Taking Steps to Safely Ease Restrictions for Older Adults in Congregate Settings to Reduce the Impact of Confinement Syndrome - FINAL March 25, 2021
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Taking Steps to Safely Ease Restrictions
for Older Adults in
Congregate Settings to Reduce the
Impact of Confinement Syndrome
FINAL
March 25, 2021INTRODUCTION
In May 2020, the North Simcoe Muskoka Specialized Geriatric Services (NSM SGS) program
released a paper entitled “The Need for a Multi-Dimensional Strategy to Address the Care of
Older Adults & Their Caregivers in COVID-19”. Within that paper and associated placemat, a
strategy was proposed to better support the breadth of needs of older adults and their
caregivers during COVID-19. Since May, the NSM SGS program has been working to address all
dimensions of the strategy, with specific attention on the impact of COVID-19 restrictions
(Dimension 3), including Confinement Syndrome.
Recognizing the impact of Confinement Syndrome, this discussion paper offers health system
leaders suggestions to consider to begin to safely ease restrictions in congregate settings like
Long-Term Care Homes (LTCH) and Retirement Homes (RH). Through these considerations, the
NSM SGS program hopes to stimulate discussion toward the development of a provincial
strategy to support the re-engagement of older adults and caregivers in congregate settings.
CONTEXT
Confinement Syndrome
Throughout the course of the pandemic, the NSM SGS program has led the charge locally and
provincially to raise awareness of Confinement Syndrome. Confinement Syndrome reflects the
constellation of clinical issues that emerged in older adults and caregivers during the pandemic
that could be directly or indirectly attributed to COVID restrictions. Issues include those affecting:
• Physical health & well-being (i.e. preventable acute illnesses, dehydration, inadequate
pain management)
• Mental health & cognition (i.e. loneliness, anxiety, depression, delirium, responsive
behaviours)
• Functional status (i.e. reduced mobility, falls, declining ADL and/or IADL abilities); and,
• Caregiver health & well-being (i.e. caregiver stress, elder abuse)
Restrictions
Significant restrictions were implemented in hospitals and congregate settings starting in mid-
March to protect vulnerable residents, patients and visitors from COVID-19. Recognizing the
impact of Confinement Syndrome, the NSM SGS program produced a paper in June 2020
advocating for health system leaders to find ways to safely resume visiting in these settings. At
the same time, the government updated Directive #3 and released guidelines to begin re-
opening LTCHs and RHs. Since then, varying levels of restrictions have continued more broadly
in alignment with the provincial COVID response framework and more specifically with
organization-specific policy. Policy interpretation and the state of community transmission has
created further variation between homes.
Since the outset of the pandemic, restrictions have played an important role in reducing spread
among older adults. In January 2021, Canadians over age 60 accounted for approximately 21%
of COVID-19 cases, 71% of COVID-related hospitalizations and over 95% of COVID-related
deaths, with approximately half occurring in LTCHs. While devastating, the number of cases and
deaths would have been worse if facilities had not implemented strict restrictions.
Taking Steps to Safely Ease Restrictions in Congregate Settings 1While restrictions have played an important role over the last year, the loss of usual contact with loved ones coupled with the loss of usual routine/activities has taken its toll on older adults and their caregivers. Social engagement and interaction is important to one’s sense of meaning, worth and belonging. Health care providers have provided exceptional support across homes through the pandemic; however, that support can never replicate or replace the support of loved ones. Restrictions have improved over time for essential caregivers but limits still exist on the type, amount and frequency of contact. Cohorting continues along with limitations on group activities. Virtual contact has helped support connections between residents and their loved ones but both will tell you it has not been enough. Changing Environment with Vaccine Administration Protecting the health and well-being of older adults and their caregivers during COVID-19 has been a key priority of the government and health care providers. With a growing number of residents and staff vaccinated in congregate settings like LTCHs and RHs, an opportunity exists to begin to ease restrictions to support these micro-communities in a different way than the general population. While the variants of concern continue to pose a risk i, a recent study has shown that eight weeks after the start of vaccination, the estimated relative reduction in COVID incidence was 89% in LTCH residents and 79% in LTCH staff. In that same period, the estimated relative reduction in COVID mortality in residents was 96% ii. Although it would be ideal to remove all restrictions, caution is still required. In British Columbia, the Cottonwoods Care Centre has experienced a COVID outbreak on a short-stay wing for people recovering from surgery. Of the twenty-three people infected, eight had at least one dose of the vaccine. However, the outbreak has been less lethal with no deaths or hospitalizations iii. In the United States, the CDC recently released public health recommendations for fully vaccinated people in healthcare and non-healthcare setting. These recommendations provide greater permissions in interaction between fully vaccinated individuals, although the organization has provided fewer permissions to those in congregate health care settings like LTCHs and RHs iv . SUGGESTIONS FOR CONSIDERATION To balance the impact of Confinement Syndrome with the safety of residents, staff and essential caregivers, health system leaders are encouraged to explore and identify strategies to begin to ease restrictions (and grant increasing permissions) in micro-communities like LTCHs and RHs where high rates of vaccination have occurred. The following are offered as suggestions for consideration in the development of policies and practices as they pertain to older adults, staff and essential caregivers in these congregate settings. Provide the Necessary Authority to Monitor Vaccination Rates Granting permissions require confidence in the accuracy of resident vaccination rates as well as in the vaccination rates of staff and essential caregivers. Vaccination rates can then be used as the criteria by which homes are granted increasing permissions. At this time, vaccinations remain personal health information and there is no authority by home administrators to request, collect and maintain this information. This consideration does not suggest vaccination should be mandatory – that is outside the scope of this document. Instead, the focus is on providing homes the authority to monitor uptake to determine the degree of permissions allowed. Taking Steps to Safely Ease Restrictions in Congregate Settings 2
Additional strategies that could support this may include having COVID vaccine as a mandatory
part of staff vaccination records and, if feasible, creating a secure link for administrators in the
COVAX system to support monitoring.
Support Vaccine Uptake Among Staff
While many staff in homes have been vaccinated, vaccination rates across organizations
continue to vary. Vaccine access and confidence in the vaccine have been key issues
plaguing uptake. With the establishment of clinics across regions, uptake should improve but for
some, transportation and access continue to be challenges. While we would encourage a
supportive approach to promote uptake, levers could be applied, if required. Considerations
could include:
• Providing additional on-site vaccine clinic hours in homes with lower uptake as part of
the community-based roll-out plan (i.e. the plan to deliver vaccine in local communities
to homebound individuals);
• Ensuring staff have paid leaves during work hours to attend clinics and that they are
replaced during that period (assumes sufficient staffing to replace);
• Creating home-based champions to support decision-making among staff and essential
caregivers;
• Undertaking a province wide campaign for staff using available communication
channels, including social media, to promote vaccine uptake. This campaign should
leverage available resources (i.e. public health resources, presentations like that
provided by Dr Kevin Young), outline the key criteria for easing restrictions, ensure staff
are clear on how to access vaccines, address vaccine myths and facts, and be
available in languages and with input from community leaders to effectively reach the
diversity of LTC staff;
• Monitoring the volume and rate of staff vaccination and, if appropriate, providing priority
ranking to this population ahead of any expansion to Phase 2 priority populations; and,
• If required, using levers like:
o Reduced testing frequency for vaccinated staff;
o Modified PPE requirements for vaccinated staff; and/or,
o Adjusting current reimbursement practices related to sick time should staff
experience COVID symptoms or contract COVID, as is done with flu shots in some
organizations (assuming the staff decision is based on personal choice vs health-
related criteria). In some places, incentives are being offered to encourage
uptake (i.e. gift cards). In both of these considerations we must be conscious of
the impact of such levers (i.e. financial hardship) and the precedent they set.
Support Vaccine Uptake Among Essential Caregivers
As part of Phase 1, essential caregivers were identified as priority populations for vaccine roll-out.
While many were vaccinated, a large number were not. Confidence in the vaccine, vaccine
access and communication between homes and the caregivers contributed to varying degrees
of success. With the expansion of priority populations and a move to an on-line booking process
(previously the homes were coordinating appointments), many essential caregivers are
struggling to navigate and access the system. Granting permissions in congregate settings,
including expanding visiting practices, requires optimal uptake by essential caregivers. The
Taking Steps to Safely Ease Restrictions in Congregate Settings 3following are offered as suggestions to promote uptake, with many similar to those identified
above for staff. Once again, we would encourage a supportive approach but levers could be
applied, if required:
• Providing additional on-site clinic hours in homes with lower uptake as part of the
community-based roll-out plan (i.e. the plan to deliver vaccine in local communities to
homebound individuals);
• As before, allowing congregate settings the ability to support essential caregivers in
booking appointments (this would also support monitoring uptake);
• Creating home-based champions to support decision-making among staff and essential
caregivers;
• Undertaking a province wide campaign for essential caregivers using available
communication channels, including social media, to promote vaccine uptake. This
campaign should leverage available resources (i.e. public health resources,
presentations like that provided by Dr Kevin Young), outline the key criteria for easing
restrictions, ensure essential caregivers are clear on how to access vaccines, and
address vaccine myths and facts;
• Monitoring the volume and rate of essential caregiver vaccination and, if appropriate,
providing priority ranking to this population ahead of any expansion to Phase 2 priority
populations; and,
• If required, using levers like:
o Reduced testing frequency for vaccinated essential caregivers;
o Modified restrictions around visit types, timing and frequency for vaccinated
essential caregivers; and/or,
o Modified PPE requirements for vaccinated essential caregivers.
Apply a Phased Approach to Easing Restrictions
Recognizing that not all congregate settings like LTCHs and RHs have the same success rate of
vaccination uptake, the safety of residents, staff and essential caregivers must remain the
overriding consideration.
• For the safety of older adults, the province could require homes to achieve a minimum
vaccination rate of residents (i.e. 85%) before any permissions are granted. Of note, the
CDC has defined fully vaccinated people as individuals who are at least 2 weeks out
from having received their second dose of Pfizer or Moderna v . In Canada, we would
also consider Astra-Zeneca in this list.
• Should the provincial minimum vaccination rate of residents be met, then a phased
approach could be used based on key criteria and considerations to determine the level
of permissions granted with the home:
o To ensure a clear understanding of the permissions, a standard provincial matrix
outlining the (a) criteria and (b) permissions could be helpful tool to navigate and
communicate the various possible scenarios.
o (a) The matrix structure could consider several key criteria, with each unlocking
an associated set of permissions in the home:
Resident stability may affect vaccination rates if there is high turnover in
the home. More stability could be associated with more permissions.
Taking Steps to Safely Ease Restrictions in Congregate Settings 4 Staff vaccination rate could be associated with increased permissions for
residents within the building (i.e. group activities, cohorting, outdoor
activities, testing). Rates could determine the degree to which
permissions are unlocked (i.e.permissions to monitor the impact of change. They could be required to
spend a defined period in each step before being allowed to move to
the next step.
Homes should focus initially on easing restrictions within the facility related
to resident-resident activity to monitor the impact of change. Initially
increased permissions should be allowed within existing cohorts. If
successful, cohorts could begin to expand. This could be followed by
expanding permissions for essential caregivers.
Protect At-Risk Populations
Several at-risk populations must be considered in planning:
• Those not able / not choosing / not yet vaccinated – Clear provincial direction and
organization policy could be defined for residents, staff and essential caregivers who are
not able / not choosing / not yet vaccinated. The policy could require a higher level of
safety measures, screening and monitoring for these individuals than that of the general
population in the home. This policy could supersede the matrix permissions for the home.
• New admissions – The approach to new admissions could be tied to the individual’s
vaccination status. If vaccinated, they could be provided a reduced isolation period or
no isolation period. If they are not vaccinated, they could fall into the above policy. If
appropriate, consideration could be given to cohorting these individuals for a required
period to promote safety and support monitoring.
Ensure Clear Provider & Public Communication
It will be important for communication around permissions to be clear so that the homes can
consistently apply them and so that residents, essential caregivers and the public have a clear
understanding of what to expect:
• Leveraging provincial guidance documents – At present several provincial guidance
documents exist to support policies, practices and care within the homes.
o The provincial response framework provides guidance based on the level of risk
present in communities. While these mini-communities have a degree of
protection that exceeds that currently available in the general community,
community spread should remain a consideration as vaccinated individuals may
still be able to contract and spread disease. An option could be to define
practices within homes outside the construct of this framework until community
vaccination rates increase to level comparable to these mini-communities.
o Key provincial direction documents, including Directive #3 for LTCHs (updated
December 7 2020), RH COVID-19 Visiting Policy (released December 9 2020) and
COVID-19: Visiting LTCHs Policy (published December 26 2020) should be revised
as appropriate to reflect any changes made. If appropriate, the matrix concept
could be pulled into these documents.
• Interpretation and application of provincial direction
o LTCHs are frequently navigating requests from families where on the surface there
appears to be gaps or inconsistencies in guidance documents. When it is not
appropriate or overly-prescriptive to provide greater clarity in the guidance
documents, a FAQ document could be helpful as a way to track and respond to
Taking Steps to Safely Ease Restrictions in Congregate Settings 6questions that would be applicable across homes. For example, current direction
is that two essential caregivers can be designated but that they cannot visit at
the same time unless they reside in the same household. If they are both visiting
the same resident, is there still rationale for them visiting at different times when a
simultaneous visit might significantly enhance the quality of the interaction?
• Ease of access to information - At this point, it is unclear where essential caregivers and
the public can go to source information about current home restrictions. This information
is not included in the provincial response framework and the directives and visiting policy
guidance documents are not easily found on central websites like https://covid-
19.ontario.ca/ As such, one consideration may be to make information more visible and
accessible to essential caregivers and the public.
• Ministry and public reporting – The status of all homes could be reported regionally to
Ontario Health and rolled-up to support provincial monitoring. Ideally:
o The reporting should not create undue burden on homes and should be aligned
with the provincial matrix structure.
o A status report of all homes should be made public in a timely fashion so essential
caregivers, health care partners, communities and the public are aware of each
home’s associated permissions.
o The status of permissions of each home should be well communicated. It could
be posted on the entrance of the homes and all changes should be clearly
communicated in a timely fashion to residents, staff and essential caregivers.
CONCLUSION
The purpose of this discussion paper is to support health system leaders to begin to consider
options to safely ease restrictions in congregate settings like LTCHs and RHs. The list of
suggestions was informed by some key conversations but it is far from comprehensive or perfect!
The suggestions (right or wrong) are merely offered to stimulate discussion and identify
opportunities for action. We hope it will:
• Demonstrate the link between current restrictions and Confinement Syndrome among
older adults and their caregivers.
• Highlight key considerations for health system leaders to begin to safely ease restrictions
within congregate settings like LTCHs and RHs.
• Emphasize the important role the Ministry and Public Health Ontario will play in providing
direction, including the development of a provincial strategy to support the re-
engagement of older adults and caregivers in congregate settings.
Taking Steps to Safely Ease Restrictions in Congregate Settings 7References & Notes
i COVID-19 Pandemic – RAEB’S Evidence Update: March 22, 2021. From: Davies, Jarvis,
Edmunds, Jewell, Diaz-Ordaz & Keogh (March 15 2021). Increased mortality in community-
tested cases of SARS-CoV-2 lineage B.1.1.7. Nature (2021).
Sourced March 24, 2021: https://www.nature.com/articles/s41586-021-03426-1
“To identify whether the SARS-CoV-2 variant, B.1.1.7 (i.e., the variant first identified in the UK)
leads to any change in disease severity, this study analyzed a dataset linking positive SARS-CoV-
2 community tests (n=2,245,263) and COVID-19 deaths (n=17,452) in England from September 1,
2020 to February 14, 2021. A total of 4,945 deaths were identified, indicating a hazard of death
that was 55% higher after adjustment for demographic factors. Overall, the study estimated a
61% (42-82%) higher hazard of death associated with B.1.1.7. These findings suggest that B.1.1.7 is
not only more transmissible than pre-existing SARS-CoV-2 variants but may also cause more
severe illness.”
ii Brown, Stall, Vanniyasingam, Buchan, Daneman, Hillmer, Hopkins, Johnstone, Maltsev,
McGeer, Sander, Savage, Watts, Jüni, Rochon on behalf of the Congregate Care Setting
Working Group and the Ontario COVID-19 Science Advisory Table. (March 8 2021). Early Impact
of Ontario’s COVID-19 Vaccine Rollout on Long-Term Care Home Residents and Health Care
Workers. Version 1.1.
Sourced March 21 2021: https://covid19-sciencetable.ca/sciencebrief/early-impact-of-ontarios-
covid-19-vaccine-rollout-on-long-term-care-home-residents-and-health-care-workers/
iii Hager. (March 18 2021). COVID-19 outbreak at British Columbia long-term care home
includes vaccinated residents. Globe & Mail.
Sourced March 21 2021: https://www.theglobeandmail.com/canada/british-columbia/article-
outbreak-at-british-columbia-long-term-care-home-includes-vaccinated/
iv Christie, Mbaeyi, Walensky. (March 10 2021). CDC Interim Recommendations for Fully
Vaccinated People: An Important First Step. JAMA. Published online March 10, 2021.
Sourced on March 24 2021: https://jamanetwork.com/journals/jama/fullarticle/2777536
• “Preliminary evidence suggests that the currently authorized COVID-19 vaccines may
provide some protection against a variety of strains, including B.1.1.7 (originally identified
in the UK). However, reduced antibody neutralization and efficacy have been observed
for the B.1.351 strain (originally identified in South Africa).
• A growing body of evidence suggests that fully vaccinated people are less likely to have
asymptomatic infection and potentially less likely to transmit SARS-CoV-2 to others.
However, further investigation is ongoing.
• Modeling studies suggest that preventive measures such as mask use and social
distancing will continue to be important during vaccine implementation. However, there
Taking Steps to Safely Ease Restrictions in Congregate Settings 8are ways to take a balanced approached by allowing vaccinated people to resume
some lower-risk activities.
• Taking steps toward relaxing certain measures for vaccinated persons may help improve
COVID-19 vaccine acceptance and uptake.
• The risks of SARS-CoV-2 infection in fully vaccinated people cannot be completely
eliminated as long as there is continued community transmission of the virus. Vaccinated
people could potentially still get COVID-19 and spread it to others. However, the benefits
of relaxing some measures, such as quarantine requirements, and reducing social
isolation may outweigh the residual risk of fully vaccinated people becoming ill with
COVID-19 or transmitting the virus to others.”
CDC (March 8 2021). Interim Public Health Recommendations for Fully Vaccinated People.
Sourced March 24 2021: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-
vaccinated-guidance.html#anchor_1615143434429
“The following recommendations apply to non-healthcare settings. … Fully vaccinated
people can:
• Visit with other fully vaccinated people indoors without wearing masks or physical
distancing
• Visit with unvaccinated people from a single household who are at low risk for
severe COVID-19 disease indoors without wearing masks or physical distancing
• Refrain from quarantine and testing following a known exposure if asymptomatic
For now, fully vaccinated people should continue to:
• Take precautions in public like wearing a well-fitted mask and physical distancing
• Wear masks, practice physical distancing, and adhere to other prevention
measures when visiting with unvaccinated people who are at increased risk for
severe COVID-19 disease or who have an unvaccinated household member who
is at increased risk for severe COVID-19 disease
• Wear masks, maintain physical distance, and practice other prevention measures
when visiting with unvaccinated people from multiple households
• Avoid medium- and large-sized in-person gatherings
• Get tested if experiencing COVID-19 symptoms
• Follow guidance issued by individual employers
• Follow CDC and health department travel requirements and recommendation”
CDC. (March 10 2021). Updated Healthcare Infection Prevention and Control
Recommendations in Response to COVID-19 Vaccination.
Sourced March 24 2021: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-
after-vaccination.html
“This guidance applies to all healthcare personnel (HCP) while at work and all patients and
residents while they are being cared for in a healthcare setting.
Taking Steps to Safely Ease Restrictions in Congregate Settings 9Visitation in Post-Acute Care Facilities, including Nursing Homes
During the pandemic, guidance from the Centers for Medicare and Medicaid Services (CMS)
has limited (except for compassionate care situations) indoor visitation for residents in post-acute
care facilities when the COVID-19 county positivity rate is >10% or when there is an outbreak
occurring in the facility. Relaxing current restrictions on indoor visitation might increase the risk for
transmission of SARS-CoV-2 in post-acute care facilities. However, vaccination of residents and
HCP can mitigate some of these risks, and expanding visitation has substantial benefits to
residents.
Indoor visitation could be permitted for all residents except as noted below:
• Indoor visitation for unvaccinated residents should be limited solely to compassionate
care situations if the COVID-19 county positivity rate is >10% and• Facilities should have a plan to manage visitation and visitor flow. Visitors should
physically distance from other residents and HCP in the facility. Facilities may need to
limit the number of visitors per resident at one time as well as the total number of visitors in
the facility at one time in order to maintain infection control precautions.
• Visits for residents who share a room should ideally not be conducted in the resident’s
room. If in-room visitation must occur (e.g., resident is unable to leave the room), an
unvaccinated roommate should not be present during the visit. If neither resident is able
to leave the room, facilities should attempt to enable in-room visitation while maintaining
recommended infection prevention and control practices, including physical distancing
and source control.”
v Christie, Mbaeyi, Walensky. (March 10, 2021). CDC Interim Recommendations for Fully
Vaccinated People: An Important First Step. JAMA. Published online March 10, 2021.
Sourced on March 24 2021: https://jamanetwork.com/journals/jama/fullarticle/2777536
vi Kain, Stall, Allen, et al. Routine asymptomatic SARS-CoV-2 screen testing of Ontario long-term
care staff after COVID-19 vaccination. Science Briefs of the Ontario COVID -19 Science Advisory
Table. 2021;2(15). https://doi.org/10.47326/ocsat.2021.02.15.1.0
“There is no available real-world evidence to either support or refute the benefit of routine
asymptomatic screen testing in preventing COVID-19 outbreaks. Screen testing among Ontario
LTC staff between June 28, 2020 and March 13, 2021 yielded an overall test positivity of 0.16%,
which decreased toYou can also read
