The impact of the COVID-19 pandemic on the residential aged care sector, responses and recommendations: A systematic scoping review

DOI: https://doi.org/10.21203/rs.3.rs-2637020/v1

Abstract

Objective: This systematic scoping review sought to identify the impact of the COVID-19 pandemic on the residential aged care (RAC) sector, its system components, and the range of COVID-19 response strategies across the sector. 

Methods: ProQuest, PubMed, CINAHL, Google Scholar and Cochrane Central were searched April-August 2022 for peer reviewed articles and grey literature. One hundred and forty six articles on the impact of the COVID-19 pandemic on the RAC sector and sector interventions/policy responses are included in this review. 

Results:The World Health Organization’s (WHO) six building blocks of health systems were used to categorise impacts and interventions. The COVID-19 pandemic generally highlighted poor resourcing of the RAC sector and exacerbated workforce shortages; led to increased workload, changes in job demand and declines in worker mental health; revealed poor integration across health and aged care sectors and reduced advance care and palliative care planning. Social restriction measures led to declines in the physical, mental health and cognitive decline of residents in RACFs, in particular those with cognitive impairment. Innovative care models included the introduction of outreach teams and primary care models for RACFs and increased use of telehealth and videoconferencing for social engagement, although there was mixed evidence on the use of telehealth for people with cognitive impairment.

Discussion: Additional funding of the RAC sector is required to boost workforce numbers and training, and support worker mental health, along with policies which attract, maintain and support workers from culturally and linguistically diverse (CALD) backgrounds. COVID-19 response strategies in RACFs need to ensure that all residents have access to resources such as telehealth for health and social engagement, including residents with cognitive impairment. Clear guidelines and additional resourcing are required for utilisation of telehealth during a pandemic. Additional research on appropriate COVID-19 responses for residents with cognitive impairment is required, along with a balance between infection prevention and control and social engagement strategies.

Background

Containment of the COVID-19 pandemic has been associated with smaller country population size and better public governance, including investment within the health system [1], however COVID-19 responses across health and aged care systems have differed. Chan et al. (2021) compared the impact of initial government policies in UK and Australia on people living in RACFs during the first wave of the COVID-19 pandemic [2]. Both countries prioritised hospital resources and placed a low priority for aged care residents being in hospitals, and either discouraged admissions or discharged from hospitals without testing for COVID-19, placing a greater burden on RACFs. Chan et al. (2021) concludes that research on government policies and their impact on RACFs is limited, and there is little published data on the availability of Personal Protective Equipment (PPE) and viral testing early in the pandemic [2]. Ibrahim (2020) describes the Australian aged care sector’s initial resilience to the first wave of COVID-19 as being good fortune, but argues that good management is required for subsequent waves [3].

The SARS-CoV-2 virus (COVID-19) has had a significant impact on residents of residential aged care facilities (RACFs) [4–6], in particular those with dementia and cognitive impairment [7–14]. Factors such as facility size, number of stand-alone buildings [4, 5, 12, 15], crowding [4] and location of facilities [16] were associated with COVID-19 rates in RACFs, along with higher COVID-19 rates in the general community [17].

In this paper, we consider the impact of the COVID-19 pandemic upon the RAC sector, and government and sector responses. We adapted the six building blocks of the World Health Organization’s (WHO) health systems framework for this purpose: leadership and governance; health workforce; health systems financing; health information systems; health service delivery and access to essential medicines [18].

We explored sector preparedness and innovative strategies in response to COVID-19 across the system, particularly for people with cognitive impairment who are most impacted by the pandemic. For example, a report on dementia and COVID-19 mortality in Australia found that in the first 10 months of 2020, 30% of those who died from COVID-19 in Australia had dementia – these people were older and more likely to be living in RACFs where outbreaks occurred [19]. In terms of workforce, we particularly explored strategies that take into account people from CALD backgrounds, who make up a significant proportion of the RACF workforce [20].

This systematic scoping review was undertaken as part of a broader study which arose from a research collaboration between five large aged care organisations in Western Australia. The overall goal was to increase residential aged care sector preparedness, readiness and response actions for an infectious disease outbreak or pandemic in the future. Aims of the broader study include to: 1) Identify the health impacts of social restrictions during COVID-19 on (a) residents with cognitive impairment, and (b) on the aged care workforce (with a focus on the Culturally and Linguistically Diverse -CALD), and 2) Evaluate strategies to support psychosocial and physical well-being of (a) residents with cognitive impairment, and (b) aged care workforce (focusing on the CALD). The broader study aims to have a short-term impact through application of findings by the five partner organisations, and in the longer term, will assist the aged care sector to understand the impact of COVID-19 restrictions, and inform development of sector-wide interventions and service models, specifically for residents with cognitive impairment, and the workforce (focusing on the CALD). This paper is based on findings from the systematic scoping review conducted for the broader study, and aimed to answer the following questions:

Methods

This systematic scoping review was undertaken as part of a broader study that considered the impact of COVID-19 on the RAC sector. This article focuses on the peer reviewed articles and grey literature on the impact of COVID-19 upon the RAC sector and elements of the aged care system, and sector preparedness, response and innovations. Other articles arising from the broader study focus on the impact of the COVID-19 pandemic on the RAC workforce, including the CALD workforce, and residents with cognitive impairment (Authors, forthcoming).

This broader review followed guidance for conducting systematic scoping reviews [21]. The databases ProQuest, PubMed, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Google Scholar and Cochrane Central were searched between 6 April and 9 May 2022 for review articles and original studies related to organisational challenges, sector (including workforce) impact and innovations related to COVID-19, and residents with cognitive impairment (using concept areas 1–5 below). Additional Google Scholar searches related to interventions for RACF residents with cognitive impairment during the COVID-19 pandemic were undertaken on 9 May 2022 (using concept areas 1, 2, 4 and 6 below). Additional searches were undertaken for papers which considered the workforce from CALD backgrounds on 24 May 2022 (using concept areas 1, 2, 7 and 8 below). Inclusion criteria for peer-reviewed articles were 1) peer reviewed review articles that included reviews, original studies and commentary articles, 2) published between December 2019 and May 2022, 3) articles in English.

In mid-June, further searches sought grey and academic literature on international and national (Australian) policy documents (and websites), along with academic literature on the assessment of country level policies and guidelines (using concept areas 1, 2, 4 and 9 below), with a focus on Australian policies within the grey literature. In late August 2022, additional searches were conducted on service delivery guidelines in the RAC sector during COVID-19 (using concept areas 1, 2 and 10), with a focus on international and national (Australian) guidelines. Search terms for various concept areas are in Table 1 below.

 
 
Table 1

Search concepts and terms

Concept Area

Search Terms

1. Residential aged care facility

Residential OR aged care OR nursing home OR long term care

2. COVID-19

COVID-19 OR COVID OR COVID19 OR Sars-Cov-2 OR Coronavirus OR Pandemic OR Outbreak

3. Organisational/Sectoral challenges

Organisation OR challenges OR sector OR impact OR preparedness OR Response OR Lessons Learnt

4. Cognitive Impairment

Cognitive Impairment OR dementia OR severe dementia OR moderate dementia

5. Sector Innovation

Leadership OR governance OR workforce OR finance OR consumer participation OR consumer information OR partner* OR social determinants of health OR codesign OR best practice

6. Interventions

Interventions OR strategies

7. Workforce

Workforce

8. CALD

Culture OR Culturally and linguistically diverse OR CALD OR Ethnic OR Multi-cultural OR Culturally diverse

9. Policy

Policy OR guidelines

10. Service delivery

Service delivery OR service delivery models

 

Following the initial searches, titles of papers were screened, and abstracts were read to conduct an initial assessment for eligibility, and articles downloaded into Endnote. Given the high volume of articles identified, the decision was made to focus upon review articles for sector impact; and review and individual studies in other areas. Articles were transferred across of Endnote files and/or included or excluded based upon relevance to the study and bibliographies.

A database was established for data extraction for the academic review, research and commentary articles, with information extracted including: author/title/year of publication, purpose of study, country of origin, setting, research design, methodology, search period, databases searched and type of papers included (for review articles), study population and sample size (if applicable), type of intervention, exposure and control (if applicable), measures, key findings (including statistical findings) and implications, and quality of study/review (considering the level of evidence in the National Health and Medical Research Council framework) [22].

A full explanation of the search methodology is outlined in an integrative literature review report (Authors 2022). The following table indicates the number of articles identified, screened, downloaded into the Endnote files, read and included in the review. Using the National Health and Medical Research Council framework [22], the level of evidence of reviews and studies included were also considered.

Table 2 (below) provides the PRSIMA flow diagram for the review process; there were 7185 papers initially identified, 3322 articles screened, 560 articles initially assessed and 345 articles retrieved and assessed for eligibility (downloaded to Endnote files). There were 143 full papers read, with the total number of articles included in the review being 146 articles. Due to resource constraints, when it came to ‘sector impact,’ articles included were review articles only, whilst review articles and individual articles were included for other areas.

 

Table 2: PRISMA flow diagram based on search process

 

 

Results

In this section we discuss the results in relation to the components of the WHO health systems framework [18] which we have adapted as follows: leadership and governance, aged care sector workforce, aged care sector financing and resources, aged care information systems, and aged care sector service delivery (including care models and access to infection prevention and control resources). As part of the aged care sector service delivery domain, we also considered social determinants of health, in particular social inclusion [23]. In each section below we consider the findings according to the WHO health systems framework, including the impact, responses, and recommendations in each area.

Table 3 (below) indicates the broad focus of articles included (e.g. sector impact, interventions) and their country of origin whilst Table 4 (below) indicates the types of research design (where applicable) or nature of the article included.

 
 
 
Table 3

Broad focus of articles included and their country of origin

Category

Origin

Articles

Reviews and commentary articles on overall sector impact (27)

• 10 from the USA/Canada

• 11 from Europe

• 3 from Australia

• 1 each from China, Japan and Lebanon

[4, 5, 7–13, 15, 16, 25, 35, 59, 90, 94, 96, 102–104, 106–108, 117, 121–123]

Reviews and studies on resident interventions (16)

• 7 from the USA/Canada

• 7 from Europe

• 1 each from China and Qatar

[91–93, 97, 101, 105, 116, 124–132]

Reviews and individual articles on workforce impact and interventions (25)

• 13 from USA/Canada

• 7 from Europe

• 3 from Australia

• 1 from Japan

[26, 27, 29, 32, 33, 57, 58, 60, 61, 63, 65–74, 77, 78, 83, 133, 134]

Policies, policy reports, resources and related articles (78)

• 50 Australian policies and reports (9 Australian national policies/policy reports, 26 Australian and state service delivery policies/guidelines, 15 communiques from the Australian Government’s Culturally and Linguistically Diverse Communities COVID-19 Health Advisory Group)

• 4 international (WHO) policies and resources

• 1 USA policy position

• 2 European policy positions

• 11 academic articles with a policy or care model focus (4 Australian, 3 from the USA, 1 Dutch, 1 Japanese, 2 Chinese)

Broader policy focus:

[2, 19, 24, 25, 31, 34, 36–39, 41–56, 75, 76, 109–112, 114, 115, 135–147]

Service delivery focused:

[3, 28, 30, 64, 79, 80, 82, 84, 86, 87, 89, 98, 99, 148–165]
 
 
Table 4

Types of research design and articles included

Type of Article

Number

Meta-analysis

2

Systematic review/rapid review

13

Scoping review

8

Literature review/Commentary

27

Randomised controlled trial

1

Prospective cohort study

1

Case-control study

2

Pre-post test (no comparison group)

4

Observational study (e.g. cross-sectional)

16

Qualitative study

13

Case study

2

Study Protocol

1

Government Policy/Service Delivery Guideline/Research Report/Inquiry Report/Communique/web resource

50

Submission to Inquiry or Position Statement (non-government)

7

Total

146

Impact Of The Covid-19 Pandemic On The Residential Aged Care Sector, Responses And Recommendations

Leadership and governance

Infection prevention and control governance, guidelines and structures

The success of infection prevention and control initiatives in RACFs were influenced by public discourses, and prior experiences of infectious disease. The prior experience of severe acute respiratory syndrome (SARS), H1N1 influenza in 2009 and Middle East Respiratory Syndrome (MERS) coronavirus in 2012 may have led Asian systems to be more prepared and responsive, with prior staff training on IPC [24]. Chu et al. (2021) note the differences in public discourse surrounding IPC policies across countries, for example mask wearing was mediated by political partisanship in the United States (US) and conflated with personal freedom, whilst it was considered the norm in China and Japan where there were high compliance rates [25]. Calcaterra et al. (2022) state that Asian systems, and the RAC sector, may have been more prepared for COVID-19 as they may have been supported by socio-cultural values towards older people which value older people [24]. Whilst US research discussed vaccine hesitancy among RAC workers from CALD backgrounds [26, 27], in Australia vaccination for workers in the RAC sector was mandatory [28]. However, one study suggested the need for tailored training/upskilling for CALD workers on cognitive impairment and dementia [29].

In Australia, the COVID-19 pandemic highlighted lack of adequate governance and a need to strengthen regulation and compliance in aged care [3, 30], along with greater consumer engagement within aged care services [30]. A special hearing on aged care services and COVID-19 was held [31] as part of the Royal Commission into Aged Care Safety and Quality, which highlighted workforce issues and a range of safety and quality issues for RACFs, including significant outbreaks and lack of access to allied health and mental health services for residents in RACFs [31]. Challenges for service delivery during COVID-19 included changing and burdensome regulation and guidelines related to COVID-19 [32, 33].

Service Integration, Partnerships and Intersectoral Collaboration

The World Health Organization’s (WHO) (2020) policy brief on preventing and managing COVID-19 in long-term care services had 11 key recommendations, including ensuring a continuum of care, prioritising the psychosocial wellbeing of residents and staff, and ensuring effective communication across health and aged care services [34]. However, the COVID-19 generally indicated a lack of coordination across acute care, palliative care and long-term care [35]. In Australia, lack of integration between health and aged care occurred [30]. However, RACFs were better connected to the health system in many Asian countries, which facilitated connections across public health and RACFs [24]. Studies cited by Dykgraaf et al. (2021) used intersectoral collaboration across hospitals, public health organisations, primary care or academic institutions, focusing on providing IPC support, increased testing capability education for nursing home staff and collaborative management, with limited evidence for their effectiveness [15].

Responses and Recommendations

The successful containment of the COVID-19 pandemic in Hong Kong was attributed to learning from the experience of SARS and the development of public guidelines to prevent the spread of communicable diseases in 2004 which required all RACF operators to designate an Infection Control Officer to coordinate and implement IPC measures [36]. Similarly, the European Geriatric Medicine Society recommended that an IPC focal point should be set up in every long-term care facility [37]. In China, each RACF developed an epidemic IPC structure and leadership group, overseen by a Dean [38]. In Japan, it was recommended that nursing homes be evaluated by independent organisations using a comprehensive IPC checklist, prior to an outbreak emerging [39].

In Australia, the Royal Commission into Aged Care Quality and Safety’s report made a number of recommendations, including an overall of the aged care system, including aged care financing and new legislation to protect the rights and social engagement of older people in RACFs [40]. The ‘COVID-19 and Aged Care’ report emerging from a special hearing recommended: a national aged care plan for COVID-19; the establishment of a national aged care advisory body; Medicare items for allied health and mental health in RACFs; guidelines on the transfer to hospital from RACFs for people with COVID-19; government infection control officers to inspect RACFs; and, an independent investigation of significant outbreaks in nursing homes to determine lessons learnt [31]. When it came to CALD communities, there was a strong focus in government strategies on increasing vaccination rates in these communities [41–55], rather than using the CALD workforce in RACFs as resources for infection prevention and control in the broader CALD community.

At an organisational level, the need for clear organisational communication and leadership have been highlighted as important during the COVID-19 pandemic [26, 56–58], including for promoting team resilience and managing crisis [57]. Confidence in organisational leadership was associated with greater confidence in COVID-19 vaccine efficacy and less vaccine hesitancy [26]. Scheffler et al. (2021) stated that leadership commitment to upskilling is required, along with more recognition and support for nursing assistants [32]. Palacios-Cena et al. (2021) reported emerging leadership practices including RACFs forming closer relationships with local communities, and groups who provided needed equipment or volunteer support [59]. They also highlighted the importance of designing protocols that clearly define the role of communities, hospitals and primary care facilities and their support for RACFs, and developing tools for communication between professionals, residents and their families during lockdown [59].

Table 5 (below) summarises the strategies, responses, innovations and/or recommendations across the elements of the residential aged care system.

 
 
 
 
 
 
 
Table 5

Summary of strategies, responses and innovations across elements of the residential aged care system
 

Leadership and governance

Aged Care Sector Workforce

Aged Care Sector Financing & Resources

Aged Care Information systems

Aged Care Service Delivery

Access to Infection Prevention and Control Resources

Strategies, Responses,

Innovations or Recommendations

• Pandemic prevention and control structure with person responsible in each RACF [38].

• Independent evaluation of IPC [39].

• Collaboration across levels of government, ranks and disciplines in response to COVID-19. Changes in the certification process for nursing homes in the US and deployment of strike teams to support nursing homes in crisis [83].

• Collaboration across tertiary care, RACFs and primary care, and academic institutions [15].

• Partnerships with local communities [59].

• Guidelines on telehealth use.

• Increased funding for staffing resources and enable RN at each site at all times.

• Improved workforce governance and alignment with migration policies [74].

• Preventing staff working across sites and compartmentalised staffing zones [12, 15].

• Staff training on dementia and assessment using the Neuropsychiatric Inventory (NPI) [78] and upskilling on COVID-19 preparedness and response, IPC [133]. Face to face training preferable [78].

• Calls for innovative training to enable more students to study gerontology across disciplines [76].

• Supporting the mental health of staff via access to professional support services, including a Psychologist at the workplace [10, 16, 70].

• Peer and supervisor support strategies [65].

• Pandemic relief payments to support staff who are sick or whose relatives are sick [86].

• Increase funding to the aged care sector [40].

• Increased funding for allied health services within aged care [40].

• Value-based payment models which meaningfully engage clinicians [79].

• COVID-19 relief for nursing homes in the US [82] and other countries such as Australia [87].

Few articles were focused on information systems in the RACF sector.

Consistency of data definitions and collection of indicators is required within and across countries. Wellbeing and independence indicators are required for residents within RACFs.

• Advance care planning in primary care [35]. Development of a COVID-19 Communication and Care Planning Tool to facilitate a structured approach to advance care planning conversations with RACF residents during COVID-19 [166].

• Outreach geriatric and palliative care in RACFs [98, 99].

• Innovations to improve quality of life, including those that increased resident social connection, improved physical fitness, promoted communication between families and care staff/administrators, and support relationships between residents and staff [100].

• Exergames for people with cognitive impairment [101].

• Balancing IPC with human rights concerns [40].

• Early planning involving the RACF sector for IPC is required.

• Clear and effective organisational communication strategies on infection prevention and control, PPE and social distancing [25, 58].

• Increased used of telehealth, telemedicine and videoconferencing for diagnosis, treatment and social engagement [15, 92–94], with positive outcomes including reduced emergency and hospital admissions, cost savings, less use of physical restraint and improved access to specialists [91]

• Use of videoconferencing for sharing information with groups of families [109].

 

Aged Care Sector Workforce

Workforce shortages, increased workload, staff mental health and retention

The COVID-19 pandemic highlighted existing staffing shortages in RACFs [60–62], particularly in rural areas [63], including, a shortage of Registered Nurses and Enrolled Nurses working in facilities [63, 64]. Issues with resident-staff ratios were also highlighted [5, 15, 60, 61]. Prevalence of COVID-19 in RACFs have been associated with workforce factors [4, 15, 16]. In the US, RACFs that had under the recommended minimum of RNs had twice the rate of COVID-19 as those that did not [60].

There were increased workloads and job demands as a result of COVID-19 [33, 65–68], associated with intention to quit the profession [58, 68]. Residential aged care sector staff experienced stress and mental health problems as a result of responding to the pandemic [58, 65–67, 69–72], including anxiety about acquiring and transmitting COVID-19 [57, 65, 67, 72]. Work-life balance stressors were also reported by staff in RACFs [73]. Studies also indicated that staff in RACFs felt a lack of support and recognition [32, 33]. Senczyszyn et al. (2020) underscored the importance of institutional factors including access to PPE, safety guidelines and availability of psychological support, to the mental health of nursing home staff. Lack of access to PPE, lack of workplace safety guidelines or perceived shortage of staff in the workplace, were associated with lower staff mental health [70].

Responses and recommendations

To address workforce shortages in aged care, Kuhlmann et al. (2021) called for improved aged care workforce governance and European health labour market regulation and governance models that help to balance national interests with health system needs, health labour markets and individual migrant carers [74]. Migration policies are important in this area as they determine the migration flows of migrant carers [74]. One of the Australian government policy responses was to increase the hours that international students working in aged care and nursing were able to work during the COVID-19 pandemic [75]. Other government measures included enabling workers whose visa was expiring, and who were unable to leave the country, to apply for a COVID-19 Pandemic event Temporary Activity Visa to stay up to 12 months if working in a critical sector, which included aged care [75].

The WHO recognised that RACFs are often highly dependent upon migrant and CALD workers, who may be more vulnerable to COVID-19, and states that COVID-19 responses should include long term care to ensure that ethnic groups are not marginalised [34]. Despite this, studies which focused on this group of workers were limited, and where they did exist, the focus was on vaccine hesitancy and interventions to increase vaccine uptake [26, 27], rather than issues such as training needs. A scoping review that commenced prior to the pandemic recommended organisational support and resources, professional development and good working conditions for the retention of migrant aged care workers [29].

Training and support needs identified for all RACF staff included innovative training methods to ensure that more staff across disciplines are trained on gerontology [76], training on the use of PPE [32], and information and communications technology training for diagnosis and treatment and to reduce residents’ social isolation [29, 32, 77]. Dementia training for migrant aged care workers as also recommended [29]. However, one study tested online dementia training for staff (introduced by the government in response to the COVID-19 pandemic), and subsequent assessment using the web based Neuropsychiatric Inventory (NPI) and found that those that undertook face to face training were more likely to undertake NPI assessments [78].

Recommendations also included supporting the mental health of staff, for example via the provision of psychology services and professional and supervisor support strategies [10, 16, 65, 70].

Aged care sector financing and resources

The COVID-19 pandemic highlighted issues with financing and resources for the RAC sector across countries, such as Australia and the US [3, 31, 79], or centre based aged care services for people with dementia and their carers in Australia [80]. The Royal Commission into Aged Care Quality and Safety in Australia recognised financing issues for the aged care sector [31, 40].

In the US, it was found that the COVID-19 pandemic had little fiscal impact on publicly traded nursing home corporations [81]. One US case study examined for profit nursing homes (70% owned by for profit corporations and 58% by for profit chains, with some being publicly traded companies and other private companies or owned through private equity [82]. The Ensign Inc Group, the second largest US for profit nursing home chain (on the public market), grew rapidly during the COVID-19 pandemic, with US government funds including Medicare, Medicaid and COVID-19 relief major revenue sources. Real estate purchasing, debt financing, spin-off companies and tax arbitrage facilitated the success. However, managers promoted shareholder interest at the expense of professional standards and quality care, as the chain’s nursing homes had low registered nurse and total nurse staffing levels, regulatory violations and below average ratings, with high COVID-19 infections rates [82].

In some countries a surge workforce was employed during COVID-19, or the defence force was engaged to boost the RAC workforce (as occurred, for example, in the US and Australia) [83]. In the US extra staff and resources were deployed for the RACF sector, in the form of strike teams to support nursing homes in crisis [83]. Collaboration occurred across levels of government, ranks and disciplines, and there were changes in the certification process for nursing homes in the US, a relaxing of audit (survey) requirements, and deployment of strike teams to support nursing homes in crisis [83]. The Australian government also deployed a surge workforce to work across states, and Australian Defence Force teams to provide clinical and non-clinical support for nursing homes in crisis [84].

The Australian government also offered short-term pandemic relief payments during the COVID-19 pandemic. The COVID-19 Disaster Payment introduced in June 2021 provided income support to workers who were unable to work due to a public health order [85]. The Pandemic Leave Disaster Payment was also introduced as a lump sum payment for lost employment because of isolation, quarantine, or caring responsibilities throughout 2020 [86]. In addition, the government introduced the COVID-19 Aged Care Support program for aged care providers to receive reimbursement for eligible expenses for managing the direct impacts of COVID-19 [87].

Responses and recommendations

In Australia, recommendations included increased aged care financing and increased resources to promote access to Medicare Benefits Schedule (MBS) items for allied health and mental health in RACFs [31, 40].

Grabowski (2020) claims that the aged care sector in the US is in crisis and requires financing reform, such as the introduction of ‘value-based payment models,’ accompanied by service delivery reform which engages clinicians in key leadership positions in post-acute and long-term residential care [79].

Aged care information systems

The information systems aspect of the WHO (2010) health systems framework refers to information to inform health service policy, planning and delivery [18]. Few articles discussed information systems and systems performance measures within the RAC sector, however where they did, the focus was upon workforce performance measures such as the number of registered nurses per resident and staff-patient ratios (e.g., Harrington et al., 2020). In the US, there was inconsistent information about workforce shortages, which underscored issues with the uniformity of data collection systems.

In Australia, there was initially no national reporting on COVID-19 morbidity and mortality in residential aged care facilities [17]. Additionally, clinical level data are not readily available to determine potential for morbidity and mortality from COVID-19 [88]. It has also been noted that the way mortality data is collected and recorded across countries differs, so caution is advised in comparing data [40].

Responses and recommendations

Ibrahim and Aitkin (2021) suggest that, ideally, in order to determine COVID-19 risk in RACFs data would be collected via on-site surveys through externally trained observers, and standard collection for objective variables [88]. However, this is deemed impractical given time and other logistical constraints, and public domain data also overcomes issues of politicised responses [88].

In Australia, a main resource for providing information about aged care services is the national Productivity Commission’s Report on Government Services [89]. High level objectives for aged care services include their accessibility and use by different population groups, appropriateness to the needs of clients, and quality and safety [89]. However, many of the indicators do not have comparable or complete data; for example, wellbeing and independence in residential care [89], which are major concerns during the COVID-19 pandemic. More and consistent data collection is required in Australia and other countries.

Aged care service delivery

Advanced care planning

There was a reduction in advance care planning during the pandemic [35, 90], which had an impact on unnecessary hospital admissions [90]. Residential care staff were taking on responsibilities usually held by primary care Doctors, and untrained care home staff were administering medication during end-of-life care [90]. One study showed that only 13% of RACF residents had a relative with them when they died from COVID-19, putting further responsibility on to staff at end of life (see Spacey et al. 2021). Both families and RACF staff were not able to attend funerals which did not allow for time to process, grieve or mourn. Advanced care planning was also disrupted by the unpredictable and unplanned decline of residents, social distancing measures, and fewer visits by General Practitioners and specialist palliative care teams, including at end of life [90]. Orders such as ‘do not hospitalise’ or ‘do not resuscitate’ increasing during the pandemic [90]. A reduction in ACP for residents in aged care facilities was also associated with the bureaucratic requirements of an ACP (e.g., obtaining signatures/sign-off), and increased flexibility is required during pandemic conditions. Hirakawa et al. (2021) described situations where some jurisdictions used audio-visual witnessing and counter signing electronic copies of documents [35]. However, it was difficult to develop and maintain mutual trust for interprofessional and intersectoral communication through virtual platforms. In addition, health professionals in hospital settings had limited time for communication with RAC and palliative care sectors due to high workload, and there were difficulties discussing ACP in the emergency department setting [35].

New models of care arising

We summarise the strategies, responses, innovations and recommendations in response to COVID-19 in the following table.

INSERT Table 5 HERE

Information and communications technology and telehealth

Whilst residents’ access to services posed an issue during the COVID-19 pandemic, increased use of information and communications technology (ICT) occurred for diagnosis, treatment and social engagement [15, 91–94]. However, a small Australian qualitative study (n = 11, including 4 General Practitioners) highlighted barriers for telehealth use in RACFs during COVID-19 [95].

Positive outcomes from using telemedicine and telehealth included: reduced emergency and hospital admissions, financial/Medicare savings (due to fewer hospital admissions), less use of physical restraint on residents, and improved access to specialists [91]. Specialist recommendations provided through telehealth were more likely to be followed where residents were at risk for depression, or where a hospital transfer was recommended [91]. However, findings on the effectiveness of telehealth or ICT for social engagement for people with cognitive impairment was mixed [96]. One study claimed that people with dementia found videoconferencing difficult to use [94]. Brown et al. (2020) claim that virtual care may not be adequate for diagnosis or monitoring progression of Alzheimer’s and related dementias [8]. A meta-analysis determined that the neuropsychological test scores obtained by videoconferencing are comparable to those undertaken in person [97]. One randomised controlled trial involving patients with dementia found that monthly telephone follow-up visits with collaborative care teams improved the quality of life of people with dementia when compared to standard care [97].

Gosse et al.’s review (2021) also found inequitable access to virtual care for people with dementia [97]. Schifeling et al. (2020) discovered that there was inequitable access to video conferencing, as non-white patients, patients who needed interpreter services and those who received Medicaid were less likely to have videoconferencing visits than white patients [93]. Barriers to using telehealth included technical issues, reimbursement challenges and failure to allocate staff time for telemedicine [91].

Specialised hospitals and outreach to residential aged care

Some countries invested in specialised acute facilities, for example Singapore developed a National Centre for Infectious disease with a 330-bed hospital [24]. In Hong Kong, hospital geriatric outreach teams (including geriatricians, nurses and other professionals) visited RACFs to ensure that preventive measures were followed by RACFs, and to avoid residents transferring to acute hospitals unnecessarily. Singapore also used medical mobile teams from acute hospitals visiting nursing home facilities. One Australian hospital department of geriatric medicine reported implementation of a geriatric outreach service to RACFs, resulting in significant hospital avoidance, with the outreach team including a geriatric medicine consultant, clinical nurse specialist and advanced trainee [98]. An Australian study included an innovative model of palliative care service delivery within RACFs during the COVID-19 pandemic, that involved collaboration between a tertiary teaching hospital palliative care outreach service, residential in-reach geriatric service and a community palliative care service [99].

Primary care, and the emergence of nurse practitioner models

Few studies focused on the role of primary care in pandemic planning and response in nursing homes, despite its pivotal role in providing care in nursing homes across many countries [15]. Grabowski (2020) discussed a US trend showing an increase in primary care services delivered within RACFs by specialist primary care clinicians, many of whom are nurse practitioners [79]. This reduced hospital transfers amongst long term residents, decreasing costs and enabling more primary care delivery within the RAC sector [79].

Quality of life and interventions

Bowers et al. (2021) identified 19 innovative interventions to improve quality of life across Canada, Japan, Switzerland, United Kingdom, USA, China, Jamaica and Ethiopia, seven of which used ICT [100]. The benefits of the various innovations were categorised as follows: increase resident social connection (12 innovations); improve physical fitness (3 innovations); promote communication between families and care staff/administrators (6 innovations); and support relationships between residents and staff (4 innovations) [100]. A range of software was utilised by RACFs for videoconferencing between residents and families, using phones and tables, whilst other technologies included ‘granny cams’ robots using voice recordings. Almost all of these innovations required staff assistance, which had workload implications. Other initiatives included virtual pen pal and chat programs (sometimes initiated by schools and church groups). Schools and colleges also initiated ‘new friends’ writing campaigns, which involved sending postcards, stories, poetry and messages, or photographs. One program involved resident contact with medical students via telephone. Other initiatives included using social robots in the form of cats, dogs, or seals, ‘vacations’ through virtual technology, outdoor walking, roving musicians and outdoor concerts [100]. Swinnen et al. (2021) tested a stepping exergame program with older adults with neurocognitive disorder (n = 22) living in RACFs. The exergame was deemed usable and useful for older adults with neurocognitive disorder, but there were some technical issues and instructions to be addressed before full implementation in a longitudinal study [101].

Social isolation and social inclusion as a social determinant of health

Initial failure to mitigate the impact of COVID-19 on RACFs led to overcompensation in the form of overly restrictive policies [25]. COVID-19 measures such as visitor restrictions and social isolation measures had an impact on loneliness, mental and physical health, and cognitive decline in RACFs [25, 78, 96, 102–108]. Several articles were concerned with RACF residents’ human rights and the way in which lockdowns, social distancing measures and blanket bans on visiting nursing homes (to prevent the spread of COVID-19) have adversely impacted residents, both mentally and physically [30, 37, 76, 109–112]. Social isolation had a significant impact upon the mental health and cognition of residents both with and without dementia [102]. These findings can be expected in light of what we know about social exclusion/social capital as a determinant of health [23].

People with cognitive impairment

Few policies, research articles or service delivery guidelines specifically considered people with cognitive impairment at all, and especially those with cognitive impairment. However the Centre for Disease Control (CDC) in the US made recommendations for risk reduction for people with a history of dementia, including regular reminders for everyday hygiene practices (e.g. alarms, or timers for hand washing) [113].

Where articles did consider this population group, the focus was frequently on the way in which people with cognitive impairment were impacted by COVID-19 physically and mentally, including as a result of social restrictions [34, 110, 112, 114]. The impact of COVID-19 was greater for those with dementia [9, 10, 107], including those with severe dementia and who had experienced longer social isolation [107].

Access to infection prevention and control resources

In Australia, as in other countries, the risk of COVID-19 for older people in RACFs was slow to be recognised [2, 3, 25]. Residential aged care facilities were initially not prioritised for resources such as PPE [2], leading to shortages of, or issues with access to, PPE and COVID-19 testing [2, 33, 65, 66, 70].

Responses and recommendations

Key factors for successful outbreak management included external support and assistance, staff training and education in infection prevention and control, workplace culture and organisational leadership, coordination and communication and adequate staffing levels [77]. Clear and effective communication strategies on infection prevention and control (IPC), PPE and social distancing with staff, residents and families were deemed necessary [25, 58]. One Chinese study recommended more medical staff, adequate resources, developing cooperation with hospitals and the transformational leadership of managers, to increase implementation of COVID-19 guidelines [115].

Lester et al. (2020) also highlight the importance of communication regarding COVID-19 guidelines in service delivery [56]. They recommend the use of telehealth visits for medical consultation providers; video or window visits with families; providing regular COVID-19 updates to staff; providing identification cards for staff for resident recognition; providing signs and colour coding system for doors to remind staff to use appropriate PPE; providing basic communication boards in rooms for residents with hearing impairment; developing protocols for notifying families about the COVID-19 status of residents; and arranging memorial or remembrance services following the death of a resident from COVID-19, when social distancing allows [56].

This review highlighted the importance of having advance care planning discussions early and community-based ACP (i.e., before hospital admission, including in nursing homes). Studies suggested that ACP (which may need to involve telehealth), led by nurses/allied health, should be part of COVID-19 response strategy and guidelines and include communication tools to support ACP [35]. Hirakawa’s (2021) review found that more ACP in palliative care is needed, which should include anticipatory grief work and discuss bereavement care to support families.

Groom et al. (2021) found that strong facility leadership was crucial for the implementation of telemedicine during the COVID-19 pandemic [91]. Many studies highlighted the additional resources required for the use of telemedicine and videoconferencing, particularly for people with cognitive impairment. Hoel et al.’s (2022) study identified the need for policy and legislation on the use of ICT, including to ensure cost coverage (e.g., for hardware, software and internet connection) and network infrastructure (e.g., broadband coverage) [116]. Considerations include the availability (e.g., of hardware, software and internet) and user-friendliness of technology [116].

Bethell et al.’s (2021) scoping review identified twelve strategies to improve social connection and mental health outcomes in RACFs, including managing pain, addressing vision/hearing loss, addressing sleeping problems, developing opportunities for creative expression, maintaining exercise, religious and cultural practices, gardening activities, visiting with pets and using ICT for communication, and laughing, reminiscing and addressing communication impairments [117]. Ferdous (202) identified four main strategies to address social isolation, including use of ICT, remote communication, therapeutic care/stress management and preventive measures [103]. Chu et al. (2021) suggests five strategies to address or mitigate social isolation for residents during the COVID-19 pandemic that could also be applied post pandemic, including: increased monitoring and providing resident support (e.g., through more staff) to identify and reduce the negative impacts of visitor restrictions; maintaining and supporting interactions for residents (including staff-resident, family-resident and resident-resident interactions); developing a leadership and management task force responsible for lockdown preparation, collaboration and communication with families; using technologies (e.g. videoconferencing) to connect residents with the world outside; and communication of policies, for example government protocols, in a clear and timely fashion [101].

Lessons learnt include that people with cognitive impairment require additional support to practice infection prevention and control, and require higher frequency monitoring of clinical status [7]. Hardan et al. (2021) state that seclusion guidelines should be considered together with the risk of cognitive deterioration due to such guidelines being implemented [9]. Numbers and Brodaty (2021) suggest providing caregiver support and developing skilled nursing home staff to maintain social interaction and provide support for older people with dementia in RACFs [11]. Zhang et al. (2021) suggest that the assessment of frailty could help clinicians determine and manage the risks for older patients with COVID-19 [13]. Keng et al. (2020) recommend for residents with behavioural and psychological symptoms of dementia in RACFs: using audio-video conferencing, physical activity programs, music and doll therapy, relaxation training, ensuring advanced directives and substitute decision making are in place, and providing grief counselling and professional support services for staff [10]. Gosse et al. (2021) recommend that RACFs use videoconferencing to educate patients and carers about behavioural and psychological symptoms of dementia and dementia management techniques, and that informal caregivers should be included in three-way calling during the COVID-19 pandemic. They also suggest that virtual care be supplemented in RACFs with in person visits where possible [97].

In Switzerland, concerns about fundamental rights led to the National Ethics Committee to publish ethical guidelines for long term care institutions, which advised them to permit relatives to visit a dying relative in RACFs [109]. In France, nursing homes offered video conference services, where families could obtain specific information about their loved one and share experiences with other families[109] In Australia, there was lack of communication with families of residents in RACFs during COVID-19 [30]. The final report of the Royal Commission into Aged Care Safety and Quality in Australia recommends new legislation, with one proposed objective being to protect and advance the rights of older people receiving aged care, including the right of social participation [40]. One recommendation was that government funding ensure adequate staffing to enable people in RACFS to be visited by their family and friends [31].

Gaps in research

Considering the WHO health systems framework [18] and aspects of good service delivery as defined within this system, this review identified gaps in the research and grey literature under the following areas:

  • Governance – There were few research articles on good governance and community participation in governance and service delivery within RACFs during the COVID-19 pandemic.

  • Service delivery – Evidence on the use of telehealth for people with cognitive impairment was mixed, and further research is required to determine its value given recommended conditions are in place (e.g., training and resources for staff, residents and families). Strategies to better utilise the CALD workforce as resources for IPC.

  • Residents with cognitive impairment - More research is required on strategies and innovation for people with cognitive impairment, particularly to reduce social isolation and increase social engagement. Liu et al. (2021) identify 21 areas for future research arising to address concerns for people with dementia and their carers during the COVID-19 pandemic. These include longitudinal studies on the impact of COVID-19 and social isolation which also consider inequalities, dementia risk and progression, wellbeing of those with dementia and staff, long COVID-19 and post-COVID-19 syndrome, the acceptability of telehealth for people with dementia [94]. They also suggest researching best-practice in care homes in terms of visiting, remote communication, infection control, reducing loneliness and protecting human rights [94]. Similarly, Veiga-Seijo et al. (2022) suggest more research to understand strategies and actions that enable meaningful connections between families and residents in aged care, and on the needs of people with dementia in relation to their use of information and communications technology (ICT) [106].

  • Information systems – There was limited research on information systems and data governance in the RAC sector during COVID-19, and reliable data on resident wellbeing and independence indicators. There is scope for future research in this area, including indicators of wellbeing, independence and human rights of residents.

  • Workforce – Few studies considered the implications of the cultural diversity of the workforce, especially for pandemic preparedness and public health messaging.

  • Mental health impacts - Manca et al. (2020) suggest the need for more research on the long-term mental health impacts of the COVID-19 pandemic and mitigation strategies [102].

  • Research partnerships - There have been calls for more sharing of research and the development of research partnerships in aged care [76].

Discussion

This review highlighted the need for improved resources for the RAC sector, better governance, and service integration and communication across health and RACFs. The need to ensure primary care, outreach teams and advance care and palliative care planning within COVID-19 responses was also emphasised. Clear guidelines and resourcing to enhance the use of telehealth is required, particularly to facilitate its use for those with cognitive impairment. The review also underscored the need for a greater focus on people with cognitive impairment in RACFs and their informal carers within COVID-19 responses, including in service delivery, social engagement, governance and participation. Future research should adopt a systems approach, take a health equity lens, and explore information systems and indicators for the RAC sector during the COVID-19 pandemic and beyond.

The COVID-19 pandemic has highlighted the inequitable impact of COVID-19, with significantly higher mortality rates amongst older people, in particularly people with cognitive impairment and residents in RACFs with dementia, and people of low socio-economic status [118]. The pandemic has also inequitably impacted racial and ethnic minority groups [119]: in Australia, mortality rates for people born outside of the country were four times higher during the Delta wave [118]. Addressing these health inequities will require greater consideration of national policies, strategies and resources for the aged care sector and the RACF workforce, including labour and migration policies, and national and organisational policies tailored to the workforce from CALD backgrounds. In addition, there appears to be greater scope to utilise the CALD workforce in RACFs as resources for infection prevention and control in the broader CALD community.

This review also highlighted that infection prevention and control strategies must include consideration of social inclusion as a key determinant of health [23], as visitor restrictions and other social isolation measures negatively impacted the mental health of staff, residents and family carers in RACFs, and the physical and mental health of residents.

Inadequate public sector investment in the RAC sector was revealed through the experience of the COVID-19 pandemic, and the pandemic further exacerbated workforce shortages across countries. The low priority given to the sector in initial COVID-19 responses in countries such as the UK and Australia greatly impacted the sector and residents. Conversely in the US, some companies fared well financially as a result of the pandemic (and associated public relief), at the expense of professional standards [79]. The pandemic generally exposed quality and safety issues within RACFs during the COVID-19 pandemic.

In Australia, such issues have been recognised through the Royal Commission into Aged Care Quality and Safety [40] and responses. The Australian Government has recently passed new aged care legislation in response to the Royal Commission into Aged Care Quality and Safety; the Aged Care and Other Legislation Amendment (Royal Commission Response No. 1) Act 2021.73 Amongst reforms, there will be a new system for calculating aged care basic subsidies, new governance responsibilities, restrictive practices are to be used as a ‘last resort,’ a code of conduct will be implemented, and a registered nurse at RACFs on site at all times [120].

There were some good examples of collaboration across health and aged care systems during the COVID-19 pandemic, and successful outreach models to RACFs and service models that included primary care. However, collaboration frequently occurred at the service delivery level, rather than governance level. At an organisational level, the review identified the importance of good leadership and commitment to training and organisational communication, and in turn, staff retention. It underscored that workforce strategies need to support the mental health and wellbeing of the workforce, and more closely consider those from CALD backgrounds, including for support and training needs such as on dementia (identification, treatment responses, and response to COVID-19).

Future research should consider a systems approach, employ a health equity lens, and consider the way in which research on the RAC sector is conducted by researchers during infectious disease outbreaks. Adoption of a health systems approach within future policy and research (including consideration of the comprehensiveness of service delivery and access to services) will help to address the inequitable impact of the COVID-19 pandemic. This review also suggests that national infection prevention and control strategies need to consider the role of public and political discourse on the acceptance of IPC strategies within countries.

Limitations

Limitations of this review include that it was a scoping review which did not assess the quality of individual research studies. The quality of studies included varied, and the review combined both academic and grey literature on the topics. When it came to overall sector impact, only review studies were included (due to the volume of studies originally identified and the time and resource constraints of the project). Many of the research studies included in this review were from the United States and Europe, with fewer studies from other countries and regions. Conversely, although many comparative articles were included in this review, many of the policies considered were Australian (national and state) policies, although comparative.

Declarations

Ethics approval and consent to participate – Ethics approval by the University of Western Australia, Human Research Ethics Committee (UWA HREC is 2021/ET000343). Consent to participate not applicable.

Consent for publication - Not applicable.

Availability of data and materials – The datasets used and/or analysed during the current study available from the Brightwater Research Centre on reasonable request.

Competing interests – There are no competing interests.

Funding - Lotterywest (Grant number 420173484). There was no involvement of the funder in study design, collection, analysis and writing of reports.

Authors’ contributions – Samantha Battams developed the methodology for the review, conducted the searches, undertook screening, assessed papers for eligibility and wrote the paper. Angelita Martini obtained funding for the review, approved and revised the methodology and reviewed the paper.

Acknowledgements – Study partners: Brightwater Care Group, Bethanie, Amana Living, Baptist Care, and Juniper.

 

 

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