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19 (41). 4 Preventing and managing COVID-19 across long-term care services Part 2. Responding to the COVID-19 pandemic in long-term care While the pandemic has brought public attention to the immediate impacts of the pandemic, and the need to be prepared for present contingencies and possible future waves, it has also shown that there are major structural challenges that need to be addressed to improve the safety and resilience of long-term care systems. So far, most countries have struggled to develop coherent systems to ensure access to person-centred, quality, long-term care services that meet the growing health and assistive care needs and that are consistent with basic rights, fundamental freedoms and human dignity (1, 42–45). Even in high-income countries, a review by the Organisation for Economic Co-operation and Development (OECD) concluded that “there is a history in many countries of long-term care policies being developed in a piecemeal manner, responding to immediate political or financial problems, rather than being constructed in a sustainable, transparent manner” (43). This section looks into the unique challenges that have affected the ability of long-term care systems to respond to the COVID-19 pandemic and proposes policy objectives and key actions to address these challenges in the short and longer term. Informed by the available evidence and international experience thus far, the 11 policy objectives presented on the next page will be key to addressing COVID-19 in long-term care systems. The following subsections address each of these policy objectives in turn. UN SP LA SH / A P X 90 5 Preventing and managing COVID-19 across long-term care services Eleven policy objectives to mitigate the impact of COVID-19 across long-term care 1. Include long-term care in all phases of the national response to the COVID-19 pandemic. 2. Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic. 3. Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses. 4. Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services. 5. Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation. 6. Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases. 7. Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services. 8. Provide support for family and voluntary caregivers. 9. Prioritize the psychosocial well-being of people receiving and providing long-term care services. 10. Ensure a smooth transition to the recovery phase. 11. Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services. 6 Preventing and managing COVID-19 across long-term care services 2.1 INCLUDE LONG-TERM CARE IN ALL PHASES OF THE NATIONAL RESPONSE TO THE COVID-19 PANDEMIC 2.1.1 The challenge Long-term care has low political priority compared to health and other policy areas Long-term care tends to have low political priority and is often referred to as “the Cinderella of the welfare state”, where political attention to its importance is often transient and secondary to health care (46). This lack of political attention to long-term care may be one of the reasons why the initial policy responses to the pandemic in many countries did not include the long-term care sector (4). Governance of the long-term care system often involves multiple sectors, different ministries and different levels of government, making coordination difficult In most countries, long-term care falls between different ministries, typically health care and social affairs, development, or social protection. Long-term care services and health care systems are often poorly coordinated or integrated, and tend to have separate (and often complex) arrangements for financing, regulation, information systems, and the training and procurement of staff (1, 43). This has created several difficulties during the COVID-19 crisis. For example, back-up staffing models to meet the surge in COVID-19 patients in hospitals were not flexible enough to meet demand surges in the long-term care sector. It was also difficult for appropriate staff to move flexibly across the system as needed. Similarly, the long-term care sector, and especially long-term care facilities, struggled to access testing and PPE, as this had been prioritized for hospitals (47). In addition, countries frequently distribute responsibility for long-term care vertically across national, regional and local actors, creating difficulties in coordination of services and effective oversight (48). For example, in Spain and Italy, the same person may be receiving long-term care services that are organized or funded by up to three different levels of government (49–50). Long-term care services consist of a mixture of public, private for-profit and private not-for-profit service providers, in addition to family caregivers Long-term care services are also characterized by a mix of public, private for-profit and private not- for-profit service providers (51). In some countries, most long-term care facilities are operated by private for-profit providers and, particularly in low- and middle-income countries, these are often unregulated (52–53). Particularly in low- and middle-income countries, nongovernmental organizations (NGOs) play an important role in the provision of long-term care services and are often the sole source of support for unpaid caregivers. However, where NGOs are non-existent, the care responsibility often falls entirely on the families themselves. This unpaid care is rarely recognized within a formal system and so is not included in any governance processes or mechanisms beyond those of the NGOs that support the work. These structures can result in a lack of ownership, diffused accountability, and fragmentation of responsibilities, causing problems with coordination and quality of care and leading to underdeveloped information systems (43, 54). 7 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 May impede inclusion of long-term care in pandemic national response May impede planning, oversight and accountability during the pandemic May impede coordinated response between long-term care and health care sectors in responding to the pandemic May impede effective resource allocation 2.1.2 Key actions Whole sector Ensure a focal point to manage long-term care (with a special focus on long-term care users and providers) in the overarching COVID-19 governing body. Establish joint steering committees and information- and data-sharing systems between sectors and subnational policy levels to ensure a coordinated response. Establish a mechanism to support unregulated providers, focusing on cooperative support rather than punitive measures. Long-term care facilities If long-term care facilities are expanding their health care role during the pandemic, establish triggers or thresholds that activate a phased reallocation of routine comprehensive health service capacity, including direct health care staff. Country examples In Singapore, the Agency for Integrated Care and the Ministry of Health, together with long-term care service providers, have jointly developed a number of measures to respond to the COVID-19 pandemic. These include infection control and prevention measures, access to PPE, distancing and zoning measures, suspension of visitors, alternative accommodation for long-term care workers, and testing to monitor people with long-term care needs and care workers. The Agency for Integrated Care also set up an incident response team to support long-term care providers in responding to COVID-19 infections. The Silver Generation Office, which is an outreach arm of the Agency for Integrated Care, has supported older people with contact, information and the provision of services during the COVID-19 pandemic (55–56). In Israel, a governing team has been appointed to manage COVID-19 outbreaks in long-term care facilities across the country. This team has provided a national plan under the Fathers and Mothers Shield project, including establishment of a headquarters from which government efforts can be coordinated. In addition, the Home Front Command has been assisting long-term care facilities throughout the pandemic with managing visitor access, disinfection, and food and equipment delivery, and has been offering training and guidance on protective and preventive measures (57). In Malta, the Social Care Standards Authority, the regulatory body for long-term care, defined the residential care settings as being high risk with regard to COVID-19 in early March. Immediately, the Social Care Standards Authority issued the directives mapped out in its COVID-19 brief (2020). There was immediate cooperation between the Public Health Authority and the Social Care Standards Authority, which proved to be the primary catalyst towards safeguarding older persons within the facilities (58). 8 Preventing and managing COVID-19 across long-term care services 2.2 MOBILIZE ADEQUATE FUNDING FOR LONG-TERM CARE TO RESPOND TO AND RECOVER FROM THE COVID-19 PANDEMIC 2.2.1 The challenge Limited public funding allocated for long-term care Average public expenditure on long-term care is very low, less than 1% of GDP globally. Such public underfunding jeopardizes access to long-term care (42). This is even more pronounced in low- and middle-income countries, many of which lack dedicated sources of public financing for long-term care. Public benefit schemes for long-term care are usually needs based and means tested, and often require co-payments, leaving large parts of the population outside the public system In most countries, public benefit schemes for long-term care support are needs based and means tested, and often require co-payments. Those with greater needs often receive more support, but some countries also set limits on the amount that can be covered through public resources. While some countries protect the most vulnerable from additional costs, considerable out-of-pocket expenses are common across countries for most people receiving long-term care services (43, 59–60). Also, due to the large share of care provided by unpaid caregivers, in practice a large share of the costs of long-term care fall on families, through a combination of the opportunity costs of providing care and out-of-pocket payments. Few countries have financing mechanisms that protect the whole population from catastrophic long- term care costs (1). Reduced income for long-term care sector and higher costs of care Increasing PPE and workforce costs mean that service providers are facing substantial additional costs. At the same time, providers are experiencing decreases in revenues due to lower occupancy in long- term care facilities (resulting from both a decrease in admissions and the higher-than-usual numbers of deaths) and the closure of community-based services such as day care centres. Several countries have already provided emergency funds to support the long-term care sector during this crisis. However, the provision and distribution of resources may be easier in countries with more developed and regulated long-term care systems. The provision of resources and support to the unregistered long-term care sector poses additional challenges. Such unique challenges in the financing of long-term care have made it difficult for the long-term care system to react and respond to the additional costs that may be incurred due to preparing for and responding to COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of adequate funding for the additional costs linked to the COVID-19 response may endanger the safety of long-term care users and providers The increase in the costs of care due to the pandemic results in increased out-of-pocket payments for care users 9 Preventing and managing COVID-19 across long-term care services 2.2.2 Key actions Whole sector Consider injecting extra ring-fenced funds for long-term care to cover the additional costs linked to the pandemic (for example, additional staff costs, infection prevention and control (IPC) training, and materials such as PPE and sanitizers). Consider how to reduce regulatory and other costs to providers for the duration of the pandemic (such as staffing requirements). Provide flexibility in the use of emergency funds allocated to long-term care providers as well as users. Long-term care facilities Provide funding to compensate for lower occupancy rates and ensure provision of quality essential health and care services. Provide funding to support providers of long-term care facilities with the additional costs incurred in ensuring the safety of their residents and staff, including additional IPC measures and testing for COVID-19. Community-based care Support providers (particularly not-for-profit) that are experiencing loss of revenue if they have to close some services, such as day care and community centres, during the pandemic. Enable flexibility in the use of personal budgets and other cash benefits, for example by allowing them to be used to employ a family member or neighbour if community centres are not available. Caregivers Support caregivers who may need to take on additional care responsibilities to compensate for the unavailability of usual care, and may need to give up employment to do so. Country examples In the United States, the US$ 3 trillion COVID-19 stimulus package (under the Coronavirus Aid, Relief, and Economic Security (CARES) Act) provides some funding for the long-term care sector. Out of the US$ 100 billion funding allocated to health care providers under the CARES Act, US$ 50 billion is being distributed to hospitals and long-term care providers, including providers of home health (61). As of 3 June 2020, US$ 4.9 billion had been targeted to skilled nursing facilities (62). In the Republic of Korea, the Ministry of Health and Welfare and the Korean National Health Insurance Service have issued temporary reimbursement guidelines for the long-term care sector. The guidelines take into consideration the need for COVID-19-related physical distancing measures and staff shortages. In addition, service providers operating in special disaster zones will not be facing payment cuts if they cannot adhere to staffing requirements during the pandemic (63). In China, subsidized long-term care providers were allocated a special one-off allowance to support staffing (for example, hiring and redeploying workers and reimbursing overtime) to ensure the continued provision of long-term care services. It is estimated that this support will amount to a total of around US$ 1.6 million (64–66). 10 Preventing and managing COVID-19 across long-term care services 2.3 ENSURE EFFECTIVE MONITORING AND EVALUATION OF THE IMPACT OF COVID-19 ON LONG-TERM CARE AND ENSURE EFFICIENT INFORMATION CHANNELLING BETWEEN HEALTH AND LONG-TERM CARE SYSTEMS TO OPTIMIZE RESPONSES 2.3.1 The challenge Few countries have information and monitoring systems for long-term care systems Relatively few countries have information and monitoring systems that include individual-level data about the characteristics, needs and outcomes of people who use formal long-term care services, and about the type and quality of care that they are receiving. This reflects the overall situation of limited data sources about older people (who are often long-term care users) and lack of age- and gender- disaggregated data (67). Where individual-level data are available, quite often they only cover people who use publicly funded long-term care or provide services. Furthermore, health and social care data are usually collected under separate systems, leading to difficulties linking data for the same individual. There are reports of unregulated long-term care facilities being “discovered” as a result of the COVID-19 pandemic (68). Lack of individual-level data about the characteristics of the residents of long-term care facilities has been identified as a barrier to response planning for the COVID-19 pandemic (69–70). This has meant, for example, that mathematical models that have informed planning for the pandemic have not accounted for residents in long-term care facilities separately from surrounding populations in their calculations (71). Data on the pandemic were initially only collected on people who had been tested and died in hospitals Very few countries publish data on the numbers of residents of long-term care facilities who have been infected or died from confirmed or suspected COVID-19. Because residents of long-term care facilities have been less likely to be tested or admitted to hospital than people living in private households, it is likely that countries that do not include deaths outside hospital are underestimating the death toll of COVID-19. An international initiative to track data on deaths of residents of long-term care facilities only found publicly available data for 21 countries in May 2020 (6). Without data on the impact of the infection on long-term care facilities and on people who rely on care and live in the community, there is a risk that the resources needed to prevent and mitigate the impact of COVID-19 in the long-term care sector (funds, workforce, tests, PPE and other equipment) may not be provided adequately and in a timely manner. There are few data available on associated health impacts of the pandemic Many people who rely on assistive care, particularly community-based care, will have had disruptions in their usual access to care, which can potentially put them at risk (for example due to malnutrition, undetected infections or other health complications). Data to identify people who may be at higher risk are needed to identify gaps and reconfigure services as needed. 11 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 Difficult to monitor the impact of COVID-19 across long-term care services Difficult to develop tailored response plans for long-term care to mitigate impact Difficult to include long-term care populations in modelling projections Difficult to monitor health impact of COVID-19 on long-term care users and long-term care workforce Fragmentation of information between long-term care facilities and health facilities 2.3.2 Key actions Whole sector Find effective ways to make use of existing long-term care management data where they are available (for example, MDS 3.0 in the United States, and the interRAI assessment systems of Canada and New Zealand) to model the impact of COVID-19 on health (including mental health) and the functioning of older people in long-term care. For countries without these systems, consider establishing such management data systems as actions for the longer term. Encourage research on the impact, and measures to mitigate the impact, of COVID-19 on long-term care to identify gaps and prepare for future pandemics. Long-term care facilities Establish a surveillance system that captures people who have COVID-19 and deaths that occur in long- term care facilities (probable and confirmed, disaggregated by age, gender, disability and existing health condition), and ensure that these are integrated with existing surveillance systems. Establish the necessary legal mechanisms to secure and transmit information relating to COVID-19 on a regular and frequent basis to and from long-term care facilities, health facilities, public health authorities and the public. Set up a mechanism to ensure that these data are analysed regularly and the findings used to refine government policy on the COVID-19 response. Community-based care Establish mechanisms to report the number of people who have COVID-19 among those receiving and providing long-term care in the community and in homes to public bodies responsible for commissioning services. 12 Preventing and managing COVID-19 across long-term care services Examples In South Africa, managers of long-term care facilities have to inform the Department of Social Development if a COVID-19 case has been confirmed (72). In the European Union, the European Centre for Disease Prevention and Control (an agency of the European Union) has included long-term care facilities in its strategy for COVID-19 surveillance at national and European Union/European Economic Area levels and is collecting data from Member States covering mitigation action, infection rates and mortality (73). In Argentina, in La Plata, an NGO co-developed a website for monitoring and sharing information about both registered and informal long-term care facilities. This platform was used to survey the COVID-19 preparation of the long-term care facilities and resulted in the local government ensuring that testing was provided to all employees of long-term care facilities (53). 13 Preventing and managing COVID-19 across long-term care services 2.4 SECURE STAFF AND RESOURCES, INCLUDING ADEQUATE HEALTH WORKFORCE AND HEALTH PRODUCTS, TO RESPOND TO THE COVID-19 PANDEMIC AND DELIVER QUALITY LONG- TERM CARE SERVICES 2.4.1 The challenge Pre-existing workforce shortages, poor pay and working conditions Before the COVID-19 pandemic, workforce shortages, poor pay and working conditions, and low proportions of professionally qualified staff were already a major concern in long-term care systems (2–3, 73). The workforce supporting people with long-term care needs is predominantly female (90%) (37), and in many countries migrant care workers make up a large proportion of the long-term care workforce (74). It is common for care workers to have zero-hour contracts and to work for multiple facilities or agencies (75). Long-term care staff shortages during pandemic In many countries, long-term care services, particularly long-term care facilities, have experienced acute staff shortages during the COVID-19 pandemic when their staff had to isolate due to suspected or confirmed infection with COVID-19 (49–50, 76–77). This has happened at a time when family and other unpaid caregivers, due to visiting and movement restrictions, have been less able to provide support (even in long-term care facilities, family and volunteer caregivers make an important care contribution). On some occasions countries had to rely on extreme measures such as calling on the military or other emergency services when long-term care facilities became overwhelmed and understaffed (49). In some countries, long-term care workers and caregivers were not initially considered key workers and lockdown measures and curfews meant they were not able to travel to work (or continue to provide care to people in other households) (78–79). Using public transport or living in crammed accommodation may have increased the risk for care staff to be exposed to the virus. Difficulties adapting to increased health care needs in long-term care facilities While some long-term care facilities employ nurses and other health care staff, this is not the case in all facilities, and there are reports of the difficulties faced by non-medically trained staff in long-term care facilities needing to provide care to people with COVID-19 infections or to those who need palliative care without health care staff support or oversight by qualified health professionals such as physicians and nurses. Administrative barriers to transferring staff and medical supplies from the health service to long-term care facilities led, in the case of a region of Spain, to all long-term care facilities being put under the control of the Department of Health during the pandemic (49). Long-term care providers and caregivers not able to obtain PPE Difficulties faced by long-term care providers and caregivers in accessing PPE and other resources (such as hand sanitizer and disinfectant) have emerged in many countries, due to global shortages and the prioritization of hospitals and other health care settings. Long-term care providers reported having to buy PPE at inflated prices as a result. 14 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 A vast workforce shortage for long-term care When compensating for workforce shortage, high staff turnover can impede continuity of care and consistency in important IPC measures Decreased integrity of the work and value of a workforce dominated by women and migrant workers Increased financial pressures to work while ill due to poor working conditions, such as lack of compensation for sick leave Occupational safety of long-term care workforce not taken into careful consideration Substantial lack of PPE for long-term care facilities, long-term care workforce (including caregivers) and recipients of care Lack of essential medical supplies and health workforce in long-term care facilities Lack oversight by qualified health professionals in providing essential services in long-term care facilitie 2.4.2 Key actions Whole sector Estimate surge capacity needed to support long-term care services in coordination with the focal point on long-term care. Set up links between health and social care procurement chains to ensure a continuous and non- conflicting supply during COVID-19. Recruit additional staff and develop rapid training programmes (for example, recruit retirees, students from health and long-term care training programmes, and volunteers) on IPC measures. Address contractual and related issues and put in place policies and measures that keep staff safe but allow them to work in a flexible manner and move from health care services into long-term care services as needed. Establish rosters and secure staff from health systems who can be repurposed if needed to support staff in long-term care settings. Implement measures to prevent policies from impeding delivery of important home, community and facility-delivered care through the long-term care workforce. Implement measures to monitor staff working in multiple locations, with increased risk of transmission, and consider facilitating transport and accommodation of staff to minimize the risk of infection during local outbreaks. Provide financial payment for care staff to incentivize them to stay in their jobs during the epidemic and compensate them for additional workload and stress. Long-term care facilities Ensure adequate supply of PPE in long-term care facilities to protect care staff from infection. Provide adequate training guidance and enforce routine training of staff and family caregivers on IPC measures in long-term care facilities so they can continue providing care in those facilities. Facilitate flexible arrangements whereby palliative care teams and other relevant health and care professionals work with staff in long-term care facilities to ensure access to palliative care as needed. 15 Preventing and managing COVID-19 across long-term care services Ensure adequate oversight by appropriately trained personnel to deliver essential services in long-term care facilities. Ensure provision of PPE to home care workers, particularly those providing care in close proximity. Provide adequate training guidance and enforce routine training of community-based care providers. Family and other voluntary caregivers Ensure provision of PPE to caregivers providing care in close proximity. Provide adequate guidance and offer training for family and other voluntary caregivers. Country examples In Austria, staffing and licensing regulations for care workers have been eased substantially during the COVID-19 pandemic. This enables people who have done national service (those who opted for civilian duties) to provide basic care. People in the national service have contributed to managing the logistics of the pandemic. Their employment as care workers can be enforced by the government. In addition, people undertaking training in relevant areas and interested people who are currently unemployed can also step in (76). In Ireland, Nursing Homes Ireland started a recruitment campaign for nursing homes (private and NGO operated) in March 2020. Furthermore, the Health Service Executive agreed to redeploy staff (on a voluntary basis) to private nursing homes (77). In India, some long-term care facilities support their in-house staff with incentives, such as free food. In addition, some long-term care facilities are working to promote the mental health of their staff through regular check-ins and counselling (78). If long-term care facilities in Israel experience a shortage of staff, the Ministry of Health will send a special team for 7–14 days to support the provision of care for the acute period (57). In the Netherlands, since 19 May 2020 PPE has been available free of charge for care workers providing care activities that require close proximity (less than 1.5 metres) to persons with long-term care needs (80). In Spain, care staff from community care centres have been supporting the provision of home care, for example through phone calls. In addition, the long-term care sector can hire non-qualified staff in instances of absenteeism of their usual staff (49). In Australia, residential care workers will receive a retention bonus for two quarters of up to 800 Australian dollars after tax. The government has employed health care delivery providers to form rapid response teams in the long-term care sector where needed in each state. Visa rules were relaxed to enable staff to work more hours (81). In parts of the United Kingdom, care workers have had their wages increased and have been offered a special one-off payment for staff working during the COVID-19 pandemic (82). 16 Preventing and managing COVID-19 across long-term care services 2.5 ENSURE THE CONTINUUM AND CONTINUITY OF ESSENTIAL SERVICES FOR PEOPLE RECEIVING LONG-TERM CARE, INCLUDING PROMOTION, PREVENTION, TREATMENT, REHABILITATION AND PALLIATION 2.5.1 The challenge Requirement for continuous, complex care with high levels of physical and emotional contact People with long-term care needs often require continuous, complex and personalized support structures. Assistive care for personal tasks in particular requires high levels of physical and emotional contact. People who are receiving this care, and who are dependent on this support, benefit enormously from continuity of care (1). In many countries, the majority of residents of long-term care facilities have dementia (83–85). Variability in health care provision in long-term care facilities Long-term care facilities are very diverse, and while some may be specialized in providing medical care, such as long-term care hospitals or some nursing facilities, others, typically residential homes or supported accommodation, may not have any health care trained staff members. Long-term care facilities in many countries have experienced difficulties providing health care support and resources for essential health services, in addition to responding to the new burden of COVID-19 (including in the areas of rehabilitative and palliative care). Potential for discriminatory triage practices in hospital admissions There have been reports that residents of long-term care facilities have not been able to access health care in hospitals (49–50), and have had limited access to primary care. It has also been reported that advance care directives have sometimes been put in place without adhering to the usual person- centred standards (86). Countries have responded by emphasizing the importance of equitable access to health and palliative care for older adults and people with existing conditions during the COVID-19 pandemic (36–37). IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities in many countries have experienced difficulties providing health care support and resources to continue essential health services and to provide assistive care services for the new challenge of COVID-19 Residents of long-term care facilities have sometimes been denied hospital care based on irrelevant or discriminatory criteria, such as age, under the presumption that they are too frail to survive 17 Preventing and managing COVID-19 across long-term care services 2.5.2 Key actions Whole sector Consider developing clear COVID-19 care pathways, inclusive of long-term care facilities and home- and community-based care, for transfers to primary, secondary and tertiary care for people with COVID-19 and non-COVID-19 symptoms (87–89). Consider appropriate tele-health and virtual technologies for consultations, taking account of the views of older people, and provide any support necessary to use this technology effectively. Ensure that all palliative care plans and advanced care directives are up to date and applied through a person-centred approach. Ensure that national and regional policies, programmes and guidelines are in place to support the provision of palliative care in long-term care facilities and long-term care services (including physical, psychological, social and spiritual support). Long-term care facilities Consider involving the residents of long-term care facilities in the development of protocols for referral and access to essential health services. Ensure there is no selection based on age or disease in such protocols, but that people’s needs and preferences determine care decisions. Ensure that all long-term care facilities are supported by a primary care service. Establish rapid response teams, preferably with geriatric and palliative care training, for long-term care facilities for older people, to reduce avoidable hospitalizations and ensure optimal person-centred communication and decision-making. Ensure that staff are trained in providing palliative care and know how to communicate about death, dying and end-of-life decisions (35). Country examples In the United States, the use of home-based tele-health has been expanded as remote patient monitoring can now be reimbursed. Since March 2020, Medicare beneficiaries have been able to receive behavioural or substance use disorder interventions. For people with severe symptoms of COVID-19, post-acute tele-health visits are now possible. This enables social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists to perform remote evaluations and therapy. This may also support people with long-term care needs living in the community (61). In Italy, special palliative care teams were able to reorganize themselves rapidly in order to respond to demand quickly and flexibly. For example, they created networks of hospice care services by shifting staff from hospice inpatient to home care services. The experiences also highlighted the important need for case conferences and similar team collaborations to be able to decide quickly where to prioritize resources (for example, by deciding who will get support after hospital discharge) (50, 90). In Austria, the National Association for Palliative Care has issued a position paper on palliative care during the COVID-19 pandemic and has provided guidance on ensuring access to palliative care for people who will not receive the intensive care that normally is provided. The association has also published guidelines for family caregivers and long-term care workers. Furthermore, multidisciplinary guidance provided by the government is available to support people with COVID-19 who are reaching the end of life. There are also clinical guidelines and resources on how to facilitate social support and on bereavement for family carers and care workers supporting a person who reaches the end of life during the COVID-19 pandemic (76). In Slovenia, medical teams are ready to be sent to residential long-term care facilities to support regular staff if they become exhausted or overwhelmed (91). 18 Preventing and managing COVID-19 across long-term care services 2.6 ENSURE THAT INFECTION PREVENTION AND CONTROL STANDARDS ARE IMPLEMENTED AND ADHERED TO IN ALL LONG-TERM CARE SETTINGS TO PREVENT AND SAFELY MANAGE COVID-19 CASES 2.6.1 The challenge Lack of mandatory implementation of IPC guidance for long-term care Guidance on IPC for long-term care providers has been developed relatively late in the pandemic in many countries, and many of the guidelines have been slow to incorporate evidence of asymptomatic transmission and atypical symptoms of COVID-19. In many countries, guidance has only been developed for long-term care facilities, with no guidance available for providers of community-based care and for family caregivers. Finally, there is a lack of mechanisms to ensure implementation of these guidelines and to monitor their implementation. Lack of IPC experience and training in long-term care and resultant implementation difficulties In many countries, long-term care providers have weak IPC systems and training in place, resulting in many staff being unfamiliar with IPC and the correct use of PPE. This is a particular challenge for long-term care facilities that make high use of temporary or agency staff. Even where guidance and training are available, implementing some of the measures can be challenging due to the need for personal assistive care to be provided in close proximity. Lack of availability of testing and PPE, shortages of staff, difficulties in implementing physical distancing (given the design of traditional long-term care facilities), and a lack of alternative isolation facilities have been reported in countries that have struggled to contain infections in long-term care facilities. Across countries, guidelines have identified the importance of isolating residents exhibiting COVID-19- related symptoms, as well as those who have been in contact with people who are suspected of having or confirmed to have COVID-19. While in some countries residents in long-term care facilities live in single rooms with their own wet rooms, this is not the case in others. The specific structure of buildings in which long-term care facilities are housed may also pose barriers to the establishment of effective quarantine zones. Managers of long-term care facilities need to be supported in assessing the capacity of facilities to enable effective isolation policies and to provide additional quarantine spaces should the care setting not lend itself to effective isolation strategies. Countries that had experienced severe acute respiratory syndrome and Middle East respiratory syndrome had recently strengthened their IPC systems in long-term care facilities and community-based settings and have tended to systematically transfer people who are suspected or confirmed to have COVID-19 to isolation facilities, which appears to have been successful in controlling outbreaks (63). However, evidence on the impact of these measures on the mental and physical well-being of residents is not yet available. In some countries, there are large numbers of unregistered and therefore unregulated long-term care facilities. It is essential to support these facilities to ensure that they can keep their residents safe (53). Similarly, community-based care services are less often subject to direct regulatory control than residential long-term care facilities, and there are even fewer well developed information and monitoring systems that would enable the gathering of timely information on how the pandemic is affecting, directly or indirectly, people who rely on community-based care. Home care providers typically visit people with care 19 Preventing and managing COVID-19 across long-term care services needs in their own home. This means that care workers need to travel between homes and often visit multiple people with care needs. There is evidence that families have stopped using home care support to reduce the risk of infection for the person with care needs; however, this may create other risks (77, 81). IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of mechanisms to ensure implementation of IPC guidelines and monitor and assess implementation Lack of training of long-term care workforce on IPC measures High staff turnover impedes continuity of care and consistency of IPC measures Physical distancing is difficult to achieve for long-term care services Care workers cannot adequately access information on limiting transmission in the context of COVID-19 2.6.2 Key actions Whole sector Establish a coordinating body to develop, adjust and update IPC guidance and protocols during the COVID-19 pandemic for long-term care, based on the best available evidence (87-88, 92-93). Ensure implementation of the IPC guidance across long-term care services (for all settings). Establish a mechanism to plan, prioritize support for, and monitor implementation of measures to protect staff and people receiving long-term care from infection or spread of COVID-19. Establish early recognition, surveillance thresholds and escalation strategies for outbreaks of COVID-19 across long-term care. Consider how to ensure that providers of long-term care who may be operating outside the system (unregulated or illegal providers) can be supported to ensure the safety of the people living in their facilities or using their services. Ensure that everyone involved in direct delivery of care (staff and family caregivers), in long-term care facilities or in home care services, has access to IPC training (including use of PPE, hand hygiene, cleaning and disinfection of environments and waste management). This should be carried out regardless of their role, and especially for those having direct contact with older people with underlying health conditions (93). Consider developing and circulating standard operating procedures that give direction on how and when to rapidly isolate people receiving long-term care services, using the most up-to-date COVID-19 guidance. Implement extended IPC precautions for people discharged from hospital, based ideally on an agreed protocol for testing to determine individual needs for isolation and PPE required. Translate any strategies for standard operating procedures into clear referral systems that are made available to all staff delivering long-term care services. Long-term care facilities Ensure implementation of IPC guidance in long-term care facilities with reference to the WHO IPC guidance for long-term care facilities in the context of COVID-19 (92). Implement administrative controls, including syndromic surveillance upon entrance to a facility, for all staff and visitors. 20 Preventing and managing COVID-19 across long-term care services Ensure that staff in long-term care facilities have working conditions and arrangements that minimize their movement between settings and people receiving long-term care services, and that sick pay enables them to stay at home if they are unwell. Ensure that long-term care facilities have access to the resources needed to implement IPC (such as PPE, hand sanitizers and disinfectant). Develop the necessary IPC protocols and guidance and ensure that they are made available for visitors and are clearly visible in easy-to-understand formats (94). Develop guidance and ensure implementation of IPC protocol for staff and ensure educational resources are provided alongside continuous training. Ensure that long-term care facilities have an IPC focal point to lead and coordinate IPC activities, ideally supported by an IPC team with delegated responsibilities and advised by a multidisciplinary committee. Community-based care and caregivers Increase training and decision-making support for the long-term care workforce in the community to effectively manage COVID-19, including family caregivers, keeping in mind constraints, especially gender- related constraints, that family caregivers may face (87–88). Country examples In Jamaica, a temporary employment programme was created for regular cleaning of public sector long- term care facilities, and spaces were set aside in those facilities for isolation of symptomatic residents. Also, a multisectoral exercise between multiple State and private sector agencies facilitated deep sanitization of public long-term care facilities (79). In Indonesia, prevention measures in long-term care facilities include knowledge-sharing on hygiene principles with care workers and residents, regular disinfection and ventilation, and abstaining from sharing personal medical equipment. Residential long-term care facilities have put in place a registration system and do not allow visitors with symptoms of COVID-19 to enter the premises (95). In one region of China, after the severe acute respiratory syndrome epidemic, the regional authorities published the first guidelines on prevention of communicable diseases in residential long-term care facilities for the elderly in 2004, and required all operators of long-term care facilities to designate an infection control officer to coordinate and implement infection control measures within the facility, according to the guidelines (65). In Germany, the Robert Koch Institute recommends that domiciliary care workers wear face masks when providing care and that they regularly monitor their health. Additional equipment should be made available if the person they care for shows COVID-19-related symptoms (96). In the Netherlands, some home care workers are organized into special “Corona teams”. These teams look after people with COVID-19, while other teams care for people without infection (80). 21 Preventing and managing COVID-19 across long-term care services 2.7 PRIORITIZE TESTING, CONTACT TRACING AND MONITORING OF THE SPREAD OF COVID-19 AMONG PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.7.1 The challenge Many countries have experienced shortages in testing capacity as hospital services were prioritized In many countries there have been shortages of testing capacity as initially the available capacity was used mostly in hospitals, leaving providers of long-term residential and community services with difficulties in detecting people who had COVID-19. This approach is increasingly understood to have been a major problem, given the high rates of pre-symptomatic or asymptomatic people who have COVID-19 and could be spreading infection. Effective contact tracing in long-term care settings requires coordination and collaboration between long-term care providers and the relevant health authorities Effective testing, tracing and monitoring of COVID-19 in long-term care require coordination and collaboration between long-term care providers and the relevant health authorities. However, due to challenges in governance, such coordination has been difficult in the initial phases of the response. A growing number of countries are now including contact tracing in guidance for the long-term care sector and are developing apps and other systems to support contact tracing. Lack of systematic monitoring of the health status of people receiving and providing care Regular monitoring enables staff to detect changes in people’s health status, including the development of atypical symptoms (13), and to respond faster if a person with care needs or staff develop symptoms of COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities have become a blind spot for priority testing, tracing and monitoring of COVID-19 High rates of asymptomatic people who have COVID-19 have made early recognition and subsequent appropriate steps difficult 2.7.2 Key actions Whole sector Ensure testing data are aggregated and shared with local and national public health agencies so that the pandemic is managed at both the population and individual levels. Ensure contact tracing and isolation based on national guidance, with reference to WHO guidance on contact tracing in the context of COVID-19 (36, 97). Trace any clusters of infections or deaths of people in long-term care facilities or amongst those receiving home care services. 22 Preventing and managing COVID-19 across long-term care services Do not rely on symptoms alone, particularly “typical” cough and fever symptoms, when screening for COVID-19, and ensure that staff are trained in identifying other atypical symptoms, especially in older persons (36). Ensure that the health of people receiving and providing long-term care is monitored so that the development of symptoms (including atypical symptoms) can be detected quickly. Long-term care facilities In areas with ongoing or suspected community transmission, rigorous testing of both residents (including new admissions) and staff and tracing of close contacts are essential to develop isolation policies. Community-based care Ensure that people providing and receiving care in the community as well as their household members have access to testing and contact tracing, and have support if they need to isolate (87–88). Include household members of people with care needs in symptom monitoring. Examples In Denmark, both symptomatic and asymptomatic residents and staff in long-term care facilities can access testing at regional hospitals (since 12 May 2020). Even before that date, residents and staff were tested if there was an outbreak in a residential long-term care facility. If one resident shows symptoms, all residents and staff are tested within 24 hours and retested after seven days. If a staff member tests positive, all residents in the same area are also tested (98). In the Netherlands, all family caregivers that experience symptoms of COVID-19 can get tested (since 18 May 2020). In addition, family carers have been able to access free PPE since 19 May 2020 if they support vulnerable people (aged 70 years and older, with chronic conditions) who experience symptoms of COVID-19 and where personal assistive care (with less than 1.5 metres distance) is required (80). In Malaysia, all registered and unregistered long-term care facilities have undergone testing for COVID-19 (99). In the European Union, the European Centre for Disease Prevention and Control guidance recommends testing strategies that distinguish between “affected local areas” (random testing of residents and staff) and “unaffected areas”. Affected areas are those with actual or presumed continuing community transmission (73). 23 Preventing and managing COVID-19 across long-term care services 2.8 PROVIDE SUPPORT FOR FAMILY AND VOLUNTARY CAREGIVERS 2.8.1 The challenge Family caregivers provide an important share of care, but support such as respite care, training or care leave schemes remain limited and without compensation An important share of long-term care across countries is provided by family caregivers who provide care directly, and also help coordinate and complement formal services. In countries without established formal long-term care services, family caregivers provide almost all long-term care. Caregivers usually do not have access to any training for their role. Some countries recognize the impact of caregiving and offer support such as paid care leave, flexible work arrangements, respite care, training and psychological interventions, as well as cash benefits to mitigate negative impacts (29). However, access to these support structures remains limited in most countries and caregivers traditionally provide support without compensation, training or support (1). Even though caregivers’ important contribution is increasingly recognized, available support structures and financial support were already limited before the COVID-19 pandemic (100). The provision of intense levels of care has generally been associated with lower income and ultimately higher poverty rates, as well as poor mental health The largest share of this care is provided by women (61%), though the share of male caregivers increases with age (74). There are also many young (including children) and older caregivers who support family members with long-term care needs. The provision of intense levels of care has generally been associated with reduced labour force attachment (for those of working age), lower income and ultimately higher poverty rates (101). In addition, reduced income and lack of pension contributions exacerbate the risk of vulnerability and poverty in old age. Caregivers also have a higher prevalence of mental health problems (101). The COVID-19 pandemic has meant that some caregivers have had to adjust or give up their jobs to provide care or to avoid exposing the person they support to the risk of a COVID-19 infection. Caregivers working in the informal economy may also have experienced reduced working opportunities due to restrictions, posing a risk to their income. Caregivers also require support for the financial impact of the pandemic (102). The discontinuation of residential care options has left many family caregivers with increased responsibilities and without their usual support structures The COVID-19 pandemic has led to the closure of many day and respite care options, including community-based or short-term care, leaving many caregivers with additional responsibilities and without their established support structures. It is important to understand the issues caregivers face during this pandemic and how they can best be supported (102). Caregivers need to be able to get to the person with care needs, have access to information, PPE and testing, and be supported in developing contingency plans In many countries, government and NGOs have responded to this need by providing guidance and resource documents on hygiene measures to prevent infection and how to respond if the person with care needs or the caregivers themselves develop symptoms. Issues that have emerged during the pandemic include the need for caregivers to have permission to travel due to their care responsibility (78–79), supporting caregivers with access to testing and PPE (80), and developing contingency plans in case they can no longer continue to provide care (77). 24 Preventing and managing COVID-19 across long-term care services Changes in care needs and violence or abuse towards the caregiver Many caregivers are coping with changes in the needs of the person for whom they care (which may be due to infection or to the impact of the restrictive measures). Also, disruption to the normal routine may cause anxiety and stress in people with care needs, increasing pressure on caregivers (29). The COVID-19 pandemic has brought domestic violence and abuse to the surface (38). Family caregivers may also experience violence and abuse in their care relationship and require support (103). IMPLICATIONS IN THE CONTEXT OF COVID-19 Many caregivers have additional responsibilities without established support structures (such as day and respite care options) Social and physical distancing measures across countries are having negative health impacts on caregivers Even though caregivers’ important contribution is increasingly recognized, available financial support remains limited Caregivers experience difficulties in getting the necessary supplies, as they cannot easily leave the person they support alone Access to PPE and testing has largely been absent for family and voluntary caregivers Prolonged isolation, care responsibility without breaks, concerns about the person with care needs, worries about contingency care in case the caregiver becomes incapacitated, as well as violence or abuse towards the caregiver, have implications for caregivers’ mental health 2.8.2 Key actions Whole sector Record the main caregiver in health and long-term care records so that they become recognized as an important source of information and support. Long-term care facilities Enable family caregivers who provide psychological and practical support for people living in long-term care facilities to continue such roles through supportive measures that ensure the safety of the caregivers. Caregivers Provide information, training, support and, if possible, respite care at national level to caregivers, particularly those caring for older people living with dementia, including information on how to manage increased caregiving responsibilities and stress. Consider establishing a telephone helpline or online portal to offer advice, information and support (104). Consider rolling out an assessment to monitor family caregiver needs. Develop clear guidance for family caregivers on when and how to self-isolate. Increase vigilance and monitoring of domestic violence and support for family caregivers. Ensure access to PPE (without family caregivers bearing the inflated cost) and to equipment and medications. Explore new ways of providing support services to caregivers through technology, and support caregivers in accessing relevant technologies. Introduce or expand financial and psychosocial support for family caregivers. Provide bereavement support and ensure careful communication on decision-making with family. 25 Preventing and managing COVID-19 across long-term care services Country examples In Brazil, NGOs (such as the Brazilian Society of Geriatrics and Gerontology and the Brazilian Alzheimer’s Association) have published technical and educational caregiver guidance documents. A booklet has been prepared by FioCruz and other health-related organizations to educate caregivers of older people on preventive and protective measures for COVID-19. There is also a website by the Ministry of Women, Family and Human Rights dedicated to the provision of information for people with rare conditions and disabilities and their caregivers. A collaboration between the Ministry of Health and the Pan American Health Organization has developed a video campaign to support the mental health of people in Brazil who struggle with feelings of isolation, loneliness and distress. NGOs, such as the Alzheimer’s Association, provide helplines and online forums. Other groups have organized psychosocial activities (105). In India, guidelines issued by the Indian Ministry of Social Justice and Empowerment on 27 March 2020 recognized the importance of caregivers being able to get to the people they support. It was recommended that caregivers should be issued with passes that enable them to travel during the period of movement restrictions. Also, NGOs (such as the Alzheimer’s and Related Disorders Society of India, Nightingales Medical Trust and Silver Innings) and specialist services (National Institute of Mental Health and Neuro-Sciences, Cognitive Disorders Clinic) offer information and resources for caregivers of people living with dementia. The Nightingales Medical Trust provides the DemKonnect app, which offers expert advice to caregivers. The Ministry of Health and Family Welfare offers a psychosocial and behavioural helpline. In addition, it has provided videos (including on meditation and yoga) for stress management and mental health tips for different age groups on its website (78). In Ireland, the Dementia Services Information and Development Centre has provided resources for caregivers, including suggested activities for people living with dementia to mitigate the impact of social isolation. The Alzheimer Society of Ireland also offers relevant resources for support and information. Caregivers in receipt of the means-tested carer’s allowance continue to receive payments during the COVID-19 pandemic. In addition, working caregivers in receipt of the carer’s allowance who have lost their jobs due to the pandemic can also access the new pandemic unemployment payment of 350 euros. Similarly, Family Carers Ireland has developed guidance for the development of an emergency plan for caregivers (77). In Germany, the period for receiving long-term care allowance (Pflegeunterstützungsgeld) to respond to an emergency care situation in the family or to organize care arrangements has been doubled in response to the COVID-19 pandemic from 10 to 20 days (until 30 September 2020). The right to stay away from work to respond to an acute care situation has also been extended to 20 days. People who usually receive in-kind services that have become unavailable during the COVID-19 pandemic (such as day care) can be reimbursed to finance replacement care (96). 26 Preventing and managing COVID-19 across long-term care services 2.9 PRIORITIZE THE PSYCHOLOGICAL WELL-BEING OF PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.9.1 The challenge Many people with care needs experience a change to their routines and prolonged periods of isolation Many people, particularly older adults, with long-term care needs have been isolated in homes or facilities for many weeks, leading to reduced social contact and disrupted and changed routines. Some people with long-term care needs, such as people living with dementia, experience changes in their physical and cognitive status. Rapid changes to their routine may also increase their vulnerability to pre-existing conditions (84, 104). Specifically, in long-term care facilities, residents have struggled with not being able to socialize with fellow residents or to receive visits from their family and friends. Families are also extremely distressed that they are not able to visit and oversee the resident’s care. Long-term care facilities have recognized the importance of supporting residents with social contacts and have introduced innovative solutions, such as technical tools that enable virtual contact with their families and friends. Sharp increase in the risk of violence against older people Violence against older people, who are already bearing the brunt of this pandemic, has risen sharply since the beginning of the COVID-19 pandemic and imposition of restrictive stay-at-home measures. Violence is occurring in homes, in institutions such as long-term care facilities, and online, with a surge in scams directed at older people (106). Long-term care workers experience substantial pressure on their mental health during the COVID-19 pandemic Long-term care workers (compensated through pay) have experienced sustained pressure to provide care to vulnerable groups during the COVID-19 pandemic, and have worked hard to prevent the spread of COVID-19 to the people they assist. Many will have experienced traumatic situations and multiple bereavements. This leads to substantial pressure on their mental health. In the Netherlands, a survey by the Dutch Nurses’ Association (V&VN) found that 69% of community carers have felt greater pressure on their mental health during the COVID-19 pandemic. Among the 3325 respondents, 28% reported that there was no mental health support provided by their employer (80). Specific interventions to support the well-being of care workers are largely lacking. Some countries have recognized the mental health toll that the COVID-19 situation in long-term care facilities has taken on their staff and have put in place interventions to support the mental health of staff. In the United Kingdom, efforts have been made through support services to enhance the well- being of care workers. Migrant carers, particularly those who were commuting to provide care in other countries, may have found themselves either unable to return home after their shifts or unable to go to work (and therefore be paid) as countries closed their borders, leading to considerable hardship (76, 107). 27 Preventing and managing COVID-19 across long-term care services Family and voluntary caregivers experience great care responsibility and isolation, while their usual support services have largely been suspended Many family caregivers have been isolating with the person they care for to protect them from a COVID-19 infection. This has left them feeling disconnected from their social networks. In addition, their usual support structures (such as day care, home care, other family caregivers and carer support groups) have been reduced in frequency or suspended, leaving family caregivers without important social contacts and sources of practical support. In some countries, helplines, virtual counselling and carer support groups have been established to support caregivers’ psychosocial well-being during the COVID-19 pandemic. IMPLICATIONS IN THE CONTEXT OF COVID-19 There has been a significant impact on the mental health of the staff of long-term care facilities, family and voluntary caregivers, and people with assistive care needs Many residents of long-term care facilities have struggled with not being able to socialize with fellow residents, to participate in regular social activities, or to receive visits from their family and friends Specific interventions to support the well-being of people providing and receiving care are largely lacking 2.9.2 Key actions Whole sector Establish an intersectoral working group to monitor long-term care staff stress and burn-out, and assess and implement strategies to provide mental health and psychosocial support to staff delivering long- term care. Establish a dedicated helpline for mental health and psychological support for anyone who requests it. Consider providing guidance on training care staff and volunteers to improve communication skills on sensitive issues such as end-of-life decisions, death, dying and bereavement. Encourage long-term care providers on the use of screening tools, review staffing procedures (such as flexible schedules and work breaks) to better manage the burden of care, and seek to reduce the use of physical restraints. Ensure mental and emotional support is available from mental health professionals and family caregiver networks, using digital media when required to support recipients and providers of care. Support the monitoring of violence towards older people. Long-term care facilities Establish clear visiting policies that provide balance between IPC measures and the need for people to maintain their psychological well-being (enable residents to have visitors while minimizing the risk of COVID-19 entering long-term care facilities). Facilitate residents’ contact with family and friends by phone, the Internet or written messages if access is restricted. Increase recruitment of volunteers to help with providing social interaction for isolated residents. 28 Preventing and managing COVID-19 across long-term care services Community-based care Ensure access to and scale-up of resources for migrant live-in care workers. Encourage and enhance psychosocial support structures for family caregivers. Consider introducing mental health first aid training for volunteers and community members. Country examples In Chile, the National Service for Older Persons and the Society of Geriatrics and Gerontology have issued videos and graphics to support older people and family caregivers to cope with the COVID-19 situation. This material includes information on the use of PPE, distancing and mental health recommendations (108). It also offers templates to support the organization of community support for people needing help with the basic activities of daily living (109). In Mexico, the Ministry of Health implemented a mental health support campaign, which includes a rapid telephone assessment, to provide support strategies and to make referrals for specific support. Part of the strategy includes a campaign targeted at health care workers (110). In Kenya, some NGOs have moved to virtual peer support. However, poor connectivity in some areas, the cost of purchasing Internet bundles, and online fatigue pose challenges to efforts to support family carers. The Ministry of Labour and Social Protection published guidance for long-term care facilities, which explicitly states that staff should ensure that residents can maintain regular communication (through mobile calls or online chats) with their families and social networks, and should promote the well-being of residents by establishing regular routines and reducing interruptions to those (111). In Malaysia, staff of day care centres continue to look after the people they support through video calls, as well as sharing activities and exercise videos (99). In the United Kingdom, the COVID Trauma Response Working Group has developed guidance for managers and service planners concerned with looking after staff of long-term care facilities who may have experienced trauma (112). 29 Preventing and managing COVID-19 across long-term care services 2.10 ENSURE A SMOOTH TRANSITION TO THE RECOVERY PHASE 2.10.1 The challenge Loss in public confidence in long-term care facilities The COVID-19 pandemic has disproportionately affected people who live in long-term care facilities, and the share of deaths in those facilities appears to increase with the number of people affected in the community. This suggests that as long as there is community transmission of COVID-19 locally, long- term care facilities are at high risk of infection and large numbers of deaths. There are concerns in many countries about the loss in public confidence in long-term care facilities, and the possible negative impacts that might result if people who would benefit from living in a long- term care facility fail to do so because of fear. This may have negative consequences for these persons, for their families, and also for the financial viability of providers of long-term care facilities. Movement restrictions and other shielding measures in long-term care facilities One of the first measures adopted in almost all countries has been restricting visitors to long-term care facilities. While this measure is relatively easy to implement, it is increasingly recognized that it has an enormous impact on the well-being of both the residents of long-term care facilities and their families, and that, particularly where the resident has dementia, a lack of understanding of why the visits have stopped may generate additional distress. Concerns have also been expressed that many family members provide care in their regular (sometimes daily) visits, and that not allowing them to visit at a time when the staff of long-term care facilities may already be overburdened due to increased complexity of care and lower staffing ratios may compound staffing problems. Difficulties in monitoring quality of services in long-term care facilities Another concern is that family member visits have stopped at a time when many countries have suspended inspections. Families may be concerned about the quality of care the residents are receiving, and not being allowed to visit may exacerbate their fears. Ensuring safe visiting is increasingly recognized as a key step in rebuilding trust in long-term care facilities. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of exit strategy on restrictive measures applied to long-term care facilities Lack of monitoring quality of care within long-term care facilities when movement restrictions are implemented for those facilities 30 Preventing and managing COVID-19 across long-term care services 2.10.2 Key actions Long-term care facilities Make available surveillance mechanisms to monitor the quality of care within long-term care facilities during implementation of public health and social measures. Make available guidance on thresholds as to when and how to phase in or out isolation of residents and loosen restrictions on visitors. Establish clear criteria on when and how people living in long-term care facilities can move to and from hospitals to protect both staff and other residents. Ensure that the needs of long-term care residents are considered in providing acute, primary and community health services, and that pre-COVID-19 levels of support from primary care and community nursing are reinstated as early as possible. Community-based care Ensure that protocols are being developed so that people receiving community care (for example, day care) can access these services again. Country examples In Malta, day care services started again on a rotational basis on 1 June 2020. People with care needs receiving no services were given priority. Strict hygiene procedures and distancing measures were put in place. For example, staff and people with care needs keep shoes at the day care facility and change when they leave. People with care needs have to wear masks and visors while attending the centre. Staff also wear visors throughout the working day. In addition, people receiving and providing care have their temperature monitored (58). In Denmark, people could continue to visit residents receiving end-of-life care while adhering to hygiene protocols. Since 24 April 2020, residents in long-term care facilities can receive visitors in the outdoor areas (98). In Germany, restrictions around visitors started to be relaxed again in May 2020. While specific rules on the number of people visiting and the frequency and lengths of their visits vary between federal states, all states require that long-term care facilities put clear infection prevention measures in place. Visitors also have to register so that they can be identified for contact tracing if this becomes necessary (96). 31 Preventing and managing COVID-19 across long-term care services 2.11 INITIATE STEPS FOR TRANSFORMATION OF HEALTH AND LONG-TERM CARE SYSTEMS TO APPROPRIATELY INTEGRATE AND ENSURE CONTINUOUS, EFFECTIVE GOVERNANCE OF LONG-TERM CARE SERVICES The COVID-19 pandemic has highlighted fragmentation between long-term care services within health care systems. This fragmentation, along with inherent weaknesses in the current overarching governance structure for long-term care, has led to devastating consequences for long-term care facilities during the COVID-19 pandemic. It is with urgency that we need to transform health and long-term care systems so that long-term care services are readily integrated and provided alongside the traditional continuum of care: promotion, prevention, treatment, rehabilitation and palliation. It must be emphasized that assistive care, defined in this document as assistance provided to help a person perform a particular task to maintain functional ability and preserve independence, is considered an essential service that helps to promote ageing in place and ensure that a person can continue to do what they have reason to value even after significant declines in physical and mental capacity. The WHO Global Strategy and Action Plan on Ageing and Health, adopted in 2016, states that “Every country should have a sustainable and equitable system of long-term care” (44). The Decade of Healthy Ageing (2020–2030) also emphasizes access to long-term care for older people who need it (113). Although long-term care is not just for older people and includes a diverse range of users, the fundamentals are the same: providing services to those that are in need of long-term care in order to ensure a life consistent with their basic rights, fundamental freedoms and human dignity. The following actions reflect the lessons we are learning from the COVID-19 pandemic to realize sustainable and equitable long-term care for all. Key actions Ensure legislation and establish national strategy and frameworks on long-term care. Strengthen relationships between different levels of government involved in long-term care and health care and develop concrete vertical and intersectoral coordination mechanisms. Integrate regular national data collection of health and long-term care systems to enable systemwide evaluation and monitoring. Ensure sustainable and equitable financing mechanisms for long-term care that protect people from catastrophic costs of care. Ensure integrated person-centred care pathways spanning the health and long-term care continuum to enable people with long-term care needs to receive comprehensive care. Ensure continuous training and improved working conditions for the long-term care workforce. Introduce and expand financial and in-kind support for family and voluntary caregivers. Identify mechanisms to ensure quality services in the unregulated long-term care sector and strengthen accreditation. Ensure health sector oversight of long-term care facilities to prepare for future pandemics. Promote research building on lessons learned from the COVID-19 pandemic to address weaknesses in the health and long-term care system. 32 Preventing and managing COVID-19 across long-term care services References 1. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ handle/10665/186463). 2. Care work and care jobs for the future of decent work. Geneva: International Labour Organization; 2018 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/documents/publication/ wcms_633135.pdf, accessed 21 June 2020). 3. Who cares? Attracting and retaining care workers for the elderly. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd.org/publications/who-cares-attracting-and- retaining-elderly-care-workers-92c0ef68-en.htm, accessed 23 June 2020). 4. Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region: strengthening the health systems response to COVID-19. Technical Working Guidance No. 6. WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health-topics/Health-systems/ health-services-delivery/publications/2020/strengthening-the-health-systems-response-to-covid-19- technical-guidance-6,-21-may-2020, accessed 21 June 2020). 5. Salcher-Konrad M, Jhass A, Naci H, Tan M, El-Tawil Y, Comas-Herrera A. COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence. medRxiv. 2020. doi:10.1101/2020.06.09.20125237. 6. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N, Fernández J-L. Mortality associated with COVID-19 outbreaks in LTCFs: early international evidence. International Long-Term Care Policy Network; 2020 (https:// ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in-care-homes-early-international- evidence/, accessed 21 June 2020). 7. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 8. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 9. American Geriatrics Society. American Geriatrics Society (AGS) policy brief: CCOVID-19 and assisted living facilities. Journal of the American Geriatrics Society. May 2020:jgs.16510. doi:10.1111/jgs.16510. 10. American Geriatrics Society. American Geriatrics Society policy brief: COVID-19 and nursing homes. Journal of the American Geriatrics Society. 2020;68(5):908–11. doi:10.1111/jgs.16477. 11. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. New England Journal of Medicine. 2020;382:2081– 90. doi:10.1056/nejmoa2008457. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. UN SP LA SH / AR NE L HA SA NO VI C 33 Preventing and managing COVID-19 across long-term care services 13. Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A et al. SARS-CoV-2 infection: clinical features and outcome of COVID-19 in United Kingdom nursing homes. Journal of Infection. 2020;5:38. doi:10.1016/j. jinf.2020.05.073. 14. Goldberg SA, Pu CT, Thompson RW, Mark E, Sequist TD, Grabowski DC. Asymptomatic spread of COVID-19 in 97 patients at a skilled nursing facility. Journal of the American Medical Directors Association. 2020. doi:10.1016/j.jamda.2020.05.040. 15. Guery R, Cécile D, Noëlle B, Nael V, Castain L, Raffi F et al. Limited effectiveness of systematic screening by nasopharyngeal RT-PCR of medicalized nursing home staff after a first case of COVID-19 in a resident. Médecine et Maladies Infectieuses. May 2020. doi:10.1016/j.medmal.2020.04.020. 16. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A et al. Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults: Seattle, Washington, 2020. Morbidity and Mortality Weekly Report. 2020;69(14):416–8. doi:10.15585/mmwr. mm6914e2. 17. Grabenhorst U, Stiels-Prechtel R, Niemann M, Weckbecker K. COVID-19 in the nursing home: a case report. MMW-Fortschritte der Medizin. 2020;162(9):60–2. doi:10.1007/s15006–020–0481–0. 18. Dora AV, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans: Los Angeles, California, 2020. Morbidity and Mortality Weekly Report. 2020;69(21):651–5. doi:10.15585/mmwr.mm6921e1. 19. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. 2020;382(21):2005– 11. doi:10.1056/NEJMoa2005412. 20. Coronavirus (COVID-19) related deaths by occupation, England and Wales. Office for National Statistics; 2020 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/ bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistereduptoandinc luding20april2020#:~:text=A%20total%20of%20131%20deaths,100%2C000%20females%20(86%20 deaths), accessed 21 June 2020). 21. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 22. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherapy. May 2020. 23. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 24. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 25. COVID-19. Sciensano (https://epistat.wiv-isp.be/covid, accessed 21 June 2020). 26. Fisman D, Lapointe-Shaw L, Bogoch I, McCready J, Tuite A. Failing our most vulnerable: COVID-19 and long- term care facilities in Ontario. medRxiv. doi:10.1101/2020.04.14.20065557. 27. Yanover C, Mizrahi B, Kalkstein N, Marcus K. What factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization. medRxiv. 2020. doi:10.1101/ 2020.05.07.20091652. 28. Dawson WD, Ashcroft E, Lorenz-Dant K, Comas-Herrera A. Impact of the COVID-19 outbreak on community- based care services: a review of initial international policy responses. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Community-Based-Care-Report-19- May.pdf, accessed 21 June 2020). 29. Lorenz-Dant K. International examples of measures to support unpaid carers during the COVID-19 pandemic. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ 34 Preventing and managing COVID-19 across long-term care services International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-20.05.20-complete-2. pdf, accessed 21 June 2020). 30. COVID-19 supercharges existing inequalities faced by Glasgow’s 150,000 disabled people. Glasgow Disability Alliance; 2020 (http://gda.scot/our-community/news/2020/4/28/covid-19-supercharges-existing- inequalities-faced-by-glasgows-150–000-disabled-people, accessed 21 June 2020). 31. Noncommunicable diseases and COVID-19. Geneva: World Health Organization (https://www.who.int/ teams/ncds/covid-19, accessed 21 June 2020). 32. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–332240, accessed 21 June 2020). 33. Coronavirus: Spanish army finds care home residents “dead and abandoned”. BBC News, 24 March 2020 (https://www.bbc.co.uk/news/world-europe-52014023, accessed 21 June 2020). 34. 31 Senioren in Kanada tot: Pfleger kamen aus Angst vor Corona nicht [31 seniors dead in Canada: carers did not come for fear of Corona]. MSN, 18 April 2020 (https://www.msn.com/de-at/news/other/31-senioren- in-kanada-tot-pfleger-kamen-aus-angst-vor-corona-nicht/ar-BB12QiDh#image=1, accessed 21 June 2020). 35. Bauer A, Dixon J. The challenges of providing end-of-life support in LTCFs during the COVID-19 pandemic, and opportunities for the future: an international perspective. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Challenges-of-providing-end-of-life-support-in- care-homes-during-the-COVID-19-pandemic-1.pdf, accessed 21 June 2020). 36. Clinical management of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https:// www.who.int/publications-detail/clinical-management-of-covid-19, accessed 21 June 2020). 37. Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions. In: Gender equality. Paris: Organisation for Economic Co-operation and Development; 2019 (https://www.oecd.org/gender/data/womenare-well-represented-in-health-and-long-term-care- professions-but-often-in-jobs-with-poor-workingconditions.ht, accessed 21 June 2020). 38. COVID-19 and violence against women: what the health sector/system can do. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/331699. 39. Shippee T, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao M et al. COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging and Social Policy. June 2020. doi:10.1080/08959420.2020.1772004. 40. Long-term care for older people: a new global gender priority. New York; UN Women; 2017. 41. Policy brief: the impact of COVID-19 on older persons. New York: United Nations; 2020. 42. Scheil-Adlung X. Global estimates of deficits in long-term care protection for older persons. Extension of Social Security Series, No. 50. Geneva: International Labour Organization; 2015. 43. Help wanted? Providing and paying for long-term care. Paris: Organisation for Economic Co-operation and Development; 2011. 44. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. Report by the Secretariat. Sixty-ninth World Health Assembly, April 2016. Geneva: World Health Organization; 2016 (https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17-en.pdf?ua=1, accessed 21 June 2020). 45. Accelerating global actions for a world without poverty: United Nations System-wide Plan of Action for the Third United Nations Decade for the Eradication of Poverty (2018–2027). New York: United Nations; 2018 (https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/03/SWAP-Poverty- Booklet-Digital-Feb27.pdf, accessed 21 June 2020). 46. Barr N. Long-term care: a suitable case for social insurance. Social Policy and Administration. 2010;44(4):359– 74. doi:10.1111/j.1467–9515.2010.00718.x. 47. Protective equipment being diverted from LTCFs to hospitals, say bosses. The Guardian, 30 March 2020 (https://www.theguardian.com/world/2020/mar/30/protective-equipment-being-diverted-from-care- homes-to-hospitals-say-bosses, accessed 21 June 2020). 35 Preventing and managing COVID-19 across long-term care services 48. Spasova S, Baeten R, Coster S, Ghailani D, Pena-Casas R, Vanhercke B. Challenges in long-term care in Europe: a study of national policies. Brussels: European Commission; 2018. 49. Zalakain J, Davey V, Suárez-González A. The COVID-19 on users of long-term care services in Spain. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTCcovid-Spain-country-report-28-May-1.pdf, accessed 21 June 2020). 50. Berloto S, Notarnicola E, Perobelli E, Rotolo A. Italy and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID19- situation-in-Italy-30-April-2020.pdf, accessed 21 June 2020). 51. King D, Zigante V. Quality assurance practices in long-term care in Europe: emerging evidence on care market management. Brussels: Publications Office of the European Union; 2020. 52. Lloyd-Sherlock P, Neto J, Comas-Herrera A, Redondo N. Re: Covid-19: why we need a national health and social care service. BMJ. 2020;369. doi:10.1136/bmj.m1465. 53. Lloyd-Sherlock P, Bastos J, Geffen L, Giacomin K, Redondo N, Sasat S et al. An emergency strategy for managing COVID-19 in LTCFs in LMICs: the CIAT Framework. 2020 (https://www.corona-older.com/post/ an-emergency-strategy-for-managing-covid-19-in-care-homes-in-lmics-the-ciat-framework-version-1, accessed 21 June 2020). 54. Country assessment framework for the integrated delivery of long-term care. Copenhagen: WHO Regional Office for Europe; 2019. 55. COVID-19: Singapore to house nursing home staff in hotels to protect the elderly. Channel News Asia, 8 May 2020 (https://www.facebook.com/ChannelNewsAsia/videos/1098221953890384/, accessed 21 June 2020). 56. Covid-19 testing completed for nursing home residents and staff; no new cases found apart from 5 earlier ones. The Straits Times, 31 May 2020 (https://www.straitstimes.com/singapore/health/covid-19-testing- completed-for-all-nursing-home-residents-and-staff, accessed 21 June 2020). 57. Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G, Brammli-Greenberg S. The impact of COVID-19 on people using and providing long-term care in Israel. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4- May.pdf, accessed 21 May 2020). 58. Fenech MA, Vella M, Calleja N. The COVID-19 long-term care situation in Malta and Gozo. International Long-Term Care Policy Network; 2020. 59. Cès S, Coster S. Mapping long-term care quality assurance practices in the EU: summary report. Brussels: European Commission; 2019. 60. Hashiguchi T, Llena-Nozal A. The effectiveness of social protection for long-term care in old age: is social protection reducing the risk of poverty associated with care needs? OECD Health Working Papers. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd-ilibrary.org/social- issues-migration-health/the-effectiveness-of-social-protection-for-long-term-care-in-old-age_2592f06e-en, accessed 21 June 2020). 61. Van Houtven CH, Boucher NA, Dawson WD. The impact of COVID-19 outbreak on long term care in the United States. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf, accessed 21 June 2020). 62. HHS Provider Relief Fund. Centers for Disease Control and Prevention; 2020 (https://data.cdc.gov/ Administrative/HHS-Provider-Relief-Fund/kh8y-3es6, accessed 21 June 2020). 63. Kim H. The impact of COVID-19 on long-term care in South Korea and measures to address it. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term- Care-COVID19-situation-in-South-Korea-7-May-2020.pdf, accessed 21 June 2020). 64. Lum T, Shi C, Wong G, Wong K. COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging and Social Policy. 2020. doi:10.1080/08959420.2020.1773192. 36 Preventing and managing COVID-19 across long-term care services 65. Wong K, Lum T, Wong G. The COVID-19 long-term care situation in Hong Kong: impact and measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/ Hong-Kong-COVID-19-Long-term-Care-situation-27-April-2020–1.pdf, accessed 21 June 2020). 66. Shi C, Hu B, Feng M, Wong G. Report from mainland China: policies to support long-term care during the COVID-19 outbreak. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/Report-from-Mainland-China-18-April-final.pdf, accessed 21 June 2020). 67. Statistics Commission endorses new Titchfield City Group on Ageing. New York: United Nations Department of Economic and Social Affairs; 16 March 2018 (https://www.un.org/development/desa/ageing/ news/2018/03/title-statistics-commission-endorses-new-titchfield-city-group-on-ageing/, accessed 21 June 2020). 68. Descubren una residencia ilegal en La Laguna por las pruebas del Covid-19 [They discover an illegal residence in La Laguna by the tests of Covid-19]. La Provincia, 4 April 2020 (https://www.laprovincia.es/ sociedad/2020/04/04/descubren-residencia-ilegal-laguna-pruebas/1271776.html, accessed 21 June 2020). 69. Burton A, Goodman C, Quinn T. The invisibility of the UK care home population: UK care homes and a minimum dataset. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/ the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/, accessed 21 June 2020). 70. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 71. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.9540. 72. Jacobs R, Ashwell A, Docrat S, Schneider M. The impact of COVID-19 on long-term care in South Africa. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/ COVID-19-Long-Term-Care-Situation-in-South-Africa.docx, accessed 21 June 2020). 73. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. European Centre for Disease Prevention and Control; 2020 (https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term- care-facilities-EU-EEA, accessed 21 June 2020). 74. Rodrigues R, Huber M, Lamura G. Facts and figures on healthy ageing and long-term care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research; 2012. 75. Van Houtven CH, DePasquale N, Coe NB. Essential long-term care workers commonly hold second jobs and double- or triple-duty caregiving roles. Journal of the American Geriatrics Society. 2020. doi:10.1111/ jgs.16509. 76. Schmidt AE, Leichsenring K, Staflinger H, Litwin C, Bauer A. The impact of COVID-19 on users and providers of long-term care services in Austria. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/ wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Austria-15-May.pdf, accessed 22 June 2020). 77. Pierce M, Keogh F, O’Shea E. The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf, accessed 22 June 2020). 78. Rajagopalan J, Huzruk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTC-COVID-situation-in-India-30th-May.pdf, accessed 22 June 2020). 79. Amour R, Robinson JN, Govia I. The COVID-19 long-term care situation in Jamaica. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term- Care-situation-in-Jamaica-25-May-2020–1.pdf, accessed 22 June 2020). 37 Preventing and managing COVID-19 across long-term care services 80. Kruse F, Abma I, Jeurissen P. The impact of COVID-19 on long-term care in the Netherlands. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long- Term-Care-situation-in-the-Netherlands-25-May-2020–1.pdf, accessed 22 June 2020). 81. Low L-F. The long-term care COVID-19 situation in Australia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Australia-LTC-COVID19-situation-24-April-2020. pdf, accessed 22 June 2020). 82. Extra payment for unpaid carers. Scottish Government, 6 May 2020 (https://www.gov.scot/news/extra- payment-for-unpaid-carers/, accessed 22 June 2020). 83. Global action plan on the public health response to dementia 2017–2025. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259615). 84. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo J et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190–1. 85. Suarez-Gonzalez A, Livingston G, Comas-Herrera. Report: the impact of the COVID-19 pandemic on people living with dementia in UK. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/2020/05/03/report-the-impact-of-the-covid-19-pandemic-on-people-living-with-dementia-in-uk/, accessed 22 June 2020). 86. Joint statement on advance care planning. Care Quality Commission; 2020 (https://www.who.int/ publications/i/item/WHO-2019-nCoV-Comm_health_care-2020.1). 87. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ WHO-2019-nCoV-Comm_health_care-2020.1 accessed 22 June 2020). 88. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms- and-management-of-contacts, accessed 22 June 2020). 89. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 90. Bauer A. COVID19: providing palliative care for the many. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/03/31/covid19-proving-palliative-care-for-the-many/, accessed 22 June 2020). 91. Oven A. COVID-19 and long-term care in Slovenia: impact, measures and lessons learnt. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/COVID19-and- Long-Term-Care-in-Slovenia-impact-measures-and-lessons-learnt-21-April-2020.pdf, accessed 22 June 2020). 92. Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO- 2019-nCoV-Comm_health_care-2020.1, accessed 22 June 2020). 93. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. Geneva: World Health Organization; 2020 (https://www. who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-of- health-workers-including-key-considerations-for-occupational-safety-and-health, accessed 22 June 2020). 94. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–331495, accessed 22 June 2020). 95. Sani TP, Tan M, Rustandi KK, Turana Y. COVID-19 long-term care situation in Indonesia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19- Long-Term-Care-situation-in-Indonesia-30-May-1.pdf, accessed 22 June 2020). 96. Lorenz-Dant K. Germany and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19–26-May-2020. pdf, accessed 22 June 2020). 38 Preventing and managing COVID-19 across long-term care services 97. Contact tracing in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who. int/publications/i/item/contact-tracing-in-the-context-of-covid-19, accessed 22 June 2020). 98. Rostgaard T. The COVID-19 long-term care situation in Denmark. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care- situation-in-Denmark-29-May-2020.pdf, accessed 22 June 2020). 99. Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST. The long term care COVID-19 situation in Malaysia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/05/Malaysia-LTC-COVID-situation-report-30-May.pdf, accessed 22 June 2020). 100. Health at a glance 2019: OECD indicators. Paris: Organisation for Economic Co-operation and Development; 2019 (http://www.oecd.org/health/health-systems/health-at-aglance-19991312.htm, accessed 22 June 2020). 101. Brimblecombe N, Fernandez J-L, Knapp M, Rehill A, Wittenberg R. Unpaid care in England: future patterns and potential support strategies. London: London School of Economics; 2018. 102. Caring behind closed doors: forgotten families in the coronavirus outbreak. London: Carers UK; 2020 (https:// www.carersuk.org/for-professionals/policy/policy-library/caring-behind-closed-doors-report, accessed 22 June 2020). 103. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? Journal of Gerontological Social Work. 2014;57(5):460–77. doi:10.1080/01634372.2014.882466. 104. Mental health and psychosocial considerations during the COVID-19 outbreak: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/mental-health-and- psychosocial-considerations-during-the-covid-19-outbreak, accessed 22 June 2020). 105. Da Mata F, Oliveira D. COVID-19 and long-term care in Brazil: impact, measures and lessons learned. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf, accessed 22 June 2020). 106. COVID-19 and violence against older people. Geneva: World Health Organization; 2020 (https://www.who. int/publications/m/item/covid-19-and-violence-against-older-people, accessed 22 June 2020). 107. Leiblfinger M, Prieler V, Schwiter K, Steiner J, Benazha A, Lutz H. Impact of the COVID-19 pandemic on live-in care workers in Germany, Austria and Switzerland. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/impact-of-the-covid-19-pandemic-on-live-in-care-workers-in-germany- austria-and-switzerland/, accessed 22 June 2020). 108. Coronavirus Plan of Action. Chile: Senama (http://www.senama.gob.cl/protocolos-covid-19, accessed 22 June 2020). 109. Cuenta con migo [count on me]. Government of Chile (https://www.gob.cl/cuentaconmigo/, accessed 22 June 2020). 110. López-Ortega M, Sosa-Tinoco E. COVID-19 and long-term care in Mexico: questions, challenges, and the way forward. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/06/LTC-Covid-19-situation-in-Mexico-8-June.pdf, accessed 22 June 2020). 111. Musyimi C, Mutunga E, Ndetei D. COVID-19 and long-term care in Kenya. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/06/02/new-country-report-the-covid-19-long-term-care- situation-in-kenya/, accessed 22 June 2020). 112. COVID Trauma Response Working Group (https://www.traumagroup.org/, accessed 22 June 2020). 113. Decade of Healthy Ageing 2020–2030. Geneva: World Health Organization; 2020 (https://www.who.int/ docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en. pdf?sfvrsn=b4b75ebc_3, accessed 22 June 2020). 114. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 39 Preventing and managing COVID-19 across long-term care services 40 Preventing and managing COVID-19 across long-term care services Annex 1. Methods Living systematic review A living systematic review was undertaken, aiming to synthesize early international evidence on mortality rates and incidence of COVID-19 among people who use and provide long-term care. The review was registered with Prospero (CRD42020183557) and includes studies identified through database searches conducted on 15 May 2020 and updated up to 5 June 2020. The methods and findings have been published in full in medRxiv. Seven databases were searched (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv) to identify all studies reporting primary data on COVID-19-related mortality and incidence of disease among long-term care users and staff. In addition, evidence on country-level mortality rates was identified from LTCcovid.org, an international network of long- term care experts. Studies not focusing on long-term care were excluded. Included primary studies were critically appraised and results on number of deaths and COVID-19-related mortality rates, case fatality rates, and excess deaths (co-primary outcomes), as well as incidence of disease, hospitalizations, and intensive care unit admissions, were synthesized narratively. Title and abstract screening, and a full text review, were undertaken by three reviewers and records reporting on the same study or outbreak were combined. A standardized template was used to extract data at the study level, including information on study design; care setting (institutional versus community); how COVID-19 was diagnosed and confirmed; baseline characteristics of participants; absolute number of deaths and mortality rates from confirmed and suspected COVID-19 cases; case fatality rates; excess deaths; absolute numbers and rates of confirmed and suspected COVID-19; and rates of hospitalization and intensive care unit admissions among confirmed and suspected COVID-19 cases. All study participant characteristics and outcome data were extracted separately for long-term care users and staff. Information was also extracted on the proportion of asymptomatic cases at time of testing, and findings of studies comparing outcomes in long-term care users to others. Due to heterogeneity in the definitions of numerators, denominators, and follow-up times across included studies, data were not pooled. Instead, results were summarized narratively and presented in tables, including information on sample characteristics, follow-up time, and case definitions, as appropriate. Where studies reported on overlapping populations, preference was given to those with larger sample sizes and longer follow-up times. The quality of included primary studies reporting figures relating to mortality rates, case fatality rates, or disease incidence were assessed using the Joanna Briggs Institute critical appraisal tool for prevalence studies. Risk of bias across studies was not assessed. A total of 33 study reports for 30 unique primary studies or outbreak reports were included (Figure A1.1). UN SP LA SH / R IZ AL H IL M AN 41 Preventing and managing COVID-19 across long-term care services MEDLINE: n=673 Embase: n=43 CINAHL Plus: n=221 Web of Science: n= 184 Global Health: n=7 WHO COVID-19 Research Database n=202 medRxiv: n=3454 LTCcovid.org: n=22 Total included: n=33 (30 unique, original studies) Updated database searches: n=418 Database searches: n=4806 Included in first review: n=30 (27 unique, original studies) After deduplication: n=418 Full text review: n=33 Newly included: n=4 After deduplication: n=4457 Full text review: n=247 Excluded after title and abstract screening: n=4210 Excluded after full text review Not focused on LTC: n=75 Review article: n=52 No mortality or infection data: n=56 Opinion piece: n=25 Full text not accessible: n=7 Modelling study: n=3 Not focused on COVID-19: n=3 Duplicate: n=3 Excluded after title and abstract screening: n=385 Excluded after full text review Review article: n=8 Opinion piece: n=6 No mortality or infection data: n=4 Not focused on LTC: n=3 Not focused on COVID-19: n=2 Duplicate: n=1 Full text not accessible: n=0 Modelling study: n=0 Excluded: 1 previously included study (withdrawn by author) Records identified through other sources: n=3 Figure A1.1 Flow chart for selection of included primary studies 42 Preventing and managing COVID-19 across long-term care services Pilot of a systematic review of effectiveness of interventions to mitigate the impact of COVID-19 on people who use and provide long-term care A systematic review on the effectiveness of interventions to manage the impact of COVID-19 on people who use and provide long-term care is under development. While piloting the search strategy across seven databases (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv), 21 studies were identified that described responses to the COVID-19 pandemic and provided some sort of evaluation of effectiveness or aimed to assess characteristics of long-term care services associated with COVID-19 infection rates and associated mortality. There were five reports from the United States, three from Italy, two each from Canada, China, the Republic of Korea and Spain, and one report each from Belgium, France, Ireland, Singapore and the United Kingdom. The interventions identified and target groups varied. Three of the studies related to pharmacological therapies in care homes (1–3), additional studies described the implementation of measures to prevent (China and Singapore) and contain (Canada, China, the Republic of Korea and the United States of America) outbreaks in care homes (1, 4–8), one study reported about prevention measures for community-based care in the United States (9), four reported on multifaceted organizational changes to deal with COVID-19 in long-term care settings, including multidisciplinary collaboration and coordination (6, 10–12), three were pilot studies for detecting COVID-19 through rapid point-of-care testing, pooled testing, and bedside chest ultrasonography (13–15), and one adapted an existing cognitive stimulation intervention for people with dementia to provide information and support in relation to COVID-19 (16). These studies were mostly descriptive and, lacking a control group, were not designed to rigorously evaluate the effectiveness of implemented measures. Nevertheless, the prevention and outbreak management interventions described in the papers from China, the Republic of Korea and Singapore all reported successes in preventing or containing outbreaks. Another three studies assessed the association between different characteristics of care homes and COVID-19 outbreaks and outcomes. Stall et al. found that for-profit status of nursing homes in Ontario, Canada, was associated with both the size of a nursing home outbreak and the number of resident deaths (17). However, for-profit status was not associated with a higher likelihood of an outbreak. Romero-Ortuño and Kennelly found moderate, statistically significant association between crude number of deaths and maximum occupancy in Irish care homes, but no statistically significant association was found for quality of care homes (18). Similarly, Abrams et al. did not find a statistically significant association between the reporting of at least one COVID-19 case in United States nursing homes and traditional quality criteria (19). However, a statistically significant association was found for larger facility size, urban location, percentage of African-American residents, non-chain status, and state. Finally, two studies analysed the association between regional characteristics, including features of the long- term care system such as the proportion of private versus public long-term care beds and the availability of nursing home beds, and spread of COVID-19 in Italian regions (20–21). Country reports on the COVID-19 long-term care situation Country reports published on the LTCcovid website (an initiative of the International Long-Term Care Policy Network) were reviewed. The reports were produced by experts in long-term care, usually academics. The reports aimed to document the impact of COVID-19 on people who use and provide long-term care in each country, and the measures adopted to mitigate the impacts of the pandemic on this population. Information from these reports informed the examples of measures adopted by different countries. 43 Preventing and managing COVID-19 across long-term care services References 1. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 2. Ahmad I, Alam M, Saadi R, Mahmud S, Saadi E. Doxycycline and hydroxychloroquine as treatment for high- risk COVID-19 patients: experience from case series of 54 patients in long-term care facilities. medRxiv. May 2020. doi:10.1101/2020.05.18.20066902. 3. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 4. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherarpy. May 2020. 5. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 6. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 7. Munanga A. Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing. 2020;46(6):3–5. doi:10.3928/00989134–20200511–03. 8. Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M et al. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. Journal of Intellectual Disability Research. 2020. doi:10.1111/jir.12740. 9. Archbald-Pannone LR, Harris DA, Albero K, Steele RL, Pannone AF, Mutter JB. COVID-19 collaborative model for an academic hospital and long-term care facilities. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.044. 10. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 11. Koeberle S, Tannou T, Bouiller K, Becoulet N, Outrey J, Chirouze C et al. COVID 19 outbreak: organisation of a geriatric assessment and coordination unit – a French example. Age and Ageing. May 2020. doi:10.1093/ ageing/afaa092. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Cabrera JJ, Rey S, Perez S, Martinez-Lamas L, Cores-Calvo O, Torres J et al. Pooling for SARS-CoV-2 control in care institutions. medRxiv. June 2020. doi:10.1101/2020.05.30.20108597. 14. Nouvenne A, Ticinesi A, Parise A, Prati B, Esposito M, Cocchi V et al. Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.050. 15. Goodman-Casanova JM, Dura-Perez E, Guzman-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study. Journal of Medical Internet Research. 2020;22(5):e19434. doi:10.2196/19434. 16. Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit nursing homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada. Medrxiv. 2020. doi:10.1101/2020.05.25.20112664. 44 Preventing and managing COVID-19 across long-term care services 17. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 18. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16661. 19. Buja A, Paganini M, Cocchio S, Scioni M, Rebba V, Baldo V. Demographic and socio-economic factors, and healthcare resource indicators associated with the rapid spread of COVID-19 in northern Italy: an ecological study. medRxiv. 2020. doi:10.1101/2020.04.25.20078311. 20. Liotta G, Marazzi MC, Orlando S, Palombi L. Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox. PLoS One. 2020;15(5):e0233329. doi:10.1371/journal. pone.0233329. 45 Preventing and managing COVID-19 across long-term care services World Health Organization Avenue Appia 20 1202 Geneva, Switzerland

Policy brief Preventing and managing COVID-19 across long-term care services 24 July 2020

Preventing and managing COVID-19 across long-term care services Policy brief 24 July 2020 WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/) Suggested citation. Preventing and managing COVID-19 across long-term care services : policy brief. Geneva: World Health Organization; 2020 (WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Inis Communication Contents Acknowledgements iv Executive summary v Part 1. Overview 1 1.1 Aim of the document 1 1.2 Impact of COVID-19 on long-term care: what the evidence tells us 2 1.3 The case for action: leaving no one behind 3 Part 2. Responding to the COVID-19 pandemic in long-term care 5 2.1 Include long-term care in all phases of the national response to the COVID-19 pandemic 7 2.2 Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic 9 2.3 Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses 11 2.4 Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services 14 2.5 Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation 17 2.6 Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases 19 2.7 Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services 22 2.8 Provide support for family and voluntary caregivers 24 2.9 Prioritize the psychological well-being of people receiving and providing long-term care services 27 2.10 Ensure a smooth transition to the recovery phase 30 2.11 Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services 32 References 33 Annex 1. Methods 41 Web Annex: Key objectives and actions to prevent and manage COVID-19 in long-term care facilities https://apps.who.int/iris/bitstream/handle/10665/334020/WHO-2019-nCoV-Policy_Brief-Long-term_ Care-Web_Annex-2020.1-eng.pdf iii Acknowledgements This policy brief was developed by WHO through new analysis, expert consensus and reference to existing WHO guidance. Coordinating departments Department of Integrated Health Services (Shannon Barkley, Edward Kelley) Department of Maternal, Newborn, Child and Adolescent Health and Ageing (Zee-A Han, Anshu Banerjee) Principal writers World Health Organization: Zee-A Han (responsible officer), Shannon Barkley, Yuka Sumi London School of Economics and Political Science: Adelina Comas-Herrera, Klara Lorenz-Dant, Maximilian Salcher-Konrad Other contributors and reviewers WHO Steering Committee: Ageing and Health; Clinical Services and Systems; Gender, Equity and Human Rights; Integrated Health Services; Maternal, Newborn, Child and Adolescent Health and Ageing; Mental Health and Substance Use; Sensory Functions, Disability and Rehabilitation; Infection Prevention and Control Hub and Task Force; WHO Kobe Centre, and regional offices (Benedetta Allegranzi, Jotheeswaran Amuthavalli Thiyagarajan, Sarah Louise Barber, Anjana Bhushan, Alessandro Cassini, Alarcos Cieza, Theresa Diaz, Stefanie Freel, Manfred Huber, Anne Johansen, Theadora Koller, Margrieta Langins, Madison Moon, Paul Ong, Ritu Sadana, Nicoline Schiess, Katrin Seeher, Enrique Vega). The following individuals contributed to or reviewed the document. Confidentiality agreements were signed and declarations of interest were collected and reviewed. Non-WHO experts: WHO Global Network on Long-term Care for Older People (Liat Ayalon, Pablo Villalobos Dintrans, Walter Frontera, Muthoni Gichu, Sandhya Gupta, Hanadi Khamis Al Hamad, Arvind Mathur, Reshma A. Merchant, Stephen O’Connor, Vinod Shah, Lieve Van den Block) and Rachel Albone, Sean Cannone, Leon Geffen, Terry Fulmer, Richard Humphries, Caitlin Littleton, Terry Lum, Saniya Sabzwari, David Stewart. WHO continues to monitor the situation closely for any changes that may affect this policy brief. Should any factors change, WHO will issue a further update. WHO gratefully acknowledges the kind support of the Government of the Republic of Korea, Ministry of Health and Welfare. iv Preventing and managing COVID-19 across long-term care services Executive summary The COVID-19 pandemic has affected older people disproportionately, especially those living in long-term care facilities. In many countries, evidence shows that more than 40% of COVID-19 related deaths have been linked to long-term care facilities, with figures being as high as 80% in some high-income countries. Furthermore, in long-term care facilities, the case fatality for residents with COVID-19 may be higher than in the population of the same age living outside long-term care facilities. Residents of long-term care facilities often face high risk, low preventive measures and inadequate resources to recover from COVID-19, as well as reduced access to essential health services in a context where health systems are experiencing constraints during the COVID-19 surge. The impact of COVID-19 has additionally been high in providers of long-term care services, within long- term facilities and in other settings. A 2020 study by the United Kingdom Office for National Statistics of deaths by occupation found that the social care workforce had a significantly raised death rate associated with COVID-19. So far, COVID-19 has disproportionately affected long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community-based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. The response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries. Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19. This policy brief provides 11 policy objectives and key action points to prevent and manage COVID-19 across long-term care. Its intended audience is policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on currently available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and to mitigate impact across long-term care services, including care providers. While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized because they have experienced extremely high COVID-19 incidence, morbidity and mortality. Furthermore, the policy brief addresses long-standing problems in long-term care systems, including underfunding, lack of accountability, fragmentation between health and long-term care and an undervalued workforce. The brief suggests ways to transform health and long-term care services so that long-term care services are readily integrated and provided as part of the continuum of care that includes health promotion, prevention, treatment, rehabilitation and palliation. It is only through these measures that people in need of long-term care can receive quality, equitable and sustainable care that allows them to live in a manner respecting their basic rights, fundamental freedoms and human dignity. v Preventing and managing COVID-19 across long-term care services vi Preventing and managing COVID-19 across long-term care services Part 1. Overview 1.1 Aim of the document The COVID-19 pandemic has revealed weaknesses in emergency response where long-term care services has been underprioritized, resulting in the devastating impact seen across long-term care services globally. These events have highlighted long-standing problems in the long-term care systems in most countries: underfunding, lack of accountability, fragmentation, poor coordination between health and long-term care, and an undervalued workforce (1–3). This policy brief provides policy objectives and key action points to prevent and manage COVID-19 across long-term care for policy-makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on current available evidence on the measures taken to prevent, prepare for and respond to the COVID-19 pandemic and its impact on those who use long-term care and care providers (including paid staff and family and other voluntary caregivers). It also expands on the technical working guidance on preventing and managing the COVID-19 pandemic across long-term care services in the World Health Organization (WHO) European Region to provide global perspectives and country examples across all WHO regions (4). While this document contains policy options and actions relevant to all long-term care settings, long-term care facilities are emphasized as they have experienced extremely high incidence, morbidity and mortality due to COVID-19. However, although long-term care facilities are an integral part of long-term care, it must be highlighted that community-based services are the key to promoting ageing in place, reducing institutionalization, and supporting deinstitutionalization, so that people can live in a manner consistent with their basic rights, fundamental freedoms and human dignity. Box 1 presents definitions of the terminology used in this document. Box 1. Working terminology: definitions of terms used Long-term care systems National systems that ensure integrated long-term care that is appropriate, affordable, accessible and upholds the rights of people and caregivers alike (1). Long-term care Services to ensure that people with or at risk of significant loss of physical and mental capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity (1). These services typically involve care and assistance with everyday tasks (including dressing, bathing, shopping, cooking and cleaning), support with social participation, and management of advanced chronic conditions through community nursing, rehabilitation and end-of-life care. Services are provided by both unpaid caregivers (typically family but also volunteers) and paid care staff. Throughout the document, the use of the term “long- term care services” covers care at home, in the community and in facilities (residential long-term care facilities, nursing homes or other group living facilities), unless otherwise specified. Long-term care facilities Long-term care facilities may vary by country. Nursing homes, skilled nursing facilities, assisted living facilities, residential facilities and residential long-term care facilities are collectively known as long-term care facilities that provide a variety of services, including medical and assistive care, to people who are unable to live independently in the community. Throughout the document, the use of the term “long-term care facilities” does not include home-based long-term care, community centres, adult day care facilities or respite care. Caregiver A person who provides care and support to someone else. Caregivers may include family members, friends, neighbours, volunteers, care workers and health professionals (1). UN SP LA SH / JE RE M Y ST EN UI T 1 Preventing and managing COVID-19 across long-term care services 1.2 Impact of COVID-19 on long-term care: what the evidence tells us Evidence from a systematic review (5) and compiled reports on the COVID-19 situation in long-term care facilities (Annex 1) shows that, while there is little evidence of the impact of COVID-19 on people who use and provide long-term care services in the community, the pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities. In countries with large numbers of deaths from COVID-19, about half of all those deaths have been among residents of long-term care facilities. The methods for the systematic review and other reviewing carried out for this report are described in more detail in Annex 1. Early evidence shows that the extent of COVID-19 infections in long-term care facilities has varied widely, between and within countries: some countries (such as Jordan) have had no infections reported in long-term care facilities so far, whereas in Sweden, for example, by the end of April, 25% of long-term care facilities in the whole country had COVID-19 outbreaks, with 67% of long-term care facilities in Stockholm affected. Data from 21 high-income countries show that while some countries have had no or very few deaths among residents in long-term care facilities, other countries report that on average nearly half of all deaths linked to COVID-19 in the country were of long-term care facility residents (ranging from 24% in Hungary to as high as 82% in Canada). In some countries, the share of deaths among all residents of long- term care facilities linked to COVID-19 has been as high as 3% to 6% of all residents (6). Disaggregated data by age and gender are not available for many countries. The evidence also shows that once COVID-19 infection is present in long-term care facilities it is difficult to control, in part due to the large number of people living close together in facilities designed for communal living and the fact that personal care requires close proximity. Although case reports from the Republic of Korea, demonstrated successful mitigation of further infections in long-term care facilities after a member of staff had tested positive (7–8), case studies in several other countries demonstrate how difficult it is to contain the infection in these settings. For example, studies in the United Kingdom of Great Britain and Northern Ireland and the United States of America have shown incidence rates between 40% and 72% among residents (9–14), with infection rates among staff between 1.5% and 5.9% when all staff members at outbreak facilities were tested (7–8, 15–18). There is also evidence from one study that staff working across more than one home may have been the source of transmission (19). An analysis of deaths by occupation in the United Kingdom showed that men and women working in social care had significantly raised rates of deaths involving COVID-19 (23.4 per 100 000 males compared to 9.9 for males aged 20–64 years, and 9.6 per 100 000 females compared to 5.2 for females aged 20–64 years) (20). Six studies describing measures to prevent (China and Singapore) and contain or manage (Canada and the Republic of Korea) outbreaks in long-term care facilities reported some success, although these studies did not have a control group (7–8, 22–23). There is increasing evidence of potential transmission from presymptomatic or asymptomatic people who have COVID-19 and people presenting with “atypical symptoms” in long-term care facilities. Studies of outbreaks show that 7% to 75% of residents and 50% to 100% of staff who tested positive are presymptomatic or asymptomatic (11–13, 15, 17, 19, 24). Between 57% and 89% of asymptomatic positive residents develop symptoms later (11, 19). Systematic nationwide testing of residents and staff in Belgium showed that 74% of cases among residents and 76% of cases among staff were asymptomatic at the time of testing (25). “Men and women working in social care have significantly raised rates of deaths involving COVID-19.” “The pandemic has had a disproportionate effect on people, especially older people, who live in long-term care facilities.” 2 Preventing and managing COVID-19 across long-term care services Once people living in long-term care facilities have COVID-19, the case fatality for residents may be higher than in the population of the same age outside long-term care facilities. For example, the incidence rate of COVID-19 deaths among residents of long-term care facilities in Ontario, Canada, was 13 times higher compared to community-dwelling cases aged 70 years or older (26), and the risk for severe disease, including death, was 2.5 times higher for Israeli nursing home residents with COVID-19 compared to other cases over 65 years of age (27). No studies report on the detrimental health sequelae of either the infection itself or the measures taken to prevent infection in long-term care facilities, although many editorials and commentary articles mention potential impacts on both mental and physical health (for example, distress, depression, anorexia, loss of physical condition due to lack of exercise, and consequences of increased chemical and physical restraints). This has raised concerns for increased direct and indirect morbidity and mortality (28–29). There is limited evidence on the impact of the COVID-19 pandemic on people who use and provide community-based long-term care, including home help, day care facilities and unpaid caregivers. Some public health and infection prevention measures (including movement restrictions, physical distancing and curfews) may resulted in restriction of the usual sources of care and support that many people with care needs rely on. Evidence from the United Kingdom found that people with disabilities experienced widening inequalities during the COVID-19 pandemic. People with disabilities reported difficulty in accessing food and medication and delays in the benefit system, with some experiencing food insecurity and poverty. Many people with disabilities reported feeling isolated and, for some, lack of Internet access meant that they could not access virtual replacement services. Furthermore, reduction of ongoing support structures left people reliant on family and neighbours (30). It is also likely that people living with existing health conditions experience difficulties in accessing essential health care services, including rehabilitation, which further increases care needs. Furthermore, discontinuity of health care services can result in heightened need for care (31–32). It is increasingly recognized that in many countries the initial plans to contain the pandemic did not include long-term care facilities; it was only when media reports of large numbers of deaths started to emerge that resources were mobilized. In some countries, the army and other emergency response units had to be deployed to support long-term care facilities that had been overwhelmed by large numbers of deaths and insufficient staff (33). In many countries, long-term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred (34). 1.3 The case for action: leaving no one behind Health systems have a responsibility to offer safe, accessible, affordable and quality health care, including assistive and palliative care, for all people, without discrimination. However, as the evidence shows, residents of long-term care facilities are often facing higher risk, lower preventive measures and inadequate resources to manage COVID-19, as well as reduced access to essential health services, as health systems experience constraints in the context of a COVID-19 surge (35). Older people, particularly those with underlying conditions who are more likely to develop severe COVID-19, make up a large proportion of those using long-term care services, including those living in long-term care facilities (36). Immediate action is required to prevent infection and mitigate the impact of the COVID-19 pandemic among this population and to ensure that essential health and assistive care services are provided. “In many countries, long- term care facilities were only able to access testing, personal protective equipment (PPE) and medical support after large outbreaks in long-term care facilities had occurred.” 3 Preventing and managing COVID-19 across long-term care services Furthermore, women, especially older women, represent the highest share of people who use care services, dominate the long-term care workforce, and are the main providers of family care (1, 37). In addition, long- term care services often depend heavily on migrant workers and workers from ethnic groups, who may be at higher risk (1, 38–40). The response to the pandemic must include long-term care to ensure that ethnic, age and gender groups are not marginalized. Concerns about human rights have also been expressed, both in the potential neglect of the population relying on (and providing) long-term care, and in measures adopted in an attempt to reduce the risk of infection (for example, a ban on visitation and forbidding outside physical activity). It is mandatory that the response to the pandemic is inclusive of long-term care, so that appropriate and tailored measures are implemented and issues specific to long-term care are addressed. So far, COVID-19 has disproportionately affected people living in long-term care facilities. However, concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community- based care, given that most users and providers of care are those who are vulnerable to severe COVID-19. Considering the magnitude of the impact of COVID-19 on long-term care, response actions for long-term care will be one of the fundamental and essential steps in mitigating the COVID-19 pandemic in many countries (4). Only by addressing long-term care will countries be able to truly leave no one behind in the response to COVID-19 (41). 4 Preventing and managing COVID-19 across long-term care services Part 2. Responding to the COVID-19 pandemic in long-term care While the pandemic has brought public attention to the immediate impacts of the pandemic, and the need to be prepared for present contingencies and possible future waves, it has also shown that there are major structural challenges that need to be addressed to improve the safety and resilience of long-term care systems. So far, most countries have struggled to develop coherent systems to ensure access to person-centred, quality, long-term care services that meet the growing health and assistive care needs and that are consistent with basic rights, fundamental freedoms and human dignity (1, 42–45). Even in high-income countries, a review by the Organisation for Economic Co-operation and Development (OECD) concluded that “there is a history in many countries of long-term care policies being developed in a piecemeal manner, responding to immediate political or financial problems, rather than being constructed in a sustainable, transparent manner” (43). This section looks into the unique challenges that have affected the ability of long-term care systems to respond to the COVID-19 pandemic and proposes policy objectives and key actions to address these challenges in the short and longer term. Informed by the available evidence and international experience thus far, the 11 policy objectives presented on the next page will be key to addressing COVID-19 in long-term care systems. The following subsections address each of these policy objectives in turn. UN SP LA SH / A P X 90 5 Preventing and managing COVID-19 across long-term care services Eleven policy objectives to mitigate the impact of COVID-19 across long-term care 1. Include long-term care in all phases of the national response to the COVID-19 pandemic. 2. Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic. 3. Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channelling between health and long-term care systems to optimize responses. 4. Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and deliver quality long-term care services. 5. Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation. 6. Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases. 7. Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services. 8. Provide support for family and voluntary caregivers. 9. Prioritize the psychosocial well-being of people receiving and providing long-term care services. 10. Ensure a smooth transition to the recovery phase. 11. Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services. 6 Preventing and managing COVID-19 across long-term care services 2.1 INCLUDE LONG-TERM CARE IN ALL PHASES OF THE NATIONAL RESPONSE TO THE COVID-19 PANDEMIC 2.1.1 The challenge Long-term care has low political priority compared to health and other policy areas Long-term care tends to have low political priority and is often referred to as “the Cinderella of the welfare state”, where political attention to its importance is often transient and secondary to health care (46). This lack of political attention to long-term care may be one of the reasons why the initial policy responses to the pandemic in many countries did not include the long-term care sector (4). Governance of the long-term care system often involves multiple sectors, different ministries and different levels of government, making coordination difficult In most countries, long-term care falls between different ministries, typically health care and social affairs, development, or social protection. Long-term care services and health care systems are often poorly coordinated or integrated, and tend to have separate (and often complex) arrangements for financing, regulation, information systems, and the training and procurement of staff (1, 43). This has created several difficulties during the COVID-19 crisis. For example, back-up staffing models to meet the surge in COVID-19 patients in hospitals were not flexible enough to meet demand surges in the long-term care sector. It was also difficult for appropriate staff to move flexibly across the system as needed. Similarly, the long-term care sector, and especially long-term care facilities, struggled to access testing and PPE, as this had been prioritized for hospitals (47). In addition, countries frequently distribute responsibility for long-term care vertically across national, regional and local actors, creating difficulties in coordination of services and effective oversight (48). For example, in Spain and Italy, the same person may be receiving long-term care services that are organized or funded by up to three different levels of government (49–50). Long-term care services consist of a mixture of public, private for-profit and private not-for-profit service providers, in addition to family caregivers Long-term care services are also characterized by a mix of public, private for-profit and private not- for-profit service providers (51). In some countries, most long-term care facilities are operated by private for-profit providers and, particularly in low- and middle-income countries, these are often unregulated (52–53). Particularly in low- and middle-income countries, nongovernmental organizations (NGOs) play an important role in the provision of long-term care services and are often the sole source of support for unpaid caregivers. However, where NGOs are non-existent, the care responsibility often falls entirely on the families themselves. This unpaid care is rarely recognized within a formal system and so is not included in any governance processes or mechanisms beyond those of the NGOs that support the work. These structures can result in a lack of ownership, diffused accountability, and fragmentation of responsibilities, causing problems with coordination and quality of care and leading to underdeveloped information systems (43, 54). 7 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 May impede inclusion of long-term care in pandemic national response May impede planning, oversight and accountability during the pandemic May impede coordinated response between long-term care and health care sectors in responding to the pandemic May impede effective resource allocation 2.1.2 Key actions Whole sector Ensure a focal point to manage long-term care (with a special focus on long-term care users and providers) in the overarching COVID-19 governing body. Establish joint steering committees and information- and data-sharing systems between sectors and subnational policy levels to ensure a coordinated response. Establish a mechanism to support unregulated providers, focusing on cooperative support rather than punitive measures. Long-term care facilities If long-term care facilities are expanding their health care role during the pandemic, establish triggers or thresholds that activate a phased reallocation of routine comprehensive health service capacity, including direct health care staff. Country examples In Singapore, the Agency for Integrated Care and the Ministry of Health, together with long-term care service providers, have jointly developed a number of measures to respond to the COVID-19 pandemic. These include infection control and prevention measures, access to PPE, distancing and zoning measures, suspension of visitors, alternative accommodation for long-term care workers, and testing to monitor people with long-term care needs and care workers. The Agency for Integrated Care also set up an incident response team to support long-term care providers in responding to COVID-19 infections. The Silver Generation Office, which is an outreach arm of the Agency for Integrated Care, has supported older people with contact, information and the provision of services during the COVID-19 pandemic (55–56). In Israel, a governing team has been appointed to manage COVID-19 outbreaks in long-term care facilities across the country. This team has provided a national plan under the Fathers and Mothers Shield project, including establishment of a headquarters from which government efforts can be coordinated. In addition, the Home Front Command has been assisting long-term care facilities throughout the pandemic with managing visitor access, disinfection, and food and equipment delivery, and has been offering training and guidance on protective and preventive measures (57). In Malta, the Social Care Standards Authority, the regulatory body for long-term care, defined the residential care settings as being high risk with regard to COVID-19 in early March. Immediately, the Social Care Standards Authority issued the directives mapped out in its COVID-19 brief (2020). There was immediate cooperation between the Public Health Authority and the Social Care Standards Authority, which proved to be the primary catalyst towards safeguarding older persons within the facilities (58). 8 Preventing and managing COVID-19 across long-term care services 2.2 MOBILIZE ADEQUATE FUNDING FOR LONG-TERM CARE TO RESPOND TO AND RECOVER FROM THE COVID-19 PANDEMIC 2.2.1 The challenge Limited public funding allocated for long-term care Average public expenditure on long-term care is very low, less than 1% of GDP globally. Such public underfunding jeopardizes access to long-term care (42). This is even more pronounced in low- and middle-income countries, many of which lack dedicated sources of public financing for long-term care. Public benefit schemes for long-term care are usually needs based and means tested, and often require co-payments, leaving large parts of the population outside the public system In most countries, public benefit schemes for long-term care support are needs based and means tested, and often require co-payments. Those with greater needs often receive more support, but some countries also set limits on the amount that can be covered through public resources. While some countries protect the most vulnerable from additional costs, considerable out-of-pocket expenses are common across countries for most people receiving long-term care services (43, 59–60). Also, due to the large share of care provided by unpaid caregivers, in practice a large share of the costs of long-term care fall on families, through a combination of the opportunity costs of providing care and out-of-pocket payments. Few countries have financing mechanisms that protect the whole population from catastrophic long- term care costs (1). Reduced income for long-term care sector and higher costs of care Increasing PPE and workforce costs mean that service providers are facing substantial additional costs. At the same time, providers are experiencing decreases in revenues due to lower occupancy in long- term care facilities (resulting from both a decrease in admissions and the higher-than-usual numbers of deaths) and the closure of community-based services such as day care centres. Several countries have already provided emergency funds to support the long-term care sector during this crisis. However, the provision and distribution of resources may be easier in countries with more developed and regulated long-term care systems. The provision of resources and support to the unregistered long-term care sector poses additional challenges. Such unique challenges in the financing of long-term care have made it difficult for the long-term care system to react and respond to the additional costs that may be incurred due to preparing for and responding to COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of adequate funding for the additional costs linked to the COVID-19 response may endanger the safety of long-term care users and providers The increase in the costs of care due to the pandemic results in increased out-of-pocket payments for care users 9 Preventing and managing COVID-19 across long-term care services 2.2.2 Key actions Whole sector Consider injecting extra ring-fenced funds for long-term care to cover the additional costs linked to the pandemic (for example, additional staff costs, infection prevention and control (IPC) training, and materials such as PPE and sanitizers). Consider how to reduce regulatory and other costs to providers for the duration of the pandemic (such as staffing requirements). Provide flexibility in the use of emergency funds allocated to long-term care providers as well as users. Long-term care facilities Provide funding to compensate for lower occupancy rates and ensure provision of quality essential health and care services. Provide funding to support providers of long-term care facilities with the additional costs incurred in ensuring the safety of their residents and staff, including additional IPC measures and testing for COVID-19. Community-based care Support providers (particularly not-for-profit) that are experiencing loss of revenue if they have to close some services, such as day care and community centres, during the pandemic. Enable flexibility in the use of personal budgets and other cash benefits, for example by allowing them to be used to employ a family member or neighbour if community centres are not available. Caregivers Support caregivers who may need to take on additional care responsibilities to compensate for the unavailability of usual care, and may need to give up employment to do so. Country examples In the United States, the US$ 3 trillion COVID-19 stimulus package (under the Coronavirus Aid, Relief, and Economic Security (CARES) Act) provides some funding for the long-term care sector. Out of the US$ 100 billion funding allocated to health care providers under the CARES Act, US$ 50 billion is being distributed to hospitals and long-term care providers, including providers of home health (61). As of 3 June 2020, US$ 4.9 billion had been targeted to skilled nursing facilities (62). In the Republic of Korea, the Ministry of Health and Welfare and the Korean National Health Insurance Service have issued temporary reimbursement guidelines for the long-term care sector. The guidelines take into consideration the need for COVID-19-related physical distancing measures and staff shortages. In addition, service providers operating in special disaster zones will not be facing payment cuts if they cannot adhere to staffing requirements during the pandemic (63). In China, subsidized long-term care providers were allocated a special one-off allowance to support staffing (for example, hiring and redeploying workers and reimbursing overtime) to ensure the continued provision of long-term care services. It is estimated that this support will amount to a total of around US$ 1.6 million (64–66). 10 Preventing and managing COVID-19 across long-term care services 2.3 ENSURE EFFECTIVE MONITORING AND EVALUATION OF THE IMPACT OF COVID-19 ON LONG-TERM CARE AND ENSURE EFFICIENT INFORMATION CHANNELLING BETWEEN HEALTH AND LONG-TERM CARE SYSTEMS TO OPTIMIZE RESPONSES 2.3.1 The challenge Few countries have information and monitoring systems for long-term care systems Relatively few countries have information and monitoring systems that include individual-level data about the characteristics, needs and outcomes of people who use formal long-term care services, and about the type and quality of care that they are receiving. This reflects the overall situation of limited data sources about older people (who are often long-term care users) and lack of age- and gender- disaggregated data (67). Where individual-level data are available, quite often they only cover people who use publicly funded long-term care or provide services. Furthermore, health and social care data are usually collected under separate systems, leading to difficulties linking data for the same individual. There are reports of unregulated long-term care facilities being “discovered” as a result of the COVID-19 pandemic (68). Lack of individual-level data about the characteristics of the residents of long-term care facilities has been identified as a barrier to response planning for the COVID-19 pandemic (69–70). This has meant, for example, that mathematical models that have informed planning for the pandemic have not accounted for residents in long-term care facilities separately from surrounding populations in their calculations (71). Data on the pandemic were initially only collected on people who had been tested and died in hospitals Very few countries publish data on the numbers of residents of long-term care facilities who have been infected or died from confirmed or suspected COVID-19. Because residents of long-term care facilities have been less likely to be tested or admitted to hospital than people living in private households, it is likely that countries that do not include deaths outside hospital are underestimating the death toll of COVID-19. An international initiative to track data on deaths of residents of long-term care facilities only found publicly available data for 21 countries in May 2020 (6). Without data on the impact of the infection on long-term care facilities and on people who rely on care and live in the community, there is a risk that the resources needed to prevent and mitigate the impact of COVID-19 in the long-term care sector (funds, workforce, tests, PPE and other equipment) may not be provided adequately and in a timely manner. There are few data available on associated health impacts of the pandemic Many people who rely on assistive care, particularly community-based care, will have had disruptions in their usual access to care, which can potentially put them at risk (for example due to malnutrition, undetected infections or other health complications). Data to identify people who may be at higher risk are needed to identify gaps and reconfigure services as needed. 11 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 Difficult to monitor the impact of COVID-19 across long-term care services Difficult to develop tailored response plans for long-term care to mitigate impact Difficult to include long-term care populations in modelling projections Difficult to monitor health impact of COVID-19 on long-term care users and long-term care workforce Fragmentation of information between long-term care facilities and health facilities 2.3.2 Key actions Whole sector Find effective ways to make use of existing long-term care management data where they are available (for example, MDS 3.0 in the United States, and the interRAI assessment systems of Canada and New Zealand) to model the impact of COVID-19 on health (including mental health) and the functioning of older people in long-term care. For countries without these systems, consider establishing such management data systems as actions for the longer term. Encourage research on the impact, and measures to mitigate the impact, of COVID-19 on long-term care to identify gaps and prepare for future pandemics. Long-term care facilities Establish a surveillance system that captures people who have COVID-19 and deaths that occur in long- term care facilities (probable and confirmed, disaggregated by age, gender, disability and existing health condition), and ensure that these are integrated with existing surveillance systems. Establish the necessary legal mechanisms to secure and transmit information relating to COVID-19 on a regular and frequent basis to and from long-term care facilities, health facilities, public health authorities and the public. Set up a mechanism to ensure that these data are analysed regularly and the findings used to refine government policy on the COVID-19 response. Community-based care Establish mechanisms to report the number of people who have COVID-19 among those receiving and providing long-term care in the community and in homes to public bodies responsible for commissioning services. 12 Preventing and managing COVID-19 across long-term care services Examples In South Africa, managers of long-term care facilities have to inform the Department of Social Development if a COVID-19 case has been confirmed (72). In the European Union, the European Centre for Disease Prevention and Control (an agency of the European Union) has included long-term care facilities in its strategy for COVID-19 surveillance at national and European Union/European Economic Area levels and is collecting data from Member States covering mitigation action, infection rates and mortality (73). In Argentina, in La Plata, an NGO co-developed a website for monitoring and sharing information about both registered and informal long-term care facilities. This platform was used to survey the COVID-19 preparation of the long-term care facilities and resulted in the local government ensuring that testing was provided to all employees of long-term care facilities (53). 13 Preventing and managing COVID-19 across long-term care services 2.4 SECURE STAFF AND RESOURCES, INCLUDING ADEQUATE HEALTH WORKFORCE AND HEALTH PRODUCTS, TO RESPOND TO THE COVID-19 PANDEMIC AND DELIVER QUALITY LONG- TERM CARE SERVICES 2.4.1 The challenge Pre-existing workforce shortages, poor pay and working conditions Before the COVID-19 pandemic, workforce shortages, poor pay and working conditions, and low proportions of professionally qualified staff were already a major concern in long-term care systems (2–3, 73). The workforce supporting people with long-term care needs is predominantly female (90%) (37), and in many countries migrant care workers make up a large proportion of the long-term care workforce (74). It is common for care workers to have zero-hour contracts and to work for multiple facilities or agencies (75). Long-term care staff shortages during pandemic In many countries, long-term care services, particularly long-term care facilities, have experienced acute staff shortages during the COVID-19 pandemic when their staff had to isolate due to suspected or confirmed infection with COVID-19 (49–50, 76–77). This has happened at a time when family and other unpaid caregivers, due to visiting and movement restrictions, have been less able to provide support (even in long-term care facilities, family and volunteer caregivers make an important care contribution). On some occasions countries had to rely on extreme measures such as calling on the military or other emergency services when long-term care facilities became overwhelmed and understaffed (49). In some countries, long-term care workers and caregivers were not initially considered key workers and lockdown measures and curfews meant they were not able to travel to work (or continue to provide care to people in other households) (78–79). Using public transport or living in crammed accommodation may have increased the risk for care staff to be exposed to the virus. Difficulties adapting to increased health care needs in long-term care facilities While some long-term care facilities employ nurses and other health care staff, this is not the case in all facilities, and there are reports of the difficulties faced by non-medically trained staff in long-term care facilities needing to provide care to people with COVID-19 infections or to those who need palliative care without health care staff support or oversight by qualified health professionals such as physicians and nurses. Administrative barriers to transferring staff and medical supplies from the health service to long-term care facilities led, in the case of a region of Spain, to all long-term care facilities being put under the control of the Department of Health during the pandemic (49). Long-term care providers and caregivers not able to obtain PPE Difficulties faced by long-term care providers and caregivers in accessing PPE and other resources (such as hand sanitizer and disinfectant) have emerged in many countries, due to global shortages and the prioritization of hospitals and other health care settings. Long-term care providers reported having to buy PPE at inflated prices as a result. 14 Preventing and managing COVID-19 across long-term care services IMPLICATIONS IN THE CONTEXT OF COVID-19 A vast workforce shortage for long-term care When compensating for workforce shortage, high staff turnover can impede continuity of care and consistency in important IPC measures Decreased integrity of the work and value of a workforce dominated by women and migrant workers Increased financial pressures to work while ill due to poor working conditions, such as lack of compensation for sick leave Occupational safety of long-term care workforce not taken into careful consideration Substantial lack of PPE for long-term care facilities, long-term care workforce (including caregivers) and recipients of care Lack of essential medical supplies and health workforce in long-term care facilities Lack oversight by qualified health professionals in providing essential services in long-term care facilitie 2.4.2 Key actions Whole sector Estimate surge capacity needed to support long-term care services in coordination with the focal point on long-term care. Set up links between health and social care procurement chains to ensure a continuous and non- conflicting supply during COVID-19. Recruit additional staff and develop rapid training programmes (for example, recruit retirees, students from health and long-term care training programmes, and volunteers) on IPC measures. Address contractual and related issues and put in place policies and measures that keep staff safe but allow them to work in a flexible manner and move from health care services into long-term care services as needed. Establish rosters and secure staff from health systems who can be repurposed if needed to support staff in long-term care settings. Implement measures to prevent policies from impeding delivery of important home, community and facility-delivered care through the long-term care workforce. Implement measures to monitor staff working in multiple locations, with increased risk of transmission, and consider facilitating transport and accommodation of staff to minimize the risk of infection during local outbreaks. Provide financial payment for care staff to incentivize them to stay in their jobs during the epidemic and compensate them for additional workload and stress. Long-term care facilities Ensure adequate supply of PPE in long-term care facilities to protect care staff from infection. Provide adequate training guidance and enforce routine training of staff and family caregivers on IPC measures in long-term care facilities so they can continue providing care in those facilities. Facilitate flexible arrangements whereby palliative care teams and other relevant health and care professionals work with staff in long-term care facilities to ensure access to palliative care as needed. 15 Preventing and managing COVID-19 across long-term care services Ensure adequate oversight by appropriately trained personnel to deliver essential services in long-term care facilities. Ensure provision of PPE to home care workers, particularly those providing care in close proximity. Provide adequate training guidance and enforce routine training of community-based care providers. Family and other voluntary caregivers Ensure provision of PPE to caregivers providing care in close proximity. Provide adequate guidance and offer training for family and other voluntary caregivers. Country examples In Austria, staffing and licensing regulations for care workers have been eased substantially during the COVID-19 pandemic. This enables people who have done national service (those who opted for civilian duties) to provide basic care. People in the national service have contributed to managing the logistics of the pandemic. Their employment as care workers can be enforced by the government. In addition, people undertaking training in relevant areas and interested people who are currently unemployed can also step in (76). In Ireland, Nursing Homes Ireland started a recruitment campaign for nursing homes (private and NGO operated) in March 2020. Furthermore, the Health Service Executive agreed to redeploy staff (on a voluntary basis) to private nursing homes (77). In India, some long-term care facilities support their in-house staff with incentives, such as free food. In addition, some long-term care facilities are working to promote the mental health of their staff through regular check-ins and counselling (78). If long-term care facilities in Israel experience a shortage of staff, the Ministry of Health will send a special team for 7–14 days to support the provision of care for the acute period (57). In the Netherlands, since 19 May 2020 PPE has been available free of charge for care workers providing care activities that require close proximity (less than 1.5 metres) to persons with long-term care needs (80). In Spain, care staff from community care centres have been supporting the provision of home care, for example through phone calls. In addition, the long-term care sector can hire non-qualified staff in instances of absenteeism of their usual staff (49). In Australia, residential care workers will receive a retention bonus for two quarters of up to 800 Australian dollars after tax. The government has employed health care delivery providers to form rapid response teams in the long-term care sector where needed in each state. Visa rules were relaxed to enable staff to work more hours (81). In parts of the United Kingdom, care workers have had their wages increased and have been offered a special one-off payment for staff working during the COVID-19 pandemic (82). 16 Preventing and managing COVID-19 across long-term care services 2.5 ENSURE THE CONTINUUM AND CONTINUITY OF ESSENTIAL SERVICES FOR PEOPLE RECEIVING LONG-TERM CARE, INCLUDING PROMOTION, PREVENTION, TREATMENT, REHABILITATION AND PALLIATION 2.5.1 The challenge Requirement for continuous, complex care with high levels of physical and emotional contact People with long-term care needs often require continuous, complex and personalized support structures. Assistive care for personal tasks in particular requires high levels of physical and emotional contact. People who are receiving this care, and who are dependent on this support, benefit enormously from continuity of care (1). In many countries, the majority of residents of long-term care facilities have dementia (83–85). Variability in health care provision in long-term care facilities Long-term care facilities are very diverse, and while some may be specialized in providing medical care, such as long-term care hospitals or some nursing facilities, others, typically residential homes or supported accommodation, may not have any health care trained staff members. Long-term care facilities in many countries have experienced difficulties providing health care support and resources for essential health services, in addition to responding to the new burden of COVID-19 (including in the areas of rehabilitative and palliative care). Potential for discriminatory triage practices in hospital admissions There have been reports that residents of long-term care facilities have not been able to access health care in hospitals (49–50), and have had limited access to primary care. It has also been reported that advance care directives have sometimes been put in place without adhering to the usual person- centred standards (86). Countries have responded by emphasizing the importance of equitable access to health and palliative care for older adults and people with existing conditions during the COVID-19 pandemic (36–37). IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities in many countries have experienced difficulties providing health care support and resources to continue essential health services and to provide assistive care services for the new challenge of COVID-19 Residents of long-term care facilities have sometimes been denied hospital care based on irrelevant or discriminatory criteria, such as age, under the presumption that they are too frail to survive 17 Preventing and managing COVID-19 across long-term care services 2.5.2 Key actions Whole sector Consider developing clear COVID-19 care pathways, inclusive of long-term care facilities and home- and community-based care, for transfers to primary, secondary and tertiary care for people with COVID-19 and non-COVID-19 symptoms (87–89). Consider appropriate tele-health and virtual technologies for consultations, taking account of the views of older people, and provide any support necessary to use this technology effectively. Ensure that all palliative care plans and advanced care directives are up to date and applied through a person-centred approach. Ensure that national and regional policies, programmes and guidelines are in place to support the provision of palliative care in long-term care facilities and long-term care services (including physical, psychological, social and spiritual support). Long-term care facilities Consider involving the residents of long-term care facilities in the development of protocols for referral and access to essential health services. Ensure there is no selection based on age or disease in such protocols, but that people’s needs and preferences determine care decisions. Ensure that all long-term care facilities are supported by a primary care service. Establish rapid response teams, preferably with geriatric and palliative care training, for long-term care facilities for older people, to reduce avoidable hospitalizations and ensure optimal person-centred communication and decision-making. Ensure that staff are trained in providing palliative care and know how to communicate about death, dying and end-of-life decisions (35). Country examples In the United States, the use of home-based tele-health has been expanded as remote patient monitoring can now be reimbursed. Since March 2020, Medicare beneficiaries have been able to receive behavioural or substance use disorder interventions. For people with severe symptoms of COVID-19, post-acute tele-health visits are now possible. This enables social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists to perform remote evaluations and therapy. This may also support people with long-term care needs living in the community (61). In Italy, special palliative care teams were able to reorganize themselves rapidly in order to respond to demand quickly and flexibly. For example, they created networks of hospice care services by shifting staff from hospice inpatient to home care services. The experiences also highlighted the important need for case conferences and similar team collaborations to be able to decide quickly where to prioritize resources (for example, by deciding who will get support after hospital discharge) (50, 90). In Austria, the National Association for Palliative Care has issued a position paper on palliative care during the COVID-19 pandemic and has provided guidance on ensuring access to palliative care for people who will not receive the intensive care that normally is provided. The association has also published guidelines for family caregivers and long-term care workers. Furthermore, multidisciplinary guidance provided by the government is available to support people with COVID-19 who are reaching the end of life. There are also clinical guidelines and resources on how to facilitate social support and on bereavement for family carers and care workers supporting a person who reaches the end of life during the COVID-19 pandemic (76). In Slovenia, medical teams are ready to be sent to residential long-term care facilities to support regular staff if they become exhausted or overwhelmed (91). 18 Preventing and managing COVID-19 across long-term care services 2.6 ENSURE THAT INFECTION PREVENTION AND CONTROL STANDARDS ARE IMPLEMENTED AND ADHERED TO IN ALL LONG-TERM CARE SETTINGS TO PREVENT AND SAFELY MANAGE COVID-19 CASES 2.6.1 The challenge Lack of mandatory implementation of IPC guidance for long-term care Guidance on IPC for long-term care providers has been developed relatively late in the pandemic in many countries, and many of the guidelines have been slow to incorporate evidence of asymptomatic transmission and atypical symptoms of COVID-19. In many countries, guidance has only been developed for long-term care facilities, with no guidance available for providers of community-based care and for family caregivers. Finally, there is a lack of mechanisms to ensure implementation of these guidelines and to monitor their implementation. Lack of IPC experience and training in long-term care and resultant implementation difficulties In many countries, long-term care providers have weak IPC systems and training in place, resulting in many staff being unfamiliar with IPC and the correct use of PPE. This is a particular challenge for long-term care facilities that make high use of temporary or agency staff. Even where guidance and training are available, implementing some of the measures can be challenging due to the need for personal assistive care to be provided in close proximity. Lack of availability of testing and PPE, shortages of staff, difficulties in implementing physical distancing (given the design of traditional long-term care facilities), and a lack of alternative isolation facilities have been reported in countries that have struggled to contain infections in long-term care facilities. Across countries, guidelines have identified the importance of isolating residents exhibiting COVID-19- related symptoms, as well as those who have been in contact with people who are suspected of having or confirmed to have COVID-19. While in some countries residents in long-term care facilities live in single rooms with their own wet rooms, this is not the case in others. The specific structure of buildings in which long-term care facilities are housed may also pose barriers to the establishment of effective quarantine zones. Managers of long-term care facilities need to be supported in assessing the capacity of facilities to enable effective isolation policies and to provide additional quarantine spaces should the care setting not lend itself to effective isolation strategies. Countries that had experienced severe acute respiratory syndrome and Middle East respiratory syndrome had recently strengthened their IPC systems in long-term care facilities and community-based settings and have tended to systematically transfer people who are suspected or confirmed to have COVID-19 to isolation facilities, which appears to have been successful in controlling outbreaks (63). However, evidence on the impact of these measures on the mental and physical well-being of residents is not yet available. In some countries, there are large numbers of unregistered and therefore unregulated long-term care facilities. It is essential to support these facilities to ensure that they can keep their residents safe (53). Similarly, community-based care services are less often subject to direct regulatory control than residential long-term care facilities, and there are even fewer well developed information and monitoring systems that would enable the gathering of timely information on how the pandemic is affecting, directly or indirectly, people who rely on community-based care. Home care providers typically visit people with care 19 Preventing and managing COVID-19 across long-term care services needs in their own home. This means that care workers need to travel between homes and often visit multiple people with care needs. There is evidence that families have stopped using home care support to reduce the risk of infection for the person with care needs; however, this may create other risks (77, 81). IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of mechanisms to ensure implementation of IPC guidelines and monitor and assess implementation Lack of training of long-term care workforce on IPC measures High staff turnover impedes continuity of care and consistency of IPC measures Physical distancing is difficult to achieve for long-term care services Care workers cannot adequately access information on limiting transmission in the context of COVID-19 2.6.2 Key actions Whole sector Establish a coordinating body to develop, adjust and update IPC guidance and protocols during the COVID-19 pandemic for long-term care, based on the best available evidence (87-88, 92-93). Ensure implementation of the IPC guidance across long-term care services (for all settings). Establish a mechanism to plan, prioritize support for, and monitor implementation of measures to protect staff and people receiving long-term care from infection or spread of COVID-19. Establish early recognition, surveillance thresholds and escalation strategies for outbreaks of COVID-19 across long-term care. Consider how to ensure that providers of long-term care who may be operating outside the system (unregulated or illegal providers) can be supported to ensure the safety of the people living in their facilities or using their services. Ensure that everyone involved in direct delivery of care (staff and family caregivers), in long-term care facilities or in home care services, has access to IPC training (including use of PPE, hand hygiene, cleaning and disinfection of environments and waste management). This should be carried out regardless of their role, and especially for those having direct contact with older people with underlying health conditions (93). Consider developing and circulating standard operating procedures that give direction on how and when to rapidly isolate people receiving long-term care services, using the most up-to-date COVID-19 guidance. Implement extended IPC precautions for people discharged from hospital, based ideally on an agreed protocol for testing to determine individual needs for isolation and PPE required. Translate any strategies for standard operating procedures into clear referral systems that are made available to all staff delivering long-term care services. Long-term care facilities Ensure implementation of IPC guidance in long-term care facilities with reference to the WHO IPC guidance for long-term care facilities in the context of COVID-19 (92). Implement administrative controls, including syndromic surveillance upon entrance to a facility, for all staff and visitors. 20 Preventing and managing COVID-19 across long-term care services Ensure that staff in long-term care facilities have working conditions and arrangements that minimize their movement between settings and people receiving long-term care services, and that sick pay enables them to stay at home if they are unwell. Ensure that long-term care facilities have access to the resources needed to implement IPC (such as PPE, hand sanitizers and disinfectant). Develop the necessary IPC protocols and guidance and ensure that they are made available for visitors and are clearly visible in easy-to-understand formats (94). Develop guidance and ensure implementation of IPC protocol for staff and ensure educational resources are provided alongside continuous training. Ensure that long-term care facilities have an IPC focal point to lead and coordinate IPC activities, ideally supported by an IPC team with delegated responsibilities and advised by a multidisciplinary committee. Community-based care and caregivers Increase training and decision-making support for the long-term care workforce in the community to effectively manage COVID-19, including family caregivers, keeping in mind constraints, especially gender- related constraints, that family caregivers may face (87–88). Country examples In Jamaica, a temporary employment programme was created for regular cleaning of public sector long- term care facilities, and spaces were set aside in those facilities for isolation of symptomatic residents. Also, a multisectoral exercise between multiple State and private sector agencies facilitated deep sanitization of public long-term care facilities (79). In Indonesia, prevention measures in long-term care facilities include knowledge-sharing on hygiene principles with care workers and residents, regular disinfection and ventilation, and abstaining from sharing personal medical equipment. Residential long-term care facilities have put in place a registration system and do not allow visitors with symptoms of COVID-19 to enter the premises (95). In one region of China, after the severe acute respiratory syndrome epidemic, the regional authorities published the first guidelines on prevention of communicable diseases in residential long-term care facilities for the elderly in 2004, and required all operators of long-term care facilities to designate an infection control officer to coordinate and implement infection control measures within the facility, according to the guidelines (65). In Germany, the Robert Koch Institute recommends that domiciliary care workers wear face masks when providing care and that they regularly monitor their health. Additional equipment should be made available if the person they care for shows COVID-19-related symptoms (96). In the Netherlands, some home care workers are organized into special “Corona teams”. These teams look after people with COVID-19, while other teams care for people without infection (80). 21 Preventing and managing COVID-19 across long-term care services 2.7 PRIORITIZE TESTING, CONTACT TRACING AND MONITORING OF THE SPREAD OF COVID-19 AMONG PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.7.1 The challenge Many countries have experienced shortages in testing capacity as hospital services were prioritized In many countries there have been shortages of testing capacity as initially the available capacity was used mostly in hospitals, leaving providers of long-term residential and community services with difficulties in detecting people who had COVID-19. This approach is increasingly understood to have been a major problem, given the high rates of pre-symptomatic or asymptomatic people who have COVID-19 and could be spreading infection. Effective contact tracing in long-term care settings requires coordination and collaboration between long-term care providers and the relevant health authorities Effective testing, tracing and monitoring of COVID-19 in long-term care require coordination and collaboration between long-term care providers and the relevant health authorities. However, due to challenges in governance, such coordination has been difficult in the initial phases of the response. A growing number of countries are now including contact tracing in guidance for the long-term care sector and are developing apps and other systems to support contact tracing. Lack of systematic monitoring of the health status of people receiving and providing care Regular monitoring enables staff to detect changes in people’s health status, including the development of atypical symptoms (13), and to respond faster if a person with care needs or staff develop symptoms of COVID-19. IMPLICATIONS IN THE CONTEXT OF COVID-19 Long-term care facilities have become a blind spot for priority testing, tracing and monitoring of COVID-19 High rates of asymptomatic people who have COVID-19 have made early recognition and subsequent appropriate steps difficult 2.7.2 Key actions Whole sector Ensure testing data are aggregated and shared with local and national public health agencies so that the pandemic is managed at both the population and individual levels. Ensure contact tracing and isolation based on national guidance, with reference to WHO guidance on contact tracing in the context of COVID-19 (36, 97). Trace any clusters of infections or deaths of people in long-term care facilities or amongst those receiving home care services. 22 Preventing and managing COVID-19 across long-term care services Do not rely on symptoms alone, particularly “typical” cough and fever symptoms, when screening for COVID-19, and ensure that staff are trained in identifying other atypical symptoms, especially in older persons (36). Ensure that the health of people receiving and providing long-term care is monitored so that the development of symptoms (including atypical symptoms) can be detected quickly. Long-term care facilities In areas with ongoing or suspected community transmission, rigorous testing of both residents (including new admissions) and staff and tracing of close contacts are essential to develop isolation policies. Community-based care Ensure that people providing and receiving care in the community as well as their household members have access to testing and contact tracing, and have support if they need to isolate (87–88). Include household members of people with care needs in symptom monitoring. Examples In Denmark, both symptomatic and asymptomatic residents and staff in long-term care facilities can access testing at regional hospitals (since 12 May 2020). Even before that date, residents and staff were tested if there was an outbreak in a residential long-term care facility. If one resident shows symptoms, all residents and staff are tested within 24 hours and retested after seven days. If a staff member tests positive, all residents in the same area are also tested (98). In the Netherlands, all family caregivers that experience symptoms of COVID-19 can get tested (since 18 May 2020). In addition, family carers have been able to access free PPE since 19 May 2020 if they support vulnerable people (aged 70 years and older, with chronic conditions) who experience symptoms of COVID-19 and where personal assistive care (with less than 1.5 metres distance) is required (80). In Malaysia, all registered and unregistered long-term care facilities have undergone testing for COVID-19 (99). In the European Union, the European Centre for Disease Prevention and Control guidance recommends testing strategies that distinguish between “affected local areas” (random testing of residents and staff) and “unaffected areas”. Affected areas are those with actual or presumed continuing community transmission (73). 23 Preventing and managing COVID-19 across long-term care services 2.8 PROVIDE SUPPORT FOR FAMILY AND VOLUNTARY CAREGIVERS 2.8.1 The challenge Family caregivers provide an important share of care, but support such as respite care, training or care leave schemes remain limited and without compensation An important share of long-term care across countries is provided by family caregivers who provide care directly, and also help coordinate and complement formal services. In countries without established formal long-term care services, family caregivers provide almost all long-term care. Caregivers usually do not have access to any training for their role. Some countries recognize the impact of caregiving and offer support such as paid care leave, flexible work arrangements, respite care, training and psychological interventions, as well as cash benefits to mitigate negative impacts (29). However, access to these support structures remains limited in most countries and caregivers traditionally provide support without compensation, training or support (1). Even though caregivers’ important contribution is increasingly recognized, available support structures and financial support were already limited before the COVID-19 pandemic (100). The provision of intense levels of care has generally been associated with lower income and ultimately higher poverty rates, as well as poor mental health The largest share of this care is provided by women (61%), though the share of male caregivers increases with age (74). There are also many young (including children) and older caregivers who support family members with long-term care needs. The provision of intense levels of care has generally been associated with reduced labour force attachment (for those of working age), lower income and ultimately higher poverty rates (101). In addition, reduced income and lack of pension contributions exacerbate the risk of vulnerability and poverty in old age. Caregivers also have a higher prevalence of mental health problems (101). The COVID-19 pandemic has meant that some caregivers have had to adjust or give up their jobs to provide care or to avoid exposing the person they support to the risk of a COVID-19 infection. Caregivers working in the informal economy may also have experienced reduced working opportunities due to restrictions, posing a risk to their income. Caregivers also require support for the financial impact of the pandemic (102). The discontinuation of residential care options has left many family caregivers with increased responsibilities and without their usual support structures The COVID-19 pandemic has led to the closure of many day and respite care options, including community-based or short-term care, leaving many caregivers with additional responsibilities and without their established support structures. It is important to understand the issues caregivers face during this pandemic and how they can best be supported (102). Caregivers need to be able to get to the person with care needs, have access to information, PPE and testing, and be supported in developing contingency plans In many countries, government and NGOs have responded to this need by providing guidance and resource documents on hygiene measures to prevent infection and how to respond if the person with care needs or the caregivers themselves develop symptoms. Issues that have emerged during the pandemic include the need for caregivers to have permission to travel due to their care responsibility (78–79), supporting caregivers with access to testing and PPE (80), and developing contingency plans in case they can no longer continue to provide care (77). 24 Preventing and managing COVID-19 across long-term care services Changes in care needs and violence or abuse towards the caregiver Many caregivers are coping with changes in the needs of the person for whom they care (which may be due to infection or to the impact of the restrictive measures). Also, disruption to the normal routine may cause anxiety and stress in people with care needs, increasing pressure on caregivers (29). The COVID-19 pandemic has brought domestic violence and abuse to the surface (38). Family caregivers may also experience violence and abuse in their care relationship and require support (103). IMPLICATIONS IN THE CONTEXT OF COVID-19 Many caregivers have additional responsibilities without established support structures (such as day and respite care options) Social and physical distancing measures across countries are having negative health impacts on caregivers Even though caregivers’ important contribution is increasingly recognized, available financial support remains limited Caregivers experience difficulties in getting the necessary supplies, as they cannot easily leave the person they support alone Access to PPE and testing has largely been absent for family and voluntary caregivers Prolonged isolation, care responsibility without breaks, concerns about the person with care needs, worries about contingency care in case the caregiver becomes incapacitated, as well as violence or abuse towards the caregiver, have implications for caregivers’ mental health 2.8.2 Key actions Whole sector Record the main caregiver in health and long-term care records so that they become recognized as an important source of information and support. Long-term care facilities Enable family caregivers who provide psychological and practical support for people living in long-term care facilities to continue such roles through supportive measures that ensure the safety of the caregivers. Caregivers Provide information, training, support and, if possible, respite care at national level to caregivers, particularly those caring for older people living with dementia, including information on how to manage increased caregiving responsibilities and stress. Consider establishing a telephone helpline or online portal to offer advice, information and support (104). Consider rolling out an assessment to monitor family caregiver needs. Develop clear guidance for family caregivers on when and how to self-isolate. Increase vigilance and monitoring of domestic violence and support for family caregivers. Ensure access to PPE (without family caregivers bearing the inflated cost) and to equipment and medications. Explore new ways of providing support services to caregivers through technology, and support caregivers in accessing relevant technologies. Introduce or expand financial and psychosocial support for family caregivers. Provide bereavement support and ensure careful communication on decision-making with family. 25 Preventing and managing COVID-19 across long-term care services Country examples In Brazil, NGOs (such as the Brazilian Society of Geriatrics and Gerontology and the Brazilian Alzheimer’s Association) have published technical and educational caregiver guidance documents. A booklet has been prepared by FioCruz and other health-related organizations to educate caregivers of older people on preventive and protective measures for COVID-19. There is also a website by the Ministry of Women, Family and Human Rights dedicated to the provision of information for people with rare conditions and disabilities and their caregivers. A collaboration between the Ministry of Health and the Pan American Health Organization has developed a video campaign to support the mental health of people in Brazil who struggle with feelings of isolation, loneliness and distress. NGOs, such as the Alzheimer’s Association, provide helplines and online forums. Other groups have organized psychosocial activities (105). In India, guidelines issued by the Indian Ministry of Social Justice and Empowerment on 27 March 2020 recognized the importance of caregivers being able to get to the people they support. It was recommended that caregivers should be issued with passes that enable them to travel during the period of movement restrictions. Also, NGOs (such as the Alzheimer’s and Related Disorders Society of India, Nightingales Medical Trust and Silver Innings) and specialist services (National Institute of Mental Health and Neuro-Sciences, Cognitive Disorders Clinic) offer information and resources for caregivers of people living with dementia. The Nightingales Medical Trust provides the DemKonnect app, which offers expert advice to caregivers. The Ministry of Health and Family Welfare offers a psychosocial and behavioural helpline. In addition, it has provided videos (including on meditation and yoga) for stress management and mental health tips for different age groups on its website (78). In Ireland, the Dementia Services Information and Development Centre has provided resources for caregivers, including suggested activities for people living with dementia to mitigate the impact of social isolation. The Alzheimer Society of Ireland also offers relevant resources for support and information. Caregivers in receipt of the means-tested carer’s allowance continue to receive payments during the COVID-19 pandemic. In addition, working caregivers in receipt of the carer’s allowance who have lost their jobs due to the pandemic can also access the new pandemic unemployment payment of 350 euros. Similarly, Family Carers Ireland has developed guidance for the development of an emergency plan for caregivers (77). In Germany, the period for receiving long-term care allowance (Pflegeunterstützungsgeld) to respond to an emergency care situation in the family or to organize care arrangements has been doubled in response to the COVID-19 pandemic from 10 to 20 days (until 30 September 2020). The right to stay away from work to respond to an acute care situation has also been extended to 20 days. People who usually receive in-kind services that have become unavailable during the COVID-19 pandemic (such as day care) can be reimbursed to finance replacement care (96). 26 Preventing and managing COVID-19 across long-term care services 2.9 PRIORITIZE THE PSYCHOLOGICAL WELL-BEING OF PEOPLE RECEIVING AND PROVIDING LONG-TERM CARE SERVICES 2.9.1 The challenge Many people with care needs experience a change to their routines and prolonged periods of isolation Many people, particularly older adults, with long-term care needs have been isolated in homes or facilities for many weeks, leading to reduced social contact and disrupted and changed routines. Some people with long-term care needs, such as people living with dementia, experience changes in their physical and cognitive status. Rapid changes to their routine may also increase their vulnerability to pre-existing conditions (84, 104). Specifically, in long-term care facilities, residents have struggled with not being able to socialize with fellow residents or to receive visits from their family and friends. Families are also extremely distressed that they are not able to visit and oversee the resident’s care. Long-term care facilities have recognized the importance of supporting residents with social contacts and have introduced innovative solutions, such as technical tools that enable virtual contact with their families and friends. Sharp increase in the risk of violence against older people Violence against older people, who are already bearing the brunt of this pandemic, has risen sharply since the beginning of the COVID-19 pandemic and imposition of restrictive stay-at-home measures. Violence is occurring in homes, in institutions such as long-term care facilities, and online, with a surge in scams directed at older people (106). Long-term care workers experience substantial pressure on their mental health during the COVID-19 pandemic Long-term care workers (compensated through pay) have experienced sustained pressure to provide care to vulnerable groups during the COVID-19 pandemic, and have worked hard to prevent the spread of COVID-19 to the people they assist. Many will have experienced traumatic situations and multiple bereavements. This leads to substantial pressure on their mental health. In the Netherlands, a survey by the Dutch Nurses’ Association (V&VN) found that 69% of community carers have felt greater pressure on their mental health during the COVID-19 pandemic. Among the 3325 respondents, 28% reported that there was no mental health support provided by their employer (80). Specific interventions to support the well-being of care workers are largely lacking. Some countries have recognized the mental health toll that the COVID-19 situation in long-term care facilities has taken on their staff and have put in place interventions to support the mental health of staff. In the United Kingdom, efforts have been made through support services to enhance the well- being of care workers. Migrant carers, particularly those who were commuting to provide care in other countries, may have found themselves either unable to return home after their shifts or unable to go to work (and therefore be paid) as countries closed their borders, leading to considerable hardship (76, 107). 27 Preventing and managing COVID-19 across long-term care services Family and voluntary caregivers experience great care responsibility and isolation, while their usual support services have largely been suspended Many family caregivers have been isolating with the person they care for to protect them from a COVID-19 infection. This has left them feeling disconnected from their social networks. In addition, their usual support structures (such as day care, home care, other family caregivers and carer support groups) have been reduced in frequency or suspended, leaving family caregivers without important social contacts and sources of practical support. In some countries, helplines, virtual counselling and carer support groups have been established to support caregivers’ psychosocial well-being during the COVID-19 pandemic. IMPLICATIONS IN THE CONTEXT OF COVID-19 There has been a significant impact on the mental health of the staff of long-term care facilities, family and voluntary caregivers, and people with assistive care needs Many residents of long-term care facilities have struggled with not being able to socialize with fellow residents, to participate in regular social activities, or to receive visits from their family and friends Specific interventions to support the well-being of people providing and receiving care are largely lacking 2.9.2 Key actions Whole sector Establish an intersectoral working group to monitor long-term care staff stress and burn-out, and assess and implement strategies to provide mental health and psychosocial support to staff delivering long- term care. Establish a dedicated helpline for mental health and psychological support for anyone who requests it. Consider providing guidance on training care staff and volunteers to improve communication skills on sensitive issues such as end-of-life decisions, death, dying and bereavement. Encourage long-term care providers on the use of screening tools, review staffing procedures (such as flexible schedules and work breaks) to better manage the burden of care, and seek to reduce the use of physical restraints. Ensure mental and emotional support is available from mental health professionals and family caregiver networks, using digital media when required to support recipients and providers of care. Support the monitoring of violence towards older people. Long-term care facilities Establish clear visiting policies that provide balance between IPC measures and the need for people to maintain their psychological well-being (enable residents to have visitors while minimizing the risk of COVID-19 entering long-term care facilities). Facilitate residents’ contact with family and friends by phone, the Internet or written messages if access is restricted. Increase recruitment of volunteers to help with providing social interaction for isolated residents. 28 Preventing and managing COVID-19 across long-term care services Community-based care Ensure access to and scale-up of resources for migrant live-in care workers. Encourage and enhance psychosocial support structures for family caregivers. Consider introducing mental health first aid training for volunteers and community members. Country examples In Chile, the National Service for Older Persons and the Society of Geriatrics and Gerontology have issued videos and graphics to support older people and family caregivers to cope with the COVID-19 situation. This material includes information on the use of PPE, distancing and mental health recommendations (108). It also offers templates to support the organization of community support for people needing help with the basic activities of daily living (109). In Mexico, the Ministry of Health implemented a mental health support campaign, which includes a rapid telephone assessment, to provide support strategies and to make referrals for specific support. Part of the strategy includes a campaign targeted at health care workers (110). In Kenya, some NGOs have moved to virtual peer support. However, poor connectivity in some areas, the cost of purchasing Internet bundles, and online fatigue pose challenges to efforts to support family carers. The Ministry of Labour and Social Protection published guidance for long-term care facilities, which explicitly states that staff should ensure that residents can maintain regular communication (through mobile calls or online chats) with their families and social networks, and should promote the well-being of residents by establishing regular routines and reducing interruptions to those (111). In Malaysia, staff of day care centres continue to look after the people they support through video calls, as well as sharing activities and exercise videos (99). In the United Kingdom, the COVID Trauma Response Working Group has developed guidance for managers and service planners concerned with looking after staff of long-term care facilities who may have experienced trauma (112). 29 Preventing and managing COVID-19 across long-term care services 2.10 ENSURE A SMOOTH TRANSITION TO THE RECOVERY PHASE 2.10.1 The challenge Loss in public confidence in long-term care facilities The COVID-19 pandemic has disproportionately affected people who live in long-term care facilities, and the share of deaths in those facilities appears to increase with the number of people affected in the community. This suggests that as long as there is community transmission of COVID-19 locally, long- term care facilities are at high risk of infection and large numbers of deaths. There are concerns in many countries about the loss in public confidence in long-term care facilities, and the possible negative impacts that might result if people who would benefit from living in a long- term care facility fail to do so because of fear. This may have negative consequences for these persons, for their families, and also for the financial viability of providers of long-term care facilities. Movement restrictions and other shielding measures in long-term care facilities One of the first measures adopted in almost all countries has been restricting visitors to long-term care facilities. While this measure is relatively easy to implement, it is increasingly recognized that it has an enormous impact on the well-being of both the residents of long-term care facilities and their families, and that, particularly where the resident has dementia, a lack of understanding of why the visits have stopped may generate additional distress. Concerns have also been expressed that many family members provide care in their regular (sometimes daily) visits, and that not allowing them to visit at a time when the staff of long-term care facilities may already be overburdened due to increased complexity of care and lower staffing ratios may compound staffing problems. Difficulties in monitoring quality of services in long-term care facilities Another concern is that family member visits have stopped at a time when many countries have suspended inspections. Families may be concerned about the quality of care the residents are receiving, and not being allowed to visit may exacerbate their fears. Ensuring safe visiting is increasingly recognized as a key step in rebuilding trust in long-term care facilities. IMPLICATIONS IN THE CONTEXT OF COVID-19 Lack of exit strategy on restrictive measures applied to long-term care facilities Lack of monitoring quality of care within long-term care facilities when movement restrictions are implemented for those facilities 30 Preventing and managing COVID-19 across long-term care services 2.10.2 Key actions Long-term care facilities Make available surveillance mechanisms to monitor the quality of care within long-term care facilities during implementation of public health and social measures. Make available guidance on thresholds as to when and how to phase in or out isolation of residents and loosen restrictions on visitors. Establish clear criteria on when and how people living in long-term care facilities can move to and from hospitals to protect both staff and other residents. Ensure that the needs of long-term care residents are considered in providing acute, primary and community health services, and that pre-COVID-19 levels of support from primary care and community nursing are reinstated as early as possible. Community-based care Ensure that protocols are being developed so that people receiving community care (for example, day care) can access these services again. Country examples In Malta, day care services started again on a rotational basis on 1 June 2020. People with care needs receiving no services were given priority. Strict hygiene procedures and distancing measures were put in place. For example, staff and people with care needs keep shoes at the day care facility and change when they leave. People with care needs have to wear masks and visors while attending the centre. Staff also wear visors throughout the working day. In addition, people receiving and providing care have their temperature monitored (58). In Denmark, people could continue to visit residents receiving end-of-life care while adhering to hygiene protocols. Since 24 April 2020, residents in long-term care facilities can receive visitors in the outdoor areas (98). In Germany, restrictions around visitors started to be relaxed again in May 2020. While specific rules on the number of people visiting and the frequency and lengths of their visits vary between federal states, all states require that long-term care facilities put clear infection prevention measures in place. Visitors also have to register so that they can be identified for contact tracing if this becomes necessary (96). 31 Preventing and managing COVID-19 across long-term care services 2.11 INITIATE STEPS FOR TRANSFORMATION OF HEALTH AND LONG-TERM CARE SYSTEMS TO APPROPRIATELY INTEGRATE AND ENSURE CONTINUOUS, EFFECTIVE GOVERNANCE OF LONG-TERM CARE SERVICES The COVID-19 pandemic has highlighted fragmentation between long-term care services within health care systems. This fragmentation, along with inherent weaknesses in the current overarching governance structure for long-term care, has led to devastating consequences for long-term care facilities during the COVID-19 pandemic. It is with urgency that we need to transform health and long-term care systems so that long-term care services are readily integrated and provided alongside the traditional continuum of care: promotion, prevention, treatment, rehabilitation and palliation. It must be emphasized that assistive care, defined in this document as assistance provided to help a person perform a particular task to maintain functional ability and preserve independence, is considered an essential service that helps to promote ageing in place and ensure that a person can continue to do what they have reason to value even after significant declines in physical and mental capacity. The WHO Global Strategy and Action Plan on Ageing and Health, adopted in 2016, states that “Every country should have a sustainable and equitable system of long-term care” (44). The Decade of Healthy Ageing (2020–2030) also emphasizes access to long-term care for older people who need it (113). Although long-term care is not just for older people and includes a diverse range of users, the fundamentals are the same: providing services to those that are in need of long-term care in order to ensure a life consistent with their basic rights, fundamental freedoms and human dignity. The following actions reflect the lessons we are learning from the COVID-19 pandemic to realize sustainable and equitable long-term care for all. Key actions Ensure legislation and establish national strategy and frameworks on long-term care. Strengthen relationships between different levels of government involved in long-term care and health care and develop concrete vertical and intersectoral coordination mechanisms. Integrate regular national data collection of health and long-term care systems to enable systemwide evaluation and monitoring. Ensure sustainable and equitable financing mechanisms for long-term care that protect people from catastrophic costs of care. Ensure integrated person-centred care pathways spanning the health and long-term care continuum to enable people with long-term care needs to receive comprehensive care. Ensure continuous training and improved working conditions for the long-term care workforce. Introduce and expand financial and in-kind support for family and voluntary caregivers. Identify mechanisms to ensure quality services in the unregulated long-term care sector and strengthen accreditation. Ensure health sector oversight of long-term care facilities to prepare for future pandemics. Promote research building on lessons learned from the COVID-19 pandemic to address weaknesses in the health and long-term care system. 32 Preventing and managing COVID-19 across long-term care services References 1. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ handle/10665/186463). 2. Care work and care jobs for the future of decent work. Geneva: International Labour Organization; 2018 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/documents/publication/ wcms_633135.pdf, accessed 21 June 2020). 3. Who cares? Attracting and retaining care workers for the elderly. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd.org/publications/who-cares-attracting-and- retaining-elderly-care-workers-92c0ef68-en.htm, accessed 23 June 2020). 4. Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region: strengthening the health systems response to COVID-19. Technical Working Guidance No. 6. WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health-topics/Health-systems/ health-services-delivery/publications/2020/strengthening-the-health-systems-response-to-covid-19- technical-guidance-6,-21-may-2020, accessed 21 June 2020). 5. Salcher-Konrad M, Jhass A, Naci H, Tan M, El-Tawil Y, Comas-Herrera A. COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence. medRxiv. 2020. doi:10.1101/2020.06.09.20125237. 6. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N, Fernández J-L. Mortality associated with COVID-19 outbreaks in LTCFs: early international evidence. International Long-Term Care Policy Network; 2020 (https:// ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in-care-homes-early-international- evidence/, accessed 21 June 2020). 7. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 8. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 9. American Geriatrics Society. American Geriatrics Society (AGS) policy brief: CCOVID-19 and assisted living facilities. Journal of the American Geriatrics Society. May 2020:jgs.16510. doi:10.1111/jgs.16510. 10. American Geriatrics Society. American Geriatrics Society policy brief: COVID-19 and nursing homes. Journal of the American Geriatrics Society. 2020;68(5):908–11. doi:10.1111/jgs.16477. 11. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. New England Journal of Medicine. 2020;382:2081– 90. doi:10.1056/nejmoa2008457. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. UN SP LA SH / AR NE L HA SA NO VI C 33 Preventing and managing COVID-19 across long-term care services 13. Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A et al. SARS-CoV-2 infection: clinical features and outcome of COVID-19 in United Kingdom nursing homes. Journal of Infection. 2020;5:38. doi:10.1016/j. jinf.2020.05.073. 14. Goldberg SA, Pu CT, Thompson RW, Mark E, Sequist TD, Grabowski DC. Asymptomatic spread of COVID-19 in 97 patients at a skilled nursing facility. Journal of the American Medical Directors Association. 2020. doi:10.1016/j.jamda.2020.05.040. 15. Guery R, Cécile D, Noëlle B, Nael V, Castain L, Raffi F et al. Limited effectiveness of systematic screening by nasopharyngeal RT-PCR of medicalized nursing home staff after a first case of COVID-19 in a resident. Médecine et Maladies Infectieuses. May 2020. doi:10.1016/j.medmal.2020.04.020. 16. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A et al. Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults: Seattle, Washington, 2020. Morbidity and Mortality Weekly Report. 2020;69(14):416–8. doi:10.15585/mmwr. mm6914e2. 17. Grabenhorst U, Stiels-Prechtel R, Niemann M, Weckbecker K. COVID-19 in the nursing home: a case report. MMW-Fortschritte der Medizin. 2020;162(9):60–2. doi:10.1007/s15006–020–0481–0. 18. Dora AV, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans: Los Angeles, California, 2020. Morbidity and Mortality Weekly Report. 2020;69(21):651–5. doi:10.15585/mmwr.mm6921e1. 19. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. 2020;382(21):2005– 11. doi:10.1056/NEJMoa2005412. 20. Coronavirus (COVID-19) related deaths by occupation, England and Wales. Office for National Statistics; 2020 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/ bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistereduptoandinc luding20april2020#:~:text=A%20total%20of%20131%20deaths,100%2C000%20females%20(86%20 deaths), accessed 21 June 2020). 21. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 22. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherapy. May 2020. 23. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 24. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 25. COVID-19. Sciensano (https://epistat.wiv-isp.be/covid, accessed 21 June 2020). 26. Fisman D, Lapointe-Shaw L, Bogoch I, McCready J, Tuite A. Failing our most vulnerable: COVID-19 and long- term care facilities in Ontario. medRxiv. doi:10.1101/2020.04.14.20065557. 27. Yanover C, Mizrahi B, Kalkstein N, Marcus K. What factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization. medRxiv. 2020. doi:10.1101/ 2020.05.07.20091652. 28. Dawson WD, Ashcroft E, Lorenz-Dant K, Comas-Herrera A. Impact of the COVID-19 outbreak on community- based care services: a review of initial international policy responses. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Community-Based-Care-Report-19- May.pdf, accessed 21 June 2020). 29. Lorenz-Dant K. International examples of measures to support unpaid carers during the COVID-19 pandemic. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ 34 Preventing and managing COVID-19 across long-term care services International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-20.05.20-complete-2. pdf, accessed 21 June 2020). 30. COVID-19 supercharges existing inequalities faced by Glasgow’s 150,000 disabled people. Glasgow Disability Alliance; 2020 (http://gda.scot/our-community/news/2020/4/28/covid-19-supercharges-existing- inequalities-faced-by-glasgows-150–000-disabled-people, accessed 21 June 2020). 31. Noncommunicable diseases and COVID-19. Geneva: World Health Organization (https://www.who.int/ teams/ncds/covid-19, accessed 21 June 2020). 32. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–332240, accessed 21 June 2020). 33. Coronavirus: Spanish army finds care home residents “dead and abandoned”. BBC News, 24 March 2020 (https://www.bbc.co.uk/news/world-europe-52014023, accessed 21 June 2020). 34. 31 Senioren in Kanada tot: Pfleger kamen aus Angst vor Corona nicht [31 seniors dead in Canada: carers did not come for fear of Corona]. MSN, 18 April 2020 (https://www.msn.com/de-at/news/other/31-senioren- in-kanada-tot-pfleger-kamen-aus-angst-vor-corona-nicht/ar-BB12QiDh#image=1, accessed 21 June 2020). 35. Bauer A, Dixon J. The challenges of providing end-of-life support in LTCFs during the COVID-19 pandemic, and opportunities for the future: an international perspective. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Challenges-of-providing-end-of-life-support-in- care-homes-during-the-COVID-19-pandemic-1.pdf, accessed 21 June 2020). 36. Clinical management of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https:// www.who.int/publications-detail/clinical-management-of-covid-19, accessed 21 June 2020). 37. Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions. In: Gender equality. Paris: Organisation for Economic Co-operation and Development; 2019 (https://www.oecd.org/gender/data/womenare-well-represented-in-health-and-long-term-care- professions-but-often-in-jobs-with-poor-workingconditions.ht, accessed 21 June 2020). 38. COVID-19 and violence against women: what the health sector/system can do. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/331699. 39. Shippee T, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao M et al. COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging and Social Policy. June 2020. doi:10.1080/08959420.2020.1772004. 40. Long-term care for older people: a new global gender priority. New York; UN Women; 2017. 41. Policy brief: the impact of COVID-19 on older persons. New York: United Nations; 2020. 42. Scheil-Adlung X. Global estimates of deficits in long-term care protection for older persons. Extension of Social Security Series, No. 50. Geneva: International Labour Organization; 2015. 43. Help wanted? Providing and paying for long-term care. Paris: Organisation for Economic Co-operation and Development; 2011. 44. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. Report by the Secretariat. Sixty-ninth World Health Assembly, April 2016. Geneva: World Health Organization; 2016 (https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17-en.pdf?ua=1, accessed 21 June 2020). 45. Accelerating global actions for a world without poverty: United Nations System-wide Plan of Action for the Third United Nations Decade for the Eradication of Poverty (2018–2027). New York: United Nations; 2018 (https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/03/SWAP-Poverty- Booklet-Digital-Feb27.pdf, accessed 21 June 2020). 46. Barr N. Long-term care: a suitable case for social insurance. Social Policy and Administration. 2010;44(4):359– 74. doi:10.1111/j.1467–9515.2010.00718.x. 47. Protective equipment being diverted from LTCFs to hospitals, say bosses. The Guardian, 30 March 2020 (https://www.theguardian.com/world/2020/mar/30/protective-equipment-being-diverted-from-care- homes-to-hospitals-say-bosses, accessed 21 June 2020). 35 Preventing and managing COVID-19 across long-term care services 48. Spasova S, Baeten R, Coster S, Ghailani D, Pena-Casas R, Vanhercke B. Challenges in long-term care in Europe: a study of national policies. Brussels: European Commission; 2018. 49. Zalakain J, Davey V, Suárez-González A. The COVID-19 on users of long-term care services in Spain. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTCcovid-Spain-country-report-28-May-1.pdf, accessed 21 June 2020). 50. Berloto S, Notarnicola E, Perobelli E, Rotolo A. Italy and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID19- situation-in-Italy-30-April-2020.pdf, accessed 21 June 2020). 51. King D, Zigante V. Quality assurance practices in long-term care in Europe: emerging evidence on care market management. Brussels: Publications Office of the European Union; 2020. 52. Lloyd-Sherlock P, Neto J, Comas-Herrera A, Redondo N. Re: Covid-19: why we need a national health and social care service. BMJ. 2020;369. doi:10.1136/bmj.m1465. 53. Lloyd-Sherlock P, Bastos J, Geffen L, Giacomin K, Redondo N, Sasat S et al. An emergency strategy for managing COVID-19 in LTCFs in LMICs: the CIAT Framework. 2020 (https://www.corona-older.com/post/ an-emergency-strategy-for-managing-covid-19-in-care-homes-in-lmics-the-ciat-framework-version-1, accessed 21 June 2020). 54. Country assessment framework for the integrated delivery of long-term care. Copenhagen: WHO Regional Office for Europe; 2019. 55. COVID-19: Singapore to house nursing home staff in hotels to protect the elderly. Channel News Asia, 8 May 2020 (https://www.facebook.com/ChannelNewsAsia/videos/1098221953890384/, accessed 21 June 2020). 56. Covid-19 testing completed for nursing home residents and staff; no new cases found apart from 5 earlier ones. The Straits Times, 31 May 2020 (https://www.straitstimes.com/singapore/health/covid-19-testing- completed-for-all-nursing-home-residents-and-staff, accessed 21 June 2020). 57. Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G, Brammli-Greenberg S. The impact of COVID-19 on people using and providing long-term care in Israel. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4- May.pdf, accessed 21 May 2020). 58. Fenech MA, Vella M, Calleja N. The COVID-19 long-term care situation in Malta and Gozo. International Long-Term Care Policy Network; 2020. 59. Cès S, Coster S. Mapping long-term care quality assurance practices in the EU: summary report. Brussels: European Commission; 2019. 60. Hashiguchi T, Llena-Nozal A. The effectiveness of social protection for long-term care in old age: is social protection reducing the risk of poverty associated with care needs? OECD Health Working Papers. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd-ilibrary.org/social- issues-migration-health/the-effectiveness-of-social-protection-for-long-term-care-in-old-age_2592f06e-en, accessed 21 June 2020). 61. Van Houtven CH, Boucher NA, Dawson WD. The impact of COVID-19 outbreak on long term care in the United States. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf, accessed 21 June 2020). 62. HHS Provider Relief Fund. Centers for Disease Control and Prevention; 2020 (https://data.cdc.gov/ Administrative/HHS-Provider-Relief-Fund/kh8y-3es6, accessed 21 June 2020). 63. Kim H. The impact of COVID-19 on long-term care in South Korea and measures to address it. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term- Care-COVID19-situation-in-South-Korea-7-May-2020.pdf, accessed 21 June 2020). 64. Lum T, Shi C, Wong G, Wong K. COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging and Social Policy. 2020. doi:10.1080/08959420.2020.1773192. 36 Preventing and managing COVID-19 across long-term care services 65. Wong K, Lum T, Wong G. The COVID-19 long-term care situation in Hong Kong: impact and measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/ Hong-Kong-COVID-19-Long-term-Care-situation-27-April-2020–1.pdf, accessed 21 June 2020). 66. Shi C, Hu B, Feng M, Wong G. Report from mainland China: policies to support long-term care during the COVID-19 outbreak. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/04/Report-from-Mainland-China-18-April-final.pdf, accessed 21 June 2020). 67. Statistics Commission endorses new Titchfield City Group on Ageing. New York: United Nations Department of Economic and Social Affairs; 16 March 2018 (https://www.un.org/development/desa/ageing/ news/2018/03/title-statistics-commission-endorses-new-titchfield-city-group-on-ageing/, accessed 21 June 2020). 68. Descubren una residencia ilegal en La Laguna por las pruebas del Covid-19 [They discover an illegal residence in La Laguna by the tests of Covid-19]. La Provincia, 4 April 2020 (https://www.laprovincia.es/ sociedad/2020/04/04/descubren-residencia-ilegal-laguna-pruebas/1271776.html, accessed 21 June 2020). 69. Burton A, Goodman C, Quinn T. The invisibility of the UK care home population: UK care homes and a minimum dataset. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/ the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/, accessed 21 June 2020). 70. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 71. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.9540. 72. Jacobs R, Ashwell A, Docrat S, Schneider M. The impact of COVID-19 on long-term care in South Africa. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/ COVID-19-Long-Term-Care-Situation-in-South-Africa.docx, accessed 21 June 2020). 73. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. European Centre for Disease Prevention and Control; 2020 (https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term- care-facilities-EU-EEA, accessed 21 June 2020). 74. Rodrigues R, Huber M, Lamura G. Facts and figures on healthy ageing and long-term care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research; 2012. 75. Van Houtven CH, DePasquale N, Coe NB. Essential long-term care workers commonly hold second jobs and double- or triple-duty caregiving roles. Journal of the American Geriatrics Society. 2020. doi:10.1111/ jgs.16509. 76. Schmidt AE, Leichsenring K, Staflinger H, Litwin C, Bauer A. The impact of COVID-19 on users and providers of long-term care services in Austria. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/ wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Austria-15-May.pdf, accessed 22 June 2020). 77. Pierce M, Keogh F, O’Shea E. The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf, accessed 22 June 2020). 78. Rajagopalan J, Huzruk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ LTC-COVID-situation-in-India-30th-May.pdf, accessed 22 June 2020). 79. Amour R, Robinson JN, Govia I. The COVID-19 long-term care situation in Jamaica. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term- Care-situation-in-Jamaica-25-May-2020–1.pdf, accessed 22 June 2020). 37 Preventing and managing COVID-19 across long-term care services 80. Kruse F, Abma I, Jeurissen P. The impact of COVID-19 on long-term care in the Netherlands. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/COVID19-Long- Term-Care-situation-in-the-Netherlands-25-May-2020–1.pdf, accessed 22 June 2020). 81. Low L-F. The long-term care COVID-19 situation in Australia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Australia-LTC-COVID19-situation-24-April-2020. pdf, accessed 22 June 2020). 82. Extra payment for unpaid carers. Scottish Government, 6 May 2020 (https://www.gov.scot/news/extra- payment-for-unpaid-carers/, accessed 22 June 2020). 83. Global action plan on the public health response to dementia 2017–2025. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259615). 84. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo J et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190–1. 85. Suarez-Gonzalez A, Livingston G, Comas-Herrera. Report: the impact of the COVID-19 pandemic on people living with dementia in UK. International Long-Term Care Policy Network; 2020 (https://ltccovid. org/2020/05/03/report-the-impact-of-the-covid-19-pandemic-on-people-living-with-dementia-in-uk/, accessed 22 June 2020). 86. Joint statement on advance care planning. Care Quality Commission; 2020 (https://www.who.int/ publications/i/item/WHO-2019-nCoV-Comm_health_care-2020.1). 87. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ WHO-2019-nCoV-Comm_health_care-2020.1 accessed 22 June 2020). 88. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/ home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms- and-management-of-contacts, accessed 22 June 2020). 89. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 90. Bauer A. COVID19: providing palliative care for the many. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/03/31/covid19-proving-palliative-care-for-the-many/, accessed 22 June 2020). 91. Oven A. COVID-19 and long-term care in Slovenia: impact, measures and lessons learnt. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/COVID19-and- Long-Term-Care-in-Slovenia-impact-measures-and-lessons-learnt-21-April-2020.pdf, accessed 22 June 2020). 92. Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO- 2019-nCoV-Comm_health_care-2020.1, accessed 22 June 2020). 93. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. Geneva: World Health Organization; 2020 (https://www. who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-of- health-workers-including-key-considerations-for-occupational-safety-and-health, accessed 22 June 2020). 94. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665–331495, accessed 22 June 2020). 95. Sani TP, Tan M, Rustandi KK, Turana Y. COVID-19 long-term care situation in Indonesia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19- Long-Term-Care-situation-in-Indonesia-30-May-1.pdf, accessed 22 June 2020). 96. Lorenz-Dant K. Germany and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19–26-May-2020. pdf, accessed 22 June 2020). 38 Preventing and managing COVID-19 across long-term care services 97. Contact tracing in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who. int/publications/i/item/contact-tracing-in-the-context-of-covid-19, accessed 22 June 2020). 98. Rostgaard T. The COVID-19 long-term care situation in Denmark. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care- situation-in-Denmark-29-May-2020.pdf, accessed 22 June 2020). 99. Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST. The long term care COVID-19 situation in Malaysia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/05/Malaysia-LTC-COVID-situation-report-30-May.pdf, accessed 22 June 2020). 100. Health at a glance 2019: OECD indicators. Paris: Organisation for Economic Co-operation and Development; 2019 (http://www.oecd.org/health/health-systems/health-at-aglance-19991312.htm, accessed 22 June 2020). 101. Brimblecombe N, Fernandez J-L, Knapp M, Rehill A, Wittenberg R. Unpaid care in England: future patterns and potential support strategies. London: London School of Economics; 2018. 102. Caring behind closed doors: forgotten families in the coronavirus outbreak. London: Carers UK; 2020 (https:// www.carersuk.org/for-professionals/policy/policy-library/caring-behind-closed-doors-report, accessed 22 June 2020). 103. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? Journal of Gerontological Social Work. 2014;57(5):460–77. doi:10.1080/01634372.2014.882466. 104. Mental health and psychosocial considerations during the COVID-19 outbreak: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/mental-health-and- psychosocial-considerations-during-the-covid-19-outbreak, accessed 22 June 2020). 105. Da Mata F, Oliveira D. COVID-19 and long-term care in Brazil: impact, measures and lessons learned. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/ COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf, accessed 22 June 2020). 106. COVID-19 and violence against older people. Geneva: World Health Organization; 2020 (https://www.who. int/publications/m/item/covid-19-and-violence-against-older-people, accessed 22 June 2020). 107. Leiblfinger M, Prieler V, Schwiter K, Steiner J, Benazha A, Lutz H. Impact of the COVID-19 pandemic on live-in care workers in Germany, Austria and Switzerland. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/impact-of-the-covid-19-pandemic-on-live-in-care-workers-in-germany- austria-and-switzerland/, accessed 22 June 2020). 108. Coronavirus Plan of Action. Chile: Senama (http://www.senama.gob.cl/protocolos-covid-19, accessed 22 June 2020). 109. Cuenta con migo [count on me]. Government of Chile (https://www.gob.cl/cuentaconmigo/, accessed 22 June 2020). 110. López-Ortega M, Sosa-Tinoco E. COVID-19 and long-term care in Mexico: questions, challenges, and the way forward. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/ uploads/2020/06/LTC-Covid-19-situation-in-Mexico-8-June.pdf, accessed 22 June 2020). 111. Musyimi C, Mutunga E, Ndetei D. COVID-19 and long-term care in Kenya. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/06/02/new-country-report-the-covid-19-long-term-care- situation-in-kenya/, accessed 22 June 2020). 112. COVID Trauma Response Working Group (https://www.traumagroup.org/, accessed 22 June 2020). 113. Decade of Healthy Ageing 2020–2030. Geneva: World Health Organization; 2020 (https://www.who.int/ docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en. pdf?sfvrsn=b4b75ebc_3, accessed 22 June 2020). 114. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 39 Preventing and managing COVID-19 across long-term care services 40 Preventing and managing COVID-19 across long-term care services Annex 1. Methods Living systematic review A living systematic review was undertaken, aiming to synthesize early international evidence on mortality rates and incidence of COVID-19 among people who use and provide long-term care. The review was registered with Prospero (CRD42020183557) and includes studies identified through database searches conducted on 15 May 2020 and updated up to 5 June 2020. The methods and findings have been published in full in medRxiv. Seven databases were searched (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv) to identify all studies reporting primary data on COVID-19-related mortality and incidence of disease among long-term care users and staff. In addition, evidence on country-level mortality rates was identified from LTCcovid.org, an international network of long- term care experts. Studies not focusing on long-term care were excluded. Included primary studies were critically appraised and results on number of deaths and COVID-19-related mortality rates, case fatality rates, and excess deaths (co-primary outcomes), as well as incidence of disease, hospitalizations, and intensive care unit admissions, were synthesized narratively. Title and abstract screening, and a full text review, were undertaken by three reviewers and records reporting on the same study or outbreak were combined. A standardized template was used to extract data at the study level, including information on study design; care setting (institutional versus community); how COVID-19 was diagnosed and confirmed; baseline characteristics of participants; absolute number of deaths and mortality rates from confirmed and suspected COVID-19 cases; case fatality rates; excess deaths; absolute numbers and rates of confirmed and suspected COVID-19; and rates of hospitalization and intensive care unit admissions among confirmed and suspected COVID-19 cases. All study participant characteristics and outcome data were extracted separately for long-term care users and staff. Information was also extracted on the proportion of asymptomatic cases at time of testing, and findings of studies comparing outcomes in long-term care users to others. Due to heterogeneity in the definitions of numerators, denominators, and follow-up times across included studies, data were not pooled. Instead, results were summarized narratively and presented in tables, including information on sample characteristics, follow-up time, and case definitions, as appropriate. Where studies reported on overlapping populations, preference was given to those with larger sample sizes and longer follow-up times. The quality of included primary studies reporting figures relating to mortality rates, case fatality rates, or disease incidence were assessed using the Joanna Briggs Institute critical appraisal tool for prevalence studies. Risk of bias across studies was not assessed. A total of 33 study reports for 30 unique primary studies or outbreak reports were included (Figure A1.1). UN SP LA SH / R IZ AL H IL M AN 41 Preventing and managing COVID-19 across long-term care services MEDLINE: n=673 Embase: n=43 CINAHL Plus: n=221 Web of Science: n= 184 Global Health: n=7 WHO COVID-19 Research Database n=202 medRxiv: n=3454 LTCcovid.org: n=22 Total included: n=33 (30 unique, original studies) Updated database searches: n=418 Database searches: n=4806 Included in first review: n=30 (27 unique, original studies) After deduplication: n=418 Full text review: n=33 Newly included: n=4 After deduplication: n=4457 Full text review: n=247 Excluded after title and abstract screening: n=4210 Excluded after full text review Not focused on LTC: n=75 Review article: n=52 No mortality or infection data: n=56 Opinion piece: n=25 Full text not accessible: n=7 Modelling study: n=3 Not focused on COVID-19: n=3 Duplicate: n=3 Excluded after title and abstract screening: n=385 Excluded after full text review Review article: n=8 Opinion piece: n=6 No mortality or infection data: n=4 Not focused on LTC: n=3 Not focused on COVID-19: n=2 Duplicate: n=1 Full text not accessible: n=0 Modelling study: n=0 Excluded: 1 previously included study (withdrawn by author) Records identified through other sources: n=3 Figure A1.1 Flow chart for selection of included primary studies 42 Preventing and managing COVID-19 across long-term care services Pilot of a systematic review of effectiveness of interventions to mitigate the impact of COVID-19 on people who use and provide long-term care A systematic review on the effectiveness of interventions to manage the impact of COVID-19 on people who use and provide long-term care is under development. While piloting the search strategy across seven databases (MEDLINE; Embase; CINAHL Plus; Web of Science; Global Health; WHO COVID-19 Research Database; medRxiv), 21 studies were identified that described responses to the COVID-19 pandemic and provided some sort of evaluation of effectiveness or aimed to assess characteristics of long-term care services associated with COVID-19 infection rates and associated mortality. There were five reports from the United States, three from Italy, two each from Canada, China, the Republic of Korea and Spain, and one report each from Belgium, France, Ireland, Singapore and the United Kingdom. The interventions identified and target groups varied. Three of the studies related to pharmacological therapies in care homes (1–3), additional studies described the implementation of measures to prevent (China and Singapore) and contain (Canada, China, the Republic of Korea and the United States of America) outbreaks in care homes (1, 4–8), one study reported about prevention measures for community-based care in the United States (9), four reported on multifaceted organizational changes to deal with COVID-19 in long-term care settings, including multidisciplinary collaboration and coordination (6, 10–12), three were pilot studies for detecting COVID-19 through rapid point-of-care testing, pooled testing, and bedside chest ultrasonography (13–15), and one adapted an existing cognitive stimulation intervention for people with dementia to provide information and support in relation to COVID-19 (16). These studies were mostly descriptive and, lacking a control group, were not designed to rigorously evaluate the effectiveness of implemented measures. Nevertheless, the prevention and outbreak management interventions described in the papers from China, the Republic of Korea and Singapore all reported successes in preventing or containing outbreaks. Another three studies assessed the association between different characteristics of care homes and COVID-19 outbreaks and outcomes. Stall et al. found that for-profit status of nursing homes in Ontario, Canada, was associated with both the size of a nursing home outbreak and the number of resident deaths (17). However, for-profit status was not associated with a higher likelihood of an outbreak. Romero-Ortuño and Kennelly found moderate, statistically significant association between crude number of deaths and maximum occupancy in Irish care homes, but no statistically significant association was found for quality of care homes (18). Similarly, Abrams et al. did not find a statistically significant association between the reporting of at least one COVID-19 case in United States nursing homes and traditional quality criteria (19). However, a statistically significant association was found for larger facility size, urban location, percentage of African-American residents, non-chain status, and state. Finally, two studies analysed the association between regional characteristics, including features of the long- term care system such as the proportion of private versus public long-term care beds and the availability of nursing home beds, and spread of COVID-19 in Italian regions (20–21). Country reports on the COVID-19 long-term care situation Country reports published on the LTCcovid website (an initiative of the International Long-Term Care Policy Network) were reviewed. The reports were produced by experts in long-term care, usually academics. The reports aimed to document the impact of COVID-19 on people who use and provide long-term care in each country, and the measures adopted to mitigate the impacts of the pandemic on this population. Information from these reports informed the examples of measures adopted by different countries. 43 Preventing and managing COVID-19 across long-term care services References 1. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 2. Ahmad I, Alam M, Saadi R, Mahmud S, Saadi E. Doxycycline and hydroxychloroquine as treatment for high- risk COVID-19 patients: experience from case series of 54 patients in long-term care facilities. medRxiv. May 2020. doi:10.1101/2020.05.18.20066902. 3. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 4. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherarpy. May 2020. 5. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 6. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 7. Munanga A. Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing. 2020;46(6):3–5. doi:10.3928/00989134–20200511–03. 8. Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M et al. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. Journal of Intellectual Disability Research. 2020. doi:10.1111/jir.12740. 9. Archbald-Pannone LR, Harris DA, Albero K, Steele RL, Pannone AF, Mutter JB. COVID-19 collaborative model for an academic hospital and long-term care facilities. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.044. 10. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 11. Koeberle S, Tannou T, Bouiller K, Becoulet N, Outrey J, Chirouze C et al. COVID 19 outbreak: organisation of a geriatric assessment and coordination unit – a French example. Age and Ageing. May 2020. doi:10.1093/ ageing/afaa092. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Cabrera JJ, Rey S, Perez S, Martinez-Lamas L, Cores-Calvo O, Torres J et al. Pooling for SARS-CoV-2 control in care institutions. medRxiv. June 2020. doi:10.1101/2020.05.30.20108597. 14. Nouvenne A, Ticinesi A, Parise A, Prati B, Esposito M, Cocchi V et al. Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.050. 15. Goodman-Casanova JM, Dura-Perez E, Guzman-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study. Journal of Medical Internet Research. 2020;22(5):e19434. doi:10.2196/19434. 16. Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit nursing homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada. Medrxiv. 2020. doi:10.1101/2020.05.25.20112664. 44 Preventing and managing COVID-19 across long-term care services 17. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 18. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16661. 19. Buja A, Paganini M, Cocchio S, Scioni M, Rebba V, Baldo V. Demographic and socio-economic factors, and healthcare resource indicators associated with the rapid spread of COVID-19 in northern Italy: an ecological study. medRxiv. 2020. doi:10.1101/2020.04.25.20078311. 20. Liotta G, Marazzi MC, Orlando S, Palombi L. Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox. PLoS One. 2020;15(5):e0233329. doi:10.1371/journal. pone.0233329. 45 Preventing and managing COVID-19 across long-term care services World Health Organization Avenue Appia 20 1202 Geneva, Switzerland

-1- والتدبير العلاجي له في مختلف 91-كوفيد الوقاية من خدمات الرعاية الطويلة الأجل موجز سياسات 42 تموز/ يولي و 0202 المحتويات 2 ........................................................................................................................................ الملخص التنفيذي 4 ....................................................................................................................................... نظرة عامة -1 4 ........................................................................................................................... الغاية من الوثيقة 1-1 6 .........................................................على الرعاية الطويلة الأجل: بماذا تخبرنا البي ِّنات 91-أثر عدوى كوفيد 2-1 8 ............................................................................................. أساس العمل: عدم ترك أحد خلف الركب 3-1 01 ................................................................................في الرعاية الطويلة الأجل 91-الاستجابة لجائحة كوفيد -2 11 ...................................... 91-إدراج الرعاية الطويلة الأجل في جميع مراحل الاستجابة الوطنية لجائحة كوفيد 1-2 41 ................................والتعافي منها 91-ٍف للرعاية الطويلة الأجل بهدف الاستجابة لجائحة كوفيدحشد تمويل كا 2-2 ات بكفاءة بين نظم على الرعاية الطويلة الأجل وضمان توجيه المعلوم 91-ضمان الرصد والتقييم الفعالين لأثر كوفيد 3-2 81 .............................................................................الرعاية الصحية والرعاية الطويلة الأجل لتحسين الاستجابات وتقديم 91-الكافية، للاستجابة لجائحة كوفيدتأمين الموظفين والموارد، ومنها القوى العاملة الصحية والمنتجات الصحية 4-2 12 ............................................................................................................... خدمات رعاية طويلة الأجل جيدة ، ومنها خدمات التعزيز ضمان توافر سلسلة الخدمات الأساسية للأفراد الذين يتلقون رعاية طويلة الأجل، واستمراريتها 5-2 62 .......................................................................................... والوقاية والعلاج وإعادة التأهيل والرعاية الملطفة. التأكد من تنفيذ معايير الوقاية من العدوى ومكافحتها والالتزام بها في جميع أماكن الرعاية الطويلة الأجل للوقاية من 6-2 92 ................................................................................................والتدبير العلاجي الآمن لها. 91-حالات كوفيد بين الأفراد الذين يتلقون خدمات الرعاية الطويلة 91-إعطاء الأولوية للاختبارات وتتبع المخالطين ورصد انتشار كوفيد 7-2 53 ........................................................................................................................... الأجل والذين يقدمونها. 73 ..............................................................................تقديم الدعم لمقدمي الرعاية من الأسرة والمتطوعين 8-2 24 الرعاية الطويلة الأجل والذين يقدمونها. إعطاء الأولوية للسلامة النفسية الاجتماعية للأشخاص الذين يتلقون خدمات 9-2 74 ..........................................................................................ضمان الانتقال السلس إلى مرحلة التعافي. 01-2 الشروع في خطوات لتحويل نظم الرعاية الصحية والرعاية الطويلة الأجل بهدف إدماج خدمات الرعاية الطويلة الأجل 11-2 94 ..................................................................................... بالشكل المناسب وضمان الإدارة المستمرة والفعالة لها 25 .................................................................................................................................................. المراجع 26 ........................................................................................................................... الأساليب المتبعة. 1الملحق 96 ............................................................................................................................................. شكر وتقدير والتدبير العلاجي له في مرافق 91-ملحق للنشر على شبكة الإنترنت. الأهداف والإجراءات الرئيسية اللازمة للوقاية من كوفيد الرعاية الطويلة الأجل fdp.ara-1.0202-xennA_beW-eraC_mret-gnoL-feirB_yciloP-VoCn-9102-OHW/020433/56601/eldnah/maertstib/siri/tni.ohw.sppa//:sptth والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -2- الملخص التنفيذي ما من يعيش منهم في مرافق الرعاية الطويلة الأجل، ، ولا سي المسنينتأثيرًا بالغًا على 91-أثرت جائحة كوفيد ٪ من حالات الوفاة 04يفوق تأثيرها على أي فئة أخرى. وتظهر البّينات، في كثير من البلدان، أن أكثر من ٪ في بعض 08جرى ربطها بمرافق الرعاية الطويلة الأجل، وتصل هذه النسبة إلى 91- المرتبطة بعدوى كوفيد الحالات في مرافق الرعاية الطويلة الأجل بين إماتة. وعلاوة على ذلك، قد يكون معدل ل المرتفعذات الدخالبلدان ممن يعيشون خارج تلك نفسه أعلى مما هو عليه بين السكان من العمر 91-المقيمين المصابين بعدوى كوفيد مرافق الرعاية الطويلة الأجل مخاطر عالية، مصحوبة بانخفاض في التدابير المقيمون في المرافق. وغالبًا ما يواجه انخفاض إمكانية الوصول إلى ذلك إلى جانب ، 91-عدم كفاية الموارد اللازمة للتعافي من عدوى كوفيد و ،الوقائية . 91-تواجه فيه النظم الصحية عوائق أثناء التفاقم المفاجئ لعدوى كوفيد سياٍق الخدمات الصحية الأساسية في ق داخل مراف الرعاية الطويلة الأجل،ين مقدمي مرتفعًا أيضًا ب 91-كان تأثير عدوى كوفيد علاوة على ذلك، و وغير ذلك من السياقات. وقد انتهت دراسة أجراها مكتب المملكة المتحدة للإحصاءات الرعاية الطويلة الأجل ارتفاعًا كبيرًا 91- الوفيات حسب المهنة إلى ارتفاع معدل الوفاة المرتبط بعدوى كوفيد عن 0202الوطنية عام العاملة في مجال الرعاية الاجتماعية. بين أفراد القوى على مرافق الرعاية الطويلة الأجل تأثيرًا يفوق غيرها من السياقات. ومع ذلك، 91-رت عدوى كوفيد أث وحتى الآن، هناك حاجة إلى عمل متضافر للتخفيف من الأثر الناجم على جميع جوانب الرعاية الطويلة الأجل، ومنها الرعاية في 91-جتمعية، بالنظر إلى أن معظم المستفيدين من الرعاية ومقدميها هم الفئة المعرضة لكوفيد المنزلية والم صورته الوخيمة. وستكون إجراءات الاستجابة بشأن الرعاية الطويلة الأجل إحدى الخطوات الأساسية والجوهرية ة على عدم ترك أحد يتخلف عن في كثير من البلدان. ولن تغدو البلدان قادر 91-في تخفيف أثر جائحة كوفيد طويلة الأجل. ال الركب في الاستجابة حقًا إلا من خلال معالجة الرعاية بالسياسات ونقاط عمل رئيسية للوقاية من عدوى ا ًهدفًا مرتبط 11ويوفر موجز السياسات الذي بين يدي القارئ ر المستهدف بهذا الموجز هم راسمو السياسات والتدبير العلاجي لها في الرعاية الطويلة الأجل. والجمهو 91-كوفيد . ويستند الموجز 91-كة في جهود الاستجابة لجائحة كوفيد والسلطات (الوطنية ودون الوطنية والمحلية) المشار ، والتأهب لها والاستجابة لمقتضياتها 91- إلى البي ّنات المتاحة حاليًا عن التدابير المتخذة للوقاية من جائحة كوفيد مقدمي الرعاية. أثرها على ف الأثر الناجم عنها في خدمات الرعاية الطويلة الأجل، بما في ذلكوتخفي والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -3- وفي حين تحتوي هذه الوثيقة على خيارات وإجراءات سياساتية ذات صلة بجميع أماكن الرعاية الطويلة الأجل، ت ارتفاعًا كبيرًا في معدل الإصابة أنها شهد على اعتبار ،الضوء على مرافق الرعاية الطويلة الأجل فإنها تسلط والمراضة والوفيات المرتبطة بها. 91- بعدوى كوفيد وعلاوة على ذلك، يتطرق الموجز إلى مشاكل قديمة العهد في نظم الرعاية الطويلة الأجل، بما في ذلك نقص القوة العاملة التي لا تحظى التمويل، وانعدام المساءلة، وتفتتها بين الرعاية الصحية والرعاية الطويلة الأجل، و الطويلة الأجل، بحيث الرعاية لإحداث تحوٍل في خدمات الرعاية الصحية و بالتقدير الكافي. ويقترح الموجز طرقا ً ُتدَمج خدمات الرعاية الطويلة الأجل بسهولة وتقد م في إطار سلسلة الرعاية المتواصلة التي تشمل تعزيز الصحة والعلاج وإعادة التأهيل والرعاية الملطفة. ومن خلال هذه التدابير فقط يمكن للأشخاص الذين يحتاجون والوقاية تتيح لهم العيش بطريقة تحترم حقوقهم ،إلى رعاية طويلة الأجل الحصول على رعاية جيدة ومنصفة ومستدامة الأساسية وحرياتهم الأساسية وكرامتهم الإنسانية. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -4- نظرة عامة -1 الغاية من الوثيقة 1- 1 واطن ضعف في الاستجابة لحالات الطوارئ تسببت في تراجع الرعاية الستار عن م َ 91-لقد أزاحت جائحة كوفيد خدمات الرعاية الطويلة الأجل شهدته الطويلة الأجل على قائمة الأولويات، وهو ما أسفر عن الأثر المدمر الذي ان، وهي: حول العالم. وقد أبرزت هذه الأحداث مشاكل قديمة العهد في نظم الرعاية الطويلة الأجل في معظم البلد نقص التمويل، وانعدام المساءلة، والتفتت، وسوء التنسيق ما بين الرعاية الصحية والرعاية الطويلة الأجل، والقوة ). 3-1العاملة التي لا تحظى بالتقدير الكافي ( الرعاية والتدبير العلاجي له في 91- ويقد ّ م هذا الموجز أهدافًا سياساتية ونقاط عمل رئيسية للوقاية من كوفيد الطويلة الأجل لراسمي السياسات والسلطات (الوطنية ودون الوطنية والمحلية) المشاركة في جهود الاستجابة 91- نات المتاحة حاليًا عن التدابير المتخذة للوقاية من عدوى كوفيد . ويستند الموجز إلى البي ّ 91-لجائحة كوفيد الرعاية من الأسرة وومقدمن بأجر و قدمي الرعاية (ومنهم الموظفوتأثيرها على مستخدمي الرعاية الطويلة الأجل وم ذلك كتدابير التأهب للعدوى وتأثيرها والاستجابة لمقتضياتها. ن عوغيرهم من مقدمي الرعاية المتطوعين)، فضًلا خدمات والتدبير العلاجي لها في 91- يسهب الموجز في شرح إرشادات العمل التقنية بشأن الوقاية من عدوى كوفيد عرض رؤى عالمية وأمثلة من البلدان بغية َ ،الرعاية الطويلة الأجل في الإقليم الأوروبي لمنظمة الصحة العالمية . )4(من مختلف أقاليم المنظمة وفي حين تحتوي هذه الوثيقة على خيارات وإجراءات سياساتية ذات صلة بجميع أماكن الرعاية الطويلة الأجل، لأنها شهدت ارتفاعًا كبيرًا في معدل الإصابات والمراضة ،الضوء على مرافق الرعاية الطويلة الأجل فإنها تسلط . 91-والوفيات من جراء عدوى كوفيد أن مرافق الرعاية الطويلة الأجل جزء لا يتجزأ من الرعاية الطويلة الأجل، يجب تسليط ومع ذلك، وعلى الرغم من الضوء على أن الخدمات المجتمعية هي المفتاح لتعزيز الشيخوخة في مكان الإقامة، والحد من الإيداع بالمؤسسات، قهم الأساسية وحرياتهم ودعم التأهيل خارج المؤسسات، حتى يتمكن الناس من العيش بطريقة تتوافق مع حقو الأساسية وكرامتهم الإنسانية. تعريفات للمصطلحات المستعملة في هذه الوثيقة. 1يعرض الإطار و والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -5- الإطار 1. مصطلحات العمل: تعريفات المصطلحات المستعملة ظم الرعاية الطويلة الأجل ن ، ويمكن الوصول إليها ،تتسم بأنها ملائمة وميسورة التكلفة ،الأجلظم وطنية تضمن رعاية متكاملة طويلة ن ُ .)1(وتدعم حقوق الأفراد ومقدمي الرعاية على حد سواء الرعاية الطويلة الأجل أو يواجهون مخاطر ،والعقليةالخدمات التي تضمن أن الأفراد الذين يعانون من فقدان كبير للقدرات البدنية يمكنهم الحفاظ على مستوى من القدرة الوظيفية يتسق مع حقوقهم الأساسية وحرياتهم الأساسية ،التعرض لذلك . وتتضمن هذه الخدمات عادًة الرعاية والمساعدة في المهام اليومية (بما في ذلك ارتداء )1( وكرامتهم الإنسانية والطبخ والتنظيف)، ودعم المشاركة الاجتماعية، والتدبير العلاجي للحالات المزمنة الملابس والاستحمام والتسوق الخدمات مقدمو المتقدمة من خلال الرعاية المجتمعية وإعادة التأهيل والرعاية في نهاية الحياة. ويتولى تقديم َ وكذلك موظفو تقديم الرعاية من الأسرة، ولكن أيضًا من المتطوعين)، ا ًرعاية بلا أجر (عادة ما يكونون أفراد مقابل أجر. وفي جميع أجزاء الوثيقة، يشمل استعمال مصطلح "خدمات الرعاية الطويلة الأجل" الرعاية في المنزل، وفي المجتمع، وفي المرافق (مرافق الرعاية الطويلة الأجل السكنية أو دور الرعاية أو غيرها من مرافق المعيشة خلاف ذلك. الجماعية)، ما لم ُيحدد مرافق الرعاية الطويلة الأجل ف دور الرعاية ومرافق الرعاية الماهرة ومرافق المعيشة قد تختلف مرافق الرعاية الطويلة الأجل حسب البلد. وُتعر أنها مرافق رعاية طويلة ب المصحوبة بالمساعدة والمرافق السكنية ومرافق الرعاية الطويلة الأجل السكنية مجتمعة ً الأجل توفر مجموعة متنوعة من الخدمات، ومنها الرعاية الطبية والُمساع دة، للأفراد غير القادرين على أن في كل أجزاء طويلة الأجل"، اليعيشوا حياة مستقلة داخل المجتمع. ولا يشمل استعمال مصطلح "مرافق الرعاية زلية والمراكز المجتمعية ومرافق الرعاية النهارية للبالغين أو الرعاية المؤقتة. الوثيقة، الرعاية الطويلة الأجل المن مقد ّ م الرعاية الأسرة والأصدقاء والجيران والمتطوعين وقد يشمل مقدمو الرعاية أفراد َ؛ خص يقدم الرعاية والدعم لشخص آخرش .)1( والعاملين في مجال الرعاية والمهنيين الصحيين والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -6- على الرعاية الطويلة الأجل: بماذا تخبرنا البي ّنات 91-أثر عدوى كوفيد 2- 1 في 91- كوفيد رير المجم عة عن وضع عدوى والتقا )5(المنهجية إحدى المراجعات تشير البي ّنات المستمدة من ) إلى أنه في حين لا يوجد سوى القليل من البّينات على تأثير عدوى 1طويلة الأجل (الملحق ال مرافق الرعاية على الأشخاص الذين يستفيدون من خدمات الرعاية الطويلة الأجل في المجتمع أو يقدمونها، كان 91-كوفيد ن يعيشون في مرافق الرعاية الطويلة الأجل أكثر من الفئات ، الذيالمسنينللجائحة أثر بالغ على الأفراد، وخاصة ، كان نحو نصف جميع هذه 91- الأخرى. ففي البلدان التي شهدت أعدادًا كبيرة من الوفيات جراء عدوى كوفيد المراجعة بمزيد من التفصيل طرق 1الوفيات بين المقيمين في مرافق الرعاية الطويلة الأجل. ويبين الملحق هذا التقرير.في سبيل إعداد جريت ة وأعمال المراجعة الأخرى التي أ ُالمنهجي تباينًا ن َفي مرافق الرعاية الطويلة الأجل قد تباي َ 91-وتشير البّينات المبكرة إلى أن مدى الإصابات بعدوى كوفيد فق الرعاية الطويلة كبيرًا بين البلدان وداخلها: بعض البلدان (مثل الأردن) لم ُيبَلغ فيها عن إصابات في مرا ٪ من 52الأجل حتى الآن، بينما كان الأمر مختلفًا في السويد، مثًلا، حيث إنه بحلول نهاية نيسان/أبريل، كان ٪ من 76، مع تضرر 91- مرافق الرعاية الطويلة الأجل في جميع أنحاء البلاد يعاني من تفشي عدوى كوفيد مرافق الرعاية الطويلة الأجل في ستوكهولم. بلدًا مرتفع الدخل إلى أنه في حين لم تشهد بعض البلدان حالات وفاة أو كانت 12تشير البيانات الواردة من و في مرافق الرعاية الطويلة الأجل، فإن بلدانًا أخرى أفادت بأن ما يقرب من نصف جميع المقيمين قليلة جدًا بين د كانت لمقيمين في مرافق رعاية طويلة الأجل في البلا 91- الوفيات، في المتوسط، المرتبطة بعدوى كوفيد ٪ في كندا). وفي بعض البلدان، كانت نسبة الوفيات بين جميع المقيمين في 28و٪ في المجر 42 بين(تتراوح ٪ من جميع 6و٪ 3 بين ت تراوحبحيث ،مرتفعة 91- بطة بعدوى كوفيد مرافق الرعاية الطويلة الأجل المرت . ولا تتوافر البيانات المصنفة حسب العمر والجنس في العديد من البلدان.)6(المقيمين في مرافق الرعاية الطويلة الأجل، يكون من الصعب 91-وتفيد البي ّنات أيضًا بأنه بمجرد وجود عدوى كوفيد من بعضهم الذين يعيشون بالقرب السيطرة عليها، ويرجع بعض السبب في ذلك إلى العدد الكبير من الأشخاص بعض في مرافق مصممة للعيش الجماعي، ناهيك عن أن الرعاية الشخصية إنما تتطلب التقارب الوثيق. وعلى الرغم من أن تقارير الحالات الواردة من جمهورية كوريا أثبتت النجاح في كبح ظهور المزيد من الإصابات في ، فإن دراسات الحالة في )8، 7(ثبتت إيجابية نتيجة اختبار أحد الموظفين مرافق الرعاية الطويلة الأجل بعد أن ر مدى صعوبة احتواء العدوى في هذه الأماكن. فمثًلا، أظهرت الدراسات في ظه العديد من البلدان الأخرى ت ُ ٪ 04المملكة المتحدة لبريطانيا العظمى وأيرلندا الشمالية والولايات المتحدة الأمريكية معدلات إصابة تتراوح بين والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -7- اختبار جميع ٪ عند 9,5و % 5,1 ، مع معدلات إصابة بين الموظفين تتراوح بين)41- 9(٪ بين المقيمين 27و . وثمة بي ّنات كذلك من دراسة واحدة على أن العاملين )81- 51، 8، 7(الموظفين في المرافق التي تشهد فاشية . )91(الذين يعملون في أكثر من دار ربما كانوا مصدر انتقال للعدوى 91- كوفيد المرتبطة بوفيات معدلات الارتفاعًا كبيرًا في للوفيات حسب المهنة في المملكة المتحدة وأظهر تحليل للذكور الذين 9,9ذكر مقارنة بـ 001 000 لكل 4,32الرجال والنساء العاملين في الرعاية الاجتماعية (بين للإناث اللواتي تتراوح أعمارهن 2,5أنثى مقارنة بـ 001 000 لكل 6,9عامًا، و 46و 02تتراوح أعمارهم بين .)02(عامًا) 46-02بين طويلة الأجل (الصين وسنغافورة) الجريت ست دراسات تصف تدابير للوقاية من الفاشيات في مرافق الرعاية وأ ُ بعض النجاح، على الرغم من أنها بالدراسات وأفادت أو التدبير العلاجي لها (كندا وجمهورية كوريا)، ها ئواحتوا . )32- 22، 8، 7(تتوافر لها مجموعة مرجعية لم وهناك بي ّنات متزايدة على انتقال محتمل من الأفراد ما قبل ظهور الأعراض أو العديمي الأعراض المصابين والأفراد الذين يعانون من "أعراض غير نمطية" في مرافق الرعاية الطويلة الأجل. وتشير 91- بعدوى كوفيد ٪ من الموظفين الذين كان 001٪ إلى 05٪ من المقيمين و57٪ إلى 7الفاشيات إلى أن عنالدراسات . )42، 91، 71، 51، 31-11(اختبارهم إيجابيًا كانوا في مرحلة ما قبل الأعراض أو عديمي الأعراض . ويشير )91، 11(عديمي الأعراض الالإيجابيين مقيمين٪ من ال98و ٪75 على تظهر أعراض فيما بعد ُو ٪ من الحالات بين المقيمين 47فين في بلجيكا إلى أن الاختبار المنتظم على المستوى الوطني للمقيمين والموظ . )52(٪ من الحالات بين الموظفين كانت عديمة الأعراض في وقت إجراء الاختبار 67و إماتة، قد يصبح معدل 91- وعند إصابة الأفراد الذين يعيشون في مرافق الرعاية الطويلة الأجل بعدوى كوفيد ممن يعيشون خارج تلك المرافق. فمثًلا، نفسه الحالات بين المقيمين أعلى مما هو عليه بين السكان من العمر بين المقيمين في مرافق الرعاية الطويلة الأجل في أونتاريو، 91- كان معدل حدوث الوفيات الناجمة عن كوفيد ، وكان خطر )62(عامًا أو أكثر 07لبالغين مرة مقارنة بالحالات التي تعيش في المجتمع ل 31كندا، أعلى الإسرائيليةمرة بين المقيمين في دور الرعاية 5,2الإصابة بدرجة وخيمة من المرض، بما في ذلك الوفاة، أعلى . )72عاما ً( 56مقارنة بالحالات الأخرى فوق 91- المصابين بعدوى كوفيد عدوى نفسها أو التدابير المتخذة للوقاية من العدوى في ولا تشير أي دراسات إلى العواقب الصحية الضارة لل مرافق الرعاية الطويلة الأجل، على الرغم من أن العديد من المقالات الافتتاحية ومقالات التعليقات تتحدث عن د الشهية، وفقدان ق الآثار المحتملة على الصحة النفسية والبدنية (على سبيل المثال، الضيق، والاكتئاب، وف َ والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -8- أثار ، وهو الأمر الذي ادة القيود الكيميائية والمادية)لحالة البدنية بسبب عدم ممارسة الرياضة، وعواقب زيا . )92، 82(مخاوف بشأن زيادة المراضة والوفيات المباشرة وغير المباشرة يلة الأجل على الأفراد الذين يستفيدون من الرعاية الطو 91- نات محدودة على تأثير جائحة كوفيد وهناك بي ّ يقدمونها، بما في ذلك المساعدة المنزلية ومرافق الرعاية النهارية ومقدمو الرعاية بلا أجر. وقد الذينالمجتمعية و تؤدي بعض تدابير الصحة العمومية والوقاية من العدوى (ومنها القيود المفروضة على الحركة، والتباعد والدعم المعتادة التي يعتمد عليها كثير من الأفراد الذين الجسدي وحظر التجول) إلى تقييد مصادر الرعاية نات الواردة من المملكة المتحدة إلى أن الأشخاص ذوي الإعاقة قد عانوا من يحتاجون إلى الرعاية. وخلصت البي ّ . وأبلغ الأشخاص ذوو الإعاقة عن صعوبة في الوصول إلى 91-أوجه عدم مساواة متزايدة أثناء جائحة كوفيد وأبلغ كثير من . ذاء والدواء والتأخير في نظام الإعانات، مع معاناة البعض من انعدام الأمن الغذائي والفقرالغ ولبعضهم، كان انقطاع الإنترنت يعني عدم قدرتهم على الوصول .الإعاقة عن شعورهم بالعزلة ي ذو الأشخاص يعتمدون فراد الأ ت ياكل الدعم المستمرة قد جعلعلاوة على ذلك، فإن قلة هو الافتراضية البديلة.لخدمات إلى ا . )03( على الأسرة والجيران ومن المحتمل أيضًا أن يواجه الأشخاص الذين يعانون حالات صحية حالية صعوبات في الوصول إلى خدمات الرعاية الصحية الأساسية، ومنها إعادة التأهيل، وهو ما يزيد من احتياجات الرعاية. ويمكن أن يؤدي انقطاع . )23، 13(خدمات الرعاية الصحية أيضًا إلى زيادة الحاجة إلى الرعاية ومن المعترف به على نحو متزايد أن خطط احتواء الجائحة في كثير من البلدان لم تشمل مرافق الرعاية الطويلة في بعض و الأجل؛ ولم ُتحَشد الموارد لذلك إلا مع بداية ظهور التقارير الإعلامية عن الأعداد الكبيرة للوفيات. التي الطويلة الأجلمرافق الرعاية تجابة للطوارئ لدعمالبلدان، كان لا بد من نشر الجيش وسائر وحدات الاس وفي كثير من البلدان، لم تتمكن مرافق . )33( الوفيات وعدم كفاية الموظفينمن كانت قد أرهقتها الأعداد الكبيرة الرعاية الطويلة الأجل من الحصول على الاختبارات ومعدات الحماية الشخصية والدعم الطبي إلا عقب حدوث ). 43يات واسعة النطاق بها ( فاش أساس العمل: عدم ترك أحد خلف الركب 3-1 تتحمل النظم الصحية المسؤولية عن تقديم رعاية صحية آمنة وسهلة المنال وميسورة التكلفة وعالية الجودة، ومنها دون تمييز. الرعاية الُمَساع دة والملطفة للناس كافة ً والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -9- البي ّنات، يواجه سكان مرافق الرعاية الطويلة الأجل مخاطر عالية، مصحوبة بانخفاض في التدابير ، حسبما تشير لكن ، فضًلا عن انخفاض إمكانية الوصول إلى 91- الوقائية وعدم كفاية الموارد اللازمة للتدبير العلاجي لعدوى كوفيد . 91- التفاقم المفاجئ لعدوى كوفيد الخدمات الصحية الأساسية في ظل مواجهة النظم الصحية عوائق في سياق ويشكل المسنون، وخاصة الذين يعانون منهم من حالات صحية كامنة وتزيد احتمالات إصابتهم بدرجة مرضية ، نسبة كبيرة من المستفيدين من خدمات الرعاية الطويلة الأجل، بمن فيهم أولئك الذين 91- وخيمة من عدوى كوفيد وتخفيف 91- عدوى كوفيد ب. ويلزم اتخاذ إجراءات فورية للوقاية من )63(ويلة الأجل يعيشون في مرافق الرعاية الط ولضمان توفير خدمات الرعاية الصحية والرعاية الُمَساع دة الأساسية. ،بين هذه الفئة السكانية الجائحة أثر وعلاوة على ذلك، تمثل النساء، وخاصة المسنات، أعلى نسبة من الأشخاص الذين يستفيدون من خدمات الرعاية، ، 1( ة الأسر داخل للرعاية المقدمون الرئيسيون طويلة الأجل، وهن الويهيمن على القوى العاملة في مجال الرعاية يضًا اعتمادًا كبيرًا على العمال المهاجرين والعمال من . وغالبًا ما تعتمد خدمات الرعاية الطويلة الأجل أ)73 . )04- 83، 1(رقية، الذين قد يكونون أكثر عرضة للخطر المجموعات الع ويجب أن تتضمن الاستجابة للجائحة رعاية طويلة الأجل لضمان عدم تهميش الفئات العرقية والعمرية والجنسانية. نسان، سواء في الإهمال المحتمل للسكان الذين يعتمدون على الرعاية أيضًا مخاوف بشأن حقوق الإهناك ت وكان في التدابير المعتمدة في محاولٍة للحد من خطر الإصابة بالعدوى (مثل، منع وأطويلة الأجل (ويقد ّ مونها)، ال للرعاية الطويلة الأجل الزيارات وحظر النشاط البدني الخارجي). ومن الواجب أن تكون الاستجابة للجائحة شاملة ى المسائل الخاصة بالرعاية الطويلة الأجل. حتى ُتنف ذ تدابير ملائمة ومصممة خصيصًا وُتلب على الأفراد الذين يعيشون في مرافق الرعاية الطويلة الأجل تأثيرًا يفوق الفئات 91-رت عدوى كوفيد أث وحتى الآن، ضافر للتخفيف من الأثر الناجم على جميع جوانب الرعاية الطويلة الأخرى. ومع ذلك، هناك حاجة إلى عمل مت الأجل، ومنها الرعاية المنزلية والمجتمعية، بالنظر إلى أن معظم المستفيدين من الرعاية ومقدميها هم الفئة المعرضة في صورته الوخيمة. 91-لكوفيد الطويلة الأجل، ستكون إجراءات الاستجابة على الرعاية91- وبالنظر إلى ضخامة الأثر الناجم عن عدوى كوفيد في كثير من 91- بشأن الرعاية الطويلة الأجل إحدى الخطوات الأساسية والجوهرية في تخفيف أثر جائحة كوفيد البلدان. بالتصدي لمسألة الرعاية إلا 91-ولن تتمكن البلدان من عدم ترك أحد حقًا خلف الركب في الاستجابة لعدوى كوفيد لة الأجل. الطوي والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -01- في الرعاية الطويلة الأجل 91-الاستجابة لجائحة كوفيد -2 الجائحة الانتباه العام إلى آثارها المباشرة، والحاجة إلى الاستعداد لمواجهة حالات الطوارئ الحالية جذبت في حين والموجات المستقبلية المحتملة، فقد أظهرت أيضًا وجود تحديات هيكلية كبيرة ينبغي التصدي لها من أجل تحسين سلامة نظم الرعاية الطويلة الأجل ومرونتها. واجهت معظم البلدان صعوبات في تطوير نظم متماسكة لضمان الوصول إلى خدمات رعاية وحتى وقتنا هذا، تلبي الاحتياجات المتزايدة للرعاية الصحية والمَساع دة التي ،طويلة الأجل تركز على الأشخاص وذات جودة عالية ى في البلدان ذات الدخل . وحت)54- 24، 1(تتسق مع الحقوق الأساسية والحريات الأساسية والكرامة الإنسانية سجًلا من وضع المرتفع، خلص استعراض أجرته منظمة التعاون والتنمية في الميدان الاقتصادي إلى أن "هناك في الكثير من البلدان، بحيث تستجيب للمشاكل السياسية والمالية على نحو مجزأ لرعاية الطويلة الأجلا سياسات .) 34( ستدام وشفاف" على نحو م بنائها، بدًلا من الحالية رت على قدرة نظم الرعاية الطويلة الأجل على الاستجابة لجائحة ويبحث هذا القسم في التحديات الفريدة التي أث ، ويقترح أهدافًا سياساتية وإجراءات رئيسية لمواجهة هذه التحديات على المدى القصير والطويل.91-كوفيد ، التي استرشدت بالبي ّنات والخبرة الدولية المتاحة 2الواردة في الإطار وستكون الأهداف السياساتية الأحد عشر في نظم الرعاية الطويلة الأجل. 91-إلى الآن، ركنًا أساسيًا في التصدي لعدوى كوفيد الإطار 2: أحد عشر هدفًا سياساتيًا للتخفيف من أثر كوفيد -91 على مختلف جوانب الرعاية الطويلة الأجل .91-إدراج الرعاية الطويلة الأجل في جميع مراحل الاستجابة الوطنية لجائحة كوفيد .1 والتعافي منها. 91- حشد تمويل كاٍف للرعاية الطويلة الأجل بهدف الاستجابة لجائحة كوفيد .2 وضمان توجيه ،على الرعاية الطويلة الأجل 91-ضمان الرصد والتقييم الفعالين لأثر كوفيد .3 ظم الرعاية الصحية والرعاية الطويلة الأجل لتحسين الاستجابات.المعلومات بكفاءة بين ن ُ تأمين الموظفين والموارد، ومنها القوى العاملة الصحية والمنتجات الصحية الكافية، للاستجابة .4 وتقديم خدمات رعاية طويلة الأجل عالية الجودة. 91-لجائحة كوفيد ضمان توافر سلسلة الخدمات الأساسية للأفراد الذين يتلقون رعاية طويلة الأجل، واستمراريتها، .5 ز والوقاية والعلاج وإعادة التأهيل والرعاية الملطفة. ومنها خدمات التعزي والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -11- التأكد من تنفيذ معايير الوقاية من العدوى ومكافحتها والالتزام بها في جميع أماكن الرعاية الطويلة .6 والتدبير العلاجي الآمن لها. 91-الأجل للوقاية من حالات كوفيد بين الأفراد الذين يتلقون خدمات 91-تشار كوفيد ع المخالطين ورصد انإعطاء الأولوية للاختبار وتتب .7 الرعاية الطويلة الأجل والذين يقدمونها. تقديم الدعم لمقدمي الرعاية من الأسرة والمتطوعين. .8 للأشخاص الذين يتلقون خدمات الرعاية الطويلة الأجل النفسية الاجتماعيةإعطاء الأولوية للسلامة .9 والذين يقدمونها. لسلس إلى مرحلة التعافي.ضمان الانتقال ا .01 الشروع في خطوات لتحويل نظم الرعاية الصحية والرعاية الطويلة الأجل بهدف إدماج .11 خدمات الرعاية الطويلة الأجل بالشكل المناسب وضمان الإدارة المستمرة والفعالة لها. الأهداف السياساتية تباعًا. تيةتتناول الأقسام الفرعية الآو 91-جميع مراحل الاستجابة الوطنية لجائحة كوفيد إدراج الرعاية الطويلة الأجل في 1- 2 التحدي 1-1- 2 انخفاض الأولوية السياسية الممنوحة للرعاية الطويلة الأجل مقارنة بالصحة وغيرها من مجالات السياسات الة وغالبًا ما يشار إليها باسم "سندريلا ح ،تميل الرعاية الطويلة الأجل إلى أن تكون ذات أولوية سياسية منخفضة عدم . وقد يكون )64( لرعاية الصحية لما يكون الاهتمام السياسي بأهميتها عابرًا وثانويًا الرفاه"، حيث غالبا ً الاهتمام السياسي بالرعاية الطويلة الأجل أحد الأسباب وراء عدم تضمين قطاع الرعاية الطويلة الأجل في . )4(البلدان الاستجابات السياساتية الأولية للجائحة في العديد من تصريف شؤون نظام الرعاية الطويلة الأجل غالبا ًما يتضمن قطاعات متعددة ووزارات مختلفة ومستويات نوعة، وهو ما يجعل التنسيق صعبا ًحكومية مت بين وزارات مختلفة، وعادة ما تكون الرعاية الصحية والشؤون في معظم البلدان، ،الرعاية الطويلة الأجل تتوزع الاجتماعية أو التنمية أو الحماية الاجتماعية. وغالبًا ما تكون خدمات الرعاية الطويلة الأجل ونظم الرعاية الصحية والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -21- دة) للتمويل على درجة متدنية من التنسيق والتكامل، وتميل إلى أن تخضع لترتيبات منفصلة (وغالبًا ما تكون معق . )34، 1(والتنظيم ونظم المعلومات وتدريب الموظفين وتأمينهم . فعلى سبيل المثال، لم تكن نماذج التوظيف الاحتياطية 91- وقد أوجد ذلك العديد من الصعوبات خلال أزمة كوفيد الزيادات الكبيرة في نة بما يكفي لتلبية في المستشفيات مر 91- لمواجهة الزيادة المفاجئة في أعداد مرضى كوفيد مناسبين التنقل بمرونة الطلب التي نشأت في قطاع الرعاية الطويلة الأجل. وكان من الصعب أيضًا على الموظفين ال حسب الحاجة. وبالمثل، واجه قطاع الرعاية الطويلة الأجل، وخاصة مرافق الرعاية الطويلة الأجل، منظومة عبر ال .) 74( الشخصية، حيث أُعط يت الأولوية للمستشفيات الحماية ات ومعدات صعوبات في الوصول إلى الاختبار وبالإضافة إلى ذلك، كثيرًا ما توزع البلدان المسؤولية عن الرعاية الطويلة الأجل رأسيًا عبر جهات فاعلة وطنية . فعلى سبيل المثال، في إسبانيا )84(وإقليمية ومحلية، وهو ما يخلق صعوبات في تنسيق الخدمات والرقابة الفعالة طويلة الأجل التي ينظمها أو يمولها ما يصل إلى ثلاثة خدمات الرعاية النفسه وإيطاليا، قد يتلقى الشخص . )05، 94( مستويات حكومية مختلفة تتألف خدمات الرعاية الطويلة الأجل من مزيج من مقدمي الخدمات من القطاع العام والقطاع الخاص الهادف للربح والخاص غير الهادف للربح، بالإضافة إلى مقدمي الرعاية من الأسرة. مات الرعاية الطويلة الأجل أيضًا بمزيج من مقدمي الخدمات من القطاع العام والقطاع الخاص الهادف تتميز خد معظم مرافق الرعاية الطويلة الأجل . وفي بعض البلدان، يتولى تشغيل َ)15(للربح والخاص غير الهادف للربح سيما مقدمو خدمات من القطاع الخاص الهادف للربح، وغالبًا ما تكون هذه الخدمات غير خاضعة للتنظيم، ولا .)35، 25(في البلدان المنخفضة الدخل والمتوسطة الدخل وسطة الدخل، بدور مهم في وتضطلع المنظمات غير الحكومية، وعلى الأخص في البلدان المنخفضة الدخل والمت توفير خدمات الرعاية الطويلة الأجل، وغالبًا ما تكون المصدر الوحيد لدعم مقدمي الرعاية بلا أجر. ومع ذلك، ما فعند عدم وجود المنظمات غير الحكومية، غالبًا ما تقع مسؤولية الرعاية بالكامل على الأسر نفسها. ونادرًا ها في أي عمليات أو آليات لا يجري تضمينمن َثم فوعة الأجر ضمن نظام رسمي، و ُيعَترف بهذه الرعاية غير مد بخلاف تلك الخاصة بالمنظمات غير الحكومية التي تدعم العمل. ويمكن أن تؤدي هذه الهياكل تصريف الشؤون ل وجودتها، ويؤدي ق المساءلة، وتفتت المسؤوليات، وهو ما يسبب مشاكل في تنسيق الرعايةإلى نقص الملكية، وتفر .)45، 34(إلى تخلف نظم معلومات والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -31- 91- كوفيد عدوى الآثار المترتبة في سياق إدراج الرعاية الطويلة الأجل ضمن الاستجابة الوطنية للجائحة تعيققد ➔ عيق التخطيط والرقابة والمساءلة أثناء الجائحة تد ق ➔ الطويلة الأجل والرعاية الصحية عند قة بين قطاعات الرعاية عيق الاستجابة المنس تقد ➔ الاستجابة للجائحة عيق التخصيص الفع ال للمواردتقد ➔ الإجراءات الرئيسية 2-1- 2 القطاع كاملا ً معني بإدارة الرعاية الطويلة الأجل (مع التركيز بشكل خاص على المستفيدين مسؤول تنسيق ضمان وجود • . 91- كوفيد المعنية بمن الرعاية الطويلة الأجل ومقدميها) ضمن الهيئة العامة إنشاء لجان توجيهية مشتركة ونظم لتبادل المعلومات والبيانات بين القطاعات ومستويات السياسات دون • ابة المنس قة. الوطنية لضمان الاستج إنشاء آلية لدعم مقدمي الخدمات غير الخاضعين للتنظيم، مع التركيز على الدعم التعاوني بدًلا من • التدابير العقابية. مرافق الرعاية الطويلة الأجل دورها في الرعاية الصحية أثناء الجائحة، ينبغي بصدد توسيعإذا كانت مرافق الرعاية الطويلة الأجل • وضع المحفزات أو الحدود التي تنشط إعادة التوزيع التدريجي لقدرات الخدمات الصحية الشاملة الروتينية، في ذلك موظفو الرعاية الصحية المباشرة. نبم والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -41- أمثلة من البلدان ة، جنبًا إلى جنب مع مقدمي خدمات الرعاية ، وضعت وكالة الرعاية المتكاملة ووزارة الصحسنغافورةفي . وتشمل هذه التدابير تدابير مكافحة 91-الطويلة الأجل، عددًا من التدابير للاستجابة لجائحة كوفيد العدوى والوقاية، والوصول إلى معدات الحماية الشخصية، وإجراءات التباعد وتحديد المناطق، وتعليق ملين في الرعاية الطويلة الأجل، وإجراء الاختبارات لرصد الأشخاص الذين الزيارات، والإقامة البديلة للعا يحتاجون إلى رعاية طويلة الأجل والعاملين في مجال الرعاية. وشكلت وكالة الرعاية المتكاملة فريقًا . ودعم 91-للاستجابة للحوادث بهدف دعم مقدمي الرعاية الطويلة الأجل في الاستجابة لعدوى كوفيد الجيل الفضي، وهو ذراع التوعية لوكالة الرعاية المتكاملة، المسنين من خلال الاتصال والمعلومات مكتب ).65، 55وتوفير الخدمات أثناء الجائحة ( في مرافق الرعاية الطويلة الأجل في جميع 91- ، ُعي ّن فريق إدارة ليتولى إدارة فاشية كوفيد إسرائيلوفي الفريق خطة وطنية في إطار مشروع درع الآباء والأمهات، بما في ذلك إنشاء أنحاء البلاد. وقد م هذا مقر رئيسي يمكن من خلاله تنسيق الجهود الحكومية. وبالإضافة إلى ذلك، قد مت قيادة الجبهة الداخلية المساعدة لمرافق الرعاية الطويلة الأجل طوال وقت الجائحة من خلال إدارة دخول الزوار، والتطهير، .) 75( م التدريب والتوجيه بشأن تدابير الحماية والوقاية يوتوصيل المواد الغذائية، وتقد هيئة معايير الرعاية الاجتماعية، وهي الهيئة التنظيمية للرعاية الطويلة الأجل، فت صن ، مالطاوفي في مطلع شهر 91- أماكن الرعاية السكنية على أنها أماكن عالية المخاطر فيما يتعلق بعدوى كوفيد آذار/مارس. وعلى الفور، أصدرت هيئة معايير الرعاية الاجتماعية التوجيهات التي جرى تحديدها في ). وكان هناك تعاون مباشر بين هيئة الصحة العمومية وهيئة معايير الرعاية 0202( 91-وجز كوفيد م . )85(داخل المرافق المسنين الاجتماعية، ثبت أنه المحفز الأساسي لحماية والتعافي منها 91- حشد تمويل كاٍف للرعاية الطويلة الأجل بهدف الاستجابة لجائحة كوفيد 2- 2 يالتحد 1-2-2 ام المخصص للرعاية الطويلة الأجلمحدودية التمويل الع ٪ من الناتج المحلي الإجمالي 1يعد متوسط الإنفاق العام على الرعاية الطويلة الأجل منخفضًا للغاية، إذ يقل عن . )24( على مستوى العالم. وهذا النقص في التمويل العام يهدد إمكانية الحصول على الرعاية الطويلة الأجل والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -51- الدخل، التي يفتقر الكثير منها إلى مصادر التمويل ويتضح ذلك أكثر في البلدان المنخفضة الدخل والمتوسطة العام المخصصة للرعاية الطويلة الأجل. وعادة ما تكون خطط المزايا العامة للرعاية الطويلة الأجل قائمة على الاحتياجات وتقييم الإمكانيات المادية، وغالبا ً ان خارج النظام العام. ما تتطلب مدفوعات مشتركة، وهو ما يبقي على شرائح كبيرة من السك وفي معظم البلدان، تعتمد خطط المزايا العامة لدعم الرعاية الطويلة الأجل على الاحتياجات وتقييم الإمكانيات مزيدًا من الدعم، لكن ى ما تتطلب مدفوعات مشتركة. وغالبًا ما يتلقى أصحاب الاحتياجات الكبر المادية، وغالبا ً على المبلغ الذي يمكن تغطيته من خلال الموارد العامة. وفي حين أن بعض بعض البلدان تضع أيضًا قيودا ً البلدان تحمي الفئات الأكثر ضعفًا من التكاليف الإضافية، تشيع في معظم البلدان النفقات الكبيرة التي يتكبدها ذلك، نظرًا . وك)06، 95، 34(الأشخاص الذين يتلقون خدمات الرعاية الطويلة الأجل من جيوبهم الخاصة للحصة الكبيرة من الرعاية التي يقدمها مقدمو رعاية بلا أجر، فمن الناحية العملية، تقع حصة كبيرة من تكاليف الرعاية الطويلة الأجل على كاهل الأسر، من خلال مزيج من تكاليف الفرصة البديلة لتوفير الرعاية والمدفوعات دان التي تمتلك آليات تمويل تحمي جميع السكان من تكاليف من الجيوب الخاصة. وهناك عدد قليل من البل .)1(الباهظة الرعاية الطويلة الأجل انخفاض دخل قطاع الرعاية الطويلة الأجل وارتفاع تكاليف الرعاية إن زيادة تكاليف معدات الحماية الشخصية والقوى العاملة تعني أن مقدمي الخدمات يتكبدون تكاليف إضافية كبيرة. وفي الوقت نفسه، يعاني مقدمو الخدمات من انخفاض في الإيرادات بسبب انخفاض نسبة الإشغال في عدد الوفيات عن المعتاد) وإغلاق مرافق الرعاية الطويلة الأجل (بسبب انخفاض عدد حالات الدخول وارتفاع الخدمات المجتمعية مثل مراكز الرعاية النهارية. مخصصة للطوارئ لدعم قطاع الرعاية الطويلة الأجل خلال هذه الأزمة. العديد من البلدان بالفعل أموالا ً وف روقد تطورًا رعاية طويلة الأجل أكثر نظمومع ذلك، قد يكون توفير الموارد وتوزيعها أسهل في البلدان التي لديها . ويطرح توفير الموارد والدعم لقطاع الرعاية الطويلة الأجل غير المسجل تحديات إضافية. ا ًوتنظيم ومثل هذه التحديات الفريدة التي تواجه تمويل الرعاية الطويلة الأجل جعلت من الصعب على نظام الرعاية الطويلة والاستجابة له. 91-للتكاليف الإضافية التي قد تنشأ عن الاستعداد لكوفيد الأجل التفاعل والتصدي والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -61- 91- الآثار المترتبة في سياق كوفيد إلى تعريض 91- قد يؤدي نقص التمويل الكافي للتكاليف الإضافية المرتبطة بالاستجابة لكوفيد ➔ سلامة المستفيدين من الرعاية الطويلة الأجل ومقدميها للخطر. ة في تكاليف الرعاية بسبب الجائحة إلى زيادة مدفوعات المستفيدين من الرعاية من تؤدي الزياد ➔ جيوبهم الخاصة. الإجراءات الرئيسية 2-2- 2 القطاع كاملا ً النظر في ضخ المزيد من الأموال المحمية لصالح الرعاية الطويلة الأجل لتغطية التكاليف الإضافية • بالجائحة (مثل، تكاليف الموظفين الإضافية، والتدريب على الوقاية من العدوى ومكافحتها، المرتبطة والمواد مثل معدات الحماية الشخصية والمعقمات). النظر في كيفية تقليل التكاليف التنظيمية والتكاليف الأخرى لمقدمي الخدمات طوال فترة الجائحة (مثل • متطلبات التوظيف). في استخدام أموال الطوارئ المخصصة لمقدمي الرعاية الطويلة الأجل وكذلك المستفيدين. إبداء المرونة • مرافق الرعاية الطويلة الأجل توفير التمويل لتعويض معدلات الإشغال المنخفضة، وضمان توفير خدمات الرعاية الصحية الأساسية • الجيدة. توفير التمويل لدعم مقدمي خدمات مرافق الرعاية الطويلة الأجل إلى جانب التكاليف الإضافية المتكبدة • فية للوقاية من العدوى ومكافحتها في سبيل ضمان سلامة المقيمين والموظفين، بما في ذلك التدابير الإضا . 91-وإجراء اختبارات كوفيد الرعاية المجتمعية دعم مقدمي الخدمات (خاصة غير الهادفين للربح) الذين يعانون من فقد الإيرادات إذا اضطروا لإغلاق • بعض الخدمات، مثل الرعاية النهارية والمراكز المجتمعية، أثناء الجائحة. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -71- ميزانيات الشخصية والمنافع النقدية الأخرى، مثًلا بإتاحة استخدامها في توظيف أحد السماح باستخدام ال • أفراد الأسرة أو الجيران إذا لم تتوافر المراكز المجتمعية. مقدمو الرعاية ل مسؤوليات رعاية إضافية لتعويض عدم توافر الرعاية دعم مقدمي الرعاية الذين قد يحتاجون إلى تحم • ذلك.فعل يحتاجون إلى التخلي عن وظيفة لالمعتادة، وقد أمثلة من البلدان دولار أمريكي ات تريليون 3بقيمة 91-، توفر حزمة التحفيز لمواجهة آثار كوفيد الولايات المتحدةفي (بموجب قانون المساعدة والإغاثة، والأمن الاقتصادي لمكافحة فيروس كورونا) بعض التمويل لقطاع مليار دولار مخصص لمقدمي خدمات الرعاية 001 تهل. فمن أصل تمويل قيمالرعاية الطويلة الأج مليار دولار أمريكي على 05الصحية بموجب قانون المساعدة والإغاثة والأمن الاقتصادي، يجري توزيع ا ً. واعتبار )16(الرعاية الصحية المنزلية ومقدمفي ذلك نبم المستشفيات ومقدمي الرعاية الطويلة الأجل، . )26( دولار أمريكي لمرافق الرعاية الماهرة ات مليار 9,4، ُخص ّ ص 0202حزيران/يونيو 3من أصدرت وزارة الصحة والرعاية الاجتماعية ودائرة التأمين الصحي الوطنية الكورية جمهورية كوريا،وفي الرعاية الطويلة الأجل. وتأخذ المبادئ التوجيهية في الاعتبار مبادئ توجيهية مؤقتة لسداد تكاليف قطاع . وبالإضافة إلى 91-الحاجة إلى تدابير التباعد الجسدي والنقص في عدد الموظفين المتعلقة بكوفيد ذلك، لن يواجه مقدمو الخدمات الذين يعملون في مناطق كوارث خاصة تخفيضات في أجورهم إذا لم .)36(بمتطلبات التوظيف أثناء الجائحة يتمكنوا من الالتزام ، ُخص ّ ص لمقدمي الرعاية الطويلة الأجل الذين يحصلون على دعم مالي بدل خاص ُيدَفع الصينوفي ، وسداد مقابل العمل الإضافي) لضمان وإعادة نشرهم لمرة واحدة لدعم التوظيف (مثل، توظيف العمال إلى . وبحسب التقديرات، سوف يصل إجمالي هذا الدعماستمرار تقديم خدمات الرعاية الطويلة الأجل .)66، 56، 46(مليون دولار أمريكي 6,1نحو والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -81- على الرعاية الطويلة الأجل وضمان توجيه المعلومات 91- ضمان الرصد والتقييم الفعالين لأثر كوفيد 3- 2 الاستجابات بكفاءة بين نظم الرعاية الصحية والرعاية الطويلة الأجل لتحسين التحدي 1-3- 2 عدد قليل من البلدان يمتلك نظم معلومات ورصد لنظم الرعاية الطويلة الأجل يمتلك عدد قليل نسبيًا من البلدان نظم معلومات ورصد تتضمن بيانات على مستوى الأفراد عن خصائص الأفراد ، وعن نوع الرعاية التي هموحصائل همتاحتياجا، وعن ةالرسميالذين يستعينون بخدمات الرعاية الطويلة الأجل يحصلون عليها وجودتها. وهو ما يعكس الوضع العام لمصادر البيانات المحدودة عن المسنين (الذين يكونون . )76(غالبًا مستفيدين من الرعاية الطويلة الأجل) ونقص البيانات المصنفة حسب العمر والجنس فراد، فإنها غالبًا ما تغطي الأفراد الذين يستفيدون من الرعاية وفي الحالات التي تتوافر فيها بيانات على مستوى الأ الطويلة الأجل الممولة من مصادر عامة أو الذين يقدمون الخدمات. وعلاوة على ذلك، ُتجَمع بيانات الرعاية فرد اصة بالالصحية والاجتماعية عادًة في إطار أنظمة منفصلة، وهو ما يؤدي إلى صعوبات في ربط البيانات الخ نفسه. ). 86( 91-وثمة تقارير عن مرافق رعاية طويلة الأجل غير خاضعة للتنظيم يجري "اكتشافها" نتيجة لجائحة كوفيد وقد جرى تحديد نقص البيانات على مستوى الأفراد عن خصائص المقيمين في مرافق الرعاية الطويلة الأجل على ). وهو الأمر الذي كان يعني، مثًلا، 07، 96( 91-ئحة كوفيد أنه أحد الحواجز التي تعيق التخطيط للاستجابة لجا في حساباتها المقيمين في مرافق الرعاية أن النماذج الحسابية التي استخدمت في توجيه التخطيط للجائحة لم تراع الطويلة الأجل بشكل منفصل عن الفئات السكانية المحيطة. ا للاختبار وماتوا في المستشفيات إلا عن الأفراد الذين خضعو لم تُجمَع البيانات عن الجائحة في بادئ الأمر ينشر عدد قليل جدًا من البلدان بيانات عن أعداد المقيمين في مرافق الرعاية الطويلة الأجل الذين ُأصيبوا وماتوا الأجل كانوا المؤكدة أو المشتبه فيها. ونظرًا لأن المقيمين في مرافق الرعاية الطويلة 91-من جراء عدوى كوفيد بالأفراد الذين يعيشون في منازل خاصة، فمن لديهم فرص أقل للخضوع للاختبار أو دخول المستشفى مقارنة ً . 91- كوفيد بسبب المرجح أن البلدان التي لا تحتسب الوفيات خارج المستشفى تقلل من تقديرات أعداد الوفيات بوفيات المقيمين في مرافق الرعاية الطويلة الأجل، ولم تعثر على وقد أجريت مبادرة دولية لتتبع البيانات المتعلقة . ومن دون بيانات عن تأثير العدوى على ) 6( 0202بلدًا، وذلك في أيار/مايو 12بيانات متاحة للجمهور سوى في والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -91- مرافق الرعاية الطويلة الأجل وعلى الأشخاص الذين يعتمدون على الرعاية ويعيشون في المجتمع، يكون هناك خطر في قطاع الرعاية الطويل الأجل (الأموال والقوى العاملة وتخفيف أثره 91- متمثل في أن الموارد اللازمة لمنع كوفيد ومعدات الحماية الشخصية وغيرها من المعدات) قد لا ُتتاح بصورة ملائمة وفي الوقت المناسب. والاختبارات ثمة قليل من البيانات المتاحة عن الآثار الصحية المرتبطة بالجائحة سيكون العديد من الأفراد الذين يعتمدون على الرعاية المَساع دة، وخاصة الرعاية المجتمعية، قد واجهوا معوقات في وصولهم المعتاد إلى الرعاية، وهو ما قد يعرضهم للخطر (مثًلا، بسبب سوء التغذية أو العدوى غير المكتشفة أو المضاعفات الصحية الأخرى). وهناك حاجة إلى البيانات لتحديد الأفراد الذين قد يكونون في خطر أعلى للوقوف على الفجوات وإعادة تشكيل الخدمات حسب الحاجة. 91- الآثار المترتبة في سياق كوفيد عبر خدمات الرعاية الطويلة الأجل 91-من الصعب رصد أثر كوفيد ➔ من الصعب وضع خطط استجابة مصممة خصيصًا للرعاية الطويلة الأجل للتخفيف من شدة الأثر ➔ النمذجةمن الصعب تضمين الفئات السكانية المستفيدة من الرعاية الطويلة الأجل في تقديرات ➔ على المستفيدين من الرعاية الطويلة الأجل والقوى 91-من الصعب رصد الأثر الصحي لكوفيد ➔ العاملة في الرعاية الطويلة الأجل تفتت المعلومات بين مرافق الرعاية الطويلة الأجل والمرافق الصحية ➔ الإجراءات الرئيسية 2-3- 2 القطاع كاملا ً فعالة لاستغلال بيانات إدارة الرعاية الطويلة الأجل الحالية متى ُأتيحت (مثًلا، أداة مجموعة إيجاد طرق • في الولايات المتحدة، وأنظمة تقييم المقيمين SDM 0.3 الحد الأدنى من بيانات الرعاية الطويلة الأجل النفسية) وأداء المسنين على الصحة (ومنها الصحة 91-في كندا ونيوزيلندا) لنمذجة أثر كوفيد IARretni في الرعاية الطويلة الأجل. وللبلدان التي لا تمتلك هذه الأنظمة، ينبغي النظر في إنشاء هذا النوع من نظم بيانات الإدارة بوصفها إجراءات على المدى الطويل. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -02- ا الأثر، على الرعاية الطويلة الأجل، وتدابير التخفيف من هذ 91-تشجيع إجراء البحوث عن أثر كوفيد • لتحديد الثغرات والاستعداد للجوائح في المستقبل. مرافق الرعاية الطويلة الأجل والوفيات التي تحدث في مرافق الرعاية 91-إنشاء نظام ترصد يسجل الأشخاص الذين يعانون من كوفيد • الصحية الموجودة)، الطويلة الأجل (المحتملة والمؤكدة، مصنفة حسب العمر والجنس والإعاقة والحالة والتأكد من دمجها ضمن أنظمة الترصد القائمة. ومتكرر على أساس منتظم 91- إنشاء الآليات القانونية اللازمة لتأمين ونقل المعلومات المتعلقة بكوفيد • .يهاوإل من مرافق الرعاية الطويلة الأجل والمرافق الصحية وسلطات الصحة العمومية والجمهور ان تحليل هذه البيانات بانتظام واستخدام النتائج لتحسين سياسة الحكومة بشأن الاستجابة إنشاء آلية لضم • .91-لكوفيد الرعاية المجتمعية من بين أولئك الذين يتلقون رعاية 91- إنشاء آليات للإبلاغ عن عدد الأشخاص الذين يعانون من كوفيد • العامة المسؤولة عن التكليف بالخدمات. طويلة الأجل ويقدمونها في المجتمع وفي المنازل للهيئات والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -12- أمثلة من البلدان طويلة الأجل إبلاغ وزارة التنمية الاجتماعية إذا ما ال، يجب على مديري مرافق الرعاية جنوب أفريقيافي ). 27( 91-ظهرت حالة إصابة مؤكدة بكوفيد ، أدرج المركز الأوروبي للوقاية من الأمراض ومكافحتها (إحدى وكالات الاتحاد الاتحاد الأوروبيوفي لمستوى الوطني على ا 91-استراتيجيته لترصد كوفيد ضمن طويلة الأجل ال الأوروبي) مرافق الرعاية ومستوى الاتحاد الأوروبي/المنطقة الاقتصادية الأوروبية، ويجمع المركز البيانات من الدول الأعضاء . )37(بحيث تغطي إجراءات التخفيف ومعدلات الإصابة بالعدوى والوفيات ، في لابلاتا، منظمة غير حكومية شاركت في تطوير موقع على شبكة الإنترنت للرصد الأرجنتينوفي اسُتخد مت هذه قد من مرافق الرعاية الطويلة الأجل المسجلة وغير الرسمية. و كل ٍّ عنوتبادل المعلومات ، وأسفرت عن ضمان الحكومة 91-المنصة لمسح استعدادات مرافق الرعاية الطويلة الأجل لكوفيد .)35(لمحلية توفير الاختبارات لجميع العاملين في مرافق الرعاية الطويلة الأجل ا تأمين الموظفين والموارد، ومنها القوى العاملة الصحية والمنتجات الصحية الكافية، للاستجابة لجائحة 4- 2 وتقديم خدمات رعاية طويلة الأجل جيدة 91-كوفيد التحدي 1-4- 2 العاملة الموجود سلفا،ً وضعف الأجور، وسوء ظروف العمل نقص القوى ، كان نقص القوى العاملة، وضعف الأجور وسوء ظروف العمل، وانخفاض نسب الموظفين 91- قبل جائحة كوفيد القوى ويمثل الإناث أغلب . )37، 3، 2(المؤهلين مهنيًا، بالفعل، مصدر قلق كبير في نظم الرعاية الطويلة الأجل ، وفي كثير من البلدان يشكل )73(٪) 09التي تدعم الأشخاص الذين يحتاجون إلى رعاية طويلة الأجل ( العاملة . ومن الشائع أن يعمل )47(نسبة كبيرة من القوى العاملة في الرعاية الطويلة الأجل ن و المهاجر عمال الرعاية د أدنى من ساعات العمل أو إجبار على العاملون في مجال الرعاية بعقود ساعة الصفر (عقود لا يشترط فيها ح . )57(متعددة مؤسسات قبول أي عمل) والعمل في مرافق أو نقص موظفي الرعاية الطويلة الأجل أثناء الجائحة طويلة الأجل، في العديد من البلدان، من نقص العانت خدمات الرعاية الطويلة الأجل، لا سيما مرافق الرعاية عندما اضطر موظفوها إلى الخضوع للعزل بسبب الاشتباه في الإصابة 91- ئحة كوفيد حاد في الموظفين خلال جا . وقد حدث هذا في وقت كان فيه أفراد الأسرة )77، 67، 05، 94(أو الإصابة المؤكدة بها 91- بعدوى كوفيد والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -22- على تقديم الدعم وغيرهم من مقدمي الرعاية بلا أجر، بسبب القيود المفروضة على الزيارات والتنقلات، أقل قدرة (حتى في مرافق الرعاية الطويلة الأجل، يقدم مقدمو الرعاية من الأسرة والمتطوعون مساهمة مهمة في الرعاية). مثل استدعاء الجيش أو خدمات الطوارئ ،وفي بعض المناسبات، كان على البلدان الاعتماد على تدابير صارمة . )94(وعانت من نقص الموظفين ،الرعاية الطويلة الأجل بالإنهاكصيبت مرافق عندما أ ُ ،الأخرى ، أساسيين رون في البداية عمالا ًعتب َوفي بعض البلدان، لم يكن العاملون في الرعاية الطويلة الأجل ومقدمو الرعاية ي ُ ار في تقديم الرعاية م فإن تدابير الإغلاق وحظر التجول لم تمكنهم من التنقل إلى مكان العمل (أو الاستمر ومن ث َ . كما أن استخدام وسائل النقل العام أو العيش في أماكن مزدحمة قد يؤدي )97، 87( في منازل أخرى) أفراد إلى إلى زيادة خطر تعرض موظفي الرعاية للفيروس. صعوبات التكيف مع احتياجات الرعاية الصحية المتزايدة في مرافق الرعاية الطويلة الأجل عض مرافق الرعاية الطويلة الأجل توظف طواقم التمريض وغيرهم من العاملين في مجال الرعاية في حين أن ب الصحية، فإن هذا ليس هو الحال في جميع المرافق، إذ توجد تقارير عن الصعوبات التي يواجهها الموظفون غير ير الرعاية للأفراد المصابين بعدوى الحاصلين على تعليم طبي في مرافق الرعاية الطويلة الأجل التي تحتاج إلى توف أو لأولئك الذين يحتاجون إلى الرعاية الملطفة دون دعم من موظفي الرعاية الصحية أو الإشراف من 91-كوفيد قبل المهنيين الصحيين المؤهلين مثل الأطباء وطواقم التمريض. ات الطبية من الخدمة الصحية إلى مرافق العقبات الإدارية التي تحول دون نقل الموظفين والإمداد كذلك قد أدت الرعاية الطويلة الأجل، في حالة إحدى مناطق إسبانيا، إلى وضع جميع مرافق الرعاية الطويلة الأجل تحت إشراف . )94(وزارة الصحة أثناء الجائحة الشخصيةالحماية عدم قدرة مقدمي الرعاية الطويلة الأجل على الحصول على معدات ظهرت في العديد من البلدان صعوبات واجهها مقدمو الرعاية الطويلة الأجل في الوصول إلى معدات الحماية الشخصية والموارد الأخرى (مثل معقم اليدين والمطهرات)، بسبب النقص العالمي وإعطاء الأولوية للمستشفيات باضطرارهم إلى شراء معدات الحماية الشخصية جل الأوأماكن الرعاية الصحية الأخرى. وأفاد مقدمو الرعاية الطويلة بأسعار متضخمة. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -32- 91- الآثار المترتبة في سياق كوفيد نقص كبير في القوى العاملة في الرعاية الطويلة الأجل ➔ عند تعويض النقص في القوى العاملة، يمكن أن يعيق ارتفاع معدل دوران الموظفين استمرارية ➔ ة للوقاية من العدوى ومكافحتها هممالرعاية واتساق التدابير ال عمل وقيمة القوة العاملة التي تهيمن عليها النساء والعمال المهاجرين ال تكاملانخفاض ➔ عمل أثناء المرض بسبب سوء ظروف العمل، مثل التي تجبر على ال زيادة الضغوط المالية ➔ عدم وجود تعويض عن الإجازات المرضية عدم النظر بعناية إلى السلامة المهنية للقوى العاملة في الرعاية الطويلة الأجل ➔ النقص الكبير في معدات الحماية الشخصية لمرافق الرعاية الطويلة الأجل، والقوى العاملة في ➔ الأفراد الذين يتلقون الرعاية و في ذلك مقدمو الرعاية)، نبم الرعاية طويلة الأجل ( الإمدادات الطبية الأساسية والقوى العاملة الصحية في مرافق الرعاية الطويلة الأجل نقص ➔ عدم إشراف مهنيين صحيين مؤهلين على تقديم الخدمات الأساسية في مرافق الرعاية الطويلة ➔ الأجل الإجراءات الرئيسية 2-4- 2 القطاع كاملا ً الاحتياجات المفاجئة اللازمة لدعم خدمات الرعاية الطويلة الأجل بالتنسيق مع القدرة على تلبية تقييم • مركز الاتصال المعني بالرعاية الطويلة الأجل. إنشاء روابط بين سلاسل شراء الرعاية الصحية والاجتماعية لضمان استمرارية الإمدادات وعدم تضاربها • . 91-كوفويد جائحة أثناء تطوير برامج تدريب سريعة (مثل، الاستعانة بالمتقاعدين والطلاب من برامج توظيف موظفين إضافيين و • التدريب على الرعاية الصحية والرعاية الطويلة الأجل والمتطوعين) على تدابير الوقاية من العدوى ومكافحتها. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -42- مة معالجة المسائل التعاقدية والمسائل ذات الصلة ووضع السياسات والتدابير التي تحافظ على سلا • ولكنها تسمح لهم بالمرونة في العمل والانتقال من خدمات الرعاية الصحية إلى خدمات الرعاية ،الموظفين الطويلة الأجل حسب الحاجة. إنشاء قوائم بالموظفين من النظم الصحية الذين يمكن تطويعهم إذا لزم الأمر لدعم الموظفين في أماكن • هؤلاء الموظفين. الرعاية الطويلة الأجل، وتأمين مة في المقد وأالمجتمعية وأسواء المنزلية ،همةمتنفيذ تدابير تحول دون إعاقة السياسات لتقديم الرعاية ال • المرافق من خلال القوى العاملة في الرعاية الطويلة الأجل. نتقال العدوى، والنظر تنفيذ تدابير لرصد الموظفين العاملين في مواقع متعددة، ممن يمثلون خطرًا متزايدًا لا • في تسهيل انتقال الموظفين وإقامتهم للحد من خطر الإصابة أثناء الفاشيات المحلية. تقديم مدفوعات مالية لموظفي الرعاية لتحفيزهم على البقاء في وظائفهم أثناء الوباء وتعويضهم عن أعباء • العمل الإضافية والإجهاد. مرافق الرعاية الطويلة الأجل مدادات الكافية من معدات الحماية الشخصية في مرافق الرعاية الطويلة الأجل لحماية موظفي ضمان الإ • الرعاية من الإصابة. على تدابير من الأسرة تقديم تدريب وإرشادات كافية وفرض التدريب الروتيني للموظفين ومقدمي الرعاية • حتى يتمكنوا من مواصلة تقديم الرعاية ،لالوقاية من العدوى ومكافحتها في مرافق الرعاية الطويلة الأج في تلك المرافق. تسهيل الترتيبات المرنة التي تعمل بموجبها فرق الرعاية الملطفة وغيرها من مهنيي الصحة والرعاية ذوي • الصلة مع موظفي مرافق الرعاية الطويلة الأجل لضمان إتاحة الرعاية الملطفة حسب الحاجة. ضمان الإشراف المناسب من قبل موظفين مدربين تدريبًا ملائمًا لتقديم الخدمات الأساسية في مرافق • الرعاية الطويلة الأجل. ضمان توفير معدات الحماية الشخصية للعاملين في الرعاية المنزلية، ولا سيما أولئك الذين يقدمون الرعاية • عن قرب. الكافي وفرض التدريب الروتيني لمقدمي الرعاية المجتمعية.توفير الإرشادات والتدريب • والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -52- مقدمو الرعاية من الأسرة وغيرهم من المتطوعين ضمان توفير معدات الحماية الشخصية لمقدمي الرعاية الذين يقدمون الرعاية عن قرب. • طوعين.تقديم الإرشادات الملائمة وتوفير التدريب لمقدمي الرعاية من الأسرة وغيرهم من المت • أمثلة من البلدان ، 91- ، ُخف ّفت لوائح التوظيف ومنح التراخيص للعاملين في مجال الرعاية بشكل كبير أثناء جائحة كوفيد النمسا في مك ّن الأفراد الذين أدوا الخدمة الوطنية (أولئك الذين اختاروا الواجبات المدنية) من تقديم الرعاية وهو الأمر الذي ي ُ الأساسية. وقد ساهم أفراد الخدمة الوطنية في إدارة اللوجستيات اللازمة للتصدي للجائحة. ويمكن للحكومة أن تفرض جرون تدريبًا في مجالات لك، فإن الأشخاص الذين ي ُعاملين في مجال الرعاية. وبالإضافة إلى ذ بصفتهم توظيفهم . ) 67( ذات صلة والأشخاص المهتمين العاطلين عن العمل حاليًا يمكنهم المشاركة ، بدأت هيئة دور الرعاية في أيرلندا حملة للتوظيف في دور الرعاية (التي تديرها المنظمات غير أيرلنداوفي وعلاوة على ذلك، وافقت الهيئة التنفيذية للخدمات الصحية على .0202الحكومية والخاصة) في آذار/مارس . )77( إعادة نشر الموظفين (على أساس طوعي) إلى دور الرعاية الخاصة ، تدعم بعض مرافق الرعاية الطويلة الأجل موظفيها الداخليين بالحوافز، مثل الطعام المجاني. الهندوفي وبالإضافة إلى ذلك، تعمل بعض مرافق الرعاية الطويلة الأجل على تعزيز الصحة النفسية لموظفيها من خلال . )87( عمليات الفحص والاستشارة المنتظمة ا ًوزارة الصحة فريق رسلمن نقص في الموظفين، ت ،إسرائيلفي ،ويلة الأجلوفي حالة معاناة مرافق الرعاية الط .)75(ل مدة الحاجة الحادة ايومًا لدعم تقديم الرعاية طو 41-7لمدة ا ًخاص معدات الحماية الشخصية مجانًا للعاملين في مجال الرعاية الذين تقد م ، 0202أيار/مايو 91، منذ هولنداوفي لأشخاص الذين يحتاجون إلى رعاية من ا القرب الشديد (أقل من متر ونصف) ية تتطلب يتولون أنشطة رعا . )08(طويلة الأجل ، كان موظفو الرعاية من مراكز الرعاية المجتمعية يدعمون توفير الرعاية المنزلية، على سبيل إسبانياوفي لقطاع الرعاية الطويلة الأجل تعيين موظفين المثال من خلال المكالمات الهاتفية. وبالإضافة إلى ذلك، يمكن .)94( ب موظفيهم المعتادين غير مؤهلين في حالات تغي والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -62- 008، سيحصل العاملون في مجال الرعاية السكنية على مكافأة استبقاء مدة ستة أشهر تصل إلى أسترالياوفي لصحية لتشكيل فرق الاستجابة دولار أسترالي بعد خصم الضرائب. وقد استعانت الحكومة بمقدمي الرعاية ا وخف ّفت قواعد تأشيرات الدخول لتمكين السريعة في قطاع الرعاية الطويلة الأجل عند الحاجة في كل ولاية. .)18(الموظفين من العمل لساعات أطول ، زيدت أجور العاملين في مجال الرعاية، وُصر فت منحة لمرة واحدة للموظفين المملكة المتحدةوفي أجزاء من . )28( 91- العاملين أثناء جائحة كوفيد ضمان توافر سلسلة الخدمات الأساسية للأفراد الذين يتلقون رعاية طويلة الأجل، واستمراريتها، ومنها 5-2 التأهيل والرعاية الملطفة.خدمات التعزيز والوقاية والعلاج وإعادة التحدي 1-5-2 مستويات الاتصال الجسدي والعاطفيارتفاع معقدة مع المستمرة و الرعاية للشرط صصة. ما يتطلب الأشخاص الذين يحتاجون إلى رعاية طويلة الأجل هياكل دعم مستمرة ومعقدة ومخ غالبا ً لمهام الشخصية على وجه الخصوص مستويات عالية من الاتصال الجسدي والعاطفي. لوتتطلب الرعاية المَساع دة كبيرًا على هذا الدعم من استمرارية ويستفيد الأشخاص الذين يتلقون هذا النوع من الرعاية والذين يعتمدون اعتمادا ً - 38(. وفي كثير من البلدان، يعاني غالبية المقيمين في مرافق الرعاية الطويلة الأجل من الخرف )1(الرعاية . )58 التباين في تقديم الرعاية الصحية في مرافق الرعاية الطويلة الأجل م من أن بعضها قد يكون متخصصًا في توفير الرعاية مرافق الرعاية الطويلة الأجل متنوعة للغاية، وعلى الرغ الطبية، مثل مستشفيات الرعاية الطويلة الأجل أو بعض مرافق الرعاية، فإن البعض الآخر، مثل المنازل السكنية أو أماكن الإقامة المدعومة، قد لا يكون لديه أي موظفين مدربين في مجال الرعاية الصحية. وقد واجهت مرافق الطويلة الأجل في العديد من البلدان صعوبات في توفير دعم الرعاية الصحية وموارد الخدمات الصحية الرعاية (ومنها في مجالات الرعاية التأهيلية 91- الأساسية، بالإضافة إلى الاستجابة للعبء الجديد الناجم عن كوفيد والملطفة). والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -72- إمكانية وقوع ممارسات فرز تمييزية في دخول المستشفيات وردت تقارير تفيد بأن المقيمين في مرافق الرعاية الطويلة الأجل لم يتمكنوا من الوصول إلى الرعاية الصحية في ، ولم يكن لديهم سوى إمكانية وصول محدودة إلى الرعاية الأولية. وُأبل غ أيضًا عن أن )05، 94(المستشفيات توجيهات الرعاية المتقدمة قد وض عت في بعض الأحيان دون الالتزام بالمعايير المعتادة التي تركز على الأشخاص لصحية والملطفة للمسنين والأشخاص . وقد استجابت البلدان بالتشديد على أهمية الوصول العادل إلى الرعاية ا)68( . )63، 53( 91- الذين يعانون حالات صحية سابقة أثناء جائحة كوفيد 91- الآثار المترتبة في سياق كوفيد واجهت مرافق الرعاية الطويلة الأجل في العديد من البلدان صعوبات في توفير الدعم والموارد ➔ الصحية الأساسية وتقديم خدمات الرعاية المَساع دة للرعاية الصحية من أجل مواصلة الخدمات . 91-في مواجهة التحدي الجديد الذي يفرضه كوفيد مون من الرعاية في في بعض الأحيان كان المقيمون في مرافق الرعاية الطويلة الأجل ُيحر َ ➔ المستشفى استنادًا إلى معايير غير موضوعية أو تمييزية، مثل العمر، على افتراض أنهم عفاء للغاية ولا يمكنهم البقاء على قيد الحياة. ض الإجراءات الرئيسية 2-5- 2 القطاع كاملا ً ، ومنها مرافق الرعاية الطويلة الأجل والرعاية المنزلية 91-النظر في تحديد مسارات رعاية واضحة لكوفيد • وغيرها من الأعراض إلى الرعاية 91-كوفيد والمجتمعية، لتحويل الأشخاص الذين يظهرون أعراض . )98 411 ،88، 78( الأولية والثانوية والتخصصية الصحية عد والتقنيات الافتراضية المناسبة للاستشارات، مع مراعاة آراء المسنين، النظر في تقنيات الصحة عن ب ُ • فعاًلا.وتقديم أي دعم ضروري لاستخدام هذه التكنولوجيا استخدامًا التأكد من تحديث جميع خطط الرعاية الملطفة وتوجيهات الرعاية المتقدمة وتطبيقها من خلال نهج يركز • على الأشخاص. ضمان وجود سياسات وبرامج ومبادئ توجيهية وطنية وإقليمية لدعم توفير الرعاية الملطفة في مرافق • (ومنها الدعم البدني والنفسي والاجتماعي والروحي). الرعاية الطويلة الأجل وخدمات الرعاية الطويلة الأجل والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -82- مرافق الرعاية الطويلة الأجل إشراك المقيمين في مرافق الرعاية الطويلة الأجل في تطوير بروتوكولات الإحالة والحصول النظر في • مثل تأكد من أنه لا يوجد اختيار على أساس العمر أو المرض في العلى الخدمات الصحية الأساسية. و هذه البروتوكولات، وأن احتياجات الأفراد وتفضيلاتهم هي التي تحدد قرارات الرعاية. أولية. صحية تأكد من أن جميع مرافق الرعاية الطويلة الأجل مدعومة بخدمة رعاية • إنشاء فرق للاستجابة السريعة، ويفضل أن يكون ذلك مع تدريب على رعاية المسنين والرعاية الملطفة، • وضمان ،الرعاية الطويلة الأجل للمسنين، للحد من حالات دخول المستشفى التي يمكن تجنبها لمرافق التواصل وصنع القرار الأمثل الذي يركز على الأشخاص. ضمان تدريب الموظفين على توفير الرعاية الملطفة ومعرفة كيفية التواصل بشأن الوفاة والاحتضار • . )53( وقرارات نهاية الحياة من البلدان أمثلة حيث يمكن ،عد في المنزل، جرى التوسع في نطاق استخدام الرعاية الصحية عن ب ُالولايات المتحدةفي ، تمكن المستفيدون من التأمين 0202عد. ومنذ آذار/مارس الآن سداد مقابل متابعة المرضى عن ب ُ للأشخاص الذين يعانون . وبالنسبةالإدمانالصحي من تلقي تدخلات اضطراب السلوك أو تعاطي مواد رحلة ما بعد الرعاية عد في م، يمكن الآن إجراء زيارات الصحة عن ب ُ91- من أعراض وخيمة لكوفيد ن الأخصائيين الاجتماعيين والأخصائيين النفسيين السريريين وأخصائيي العلاج وهو ما مك الحادة. عد. من إجراء التقييمات والعلاج عن ب ُالطبيعي والمعالجين المهنيين وأخصائيي أمراض النطق واللغة . )16(وقد يدعم ذلك أيضًا الأفراد ذوي احتياجات الرعاية الطويلة الأجل الذين يعيشون في المجتمع أجل الاستجابة ، تمكنت فرق خاصة للرعاية الملطفة من إعادة تنظيم نفسها بسرعة منإيطالياوفي خدمات رعاية المحتضرين من خلال نقل الموظفين ل الفرق شبكات ت أنشألطلب. فمثًلا، لالسريعة والمرنة سلطت التجارب الضوء على أهمية ذلككمن رعاية المرضى الداخليين إلى خدمات الرعاية المنزلية. كون قادرة على اتخاذ قرار سريع بشأن ق المماثلة لتات عن الحالات والتعاون بين الفر الحاجة إلى مؤتمر تحديد أولويات الموارد (مثًلا، من خلال تحديد من سيحصل على الدعم بعد الخروج من المستشفى) . )09، 05( والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -92- قف حول الرعاية الملطفة أثناء جائحة ا، أصدرت الجمعية الوطنية للرعاية الملطفة ورقة مو النمساوفي تاحة الرعاية الملطفة للأشخاص الذين لن يتلقوا الرعاية المركزة ضمان إل، وقدمت إرشادات 91-كوفيد م عادًة. ونشرت الجمعية أيضًا مبادئ توجيهية لمقدمي الرعاية من الأسرة والعاملين في مجال التي تقد الرعاية الطويلة الأجل. وعلاوة على ذلك، تتوفر إرشادات متعددة التخصصات تقدمها الحكومة لدعم الذين يصلون إلى نهاية العمر. وهناك أيضًا إرشادات وموارد سريرية 91-مصابين بكوفيد الأشخاص ال حول كيفية تسهيل الدعم الاجتماعي وحول فقدان الأحبة لمقدمي الرعاية من الأسرة والعاملين في مجال . 91-الرعاية الذين يدعمون شخصًا يصل إلى نهاية الحياة أثناء جائحة كوفيد تقف الفرق الطبية على أهبة الاستعداد لإرسالها إلى مرافق الرعاية الطويلة الأجل السكنية ،سلوفينياوفي . )19(لدعم الموظفين العاديين إذا أصيبوا بالإرهاق أو غمرتهم ضغوط العمل الطويلة التأكد من تنفيذ معايير الوقاية من العدوى ومكافحتها والالتزام بها في جميع أماكن الرعاية 6- 2 والتدبير العلاجي الآمن لها. 91-الأجل للوقاية من حالات كوفيد التحدي 1-6- 2 نقص التنفيذ الإلزامي لإرشادات الوقاية من العدوى ومكافحتها في الرعاية الطويلة الأجل من وضعت إرشادات حول الوقاية من العدوى ومكافحتها لمقدمي الرعاية الطويلة الأجل في وقت متأخر نسبيا ً نات على الانتقال العديم في إدراج البي ّ من المبادئ التوجيهية ا ًالجائحة في العديد من البلدان، وشاب البطء كثير . وفي العديد من البلدان، لم توضع الإرشادات سوى لمرافق الرعاية 91-الأعراض والأعراض غير النمطية لكوفيد ، هناك ي الرعاية المجتمعية ومقدمي الرعاية من الأسرة. وأخيرا ًالطويلة الأجل، مع عدم إتاحة الإرشادات لمقدم ورصد تنفيذها. الإرشادات نقص في الآليات التي تضمن تنفيذ هذه عدم وجود خبرة في الوقاية من العدوى ومكافحتها والتدريب عليها في الرعاية الطويلة الأجل وصعوبات التنفيذ المترتبة على ذلك ا يؤدي وهو مة الطويلة الأجل من ضعف نظم الوقاية من العدوى ومكافحتها والتدريب عليها، يعاني مقدمو الرعاي إلى عدم معرفة العديد من الموظفين بالوقاية من العدوى ومكافحتها والاستخدام الصحيح لمعدات الحماية الشخصية. كبير الموظفين المؤقتين أو التابعين ويمثل ذلك تحديًا خاصًا لمرافق الرعاية الطويلة الأجل التي تستخدم بشكل لوكالة توظيف. وحتى في الحالات التي يتوفر فيها التوجيه والتدريب، قد يتعذر تنفيذ بعض التدابير بسبب الحاجة والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -03- إلى توفير الرعاية المساع دة الشخصية عن قرب. وقد ُأبل غ عن عدم توافر الاختبارات ومعدات الحماية الشخصية، ، وصعوبات في تنفيذ التباعد الجسدي (بسبب تصميم مرافق الرعاية الطويلة الأجل التقليدية)، ونقص الموظفين ونقص مرافق العزل البديلة، في البلدان التي واجهت صعوبات في احتواء العدوى في مرافق الرعاية الطويلة الأجل. تظهر عليهم أعراض مرتبطة بعدوى وحددت المبادئ التوجيهية، في جميع البلدان، أهمية عزل المقيمين الذين أو تأكدت إصابتهم بها. وفي حين 91- شتبه في إصابتهم بعدوى كوفيد ، وكذلك المخالطين لأشخاص ي ُ91-كوفيد أن المقيمين في مرافق الرعاية الطويلة الأجل في بعض البلدان يعيشون في غرف مفردة مع حماماتها الخاصة، لأجل ها مرافق الرعاية الطويلة افيفهذا ليس هو الحال في بلدان أخرى. وقد يشكل الهيكل المحدد للمباني التي ر صحي فعالة. ولذلك، يحتاج مديرو مرافق الرعاية الطويلة الأجل إلى الدعم ج أيضًا عائقًا أمام إنشاء مناطق ح َ في تقييم قدرة المرافق على تطبيق سياسات العزل الفعالة وتوفير مساحات إضافية للحجر الصحي إذا لم يكن مكان الرعاية مناسبًا لاستراتيجيات العزل الفعالة. كانت البلدان التي عانت من متلازمة الجهاز التنفسي الحادة الوخيمة ومتلازمة الشرق الأوسط التنفسية قد عززت و مؤخرًا أنظمة الوقاية من العدوى ومكافحتها الخاصة بها في مرافق الرعاية الطويلة الأجل وأماكن الرعاية المجتمعية، أو تأكدت إصابتهم بها إلى مرافق العزل، 91-هم بعدوى كوفيد إصابتفي شتبه واتجهت إلى نقل الأشخاص الذين ي ُ . ومع ذلك، لا تتوفر حتى الآن بي ّنات على تأثير هذه التدابير )36(ويبدو أنها نجحت في السيطرة على الفاشيات على الصحة النفسية والبدنية للمقيمين. وبالتالي غير الخاضعة ،الأجل غير المسجلة وفي بعض البلدان، توجد أعداد كبيرة من مرافق الرعاية الطويلة . )35(ها فيللتنظيم. ومن الضروري دعم هذه المرافق لضمان قدرتها على الحفاظ على سلامة المقيمين وبالمثل، تخضع خدمات الرعاية المجتمعية في كثير من الأحيان لرقابة تنظيمية مباشرة أقل من مرافق الرعاية وهناك عدد أقل من نظم المعلومات والرصد المتطورة التي من شأنها أن تمكن من جمع الطويلة الأجل السكنية، كيفية تأثير الجائحة، بشكل مباشر أو غير مباشر، على الأفراد الذين يعتمدون عنالمعلومات في الوقت المناسب ن إلى الرعاية في منازلهم. على الرعاية المجتمعية. ويزور مقدمو الرعاية المنزلية عادًة الأشخاص الذين يحتاجو وهو ما يعني أن العاملين في مجال الرعاية يحتاجون إلى التنقل بين المنازل وغالبًا ما يزورون عدة أشخاص ف الأسر عن استخدام دعم الرعاية المنزلية للحد من خطر نات ما يشير إلى توق بحاجة إلى رعاية. وهناك من البي ّ . )18، 77(حتاجون إلى الرعاية؛ ومع ذلك، فقد يخلق هذا مخاطر أخرى العدوى على الأشخاص الذين ي والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -13- 91- الآثار المترتبة في سياق كوفيد عدم وجود آليات لضمان تنفيذ المبادئ التوجيهية للوقاية من العدوى ومكافحتها، ورصد التنفيذ ➔ وتقييمه نقص تدريب القوى العاملة في الرعاية الطويلة الأجل على تدابير الوقاية من العدوى ومكافحتها ➔ ية من العدوى إعاقة ارتفاع معدل دوران الموظفين لاستمرارية الرعاية واتساق تدابير الوقا ➔ ومكافحتها خدمات الرعاية الطويلة الأجل في صعوبة تحقيق التباعد الجسدي ➔ إلى المعلومات المتعلقة بالحد من انتقال يكافالعدم قدرة العاملين في الرعاية على الوصول ➔ 91-العدوى في سياق كوفيد الإجراءات الرئيسية 2-6- 2 القطاع كاملا ً الوقاية من العدوى ومكافحتها حول للرعاية الطويلة الأجلوبروتوكولات إنشاء هيئة تنسيق لإعداد إرشادات • وتحديثها، ، بناًء على أفضل البي ّنات الإرشادات والبروتوكولات تلك ، وتعديل91-أثناء جائحة كوفيد . )39، 29، 88، 78(المتاحة طويلة الأجل (لجميع الضمان تنفيذ إرشادات الوقاية من العدوى ومكافحتها في جميع خدمات الرعاية • الأماكن). إنشاء آلية للتخطيط، وتحديد أولويات الدعم، ورصد تنفيذ التدابير لحماية الموظفين والأشخاص الذين • . 91- يتلقون رعاية طويلة الأجل من العدوى أو انتشار كوفيد في الرعاية الطويلة الأجل. 91- إرساء التعرف المبكر، وحدود الترصد، واستراتيجيات التفاقم لفاشيات كوفيد • النظر في كيفية التأكد من إمكانية دعم مقدمي الرعاية الطويلة الأجل الذين قد يعملون خارج النظام • مة الأشخاص الذين يعيشون الخدمات غير الخاضعين للتنظيم أو غير القانونيين) لضمان سلا يمقدم( في مرافقهم أو يستفيدون من خدماتهم. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -23- الرعاية من الأسرة)، ي ن ومقدمي الموظفن يشارك مشاركة مباشرة في تقديم الرعاية (التأكد من أن كل م َ • في مرافق الرعاية الطويلة الأجل أو في خدمات الرعاية المنزلية، لديهم إمكانية الوصول إلى التدريب على ية من العدوى ومكافحتها (بما في ذلك استخدام معدات الحماية الشخصية، ونظافة اليدين، وتنظيف الوقا النظر عن دورهم، وخاصة ذلك بغّض حدث يوإدارة النفايات). ويجب أن ، البيئات المحيطة وتطهيرها .)39( المخالطين مخالطة مباشرة للمسنين الذين يعانون من حالات صحية كامنة كيفية ووقت العزل السريع للأشخاص بشأنالنظر في إعداد وتعميم إجراءات تشغيل قياسية تقد ّ م توجيهات • . 91-الذين يتلقون خدمات الرعاية الطويلة الأجل، وذلك باستخدام أحدث الإرشادات بشأن كوفيد المستشفى، استنادًا تنفيذ احتياطات موس عة للوقاية من العدوى ومكافحتها للأشخاص الذين خرجوا من • بروتوكول متفق عليه لإجراء الاختبارات لتحديد مدى احتياج الأفراد إلى العزل ومعدات لى إبشكل مثالي الحماية الشخصية المطلوبة. ترجمة أي استراتيجيات لإجراءات التشغيل القياسية إلى نظم إحالة واضحة تَُتاح لجميع الموظفين الذين • يلة الأجل.يقدمون خدمات رعاية طو مرافق الرعاية الطويلة الأجل ضمان تنفيذ توجيهات الوقاية من العدوى ومكافحتها في مرافق الرعاية الطويلة الأجل مع الرجوع إلى • إرشادات منظمة الصحة العالمية بشأن الوقاية من العدوى ومكافحتها لمرافق الرعاية الطويلة الأجل في .)29( 91- سياق كوفيد الضوابط الإدارية، بما في ذلك ترصد المتلازمات لجميع الموظفين والزوار عند دخول المرفق. تطبيق • التأكد من أن الموظفين في مرافق الرعاية الطويلة الأجل لديهم ظروف وترتيبات عمل تقلل من تنقلهم • اء مرضهم تمكنهم بين الأماكن والأفراد الذين يتلقون خدمات رعاية طويلة الأجل، وأن أجور الأفراد أثن من البقاء في المنزل إذا لم يكونوا على ما يرام. التأكد من أن مرافق الرعاية الطويلة الأجل لديها إمكانية الوصول إلى الموارد اللازمة لتنفيذ تدابير الوقاية • من العدوى ومكافحتها (مثل معدات الحماية الشخصية، ومعقمات اليدين والمطهرات). اللازمة، والتأكد من إتاحتها للزوار وعرضها ت وإرشادات الوقاية من العدوى ومكافحتهاإعداد بروتوكولا • . )49(بوضوح في صيغ سهلة الفهم والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -33- إعداد الإرشادات وضمان تنفيذ الموظفين لبروتوكول الوقاية من العدوى ومكافحتها وضمان توفير الموارد • التعليمية إلى جانب التدريب المستمر. معني بالوقاية من العدوى ومكافحتها لقيادة مسؤول تنسيق ن مرافق الرعاية الطويلة الأجل لديها التأكد من أ • وتنسيق أنشطة الوقاية من العدوى ومكافحتها، يدعمه بشكل مثالي فريق للوقاية من العدوى ومكافحتها ذو متعددة التخصصات. لجنة ي إليه المشورة َسد وت ُ ،مسؤوليات مفوضة إليه الرعاية المجتمعية ومقدمو الرعاية زيادة التدريب ودعم اتخاذ القرار للقوى العاملة في الرعاية الطويلة الأجل في المجتمع من أجل التدبير • ، بما في ذلك مقدمو الرعاية من الأسرة، مع مراعاة القيود، وخاصة القيود 91-العلاجي الفعال لكوفيد . )88، 78(الاجتماعي، التي قد يواجهها مقدمو الرعاية من الأسرة المتعلقة بالنوع والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -43- أمثلة من البلدان نشئ برنامج توظيف مؤقت للتنظيف المنتظم لمرافق الرعاية الطويلة الأجل في القطاع العام، ، أ ُجامايكافي لت ممارسة متعددة ه صت أماكن في تلك المرافق لعزل المقيمين الذين يعانون من الأعراض. كما س َوُخص ّ القطاعات بين العديد من المؤسسات المملوكة للدولة والخاصة عملية التعقيم العميق لمرافق الرعاية العامة .)97(الطويلة الأجل ، تشمل تدابير الوقاية في مرافق الرعاية الطويلة الأجل تبادل المعرفة حول مبادئ النظافة إندونيسياوفي الصحية مع العاملين في الرعاية والمقيمين، والتطهير المنتظم والتهوية، والامتناع عن مشاركة المعدات مح للزوار الذين يعانون الطبية الشخصية. ووضعت مرافق الرعاية السكنية الطويلة الأجل نظام تسجيل ولا تس . )59(بدخول المبنى 91-من أعراض كوفيد ، بعد وباء المتلازمة التنفسية الحادة الوخيمة، نشرت السلطات الإقليمية المبادئ الصينوفي إحدى مناطق التوجيهية الأولى للوقاية من الأمراض السارية في مرافق الرعاية الطويلة الأجل السكنية للمسنين في عام ، وطلبت من جميع مشغلي مرافق الرعاية الطويلة الأجل تعيين مسؤول مكافحة عدوى لتنسيق تدابير 4002 . )56( للمبادئ التوجيهية. مكافحة العدوى وتنفيذها داخل المرفق، وفقا ً أن و ،، يوصي معهد روبرت كوخ بأن يرتدي عمال الرعاية المنزلية أقنعة الوجه عند تقديم الرعايةألمانياوفي مرتبطة ا ًيراقبوا صحتهم بانتظام. ويجب توفير معدات إضافية إذا أظهر الشخص الذي يعتنون به أعراض . )69( 91- بكوفيد ، يجري تنظيم صفوف بعض العاملين في الرعاية المنزلية في "فرق كورونا" خاصة. وتعتني هذه هولنداوفي . )08(، بينما تهتم فرق أخرى بالأفراد الذين ليس لديهم عدوى 91-الفرق بالأفراد المصابين بكوفيد والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -53- الذين يتلقون خدمات بين الأفراد 91-إعطاء الأولوية للاختبارات وتتبع المخالطين ورصد انتشار كوفيد 7- 2 الرعاية الطويلة الأجل والذين يقدمونها. التحدي 1-7- 2 عطيت الأولوية لخدمات المستشفيات العديد من البلدان من نقص في القدرة على الاختبار حيث أ ُ ىعان ظهر، في العديد من البلدان، نقص في القدرة على إجراء الاختبارات، مع استنفاد القدرة المتاحة في البداية غالبًا في المستشفيات، وهو ما ترك مقدمي الخدمات السكنية والمجتمعية الطويلة الأجل يعانون من صعوبات في مشكلة كبيرة، بالنظر ة نزلبميد أن هذا النهج كان . ومن المفهوم بشكل متزا91-اكتشاف الأفراد المصابين بكوفيد الذين 91-يمي الأعراض المصابين بكوفيد عد الإلى المعدلات المرتفعة للأفراد في مرحلة ما قبل الأعراض أو العدوى. بإمكانهم نشر مقدمي الرعاية الطويلة ع المخالطين الفعال في أماكن الرعاية الطويلة الأجل يتطلب التنسيق والتعاون بين تتب الأجل والسلطات الصحية المعنية في الرعاية الطويلة الأجل التنسيق والتعاون بين مقدمي الرعاية 91-يتطلب الاختبار والتتبع والرصد الفعال لكوفيد بسبب التحديات في تصريف الشؤون، كان هذا التنسيق فالطويلة الأجل والسلطات الصحية المعنية. ومع ذلك، ع المخالطين في الإرشادات عبًا في المراحل الأولى من الاستجابة. ويقوم عدد متزايد من البلدان الآن بتضمين تتب ص تطبيقات ونظم أخرى لدعم تتبع المخالطين. فضًلا عن تطويرهة لقطاع الرعاية الطويلة الأجل، الموج عاية والذين يقدمونها عدم وجود رصد منهجي للوضع الصحي للأشخاص الذين يتلقون الر ، ومنها تطور الأعراض غير النمطية فراد لموظفين اكتشاف التغييرات في الحالة الصحية للأ ل الرصد المنتظم يتيح . 91- ، والاستجابة بشكل أسرع إذا ظهرت على الشخص الذي يحتاج الرعاية أو أحد الموظفين أعراض كوفيد ) 31( 91- كوفيدالآثار المترتبة في سياق أصبحت مرافق الرعاية الطويلة الأجل منطقة غير مرئية بالنسبة للاختبارات ذات الأولوية وتتبع ➔ 91-المخالطين ورصد كوفيد التعرف المبكر 91-جعلت المعدلات المرتفعة للأفراد العديمي الأعراض المصابين بكوفيد ➔ والخطوات المناسبة اللاحقة أمورًا صعبة والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -63- الإجراءات الرئيسية 2-7- 2 القطاع كاملا ً للتمكين من التأكد من تجميع بيانات الاختبار ومشاركتها مع وكالات الصحة العمومية المحلية والوطنية • إدارة الجائحة على مستوى السكان والأفراد. إرشادات منظمة الصحة ضمان تتبع المخالطين والعزل استنادًا إلى الإرشادات الوطنية، مع الرجوع إلى • . )79، 63( 91- ع المخالطين في سياق كوفيد العالمية بشأن تتب تتبع أي مجموعات من إصابات أو وفيات بين الأفراد في مرافق الرعاية الطويلة الأجل أو بين أولئك • الذين يتلقون خدمات الرعاية المنزلية. - ى "النمطية"، عند تحري عدوى كوفيد م عال والح ُعدم الاعتماد على الأعراض وحدها، لا سيما أعراض الس • . )63(، والتأكد من تدريب الموظفين على تحديد الأعراض غير النمطية الأخرى، خاصة عند المسنين 91 التأكد من رصد صحة الأشخاص الذين يتلقون رعاية طويلة الأجل والذين يقدمونها حتى يمكن اكتشاف • الأعراض غير النمطية). تطور الأعراض سريعًا (بما في ذلك مرافق الرعاية الطويلة الأجل عد الاختبار الدقيق لكل من المقيمين (بما في المناطق التي تشهد انتقاًلا مجتمعيًا حاليًا أو مشتبهًا فيه، ي ُ • في ذلك حالات الدخول الجديدة) والموظفين وتتبع المخالطين أمرًا ضروريًا لتطوير سياسات العزل. جتمعية الرعاية الم التأكد من أن الأشخاص الذين يقدمون الرعاية والذين يتلقونها في المجتمع وكذلك أفراد أسرهم لديهم إمكانية • . )88، 78(الوصول إلى الاختبار وتتبع المخالطين، وأن يحصلوا على الدعم إذا كانوا بحاجة إلى العزل إشراك أفراد أسر الأشخاص ذوي احتياجات الرعاية في رصد الأعراض. • والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -73- أمثلة من البلدان والموظفين في مرافق الرعاية الطويلة للمقيمين ذوي الأعراض والعديمي الأعراض، يمكن الدانمركفي ). وحتى قبل هذا 0202أيار/مايو 21الأجل الوصول إلى الاختبارات في المستشفيات الإقليمية (منذ في أحد مرافق الرعاية الطويلة تفشي المرض التاريخ، خضع المقيمون والموظفون للاختبار في حالة مقيمين، يخضع جميع المقيمين والموظفين للاختبار في أحد ال أعراض علىالأجل السكنية. وإذا ظهرت عادة الاختبار بعد سبعة أيام. وإذا كانت نتيجة اختبار أحد الموظفين إيجابية، لإساعة و 42غضون . )89(للاختبار نفسها فسوف يخضع جميع المقيمين في المنطقة (منذ 91-، يمكن اختبار جميع مقدمي الرعاية من الأسرة الذين يعانون من أعراض كوفيد هولنداوفي ). وبالإضافة إلى ذلك، تمكن مقدمو الرعاية من الأسرة من الحصول على معدات 0202أيار/مايو 81 إذا كانوا قائمين على رعاية أشخاص ضعفاء 0202أيار/مايو 91الحماية الشخصية المجانية منذ ، وحيث تتطلب 91- عامًا وأكثر ولديهم حالات مزمنة) يعانون من أعراض كوفيد 07راوح أعمارهم بين (تت . )08(حالتهم الرعاية الُمساع دة الشخصية (مع مسافة أقل من متر ونصف) 91-، خضعت جميع مرافق الرعاية الطويلة الأجل المسجلة وغير المسجلة لاختبار كوفيد ماليزياوفي . )99( باستراتيجيات ، توصي إرشادات المركز الأوروبي للوقاية من الأمراض ومكافحتهالاتحاد الأوروبياوفي الاختبار التي تميز بين "المناطق المحلية المتأثرة" (الاختبار العشوائي للسكان والموظفين) و"المناطق .)37(المناطق المتأثرة هي التي تشهد انتقاًلا مجتمعيًا مستمرًا فعليًا أو مفترضًا و غير المتأثرة". تقديم الدعم لمقدمي الرعاية من الأسرة والمتطوعين 8- 2 التحدي 1-8- 2 من الرعاية، غير أن الدعم مثل الرعاية المؤقتة أو برامج التدريب أو ا ًمهم ا ًيقدم مقدمو الرعاية من الأسرة جزء إجازات الرعاية تظل محدودة وبدون تعويض بل مقدمي الرعاية من الأسرة الذين يقدمون جزء مهم من الرعاية الطويلة الأجل في مختلف البلدان من ق يقد م لرسمية واستكمالها. وفي البلدان التي لا توجد فيها خدمات الرعاية مباشرة، ويساعدون أيضًا على تنسيق الخدمات ا والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -83- رعاية رسمية طويلة الأجل، يتولى مقدمو الرعاية من الأسرة تقديم كل الرعاية الطويلة الأجل تقريبًا. وعادة لا يحصل مقدمو الرعاية على أي تدريب على الدور الذي يؤدونه. مدفوعة الأجر، وترتيبات العمل المرنة، الم الدعم مثل إجازة الرعاية د ّ تدرك بعض البلدان تأثير تقديم الرعاية وتقو . ومع )92(والرعاية المؤقتة، والتدريب والتدخلات النفسية، فضًلا عن المزايا النقدية للتخفيف من الآثار السلبية م مقدمو الرعاية عادًة الدعم دون ذلك، لا يزال الوصول إلى هياكل الدعم هذه محدودًا في معظم البلدان ويقد ّ . وعلى الرغم من الاعتراف المتزايد بالمساهمة المهمة من مقدمي الرعاية، فقد )1(دريب أو دعم تعويض أو ت .)001( 91- كانت هياكل الدعم المتاحة والدعم المالي محدودة بالفعل قبل جائحة كوفيد عن تدني ارتبط تقديم مستويات مرتفعة من الرعاية بشكل عام بانخفاض الدخل وارتفاع معدلات الفقر، فضًلا الصحة النفسية ٪)، على الرغم من أن حصة مقدمي الرعاية الذكور تزداد 16تولت النساء تقديم الجزء الأكبر من هذه الرعاية ( هم الأطفال) ومقدمي الرعاية الأكبر سنًا الذين يدعمون منو هناك أيضًا العديد من الشباب (و . )47(مع تقدم العمر عام بانخفاض لى رعاية طويلة الأجل. وارتبط تقديم مستويات مرتفعة من الرعاية بشكل أفراد الأسرة الذين يحتاجون إ . )101((لمن هم في سن العمل)، وانخفاض الدخل والارتفاع الشديد في معدلات الفقر القوى العاملة برتباط الا وبالإضافة إلى ذلك، فإن انخفاض الدخل ونقص المساهمات في المعاشات التقاعدية يزيدان من خطر الضعف . )101(والفقر في الشيخوخة. ويعاني مقدمو الرعاية أيضًا من معدلات أعلى لانتشار مشاكل الصحة النفسية هم أو التخلي عنها لتقديم الرعاية أو أن بعض مقدمي الرعاية اضطروا إلى تعديل وظائف 91-وتعني جائحة كوفيد . وقد يعاني مقدمو الرعاية الذين يعملون في 91- لتجنب تعريض الشخص الذي يدعمونه لخطر الإصابة بكوفيد الاقتصاد غير الرسمي أيضًا من انخفاض فرص العمل بسبب القيود المفروضة عليهم، وهو ما يشكل خطرًا على . )201( يضًا إلى دعم من حيث التأثير المالي الذي ترتب على الجائحة دخلهم. ويحتاج مقدمو الرعاية أ مسؤولياتيأخذون على عاتقهم من مقدمي الرعاية من الأسرة العديد في جعلتسبب إيقاف خيارات الرعاية السكنية إلى هياكل الدعم المعتادة يفتقرون و إضافية عن إغلاق العديد من خيارات الرعاية النهارية والمؤقتة، ومنها الرعاية المجتمعية 91- لقد أسفرت جائحة كوفيد أو الرعاية القصيرة الأجل، وهو ما وضع على كاهل العديد من مقدمي الرعاية مسؤوليات إضافية، فضًلا عن التي يواجهها مقدمو الرعاية خلال هذه الجائحة افتقارهم إلى هياكل الدعم المعتادة. ومن المهم فهم المشكلات . )201(وكيف يمكن دعمهم على أفضل وجه والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -93- يجب أن يكون مقدمو الرعاية قادرين على الوصول إلى الشخص الذي يحتاج إلى الرعاية، والوصول إلى الطوارئ يتلقوا الدعم في وضع خطط أن المعلومات، ومعدات الحماية الشخصية والاختبارات، و لهذه الحاجة من خلال توفير إرشادات في العديد من البلدان، ، استجابت الحكومة والمنظمات غير الحكومية ووثائق مرجعية حول تدابير النظافة للوقاية من العدوى وكيفية الاستجابة إذا ظهرت الأعراض على الشخص الذي حاجة مقدمي الرعاية إلى الجائحةيتلقى الرعاية أو مقدمي الرعاية أنفسهم. وتشمل المشكلات التي ظهرت أثناء ، ودعم مقدمي الرعاية بإمكانية الوصول )97، 87(نقل بسبب مسؤوليتهم عن الرعاية الحصول على تصريح بالت ، ووضع خطط للطوارئ في حالة عدم قدرتهم على الاستمرار )08( إلى الاختبارات ومعدات الحماية الشخصية . )77( في تقديم الرعاية الرعاية التغييرات في احتياجات الرعاية والعنف أو إساءة المعاملة تجاه مقدم يتأقلم العديد من مقدمي الرعاية مع التغييرات التي تطرأ على احتياجات الشخص الذي يعتنون به (التي قد تكون بسبب العدوى أو تأثير الإجراءات التقييدية). وقد يسبب اضطراب الروتين الطبيعي القلق والإجهاد لدى الأشخاص إلى 91- . وقد جلبت جائحة كوفيد )92(ضغط على مقدمي الرعاية الذين يحتاجون إلى رعاية، وهو ما يزيد من ال . وقد يتعرض مقدمو الرعاية الأسرية أيضًا للعنف وإساءة )83(السطح مشاكل العنف المنزلي وإساءة المعاملة . )301(المعاملة في علاقة الرعاية ويحتاجون إلى الدعم والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -04- 91-الآثار المترتبة في سياق كوفيد مقدمي الرعاية مسؤوليات إضافية دون وجود هياكل الدعم المعتادة (مثل خيارات يتحمل العديد من ➔ الرعاية النهارية والمؤقتة) تدابير التباعد الاجتماعي والجسدي في مختلف البلدان لها آثار صحية سلبية على مقدمي الرعاية ➔ الدعم المالي المتاح لا يزال محدودا ًعلى الرغم من الاعتراف المتزايد بمساهمة مقدمي الرعاية المهمة، فإن ➔ يواجه مقدمو الرعاية صعوبات في الحصول على المستلزمات الضرورية، حيث لا يمكنهم بسهولة ترك ➔ الشخص الذي يعتنون به بمفرده كان الوصول إلى معدات الحماية الشخصية والاختبارات غائبًا إلى حد كبير عن مقدمي الرعاية من ➔ الأسرة والمتطوعين العزلة المطولة، ومسؤولية الرعاية من دون فترات راحة، والمخاوف بشأن الشخص الذي يحتاج إلى ➔ الرعاية، والمخاوف بشأن الرعاية الطارئة في حال أصبح مقدم الرعاية عاجزًا، وكذلك العنف أو إساءة اية المعاملة تجاه مقدم الرعاية، كل ذلك يترك أثرًا على الصحة النفسية لمقدمي الرع الإجراءات الرئيسية 2-8- 2 القطاع كاملا ً ا ًمصدر بوصفه تسجيل مقدم الرعاية الرئيسي في سجلات الرعاية الصحية والطويلة الأجل حتى ُيعتَرف به • للمعلومات والدعم. ا ًمهم مرافق الرعاية الطويلة الأجل النفسي والعملي للأشخاص الذين يعيشون في مرافق تمكين مقدمي الرعاية من الأسرة الذين يقدمون الدعم • الرعاية الطويلة الأجل من مواصلة هذه الأدوار من خلال تدابير داعمة تضمن سلامة مقدمي الرعاية. مقدمو الرعاية ، الرعاية المؤقتة على المستوى الوطني لمقدمي الرعاية، لا نتوفير المعلومات والتدريب والدعم، وإن أمك • كيفية إدارة عنسيما أولئك الذين يرعون كبار السن الذين يعانون من الخرف، بما في ذلك معلومات والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -14- مسؤوليات تقديم الرعاية المتزايدة والإجهاد. والنظر في إنشاء خط مساعدة هاتفي أو بوابة إلكترونية لتقديم . )401(المعلومات والدعم المشورة و الرعاية من الأسرة. يالنظر في إجراء تقييم لرصد احتياجات مقدم • وقت العزل الذاتي وكيفيته. لوضع إرشادات واضحة لمقدمي الرعاية من الأسرة • زيادة اليقظة ورصد العنف المنزلي ودعم مقدمي الرعاية من الأسرة. • دون تحمل مقدمي الرعاية للتكاليف المتضخمة) والمعدات ضمان الوصول إلى معدات الحماية الشخصية ( • والأدوية. تقصي طرق جديدة لتقديم خدمات الدعم ليستفيد منها مقدمو الرعاية من خلال التكنولوجيا، ودعم مقدمي • الرعاية في الوصول إلى التكنولوجيات ذات الصلة. ي الرعاية من الأسرة. تقديم أو توسيع نطاق الدعم المالي والنفسي الاجتماعي لمقدم • تقديم الدعم في حالات فقدان الأحبة والتأكد من التواصل الدقيق بشأن اتخاذ القرار مع الأسرة. • أمثلة من البلدان المنظمات غير الحكومية (مثل الجمعية البرازيلية لطب الشيخوخة وعلم الشيخوخة ت نشر ، البرازيلفي ت مؤسسة فيوكروز وثائق إرشادية تقنية وتعليمية لمقدمي الرعاية. وأعد والجمعية البرازيلية للزهايمر) - ومنظمات أخرى كتيبًا لتثقيف مقدمي الرعاية للمسنين بشأن تدابير الوقاية والحماية من عدوى كوفيد . وهناك أيضًا موقع إلكتروني لوزارة شؤون المرأة والأسرة وحقوق الإنسان مخصص لتوفير المعلومات 91 الحالات النادرة والإعاقات والقائمين على رعايتهم. وقد أثمر التعاون بين وزارة الصحة ومنظمة لذوي الصحة للبلدان الأمريكية عن إعداد حملة عبر الفيديو لدعم الصحة النفسية للأفراد في البرازيل الذين جمعية الزهايمر، يعانون من مشاعر العزلة والوحدة والضيق. وتقدم المنظمات غير الحكومية، مثل . )501( خطوط مساعدة ومنتديات عبر الإنترنت. ونظمت مجموعات أخرى أنشطة نفسية واجتماعية آذار/مارس 72ن الهندية في ، أقرت إرشادات صادرة عن وزارة العدالة الاجتماعية والتمكي الهندوفي أهمية قدرة مقدمي الرعاية على الوصول إلى الأشخاص الذين يدعمونهم. وأوصت الإرشادات 0202 م المنظمات غير تقد ّ ذلككبإصدار تصاريح لمقدمي الرعاية تمكنهم من التنقل خلال فترة تقييد الحركة. يكال تراست، الحكومية (مثل جمعية الزهايمر والاضطرابات ذات الصلة في الهند، ومؤسسة نايتينغيل ميد والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -24- ومؤسسة سيلفر إينينغز) والخدمات المتخصصة (المعهد الوطني للصحة النفسية والعلوم العصبية، وعيادة الاضطرابات الإدراكية) معلومات وموارد لمقدمي الرعاية للأفراد الذين يعانون من الخرف. وتوفر مؤسسة يقدم مشورة الخبراء لمقدمي الرعاية. ، الذيtcennoKmeDنايتينغيل ميديكال تراست تطبيق ديمكونيكت ر وزارة الصحة ورعاية الأسرة خط مساعدة نفسية وسلوكية. وقد مت، بالإضافة إلى ذلك، مقاطع وتوف ّ فيديو (ومنها عن التأمل واليوغا) للتدبير العلاجي للإجهاد ونصائح الصحة النفسية لمختلف الفئات .)87(العمرية على موقعها على الإنترنت ، قد م مركز معلومات خدمات الخرف وتطويرها موارد لمقدمي الرعاية، ومنها الأنشطة المقترحة أيرلندا وفي للأشخاص المصابين بالخرف للتخفيف من تأثير العزلة الاجتماعية. وتقدم جمعية الزهايمر في أيرلندا لذين يتلقون بدل الرعاية القائم أيضًا موارد ذات صلة للدعم والمعلومات. ويستمر حصول مقدمو الرعاية ا . وبالإضافة إلى ذلك، يمكن لمقدمي 91-إمكانياتهم المادية على المدفوعات أثناء جائحة كوفيد تقييم بعد الحصول على بدل البطالة ،وظائفهم بسبب الجائحة فقد بعد الذين يتلقون بدل الرعاية ،الرعاية العاملين يورو. وبالمثل، فقد طورت مؤسسة فاميلي كيررز أيرلندا إرشادات 053الجديدة الخاصة بالجائحة البالغ . )77(لوضع خطة طوارئ لمقدمي الرعاية فترة تلقي بدل الرعاية الطويلة الأجل للاستجابة لحالة رعاية طارئة في جرى مضاعفة ، ألمانياوفي 03(حتى يوما ً 02إلى 01من 91-لتنظيم ترتيبات الرعاية استجابًة لجائحة كوفيد الأسرة أو جرى تمديد الحق في التغيب عن العمل للاستجابة لحالة رعاية حادة إلى أيضًا ). 0202أيلول/سبتمبر - يد يومًا. ويمكن تعويض الأشخاص الذين يتلقون عادًة خدمات عينية لم تعد متوفرة أثناء جائحة كوف 02 . )69((مثل الرعاية النهارية) لتمويل الرعاية البديلة 91 الذين يتلقون خدمات الرعاية الطويلة الأجل للأشخاص الاجتماعية للسلامة النفسيةإعطاء الأولوية 9- 2 والذين يقدمونها. التحدي 1-9- 2 حياتهم وفترات طويلة من العزلة.يعاني العديد من الأشخاص الذين يحتاجون إلى رعاية من تغير نمط ، ممن يحتاجون إلى رعاية طويلة الأجل إلى العزل في المنازل أو لعديد من الأفراد، وخاصة المسنينخضع ا ويعاني بعض الأفراد ره.ل نمط الحياة وتغي المرافق عدة أسابيع، مما أدى إلى تقليل الاتصال الاجتماعي وتعط والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -34- ويلة الأجل، مثل الأشخاص المصابين بالخرف، من تغيرات في حالتهم البدنية الذين يحتاجون إلى رعاية ط سلفا ًموجودة لحالات صحيةوالإدراكية. وقد تؤدي التغييرات السريعة في نمط حياتهم أيضًا إلى زيادة تعرضهم .)401، 48( وعلى وجه التحديد، واجه المقيمون صعوبات، في مرافق الرعاية الطويلة الأجل، لعدم قدرتهم على التواصل مع رفاقهم من المقيمين أو استقبال زيارات من أسرهم وأصدقائهم. وتشعر الأسر أيضًا بالضيق الشديد لعدم قدرتها على زيارة مرافق الرعاية ومتابعة المقيمين. فق الرعاية الطويلة الأجل أهمية دعم المقيمين من خلال الاتصالات الاجتماعية وقدمت حلوًلا وقد أدركت مرا مبتكرة، مثل الأدوات التقنية التي تتيح الاتصال الافتراضي مع أسرهم وأصدقائهم. الزيادة الحادة في مخاطر العنف ضد المسنين وفرض إجراءات تقييدية للبقاء في 91- ئحة كوفيد زادت معدلات العنف ضد المسنين زيادة حادة منذ بداية جا المنزل، ناهيك عن معاناتهم من وطأة الجائحة نفسها. ويحدث العنف في المنازل، وفي مؤسسات مثل مرافق . )601( الرعاية الطويلة الأجل، وعبر الإنترنت، مع زيادة مفاجئة في عمليات الاحتيال التي تستهدف المسنين - العاملون في مجال الرعاية الطويلة الأجل لضغط كبير يؤثر على صحتهم النفسية أثناء جائحة كوفيد يتعرض 91 تعرض العاملون في مجال الرعاية الطويلة الأجل (الذين يحصلون على أجور مقابل ذلك) لضغط مستمر لتوفير نع انتشار العدوى بين الأشخاص الذين ، وبذلوا جهدًا كبيرًا في م 91- الرعاية لفئات ضعيفة أثناء جائحة كوفيد عن يساعدونهم. ومستقبًلا، سيكون الكثير منهم قد تعرض لمواقف مؤلمة وفقدان العديد من الأحبة. وهو ما يسفر ٪ 96وفي هولندا، انتهى مسح أجرته جمعية طواقم التمريض الهولندية إلى أن ضغط هائل على صحتهم النفسية. 5233. فمن بين 91-عية شعروا بضغط أكبر على صحتهم النفسية أثناء جائحة كوفيد من مقدمي الرعاية المجتم إلى جانب الافتقار الشديد )،08(٪ أنه لا يوجد دعم للصحة النفسية من قبل صاحب العمل 82مستجيبًا، أفاد إلى التدخلات النوعية لدعم رفاه العاملين في مجال الرعاية. على الموظفين في مرافق الرعاية 91- فتها حالة كوفيد حة النفسية التي خل وأدركت بعض البلدان خسائر الص الطويلة الأجل، ونفذت تدخلات استهدفت دعم الصحة النفسية للموظفين. وفي المملكة المتحدة، ُبذ لت جهود من خلال خدمات الدعم لتعزيز رفاه العاملين في مجال الرعاية. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -44- جرين، لا سيما أولئك الذين كانوا يتنقلون لتقديم الرعاية في بلدان أخرى، أنفسهم وربما وجد مقدمو الرعاية من المها وإما غير قادرين على الذهاب إلى العمل (وبالتالي ،إما غير قادرين على العودة إلى ديارهم بعد نوبات عملهم . )701، 67(الحصول على أجر) حيث أغلقت البلدان حدودها، وهو ما أدى إلى مواجهتهم مشقة كبيرة قت خدمات الدعم المعتادة يواجه مقدمو الرعاية من الأسرة والمتطوعون مسؤولية رعاية كبيرة وعزلة، في حين عُل ّ إلى حد كبير - العديد من مقدمي الرعاية من الأسرة إلى العزل مع الشخص الذي يعتنون به لحمايته من عدوى كوفيد خضع . وقد خلق ذلك لديهم شعورًا بالانفصال عن شبكاتهم الاجتماعية. وبالإضافة إلى ذلك، فإن هياكل الدعم 91 رية الآخرين ومجموعات دعم مقدمي الرعاية) المعتادة (مثل الرعاية النهارية والرعاية المنزلية ومقدمي الرعاية الأس قت، وهو ما ترك مقدمي الرعاية من الأسرة من دون الاتصالات الاجتماعية المهمة ومصادر قد تقلصت أو ُعل ّ الدعم العملي. ئت خطوط المساعدة والاستشارات الافتراضية ومجموعات دعم مقدمي الرعاية لدعم الرفاه نش وفي بعض البلدان، أ ُ . 91- فسي والاجتماعي لمقدمي الرعاية أثناء جائحة كوفيد الن 91- الآثار المترتبة في سياق كوفيد ظهر تأثير بالغ على الصحة النفسية لموظفي مرافق الرعاية الطويلة الأجل، ومقدمي الرعاية من الأسرة ➔ والمتطوعين، والأشخاص الذين يحتاجون إلى رعاية ُمساع دة. المقيمين في مرافق الرعاية الطويلة الأجل صعوبات لعدم قدرتهم على التواصل مع واجه كثير من ➔ رفاقهم من المقيمين أو المشاركة في الأنشطة الاجتماعية أو استقبال زيارات من أسرهم وأصدقائهم. . الافتقار الشديد إلى التدخلات النوعية لدعم رفاه الأفراد الذين يقدمون الرعاية والذين يتلقونها ➔ الإجراءات الرئيسية 2-9- 2 القطاع كاملا ً إنشاء فريق عامل مشترك بين القطاعات لرصد إصابة موظفي الرعاية الطويلة الأجل بالإجهاد والإرهاق، • وتقييم وتنفيذ استراتيجيات لتوفير دعم الصحة النفسية والدعم النفسي الاجتماعي للموظفين الذين يقدمون الرعاية الطويلة الأجل. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -54- إنشاء خط مساعدة مخصص للصحة النفسية والدعم النفسي لأي شخص يطلب ذلك. • النظر في تقديم إرشادات حول تدريب موظفي الرعاية والمتطوعين لتحسين مهارات الاتصال بشأن المسائل • الحساسة مثل قرارات نهاية الحياة، والوفاة، والاحتضار، وفقدان الأحبة. مقدمي الرعاية الطويلة الأجل على استخدام أدوات الفحص، ومراجعة إجراءات التوظيف (مثل تشجيع • الجداول الزمنية المرنة والإجازات من العمل) لإدارة عبء الرعاية بشكل أفضل، والسعي إلى تقليل استخدام .الماديةالقيود ية وشبكات مقدمي الرعاية من الأسرة، التأكد من توفر الدعم النفسي والعاطفي من أخصائيي الصحة النفس • باستخدام الوسائط الرقمية عند الحاجة لدعم المستفيدين من الرعاية ومقدميها. دعم رصد العنف المرتكب بحق المسنين. • مرافق الرعاية الطويلة الأجل ومكافحتها وحاجة الأفراد وضع سياسات واضحة للزيارات تراعي التوازن بين تدابير الوقاية من العدوى • إلى الحفاظ على سلامتهم النفسية (تمكين المقيمين من استقبال زوار مع تقليل مخاطر دخول عدوى إلى مرافق الرعاية الطويلة الأجل). 91-كوفيد تسهيل اتصال المقيمين بالأسرة والأصدقاء عن طريق الهاتف أو الإنترنت أو الرسائل المكتوبة إذا كان • مقيدًا.الوصول زيادة الاستعانة بالمتطوعين للمساعدة في توفير التفاعل الاجتماعي للمقيمين المعزولين. • الرعاية المجتمعية الموارد للعاملين المهاجرين المقيمين في مرافق الرعاية. وزيادةضمان الوصول • تشجيع وتعزيز هياكل الدعم النفسي الاجتماعي لمقدمي الرعاية من الأسرة. • النظر في تقديم تدريب على الإسعافات الأولية في مجال الصحة النفسية للمتطوعين وأفراد المجتمع. • والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -64- أمثلة من البلدان ، أصدرت المؤسسة الوطنية للمسنين وجمعية طب الشيخوخة وعلم الشيخوخة مقاطع فيديو شيليفي وتتضمن .91-الوضع الناجم عن كوفيد ورسومات لدعم المسنين ومقدمي الرعاية من الأسرة للتعامل مع هذه المواد معلومات عن استخدام معدات الحماية الشخصية، والتباعد، وتوصيات بشأن الصحة النفسية للمساعدة في تنظيم الدعم المجتمعي للأفراد الذين يحتاجون إلى المساعدة في نماذج م وتقد ّ )،801( . )901(الأنشطة الأساسية للحياة اليومية ، أجرت وزارة الصحة حملة لدعم الصحة النفسية، التي تشمل تقييمًا سريعًا عبر الهاتف، المكسيكفي و . وتشتمل هذه الاستراتيجية في نوعيجراء الإحالات للحصول على دعم لإلتقديم استراتيجيات الدعم و . )011(أحد مكوناتها على حملة تستهدف العاملين في مجال الرعاية الصحية ، انتقلت بعض المنظمات غير الحكومية إلى دعم الأقران الافتراضي. ومع ذلك، فإن ضعف كينيا وفي أمام الإنترنت، وسأم الإنترنت، تشكل تحديات باقات إمكانية الاتصال في بعض المناطق، وتكلفة شراء عية إرشادات ونشرت وزارة العمل والحماية الاجتما لجهود المبذولة لدعم مقدمي الرعاية من الأسرة. ا لمرافق الرعاية الطويلة الأجل تنص صراحًة على أنه ينبغي للموظفين التأكد من حفاظ المقيمين على اتصال منتظم (من خلال مكالمات الهاتف المحمول أو الدردشة عبر الإنترنت) مع عائلاتهم وشبكاتهم أنماط حياة منتظمة والحد من فرص الاجتماعية، وينبغي لهم أيضًا تعزيز رفاه المقيمين عن طريق إقامة . )111(تعطلها ، يواصل موظفو مراكز الرعاية النهارية رعاية الأشخاص الذين يدعمونهم من خلال مكالمات ماليزياوفي . )99(الفيديو، فضًلا عن مشاركة مقاطع الفيديو عن الأنشطة والتمارين إرشادات للمديرين 91-، أعد الفريق العامل المعني بالاستجابة لصدمات كوفيد المملكة المتحدةوفي ومخططي الخدمات المعنيين برعاية موظفي مرافق الرعاية الطويلة الأجل الذين ربما تعرضوا لصدمات .)211( والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -74- ضمان الانتقال السلس إلى مرحلة التعافي. 01- 2 التحدي 1- 01- 2 فقدان ثقة الجمهور في مرافق الرعاية الطويلة الأجل تأثيرًا بالغًا على الأفراد الذين يعيشون في مرافق الرعاية الطويلة الأجل، ويبدو أن نسبة 91- رت جائحة كوفيد أث ناك ه ما دام الوفيات في هذه المرافق تزداد مع زيادة عدد الأشخاص المتضررين في المجتمع. ويشير ذلك إلى أنه محليًا، فإن مرافق الرعاية الطويلة الأجل تكون معرضة لمخاطر كبيرة للعدوى 91-انتقال مجتمعي لعدوى كوفيد وارتفاع أعداد الوفيات. وثمة مخاوف في العديد من البلدان من فقدان ثقة الجمهور في مرافق الرعاية الطويلة الأجل، والآثار السلبية الرعاية الطويلة الأجل لم فقامر أن الأشخاص الذين قد يستفيدون من العيش في المحتملة التي تحدث في حالة يحققوا هذه الاستفادة بسبب الخوف. وقد يكون لذلك عواقب سلبية على هؤلاء الأشخاص، وعلى أسرهم، وكذلك على الجدوى المالية لمقدمي مرافق الرعاية الطويلة الأجل. ة الأخرى في مرافق الرعاية الطويلة الأجل القيود على الحركة وإجراءات الحماي تمثل أحد الإجراءات الأولى التي تبنتها جميع البلدان تقريبًا في منع استقبال الزوار في مرافق الرعاية الطويلة الأجل. وفي حين أن هذا الإجراء سهل التنفيذ نسبيًا، يتزايد الاعتراف بأن لذلك الإجراء تأثير بالغ على رفاه كل لمقيمين في مرافق الرعاية الطويلة الأجل وأسرهم، ولا سيما عندما يكون الشخص المقيم مصابًا بالخرف. وقد من ا يؤدي عدم فهم سبب توقف الزيارات إلى شعورهم بمزيد من الضيق. وكانت ثمة مخاوف أيضًا من أن العديد من في وقت قد ،)، وأن عدم السماح لهم بالزيارةأحيانا ًأفراد الأسرة يقدمون الرعاية أثناء زياراتهم المنتظمة (اليومية ، يكون فيه موظفو مرافق الرعاية الطويلة الأجل مثقلين بالأعباء بسبب زيادة تعقيد الرعاية وانخفاض نسب التوظيف قد يؤدي إلى تفاقم مشاكل التوظيف. الصعوبات في رصد جودة الخدمات في مرافق الرعاية الطويلة الأجل ت في وقت عل ق فيه العديد من البلدان عمليات التفتيش. وقد مصدر قلق آخر هو أن زيارات أفراد الأسرة قد توقف تشعر الأسر بالقلق بشأن جودة الرعاية التي يتلقاها المقيمون، وقد يؤدي عدم السماح لهم بالزيارة إلى تفاقم اية في إعادة بناء الثقة في مرافق الرعمهمة الآمنة هو خطوة ات مان الزيار مخاوفهم. ويتزايد الاعتراف بأن ض الطويلة الأجل. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -84- 91-الآثار المترتبة في سياق كوفيد عدم وجود استراتيجية خروج بشأن التدابير التقييدية المطبقة على مرافق الرعاية الطويلة الأجل ➔ جودة الرعاية داخل مرافق الرعاية الطويلة الأجل عند تطبيق قيود الحركة رقابة على عدم وجود ➔ على تلك المرافق الإجراءات الرئيسية 2- 01- 2 مرافق الرعاية الطويلة الأجل إتاحة آليات الترصد من أجل رصد جودة الرعاية داخل مرافق الرعاية الطويلة الأجل أثناء تنفيذ تدابير • والتدابير الاجتماعية. العمومية الصحة إتاحة إرشادات عن الحدود من حيث متى وكيف يمكن بدء عزل المقيمين أو إنهاؤه وتخفيف القيود • المفروضة على الزوار. حول متى وكيف يمكن للأشخاص الذين يعيشون في مرافق الرعاية طويلة الأجل وضع معايير واضحة • المستشفيات وإليها لحماية الموظفين والمقيمين الآخرين. الانتقال من توفير خدمات الصحة الحادة والأولية عند التأكد من مراعاة احتياجات المقيمين في الرعاية الطويلة الأجل • كان عليها الحال قبل ويات الدعم من رعاية أولية وتمريض مجتمعي التي والمجتمعية، واستعادة مست في أقرب وقت ممكن. 91-كوفيد الرعاية المجتمعية التأكد من إعداد البروتوكولات حتى يتمكن الأشخاص الذين يتلقون رعاية مجتمعية (مثل، الرعاية النهارية) • من الوصول إلى هذه الخدمات مرة أخرى. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -94- لدانأمثلة من الب عطيت . وأ ُ0202حزيران/يونيو 1، بدأت خدمات الرعاية النهارية مرة أخرى بالتناوب في مالطافي الأولوية للأشخاص الذين يحتاجون إلى رعاية ولا يتلقون أي خدمات. ووضعت إجراءات صارمة للنظافة الصحية إلى جانب تدابير التباعد. فمثًلا، يحتفظ الموظفون والأفراد الذين يحتاجون إلى رعاية طويلة جب على الأفراد الذين يحتاجون الأجل بالأحذية داخل دار الرعاية النهارية ويغيرونها عند مغادرتهم. وي أثناء حضورهم للمركز. ويرتدي الموظفون أيضًا ارتداء الأقنعة وأقنعة الوجهإلى رعاية طويلة الأجل الأقنعة طوال يوم العمل. وبالإضافة إلى ذلك، يجري رصد درجة حرارة الأشخاص الذين يتلقون الرعاية . )85( والذين يقدمونها ، يمكن للأفراد الاستمرار في زيارة المقيمين الذين يتلقون رعاية نهاية العمر مع الالتزام ركنماالدوفي ، أصبح من الممكن للمقيمين في مرافق 0202نيسان/أبريل 42ببروتوكولات النظافة الصحية. فمنذ . )89(الرعاية الطويلة الأجل استقبال الزوار في الساحات الخارجية . وفي حين أن 0202، بدأ تخفيف القيود المفروضة على الزوار مرة أخرى في أيار/مايو ألمانياوفي القواعد المحددة بشأن عدد الزوار وتكرار الزيارات ومدتها تختلف بين الولايات الفيدرالية، فإن جميع يجب على الولايات تشترط أن تضع مرافق الرعاية الطويلة الأجل تدابير واضحة للوقاية من العدوى. و .)69(الزوار أيضًا التسجيل حتى يمكن التعرف عليهم لتتبع المخالطين إذا أصبح ذلك ضروريًا الشروع في خطوات لتحويل نظم الرعاية الصحية والرعاية الطويلة الأجل بهدف إدماج خدمات الرعاية 11- 2 الطويلة الأجل بالشكل المناسب وضمان الإدارة المستمرة والفعالة لها الرعاية الصحية. وقد أدى نظمداخل الضوء على تفتت خدمات الرعاية الطويلة الأجل 91- لطت جائحة كوفيد س تفتت، إلى جانب نقاط الضعف المتأصلة في هيكل الإدارة الشامل الحالي للرعاية الطويلة الأجل، إلى عواقب هذا ال وخيمة على مرافق الرعاية الطويلة الأجل خلال الجائحة. بد من التعجيل بإحداث تحوٍل في نظم الرعاية الصحية والطويلة الأجل، بحيث ُتدَمج خدمات الرعاية الطويلة ولا قد م إلى جانب سلسلة الرعاية التقليدية: التعزيز، والوقاية، والعلاج، وإعادة التأهيل، والرعاية الأجل بسهولة وت ُ الملطفة. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -05- ، المعر فة في هذه الوثيقة على أنها تقديم يد العون لمساعدة الشخص على ويجب التأكيد على أن الرعاية المَساع دة أداء مهمة معينة للحفاظ على القدرة الوظيفية والحفاظ على الاستقلال، تعتبر خدمة أساسية تساعد على تعزيز قديرها حتى الشخص في أداء الأمور التي لديه أسباب لت إمكانية استمراروضمان ، في مكان الإقامة الشيخوخة بعد التدهور الكبير في قدراته البدنية والذهنية. دتان في وتنص الاستراتيجية وخطة العمل العالميتان لمنظمة الصحة العالمية بشأن الشيخوخة والصحة، المعتم َ . ويؤكد عقد )44(، على أنه "ينبغي أن يمتلك كل بلد نظامًا مستدامًا ومنصفًا للرعاية الطويلة الأجل" 6102عام ) أيضًا على إتاحة الرعاية الطويلة الأجل للمسنين الذين 0302- 0202التمتع بالصحة في مرحلة الشيخوخة ( . )311(يحتاجون إليها ف متنوع من المستفيدين، تظل ي وعلى الرغم من عدم اقتصار الرعاية الطويلة الأجل على المسنين واشتمالها لط َ ة طويلة الأجل من أجل ضمان : تقديم الخدمات لأولئك الذين يحتاجون إلى رعايالعناصر الأساسية هي نفسها تسق مع حقوقهم الأساسية وحرياتهم الأساسية وكرامتهم الإنسانية. ت حياة لتحقيق رعاية طويلة الأجل مستدامة ومنصفة 91-وتعكس الإجراءات التالية الدروس التي نتعلمها من جائحة كوفيد للجميع. الإجراءات الرئيسية طر وطنية للرعاية الطويلة الأجل.أضمان وجود التشريعات ووضع استراتيجية و • تعزيز العلاقات بين مختلف مستويات الحكومة المشاركة في الرعاية الطويلة الأجل والرعاية الصحية • وإنشاء آليات تنسيق رأسية وداخلية ملموسة. أعمال تمكين من أجل مة الرعاية الصحية وطويلة الأجل دمج الجمع المنتظم للبيانات الوطنية عن أنظ • . التقييم والرصد على نطاق المنظومة ضمان وجود آليات تمويل مستدامة ومنصفة للرعاية الطويلة الأجل تحمي الأفراد من التكاليف الباهظة • للرعاية. ضمان مسارات رعاية متكاملة تركز على الأشخاص وتغطي سلسلة الرعاية الصحية والطويلة الأجل • لتمكين الأفراد الذين يحتاجون إلى رعاية طويلة الأجل من تلقي رعاية شاملة. ضمان التدريب المستمر وظروف العمل المحس نة للعاملين في الرعاية الطويلة الأجل. • والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -15- العيني لمقدمي الرعاية من الأسرة والمتطوعين وتوسيع نطاقه. تقديم الدعم المالي و • تحديد الآليات لضمان جودة الخدمات في قطاع الرعاية الطويلة الأجل غير الخاضع للتنظيم وتعزيز • الاعتماد. ضمان إشراف القطاع الصحي على مرافق الرعاية الطويلة الأجل للتأهب للجوائح في المستقبل. • لمعالجة نقاط الضعف في منظومة 91-ناء على الدروس المستفادة من جائحة كوفيد تعزيز البحوث ب • الرعاية الصحية والطويلة الأجل. ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -52- عجارملا 1 ؛ةيملاعلا ةحصلا ةمظنم :فينج .ةحصلاو ةخوخيشلا نع يملاعلا ريرقتلا .2015 ]ةيزيلكنلإاب[ ).https://apps.who.int/iris/handle/10665/186463( 2. Care work and care jobs for the future of decent work. Geneva: International Labour Organization; 2018 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/--- publ/documents/publication/wcms_633135.pdf, accessed 21 June 2020). 3. Who cares? Attracting and retaining care workers for the elderly. Paris: Organization for Economic Co-operation and Development; 2020 (https://www.oecd.org/publications/who- cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm, accessed 23 June 2020). 4. Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region: strengthening the health systems response to COVID-19. Technical Working Guidance No. 6. WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health-topics/Health-systems/health-services- delivery/publications/2020/strengthening-the-health-systems-response-to-covid-19- technical-guidance-6,-21-may-2020, accessed 21 June 2020). 5. Salcher-Konrad M, Jhass A, Naci H, Tan M, El-Tawil Y, Comas-Herrera A. COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence. medRxiv. 2020. doi:10.1101/2020.06.09.20125237. 6. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N, Fernández J-L. Mortality associated with COVID-19 outbreaks in LTCFs: early international evidence. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/04/12/mortality- associated-with-covid-19-outbreaks-in-care-homes-early-international-evidence/, accessed 21 June 2020). 7. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 8. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 9. American Geriatrics Society. American Geriatrics Society (AGS) policy brief: COVID‐19 and assisted living facilities. Journal of the American Geriatrics Society. May 2020:jgs.16510. doi:10.1111/jgs.16510. 10. American Geriatrics Society. American Geriatrics Society policy brief: COVID ‐19 and nursing homes. Journal of the American Geriatrics Society. 2020;68(5):908–11. doi:10.1111/jgs.16477. 11. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. New England Journal of Medicine. 2020;382:2081–90. doi:10.1056/nejmoa2008457. ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -53- 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A et al. SARS-CoV-2 infection: clinical features and outcome of COVID-19 in United Kingdom nursing homes. Journal of Infection. 2020;5:38. doi:10.1016/j.jinf.2020.05.073. 14. Goldberg SA, Pu CT, Thompson RW, Mark E, Sequist TD, Grabowski DC. Asymptomatic spread of COVID-19 in 97 patients at a skilled nursing facility. Journal of the American Medical Directors Association. 2020. doi:10.1016/j.jamda.2020.05.040. 15. Guery R, Cécile D, Noëlle B, Nael V, Castain L, Raffi F et al. Limited effectiveness of systematic screening by nasopharyngeal RT-PCR of medicalized nursing home staff after a first case of COVID-19 in a resident. Médecine et Maladies Infectieuses. May 2020. doi:10.1016/j.medmal.2020.04.020. 16. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A et al. Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults: Seattle, Washington, 2020. Morbidity and Mortality Weekly Report. 2020;69(14):416–8. doi:10.15585/mmwr.mm6914e2. 17. Grabenhorst U, Stiels-Prechtel R, Niemann M, Weckbecker K. COVID-19 in the nursing home: a case report. MMW-Fortschritte der Medizin. 2020;162(9):60–2. doi:10.1007/s15006-020-0481-0. 18. Dora A V, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans: Los Angeles, California, 2020. MMWR Morbidity and Mortality Weekly Report. 2020;69(21):651–5. doi:10.15585/mmwr.mm6921e1. 19. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. 2020;382(21):2005–11. doi:10.1056/NEJMoa2005412. 20. Coronavirus (COVID-19) related deaths by occupation, England and Wales. Office for National Statistics; 2020 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeat h/bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistered uptoandincluding20april2020#:~:text=A%20total%20of%20131%20deaths,100%2C000%2 0females%20(86%20deaths), accessed 21 June 2020). 21. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 22. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long-term care hospitals in the Korea. Infection and Chemotherapy. May 2020. 23. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi- ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -54- phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 24. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 25. COVID-19. Sciensano (https://epistat.wiv-isp.be/covid, accessed 21 June 2020). 26. Fisman D, Lapointe-Shaw L, Bogoch I, McCready J, Tuite A. Failing our most vulnerable: COVID-19 and long-term care facilities in Ontario. medRxiv. doi:10.1101/2020.04.14.20065557. 27. Yanover C, Mizrahi B, Kalkstein N, Marcus K. What factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization. medRxiv. 2020. doi:10.1101/2020.05.07.20091652. 28. Dawson WD, Ashcroft E, Lorenz-Dant K, Comas-Herrera A. Impact of the COVID-19 outbreak on community-based care services: a review of initial international policy responses. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/06/Community-Based-Care-Report-19-May.pdf, accessed 21 June 2020). 29. Lorenz-Dant K. International examples of measures to support unpaid carers during the COVID-19 pandemic. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-support-unpaid- carers-in-manage-the-COVID19-situation-20.05.20-complete-2.pdf, accessed 21 June 2020). 30. COVID-19 supercharges existing inequalities faced by Glasgow’s 150,000 disabled people. Glasgow Disability Alliance; 2020 (http://gda.scot/our-community/news/2020/4/28/covid- 19-supercharges-existing-inequalities-faced-by-glasgows-150-000-disabled-people, accessed 21 June 2020). 31ديفوكو ةيراسلا ريغ ضارملأا .-19[ ةيملاعلا ةحصلا ةمظنم :فينج .ةيزيلكنلإاب ،] 19-https://www.who.int/teams/ncds/covid يف علاطلاا مت ،21 /ناريزحوينوي 2020 32ديفوك قايسل ةيناديم تاداشرإ :ةيساسلأا ةيحصلا تامدخلا ىلع ظافحلا .-19 ؛ةيملاعلا ةحصلا ةمظنم :فينج .2020 ]ةيزيلكنلإاب[332240-https://www.who.int/publications/i/item/10665 يف علاطلاا مت ،21 /ناريزحوينوي 2020 33. Coronavirus: Spanish army finds care home residents “dead and abandoned”. BBC News, 24 March 2020 (https://www.bbc.co.uk/news/world-europe-52014023, accessed 21 June 2020). 34. 31 Senioren in Kanada tot: Pfleger kamen aus Angst vor Corona nicht [31 seniors dead in Canada: carers did not come for fear of Corona]. MSN, 18 April 2020 (https://www.msn.com/de-at/news/other/31-senioren-in-kanada-tot-pfleger-kamen-aus- angst-vor-corona-nicht/ar-BB12QiDh#image=1, accessed 21 June 2020). ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -55- 35. Bauer A, Dixon J. The challenges of providing end-of-life support in LTCFs during the COVID-19 pandemic, and opportunities for the future: an international perspective. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/06/Challenges-of-providing-end-of-life-support-in-care-homes- during-the-COVID-19-pandemic-1.pdf, accessed 21 June 2020). 36. ديفوكل يريرسلا يجلاعلا ريبدتلا-19 تاداشرإ :ةيئدبم ؛ةيملاعلا ةحصلا ةمظنم :فينج .2020 19-covid-of-management-detail/clinical-https://www.who.int/publications يف علاطلاا مت ،21 /ناريزحوينوي 2020 37. Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions. In: Gender equality. Paris: Organisation for Economic Co- operation and Development; 2019 (https://www.oecd.org/gender/data/womenare-well- represented-in-health-and-long-term-care-professions-but-often-in-jobs-with-poor- workingconditions.ht, accessed 21 June 2020). 38. ديفوك ةحئاج-19 لاو ةمظنم :فينج .اهذاختا يحصلا ماظنلا/ةحصلا عاطقل نكمي يتلا تاءارجلإا :ةأرملا دض فنع ؛ةيملاعلا ةحصلا2020 -SRH-handle/10665/331699/WHOhttps://apps.who.int/iris/bitstream/ ara.pdf?sequence=23&isAllowed=y-20.04 39. Shippee T, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao M et al. COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging and Social Policy. June 2020. doi:10.1080/08959420.2020.1772004. 40. Long-term care for older people: a new global gender priority. New York; UN Women; 2017. 41. Policy brief: the impact of COVID-19 on older persons. New York: United Nations; 2020. 42. Scheil-Adlung X. Global estimates of deficits in long-term care protection for older persons. Extension of Social Security Series, No. 50. Geneva: International Labour Organization; 2015. 43. Help wanted? Providing and paying for long-term care. Paris: Organisation for Economic Co-operation and Development; 2011. 44. ةطخو ةيجيتارتسلاا ةدوسم :ةخوخيشلا يف ةحصلاب عتمتلل رمعلا ةليط دتمي جهن عابتا لجأ نم تاعاطقلا ددعتملا لمعلا ليربأ/ناسين ،نوتسلاو ةعساتلا ةيملاعلا ةحصلا ةيعمج .ةناملأا نم ريرقت .ةحصلاو ةخوخيشلا نأشب نيتيملاعلا لمعلا 2016 ؛ةيملاعلا ةحصلا ةمظنم :فينج .2016 ar.pdf?ua=1-https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17 ، يف علاطلاا مت21 /ناريزحوينوي 2020 45. Accelerating global actions for a world without poverty: United Nations System-wide Plan of Action for the Third United Nations Decade for the Eradication of Poverty (2018–2027). New York: United Nations; 2018 (https://www.un.org/development/desa/dspd/wp- content/uploads/sites/22/2020/03/SWAP-Poverty-Booklet-Digital-Feb27.pdf, accessed 21 June 2020). 46. Barr N. Long-term care: a suitable case for social insurance. Social Policy and Administration. 2010;44(4):359–74. doi:10.1111/j.1467-9515.2010.00718.x. ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -56- 47. Protective equipment being diverted from LTCFs to hospitals, say bosses. The Guardian, 30 March 2020 (https://www.theguardian.com/world/2020/mar/30/protective-equipment-being- diverted-from-care-homes-to-hospitals-say-bosses, accessed 21 June 2020). 48. Spasova S, Baeten R, Coster S, Ghailani D, Pena-Casas R, Vanhercke B. Challenges in long-term care in Europe: a study of national policies. Brussels: European Commission; 2018. 49. Zalakain J, Davey V, Suárez-González A. The COVID-19 on users of long-term care services in Spain. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/LTCcovid-Spain-country-report-28-May- 1.pdf, accessed 21 June 2020). 50. Berloto S, Notarnicola E, Perobelli E, Rotolo A. Italy and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/LTC-COVID19-situation-in-Italy-30-April-2020.pdf, accessed 21 June 2020). 51. King D, Zigante V. Quality assurance practices in long-term care in Europe: emerging evidence on care market management. Brussels: Publications Office of the European Union; 2020. 52. Lloyd-Sherlock P, Neto J, Comas-Herrera A, Redondo N. Re: Covid-19: why we need a national health and social care service. BMJ. 2020;369. doi:10.1136/bmj.m1465. 53. Lloyd-Sherlock P, Bastos J, Geffen L, Giacomin K, Redondo N, Sasat S et al. An emergency strategy for managing COVID-19 in LTCFs in LMICs: the CIAT Framework. 2020 (https://www.corona-older.com/post/an-emergency-strategy-for-managing-covid-19- in-care-homes-in-lmics-the-ciat-framework-version-1, accessed 21 June 2020). 54. قلا مييقتلا راطإكم :نغاهنبوك .لجلأا ةليوطلا ةياعرلل لماكتملا ميدقتلا نأشب يرط يميلقلإا ةيملاعلا ةحصلا ةمظنم بت ؛ابورولأ2019 ]ةيزيلكنلإاب[ 55. COVID-19: Singapore to house nursing home staff in hotels to protect the elderly. Channel News Asia, 8 May 2020 (https://www.facebook.com/ChannelNewsAsia/videos/1098221953890384/, accessed 21 June 2020). 56. Covid-19 testing completed for nursing home residents and staff; no new cases found apart from 5 earlier ones. The Straits Times, 31 May 2020 (https://www.straitstimes.com/singapore/health/covid-19-testing-completed-for-all-nursing- home-residents-and-staff, accessed 21 June 2020). 57. Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G, Brammli-Greenberg S. The impact of COVID-19 on people using and providing long-term care in Israel. International Long- Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The- COVID-19-Long-Term-Care-situation-in-Israel-4-May.pdf, accessed 21 May 2020). 58. Fenech MA, Vella M, Calleja N. The COVID-19 long-term care situation in Malta and Gozo. International Long-Term Care Policy Network; 2020. 59. Cès S, Coster S. Mapping long-term care quality assurance practices in the EU: summary report. Brussels: European Commission; 2019. ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -57- 60. Hashiguchi T, Llena-Nozal A. The effectiveness of social protection for long-term care in old age: is social protection reducing the risk of poverty associated with care needs? OECD Health Working Papers. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd-ilibrary.org/social-issues-migration-health/the-effectiveness-of- social-protection-for-long-term-care-in-old-age_2592f06e-en, accessed 21 June 2020). 61. Van Houtven CH, Boucher NA, Dawson WD. The impact of COVID-19 outbreak on long term care in the United States. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24- April-2020.pdf, accessed 21 June 2020). 62. HHS Provider Relief Fund. Centers for Disease Control and Prevention; 2020 (https://data.cdc.gov/Administrative/HHS-Provider-Relief-Fund/kh8y-3es6, accessed 21 June 2020). 63. Kim H. The impact of COVID-19 on long-term care in South Korea and measures to address it. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May- 2020.pdf, accessed 21 June 2020). 64. Lum T, Shi C, Wong G, Wong K. COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging and Social Policy. 2020. doi:10.1080/08959420.2020.1773192. 65. Wong K, Lum T, Wong G. The COVID-19 long-term care situation in Hong Kong: impact and measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/04/Hong-Kong-COVID-19-Long-term-Care-situation-27-April-2020- 1.pdf, accessed 21 June 2020). 66. Shi C, Hu B, Feng M, Wong G. Report from mainland China: policies to support long-term care during the COVID-19 outbreak. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Report-from-Mainland-China-18-April- final.pdf, accessed 21 June 2020). 67. Statistics Commission endorses new Titchfield City Group on Ageing. New York: United Nations Department of Economic and Social Affairs; 16 March 2018 (https://www.un.org/development/desa/ageing/news/2018/03/title-statistics-commission- endorses-new-titchfield-city-group-on-ageing/, accessed 21 June 2020). 68. Descubren una residencia ilegal en La Laguna por las pruebas del Covid-19 [They discover an illegal residence in La Laguna by the tests of Covid-19]. La Provincia, 4 April 2020 (https://www.laprovincia.es/sociedad/2020/04/04/descubren-residencia-ilegal-laguna- pruebas/1271776.html, accessed 21 June 2020). 69. Burton A, Goodman C, Quinn T. The invisibility of the UK care home population: UK care homes and a minimum dataset. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/the-invisibility-of-the-uk-care-home-population-uk-care- homes-and-a-minimum-dataset/, accessed 21 June 2020). 70. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -58- 71. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.9540. 72. Jacobs R, Ashwell A, Docrat S, Schneider M. The impact of COVID-19 on long-term care in South Africa. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/COVID-19-Long-Term-Care-Situation-in- South-Africa.docx, accessed 21 June 2020). 73. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. European Centre for Disease Prevention and Control; 2020 (https://www.ecdc.europa.eu/en/publications- data/surveillance-COVID-19-long-term-care-facilities-EU-EEA, accessed 21 June 2020). 74. Rodrigues R, Huber M, Lamura G. Facts and figures on healthy ageing and long-term care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research; 2012. 75. Van Houtven CH, DePasquale N, Coe NB. Essential long‐term care workers commonly hold second jobs and double‐ or triple‐duty caregiving roles. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16509. 76. Schmidt AE, Leichsenring K, Staflinger H, Litwin C, Bauer A. The impact of COVID-19 on users and providers of long-term care services in Austria. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19- Long-Term-Care-situation-in-Austria-15-May.pdf, accessed 22 June 2020). 77. Pierce M, Keogh F, O’Shea E. The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC- report-updated-13-May-2020.pdf, accessed 22 June 2020). 78. Rajagopalan J, Huzruk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID-situation-in-India-30th- May.pdf, accessed 22 June 2020). 79. Amour R, Robinson JN, Govia I. The COVID-19 long-term care situation in Jamaica. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Jamaica-25-May- 2020-1.pdf, accessed 22 June 2020). 80. Kruse F, Abma I, Jeurissen P. The impact of COVID-19 on long-term care in the Netherlands. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/COVID19-Long-Term-Care-situation-in-the-Netherlands-25-May- 2020-1.pdf, accessed 22 June 2020). 81. Low L-F. The long-term care COVID-19 situation in Australia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Australia- LTC-COVID19-situation-24-April-2020.pdf, accessed 22 June 2020). 82. Extra payment for unpaid carers. Scottish Government, 6 May 2020 (https://www.gov.scot/news/extra-payment-for-unpaid-carers/, accessed 22 June 2020). ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -59- 83. فرخلل ةيمومعلا ةحصلا ةباجتسا نأشب ةيملاعلا لمعلا ةطخ2017-2025 ؛ةيملاعلا ةحصلا ةمظنم :فينج .2017 ]ةيزيلكنلإاب[.5/259615https://apps.who.int/iris/handle/1066 84. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo J et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190–1. 85. Suarez-Gonzalez A, Livingston G, Comas-Herrera. Report: the impact of the COVID-19 pandemic on people living with dementia in UK. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/03/report-the-impact-of-the-covid-19- pandemic-on-people-living-with-dementia-in-uk/, accessed 22 June 2020). 86. Joint statement on advance care planning. Care Quality Commission; 2020 (https://content.govdelivery.com/accounts/UKCQC/bulletins/283e565, accessed 22 June 2020). 87. ديفوك ةحئاج قايس يف ،تلامحلاو ةيعوتلا اهنمو ،ةيعمتجملا ةيحصلا ةياعرلا-19 تاداشرإ :ةيئدبم ةمظنم :فينج . ؛ةيملاعلا ةحصلا2020 ]ةيزيلكنلإاب[-nCoV-2019-https://www.who.int/publications/i/item/WHO( 2020.1-Comm_health_care يف علاطلاا مت ،22 /ناريزحوينوي 2020 88. ديفوك ىضرمل ةيلزنملا ةياعرلا-19 يبدتلاو ةفيفخ ًاضارعأ نوناعي نيذلا تاداشرإ :نيطلاخملل يجلاعلا رةيئدبم :فينج . ؛ةيملاعلا ةحصلا ةمظنم2020 ]ةيزيلكنلإاب[ -for-care-https://www.who.int/publications/i/item/home -mild-with-presenting-infection-(ncov)-coronavirus-novel-suspected-with-patients ,contacts-of-management-and-ymptomss ، يف علاطلاا مت22 /ناريزحوينوي 2020 89. ديفوك قايس يف ةيعامتجلاا ريبادتلاو ةيمومعلا ةحصلا ىلع ةماع ةرظن-19 ؛ةيملاعلا ةحصلا ةمظنم :فينج .2020 ]ةيزيلكنلإاب[-social-and-health-public-of-who.int/publications/i/item/overviewhttps://www. 19-covid-of-context-the-in-measures ، يف علاطلاا مت10 زومت/وي هيل2020 90. Bauer A. COVID19: providing palliative care for the many. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/03/31/covid19-proving-palliative-care-for- the-many/, accessed 22 June 2020). 91. Oven A. COVID-19 and long-term care in Slovenia: impact, measures and lessons learnt. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/04/COVID19-and-Long-Term-Care-in-Slovenia-impact-measures- and-lessons-learnt-21-April-2020.pdf, accessed 22 June 2020). 92. ديفوك ضرم قايس يف دملأا ةليوطلا ةياعرلا قفارم يف اهتحفاكمو ىودعلا نم ةياقولا نأشب تاداشرإ-19 تاداشرإ : نج .ةيئدبم ؛ةيملاعلا ةحصلا ةمظنم :في2020 -nCoV-2019-https://apps.who.int/iris/bitstream/handle/10665/331508/WHO ara.pdf?sequence=14&isAllowed=y-2020.1-rm_careIPC_long_te، يف علاطلاا مت22 /ناريزحوينوي 2020. 93. ديفوك ضرم ةيشاف-19 ةملاسلل ةيساسلأا تارابتعلاا اهيف امب ،مهتايلوؤسمو مهراودأو نييحصلا نيلماعلا قوقح : ؛ةيملاعلا ةحصلا ةمظنم :فينج .نيتينهملا ةحصلاو2020 ]ةيزيلكنلإاب[-https://www.who.int/publications -health-of-responsibilities-and-roles-rights-outbreak-19)-(covid-seasedi-detail/coronavirus health-and-safety-occupational-for-considerations-key-cludingin-orkersw يف علاطلاا مت22 /ناريزحوينوي 2020 94. ةمظنم :فينج .دجتسملا انوروك سوريفب ةباصلإا يف هابتشلاا دنع ةيحصلا ةياعرلا ءانثأ اهتحفاكمو ىودعلا نم ةياقولا ؛ةيملاعلا ةحصلا2020 ]ةيزيلكنلإاب[331495-https://www.who.int/publications/i/item/10665،ت م يف علاطلاا22 /ناريزحوينوي 2020 ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -60- 95. Sani TP, Tan M, Rustandi KK, Turana Y. COVID-19 long-term care situation in Indonesia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/06/The-COVID-19-Long-Term-Care-situation-in-Indonesia-30-May- 1.pdf, accessed 22 June 2020). 96 Lorenz-Dant K. Germany and the COVID-19 long-term care situation. International Long- Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf, accessed 22 June 2020). 97. ديفوك قايس يف نيطلاخملا عبتت -19 ؛ةيملاعلا ةحصلا ةمظنم :فينج .2020 ]ةيزيلكنلإاب[ 19-covid-of-context-the-in-tracing-https://www.who.int/publications/i/item/contact، مت يف علاطلاا22 /ناريزحوينوي 2020. 98. Rostgaard T. The COVID-19 long-term care situation in Denmark. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID- 19-Long-Term-Care-situation-in-Denmark-29-May-2020.pdf, accessed 22 June 2020). 99. Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST. The long term care COVID-19 situation in Malaysia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Malaysia-LTC-COVID-situation-report- 30-May.pdf, accessed 22 June 2020). 100. Health at a glance 2019: OECD indicators. Paris: Organisation for Economic Co-operation and Development; 2019 (http://www.oecd.org/health/health-systems/health-at-aglance- 19991312.htm, accessed 22 June 2020). 101. Brimblecombe N, Fernandez J-L, Knapp M, Rehill A, Wittenberg R. Unpaid care in England: future patterns and potential support strategies. London: London School of Economics; 2018. 102. Caring behind closed doors: forgotten families in the coronavirus outbreak. London: Carers UK; 2020 (https://www.carersuk.org/for-professionals/policy/policy-library/caring-behind- closed-doors-report, accessed 22 June 2020). 103. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? Journal of Gerontological Social Work. 2014;57(5):460–77. doi:10.1080/01634372.2014.882466. 104. ديفوك ةيشاف ءانثأ يف يعامتجلااو يسفنلا معدلاو ةيسفنلا ةحصلا تارابتعا-19 تاداشرإ :ةيئدبم ةمظنم :فينج . ؛ةيملاعلا ةحصلا2020 http://www.emro.who.int/images/stories/mnh/documents/ar_mental_health_considerations_ covid_19.pdf?ua=1، يف علاطلاا مت22 /ناريزحوينوي 2020. 105. Da Mata F, Oliveira D. COVID-19 and long-term care in Brazil: impact, measures and lessons learned. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/COVID-19-Long-term-care-situation-in- Brazil-6-May-2020.pdf, accessed 22 June 2020). ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -61- 106. ديفوك-19 ؛ةيملاعلا ةحصلا ةمظنم :فينج .نينسملا دض فنعلاو2020 ]ةيزيلكنلإاب[ people-older-against-violence-and-19-https://www.who.int/publications/m/item/covid مت يف علاطلاا22 /ناريزحوينوي 2020. 107. Leiblfinger M, Prieler V, Schwiter K, Steiner J, Benazha A, Lutz H. Impact of the COVID- 19 pandemic on live-in care workers in Germany, Austria and Switzerland. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/impact-of-the- covid-19-pandemic-on-live-in-care-workers-in-germany-austria-and-switzerland/, accessed 22 June 2020). 108. Coronavirus Plan of Action. Chile: Senama (http://www.senama.gob.cl/protocolos-covid-19, accessed 22 June 2020). 109. Cuenta con migo [count on me]. Government of Chile (https://www.gob.cl/cuentaconmigo/, accessed 22 June 2020). 110. López-Ortega M, Sosa-Tinoco E. COVID-19 and long-term care in Mexico: questions, challenges, and the way forward. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/LTC-Covid-19-situation-in-Mexico-8- June.pdf, accessed 22 June 2020). 111. Musyimi C, Mutunga E, Ndetei D. COVID-19 and long-term care in Kenya. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/06/02/new-country- report-the-covid-19-long-term-care-situation-in-kenya/, accessed 22 June 2020). 112. COVID Trauma Response Working Group (https://www.traumagroup.org/, accessed 22 June 2020). 113. ةخوخيشلا ةلحرم يف ةحصلاب عتمتلا دقع2020-2030؛ةيملاعلا ةحصلا ةمظنم :فينج . 2020 -decade-ageing/final-healthy-of-source/decade-https://www.who.int/docs/default ar.pdf?sfvrsn=b4b75ebc_3-apr2020-final-proposal-eproposal/decad ، يف علاطلاا مت22 /ناريزحوينوي 2020. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -26- المتبعة الأساليب . 1الملحق المراجعة المنهجية الحية 91-كوفيد نات الدولية المبكرة على معدلات الوفيات ومعدل وقوع أجريت مراجعة منهجية حية، بهدف تجميع البي ّ لت المراجعة في قاعدة بيانات بين الأشخاص الذين يستفيدون الرعاية الطويلة الأجل والذين يقدمونها. وُسج ّ ، وتتضمن الدراسات التي ُحد ّ دت من خلال عمليات البحث في قاعدة )75538102024DRC( orepsorP بروسبيرو . وُنش رت الأساليب والنتائج 0202حزيران/يونيو 5ى ، وحد ّ ثت حت0202أيار/مايو 51البيانات التي أجريت في والمؤشر التراكمي ؛. وقد أجري البحث في سبع قواعد بيانات (ميدلاين؛ وإمباسvixRdemبالكامل في ميد أركايف ؛ وشبكة العلوم؛ والصحة العالمية؛ وقاعدة بيانات أبحاث sulP LHANICبلس -للتمريض والصحة المساعدة ابعة لمنظمة الصحة العالمية؛ وميد أركايف) لتحديد جميع الدراسات التي أفادت بالبيانات الأولية الت 91-كوفيد ومعدل الإصابة بالمرض بين المستفيدين من الرعاية الطويلة الأجل والموظفين 91-عن الوفيات المرتبطة بـكوفيد ، وهي gro.divocCTLى مستوى البلد من نات على معدلات الوفيات علوبالإضافة إلى ذلك، ُحد ّ دت البي ّ بها. شبكة دولية من خبراء الرعاية الطويلة الأجل. واسُتبع دت الدراسات التي لا تركز على الرعاية الطويلة الأجل. وجرى تقييم الدراسات الأولية المدرجة هنا بشكل نقدي والجمع السردي للنتائج المتعلقة بعدد الوفيات ومعدلات ، ومعدلات إماتة الحالات، والوفيات الزائدة (الحصائل الأولية المشتركة)، بالإضافة 91- بكوفيد الوفيات المرتبطة إلى معدل الإصابة بالمرض، وحالات دخول المستشفى، وحالات دخول وحدة العناية المركزة. أبلغت عن وأجرى ثلاثة مراجعين فحص العناوين والملخصات ومراجعة النص الكامل، وُجم عت السجلات التي الدراسة أو الفاشية نفسها. واسُتخد م نموذج موحد لاستخراج البيانات على مستوى الدراسة، بما في ذلك معلومات وتأكيده؛ والخصائص 91-عن تصميم الدراسة؛ ومكان الرعاية (مؤسسية مقابل المجتمع)؛ وكيف تم تشخيص كوفيد المؤكدة والمشتبه فيها؛ 91-ت الوفيات من حالات كوفيد الأساسية للمشاركين؛ والعدد المطلق للوفيات ومعدلا المؤكدة والمشتبه بها؛ ومعدلات 91-ومعدلات إماتة الحالات؛ والوفيات الزائدة؛ والأرقام المطلقة ومعدلات كوفيد المؤكدة والمشتبه فيها. واستخر جت جميع 91-دخول المستشفى ودخول وحدة العناية المركزة بين حالات كوفيد صائص المشاركين في الدراسة وبيانات الحصائل بشكل منفصل للمستفيدين من الرعاية الطويلة الأجل والموظفين خ بها. واستخر جت المعلومات أيضًا عن نسبة الحالات العديمة الأعراض في وقت الاختبار، ونتائج الدراسات التي خرين. تقارن الحصائل في المستفيدين من الرعاية الطويلة الأجل بالآ ولم ُتجَمع البيانات بسبب عدم التجانس في تعريفات البسط والمقام وأوقات المتابعة في الدراسات المجّمعة. وبدًلا صت النتائج سرديًا وُعرضت في جداول، بما في ذلك معلومات عن خصائص العينة، ووقت المتابعة، من ذلك، ُلخ ّ والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -36- الدراسات تداخل بين الفئات السكانية، أعطيت الأفضلية لأولئك وتعريفات الحالة، حسب الاقتضاء. وعندما ذكرت الذين لديهم أحجام عينات أكبر وأوقات متابعة أطول. وجرى تقييم جودة الدراسات الأولية المشمولة التي أبلغت عن الأرقام المتعلقة بمعدلات الوفيات أو معدلات إماتة ييم النقدي لمعهد جوانا بريجز لدراسات الانتشار. ولم ُتقي م مخاطر الحالات أو الإصابة بالمرض باستخدام أداة التق التحيز في الدراسات. ). 1-1دراسة أولية فريدة أو تقرير فاشية (الشكل أ 03تقرير دراسة ل ـ 33وجرى تضمين ما مجموعه والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -46- المدرجةمخطط اختيار الدراسات الأولية 1-1الشكل أ إجمالي الدراسات المدرجة: 33ع= دراسة فريدة أصلية) 03( مراجعة النص كاملا ً 33ع= 376ميدلاين: ع= 34إيمباس: ع= 122: ع = sulP LHANIC 481شبكة العلوم: ع= 7الصحة العالمية: ع= 202: ع=التابعة لمنظمة الصحة العالمية 91-قاعدة بيانات أبحاث كوفيد 4543ميد أركايف: ع= 22: ع= gro.divocCTL أبحاث قاعدة البيانات 6084ع= بعد إزالة التكرار: 7544ع= مراجعة النص كاملا ً 742ع= سجلات تحددت من خلال مصادر أخرى ع= 3 اسُتبع دت بعد فحص العنوان والملخص 0124ع= اسُتبع دت بعد فحص العنوان والملخص 57لا تركز على الرعاية الطويلة الأجل: ع= 25مقالة مراجعة: ع= الإصابة: لا توجد بيانات عن الوفيات أو 65ع= 52مقالة رأي: ع= 7عدم توافر النص كامًلا: ع= 3دراسة نمذجة: ع= 3: ع=91-لا تركز على كوفيد 3مكررة: ع= مدرجة في المراجعة الأولى 03ع= دراسة فريدة أصلية) 72( بعد إزالة التكرار: 814ع= اسُتبع دت بعد فحص العنوان والملخص 583ع= اسُتبع دت بعد فحص العنوان والملخص 8مقالة مراجعة: ع= 6مقالة رأي: ع= 4لا توجد بيانات عن الوفيات أو الإصابة: ع= 3لا تركز على الرعاية الطويلة الأجل: ع= 2: ع=91-لا تركز على كوفيد 1مكررة: ع= 0عدم توافر النص كامًلا: ع= 0دراسة نمذجة: ع= دة سبق إدراجها (ُسح بت من اسُتبع دت: دراسة واح قبل المؤلف) ُمدرجة حديثا ً 4ع= المحدّ ثة أبحاث قاعدة البيانات 814ع= والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -56- الأشخاص الذين يستفيدون من على 91- نموذج لمراجعة منهجية لفعالية التدخلات بهدف تخفيف أثر كوفيد الرعاية الطويلة الأجل والذين يقدمونها على الأشخاص الذين يستفيدون 91- فعالية التدخلات للتدبير العلاجي لأثر كوفيد ليجري إعداد مراجعة منهجية للبيانات (ميدلاين؛ من الرعاية الطويلة الأجل والذين يقدمونها. أثناء تجريب استراتيجية البحث عبر سبع قواعد ؛ وشبكة العلوم؛ والصحة sulP LHANICبلس -والمؤشر التراكمي للتمريض والصحة المساعدة ؛وإمباس دراسة 12ظمة الصحة العالمية؛ وميد أركايف)، جرى تحديد التابعة لمن 91-العالمية؛ وقاعدة بيانات أبحاث كوفيد ن التقييم للفعالية أو هدفت إلى تقييم خصائص خدمات وقدمت نوعًا م 91-وصفت الاستجابات لجائحة كوفيد والوفيات المرتبطة به. وكانت هناك خمسة تقارير 91-الرعاية الطويلة الأجل المرتبطة بمعدلات الإصابة بكوفيد من كندا، والصين، وجمهورية كوريا، وإسبانيا، وتقرير من الولايات المتحدة، وثلاثة من إيطاليا، واثنان من كل ٍّ من بلجيكا وفرنسا وأيرلندا وسنغافورة والمملكة المتحدة. واحد من كل ٍّ تعلقت ثلاث من الدراسات بالعلاجات الدوائية في دور و وتحددت التدخلات وتنوعت المجموعات المستهدفة. ورة) ، ووصفت دراسات إضافية تنفيذ تدابير للوقاية من الفاشية في دور الرعاية (الصين وسنغاف)3-1(الرعاية ، وأفادت إحدى الدراسات عن )8- 4، 1((كندا والصين وجمهورية كوريا والولايات المتحدة الأمريكية) واحتوائها ، وأفادت أربع دراسات عن تغييرات تنظيمية متعددة )9( تدابير الوقاية للرعاية المجتمعية في الولايات المتحدة متعدد التخصصات الطويلة الأجل، بما في ذلك التعاون والتنسيق في أماكن الرعاية ال 91-الأوجه للتعامل مع كوفيد من خلال اختبار نقطة الرعاية السريع والاختبار 91-وكانت ثلاث دراسات تجريبية لاكتشاف كوفيد )،21- 01، 6( ، ودراسة واحدة كي فت تدخل التحفيز )51-31(المجمع والتصوير بالموجات فوق الصوتية للصدر بجانب السرير .)61( 91-تعلق بكوفيد المعرفي الحالي للأشخاص المصابين بالخرف لتوفير المعلومات والدعم فيما ي كانت هذه الدراسات وصفية في الغالب، وتفتقر إلى مجموعة مرجعية، ولم ُتصم م لإجراء تقييم صارم لفعالية التدابير المنفذة. ومع ذلك، فإن تدخلات الوقاية وإدارة الفاشيات الموضحة في الورقات الواردة من الصين وجمهورية عن نجاحات في منع الفاشيات أو احتوائها. كوريا وسنغافورة أبلغت جميعها والحصائل المرتبطة 91-وقيمت ثلاث دراسات أخرى العلاقة بين الخصائص المختلفة لدور الرعاية وتفشي كوفيد به. وقد وجد ستال وآخرون أن الوضع الربحي لدور رعاية المسنين في أونتاريو، كندا، كان مرتبطًا بحجم التفشي بارتفاع احتمالية تفشي ا ًمرتبطالوضع الربحي كن ي. ومع ذلك، لم )71( دد وفيات المقيمين في دور الرعاية وع معتدًلا وذا دلالة إحصائية بين العدد الأولي للوفيات والحد الأقصى المرض. ووجد روميرو أورتونو وكينيلي ارتباطا ً والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -66- . ) 81(لالة إحصائية بجودة دور الرعاية للإشغال في دور الرعاية الأيرلندية، ولكن لم ُيعَثر على ارتباط ذي د واحدة على الأقل في 91-وبالمثل، لم يجد أبرامز وآخرون ارتباطًا ذا دلالة إحصائية بين الإبلاغ عن حالة كوفيد . ومع ذلك، ُعث ر على ارتباط ذي دلالة )91(دور رعاية المسنين بالولايات المتحدة ومعايير الجودة التقليدية المنشأة الأكبر، والموقع الحضري، والنسبة المئوية للمقيمين الأمريكيين من أصل أفريقي، وعدم إحصائية لحجم الوجود ضمن سلسلة، والولاية. أخيرًا، حللت دراستان الارتباط بين الخصائص الإقليمية، بما في ذلك سمات نظام الرعاية الطويلة الأجل مثل و ة رعاية المسنين ر س وتوافر أ َ ، طويلة الأجل العامةالة الرعاية ر مقابل أس طويلة الأجل الخاصة النسبة أسرة الرعاية . )12، 02(في الأقاليم الإيطالية 91- وانتشار كوفيد في الرعاية الطويلة الأجل 91- تقارير عن حالة كوفيد الإلكتروني (وهو مبادرة من الشبكة الدولية لسياسات الرعاية divocCTLروجعت التقارير المنشورة على موقع الطويلة الأجل). وقام على إعداد التقارير خبراء في الرعاية الطويلة الأجل، وهم عادة من الأوساط الأكاديمية. ين على الأشخاص الذين يستفيدون من الرعاية الطويلة الأجل والذ 91- وتهدف التقارير إلى توثيق أثر كوفيد يقدمونها، والتدابير المعتمدة للتخفيف من آثار الجائحة على هؤلاء السكان. وقد أفادت المعلومات المستمدة من هذه التقارير في توجيه الأمثلة على التدابير المعتمدة. المراجع sa deredisnoc eb 91-DIVOC rof sixalyhporp erusopxe-tsop naC .RK kceP ,H noS ,HS eeL .1 fo lanruoJ lanoitanretnI ?slatipsoh erac mret-gnol ni ygetarts esnopser kaerbtuo na .889501.0202.gacimitnaji.j/6101.01:iod .889501;0202 lirpA .stnegA laiborcimitnA sa eniuqorolhcyxordyh dna enilcycyxoD .E idaaS ,S dumhaM ,R idaaS ,M malA ,I damhA .2 ni stneitap 45 fo seires esac morf ecneirepxe :stneitap 91-DIVOC ksir-hgih rof tnemtaert .20966002.81.50.0202/1011.01:iod .0202 yaM .vixRdem .seitilicaf erac mret-gnol stceffe ehT .la te L snamleB ,G érT eD ,G reibettyB ,TJ oeT ,A realesnorB ,A reelegeipS eD .3 gnisrun gnoma noitcefni 91-DIVOC fo semoctuo lacinilc no snitats dna sIECA ,sBRA fo .0202 enuJ .noitaicossA srotceriD lacideM naciremA eht fo lanruoJ .stnediser emoh .810.60.0202.admaj.j/6101.01:iod ni )91-DIVOC( 91 esaesid surivanoroc ot esnopser dna rof ssenderaperp gnivorpmI .T miK .4 .0202 yaM .yprarehtomehC dna noitcefnI .aeroK eht ni slatipsoh erac mret-gnol latipsoh A .la te D niaK ,AC sutfoL ,L dlefneseiW ,C nuL-naF ,C nosrahuqraF ,MN llatS .5 -itlum a fo noitpircsed :kaerbtuo 91-DIVOC a gnicneirepxe emoh gnisrun a htiw pihsrentrap .yteicoS scirtaireG naciremA eht fo lanruoJ .adanaC ,otnoroT ni esnopser ycnegreme esahp .52661.sgj/1111.01:iod .0202 yaM ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -67- 6. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID-19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 7. Munanga A. Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing. 2020;46(6):3–5. doi:10.3928/00989134- 20200511-03. 8. Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M et al. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. Journal of Intellectual Disability Research. 2020. doi:10.1111/jir.12740. 9. Archbald-Pannone LR, Harris DA, Albero K, Steele RL, Pannone AF, Mutter JB. COVID- 19 collaborative model for an academic hospital and long-term care facilities. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.044. 10. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 11. Koeberle S, Tannou T, Bouiller K, Becoulet N, Outrey J, Chirouze C et al. COVID 19 outbreak: organisation of a geriatric assessment and coordination unit – a French example. Age and Ageing. May 2020. doi:10.1093/ageing/afaa092. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS-CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Cabrera JJ, Rey S, Perez S, Martinez-Lamas L, Cores-Calvo O, Torres J et al. Pooling for SARS-CoV-2 control in care institutions. medRxiv. June 2020. doi:10.1101/2020.05.30.20108597. 14. Nouvenne A, Ticinesi A, Parise A, Prati B, Esposito M, Cocchi V et al. Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.050. 15. Goodman-Casanova JM, Dura-Perez E, Guzman-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study. Journal of Medical Internet Research. 2020;22(5):e19434. doi:10.2196/19434. 16. Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit nursing homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada. Medrxiv. 2020. doi:10.1101/2020.05.25.20112664. 17. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. ديفوك نم ةياقولا-19 تاسايس زجوم :لجلأا ةليوطلا ةياعرلا تامدخ فلتخم يف هل يجلاعلا ريبدتلاو -68- 18. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16661. 19. Buja A, Paganini M, Cocchio S, Scioni M, Rebba V, Baldo V. Demographic and socio- economic factors, and healthcare resource indicators associated with the rapid spread of COVID-19 in northern Italy: an ecological study. medRxiv. 2020. doi:10.1101/2020.04.25.20078311. 20. Liotta G, Marazzi MC, Orlando S, Palombi L. Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox. PLoS One. 2020;15(5):e0233329. doi:10.1371/journal.pone.0233329. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -96- شكر وتقدير ق في آراء الخبراء، والرجوع إلى أعدت منظمة الصحة العالمية هذا الموجز من خلال تحليل جديد، وتواف ُ لمنظمة. لالإرشادات القائمة الأقسام المسؤولة عن التنسيق قسم الخدمات الصحية المتكاملة (شانون باركلي، إدوارد كيلي) والوليد والطفل والمراهق والشيخوخة (زي.إيه هان، أنشو بانرجي) قسم صحة الأم الكتاب الرئيسيون إيه هان (الموظف المسؤول)، شانون باركلي ، يوكا سومي-منظمة الصحة العالمية: زي كونراد -سالشرهيريرا، كلارا لورينز دانت، ماكسيميليان - كلية لندن للاقتصاد والعلوم السياسية: أديلينا كوماس مساهمون ومراجعون آخرون اللجنة التوجيهية لمنظمة الصحة العالمية: الشيخوخة والصحة؛ والخدمات والأنظمة السريرية؛ والجنسانية والإنصاف وحقوق الإنسان؛ والخدمات الصحية المتكاملة؛ وصحة الأم والوليد والطفل والمراهق والشيخوخة؛ والصحة النفسية لإدمان؛ والوظائف الحسية والإعاقة والتأهيل؛ ومركز وفرقة عمل الوقاية من العدوى ومكافحتها؛ وتعاطي مواد ا ومركز كوبي التابع لمنظمة الصحة العالمية والمكاتب الإقليمية (بينديتا أليغرانزي، وجوثيسواران أموثافالي ركوس شيسا، وتيريزا دياز، وستيفاني فريل، ثياغاراجان، وسارة لويز باربر، وأنجانا بوشان، وأليساندرو كاسيني، وألا ومانفريد هوبر، وآن جوهانسون، وثيودورا كولر، ومارجريتا لونجينز، وماديسون مور، وبول أونغ، وريتو سادانا، .ا)غ شييس، وكاترين سيهير، وإنريك في ونيكولين تفاقيات السرية وُجم عت إقرارات عدم تضارب ساهم الأفراد التالية أسماؤهم في الوثيقة أو راجعوها. وقد ُوق ّعت اوقد . خضعت للمراجعةو ،المصالح الشبكة العالمية لمنظمة الصحة العالمية المعنية بالرعاية الطويلة الأجل خبراء من خارج منظمة الصحة العالمية: يا غوبتا، وهنادي خميس ساند و للمسنين (ليات أيالون، وبابلو فيلالوبوس دينتران، ووالتر فرونتيرا، وموثوني جيشو، الحمد، وأرفيند ماتهور، وريشما إيه ميرشانت، وستيفن أوكونور، وفينود شاه، وليف فان دين بلوك)، وراشيل أبون، وشون كانون، وليون جيفين، وتيري بولمير، وريتشارد هامفريس، وكيتلين ليتلتون، وتيري لوم، وسانيا سابزواري، ودايفيد ستيوارت. والتدبير العلاجي له في مختلف خدمات الرعاية الطويلة الأجل: موجز سياسات 91-الوقاية من كوفيد -07- . وإذا تغيرت أي عوامل، تغييرات قد تؤثر على هذا الموجز ظمة رصد الوضع عن كثب بحثًا عن أيمنالوتواصل ستصدر المنظمة تحديثًا آخر. ف وزارة الصحة والرفاه. ممث لًة في وتعرب المنظمة عن امتنانها للدعم الكريم الذي قدمته حكومة جمهورية كوريا YB CC-CN-OGI 0.3 ASترخيص ال بعض الحقوق محفوظة. هذا المصنف متاح بمقتضى. 0202منظمة الصحة العالمية © 1.0202/eraC_mret-gnoL/feirB_yciloP/VoCn-9102/OHW :rebmun ecnerefer OHW

-1- 长期护理机构对2019冠状病毒病的预防和管理 政策简报 2020年7月24日 目录 执行概要 ........................................................................................................................................................... 2 1. 概述 ........................................................................................................................................................... 3 1.1 本文件的宗旨.................................................................................................................................... 3 1.2 COVID-19对长期护理的影响：证据告诉我们 ............................................................................. 4 1.3 行动的理由：不让任何一个人掉队................................................................................................ 5 2. 长期护理部门对 COVID-19大流行的应对 ........................................................................................... 6 2.1 将长期护理纳入国家应对 COVID-19大流行的所有阶段 ............................................................ 7 2.2 为长期护理调动足够的资金，以应对 COVID-19大流行并从中恢复 ........................................ 8 2.3 确保有效监测和评价 COVID-19对长期护理的影响，并确保卫生系统和长期护理系统之间 有效传递信息，以优化应对措施 .............................................................................................................. 10 2.4 确保有充足的人员和资源，包括有充足的卫生人力和卫生产品，以应对 COVID-19大流行 和提供高质量的长期护理服务 .................................................................................................................. 12 2.5 确保为接受长期护理服务的人员提供连续的基本服务，包括促进、预防、治疗、康复和姑 息治疗服务 .................................................................................................................................................. 15 2.6 确保所有长期护理机构执行和遵守感染预防和控制标准，以预防和安全管理 COVID-19病 例 16 2.7 优先考虑对接受和提供长期护理服务的人员进行检测、接触者追踪和 COVID-19传播监测 19 2.8 为家庭和志愿护理人员提供支持.................................................................................................. 21 2.9 优先考虑接受和提供长期护理服务的人员的心理健康.............................................................. 23 2.10 确保顺利过渡到恢复阶段.............................................................................................................. 25 2.11 启动卫生和长期护理系统转型工作，以适当整合并确保对长期护理服务的持续有效治理.. 27 参考文献 ......................................................................................................................................................... 29 附件 1. 方法 .................................................................................................................................................... 37 鸣谢 ................................................................................................................................................................. 42 网页附件：长期护理机构对2019冠状病毒病进行预防和管理的主要目标和关键行动 https://apps.who.int/iris/bitstream/handle/10665/334020/WHO-2019-nCoV-Policy_Brief-Long- term_Care-Web_Annex-2020.1-chi.pdf 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -2- 执行概要 COVID-19大流行对老年人的影响尤为严重，特别是那些生活在长期护理机构中的老年人。在很多国 家，有证据显示，超过40%的COVID-19相关死亡与长期护理机构有关，在一些高收入国家，这一数字 高达80%。另外，在长期护理机构中，COVID-19患者的病死率可能高于长期护理机构以外的同龄人群。 居住在长期护理机构的人员往往面临高风险，预防措施不多，用于从COVID-19中恢复的资源不足， 而且在COVID-19患者激增期间因卫生系统紧张而减少了获得基本卫生服务的机会。 另外，COVID-19对长期护理机构和其他部门长期护理服务提供者的影响也很大。联合王国国家统计 局在2020年进行的一项按职业分类的死亡研究发现，社会护理人力显著提高了与COVID-19相关的死 亡率。 迄今为止，COVID-19已对长期护理机构造成极其严重的影响。然而，在全面减缓它对长期护理机构 的影响方面仍然需要采取协调一致的行动，包括在家庭护理和社区护理方面，因为大多数护理服务 使用者和提供者都容易受到严重COVID-19的影响。长期护理的应对行动将是许多国家减缓COVID-19 大流行的基本和必要步骤之一。只有解决长期护理问题，各国才能在应对COVID-19方面真正做到不 让任何一个人掉队。 本政策简报提供了11项政策目标和关键行动点，以期在长期护理方面预防和管理COVID-19。其目标 受众是参与COVID-19大流行应对的决策者和当局（国家、国家以下一级和地方）。本简报基于目前 掌握的证据，介绍了为预防、准备和应对COVID-19大流行以及为减缓对包括护理提供者在内的长期 护理部门的影响而采取的各种措施。 虽然本文件载有与所有长期护理环境相关的政策方案和行动，但着重强调了长期护理机构，因为它 们的COVID-19发生率、发病率和死亡率极高。 此外，本政策简报还探讨了长期护理系统中存在的长期问题，包括资金不足、缺乏问责制、卫生服 务与长期护理之间存在分裂以及人力价值被低估问题。本政策简报建议转变卫生服务和长期护理服 务的方式，使长期护理服务能够便于整合，成为包括健康促进、预防、治疗、康复和姑息治疗在内 的连续护理服务的一部分。只有通过这些措施，需要长期护理的人们才能获得优质、公平和可持续 的护理服务，使他们在生活中的基本权利、基本自由和人类尊严能够得到尊重。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -3- 1. 概述 1.1 本文件的宗旨 COVID-19大流行暴露了应急反应对长期护理重视不足的弱点，导致了全球长期护理服务行业遭受毁 灭性影响。这些事件凸显了大多数国家长期护理体系中存在的长期问题：资金不足、缺乏问责制、 碎片化、卫生服务与长期护理之间协调不畅以及人力价值被低估(1-3)。 本政策简报介绍了参与应对COVID-19大流行的决策者和当局（国家、国家以下一级和地方）预防和 管理COVID-19长期护理的政策目标和关键行动点。本简报基于目前掌握的证据，介绍了为预防、准 备和应对COVID-19大流行及其对使用长期护理服务者和护理服务提供者（包括有偿工作人员和家庭 及其他志愿护理人员）的影响而采取的措施。它还更加充分地阐述了关于在世界卫生组织（世卫组 织）欧洲区域长期护理服务中预防和管理COVID-19大流行的技术工作指导，提供了全球视角和世卫 组织所有区域的国家实例(4)。 虽然本文件载有与所有长期护理环境相关的政策方案和行动，但着重强调了长期护理机构，因为它 们的COVID-19发生率、发病率和死亡率极高。 不过，尽管长期护理机构是长期护理的一个组成部分，但必须强调的是，基于社区的服务是促进就 地养老、减少养老机构中的数量和支持去机构化的关键，以便人们能够以符合其基本权利、基本自 由和人类尊严的方式生活。 专栏1介绍了本文件中所用术语的定义。 专栏 1. 工作术语：所用术语的定义 长期护理系统 确保适当、负担得起、可获得的综合长期护理并维护人们和护理人员权利的国家系统(1)。 长期护理 旨在确保身体功能和精神能力严重丧失或面临严重丧失风险的人能够保持一定程度的功能能力以 便享有其基本权利、基本自由和人类尊严的服务(1)。这些服务通常涉及日常活动 （包括穿衣、 洗澡、购物、烹饪和清洁） 的护理和协助、社会参与支持以及通过社区护理、康复和临终关怀管 理老年慢性疾病。服务由无偿护理人员（通常是家庭成员，但也包括志愿者）和有偿护理人员提 供。 在整个文件中，使用“长期护理服务”一词包括家庭护理、社区护理和机构护理（长期住在长期 护理机构、疗养院或其他集体生活机构），另有说明的除外。 长期护理机构 各国的长期护理机构可能各不相同。为无法在社区独立生活的人提供包括医疗和辅助护理在内的 各种服务的疗养院、熟练护理机构、辅助生活机构、居住类机构和居住类长期护理机构统称为长 期护理机构。在整个文件中，使用“长期护理机构”一词不包括家庭长期护理、社区中心、成人 日托机构或临时护理。 护理人员 为别人提供护理和支持的人。护理人员可能包括家庭成员、朋友、邻居、志愿者、护理工作人员 和卫生专业人员(1)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -4- 1.2 COVID-19对长期护理的影响：证据告诉我们 对长期护理机构中COVID-19情况的系统性回顾(5)和汇编报告（附件1）中的证据表明，虽然没有证 据表明COVID-19对社区中使用和提供长期护理服务的人产生了影响，但大流行对生活在长期护理机 构中的人特别是老年人产生了不成比例的影响。在COVID-19导致大量死亡的国家中，约有一半的死 亡是居住在长期护理机构中的老年人。附件1更为详细地描述了本报告在进行系统性回顾和其他审查 时所采用的方法。 有早期证据表明，各国之间以及各国内部长期护理机构中COVID-19感染的程度存在很大差异：例如， 一些国家（如约旦）的长期护理机构迄今为止没有感染报告，而在瑞典，截至4月底，全国有25%的 长期护理机构出现COVID-19疫情，斯德哥尔摩有67%的长期护理机构受到影响。 来自21个高收入国家的数据显示，虽然一些国家的长期护理机构中没有人死亡或死亡人数很少，但 其他国家报告称，在这些国家与COVID-19相关的所有死亡中，平均有近一半的死亡者是居住在长期 护理机构的人（从匈牙利的24%到加拿大的82%不等）。在有些国家，长期护理机构中与COVID-19相 关的所有死亡在长期护理机构所有居住者中所占的比例高达3%至6%(6)。很多国家没有提供按年龄和 性别分列的数据。 还有证据表明，一旦长期护理机构中出现COVID-19感染，就很难控制，部分原因是机构中拥有大量 人员，个人生活空间狭小，因为这些机构都是为了集体生活而设计的，而且事实上个人护理需要离 得很近。尽管来自大韩民国的病例报告显示，在一名工作人员检测呈阳性(7、8)之后，长期护理机 构中的进一步感染得到了成功缓解，但一些其他国家的病例研究表明，在这些环境中控制感染是多 么困难。例如，在大不列颠及北爱尔兰联合王国和美利坚合众国进行的研究显示，居住在长期护理 机构中的人的发病率在40%至72%之间(9-14)，如果对发生疫情的机构的所有工作人员进行检测，工 作人员的感染率在1.5%至5.9%之间(7、8、15-18)。还有一项研究表明，在多个家庭工作的员工可能 成为传播的源头(19)。 在联合王国，按职业分列的死亡分析表明，从事社会护理工作的男女护理人员显著提高了与COVID- 19关联的死亡率（每10万男性中死亡23.4人，而20至64岁男性死亡9.9人，每10万女性死亡9.6人， 而20至64岁女性死亡5.2人）(20)。 六项研究介绍了为预防（中国和新加坡）和控制或管理（加拿大和大韩民国） 长期护理机构暴发疫 情而采取的措施，尽管这些研究没有对照组，但研究还是认为这些措施取得了一定的成功(7、8、 22-23)。 有越来越多的证据表明，长期护理机构中出现症状前或无症状和出现“非典型症状”的COVID-19患 者可能存在传播能力。对疫情的研究表明，7%至75%检测呈阳性的长期护理机构居住者和50%至100% 检测呈阳性的工作人员为出现症状前或无症状患者(11–13、15、17、19、24)。57%至89%无症状阳 性居住者后来出现症状(11、19)。在比利时，对长期护理机构居住者和工作人员进行的系统性全国 检测表明，居住者中有74%的病例和工作人员中有76%的病例在检测时为无症状(25)。 一旦生活在长期护理机构的人患有COVID-19，居住者的病死率可能高于长期护理机构以外的同龄人 群。例如，在加拿大安大略省，长期护理机构居住者的COVID-19死亡发生率比70岁或以上社区病例 高13倍(26)，在以色列，患有COVID-19的养老院居住者发生严重疾病（包括死亡）的风险比65岁以 上其他病例高2.5倍(27)。 尽管有很多社论和评论文章提到可能对精神卫生和身体健康产生的影响（例如，痛苦、抑郁、厌食、 由于缺乏锻炼导致的身体状况下降以及由于增加化学和物理约束而产生的后果），但没有研究报告 表明感染本身或为预防长期护理机构发生感染而采取的措施会产生有害的健康后遗症。这已引起人 们对直接和间接发病率和死亡率增加的关注(28、29)。 关于COVID-19大流行对使用和提供社区长期护理服务的影响的证据有限，包括对家庭佣工、日托机 构和无偿护理人员的影响。一些公共卫生和感染预防措施（包括限制行动、保持身体距离和宵禁） 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -5- 可能导致对很多有护理需求的人所依赖的正常护理和支持来源产生限制。来自联合王国的证据发现， 在COVID-19大流行期间，残疾人遇到的不平等越来越多。残疾人报告说，他们难以获得食物和药品， 福利系统也出现延误，有些人面临粮食不安全和贫困。很多残疾人表示感觉受到孤立，对一些人来 说，无法上网意味着他们无法获得虚拟替代服务。另外，支持机构的持续减少也使人们更加依赖家 庭和邻居(30)。 身体健康的人也可能在获得包括康复在内的基本卫生保健服务方面遇到困难，这进一步增加了护理 需求。此外，卫生保健服务的中断会导致对护理的需求增加(31、32)。 人们越来越认识到，在很多国家，遏制大流行的最初计划并没有包括长期护理机构；只是在媒体报 道开始出现大量死亡时，资源才被调动起来。一些国家不得不动用军队和其他应急单位为因大量死 亡和工作人员不足而不堪重负的长期护理机构提供支持(33)。在很多国家，直到发生了大规模疫情 之后长期护理机构才获得检测、个人防护装备和医疗支持(34)。 1.3 行动的理由：不让任何一个人掉队 卫生系统有责任一视同仁地为所有人提供包括辅助治疗和姑息治疗在内的安全、可获得、负担得起 和高质量的卫生保健。 不过，有证据显示，长期护理机构的居住者往往面临更高的风险、更低的预防措施和用于控制 COVID-19的资源不足，而且获得基本卫生服务的机会减少，因为卫生系统在COVID-19激增的背景下 受到制约(35)。 老年人在使用长期护理服务的人口中占很大比例，特别是那些患有基础疾病的人更有可能发展成 COVID-19重症患者，包括那些生活在长期护理机构中的人(36)。需要立即采取行动，预防感染，减 缓COVID-19大流行对这一人群的影响，并确保提供必要的卫生保健和辅助护理服务。 此外，妇女（尤其是老年妇女）还在使用护理服务的人群中占的比例最高，在长期护理人力中占主 导地位，并且是家庭护理服务的主要提供者(1、37)。另外，长期护理服务还往往严重依赖移民工人 和少数族裔工人，他们可能面临更高的风险(1、38-40)。 大流行的应对措施必须将长期护理部门考虑在内，以确保族裔、年龄和性别群体不被边缘化。 还有人对人权表示关切，包括对依赖（和提供）长期护理服务的人口的潜在忽视以及为减少感染风 险而采取的措施（例如，禁止探视和禁止户外体育活动）。应对大流行的措施必须将长期护理部门 考虑在内，以便实施适当和有针对性的措施，解决长期护理部门存在的具体问题。 迄今为止，COVID-19已对生活在长期护理机构的人们构成不成比例的影响。不过，需要采取协调一 致的行动来减缓对长期护理所有方面的影响，包括家庭和社区护理，因为大多数护理服务使用者和 提供者都容易成为COVID-19的重症患者。 考虑到COVID-19对长期护理行业的巨大影响，长期护理行业的应对行动将是很多国家减缓COVID-19 大流行的基本和必要步骤之一(4)。 只有解决长期护理问题，各国才能在应对COVID-19时真正做到不让任何一个人掉队(41)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -6- 2. 长期护理部门对COVID-19大流行的应对 虽然大流行致使公众注意到大流行的直接影响以及必须对当前突发事件和未来可能发生的下一波疫 情做好准备，但它也表明，在提高长期护理系统的安全性和抵御力方面还有需要应对的重大结构性 挑战。 迄今为止，大多数国家都在努力发展协调一致的系统，以确保能够获得以人为本的优质长期护理服 务，满足对卫生服务和辅助性护理日益增长的需求，而且能够享有基本权利、基本自由和人类尊严 (1、42-45)。即使在高收入国家，经济合作与发展组织（经合组织）的一项审查认为，“在很多国 家，制定长期护理政策的方式非常零碎，目的是为了应对当前的政治或财政问题，而不是以可持续 和透明的方式制定的”(43) 。 本节探讨了影响长期护理系统应对COVID-19大流行能力方面的独特挑战，并提出了从短期和长期角 度应对这些挑战的政策目标和关键行动。 根据迄今为止的现有证据和国际经验，专栏2中提出的11项政策目标将是长期护理系统应对COVID-19 的关键。 专栏 2. 减缓 COVID-19对长期护理的影响的 11项政策目标 1. 将长期护理纳入国家应对 COVID-19大流行的所有阶段。 2. 为长期护理调动足够的资金，以应对 COVID-19大流行并从中恢复。 3. 确保有效监测和评价 COVID-19对长期护理的影响，并确保卫生系统和长期护理系统之间 有效传递信息，以优化应对措施。 4. 确保有充足的人员和资源，包括有充足的卫生人力和卫生产品，以应对 COVID-19大流行 和提供高质量的长期护理服务。 5. 确保为接受长期护理服务的人员提供连续的基本服务，包括促进、预防、治疗、康复和姑 息治疗服务。 6. 确保所有长期护理机构执行和遵守感染预防和控制标准，以预防和安全管理 COVID-19病 例。 7. 优先考虑对接受和提供长期护理服务的人员进行检测、接触者追踪和 COVID-19 传播监 测。 8. 为家庭和志愿护理人员提供支持。 9. 优先考虑接受和提供长期护理服务的人员的心理健康。 10. 确保顺利过渡到恢复阶段。 11. 启动卫生和长期护理系统转型工作，以适当整合并确保对长期护理服务的持续有效治理。 以下分段依次阐述了以上所述每一项政策目标。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -7- 2.1 将长期护理纳入国家应对COVID-19大流行的所有阶段 2.1.1 挑战 与卫生和其他政策领域相比，长期护理的政治优先性较低 长期护理的政治优先性低，经常被称为“福利国家的灰姑娘”，在这些国家，对它的政治关注往往 是短暂的，排在卫生保健之后(46)。对长期护理行业缺乏政治关注可能是很多国家在应对大流行的 最初政策中没有将长期护理部门考虑进去的原因之一(4)。 长期护理系统的治理往往涉及多个部门、不同部委和不同级别的政府，协调困难 在大多数国家，长期护理属于不同部门，通常是卫生保健和社会事务、发展或社会保障部。长期护 理服务和卫生保健系统往往缺乏协调或整合，往往在筹资、监管、信息系统以及人员培训和采购方 面有单独（而且往往复杂）的安排(1、43)。 这在COVID-19危机期间引起了一些困难。例如，为满足医院中COVID-19患者激增而采用的后备人员 配备模式不够灵活，无法满足长期护理部门的需求激增。在需要时，适当的工作人员也很难在整个 系统内灵活调动。同样，长期护理部门（特别是长期护理机构）难以获得检测和个人防护装备，因 为检测和个人防护装备优先供医院使用 (47)。 此外，各国经常在国家、区域和地方行为者之间垂直分配长期护理责任，为服务协调和有效监督造 成困难(48)。例如，在西班牙和意大利，同一个人可能接受由多达三个不同级别的政府机构组织或 资助的长期护理服务(49、50)。 除了家庭护理人员之外，长期护理服务还由公共、私人营利性和私人非营利性服务提供者共同组成 长期护理服务的另一个特点是由公共、私人营利性和私人非营利性服务提供者共同组成(51)。在一 些国家，大多数长期护理机构由私人营利性提供者经营，特别是在低收入和中等收入国家，而这些 机构往往不受监管(52、53)。 特别是在低收入和中等收入国家，非政府组织在提供长期护理服务方面发挥着重要作用，往往是无 偿护理人员的唯一支助来源。不过，在没有非政府组织的地方，照护责任往往完全落在家庭成员身 上。这种无偿照护很少在正规系统中得到承认，因此，除了支持这一工作的非政府组织之外，没有 被纳入任何治理进程和机制。这些机构可能导致缺乏所有权、责任分散和责任碎片化，造成协调和 照护质量问题，并导致信息系统不发达(43、54)。 在 COVID-19背景下的影响  可能会阻碍将长期护理纳入大流行国家应对措施中  可能会阻碍大流行期间的计划、监督和问责  可能会阻碍长期护理和卫生保健部门在应对大流行方面的协调应对  可能会阻碍资源的有效分配 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -8- 2.1.2 关键行动 整个部门 • 确保 COVID-19 主管部门中有一个负责长期护理事务的归口单位（特别关注长期护理服务使 用者和提供者）。 • 设立联合指导委员会以及部门与国家以下各级政策之间的信息和数据共享系统，以确保做出 协调一致的应对。 • 建立一个机制，为不受监管的供应商提供支持，侧重于合作性支持，而不是惩罚性措施。 长期护理机构 • 如果长期护理机构在大流行期间扩大其卫生保健作用，则设立旨在启动分阶段重新分配日常 综合卫生服务能力的触发机制或阈值，包括直接卫生保健人员。 国家例子 在新加坡，综合护理署和卫生部与长期护理服务提供者一道，共同制定了应对COVID-19大流行的 若干措施。这些措施包括感染控制和预防措施、获取个人防护装备、保持社交距离和分区措施、 暂停来访者、为长期护理人员提供替代住所，以及对有长期护理需求的人员和护理人员进行检测 和监测。综合护理署还成立了一个事件响应小组，支持长期护理提供者应对COVID-19感染。关爱 老人办公室是综合护理署的一个外联部门，在COVID-19大流行期间，通过联系、信息和提供服务 的方式为老年人提供支持(55，56)。 在以色列，已经任命一个负责管理全国长期护理机构中COVID-19疫情的管理小组。该小组在“保 护父母”项目下制定了一项国家计划，包括建立一个可以协调政府工作的总部。此外，“后方司 令部”也在整个大流行期间一直在协助长期护理机构对来访者出入、消毒、运送食品和设备进行 管理，并一直在防护和预防措施方面提供培训和指导(57)。 在马耳他，作为长期护理事务的监管机构，社会护理标准局已在3月初将寄宿制护理机构定为 COVID-19高风险单位。社会护理标准局立即在其COVID-19简报（2020年）上发布了防护指令。公 共卫生管理局与社会护理标准局之间开展了直接合作，事实证明，这种合作成为长期护理机构内 保护老年人的主要诱因(58)。 2.2 为长期护理调动足够的资金，以应对COVID-19大流行并从中恢复 2.2.1 挑战 为长期护理分配的公共资金有限 长期护理的平均公共支出非常低，不到全球国内生产总值的1%。这种公共资金不足的情况影响到获 得长期护理的机会(42)。这种情况在低收入和中等收入国家更为明显，其中很多国家缺少用于长期 护理的专用公共资金来源。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -9- 长期护理的公共福利方案通常以需求为基础，并进行过经济情况调查，而且往往需要共同支付，使 大部分人口处于公共体系之外 在大多数国家，支持长期护理的公共福利方案是以需求为基础，并进行过经济情况调查，通常需要 共同支付。那些有更大需求的人往往会得到更多的支持，但一些国家也对公共资源所能支付的金额 设置了限额。虽然一些国家保护最弱势群体免受额外费用的影响，但对于接受长期护理服务的大多 数人(43、59、60)来说，各国普遍存在相当大的自付费用。此外，由于无偿护理人员提供的照护所 占比例很大，实际上长期护理的很大一部分成本由家庭承担，这是通过提供护理的机会成本与自付 费用相结合的方式实现的。拥有保护全体人口免受灾难性长期护理费用影响的融资机制的国家不多 (1)。 长期护理部门收入减少，护理成本增加 个人防护装备和人力成本的提高意味着服务提供者面临成本的大量增加。与此同时，由于长期护理 机构入住率较低（住院人数减少和死亡人数高于正常水平）以及日托中心等社区服务机构的关闭， 提供者的收入正在减少。 在这场危机中，一些国家已为支持长期护理部门提供了应急资金。不过，在长期护理系统比较发达 和规范的国家，资源的提供和分配可能更加容易。向未注册的长期护理部门提供资源和支持带来了 额外的挑战。 长期护理融资方面的这种独特挑战使长期护理系统很难对准备和应对COVID-19可能产生的额外成本 做出反应。 在 COVID-19背景下的影响  缺乏足够的资金用于支付与应对 COVID-19 相关的额外费用可能会危及长期护理使用者和 提供者的安全  由于大流行导致护理费用增加，从而导致护理使用者的自付费用增加 2.2.2 关键行动 整个部门 • 考虑为长期护理注入额外的专用资金，以用于支付与大流行相关的额外费用（例如，员工成 本增加、感染预防和控制（IPC）培训以及个人防护装备和消毒剂等材料）。 • 考虑如何在大流行期间降低服务提供者的监管和其他成本（如人员配备需求）。 • 灵活使用为长期护理服务提供者和使用者分配的应急资金。 长期护理机构 • 为补偿入住率较低提供资金，并确保提供高质量的基本卫生和护理服务。 • 为长期护理机构的提供者提供资金支持，承担因确保其居住者和工作人员安全而发生的额外 费用，包括针对 COVID-19的额外预防感染和控制措施和检测。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -10- 社区护理 • 为在大流行期间不得不停止一些服务而失去收入的提供者（尤其是非盈利性机构）提供支持， 如日托和社区中心。 • 为使用个人预算和其他现金福利提供灵活性，例如，如果社区中心无法提供服务，允许将个 人预算和其他现金福利用于雇用家庭成员或邻居。 护理人员 • 为那些可能因正规护理机构不再提供服务而需要承担额外护理责任并且可能需要为此放弃工 作的护理人员提供支持。 国家例子 在美国，3万亿美元的COVID-19刺激计划（《冠状病毒援助、救济和经济安全法案》之下）为长 期护理部门提供了一些资金。在根据该法案分配给卫生保健服务提供者的1000亿美元资金中， 500亿美元正在分给医院和长期护理服务提供者，包括家庭卫生保健服务提供者(61)。截至2020 年6月3日，已有49亿美元用于熟练护理机构(62)。 在大韩民国，卫生和福利部和韩国国民健康保险局印发了长期护理部门临时报销准则。该准则考 虑了与COVID-19相关的保持身体距离措施和人员短缺的需要。此外，在特别疫区，如果服务提供 者无法在大流行期间遵守人员配备要求，则不会减少为服务提供者支付的费用(63)。 在中国，获得补贴的长期护理服务提供者得到一次性特别津贴，以支持人员配备（例如，雇用和 重新部署工人以及补偿加班），确保持续提供长期护理服务。据估计，这一支助总额约为160万 美元(64、65、66)。 2.3 确保有效监测和评价COVID-19对长期护理的影响，并确保卫生系统和长期护理 系统之间有效传递信息，以优化应对措施 2.3.1 挑战 拥有长期护理系统信息和监测系统的国家不多 拥有长期护理系统信息和监测系统的国家相对较少，包括关于正规长期护理服务使用者的特征、需 求和结果的个人数据以及关于他们接受的护理类型和质量的数据。这反映了老年人（通常是长期护 理服务使用者）的数据来源有限而且缺少按年龄和性别分列的数据的总体情况(67)。 在有个人数据的国家，这些数据通常只涉及那些使用公有资金资助的长期护理服务或提供服务的人 员。此外，卫生和社会护理数据通常是由不同的系统收集的，导致很难将同一个人的数据联系起来。 有报告称，由于COVID-19大流行，一些不受监管的长期护理机构被“发现”(68)。缺少关于长期护 理机构居住者特征的个人数据已被确定为COVID-19大流行应对计划的一个障碍(69、70)。这意味着， 例如，为大流行制定知情应对计划提供信息的数学模型没有将长期护理机构中的居住者与周围人群 分开考虑(71)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -11- 关于大流行的数据最初只收集了那些在医院接受检测和死亡的人 公布长期护理机构中感染或死于确诊或疑似COVID-19的居住者人数数据的国家很少。由于居住在长 期护理机构的人员比住在私人家庭里的人员更不太可能接受检测或住院，因此，数据中不包括院外 死亡的国家很可能低估了COVID-19的死亡人数。 一项跟踪长期护理机构居住者死亡数据的国际倡议发现仅有21个国家在2020年5月公布了数据(6)。 如果没有数据能够说明感染对长期护理机构和依赖护理并生活在社区中的人员的影响，就有可能无 法充分和及时地提供预防和减缓COVID-19对长期护理部门的影响所需的资源（资金、人力、检测、 个人防护装备和其他设备）。 关于大流行对健康的相关影响的数据很少 很多依赖辅助护理（特别是社区护理）的人在正常使用护理方面受到干扰，这可能会使他们面临风 险（例如，由于营养不良、未发现的感染或其他健康并发症）。需要有识别更高风险人群的数据， 以识别存在的差距并根据需要重新配置服务。 在 COVID-19背景下的影响  难以监测 COVID-19对整个长期护理行业的影响  难以为长期护理行业制定量身定制的应对计划，以减轻影响  很难将长期护理人口纳入预测模型  难以监测 COVID-19对长期护理使用者和长期护理人力的健康影响  长期护理机构和卫生机构之间的信息分散 2.3.2 关键行动 整个部门 • 找到有效方法，利用现有长期护理管理数据（例如，美国的 MDS 3.0 以及加拿大和新西兰的 interRAI评估系统），模拟 COVID-19对健康（包括精神卫生）和老年人长期护理系统的运行 的影响。对于没有这些系统的国家，考虑将建立这种管理数据系统作为一种长期行动。 • 鼓励研究 COVID-19 对长期护理的影响以及减轻影响的措施，以确定差距并为未来的大流行 做好准备。 长期护理机构 • 建立一个监测系统，以收集关于长期护理机构中发生的 COVID-19 患者和死亡的数据（按年 龄、性别、残疾和现有健康状况分类的疑似和确认病例），并确保这些监测系统与现有监测 系统融为一体。 • 建立必要的法律机制，以便定期和经常从长期护理机构、卫生机构、公共卫生当局和公众那 里获得和传输与 COVID-19相关的信息。 • 建立一个机制，确保定期分析这些数据，并将分析结果用于完善政府的 COVID-19 应对政策。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -12- 社区护理 • 建立向主管公共机构报告在社区和家庭接受和提供长期护理服务的人群中 COVID-19 患者人 数的机制。 实例 在南非，如果COVID-19病例得到确诊，长期护理机构的管理人员必须向社会发展部通报(72)。 在欧洲联盟，欧洲疾病预防和控制中心（欧洲联盟的一个机构）已将长期护理机构纳入其国家 和欧洲联盟/欧洲经济区一级COVID-19监测战略，并正在从成员国收集关于减缓行动、感染率和 死亡率的数据(73)。 在阿根廷拉普拉塔，与一个非政府组织共同开发了一个网站，用于监测和分享关于注册和非正 规长期护理机构的信息。该平台被用于调查长期护理机构对COVID-19的准备情况，并促使地方 政府确保向长期护理机构的所有员工提供检测(53)。 2.4 确保有充足的人员和资源，包括有充足的卫生人力和卫生产品，以应对COVID- 19大流行和提供高质量的长期护理服务 2.4.1 挑战 先前存在的缺少人力、工资低和工作条件差 在COVID-19大流行之前，缺少人力、工资低和工作条件差以及合格的专业人员比例低已经是长期护 理系统存在的一个主要问题(2、3、73)。为有长期护理需求的人提供支持的人力主要是女性 (90%)(37)，在很多国家，移民护理工在长期护理人力中占很大一部分(74)。护理工没有签订合同并 为多家护理机构工作是常见的事(75)。 大流行期间缺少长期护理工作人员 在很多国家，长期护理行业（特别是长期护理机构）在COVID-19大流行期间出现了严重缺少人手的 问题，他们的工作人员因疑似或确诊感染COVID-19而不得不隔离(49、50、76、77)。由于实行探访 和行动限制，在家庭和其他无偿护理人员不太可能提供支持（即使在长期护理机构中，家庭和志愿 护理人员也做出了重要的护理贡献）的时候，就会出现这种情况。在某些情况下，如果长期护理机 构不堪重负和人手不足时，国家不得不采取极端措施，如求助军队或其他应急服务(49)。 在一些国家，长期护理工和护理人员最初并不被视为关键人员，封锁措施和宵禁意味着他们不能去 上班（或继续为其他家庭的人员提供护理）(78、79)。使用公共交通工具或住在拥挤的房子可能会 增加护理人员感染病毒的风险。 难以适应长期护理机构中卫生保健需求的增加 虽然一些长期护理机构雇用护士和其他卫生保健人员，但并非所有机构都是如此，而且有报告称， 一些长期护理机构中未获得医学培训的工作人员面临困难，因为他们需要向患有COVID-19感染的人 或者向那些需要姑息治疗服务的人员提供护理服务，但没有卫生保健人员给予支持，也没有合格的 卫生专业人员（如医生和护士）进行监督。 在西班牙的一个地区，由于在将工作人员和医疗用品从卫生服务部门转到长期护理机构方面面临行 政阻碍，致使所有长期护理机构在大流行期间归卫生部负责(49)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -13- 长期护理服务提供者和护理人员无法获得个人防护装备 由于全球短缺和优先供应医院及其他卫生保健机构，很多国家的长期护理服务提供者和护理人员在 获得个人防护装备和其他资源（如洗手液和消毒剂）方面面临困难。长期护理服务提供者报告说， 因此不得不以高价购买个人防护装备。 在 COVID-19背景下的影响  长期护理行业缺少大量人力  在补偿人力短缺时，员工流失率高可能会影响护理的连续性以及重要感染预防和控制措施 的一致性  降低了工作的完整性和由妇女和移民工人为主的长期护理人力的价值  由于工作条件差，如缺少病假补偿，增加了生病期间工作的经济压力  长期护理人员的职业安全没有得到认真考虑  长期护理机构、长期护理人力（包括护理人员）和护理服务接受者严重缺乏个人防护装备  长期护理机构缺少基本医疗用品和卫生人力  长期护理机构在提供基本服务方面缺少合格的卫生专业人员的监督 2.4.2 关键行动 整个部门 • 与负责长期护理事务的归口单位进行协调，对支持长期护理服务所需的激增能力作出估计。 • 为卫生和社会护理采购链牵线搭桥，确保在 COVID-19期间供应的连续性和不冲突。 • 招聘额外的员工，制定关于感染预防和控制措施的快速培训规划（例如，招聘退休人员、来 自卫生和长期护理培训规划的学生以及志愿者）。 • 解决合同和相关问题，制定确保员工安全的政策和措施，但允许他们弹性工作，并在需要时 从卫生保健服务转为长期护理服务。 • 建立花名册并确保卫生系统工作人员可在需要时为长期护理机构工作人员提供支持。 • 采取措施，防止政策阻碍长期护理人员通过家庭、社区和机构提供重要护理服务。 • 采取措施，对在多个地点工作从而导致传播风险增加的员工进行监测，并考虑为员工的交通 和住宿提供便利，以便将本地疫情期间的感染风险降到最低。 • 为护理人员提供经济补偿，以激励他们在疫情期间继续工作，并对他们增加的额外工作量和 压力予以补偿。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -14- 长期护理机构 • 确保为长期护理机构中足够供应个人防护装备，以防止护理人员受到感染。 • 为长期护理机构的工作人员和家庭护理人员提供充分的感染预防和控制措施培训指导，并对 他们进行定期培训，使他们能够继续在这些机构中提供护理服务。 • 推广弹性工作制，使姑息治疗团队和其他相关的卫生和护理专业人员能够与长期护理机构的 工作人员合作，确保在需要时能够获得姑息治疗。 • 确保由经过适当培训的人员进行充分监督，以便在长期护理机构提供基本服务。 • 确保为家庭护理人员提供个人防护装备，特别是那些在家附近提供护理服务的人员。 • 提供充分的培训指导，并对社区护理服务提供者进行常规培训。 家庭和其他志愿护理人员 • 确保为在家附近提供护理服务的护理人员提供个人防护装备。 • 为家庭和其他志愿护理人员提供充分的指导和培训。 国家例子 在奥地利，在COVID-19大流行期间，护理工人的人员配备和许可条例已经大大放宽。这使那些服 过兵役的人员（选择文职工作的人）能够提供基本护理服务。服过兵役的人员已为管理大流行的 物流工作做出了贡献。政府可以强制要求他们从事护理工作。此外，接受相关领域培训的人员和 目前处于失业状态但有兴趣参与护理服务的人员也可以参与(76)。 在爱尔兰，爱尔兰养老院在2020年3月发起了养老院（私营和非政府组织经营）招聘活动。此 外，卫生服务行政部门也同意（在自愿基础上）向私人养老院调派工作人员(77)。 在印度，一些长期护理机构为其内部员工提供免费食物等激励措施。此外，一些长期护理机构还 在通过定期检查和咨询的方式来促进其工作人员的心理健康(78)。 在以色列，如果长期护理机构出现人员短缺问题，卫生部将派出一个为期7至14天的特别小组， 以便为提供紧急护理服务提供支持(57)。 在荷兰，从2020年5月19日起，为需要近距离（1.5米以内） 向需要长期护理的人员提供护理活 动的护理人员免费提供个人防护装备(80)。 在西班牙，社区护理中心的护理人员一直在为提供家庭护理服务提供支持，例如通过电话。此 外，长期护理部门还可在正式员工缺勤的情况下雇用没有资格的工作人员(49)。 在澳大利亚，居住在护理机构的护理人员将获得两个季度最高可达税后800澳元的留用奖金。政 府雇用卫生保健服务提供者为每个州需要长期护理部门组建快速反应小组。放宽签证规则，以使 工作人员能够有更多的工作时间(81)。 在联合王国的部分地区，护理人员的工资有所增加，并为在COVID-19大流行期间坚持工作的工作 人员提供了一笔一次性的特别补偿(82)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -15- 2.5 确保为接受长期护理服务的人员提供连续的基本服务，包括促进、预防、治疗、 康复和姑息治疗服务 2.5.1 挑战 需要持续、复杂的护理，并有高度的身体和情感接触 有长期护理需求的人通常需要持续、复杂和个性化的支持机构。对个人的辅助护理尤其需要高度的 身体和情感接触。接受这种护理的人和依赖这种支持的人都极其需要护理的连续性(1)。在很多国家， 长期护理机构的大多数居住者患有痴呆症(83-85)。 长期护理机构提供的卫生保健服务不固定 长期护理机构多种多样，虽然有些可能专门提供医疗护理，如长期护理医院或一些护理机构，但其 他机构通常为住宅或辅助性住所，可能没有受过卫生保健培训的工作人员。在很多国家，除了应对 新的COVID-19负担（包括在康复和姑息治疗领域）外，长期护理机构还在提供卫生保健支持和基本 卫生服务所需资源方面遇到困难。 在入院时可能存在歧视性分诊做法 有报告称，长期护理机构的居住者无法获得医院里的卫生保健服务(49、50)，而且获得初级保健的 机会有限。也有报道称，高级护理指令有时在实施时没有遵守通常的以人为本的标准(86)。各国在 应对大流行时强调了老年人和现有疾病患者在COVID-19大流行期间公平获得卫生保健和姑息治疗的 重要性(35、36)。 在 COVID-19背景下的影响  很多国家的长期护理机构在提供卫生保健支持以及维持基本卫生服务和为应对新的 COVID-19挑战提供辅助护理服务所需的资源方面遇到困难  长期护理机构中的居住者有时会因为年龄等不相关或歧视性标准而被拒绝给予医院护 理，因为他们被推定身体太弱而无法存活 2.5.2 关键行动 整个部门 • 考虑制定明确的 COVID-19 护理行动路线，其中包括长期护理机构以及家庭护理和社区护理， 为患有 COVID-19和无 COVID-19症状的患者提供初级、二级和三级护理(87、88、89)。 • 考虑采取适当的远程医疗和虚拟问诊技术，同时考虑老年人的意见，并为有效使用这种技术 提供一切必要的支持。 • 确保所有姑息治疗计划和高级护理指令都是最新的，并采取以人为本的方法予以实施。 • 确保实施国家和区域政策、规划和指南，以支持长期护理机构和长期护理服务行业提供姑息 治疗（包括身体、心理、社会和精神支持）。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -16- 长期护理机构 • 考虑让长期护理机构的居住者参与制定转诊和获得基本卫生服务的规程。确保在这些规程中 没有基于年龄或疾病的选择，只有人们的需求和偏好能够左右护理决定。 • 确保所有长期护理机构得到初级护理服务的支持。 • 为长期护理机构设立针对老年人的快速反应小组，最好为其提供老年医学和姑息治疗培训， 以减少本可避免的住院治疗，并确保以人为本的最佳沟通和决策。 • 确保员工接受过提供姑息治疗的培训，并知道如何就死亡、濒临死亡和临终决定进行沟通 (35)。 国家例子 在美国，家庭远程医疗的使用范围已经扩大，因为远程病人监护费用现在已经可以报销。自2020 年3月以来，医疗保险受益人已经能够接受行为或药物使用紊乱症干预。对于COVID-19重症患 者，现在可以进行急症后远程就诊。这使社会工作者、临床心理学家、物理治疗师、职业治疗师 和语言病理学家能够进行远程问诊和治疗。这也可以为社区内有长期护理需求的人提供支持 (61)。 在意大利，特殊姑息治疗小组能够迅速进行重组，以便快速和灵活地应对需求。例如，他们创建 了临终关怀服务网，让负责临终关怀住院病人的工作人员转岗从事家庭护理服务。这些经验也强 调了对病例讨论和类似团队协作的重要需求，以便能够快速决定资源的优先次序（例如，决定谁 将在出院后获得支持）(50、90)。 在奥地利，全国姑息治疗协会发布了一份关于在COVID-19大流行期间实行姑息治疗的立场文件， 并提供了关于确保无法获得正常提供的重症护理的人获得姑息治疗的指导。该协会还发布了家庭 护理人员和长期护理工人指南。此外，政府提供的多学科指导也可用于支持即将到达生命终点的 COVID-19患者。还有关于如何促进社会支持以及关于在COVID-19大流行期间支持临终者的家庭护 理人员和护理工人的丧亲之痛的临床指南和资源(76)。 在斯洛文尼亚，医疗队随时准备被派往住宿类长期护理机构，在正式工作人员筋疲力尽或不堪重 负时为其提供支持(91)。 2.6 确保所有长期护理机构执行和遵守感染预防和控制标准，以预防和安全管理 COVID-19病例 2.6.1 挑战 缺乏强制执行关于长期护理方面的感染预防和控制指南 在很多国家，关于长期护理服务提供者的感染预防和控制指南在大流行期间的制定时间相对较晚， 并且有很多指南在纳入COVID-19无症状传播和非典型症状的证据方面进展缓慢。在很多国家，只为 长期护理机构制定了指南，而没有为社区护理服务提供者和家庭护理人员制定指南。最后，缺少确 保执行这些指南和监测其执行情况的机制。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -17- 缺少长期护理方面的感染预防和控制经验和培训，从而导致执行困难 在很多国家，长期护理服务提供者的感染预防和控制制度和培训力量薄弱，导致很多工作人员不熟 悉感染预防和控制以及个人防护装备的正确使用。 对于大量使用临时或代理人员的长期护理机构来说，这是一个特殊的挑战。即使有指南和培训，由 于需要附近有人能够提供个人辅助护理，故一些措施的执行也可能具有挑战性。一些努力控制长期 护理机构中感染的国家报告说，它们缺乏检测和个人防护装备、缺少人手、难以执行保持身体距离 措施（鉴于传统长期护理机构的设计），并且缺少替代隔离设施。 在各国，指南强调必须对已经出现COVID-19相关症状的居住者以及那些与COVID-19疑似或确诊患者 有过接触的人进行隔离。在一些国家，虽然长期护理机构的居住者住在单独的房间里，有自己的浴 室，但在其他国家不是这样。长期护理机构所在建筑的具体结构也可能对设立有效的隔离区构成障 碍。需要为长期护理机构的管理人员提供支持，以便对其设施的能力进行评估，以便能够有效执行 隔离政策，并在护理环境不适合有效隔离的情况下提供额外的隔离场所。 经历过严重急性呼吸综合征和中东呼吸综合征的国家最近加强了其长期护理机构和社区护理机构的 感染预防和控制制度，并倾向于将COVID-19疑似和确诊病例全部转移到隔离设施，这似乎成功地控 制了疫情(63)。不过，还没有证据能够说明这些措施对居住者身心健康产生的影响。 在一些国家，有大量未注册的长期护理机构，因此没有受到监管。为这些机构提供支持以确保其居 住者的安全至关重要(53)。 同样，社区护理服务受到的直接监管控制比寄宿制长期护理机构更少，能够及时收集的关于大流行 如何直接或间接影响依靠社区护理的人员的信息和监测系统更少。家庭护理服务提供者通常为那些 有护理需求的人提供上门服务。这意味着护理人员需要在不同家庭之间穿梭，并经常为多个有护理 需求的人提供上门服务。有证据表明，一些家庭已经停止使用家庭护理支持服务以降低有护理需求 者的感染风险；不过，这也可能会产生其他风险(77、81)。 在 COVID-19背景下的影响  缺乏确保执行感染预防和控制指南以及监测和评估执行情况的机制  缺少对长期护理人力进行关于感染预防和控制措施的培训  员工更替率高阻碍了护理的连续性和感染预防和控制措施的一致性  长期护理服务很难实现保持身体距离  护理人员无法充分获取关于限制 COVID-19传播的信息 2.6.2 关键行动 整个部门 • 建立一个协调机构，以便在 COVID-19 大流行期间根据已经掌握的最佳证据，制定、调整和 更新长期护理行业的感染预防和控制指南和规程(87、88、92、93)。 • 确保在长期护理行业实施感染预防和控制指南（适用于所有环境）。 • 建立一个旨在制定支持计划、确定支持先后次序和监测支持措施执行情况的机制，以防止员 工和接受长期护理服务的人员感染或传播 COVID-19。 • 为长期护理行业制定 COVID-19疫情早期识别、阈值监测和提升应对级别的策略。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -18- • 考虑如何确保可能在系统外运行的长期护理服务提供者（不受监管或非法的提供者）能够得 到支持，以确保在其机构内生活或使用其服务的人的安全。 • 确保长期护理机构或家庭护理服务中所有参与直接提供护理服务的人员（工作人员和家庭护 理人员）都有机会接受感染预防和控制培训（包括个人防护装备的使用、手部卫生、环境的 清洁和消毒以及废物管理）。不管他们的职责是什么，都应该这么做，特别是对于那些与患 有基础疾病的老年人有直接接触的人(93)。 • 考虑使用最新 COVID-19 指南，制定和传播标准操作程序，指导如何以及何时快速隔离接受 长期护理服务的人员。 • 对出院人员执行扩大感染预防和控制预防措施，最好是基于一个商定的检测规程，以确定个 人隔离需求和所需的个人防护装备。 将标准操作程序的任何策略转化为清晰的转诊制度，并向所有提供长期护理服务的员工提供。 长期护理机构 • 确保参照世卫组织关于长期护理机构预防和控制 COVID-19 感染的指南，执行长期护理机构 感染预防和控制措施(92)。 • 实行管理控制，包括在入口处对进入机构的所有工作人员和来访者进行症状监测。 • 确保长期护理机构的工作人员的工作条件和安排能最大限度地减少他们在环境与接受长期护 理服务的人员之间的移动，确保病假工资能够让他们在身体不适时呆在家里。 • 确保长期护理机构能够获得执行感染预防和控制措施 （如个人防护装备、洗手液和消毒剂） 所需的资源。 • 制定必要的感染预防和控制规程和指南，并确保它们可供来访者使用，并以易于理解的形式 清晰可见(94)。 • 制定指南，确保执行工作人员感染预防和控制规程，并确保在提供持续培训的同时提供教育 资源。 • 确保长期护理机构安排一个感染预防和控制协调人来领导和协调感染预防和控制工作，最好 有一个感染预防和控制小组为其提供支持，并履行一个多学科委员会授予的职责和提出的建 议 社区护理和护理人员 • 增加对社区长期护理人力的培训和决策支持，以便有效控制 COVID-19，包括家庭护理人员， 同时要考虑家庭护理人员可能面临的制约因素，尤其是与性别相关的制约因素(87、88)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -19- 国家例子 在牙买加，政府制定了一项临时就业规划，对公共部门长期护理机构进行定期清洁，并在这些 机构中留出隔离有症状居住者的场所。此外，多个国营和私营部门机构开展的一项多部门活动 也有助于对公共长期护理机构进行深度卫生处理(79)。 在印度尼西亚，长期护理机构的预防措施包括与护理人员和居住者分享个人卫生原则知识、定 期消毒和通风以及避免共用个人医疗设备。寄宿制长期护理机构已实行注册制度，不允许有 COVID-19症状的来访者进入机构(95)。 在中国的一个地区，在经历严重急性呼吸系统综合症大流行之后，地区主管部门在2004年发布 了第一份寄宿制养老机构预防传染病指南，并要求长期护理机构的所有经营者按照该指南的要 求指定一名负责控制感染的官员，负责在机构内协调和实施感染控制措施(65)。 在德国，罗伯特·科赫研究所建议居家护理人员在提供护理服务时戴口罩，并定期监测其健康 状况。如果其护理的人员出现COVID-19相关症状，应配戴额外的防护装备(96)。 在荷兰，一些家庭护理人员被组织成特殊的“冠状病毒病患者照料小组”。这些小组照料 COVID-19患者，而其他小组照顾没有感染的人员(80)。 2.7 优先考虑对接受和提供长期护理服务的人员进行检测、接触者追踪和COVID-19 传播监测 2.7.1 挑战 由于优先考虑医院服务，很多国家都出现了检测能力短缺的情况 很多国家都出现了检测能力不足的情况，因为把最初可用的能力大部分都放在了医院，这使寄宿制 长期护理和社区护理服务提供者难以发现COVID-19患者。这种做法越来越被认为是一个主要问题， 因为发病前或无症状COVID-19患者的比例很高并且可能传播感染。 长期护理机构中有效的接触者追踪需要长期护理服务提供者与有关卫生当局之间的协调与合作 长期护理机构中对COVID-19的有效检测、追踪和监测需要长期护理服务提供者和有关卫生当局之间 的协调与合作。不过，由于治理方面的挑战，这种协调在应对的最初阶段面临困难。现在，有越来 越多的国家正在将接触者追踪纳入长期护理行业指南，并正在开发支持接触者追踪的应用程序和其 他系统。 缺乏对接受和提供护理服务的人员的健康状况的系统监测 定期监测使工作人员能够发现人们健康状况的变化，包括非典型症状的发展(13)，并在有护理需求 的人或工作人员出现COVID-19症状时更快地作出反应。 在 COVID-19背景下的影响  长期护理机构已经成为优先检测、追踪和监测 COVID-19的盲点  COVID-19无症状患者的比例高使早识别和随后采取适当的步骤变得困难 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -20- 2.7.2 关键行动 整个部门 • 确保对检测数据进行汇总并与本地和国家公共卫生机构共享，以便在群体和个人层面对大流 行进行管理。 • 确保参照世卫组织关于 COVID-19 接触者追踪的指南，按照国家指南对接触者进行追踪和隔 离(36、97)。 • 对长期护理机构或接受家庭护理服务的人员当中出现的任何聚集性感染或死亡进行追踪。 • 在进行 COVID-19 筛查时，不要仅仅依赖症状，特别是“典型”咳嗽和发烧症状，并确保工 作人员接受关于识别其他非典型症状的培训，尤其是识别老年人的症状(36)。 • 确保对接受和提供长期护理服务的人员的健康进行监测，以便能够迅速发现症状（包括非典 型症状）的发展。 长期护理机构 • 在存在持续或疑似社区传播的地区，对居住者（包括新入住人员）和工作人员进行严格的检 测以及追踪密切接触者对于制定隔离政策至关重要。 社区护理 • 确保在社区中提供和接受护理服务的人员及其家庭成员能够获得检测和进行接触者追踪，并 在需要隔离时获得支持(87、88)。 • 将有护理需求的家庭成员纳入症状监测范围。 实例 在丹麦，长期护理机构中有症状和无症状居住者和工作人员都可以在地区医院接受检测（自 2020年5月12日起）。甚至在那之前，就已经对出现过疫情的寄宿制长期护理机构的居住者和工 作人员进行了检测。如果一名居住者出现症状，所有居住者和工作人员都要在24小时内接受检 测，并在7天之后再次接受检测。如果有工作人员检测呈阳性，同一区域的所有居住者都要接受 检测(98)。 在荷兰，所有出现COVID-19症状的家庭护理人员都可以接受检测（自2020年5月18日起）。此 外，从2020年5月19日起，如果家庭护理人员为出现COVID-19症状且需要个人辅助护理（距离不 到1.5米）的弱势人群（70岁及以上患有慢性病者）提供支持，他们就可以获得免费的个人防护 装备(80)。 在马来西亚，所有注册和未注册的长期护理机构都接受了COVID-19检测(99)。 在欧洲联盟，欧洲疾病预防和控制中心指南建议采用区分“受影响地区”（对居住者和工作人 员进行随机检测）和“未受影响地区”的检测策略。受影响地区是那些发生实际或推定持续社 区传播的地区(73)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -21- 2.8 为家庭和志愿护理人员提供支持 2.8.1 挑战 虽然家庭护理人员提供的护理服务占很大一部分，但临时护理、培训或护理假方案等支助仍然有限， 而且没有补偿 在各国，直接提供护理的家庭护理人员提供的长期护理服务占很大一部分，而且有助于协调和对正 规护理服务予以补充。在没有正规长期护理服务的国家，家庭护理人员提供了几乎所有的长期护理。 护理人员通常无法获得任何与其职责相关的培训。 一些国家认识到护理的影响，并提供带薪护理假、弹性工作制、临时护理、培训和心理干预措施以 及现金福利等支持措施来缓解负面影响(29)。不过，在大多数国家，获得这些支持服务的机会仍然 有限，护理人员都是按照传统提供支助，没有补偿、培训或支助(1)。尽管护理人员的重要贡献越来 越得到认可，但在COVID-19大流行之前，可用的支持安排和财政支持已经有限(100)。 很多护理服务提供者通常与收入较低、最终贫困率较高而且精神健康不佳相关 妇女提供的护理服务在这里占最大的份额(61%)，尽管男性护理人员所占的份额随年龄的增长而增加 (74)。还有很多青年（包括儿童）和老年护理人员为有长期护理需求的家庭成员提供护理支持。很 多护理服务提供者通常与劳动力依附降低（对于工作年龄的人来说）、收入较低和最终贫困率较高 相关(101)。此外，收入减少和养老金缴款不足也增加了老年人的脆弱性和贫困风险。护理人员的精 神卫生问题的患病率也更高(101)。 COVID-19大流行意味着一些护理人员不得不调整或放弃工作，以便提供护理服务或避免他们所抚养 的人面临COVID-19感染的风险。在非正规经济部门工作的护理人员也可能因为各种限制而工作机会 减少，并影响其收入。护理人员还会因为大流行产生的经济影响而需要支持(102)。 寄宿制护理方案的中止使很多家庭护理人员的责任增加，而且没有正常的支持体系 COVID-19大流行导致很多日托机构和临时护理机构关闭，包括社区护理或短期护理，使很多护理人 员承担的责任增加，而且没有既定的支持体系。必须了解护理人员在大流行期间面临的问题，以及 如何最大限度地支持他们(102)。 护理人员需要能够接触到有护理需求的人、获得信息、个人防护装备和检测，并在制定应急计划时 得到支持 在很多国家，政府和非政府组织对这一需求作出了反应，提供了关于预防感染的个人卫生措施以及 在有护理需求的人或护理人员自身出现症状时如何应对的指南和参考文件。在大流行期间出现的问 题包括护理人员因其护理责任而需要允许其出行(78、79)、支持护理人员获得检测和个人防护装备 (80)以及制定应急计划以防他们无法继续提供护理服务(77)。 护理需求的变化以及对护理人员的暴力行为或虐待 很多护理人员正在应对其护理对象需求的变化（这可能是由于感染或限制性措施的影响）。此外， 正常生活的中断可能会导致有护理需求的人员的焦虑和紧张，从而增加了护理人员的压力(29)。 COVID-19大流行使家庭暴力和虐待问题浮出水面(38)。家庭护理人员也可能在其护理关系中经历暴 力行为和虐待，并且需要支持(103)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -22- 在 COVID-19背景下的影响  很多护理人员在没有既定支持体系的情况下承担了额外的责任（如日间护理和临时护理方 案）  国家间保持社交和身体距离措施正在对护理人员的健康产生负面影响  尽管护理人员的重要贡献日益得到认可，但可用的财政支持仍然有限  护理人员在获得必要的供应品方面遇到困难，因为他们不能轻易离开他们所护理的人  家庭护理人员和志愿护理人员很少能获得个人防护装备和检测  长期隔离、不间断的护理责任、对有护理需求的人的担心、在护理人员丧失能力时对应急 护理的担忧，以及对护理人员的暴力行为或虐待，都会对护理人员的心理健康产生影响 2.8.2 关键行动 整个部门 • 在卫生和长期护理记录中记录主要护理人员，以便他们成为公认的重要信息和支持来源。 长期护理机构 • 采取支持性措施，确保护理人员的安全，使那些为生活在长期护理机构的人员提供心理和实 际支持的家庭护理人员能够继续发挥护理作用。 护理人员 • 在国家一级为护理人员特别是照顾老年痴呆症患者的护理人员提供信息、培训、支持和（如 有可能）临时护理，包括关于如何管理护理责任和压力增加的信息。考虑为便于提出建议和 提供信息与支持设立电话帮助热线或在线门户网站 (104)。 • 考虑开展一项评估，以监测家庭护理人员的需求。 • 为家庭护理人员制定关于何时以及如何进行自我隔离的明确指南。 • 提高对家庭暴力的警惕和监测，为家庭护理人员提供支持。 • 确保能够获得个人防护装备（无需家庭护理人员承担过高的费用）以及设备和药物。 • 探索通过技术向护理人员提供支持服务的新途径，并支持护理人员获取相关技术。 • 引入或扩大对家庭护理人员的经济和心理支持。 • 提供丧亲支持，并确保在决策时与家人仔细沟通。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -23- 国家例子 在巴西，非政府组织（如巴西老年医学和老年学学会和巴西阿尔茨海默氏病协会）出版了护理 技术和教育指导文件。FioCruz和一些其他组织编写了一本小册子，教育老年人的护理人员如何 采取COVID-19防护措施。妇女、家庭和人权部也有一个专门为患有罕见疾病患者和残疾人及其 护理人员提供信息的网站。卫生部和泛美卫生组织合作拍摄了一个视频，以便为那些与孤独、 寂寞和苦恼作斗争的巴西人提供精神卫生支持。阿尔茨海默氏病协会等非政府组织提供了帮助 热线和在线论坛。其他团体组织了心理社会活动(105)。 在印度，印度社会正义和赋权部在2020年3月27日印发了一项指南，认识到护理人员能够接触到 其护理的人员的重要性。建议向护理人员发放通行证，以使他们能够在限制行动期间出行。此 外，非政府组织（印度老年痴呆症及相关疾病协会、夜莺医疗信托基金和Silver Innings）和 专业服务机构（国家精神卫生和神经科学研究所、认知障碍诊所）也为痴呆症患者的护理人员 提供信息和资源。夜莺医疗信托基金提供了DemKonnect应用程序，为护理人员提供专家意见。 卫生和家庭福利部提供心理和行为帮助热线。此外，它还在其网站上提供了针对不同年龄段的 压力管理和精神卫生提示视频（包括冥想和瑜伽）(78)。 在爱尔兰，痴呆症服务信息和发展中心为护理人员提供了资源，包括建议痴呆症患者减轻社会 隔离影响的活动。爱尔兰老年痴呆症协会也提供相关的支持资源和信息。根据经济状况调查领 取津贴的护理人员继续在COVID-19大流行期间领取津贴。此外，领取护理人员津贴的在职护理 人员因大流行失去工作的，也可以另外获得350欧元的大流行失业津贴。同样，爱尔兰家庭护理 者组织也为护理人员制定了应急计划指南(77)。 在德国，为应对COVID-19大流行，已将应对家庭紧急护理情况或组织护理安排而领取的长期护 理津贴（维持津贴）的期限延长了一倍，从10天延长至20天（至2020年9月30日）。请假应对紧 急护理情况的权利也延长到20天。那些平常接受实物服务（如日托）的人可以在COVID-19大流 行期间因无法获得实物服务而报销其因使用替代性护理而产生费用(96)。 2.9 优先考虑接受和提供长期护理服务的人员的心理健康 2.9.1 挑战 很多需要护理的人的日常生活出现变化和面临长时间的隔离 很多有长期护理需求的人（尤其是老年人）已被隔离在家或机构中好几周了，导致社会接触减少， 日常生活被打乱和改变。老年痴呆症患者等一些有长期护理需求的人会出现身体和认知情况的变化。 他们日常生活的迅速变化也可能增加他们对已有疾病的脆弱性(84、104)。 具体来说，在长期护理机构中，居住者一直因为无法同其他居住者社交或无法接受亲友探视而苦恼。 家庭也非常苦恼，因为他们无法探视和了解居住者的护理情况。 长期护理机构已经认识到社会联系对居住者的重要性，并采取了一些创新办法，例如采用能够让居 住者与家人和朋友进行虚拟联系的技术工具。 暴力侵害老年人的风险急剧增加 自COVID-19大流行开始和实施限制性居家措施以来，针对老年人的暴力行为急剧增加，老年人已经 成为大流行首当其冲的受害者。暴力发生在家里、长期护理机构等机构以及线上，针对老年人的诈 骗行为激增(106)。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -24- 在COVID-19大流行期间，长期护理人员的精神卫生承受着巨大的压力 在COVID-19大流行期间，长期护理工作者（通过薪酬补偿）承受了向弱势群体提供护理的持续压力， 并努力防止COVID-19向他们护理的人员传播。很多人将经历创伤和多次丧亲之痛。这为他们的精神 卫生带来了巨大压力。在荷兰，荷兰护士协会的一项调查发现，在COVID-19大流行期间，69%的社区 护理人员感到他们的精神卫生压力增加。在3,325名受访者中，28%的人报告说他们的雇主没有为其 提供精神卫生支持(80)。在很大程度上缺乏支持护理人员福祉的具体干预措施。 一些国家已经认识到COVID-19对长期护理机构工作人员造成的精神卫生损害，并已为支持工作人员 的精神卫生采取干预措施。在联合王国，已经通过支助服务做出努力，增加护理人员的福祉。 移民护理人员（特别是那些为了提供护理服务而往返其他国家的人）可能会发现自己下班后无法回家， 或者无法上班（并因此而无法获得报酬），因为国家关闭了边境，致使他们遇到很大困难(76、107)。 家庭和志愿护理人员面临巨大的护理责任和隔离，而对他们的正常支助服务基本上已经中止 很多家庭护理人员一直与他们所护理的人一起被隔离，以防止他们感染COVID-19。这让他们感到与 社会网络脱节。此外，他们的正常支助体系（如日托、家庭护理、其他家庭护理人员和护理人员支 助团体）已经减少或中止，使得家庭护理人员没有重要的社会联系和实际支助来源。 一些国家在COVID-19大流行期间为支持护理人员的心理健康设立了帮助热线、虚拟咨询和护理人员 支持团体。 在 COVID-19背景下的影响  对长期护理机构员工、家庭和志愿护理人员以及有辅助护理需求的人的精神卫生产生了重 大影响  长期护理机构的很多居住者一直在与无法与其他居住者交往、无法参加正常社交活动、也 无法接待家人和朋友的探视作斗争  很大程度上缺乏支持提供和接受护理者福祉的具体干预措施 2.9.2 关键行动 整个部门 • 建立一个跨部门工作组，以监测长期护理人员的压力和疲劳，并评估和实施为提供长期护理 的人员提供精神卫生和社会心理支持的策略。 • 设立专门的帮助热线，为所有提出要求的人提供精神卫生和心理支持。 • 考虑为培训护理人员和志愿者提供指导，以提高他们在临终决定、死亡、垂死和丧亲之痛等 敏感问题上的沟通技能。 • 鼓励长期护理服务提供者使用筛查工具，审查人员配备程序（如弹性工作制和工作休息时 间），以便更好地管理护理负担，寻求减少对身体限制措施的使用。 • 确保精神卫生专业人员和家庭护理人员网络能够提供精神和情感支持，必要时可使用数字媒 体支持护理服务接受者和提供者。 • 支持对暴力侵害老年人的行为进行监测。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -25- 长期护理机构 • 制定明确的探视政策，兼顾感染预防和控制措施和人们对保持心理健康的需要（使居住者既 能接受探视，同时又将 COVID-19进入长期护理机构的风险降至最低）。 • 如果出入受到限制，为居住者通过电话、互联网或书面信息与家人和朋友联系提供便利。 • 增加招募志愿者，帮助为被隔离居住者提供社会互动。 社区护理 • 确保为移民住家护理人员获得和扩大资源。 • 鼓励和加强针对家庭护理人员的心理支持体系。 • 考虑为志愿者和社区成员开展精神卫生急救培训。 国家例子 在智利，国家老年服务局和老年医学和老年学协会发布了一些视频和图片，以支持老年人和家 庭护理人员应对COVID-19。该材料包括个人防护装备的使用信息、保持社交距离和精神卫生建 议(108)。它还提供了支持组织社区支助的模板，以便为需要帮助的人们开展日常基本活动提供 支持(109)。 在墨西哥，卫生部开展了一项精神卫生支助运动，其中包括快速进行电话评估，以提供支持策 略和推荐具体支持。针对卫生保健工作者的运动就是该策略的一部分(110)。 在肯尼亚，一些非政府组织已经转向虚拟同伴支持。不过，一些地区的网络不好、购买互联网 捆绑包的成本以及在线疲劳都给支持家庭护理人员的工作带来了挑战。劳动和社会保障部发布 了长期护理机构指南，其中明确指出，工作人员应确保居住者能够经常与家人和社会网络保持 沟通（通过手机通话或在线聊天），并应通过建立正常程序和减少对这些居住者的干扰的方式 来促进居住者的福祉(111)。 在马来西亚，日托中心的工作人员继续通过视频通话以及共享活动和锻炼视频来照顾他们所护 理的人员(99)。 在联合王国，COVID创伤应对工作组为管理人员和服务计划制定人员制定了关于照顾长期护理机 构中可能遭受过创伤的工作人员的指南(112)。 2.10 确保顺利过渡到恢复阶段 2.10.1 挑战 公众对长期护理机构失去信心 COVID-19大流行不成比例地影响到生活在长期护理机构中的人，这些机构中的死亡比例似乎随着社 区中受影响人数的增加而增加。这表明，只要当地存在COVID-19社区传播，长期护理机构就有感染 和大量死亡的高风险。 在很多国家，人们担心公众会对长期护理机构失去信心，如果生活在长期护理机构中的人们因为恐 惧而无法从护理服务中受益，则可能会产生负面影响。这可能对这些人、他们的家庭以及长期护理 机构的提供者的经济生存能力产生负面影响。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -26- 长期护理机构中的限制行动和其他保护措施 几乎所有国家首先采取的措施之一是限制对长期护理机构进行探视。虽然这一措施相对容易实施， 但人们越来越认识到，这对长期护理机构的居住者及其家人的福祉都产生巨大影响，而且，特别是 在居住者患有痴呆症的情况下，不了解为何停止探视可能会产生更多的痛苦。还有人对很多家庭成 员在定期（有时是每天）探视时提供护理、而在长期护理机构工作人员可能由于护理的复杂性增加 和人员配备比率降低而负担过重时不允许他们探视表示担忧，这样可能会加剧人员配备问题。 难以监测长期护理机构的服务质量 另一个令人担忧的问题是，很多国家在暂停检查时停止了家属探视。家人可能会担心居住者接受的 护理质量，不允许探视可能会加剧他们的担忧。确保安全探视越来越被视为重建对长期护理机构信 任的关键一步。 在 COVID-19背景下的影响  缺乏适用于长期护理机构的限制性措施退出战略  在长期护理机构实施限制行动措施时，缺乏对这些机构内护理质量的监测 2.10.2 关键行动 长期护理机构 • 在实行公共卫生和社会措施期间，提供监测机制，以监测长期护理机构内的护理质量。 • 就何时以及如何逐步减少或停止对居住者实施隔离以及放松对探视者的限制措施的阈值提供 指导。 • 制定明确的标准，规定生活在长期护理机构的人员何时以及如何进出医院，以保护员工和其 他居住者。 • 确保在提供紧急、初级和社区卫生服务时考虑到长期护理居住者的需求，并尽早将初级护理 和社区护理恢复到 COVID-19发生前的支持水平。 社区护理 • 确保正在制定规程，以便接受社区护理（例如日托）的人能够再次获得这些服务。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -27- 国家例子 在马耳他，从2020年6月1日起再次开始轮流日托服务。优先考虑那些有护理需求但没有获得服务 的人。实行严格的个人卫生程序和保持社交距离措施。例如，工作人员和有护理需求的人在进入 日托中心时要换鞋，离开时换上自己的鞋。有护理需求的人在进入中心时必须戴口罩和护目镜。 工作人员也要在整个工作时间佩戴护目镜。此外，接受和提供护理服务的人还要进行体温监测 (58)。 在丹麦，人们可以继续探视接受临终关怀的居住者，但要遵守个人卫生要求。自2020年4月24日 起，长期护理机构的居住者可以在户外区域接待探视(98)。 在德国，从2020年5月开始再次放松对探视限制。虽然联邦各州对探视人数以及探视频率和探视 时间的具体规定各不相同，但所有州都要求长期护理机构实行明确的感染预防措施。探视者还必 须登记，以便在必要时可以对他们进行接触者追踪(96)。 2.11 启动卫生和长期护理系统转型工作，以适当整合并确保对长期护理服务的持续 有效治理 COVID-19大流行凸显了卫生保健系统内长期护理服务的分散性。这种分散性加上当前长期护理总体 治理结构本身存在的缺陷，导致了长期护理机构在COVID-19大流行期间的灾难性后果。 我们迫切需要改革卫生和长期护理系统，以便使长期护理服务能够与传统的连续护理（促进、预防、 治疗、康复和姑息治疗）服务结合起来提供。 必须强调的是，本文件中被定义为帮助他人完成特定任务以保持身体功能能力和独立性提供的帮助 的辅助护理被认为是一项重要服务，有助于促进适当解决老龄化问题，并确保一个人即使在身心能 力大幅下降以后，仍能继续做他们有理由重视的事情。 2016年通过的世卫组织《老龄化与健康全球战略和行动计划》指出，“每个国家都应该有可持续和 公平的长期护理系统”(44)。“健康老龄化行动十年 （2020-2030年） ”也强调需要长期护理的老 年人应该能够获得长期护理服务(113)。 尽管长期护理不仅仅针对老年人，而且包括各种各样的使用者，但基本原则是一样的：即向那些需 要长期护理的人提供服务，以确保他们能够在生活中享有其基本权利、基本自由和人类尊严。 以下行动反映了我们从COVID-19大流行中吸取的教训，以实现人人享有可持续和公平的长期护理。 关键行动 • 确保立法和制定国家长期护理战略和框架。 • 加强参与长期护理和卫生保健事务的各级政府之间的关系，发展具体的纵向和跨部门协调机 制。 • 整合国家卫生和长期护理系统定期数据收集工作，以实现全系统数据评估和监测。 • 确保长期护理的可持续和公平的融资机制，保护人们免受灾难性护理费用的影响。 • 确保采取贯穿卫生和长期连续护理的以人为本的综合护理方式，使有长期护理需求的人能够 获得全面的护理。 • 确保为长期护理人力提供持续培训和改善其工作条件。 • 提供和扩大对家庭和志愿护理人员的财政和实物支持。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -28- • 建立机制，确保不受监管的长期护理部门提供优质服务，并加强认证。 • 确保卫生部门对长期护理机构进行监督，为未来的大流行做好准备。 • 促进研究，以便从 COVID-19 大流行中吸取教训，以解决卫生和长期护理系统中存在的不足。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -29- 参考文献 1. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/handle/10665/186463). 2. Care work and care jobs for the future of decent work. Geneva: International Labour Organization; 2018 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/--- publ/documents/publication/wcms_633135.pdf, accessed 21 June 2020). 3. Who cares? Attracting and retaining care workers for the elderly. Paris: Organization for Economic Co-operation and Development; 2020 (https://www.oecd.org/publications/who-cares-attracting-and- retaining-elderly-care-workers-92c0ef68-en.htm, accessed 23 June 2020). 4. Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region: strengthening the health systems response to COVID-19. Technical Working Guidance No. 6. WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health- topics/Health-systems/health-services-delivery/publications/2020/strengthening-the-health-systems- response-to-covid-19-technical-guidance-6,-21-may-2020, accessed 21 June 2020). 5. Salcher-Konrad M, Jhass A, Naci H, Tan M, El-Tawil Y, Comas-Herrera A. COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence. medRxiv. 2020. doi:10.1101/2020.06.09.20125237. 6. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N, Fernández J-L. Mortality associated with COVID-19 outbreaks in LTCFs: early international evidence. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in- care-homes-early-international-evidence/, accessed 21 June 2020). 7. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 8. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID- 19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 9. American Geriatrics Society. American Geriatrics Society (AGS) policy brief: COVID‐19 and assisted living facilities. Journal of the American Geriatrics Society. May 2020:jgs.16510. doi:10.1111/jgs.16510. 10. American Geriatrics Society. American Geriatrics Society policy brief: COVID ‐19 and nursing homes. Journal of the American Geriatrics Society. 2020;68(5):908–11. doi:10.1111/jgs.16477. 11. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR et al. Presymptomatic SARS- CoV-2 infections and transmission in a skilled nursing facility. New England Journal of Medicine. 2020;382:2081–90. doi:10.1056/nejmoa2008457. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS- CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A et al. SARS-CoV-2 infection: clinical features and outcome of COVID-19 in United Kingdom nursing homes. Journal of Infection. 2020;5:38. doi:10.1016/j.jinf.2020.05.073. 14. Goldberg SA, Pu CT, Thompson RW, Mark E, Sequist TD, Grabowski DC. Asymptomatic spread of COVID-19 in 97 patients at a skilled nursing facility. Journal of the American Medical Directors Association. 2020. doi:10.1016/j.jamda.2020.05.040. 15. Guery R, Cécile D, Noëlle B, Nael V, Castain L, Raffi F et al. Limited effectiveness of systematic screening by nasopharyngeal RT-PCR of medicalized nursing home staff after a first case of 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -30- COVID-19 in a resident. Médecine et Maladies Infectieuses. May 2020. doi:10.1016/j.medmal.2020.04.020. 16. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A et al. Detection of SARS- CoV-2 among residents and staff members of an independent and assisted living community for older adults: Seattle, Washington, 2020. Morbidity and Mortality Weekly Report. 2020;69(14):416– 8. doi:10.15585/mmwr.mm6914e2. 17. Grabenhorst U, Stiels-Prechtel R, Niemann M, Weckbecker K. COVID-19 in the nursing home: a case report. MMW-Fortschritte der Medizin. 2020;162(9):60–2. doi:10.1007/s15006-020-0481-0. 18. Dora AV, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans: Los Angeles, California, 2020. MMWR Morbidity and Mortality Weekly Report. 2020;69(21):651–5. doi:10.15585/mmwr.mm6921e1. 19. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. 2020;382(21):2005–11. doi:10.1056/NEJMoa2005412. 20. Coronavirus (COVID-19) related deaths by occupation, England and Wales. Office for National Statistics; 2020 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletin s/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistereduptoandincluding2 0april2020#:~:text=A%20total%20of%20131%20deaths,100%2C000%20females%20(86%20deaths ), accessed 21 June 2020). 21. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 22. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long- term care hospitals in the Korea. Infection and Chemotherapy. May 2020. 23. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 24. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 25. COVID-19. Sciensano (https://epistat.wiv-isp.be/covid, accessed 21 June 2020). 26. Fisman D, Lapointe-Shaw L, Bogoch I, McCready J, Tuite A. Failing our most vulnerable: COVID- 19 and long-term care facilities in Ontario. medRxiv. doi:10.1101/2020.04.14.20065557. 27. Yanover C, Mizrahi B, Kalkstein N, Marcus K. What factors increase the risk of complications in SARS-CoV-2 positive patients? A cohort study in a nationwide Israeli health organization. medRxiv. 2020. doi:10.1101/2020.05.07.20091652. 28. Dawson WD, Ashcroft E, Lorenz-Dant K, Comas-Herrera A. Impact of the COVID-19 outbreak on community care services: a review of initial international policy responses. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Community-Based- Care-Report-19-May.pdf, accessed 21 June 2020). 29. Lorenz-Dant K. International examples of measures to support unpaid carers during the COVID-19 pandemic. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -31- content/uploads/2020/05/International-measures-to-support-unpaid-carers-in-manage-the-COVID19- situation-20.05.20-complete-2.pdf, accessed 21 June 2020). 30. COVID-19 supercharges existing inequalities faced by Glasgow’s 150,000 disabled people. Glasgow Disability Alliance; 2020 (http://gda.scot/our-community/news/2020/4/28/covid-19-supercharges- existing-inequalities-faced-by-glasgows-150-000-disabled-people, accessed 21 June 2020). 31. Noncommunicable diseases and COVID-19. Geneva: World Health Organization (https://www.who.int/teams/ncds/covid-19, accessed 21 June 2020). 32. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665-332240, accessed 21 June 2020). 33. Coronavirus: Spanish army finds care home residents “dead and abandoned”. BBC News, 24 March 2020 (https://www.bbc.co.uk/news/world-europe-52014023, accessed 21 June 2020). 34. 31 Senioren in Kanada tot: Pfleger kamen aus Angst vor Corona nicht [31 seniors dead in Canada: carers did not come for fear of Corona]. MSN, 18 April 2020 (https://www.msn.com/de- at/news/other/31-senioren-in-kanada-tot-pfleger-kamen-aus-angst-vor-corona-nicht/ar- BB12QiDh#image=1, accessed 21 June 2020). 35. Bauer A, Dixon J. The challenges of providing end-of-life support in LTCFs during the COVID-19 pandemic, and opportunities for the future: an international perspective. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/06/Challenges-of- providing-end-of-life-support-in-care-homes-during-the-COVID-19-pandemic-1.pdf, accessed 21 June 2020). 36. Clinical management of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/clinical-management-of-covid-19, accessed 21 June 2020). 37. Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions. In: Gender equality. Paris: Organisation for Economic Co-operation and Development; 2019 (https://www.oecd.org/gender/data/womenare-well-represented-in-health-and- long-term-care-professions-but-often-in-jobs-with-poor-workingconditions.ht, accessed 21 June 2020). 38. COVID-19 and violence against women: what the health sector/system can do. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/handle/10665/331699). 39. Shippee T, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao M et al. COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging and Social Policy. June 2020. doi:10.1080/08959420.2020.1772004. 40. Long-term care for older people: a new global gender priority. New York; UN Women; 2017. 41. Policy brief: the impact of COVID-19 on older persons. New York: United Nations; 2020. 42. Scheil-Adlung X. Global estimates of deficits in long-term care protection for older persons. Extension of Social Security Series, No. 50. Geneva: International Labour Organization; 2015. 43. Help wanted? Providing and paying for long-term care. Paris: Organisation for Economic Co- operation and Development; 2011. 44. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. Report by the Secretariat. Sixty-ninth World Health Assembly, April 2016. Geneva: World Health Organization; 2016 (https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17-en.pdf?ua=1, accessed 21 June 2020). 45. Accelerating global actions for a world without poverty: United Nations System-wide Plan of Action for the Third United Nations Decade for the Eradication of Poverty (2018–2027). New York: United Nations; 2018 (https://www.un.org/development/desa/dspd/wp- 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -32- content/uploads/sites/22/2020/03/SWAP-Poverty-Booklet-Digital-Feb27.pdf, accessed 21 June 2020). 46. Barr N. Long-term care: a suitable case for social insurance. Social Policy and Administration. 2010;44(4):359–74. doi:10.1111/j.1467-9515.2010.00718.x. 47. Protective equipment being diverted from LTCFs to hospitals, say bosses. The Guardian, 30 March 2020 (https://www.theguardian.com/world/2020/mar/30/protective-equipment-being-diverted-from- care-homes-to-hospitals-say-bosses, accessed 21 June 2020). 48. Spasova S, Baeten R, Coster S, Ghailani D, Pena-Casas R, Vanhercke B. Challenges in long-term care in Europe: a study of national policies. Brussels: European Commission; 2018. 49. Zalakain J, Davey V, Suárez-González A. The COVID-19 on users of long-term care services in Spain. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/LTCcovid-Spain-country-report-28-May-1.pdf, accessed 21 June 2020). 50. Berloto S, Notarnicola E, Perobelli E, Rotolo A. Italy and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/LTC-COVID19-situation-in-Italy-30-April-2020.pdf, accessed 21 June 2020). 51. King D, Zigante V. Quality assurance practices in long-term care in Europe: emerging evidence on care market management. Brussels: Publications Office of the European Union; 2020. 52. Lloyd-Sherlock P, Neto J, Comas-Herrera A, Redondo N. Re: Covid-19: why we need a national health and social care service. BMJ. 2020;369. doi:10.1136/bmj.m1465. 53. Lloyd-Sherlock P, Bastos J, Geffen L, Giacomin K, Redondo N, Sasat S et al. An emergency strategy for managing COVID-19 in LTCFs in LMICs: the CIAT Framework. 2020 (https://www.corona-older.com/post/an-emergency-strategy-for-managing-covid-19-in-care-homes- in-lmics-the-ciat-framework-version-1, accessed 21 June 2020). 54. Country assessment framework for the integrated delivery of long-term care. Copenhagen: WHO Regional Office for Europe; 2019. 55. COVID-19: Singapore to house nursing home staff in hotels to protect the elderly. Channel News Asia, 8 May 2020 (https://www.facebook.com/ChannelNewsAsia/videos/1098221953890384/, accessed 21 June 2020). 56. Covid-19 testing completed for nursing home residents and staff; no new cases found apart from 5 earlier ones. The Straits Times, 31 May 2020 (https://www.straitstimes.com/singapore/health/covid- 19-testing-completed-for-all-nursing-home-residents-and-staff, accessed 21 June 2020). 57. Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G, Brammli-Greenberg S. The impact of COVID-19 on people using and providing long-term care in Israel. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long- Term-Care-situation-in-Israel-4-May.pdf, accessed 21 May 2020). 58. Fenech MA, Vella M, Calleja N. The COVID-19 long-term care situation in Malta and Gozo. International Long-Term Care Policy Network; 2020. 59. Cès S, Coster S. Mapping long-term care quality assurance practices in the EU: summary report. Brussels: European Commission; 2019. 60. Hashiguchi T, Llena-Nozal A. The effectiveness of social protection for long-term care in old age: is social protection reducing the risk of poverty associated with care needs? OECD Health Working Papers. Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd- ilibrary.org/social-issues-migration-health/the-effectiveness-of-social-protection-for-long-term-care- in-old-age_2592f06e-en, accessed 21 June 2020). 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -33- 61. Van Houtven CH, Boucher NA, Dawson WD. The impact of COVID-19 outbreak on long term care in the United States. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf, accessed 21 June 2020). 62. HHS Provider Relief Fund. Centers for Disease Control and Prevention; 2020 (https://data.cdc.gov/Administrative/HHS-Provider-Relief-Fund/kh8y-3es6, accessed 21 June 2020). 63. Kim H. The impact of COVID-19 on long-term care in South Korea and measures to address it. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May- 2020.pdf, accessed 21 June 2020). 64. Lum T, Shi C, Wong G, Wong K. COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging and Social Policy. 2020. doi:10.1080/08959420.2020.1773192. 65. Wong K, Lum T, Wong G. The COVID-19 long-term care situation in Hong Kong: impact and measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/04/Hong-Kong-COVID-19-Long-term-Care-situation-27-April-2020-1.pdf, accessed 21 June 2020). 66. Shi C, Hu B, Feng M, Wong G. Report from mainland China: policies to support long-term care during the COVID-19 outbreak. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Report-from-Mainland-China-18-April-final.pdf, accessed 21 June 2020). 67. Statistics Commission endorses new Titchfield City Group on Ageing. New York: United Nations Department of Economic and Social Affairs; 16 March 2018 (https://www.un.org/development/desa/ageing/news/2018/03/title-statistics-commission-endorses- new-titchfield-city-group-on-ageing/, accessed 21 June 2020). 68. Descubren una residencia ilegal en La Laguna por las pruebas del Covid-19 [They discover an illegal residence in La Laguna by the tests of Covid-19]. La Provincia, 4 April 2020 (https://www.laprovincia.es/sociedad/2020/04/04/descubren-residencia-ilegal-laguna- pruebas/1271776.html, accessed 21 June 2020). 69. Burton A, Goodman C, Quinn T. The invisibility of the UK care home population: UK care homes and a minimum dataset. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/the-invisibility-of-the-uk-care-home-population-uk-care-homes-and- a-minimum-dataset/, accessed 21 June 2020). 70. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 71. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.9540. 72. Jacobs R, Ashwell A, Docrat S, Schneider M. The impact of COVID-19 on long-term care in South Africa. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/06/COVID-19-Long-Term-Care-Situation-in-South-Africa.docx, accessed 21 June 2020). 73. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. European Centre for Disease Prevention and Control; 2020 (https://www.ecdc.europa.eu/en/publications-data/surveillance- COVID-19-long-term-care-facilities-EU-EEA, accessed 21 June 2020). 74. Rodrigues R, Huber M, Lamura G. Facts and figures on healthy ageing and long-term care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research; 2012. 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -34- 75. Van Houtven CH, DePasquale N, Coe NB. Essential long‐term care workers commonly hold second jobs and double‐ or triple‐duty caregiving roles. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16509. 76. Schmidt AE, Leichsenring K, Staflinger H, Litwin C, Bauer A. The impact of COVID-19 on users and providers of long-term care services in Austria. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation- in-Austria-15-May.pdf, accessed 22 June 2020). 77. Pierce M, Keogh F, O’Shea E. The impact of COVID-19 on people who use and provide long-term care in Ireland and mitigating measures. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May- 2020.pdf, accessed 22 June 2020). 78. Rajagopalan J, Huzruk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/LTC-COVID-situation-in-India-30th-May.pdf, accessed 22 June 2020). 79. Amour R, Robinson JN, Govia I. The COVID-19 long-term care situation in Jamaica. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The- COVID-19-Long-Term-Care-situation-in-Jamaica-25-May-2020-1.pdf, accessed 22 June 2020). 80. Kruse F, Abma I, Jeurissen P. The impact of COVID-19 on long-term care in the Netherlands. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/COVID19-Long-Term-Care-situation-in-the-Netherlands-25-May-2020- 1.pdf, accessed 22 June 2020). 81. Low L-F. The long-term care COVID-19 situation in Australia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/04/Australia-LTC-COVID19- situation-24-April-2020.pdf, accessed 22 June 2020). 82. Extra payment for unpaid carers. Scottish Government, 6 May 2020 (https://www.gov.scot/news/extra-payment-for-unpaid-carers/, accessed 22 June 2020). 83. Global action plan on the public health response to dementia 2017–2025. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259615). 84. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo J et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190–1. 85. Suarez-Gonzalez A, Livingston G, Comas-Herrera. Report: the impact of the COVID-19 pandemic on people living with dementia in UK. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/03/report-the-impact-of-the-covid-19-pandemic-on-people-living-with- dementia-in-uk/, accessed 22 June 2020). 86. Joint statement on advance care planning. Care Quality Commission; 2020 (https://content.govdelivery.com/accounts/UKCQC/bulletins/283e565, accessed 22 June 2020). 87. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-Comm_health_care-2020.1 accessed 22 June 2020). 88. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/home-care-for-patients-with-suspected-novel-coronavirus- (ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts, accessed 22 June 2020). 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -35- 89. Overview of Public Health and Social Measures in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/overview-of-public-health-and-social- measures-in-the-context-of-covid-19, accessed 10 July, 2020). 90. Bauer A. COVID19: providing palliative care for the many. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/03/31/covid19-proving-palliative-care-for-the-many/, accessed 22 June 2020). 91. Oven A. COVID-19 and long-term care in Slovenia: impact, measures and lessons learnt. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/04/COVID19-and-Long-Term-Care-in-Slovenia-impact-measures-and- lessons-learnt-21-April-2020.pdf, accessed 22 June 2020). 92. Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-Comm_health_care-2020.1, accessed 22 June 2020). 93. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles- and-responsibilities-of-health-workers-including-key-considerations-for-occupational-safety-and- health, accessed 22 June 2020). 94. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/10665-331495, accessed 22 June 2020). 95. Sani TP, Tan M, Rustandi KK, Turana Y. COVID-19 long-term care situation in Indonesia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/06/The-COVID-19-Long-Term-Care-situation-in-Indonesia-30-May-1.pdf, accessed 22 June 2020). 96. Lorenz-Dant K. Germany and the COVID-19 long-term care situation. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf, accessed 22 June 2020). 97. Contact tracing in the context of COVID-19. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/contact-tracing-in-the-context-of-covid-19, accessed 22 June 2020). 98. Rostgaard T. The COVID-19 long-term care situation in Denmark. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long- Term-Care-situation-in-Denmark-29-May-2020.pdf, accessed 22 June 2020). 99. Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST. The long term care COVID-19 situation in Malaysia. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/Malaysia-LTC-COVID-situation-report-30-May.pdf, accessed 22 June 2020). 100. Health at a glance 2019: OECD indicators. Paris: Organisation for Economic Co-operation and Development; 2019 (http://www.oecd.org/health/health-systems/health-at-aglance-19991312.htm, accessed 22 June 2020). 101. Brimblecombe N, Fernandez J-L, Knapp M, Rehill A, Wittenberg R. Unpaid care in England: future patterns and potential support strategies. London: London School of Economics; 2018. 102. Caring behind closed doors: forgotten families in the coronavirus outbreak. London: Carers UK; 2020 (https://www.carersuk.org/for-professionals/policy/policy-library/caring-behind-closed-doors- report, accessed 22 June 2020). 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -36- 103. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? Journal of Gerontological Social Work. 2014;57(5):460–77. doi:10.1080/01634372.2014.882466. 104. Mental health and psychosocial considerations during the COVID-19 outbreak: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/mental-health- and-psychosocial-considerations-during-the-covid-19-outbreak, accessed 22 June 2020). 105. Da Mata F, Oliveira D. COVID-19 and long-term care in Brazil: impact, measures and lessons learned. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/05/COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf, accessed 22 June 2020). 106. COVID-19 and violence against older people. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/covid-19-and-violence-against-older-people, accessed 22 June 2020). 107. Leiblfinger M, Prieler V, Schwiter K, Steiner J, Benazha A, Lutz H. Impact of the COVID-19 pandemic on live-in care workers in Germany, Austria and Switzerland. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/2020/05/14/impact-of-the-covid-19-pandemic-on- live-in-care-workers-in-germany-austria-and-switzerland/, accessed 22 June 2020). 108. Coronavirus Plan of Action. Chile: Senama (http://www.senama.gob.cl/protocolos-covid-19, accessed 22 June 2020). 109. Cuenta con migo [count on me]. Government of Chile (https://www.gob.cl/cuentaconmigo/, accessed 22 June 2020). 110. López-Ortega M, Sosa-Tinoco E. COVID-19 and long-term care in Mexico: questions, challenges, and the way forward. International Long-Term Care Policy Network; 2020 (https://ltccovid.org/wp- content/uploads/2020/06/LTC-Covid-19-situation-in-Mexico-8-June.pdf, accessed 22 June 2020). 111. Musyimi C, Mutunga E, Ndetei D. COVID-19 and long-term care in Kenya. International Long- Term Care Policy Network; 2020 (https://ltccovid.org/2020/06/02/new-country-report-the-covid-19- long-term-care-situation-in-kenya/, accessed 22 June 2020). 112. COVID Trauma Response Working Group (https://www.traumagroup.org/, accessed 22 June 2020). 113. Decade of Healthy Ageing 2020–2030. Geneva: World Health Organization; 2020 (https://www.who.int/docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade- proposal-final-apr2020-en.pdf?sfvrsn=b4b75ebc_3, accessed 22 June 2020). 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -37- 附件1. 方法 正在实施的系统性审查 正在实施一项系统性审查，以期对使用和提供长期护理服务的人群中COVID-19死亡率和发病率的早 期国际证据进行综合研究。这次审查已向Prospero注册平台进行注册（CRD42020183557），包括通 过数据库检索确定的研究，这些研究已于2020年5月15日进行，并在2020年6月5日前进行了更新。研 究方法和研究结果已在medRxiv上全文发表。为了找到所有旨在公布长期护理服务使用者和工作人员 中COVID-19相关死亡率和发病率的原始数据的研究报告，审查人员检索了7个数据库（MEDLINE； Embase；CINAHL Plus；科学网；全球卫生；世卫组织COVID-19研究数据库；medRxiv）。此外，审 查人员还从长期护理专家国际网络LTCcovid.org上找到了一项关于国家一级死亡率的证据。没有关 注长期护理业务的研究报告被排除在外。审查人员对列入审查范围的原始研究报告进行了严格的评 估，并对死亡人数和COVID-19相关死亡率、病死率和非正常死亡率（共同初级结果）以及发病率、 住院率和重症监护室入住率的结果进行了叙述性综合。 标题和摘要筛选以及全文审查由三名审查人员进行，并对报告同一研究或疫情的记录进行了综合。 使用一个标准模板提取了研究数据，包括关于研究设计的信息；护理环境（机构与社区）；COVID- 19如何诊断和确诊；参与者的基本特征；COVID-19确诊和疑似病例的绝对死亡人数和死亡率；病死 率；非正常死亡率；COVID-19确诊和疑似病例的绝对数量和比率；以及COVID-19确诊和疑似病例的 住院率和重症监护室入住率。分别提取了长期护理服务使用者和工作人员的所有研究参与者特征和 结果数据。还提取了在检测时没有出现症状的病例所占比例的信息，以及长期护理服务使用者与其 他人相比较的研究结果。 由于纳入审查范围的分子、分母和随访时间的定义存在异质性，因此，没有对数据进行汇总。而是 对结果进行了叙述性总结，并在表格中列出，并酌情列出了样本特征、随访时间和病例定义方面的 信息。对于所涉人群重叠的研究，则优先考虑样本量较大和随访时间较长的人群。 利用乔安娜·布里格斯研究所流行病学研究的关键评估工具对列入审查范围的原始研究报告所提供 的与死亡率、病死率或发病率相关的数据的质量进行了评估。没有对各研究报告的偏差风险进行评 估。 审查内容共包括由30份独特的原始研究或疫情报告组成的33份研究报告（图A1.1）。 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -38- 图 A1.1 入选审查范围的原始研究的流程图 对干预措施的有效性进行系统性审查试点，以减缓 COVID-19对长期护理服务使用者和提供者的影 响 目前正在对干预措施的有效性进行系统性审查，以管理COVID-19对长期护理服务使用者和提供者的 影响。在试点过程中，对七个数据库 （MEDLINE、Embase、CINAHL Plus、科学网、全球卫生、世卫 科学网: n=184 全球卫生: n=7 世卫组织COVID 19研究数据库 202 数据库检索 通过其他来源确定的记录: n=3 消除重复之后： 标题和摘要筛选后排除： 全文审查： 全文审查后排除 非侧重于长期护理业务：n=75 审查文章：n=52 无死亡率和感染数据：n=56 观点文章：n=25 无法获取全文：n=7 建模研究：n=3 被列入第一次 审查： (27项独特的原创 研究) 更新之后的数据 检索： 消除重复之后： 标题和摘要筛选后排除： 全文审查： 新列入： 共列入： n=33(30项独特的原创研 究) 全文审查后排除 审查文章：n=8 观点文章：n=6 无死亡率和感染数据：n=4 非侧重于长期护理业务：n=3 非侧重于COVID-19：n=2 重复 n=1 排除：1项先前被列入的研究 （被作者撤回） 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -39- 组织COVID-19研究数据库、medRxiv）进行了检索；确定了21项研究报告，这些报告介绍了COVID-19 大流行的应对情况，并介绍了对有效性的某种评价或旨在评估与COVID-19感染率和相关死亡率相关 的长期护理服务的某些特征。有五份报告来自美国，三份来自意大利，加拿大、中国、大韩民国和 西班牙各有两份，比利时、法国、爱尔兰、新加坡和联合王国各有一份报告。 所确定的干预措施和目标群体各不相同。其中三项研究涉及护理中心的药物治疗(1-3)，其他研究描 述了疫情预防措施（中国和新加坡）和控制措施（加拿大、中国、大韩民国和美利坚合众国）在护 理中心的执行情况(1、4-8)，一项研究报告了美国社区护理的预防措施(9)，四项研究报告了在长期 护理环境中为应对COVID-19进行的多方面组织改革，包括多学科协作和协调(6、10-12)，三项是通 过快速护理点检测、集中检测和床边胸部超声检查来发现COVID-19的试点研究(13–15)，另一项是 对痴呆患者现有认知能力进行刺激干预，以提供与COVID-19相关的信息和支持(16)。 这些研究大多是描述性研究，缺乏对照组，不是为了严格评估所执行措施的有效性。不过，中国、 大韩民国和新加坡研究报告中描述的预防和疫情管理干预措施都报告在预防或控制疫情方面取得了 成功。 另外三项研究评估了护理中心的不同特征与COVID-19疫情和结果之间的联系。Stall等人发现，加拿 大安大略省养老院的盈利状况与养老院疫情的规模和居住者死亡人数有关(17)。不过，营利状况与 暴发疫情的可能性更高无关。Romero-Ortuño和Kennelly发现，爱尔兰护理中心的粗死亡人数与最大 入住率之间存在适度的、统计学意义上的显著关联，但没有发现与护理中心的质量存在统计学意义 上的显著关联(18)。同样，Abrams等人也发现在至少报告一名COVID-19病例的美国私人疗养院与传 统质量标准之间没有统计学意义上的关联(19)。不过，在较大的机构规模、城市位置、非裔美国居 住者的百分比、非连锁状态和州之间发现了统计学意义上的显著关联。 最后，两项研究分析了区域特征之间的联系，包括私人与公共长期护理床位的比例和疗养院有多少 床位等长期护理系统的特征，还分析了COVID-19在意大利各地的传播情况(20、21)。 关于 COVID-19长期护理状况的报告 对LTCcovid网站（长期护理政策国际网络的一项倡议）上发布的报告进行了审查。这些报告是由长 期护理专家（通常是学者）撰写的，目的是记录COVID-19对长期护理服务使用者和提供者的影响以 及为减轻大流行对这一人群的影响而采取的措施。这些报告中提供的资料让人们能够了解到各国采 取的一些实际措施。 参考文献 1. Lee SH, Son H, Peck KR. Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals? International Journal of Antimicrobial Agents. April 2020;105988. doi:10.1016/j.ijantimicag.2020.105988. 2. Ahmad I, Alam M, Saadi R, Mahmud S, Saadi E. Doxycycline and hydroxychloroquine as treatment for high-risk COVID-19 patients: experience from case series of 54 patients in long-term care facilities. medRxiv. May 2020. doi:10.1101/2020.05.18.20066902. 3. De Spiegeleer A, Bronselaer A, Teo JT, Byttebier G, De Tré G, Belmans L et al. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents. Journal of the American Medical Directors Association. June 2020. doi:10.1016/j.jamda.2020.06.018. 4. Kim T. Improving preparedness for and response to coronavirus disease 19 (COVID-19) in long- term care hospitals in the Korea. Infection and Chemotherarpy. May 2020. 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -40- 5. Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D et al. A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multi-phase emergency response in Toronto, Canada. Journal of the American Geriatrics Society. May 2020. doi:10.1111/jgs.16625. 6. Shea Y-F, Lam HY, Yuen JKY, Cheng KCA, Chan TC, Mok WYW et al. Maintaining zero COVID- 19 infection among long term care facility residents in Hong Kong. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.042. 7. Munanga A. Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing. 2020;46(6):3–5. doi:10.3928/00989134-20200511-03. 8. Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M et al. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. Journal of Intellectual Disability Research. 2020. doi:10.1111/jir.12740. 9. Archbald-Pannone LR, Harris DA, Albero K, Steele RL, Pannone AF, Mutter JB. COVID-19 collaborative model for an academic hospital and long-term care facilities. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.044. 10. Khatri P, Seetharaman S, Phang CMJ, Lee BXA. Home hospice services during COVID-19: ensuring comfort in unsettling times in Singapore. Journal of Palliative Medicine. 2020;23(5):605–6. doi:10.1089/jpm.2020.0186. 11. Koeberle S, Tannou T, Bouiller K, Becoulet N, Outrey J, Chirouze C et al. COVID 19 outbreak: organisation of a geriatric assessment and coordination unit – a French example. Age and Ageing. May 2020. doi:10.1093/ageing/afaa092. 12. Osterdahl M, Lee K, Ni Lochlainn M, Wilson S, Douthwaite S, Horsfall R et al. Detecting SARS- CoV-2 at point of care: preliminary data comparing loop-mediated isothermal amplification (LAMP) to PCR. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3564906. 13. Cabrera JJ, Rey S, Perez S, Martinez-Lamas L, Cores-Calvo O, Torres J et al. Pooling for SARS- CoV-2 control in care institutions. medRxiv. June 2020. doi:10.1101/2020.05.30.20108597. 14. Nouvenne A, Ticinesi A, Parise A, Prati B, Esposito M, Cocchi V et al. Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes. Journal of the American Medical Directors Association. May 2020. doi:10.1016/j.jamda.2020.05.050. 15. Goodman-Casanova JM, Dura-Perez E, Guzman-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study. Journal of Medical Internet Research. 2020;22(5):e19434. doi:10.2196/19434. 16. Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit nursing homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada. Medrxiv. 2020. doi:10.1101/2020.05.25.20112664. 17. Romero-Ortuño R, Kennelly S. COVID-19 deaths in Irish nursing homes: exploring variation and association with the adherence to national regulatory quality standards. International Long-Term Care Policy Network; 2020. 18. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. Journal of the American Geriatrics Society. 2020. doi:10.1111/jgs.16661. 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -41- 19. Buja A, Paganini M, Cocchio S, Scioni M, Rebba V, Baldo V. Demographic and socio-economic factors, and healthcare resource indicators associated with the rapid spread of COVID-19 in northern Italy: an ecological study. medRxiv. 2020. doi:10.1101/2020.04.25.20078311. 20. Liotta G, Marazzi MC, Orlando S, Palombi L. Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox. PLoS One. 2020;15(5):e0233329. doi:10.1371/journal.pone.0233329. 长期护理机构对2019冠状病毒病的预防和管理：政策简报 -42- 鸣谢 本政策简报由世卫组织通过新的分析、专家共识和参考世卫组织现有指南制定。 协调部门 综合卫生服务司（Shannon Barkley、Edward Kelley） 孕产妇、新生儿、儿童和青少年健康和老龄化司（Zee-A Han、Anshu Banerjee） 主要作者 世界卫生组织：Zee-A Han（负责官员）、Shannon Barkley、Yuka Sumi 伦敦政治经济学院：Adelina Comas-Herrera、Klara Lorenz-Dant、Maximilian Salcher-Konrad 其他投稿人和审稿人 世卫组织指导委员会：老龄化和卫生；临床服务和系统；性别、公平和人权；综合卫生服务；孕产 妇、新生儿、儿童和青少年健康与老龄化；精神卫生和物质使用；感官功能、残疾和康复；感染预 防和控制中心和专题小组；世卫组织神户中心以及各区域办事处（Benedetta Allegranzi、 Jotheeswaran Amuthavalli Thiyagarajan、Sarah Louise Barber、Anjana Bhushan、Alessandro Cassini、 Alarcos Cieza、Theresa Diaz、Stefanie Freel、Manfred Huber、Anne Johansen、Theadora Koller、 Margrieta Langins、Madison Moon、Paul Ong、Ritu Sadana、Nicoline Schiess、Katrin Seeher、Enrique Vega）。 以下个人参与了本文件的投稿或审稿工作。他们已经签署保密协议，并且已对他们提交的利益申报 材料进行了审查。 非世卫组织专家：世卫组织老年人长期护理全球网络（Liat Ayalon、Pablo Villalobos Dintrans、 Walter Frontera、Muthoni Gichu、Sandhya Gupta、Hanadi Khamis Al Hamad、Arvind Mathur、Reshma A. Merchant、Stephen O’Connor、Vinod Shah、Lieve Van den Block）以及Rachel Albone、Sean Cannone、Leon Geffen、Terry Fulmer、Richard Humphries、Caitlin Littleton、Terry Lum、Saniya Sabzwari、David Stewart。 世卫组织继续密切监测可能影响本政策简报的任何情况变化。如果有任何因素发生变化，世卫组织 将发布进一步的更新。 世卫组织感谢大韩民国政府卫生和福利部的大力支持。 © 世界卫生组织 2020年。保留部分版权。本作品可在知识共享署名——非商业性使用——相同方式 共享 3.0政府间组织（CC-BY-NC-SA 3.0 IGO）许可协议下使用。 WHO reference number: WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1