Minister for Health and Minister for Mental Health and Older People welcome new Visitation Guidance for Nursing Homes

From Department of Health 

The Minister for Health, Stephen Donnelly TD and the Minister for Mental Health and Older People, Mary Butler TD, have welcomed the approval by the National Public Health Emergency Team (NPHET) of new Health Protection Surveillance Centre (HPSC) COVID-19 Guidance on visitations to Long Term Residential Care Facilities, to be implemented from 22 March.

The COVID-19 pandemic has had a profound

impact across society, especially for older people. It is recognised that the necessary public health protective measures, such as the need to reduce social contacts, has effects on social, psychological and emotional well-being. The availability of vaccines brings great hope and will play a critical role in protecting the population, especially those most at risk such as older people, against COVID-19. The advanced stage of the vaccination rollout in nursing homes provides an opportunity for cautious incremental changes in some public health measures, including on visiting.

The new visitation guidance incorporates early learning from the positive impact of the vaccine rollout nationally and internationally and will provide enhanced opportunity for visiting in nursing homes across all levels of the government’s plan “COVID-19 Resilience and Recovery 2021 - The Path Ahead”.

While the guidance in place had provided for visiting on critical and compassionate grounds, this new guidance now expands the scope of visiting on general compassionate grounds. It also refines the guidance across Levels 1 to 5, which now provides for increased visiting at Levels 3, 4 and 5, subject to risk assessment and no open outbreak.

Residents may be facilitated to receive two visits per week on general compassionate grounds. This will be possible following two weeks after full vaccination of approximately 8 out of 10 of all residents and healthcare workers in the nursing home. There is no requirement to limit visits to less than one hour. This is an increase from the current guidance where one visit per resident is facilitated every two weeks.

To allow time for making arrangements and planning for the implementation of the guidance, the new guidance comes into effect from 22 March 2021.

At all times vigilance on the general infection prevention measures must be maintained. The guidance will be kept under continuing review as new evidence and data emerges.

Following the approval of the new guidance, Minister Donnelly said:

"We all know the direct impact that COVID-19 has had on older people, especially those in nursing homes, and the sad loss of life experienced at home and internationally from the virus. The virus has also had indirect consequences, such as the loss of those important social connections and engagements with loved ones.

"While the previous guidance had provided for visiting on critical and compassionate grounds this new guidance now expands the scope of visiting on general compassionate grounds. Meaningful contact with family and friends is important at all times which is why these additional grounds will be facilitated. Compassionate grounds could be for example to see a family member or friend as prolonged absence is causing upset or for personal reasons, to make financial or other arrangements or to advocate on their behalf.

"This new guidance is a welcome development and underpins the type of benefits that arise from the implementation of the vaccine programme. I hope that these modifications in the application of the public health protective measures reinforce the real hope that the vaccines are bringing us and continue the journey towards a more normal lived experience."

Welcoming the new guidance, Minister Butler said:

"Twelve months on from the life changing arrival of COVID-19 we have seen the huge impact this virus has had on society, especially for our older people. It has been an incredibly difficult time for people living in nursing homes and their families as restrictions on visiting have continued. For many there has been limited opportunity since Christmas to see their loved ones.

"The ongoing reduction in COVID-19 cases across the community and the significant progress made in vaccinating the majority of nursing home staff and residents will now result in a loosening of current visiting restrictions. Moving forward under Levels, 3, 4 and 5, residents will be able to receive two visits every week, under compassionate grounds where there is high vaccine coverage in a nursing home. The next few days will allow time for nursing home service providers to communicate with families, book visits and prepare for additional visiting.

"However, the risk associated with COVID-19 remains very real. This is why the guidance takes a cautious approach and aligns with the principles set out in the government’s revised Plan for Living with COVID-19. We all need to remain vigilant, and continue to follow public health advice, including when visiting, to reduce the spread of COVID-19 and protect those living in our communities.

"The new visiting guidance will, I hope, be widely welcomed, as it signifies a big step forward in providing opportunities for people living in nursing homes and their families to meet much more frequently. I expect that all nursing home providers will facilitate visiting, in line with the new guidance announced today."

Notes

There are Specific Critical and Compassionate Circumstances where visiting may also be facilitated, which include:

• a resident expresses a strong sense of need to see someone whether for personal reasons, to make financial or other arrangements or to advocate on their behalf
• a person nominated by the resident expresses concern that a prolonged absence is causing upset or harm to a resident
• circumstances in which a resident is significantly distressed or disturbed and although unable to express the desire for a visit there is reason to believe that a visit from a significant person may relieve distress
• when there is an exceptionally important life event for the resident (for example death of a spouse or birthday)
• when the visitor may not have another opportunity to visit for many months or years, for example because they are leaving the country
• increased visiting is recommended by their doctor as a therapeutic alternative to an increased dose of an existing agent or introduction of a new anxiolytic or sedative agent
• circumstances in which end of life is imminent
• other circumstances in which the judgement of the medical or nursing staff, registered health or social care professional, spiritual advisor or advocate acting for that the resident is that a visit is important for the person’s health or sense of well-being

The government’s revised plan for managing the virus ‘COVID-19 Resilience and Recovery 2021 - The Path Ahead ' is a cross-government approach to managing the pandemic for the coming months and was published on 23 February 2021. It sets out sets out the approach to the next Phase.

The Plan outlines Ireland's cautious, measured approach which is being taken in order to:

• make steady progress, starting with childcare and schools, while avoiding a further wave of disease and re-imposition of restrictions
• protect the most vulnerable by an efficient rollout of the vaccination programme
• remain vigilant and agile regarding the uncertainties in the face of new variants and to capitalise on emerging evidence on available vaccines
• lay the foundations for the full recovery of social life, public services and the economy

Based on this framework, the HPSC has developed new visitation guidance for long-term residential care facilities, which will be published shortly on the HPSC website.

COVID-19 is highly contagious and when it is circulating at high levels within the community, there is an increased risk that it will enter into nursing homes and other long-term residential care facilities. People in these settings are often very vulnerable to this virus and its effects, as well as the settings themselves posing risks in terms of infection control and prevention.

In order to reduce the risk of COVID-19 being transmitted to vulnerable populations, it may be necessary to reduce the number of visitors to long-term residential care facilities at certain critical times.

Visiting restrictions are widely practiced internationally as a protective measure with some variations in how they are applied. However, as per regulatory requirements, visiting is part of the normal daily functioning of nursing homes. Therefore, the nursing home provider has a legal obligation for doing all that is practical to support safe visiting. The nursing home should have the capacity and relevant skill sets within its staffing complement to manage this appropriately.

The surge in COVID-19 in January 2021 and the resulting harm to residents and staff is a reminder of the ongoing need for vigilance to prevent introduction of COVID-19 into nursing homes. Although the situation has improved considerably there is a continuing risk even with vaccination of introduction of infection. There is a particular concern about the possibility of introducing a new variant that the vaccine does not protect against.

It is important to note that the country is currently at Framework Level 5 and that therefore visiting is suspended other than on critical and compassionate grounds. Although the situation has improved since January it may not be possible to support visiting in some nursing homes because of and continuing outbreaks.

The HSE’s Health Protection Surveillance Centre (HPSC) has developed this new guidance, which fully aligns with the 5 level framework of restrictive measures as outlined in the government’s revised plan, to support long-term residential care providers in the discharge of their responsibilities and to support safe visiting, to the greatest extent possible, having regard to balancing the principle of a cautious approach to reopening with recognising the early data on the positive impacts of the vaccine. The guidance provides public health support and advice for the 5 levels of restrictive measures, when outbreaks/clusters are being experienced and visiting in compassionate and critical circumstances.

The new guidance recognises the positive early impact of the vaccine rollout, especially in nursing homes, with two visits per week now possible at Levels of 3, 4 and 5 of the framework of restrictive measures, where 8 out of every 10 residents and healthcare workers in the nursing home have been vaccinated. Aside from operational requirements, flexibility on the duration of visits is permitted and where such operational requirements exist, a minimum of one-hour visits should be facilitated. The guidance recommends that providers develop an individualised visiting plan for reach resident as part of the resident’s overall care plan.

The guidance also re-states the existing position that there are very limited, if any circumstances in which outdoor or window visiting should be suspended on infection prevention and control grounds.

The guidance notes the particular risks and challenges that arise in the context of an open outbreak in a nursing home. Where there is an open outbreak, further public health measures are required including additional limitations on visiting. The guidance outlines these measures, which apply irrespective of vaccination coverage in the nursing home. The revised guidance has been developed in consultation with key national stakeholders.

The publication of this guidance also supports the implementation of recommendation 12.1 of the COVID-19 Nursing Homes Expert Panel Report.

Recognising the difficult landscape that COVID-19 has presented for long-term residential care settings, a series of enhanced measures have been agreed by the NPHET to provide support to these settings and these are currently being implemented by the HSE, HIQA and service providers. The substantial package of support measures for nursing homes include measures to support those which have outbreaks of COVID-19 and measures aimed at breaking the chain of transmission of the virus. These supports include enhanced HSE engagement; multidisciplinary clinical supports at CHO level through 23 COVID-19 Response Teams; supply of precautionary and enhanced PPE, free of charge; serial testing programme for all staff of nursing homes; where possible, access to staff from community and acute hospitals; suite of focused public health guidance and training resources; temporary financial support scheme for private and voluntary nursing homes with over €75.1m in additional funding support provided thus far (including an additional one-off grant for visiting infrastructure). The Scheme is open until 30 June 2021; Temporary accommodation to nursing home staff to support measures to block the chain of transmission; HIQA COVID-19 quality assurance regulatory framework.