What Can We Learn for Future Integrated Care Models in Long Term Care Facilities After the COVID-19 Emergency? Lessons From an Observational Study in Catalonia

B1. First wave: identification of organizational needs (spring 2020)

We identified organizational needs in order to establish action protocols common to all LTCF in the region. The multidisciplinary task force focused its efforts on creating, updating and guaranteeing the rapid dissemination of consensus-based protocols for managing residents with COVID-19 and reinforcing the protocol for managing emergency end-of-life situations, in anticipation of the high mortality previously described in other countries. General measures for preventing infection were established. During the first wave, it became clear that respiratory symptoms in residents as the indicator for the activation of prevention measures for infection and clinical complications was too narrow. At the same time, a 24/7 care strategy with a reinforced structure was designed for all LTCF in the region to ensure there would be a group of professionals responsible for continuous care. Moreover, the need for both the provision of medication for severe cases and/or end-of-life situations, and protective equipment for health professionals was detected and met.

Regarding communication needs, a mobile app (CoVIDApp) [17] was adapted to improve communication between professionals at LTCF and primary care professionals. The LTCF managers used this app to report new daily cases and the evolution of cases already detected—which activated the primary care team for urgent care when necessary—, PCR results, and clinical variables to monitor residents remotely. It was also possible to record the status of workers and detect facilities at risk of not being able to respond to the situation adequately. A control panel was created with the tool Business Objects to specifically monitor the response at each center and region in our sphere of influence.

Strategic alliances with all the care levels and providers involved was a key element in applying measures established through institutional policy, as well as local care requirements: a) for the epidemiological strategy, alliances between health and social institutions were focused on establishing effective measures to prevent and control the spread of infection in the facilities. These measures were determined by the institutional policy framework (policy level) to be applied by the health provider (provider level). All the mandatory measures established by the institutional policy gave us common protocols for all areas: policy, primary care and LTCF, which facilitated coordination between them; b) for the care strategy, an attempt was made to involve the various actors (from health and social sectors) in the response through a comprehensive care model that could be adapted to the different realities of institutionalized patients—whether affected by COVID-19 or not—, existing needs, and the evidence available.

B2. Valley phase: adaptation of the model based on lessons learned (summer 2020)

Thanks to the support of the PCT providing direct care at the LTCF, the underlying factors that determined whether facilities were at risk of being unable to respond to the pandemic were detected and analyzed. Along with results from the CoVIDApp, these factors helped us modify the action strategy based on the following difficulties:

• Snowball effect: The facilities that did not adequately follow protection and prevention measures had a higher infection rate, both in residents and professionals. This resulted in a shortage of professionals who could adequately care for residents, and thus, worse prognosis for patients once infected. As a corrective measure, the prevention strategy was reinforced: an audit was designed with 12 mandatory items that nursing facilities had to comply with for the correct prevention of infection.

• There was a turning point when it was demonstrated that there were positive residents who were asymptomatic and that, on some occasions, the symptoms were not always respiratory in nature. Corrective proactive responses were established, consisting of the mass screening of all residents and professionals at the center when one resident tested positive. The recommendation was made to screen residents when they returned from a stay outside the facility, as well as workers upon return from a vacation period.

• To quickly respond to the demand for mass screening, a mobile regional unit was structured to help PCT performing them.

On the other hand, the Department of Health, Public Health and the Social Welfare established a series of mandatory common protocols to be applied in all areas, both at the level of healthcare providers and at the level of LTCF, based on emergent evidence. on the management of COVID-19 infection.

B3. Second and third waves (winter 2020–spring 2021)

Based on accumulated knowledge from previous phases, we applied proactive measures to prevent infection during the second wave. The aim was to prevent the virus from entering facilities and, if it did manage to get in, prevent or minimize transmission inside.

• The availability of the rapid antigen test changed the paradigm of infection in LTCF. Rapid tests made it possible to quickly diagnose (15 minutes) patients with symptoms compatible with COVID-19, thus enabling an immediate sweep of both workers and residents at the nursing facilities with PCR tests in search of asymptomatic positive patients so that sectorization and intervention in the residence could be performed quickly and early on.

• Another proactive measure established by the regional government was focused on preventing the virus from entering facilities. Both residents and workers underwent PCR screening when they returned to the nursing facilities after a vacation period of more than 15 days.

During the third wave, as evidence on the management of COVID-19 emerged and new evidence on various pharmacological treatments appeared, the action protocols were updated. Therefore, two new prevention strategies were established:

• Given the high prevalence of infection in the community, periodic screening measures were also activated for LTCF workers (both permanent and temporary workers) since the data indicated that the virus was initially entering the residences through them. If this occurred at an at-risk LTCF, the care team supervised the implementation of the process.

• Rapid communication channels, between PCT and LTCF, were established for screening results if a worker or resident tested positive.

• The irruption of vaccination: with the initiation of the mass vaccination strategy for institutionalized residents, in December 2020, a huge leap was made in epidemiological control and the minimization of the risk of complications in terms of protecting this population.

B4. Fourth wave and later (from spring 2021)

The actions consolidated during the previous waves were maintained and the various clinical management protocols were updated based on the evidence and introduction of new treatments. In September 2021, the vaccination of institutionalized patients with the third booster shot began, which alongside the other preventive and organizational measures, constituted a more proactive and coordinated care response.

C. Interaction between implemented actions and epidemiological results

Figure 2 presents the evolution of infection and mortality rates alongside the implementation of the measures adopted in the various phases.

Figure 2

The positive evolution of the COVID-19 infection rate in our population over the course of the various waves could be attributed to multiple conditioning factors, although the data suggest a relation between increased prevention measures and decreased infection rate in residents over time. In this sense, it was key, during the first wave, to implement a digital tool (as CoVIDApp) to have direct information, of both residents and workers, from LTCF. Main preventive actions, that reduced COVID-19 infections after the first wave, were mass screening after detecting a positive case, which allowed us to detect asymptomatic cases and stop the spread of the virus once it had entered the facilities, and infection prevention audits, that reflected the response capacity of the LTCF if an infection were to break out. Mass screening of the professionals, directly caring for residents, became mandatory in periods after the second wave, and from then on, the detection of asymptomatic positive workers was higher than in the first two waves. The irruption of the vaccination in the third wave, was a central action to reduce mortality, complementing the other preventive actions implemented during the previous waves.

Lastly, the drastic reduction in the mortality rate of residents in later waves as compared to the first and second waves, falls in line with the reduced infection rate of both residents and workers, which corroborates that the best strategy is to prevent infection. A decrease in the specific mortality of infected residents is also observed, which can be explained by other cofactors that were directly or indirectly controlled, such as high viral load due to risk contacts, delayed diagnosis, and reinfection.

Impact of a preventive response led by Primary Care Teams

Through the collaboration between the actions from our PCT and the other LTCF actors, we noticed a relation between increased preventive measures and decreased infection rate and mortality in residents over time, as identified in the lessons learned article by Fang et al. [23]. In this sense, a Dutch study, by van Tol et al., reinforced the impact of outbreak teams, including clinicians, managers, and policy advisers to coordinate COVID-19 infection prevention and control, in LTCF [24].

The importance of communication between health and social actors

The adaptation of information technologies to improve communication between professionals, by using a mobile App, was found a crucial tool at a time of changing information and great uncertainty. Various groups used simple tools to share information, and they have been considered key elements in the integration of services for institutionalized people [19].

Continuous adaptation to changing needs

One of the decisive elements during the COVID-19 pandemic operations was first-hand knowledge and analysis of the information available on the changing reality of facilities. Having a specific information system that was updated on a daily basis was extremely useful for planning the emergency response. In this sense, it is essential to understand the changing needs of this population to plan integrated care policies in LTCF at the micro, meso, and macro level.

Evolution of the care model from reactivity to proactivity

Especially in the early stages when there was much uncertainty and little knowledge of the disease, the pandemic demanded very intense and completely proactive intervention from Primary Care professionals based on the information received from LTCF teams. This increased intensity of healthcare opened the doors to greater joint work between different professionals. In this sense, we believe it is important to reinforce and promote the collaboration between professionals from the health and social sectors, in the context of care provision in LTCF.

The key role of strategic alliances and good governance

Another key point in the initial response to the pandemic was the alignment of objectives in the collaboration of various actors of the health and social systems. The different departments (health and social) of our regional government, and the social care and healthcare providers had to establish a common working path to respond to the emergency. In this sense, there were many micro barriers to the effective integration of the responses, which should make us reflect on what are the best ways to pose policies and manage integrated care in the future.

Extreme vulnerability of the institutionalized population

Current care services for people with extensive health and social needs due to frailty, disability and complex disease needs (including older and young populations) should consider the importance of developing personalized care plans adapted each individual’s needs (different background, and physical and mental conditions) and that can be modified continuously in changing situations. After the COVID-19 pandemic, the Government of Catalonia, as other governments worldwide, have developed specific plans to improve the care of vulnerable populations living in LTCF [26].

Lack of including the opinion of the people being served

In our experience, there was no focus on the needs of individuals when planning the epidemiological responses. In this sense, loneliness and lack of stimulation have been identified as one of the weaknesses of care in LTCF during the pandemic [27].

Lack of considering relatives needs

The residents’ loved ones have also suffered during the pandemic, especially due to restrictions on visits and companionship, and the epidemiological demands, which were prioritized over personal needs. Given the large number of people who are institutionalized due to disabling conditions, it is especially important to understand their concerns and needs.

Lack of LTCF resources

The pandemic has revealed the need to guarantee many continuous resources to meet the needs that arise from the health crisis. This has highlighted the fact that many facilities do not have the resources required to cover the needs of the people served. This issue must be corrected to guarantee good social and health care [25].

Limitations and biases of the study

Our work urges from an observational study analysing of the impact of a local strategy in a single territory in the metropolitan region of Barcelona, in South-western Europe. Main conclusions of our work need to be considered locally, and could not be representative of the reality of other territories. Moreover, the discussion of facilitators and barriers of the integrated care response was constructed based on the identification of main issues identified by our group, and it could not be representative of the views of the other actors linked to the response. In this sense, conclusions and discussions should be interpreted and adapted based on the context of other views and experiences. Unfortunately, LTCF people with lived experience have not been involved in the underlying study or in preparation of the manuscript.