As essential partners in care, family caregivers support feeding, mobility, personal hygiene, cognitive stimulation, communication, meaningful connection, relational continuity, and assistance in decision-making. 1,2,13,14,15,16,17 Prior to the pandemic, research indicates that on average, 37.4 hours of informal care was provided in LTC per resident each month by informal caregivers, most often described as family. 3 Visitor restrictions inclusive of family caregivers reduced available resources for resident care, intensifying staff shortages.1,2,3,5,13 Designation of essential caregivers, distinct from general visitors, in policy and legislation was in part recognition of these roles and contribution to resident care.1,2,13
Prior to the pandemic, the role family caregivers in providing care for other residents was described as evolving over time as family members and friends become familiar with the needs of other residents. Roles described by family members in their care of other residents include providing companionship, assisting with meals, bring additional food or supplies when brought for their own family member, and assisting with leisure activities. 17
LTC volunteers roles during the pandemic reduced their activities to maintaining (limited) activities for residents, assisting residents with use of technology to communicate with family/physicians, and providing emotional support.4
A commentary article describes an example of family caregivers who were hired on short (90 day) contracts to care for residents during acute staffing shortages (Kensington Health 2021).5 Personal communication intended as an environmental scan (AB and ON) spoke to the variability of staffing needs and the individualized response by LTC homes to address these staffing shortages. If family caregivers were to be invited to provide additional resources in the context of staff shortages, this decision was made by individual homes, in communication with residents and families and aligned with provincial visitation policy.
During the pandemic, a new paid role of comfort care aide was also created by Alberta Health Services The job involved providing comfort, support and assistance to residents, portering residents, mealtime assistance, ensuring PPE was always available, refilling equipment and care supplies as needed, cleaning and disinfecting high touch surfaces, supporting reception duties, supporting screening of staff and visitors, receiving deliveries and stocking supplies, and performing other duties as assigned.6
Myge, I; Ward, H; Tupper, S; Fox, L; Howell-Spooner, B. What are the roles or function of family caregivers in providing care to other residents in LTC? 2022 Jan 27, Document no.: LTC220101 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2022. 13 p. (CEST rapid review report).
No evidence was found as rationale for the 14-day isolation period on resident transition to LTC. This requirement likely arose from evidence that active monitoring for 14 days is sufficient to identify symptom onset in 99% of COVID-19+ cases (1).
No alternatives were found in Canada to a 14-day isolation period on transition of a resident into LTC. A rapid review of viral shedding and the need for isolation recommends a minimum 10-day isolation period, with additional consideration for high risk groups (36). The Centers for Disease Control and Prevention (2) in the US is considering decreasing the standard 14-day quarantine period to 7-10 days in recognition that the general two-week quarantine rule is onerous for many people and most of the benefit of quarantine to public health could be gained with a more flexible and contextual approach. Implications for changes in Public Health Agency of Canada’s (PHAC) policy on quarantine or duration of isolation for admission to LTC are not yet established.
The Canadian policies at the provincial government levels align with the PHAC’s recommendation of 14 days of isolation (14). Most jurisdictions across Canada follow guidelines requiring a resident to have a negative test on admission, and 14 days of self-isolation with contact and droplet precautions (4, 17).
However, a few jurisdictions stratify the level of precaution or need for isolation by community transmission (3, 5). For example, the Province of Alberta’s (5) Operational and Outbreak Standards for LTC recommends the following safety precaution: for residents with low or unknown risk of exposure, twice daily symptom checks for 14 days; for residents with medium risk, continuous use of a mask for 14 days while out of resident room; for residents with high risk, quarantine for 14 days.
Best practices on transition to LTC to support residents’ well-being
Some Canadian policies state the importance of protecting resident well-being on transition to LTC but provide little guidance on how to ensure this is done. For residents who might find self-isolation challenging (e.g. those with cognitive challenges), Government of New Brunswick (18) recommends taking efforts to ensure adequate staffing level and support residents’ individualized care plan.
Residents in LTC who have cognitive impairments will have difficulties understanding the need for isolation and absence of families and friends, and complying with isolation procedures (31). There is little guidance for long-term care facilities on how to support safe isolation of those living with cognitive impairments, while maintaining the human dignity and personhood of the individual. Strategies need to be developed to have an isolation care planning that is effective, safe, and compassionate (31).
Maintaining connections between residents and their families should be supported under safety, socio-emotional, and ethical grounds (39). Several provinces and international jurisdictions designate Essential Family Caregivers (EFCs), who are present not for social visits but to provide services and brought into the facilities under the same specific protocols as staff (39, 49, 50, 51).
Gao, Y; Ward, H; Tupper, S; Boden, C; Miller, L; Mueller, M. What is the evidence for 14-day isolation upon move-in to long-term care during COVID-19 pandemic? 2020 Dec 13; Document no.: LTC090801 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 33 p. (CEST rapid review report)
· Overall, there is a lack of high quality evidence to support recommended pandemic preparedness strategies (checklist items) to prevent or mitigate respiratory infection outbreaks in LTC.
· In the absence of high-quality or mixed evidence to support strategies for pandemic preparedness, it is advisable to follow clinical practice guideline recommendations that have been based on expert opinion (key sources are identified in red). This is particularly the case for infection control interventions that are likely to have no negative impacts on LTC residents (e.g. hand hygiene, cough etiquette). Strategies that have a potential negative impact on LTC residents (e.g. visitor restrictions) must be handled with more flexibility and individual assessment to determine how infection control can be preserved while minimizing negative consequences for residents and families.
· Internationally recognized pandemic/outbreak preparedness checklists for LTC (e.g. CDC 2020, Buynder et al. 2017) share many similarities to the current SHA Annex R checklists.
· Consideration should be given to converting the checklist into a planner with accountabilities to demonstrate how each item is being addressed (similar to CDC 2020). Links can be embedded in the planner/checklist to more detailed information, such as the PPE burn calculator (CDC 2020), education/training materials (WHO 2020), and communication materials for families (CDC 2020, WHO 2020, Buynder et al. 2017).
· Consider the addition of specific detail to the SHA pandemic preparedness checklists on the date of the next pandemic plan/checklist review, contact names for local resource acquisition or assistance with staffing, tracking forms for dates of education/training with staff and residents, tracking of audits/observation of infection control practices, surge capacity planning items, and expanded items for communication (see attached recommendations from family caregivers of the Saskatchewan LTC Network).
· Discrepancies exist between reported (77-100%) and observed (25-63%) adherence to infection control practices, indicating a need for independent audits. Adherence rates improve with direct observation, frequent education reminders and prompts.
· Even when there is not an outbreak in a home, the pandemic response results in increased workload demands on staff due to infection control practices (e.g. PPE and hand hygiene), loss of family caregiver assistance with resident care, enhanced care needs of residents due to anxiety, increased communication with family caregivers and other members of the care team, monitoring and restricting resident movement in the home, enhanced cleaning, staff absenteeism, and education/training. Consideration is needed for a provincial process for evaluation of needs within individual homes, and allocation of additional human resources, disposable supplies, equipment, or funding to ensure that both infection control and usual care needs of residents are consistently met.
· Maintaining public confidence through communication is a defined infection control strategy. Communication strategies include individual communication between family members and staff, public communication strategies by individual facilities and provincially through dedicated pandemic information pertaining to LTC (e.g. dedicated LTC section on provincial websites).
There is limited information on transferring infected LTC residents to an off-site cohort location such as a purpose-built field hospital. Lessons learned from SARS suggest that transfers to dedicated facilities for cohorting may increase spread.
A greater number of recommendations support on-site cohorting of residents infected with droplet/contact transmitted illnesses. Health Canada’s COVID-19 Interim Guidance for LTC Homes report states that transfers within and between facilities should be avoided except for medically indicated procedures that cannot be provided by the long-term care home e.g. respiratory failure requiring ventilation or hemodynamic compromise.
Family members encourage cohorting a resident in the LTC home if possible. They also recommend following residents’ advanced care directives to determine whether life-sustaining measures are preferred, robust healthcare and psychosocial support for residents who are cohorted, and clear communication with residents and family members.
Cohorting on site includes isolation of residents to their rooms (preferably single occupancy) or dedicated units in the home. Staff and equipment cohorting should also be implemented if possible (i.e.dedicated staff that do not provide care to residents in non-infected units, and resident specific equipment).
Consider cohorting in day program spaces, recreation rooms, palliative care rooms, chapels, or dining rooms in the home that are no longer being used as common spacesas long as call bells or other appropriate communication measures are in place.
Tupper, S; Ward, H; Ellsworth, C; Dalidowicz, M; Boden, C. What are the best practices for cohorting long-term care residents to reduce transmission of COVID-19? 2020 Apr 16; Document no.: LTC041501 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 10 p. (CEST rapid review report)