Department of Health and Wellness Continuing Care Sector: Wave 2 Plan October 2020 NOVA SC TIA Preamble The Wave 2 action plan will continue to evolve to account for changes in community epidemiology, sector input and emerging best practices. The plan is informed by the advice of the Chief Medical Officer of Health (CMOH) and will be adjusted to ensure continued alignment with any future direction or changes provided by the CMOH. Regular dialogue with the Continuing Care sector and system partners will support implementation of the plan. Many of the actions within this plan have already been completed or are well underway and can be quickly operationalized to respond to new outbreaks should they occur. Context The population served by Continuing Care (CC) is one of the most vulnerable groups affected by COVID-19. Proportionally, Long Term Care (LTC) residents and staff are over-represented in the number of positive cases across Canada, a combined 27% of all cases. More concerning is that almost 80% of COVID-related fatalities to-date in Canada are LTC residents. Individuals living in facilities are at greater risk of contracting COVID-19 than those in community due to the rapid spread of the virus once it enters a facility. Home care (HC) clients are also at greater risk of complications if they contract the virus, since this population is often older and typically have underlying medical conditions. There is an added challenge for HC clients when compared to facility residents in that community homes are uncontrolled environments with significant variability and uncertainty in what a service provider may face. Therefore, there is a need to prevent the contraction and spread of infection in LTC facilities and amongst HC clients. There were several lessons learned from the COVID-19 pandemic’s first wave that have informed the continued response and planning for an expected second wave. These include: • Department of Health and Wellness (DHW) and Nova Scotia Health Authority (NSHA) individually issued several protocols and guidelines at different times, which created confusion for service providers. In addition, early responses in LTC were performed on a facility-by-facility basis as opposed to applying a consistent provincial approach, leading to variability in responses. An aligned, strategic response is required. • Accessible and real-time Infection Prevention and Control (IPAC) and Occupational Health and Safety (OHS) supports were limited within the sector and are key components to successfully minimizing COVID-19 pandemic impacts. Additional support is needed in these areas. • Effective infection control measures are needed across the sector. This includes universal masking procedures, enhanced cleaning measures, and ongoing support and workforce training. During the COVID-19 pandemic, new and evolving information constantly emerged making it difficult for organizations to keep current with and assess information, which contributed to varying practices across the sector. • Enhanced screening protocols, positive test results and other challenges led to a workforce complement that was at reduced capacity. The workforce complement was reportedly exacerbated by other factors such as the introduction of the Canada Emergency Response Benefit (CERB), personal fears and lack of childcare. Additionally, in outbreak situations, staffing challenges were compounded by the contact tracing and isolation requirements for COVID positive cases, close contacts of positive cases and sick staff. Mechanisms that allow for the timely development of health workforce surge capacity and mechanics that support health workforce redeployment are needed. Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 1 • • While individual LTC facilities were supported to hold bed vacancies in the case of outbreaks (in order to cohort COVID positive residents), this has led to sustained challenges within the health system overall, increasing LTC waitlists both in hospital and in community. The approach to holding beds varied by facility and has negatively impacted Nova Scotians who require LTC and are not able to access it. Prior to the development of a provincial Personal Protective Equipment (PPE) supply chain, home and LTC service providers did not have confidence that the PPE supply would be sufficient to support their workforce especially if an outbreak occurred and also experienced challenges with their supply chains. Providers need a stable and sufficient PPE supply. Understanding how a second wave of COVID-19 may spread at the community level has been an important component of planning for a second wave. The probability of having an outbreak at a facility or within a home support agency can also be determined based on the facility/agency size and its location. By understanding where cases are likely to occur and what facilities/agencies are at greatest risk, we can better plan for resource reallocation and determine where best to position interventions such as the Regional Care Units that support multiple LTC facilities and home support service providers. In response to lessons learned and emerging leading practices, a multifaceted Wave 2 plan has been developed and organized in the following thematic categories: • • • • Coordinated Outbreak Response and Supports. A single point of contact to coordinate the outbreak response and implementation of Regional Care Units to provide safe, effective and coordinated care. Increasing Health Workforce Supply and Supporting Employee Safety. Measures including the introduction of home support aids, IPAC resource supports to staff including but not limited to OHS, and proactive distribution of PPE. Communication and Information Sharing. Mechanisms to communicate and share updates and critical information with the sector. Maintaining Resident Quality of Life. A phased approach to shifting restrictions that balances safety and the mental health and well-being of residents and families. Coordinated Outbreak Response and Supports Continuing Care Rapid Response Teams (CCRRT) Within each of the four NSHA zones, rapid response teams have been established to act as a single point of contact for HC and LTC providers experiencing a COVID-19 outbreak. The teams will provide a unified, effective and coordinated response and bring together programs and organizations to respond quickly to outbreaks. The response teams will have the following responsibilities: • • • • • Track outbreak status, risks, priorities and action plans (i.e. identify and track activities required to ensure a coordinated and effective response to outbreaks); Escalate issues to decision makers locally and provincially to address key priorities in a timely manner; Formalize communication processes; Report and share issues and trends (provider specific and system); and Support information flow to the right people at the right time. Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 2 The core membership of the zone CCRRTs will include NSHA Zone Continuing Care Directors, a DHW Zone Lead, and other NSHA Continuing Care team members. Depending on the nature of the outbreak and the provider need for support, other representatives will attend as required to support the response including, but not limited to NSHA LTC Clinical Lead, NSHA IPAC, NSHA Public Health, DHW Medical Officer of Health, NSHA Deployment Centre, NSHA and DHW Communications, and senior leaders from NSHA and DHW as well as other government departments. If Wave 2 outbreaks are concentrated in a single zone, CCRRTs from other zones can be mobilized to support the zones with multiple outbreaks. The team can be accessed by contacting the NSHA Zone Continuing Care Director Monday – Friday 8:30 and 4:30. After hours, weekends and holidays, the team can be accessed through the NSHA Management Call #. Numbers and contact information are available in the LTC Toolkit on the DHW Secure website. Regional Care Units in Long Term Care Emerging best practices from Wave 1 indicate the spread of COVID-19 can be minimized in LTC Facilities by cohorting COVID-19 positive residents with dedicated staff, clear clinical guidelines, infection control procedures, enhanced staffing and the right equipment and PPE. With over 130 LTC facilities in the province, 90 of which are Nursing Homes that care for our most vulnerable populations, taking a targeted approach based on epidemiology to cohorting COVID-19 positive residents is critical. DHW and NSHA, with sector representatives, have designed a regional model for COVID-19 care in LTC, focused on Nursing Homes (due to client vulnerability and population density). Each zone will have designated units within pre-identified Nursing Homes that will be equipped and staffed to effectively respond to outbreaks; residents will be transferred from their own LTC home to one of these specialized units with advice and guidance from clinical leadership. Units will provide expert care and reduce risk to other residents by removing them from their home-based facilities. In some cases, it may not make sense from a clinical perspective to transfer residents to the RCU. Clinical guidelines and specialized clinical support will be available to support the on-site care team in making RCU transfer decisions. Consultations with homes that have experienced outbreaks have led to the development of an augmented RCU staffing model that includes funding for enhanced RN/LPN, Social Work, CCA and housekeeping hours. The on-site care team will also be supported both in person and virtually by local physicians responsible for resident care. Sometimes RCUs may require specialized expertise that is not available at the site. Specialized clinical support resources including geriatrics, palliative care, infectious disease and Interprofessional Practice and Learning will be available for consultations to support the on-site RCU care team. In addition, DHW will continue to support exceptions to the home oxygen program for those who have an identified need for acute oxygen therapy. For homes that are not identified as regional care units, residents that test positive will be transferred to the regional care units until they are ready to return. Regional units will care for COVID-19 positive residents from their own homes and from “feeder” homes in their immediate area. Several homes, due to their size and remote geography will have COVID capacity to care for residents in their facility and may not transfer residents to these units. DHW and the NSHA will be working with the sector and individual service providers to implement the model. Sector FAQs will be developed so all providers understand the RCU plan and what specifically is expected of them in terms of caring for and transporting COVID positive residents. Critical model elements include enhanced staffing, clinical guidelines, Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 3 clinical decision support related to caring in place or transporting to the RCU, physician coverage, transportation, communication and IPAC and OHS support. Increasing Health Workforce Supply and Supporting Employee Safety Health Human Resource Modelling DHW is forecasting the demand and supply of staffing based on case projections and the distribution of health human resources (HHR). The purpose of this is to assist in forecasting the number and type of staff needed in the event of an outbreak. A Continuing Care HHR dashboard (focusing on LTC and HC) has been developed to (1) ensure we have an accurate view of where HHR are located and how staffing may change in an outbreak, (2) proactively support the changes in staffing when coupled with Case Projection Modelling, and (3) enhance executive and operational level decision-making for health human resources. Mental Health Support for Employees DHW has received federal funding to support access to mental health programs for Continuing Care staff. This is in response to reports from the sector that identified significant impacts to the mental health and wellbeing of staff working on the front line to support the most vulnerable populations in Nova Scotia during the COVID-19 pandemic. The details of implementation are forthcoming. Return of Volunteers and Introduction of Designated Caregivers Designated caregivers and volunteers play an important role in supporting LTC operations. Designated caregivers are family member or support persons with a previously established pattern of involvement in providing the residents care and/or supporting the residents wellbeing, health, and quality of life. Effective September 11, 2020, Designated caregivers can support a resident’s physical care and mental well-being for tasks such as assistance with feeding, mobility, and personal care. DHW is working with sector representatives to develop guidelines that would enable the return of volunteers to support programming, recreation and care activities. Adherence to protocols with respect to PPE and IPAC are critical in supporting this approach that enables a stronger support system for residents and staff. DHW has heard from sector partners that these caregivers and volunteers are critical in the delivery of holistic care within LTC Facilities, and would be a fundamental resource during a potential outbreak. Many pandemic plans developed by service providers pre-COVID-19 included volunteers as a key mitigating strategy for workforce shortages. However, due to Public Health measures, volunteers could not be utilized in the first wave. Given the new masking protocols and IPAC guidelines along with the availability of PPE, it is intended that volunteers will play an important role during a potential second wave. Home Support Aides A pilot to explore the use of a Home Support Aide was launched in Lunenburg in October 2019 to address the shortage of Continuing Care Assistants (CCAs). The results of this pilot have shown great benefit in deploying these resources to perform light housekeeping, meal preparation and other duties that do not require a CCA, while reducing waitlists for services. The pilot will be continued in Lunenburg and expanded to include other service providers Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 4 across the province who are facing CCA staffing challenges, enabling continued service delivery into the next wave of COVID-19. Infection Prevention and Control (IPAC) and Occupational Health Support (OHS) The Continuing Care sector requires both short-term and long-term IPAC and OHS supports, including the following: provincial pandemic planning; internal plans and policies; ongoing training; regular infection control measures; support with auditing; and assistance with administrative and clinical practice tasks. During the COVID-19 pandemic’s first phase, the variability in understanding and practicing IPAC became apparent. A recently completed DHW/NSHA IPAC review identified improvement opportunities in policies, guidelines, education curriculum, workplace practices, and access to resources. DHW is actively working with NSHA and other sector partners to implement the short- and long-term recommendations from the review. In addition to the critical role of IPAC in maintaining the health and wellbeing of residents/clients and staff, OHS plays a key role in getting people back to work in a timely manner through the provision of advice and guidance to employers and employees. During the first wave of COVID-19, the IWK supported Continuing Care providers via their provincial OHS and IPAC staff. Going forward, the NSHA, with DHW support, will be adding significant additional IPAC and OHS resources to work more closely with individual providers in Continuing Care. DHW will also invest $7.4M in federal funding to provide a capital improvement grant to support minor facility capital upgrades related to IPAC, and $4.5M to increase cleaning measures during COVID-19. Staff Deployment Model During the first wave of COVID-19, a provincial COVID-19 Staff Deployment Model was rapidly put in place in partnership with the NSHA, leveraging the HR recruitment and deployment capacity that existed within the province’s largest health care employer. The Deployment Model supported staffing needs in LTC facilities in outbreak situations. With the re-introduction of services and staff assigned to the Deployment Model returning to their “regular” jobs, an investment of $2.8M has been made to support the continuation of the Staff Deployment Model. This investment supports zone-based staffing centres that will support staffing/redeployment across the health system to respond to future COVID outbreaks. Other HR Supports In addition to the supports outlined above, DHW will continue to support the use of LTC Assistants (LTCAs) through an investment of $5M in 2020-21 Service providers are encouraged to reach out to DHW with additional requests and planned use of the LTCA role within their facilities. DHW will continue to work with the sector on identifying solutions to HR challenges associated with CCA recruitment and respond to recommendations related to the increased use of other regulated professionals within LTC. Personal Protective Equipment PPE is a critical frontline measure in protecting staff and residents/clients against COVID-19. With universal masking and other PPE protocols in place, DHW provided all publicly Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 5 funded Continuing Care service providers with a bulk supply of PPE, providing assurance that the workforce will not face supply shortages in the face of a potential second wave. Government will continue to supply PPE for publicly funded Continuing Care providers as per COVID-19 requirements and the Department will maintain a partnership with the Health Association of Nova Scotia to coordinate PPE distribution and track usage across the Continuing Care system. The current Provincial PPE approach, which includes ongoing demand monitoring and purchasing, will support the needs of the Continuing Care sector. Serial Testing of LTC Staff Due to concerns for the asymptomatic transmission of COVID, plans are being developed to conduct serial asymptomatic testing of LTC staff, designated caregivers, and volunteers involved in direct resident care to identify asymptomatic cases. This testing strategy holds the potential to implement interventions quickly, keep staff safe and healthy and prevent additional transmission. Planning is in the early stages, as more information is available, the sector will be engaged to ensure the right supports and processes are developed. Communication and Information Sharing Regular communication is needed to ensure providers have accurate and timely information. Numerous communications vehicles will be used in the Wave 2 response: • Bi-weekly Webex meetings with DHW, NSHA and the Continuing Care sector are resuming after a summer pause; • Providers will continue to have access the NSHA COVID-19 HUB and the DHW secure website; • As planning continues, sector representatives will continue to be engaged to ensure provider perspectives are incorporated; • Weekly COVID-19 update emails are being contemplated; and, • Regular engagement with health care unions to ensure the perspectives of front-line health care workers are factored into provincial decision making. Home Care and Long-Term Care Toolkits DHW, with input from NSHA, is issuing an updated COVID-19 Toolkit to LTC Facilities and a Toolkit for HC Providers which provide a step-by-step guide and tools/checklists on how to prepare a facility or agency prior to, during, and after a COVID-19 positive case. To support stakeholder communications including families, residents/clients, and staff, the toolkits provide the following critical supports: • Key messages and talking points; • Sample written communication pieces and phone scripts; • Signage to support communications within LTC homes; • Advice for managing social media accounts; and, • Support related to sharing information with the media. The updated toolkits will be posted on the DHW secure site. Northwood Quality Improvement Review The Northwood Halifax location had the highest number of COVID-19 cases and resulting fatalities in the province. Despite the challenges that were faced, and the ongoing impacts felt as a result of this outbreak, it also serves as an opportunity to identify what worked well, lessons learned, and what indicators help serve as a warning system. The results of this Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 6 review, released on September 21, 2020, will help to shape future pandemic preparation and response plans for all homes. An immediate action from this review will see the elimination of triple occupancy rooms. All service providers that have rooms with three residents should contact DHW so a plan can be put in place to transition these rooms.. Maintaining Resident Quality of Life Maintaining quality of life during the COVID-19 pandemic is critical to the wellness of those served by the Continuing Care sector. We know that public health measures to reduce the health impacts of COVID-19 while prioritizing resident and staff safety have had the unintended consequence of negatively impacting the quality of life of residents and their families. Therefore, as the infection and transmission rates have subsided recently, DHW has developed and implemented a multiphase reopening plan that balances the physical health and wellbeing of residents with their mental health and wellbeing. A 5-phase plan has been developed with input from the LTC sector to ease restrictions in LTC, guided by the following key principles: (1) Ensure lowest risk possible of increased transmission of COVID-19 within LTC, (2) Provide a safe working environment for staff, (3) Provide a safe home environment for residents/clients and (4) Appropriately balance public health and safety restrictions/measures with unintended impacts on the quality of life of residents and their families. If and when a second wave emerges, restrictions that have been eased may be reinstated as appropriate in consultation with the Chief Medical Officer of Health. Over the last 3 months, the sector has been supported to ease visitor restrictions including allowing for outdoor visits, indoor visits, and the introduction of designated caregivers. Gathering sizes within LTC have been raised, community-based Adult Day Programs may re-open based on sector-driven plans and residents can attend off site appointments. Residents may now also visit families in their homes off site. As epidemiology reports continue to confirm small to no COVID-19 cases in the province, additional measures to reunite residents with their loved ones, and that allow for the return of volunteers to augment the workforce, are planned. Further Considerations During the first wave of COVID-19, the CC sector was supported in prioritizing services within HC, and in slowing admissions to LTC to create space for movement of COVID-19 positive residents within facilities. As the health system re-opens and public health restrictions are lifted, the health system overall has experienced pressure as evidenced by increased waitlists for both LTC and HC, as well as the increase in the number of Alternate Level of Care (ALC) beds occupied by individuals waiting for LTC placement. It will require a full system response to work through these issues and ensure that Nova Scotians are getting the care they need, when they need it, where it is most appropriate. As we move into a potential second wave, DHW will be ready to re-mobilize its emergency response efforts via the DHW CC Emergency Operations Centre to work collaboratively with the NSHA and sector partners to respond to active outbreaks. Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 7 Working with the Chief Medical Officer of Health and sector partners, it will be important that DHW consider which LTC and HC restrictions/prioritizations may or may not need to be re-instated within the current context of masking and training protocols, along with the availability of other key resources such as the LTC and HC toolkits, IPAC and OHS resources, etc., that were not in place when the initial Public Health Order came into effect. Balancing the physical health and wellbeing of residents with their mental health and wellbeing is critical to ensuring a holistic and safe approach to supporting Continuing Care residents/clients and their families during the COVID-19 pandemic response. Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 8 Appendix A: Phased Approach to Shifting LTC Restrictions Phased Approach to Shifting LTC Restrictions As of September 16th, 2020 Approach Objectives • • • • Reduce the risk of transmission of COVID-19 within LTC Provide a safe working environment for staff Provide a safe home environment for residents/clients Appropriately balance public health and safety restrictions/measures with unintended impacts on the quality of life of staff, residents, and their families The following core personal PH measures must be maintained through all phases • • • • • • • • • Staying informed, being prepared and following public health advice Good hygiene (hand hygiene, avoid touching face, respiratory etiquette, disinfect frequently touched surfaces) Physical distancing as much as possible when outside of the home (i.e. from nonhousehold members) Environmental cleaning and ventilation of public spaces and worksites Staying at home and away from others if symptomatic/feeling ill – do not go to work and follow jurisdictional/local public health advice Staying at home if at high risk of severe illness Continuing to wear a medical mask, or if not available a non-medical mask or face covering if you experience symptoms, and, will be in close contacts with others or go out to access medical care Consider the use of non-medical masks in situations where physical distancing cannot be maintained Reducing personal non-essential travel Progression to next phase will be based on a number of factors. The approach must be flexible and reinstate restrictions based on Public Health advice. Phase Phase 1 [Implemented June 15] Phase 2 [Implemented July 22] • • • • • • Phase 3A [Implemented August 25] • • Measures Allow outdoor visitation, by appointment, for residents and their families. Limit of two (2) visitors. Indoor visitation with one (1) designated visitor per day. Up to three (3) individuals can be identified. Licensed hair salons that operate within LTC homes can also reopen to LTC residents only On site gatherings of up to 10 people (including residents and staff) will be permitted. Gatherings could be for the purposes of group dining, gathering for recreation activities and for socialization Up to five (5) visitors per resident for outdoor visits in LTC (NH and RCF) will now be permitted while observing public health measures LTC facilities will be permitted to use LTC facility owned and operated or leased buses to take up to 10 people (including residents, staff and driver) for “sightseeing” drives off the grounds of the facility Residents of LTCF can be taken to medical appointment by family members. Remove max limit of 3 family members for indoor visits. Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 9 • • Phase 3b [Implemented August 31] Phase 4 [Designated Caregiver Implemented September 11, Community Access on September 28] Phase 5 [Timing TBD] • • • • • • • Re-open community-based Adult Day Programs in the community. Programs can re-open pending approval of plan. Residents of LTCF can leave for compassionate reasons [Continue By exception]. Changes to admission and readmission protocols from hospital (e.g. need to isolate upon admission) Support designated Caregivers within Nursing Homes Community Access for RCF and NH Residents related to visits in family homes Volunteers permitted within LTCFs. Enhanced opportunities for indoor visitation Re-open Adult Day Programs in LTCFs Consider modifications to staff precautions (e.g. screening protocols) Department of Health and Wellness Continuing Care Sector: Wave 2 COVID-19 10