Introduction

In January 2020 the first cases of COVID-19 were detected in Italy which, by March, had become the epicentre of the COVID-19 pandemic in Europe. Even though the accurate number of deaths in long term care facilities (LTCF) from COVID-19 in Italy is still unknown, it is possible to presume that many COVID-19 related deaths occurred in Italian LTCF for older people.

At the height of the COVID-19 pandemic, public attention focused primarily on the problem of providing acute care in hospitals. (Berloto et al., 2020) Less attention was given to the COVID-19 related infections and deaths in LTCF for older people, despite the risk they posed.

Whilst all age groups are at risk of contracting COVID-19, older people face an increased risk of severe infection and death by COVID-19 due to physiological changes related to ageing and pre-existing health conditions (ECDC, 2020a; World Health Organization, 2020a).

Evidence from around the world has shown that once COVID-19 occurs in a LTCF it is difficult to control its spread due to two main reasons: the large number of people living close together and because personal care requires working in close proximity (World Health Organization, 2020b).

This commentary shows the findings from a rapid survey run among Italian professionals working in the LTC sector. The manuscript focuses on the main challenges which, according to respondents, may have determined higher death rates in long-term care facilities for older people during the COVID-19 emergency. Based on the responses received and the evidence collected at the national and international level since the beginning of the pandemic, the commentary suggests some measures which should be considered to better safeguard the health and well-being of older residents in LTCF during health emergencies, such as COVID-19.

Methods

To collect professionals’ views on the main challenges experienced in LTCF during COVID-19, we run a rapid qualitative survey. This method was chosen among others, like qualitative interviews and focus groups, because of the emergency context we were in at the time. The qualitative survey allowed us to collect responses very quickly without coming into prolonged contact with professionals working in LTCF, who were highly committed during the first months of the pandemic. Qualitative interviews, instead, would have required longer calls with professionals, and focus groups several meetings and a much more active participation. By adopting the rapid survey method, professionals were free to respond at a time that suited them best, without having to schedule any meetings during a period of uncertainty.

The rapid qualitative survey was carried out in four phases: during phase I, we identified the stakeholders to be included in the survey; in phase II, we drafted the survey’s questions; in phase III, we submitted the questions to the stakeholders identified; in phase IV, we analyzed the responses received and we compared them with some of the existing evidence collected since the beginning of the pandemic.

Phase I: Identifying representative stakeholders operating in the LTC sector.

As a first step, we identified the stakeholders to be included in the survey. To choose professionals operating in the LTC sector, we considered the following factors:

• – the provision of long-term care services in Italy is shared across national, regional, and local levels (Berloto et al., 2020).
• – The Italian long-term care sector depends on a mix of public, private for-profit and non-profit providers (Eurofund, 2017).
• – There are several stakeholders involved in the long-term care sector. These include healthcare professionals, associations, regional and national organizations managing long-term care facilities for older people as well as institutions taking care of older people’s needs and rights.

By taking these factors into account and by considering the limited time and resources available, we contacted thirty Italian professionals working in the LTC sector at different levels. These professionals were chosen as they represent the main stakeholders involved in the LTC sector in Italy and were best placed to provide an understanding on the main challenges faced by LTCF for older people during the COVID-19 pandemic. This sample included an equal share of healthcare professionals, directors of organizations managing local LTCF for older people, directors of national organizations and institutions in charge of both public and private LTCF for older people as well as associations representing older people’s interests and collaborating with LTCF. At least one professional in each Italian region was contacted to collect views and perspectives from all Italian regions.

Phase II: Drafting the questions.

As next step, we drafted the survey’s questions. We decided to include only three questions, given the very busy time that the COVID-19 pandemic has represented for professionals working in LTCF. While questions 1 and 2 left less room for answers and could be interpreted as ‘yes’ or ‘no’ questions, question 3 consisted of an open-ended question which we wanted respondents to focus particularly on. The aim of question 3 was to collect their views and opinions on main challenges and most needed measures to protect older people in LTCF. As a result, the findings section presents mostly the responses to question 3.

We shared with professionals the following questions:

1. Do you think that the needs of older people in LTCF have been put on the agenda of the Italian response to the COVID-19 outbreak?
2. Are you aware of any local or regional measures that tried to compensate for the gaps in national government policies to reduce the impact of COVID-19 on older people in LTCF?
3. What are the main challenges faced by LTCF and what measures do you think should be implemented to reduce the impact of COVID-19 on older people in LTCF, to better protect their level of health and wellbeing in case of future waves of COVID-19 or future health emergencies?

Phase III: Submitting the questions to Italian professionals working in the LTC sector.

In mid-June 2020 we sent the questions to the professionals identified. When sending out the questions, we clarified that the aim of the survey was to understand the main challenges faced by LTCF during the COVID-19 emergency and to identify the actions needed to better protect older residents’ health and wellbeing in case of future COVID-19 waves or future emergencies.

Professionals were given till the end of June 2020 to send their responses.

Phase IV: Analyzing the responses.

As first step, we identified those who had participated into the survey. By the end of June 2020, fifteen professionals responded to the questions. We believe that those who did not respond to the survey were too busy to take part in it. In fact, among the fifteen professionals contacted who did not send their responses, eight professionals responded that they did not have time to participate. Not surprisingly, we received the highest number of responses from those who were not directly working in long-term care facilities, namely the associations representing older people at the local and national level. In contrast, the lowest number of responses came from healthcare workers, who played a major role in fighting COVID-19 in LTCF.

The characteristics of respondents are summarized in the Table 1 below:

Respondents were able to provide information on LTCF in all of Italy. However, the respondents operating at the local level were all from northern and central regions. This may affect our findings as the information reported is not equally representative of all Italian regions.

To analyze the responses, we adopted a thematic analysis approach. Firstly, we reported the answers received on an excel file. This helped us to ease the comparison between answers to the same question and to get familiar with the data collected. Secondly, we grouped the answers according to the category of professionals, to see if opinions among people performing the same job were similar. Then, for each question, we identified common patterns across the responses collected. By using this approach, we were able to identify six main themes which were broadly discussed by respondents and that we reported in the Finding session.

Once we analyzed our responses, we compared them with the evidence on LTCF collected by national and international organizations since the beginning of the pandemic. This comparison aimed to see whether there was a correspondence between the main themes highlighted by respondents and those highlighted by international and national guidelines. We focused on international evidence, collected by the Centre for Disease Control (CDC), the European Centre for Disease Control (ECDC) and by the World Health Organization (WHO), and on national evidence, collected by the Italian Ministry of Health and the Italian Health Institute (ISS). We found that the actions which, according to participants, needed to be implemented to better protect older people’s health and wellbeing were also included in guidelines and recommendations published by the above- mentioned organizations and institutions. The actions which need to be considered to mitigate future health risks in LTCF and improve responses during health emergencies are reported and described in the Discussion session.

Limitations

The paper is based on two main types of information: opinions collected through a rapid qualitative survey among professionals working in LTCF and evidence gathered from national and international guidelines. As the number of healthcare professionals who responded to the survey is small, the information collected may not be representative of all workers operating in the sector in Italy. Finally, the number of the international and national guidelines reviewed is limited. Therefore, the list of actions and suggestions on how to strengthen the LTC sector and better manage LTCFs during health emergencies is not exhaustive.

Findings

When asking respondents if, in their opinion, the needs of older people were put on the agenda of the Italian response to COVID-19, all of them said older people’s needs were not prioritized as they should have. On the contrary, once the first COVID-19 cases were identified in Northern regions, attention was primarily given to hospitals and focused on the problem of providing acute care (Berloto et al., 2020). As a result, LTCF in the hardest hit regions found themselves with no guidelines on how to protect their residents (Berloto et al., 2020). In the absence of guidance, some regions moved faster than others to protect older residents in LTCF, for instance, by adopting more protective and restrictive measures (Pisano et al., 2020).

When asking respondents if they were aware of regional measures which compensated for the gaps of national policies, the strategy adopted by Veneto was positively cited as a good practice by most respondents. This strategy relied on extensive testing of both symptomatic and asymptomatic cases, proactive tracing of potential positivises and specific efforts to monitor healthcare professionals in close contact with at-risk populations, such as older residents (Pisano et al., 2020).

Differently, some other regions were mentioned by participants for their conservative approach to testing and for putting hospitals at the centre of their responses. Most LCTF in Lombardy lock downed in early March and did not allow new entries. Nevertheless, the regional government, on March 8, asked local authorities to identify LTCF for older people that were able to accommodate COVID-19 patients with mild symptoms. This measure was taken to enable hospitals to discharge elderly patients and lighten their burden (Regione Lombardia, 2020a). According to respondents operating in the LTC sector, this approach, which shows how little consideration was given to the possible devastating effects of COVID-19 on this vulnerable group, may have determined higher death rates in LTCF and accelerated the spread of the virus in the facilities. Despite some regions were quicker than others in developing strategies to protect residents in LTCF against COVID-19, the similar responses received from professionals working in LTCF in different Italian regions prove that the LTC sector faced similar challenges throughout Italy.

When asking respondents about the main challenges which LTCF faced during the pandemic, respondents mentioned six main factors which may have accelerated the spread of the virus and determined higher death rates among residents, including:

1. PPE and Protection: The most critical factor which, according to respondents, accelerated the spread of the virus has been the lack of personal protective equipment (PPE) and the lack of clear guidance on their use and disposal. To better handle future waves or other pandemics, respondents stated the need to develop clear instructions and safety protocols to manage the procurement of PPE as well as the rapid administration of tests for staff and residents.After the first COVID-19 cases were identified in early February 2020, Italian LTCF did not receive any guidance on how to handle COVID-19 cases within LTCF (Mattiacci, 2020). In addition, LTCF did not have adequate PPE to protect staff and slow the spread of the virus among residents and staff (Quotidiano Sanità, 2020a). In some cases, regions did not develop a strategy to test healthcare workers in contact with older people and instead they only tested hospitalized residents (FNOMCeO, 2020; Pisano et al., 2020). According to respondents, the inability of LTCF to test residents was a major factor that accelerated the spread of the virus, due to asymptomatic people unknowingly passing the virus on to staff and other residents (Istituto Superiore di Sanità, 2020; McMichael et al., 2020). Despite the lack of tests has been a major factor responsible for a high number of COVID-19 positive cases in LTCF, test shortages still persisted in future waves. In November 2020, for instance, the surveillance of COVID-19 at LTCF for older people was hampered by the lack of tests, needed to test visitors and healthcare workers before entering the facilities (Carnevali, 2020). According to respondents, clear guidelines and procurement procedures are needed to ensure staff and older residents’ safety and protection.
2. Management: According to respondents, the responsibilities of the Italian LTC sector, shared across local, regional and national levels, inhibited dialogue and cooperation at the beginning of the pandemic and compromised an effective response to deal with COVID-19. The lack of coordination in the LTC sector has increased delays in access to usual health services, which affected mortality rates in LTCF for older people in Italy. As specified by respondents, although the number of doctors and nurses increased during the pandemic, backlogs of care remain high (Camera dei Deputati, 2020; Quotidiano Sanità, 2020b). As people have been less able to access needed care during the pandemic, morbidity and mortality associated with preventable and treatable conditions most likely dramatically increased (Czeisler, 2020; Szczerbińska, 2020). According to respondents, joint and coordinated actions are needed to improve the management and strategic planning of LTCF.
3. Social Distancing: The lack of social distancing measures among residents and staff was identified by respondents as one of the main factors responsible for the high number of infections recorded in LTCF during the first wave of the pandemic (McMichael et al., 2020). Whilst physical distancing in most LTCF with highly dependent residents is difficult, nevertheless, physical distance needs to be maintained, for example by limiting groups activities or eliminating external visitors (OECD, 2020). According to respondents, when introducing these types of social distancing measures, it is essential to maintain an adequate balance between distancing and isolation (Wu, 2020). Respondents highlighted that, even though frequent contacts could be maintained by using IT devices for remote interactions, this might be challenging due to the limited digital skills of older people. While the risk of infection could be reduced by preventing external visits, the risk of loneliness and isolation could dramatically increase among older residents. As loneliness and isolation have been associated with higher risks of depression and anxiety and higher risks of health diseases, strokes and dementia, respondents highlighted the importance of investing in digital technologies and in training courses to allow older people to maintain social remote connections while staying safe (CDC, 2020).
4. Governance and participatory decision making: According to respondents, the lack of coordination between LTCF, health professionals and social care providers negatively affected older people’s health in LTCF and increased their hospitalisation. According to respondents, the lack of integration is related to a ‘hospital-centrism’ approach, on which some Italian regions, such as Lombardy, rely on (Scura, 2020). These systems do not rely on coordination between different actors and stakeholders, which is essential for dealing with older people’s multiple conditions, but, instead, they work in silos. To better protect older residents in LTCF in future waves and future health emergencies, coordination with different stakeholders, including GPs, social care providers, families and healthcare workers needs to be strengthened and maintained. This inclusive and integrated care structure may help to better monitor older people’s health as well as to reduce hospitalizations (Cranley et al., 2020). According to respondents, higher integration could reduce the burden on hospitals and determine a responsible use of resources, which could more easily meet and address older people’s multiple morbidities.
5. Capacity building: The lack of qualified staff in LTCF, including doctors, nurses, health care workers and auxiliary care workers, was identified by respondents as a key issue for dealing with COVID-19. LTCF for older people are characterized by a chronic shortage of professional staff which severely affect the quality of services offered by long-term care structures. Recent data show that many of those working in Italian LTCF are not qualified (Jessoula et al., 2018). Of the estimated 1.1 million workers employed by LTCF for older people in Italy the vast majority are low-skilled carers, often migrant workers with no official training or qualifications (Jessoula et al., 2018). This is largely due to a strong migration of staff members to public hospitals, offering higher salaries and more career opportunities compared to the long-term care sector (Salvalaggio, 2020). According to respondents, LTCF staff should be adequately trained to better take care of older people during emergency contexts and to avoid sending residents to hospitals. This can be done by teaching them how to assess vital signs or detect symptoms, for instance. To respond more quickly during health emergencies, respondents highlighted the importance of developing comprehensive training packages for LTCF staff and enhancing dialogue between managers and staff.
6. Ensuring high quality of care: According to respondents, LTCF for older people did not have the necessary resources to ensure high quality of care during health emergencies. They reported that the lack of skilled-professionals and digital devices made it difficult to maintain high standard of care, especially when LTCF residents were denied access to hospitals, as happened in Lombardy. To avoid further hospitalizations, on March 30, residents of LTCF aged 75 and over in Lombardy were no longer allowed to be moved to hospitals and, if needed, they had to receive treatments within the LTCF (Regione Lombardia, 2020b). According to respondents, it is critical to ensure coordination between LTCF and health services to better protect older people’s health in case of emergencies. Furthermore, to ensure remote medical supervision, respondents recommended the use of telemedicine in LTCF to be improved and strengthened (ECDC, 2020b; ISS, 2020).

Discussion

The qualitative data collected through the survey prompted reflection on how to improve the way we look after our growing older population. These actions, which according to respondents should be implemented to reduce rates of infection in LTCF, have also been highlighted by international and national guidelines and recommendations.

International experience has shown that COVID-19 is not inevitable among LTCF (World Health Organization, 2020). However, early evidence collected during the first months of the pandemic suggested that it is possible to mitigate the adverse impact of COVID-19 on LTCF by addressing structural issues in the sector and by implementing timely and coordinated measures (World Health Organization, 2020a; ECDC, 2020b) These measures need to consider the unique challenges faced by LTCF, which can help explain many of the difficulties that LTCF have addressed during the pandemic.

International evidence highlights that LTC services are often separate from health system services, and this determines the way data and information are collected, how LTCF are financed and maintained as well as how LTC staff is trained (OECD, 2019a). As LTC responsibilities are often share across national, regional and local actors, LTCF management is often complex, and the difficult coordination among the actors involved may result in a lower quality of services (Spasova et al., 2018; World Health Organization, 2019). The poor quality of services is also due to the shortage of care workers, as the job is often low paid and considered as low-skilled (OECD, 2019b). To improve the management, governance, and the strategic planning of LTCF during COVID-19, threatened by the above-mentioned structural issues, international recommendations stressed the importance of ensuring additional financial, human, and material resources in LTCF (World Health Organization, 2020b). In particular, the evidence suggests that more and better trained staff should be available during health emergencies to avoid staff shortages and ensure timely care services (World Health Organization, 2020b). To ensure a high-skilled workforce, comprehensive training packages for LTCF staff should be developed (CDC, 2020; World Health Organization, 2020a). This includes giving LTCF staff access to infection prevention and control training (IPC) (World Health Organization, 2020a). As another action, national and international guidelines also recommend the use of shared digital health systems that transmit useful data and information in real time (ISS, 2020; World Health Organization, 2020b). This could benefit the coordination between the various actors managing LTCF, which may be complex and may negatively influence staff readiness to act in emergency context (ISS, 2020; World Health Organization, 2020b). For instance, shared digital health system could ease the dialogue not only between LTCF staff, hospitals, and other healthcare professionals, but also with public health authorities, which would enable quicker decisions in emergency contexts (ISS, 2020).

Besides the issues related to the quality of care and the delivery of services in LTCF caused by structural and managerial issues, international resources have identified the lack of ownership as another main barrier to the delivery of high-quality services in LTCF (World Health Organization, 2019). As in most countries LTC responsibilities are distributed across several public, private not-for-profit and for- profit service providers acting at different levels, the lack of accountability often results in lower commitments and engagement in LTCF management (King & Zigante, 2020). This has, in part, led to a poor emergency response in the sector. To be better prepared in case of future waves of COVID- 19 and future public health emergencies, international recommendations underline the importance of developing clear emergency guidance (CDC, 2020; ISS, 2020). Emergency measures for limiting the spread of the virus refer, but are not limited to, publishing clear guidance on use of PPE, reducing the number of visiting professionals into LTCF through fixed routine appointments, reorganizing internal activities to limit contacts and ensuring social distancing, limiting the number of residents and staff moving to common spaces (CDC, 2020; ISS, 2020). When implementing emergency activities, broader communication strategies to facilitate coordination among different actors must be considered as well. For instance, planning a communication strategy among governmental bodies and the LTC sector can help establishing a prompt response during emergency crisis (CDC, 2020).

Finally, the international and national evidence collected during the pandemic have focused on protecting the physical and psychological health and well-being of LTCF staff and LTCF residents (CDC, 2020; ISS, 2020). To protect staff, which may feel overburdened by working in emergency contexts, international guidelines suggest creating space for dialogue with managers and coordinators (World Health Organization, 2018). This space can be used to better clarify each one’s role and focus on new ways of delivering care for acting fast in emergency contexts (World Health Organization, 2018). To protect the health and well-being of older people living in LTCF, the evidence collected suggests keeping an adequate balance among social distancing, to reduce the spread of the virus, and social isolation (Cranley et al., 2020). According to recent studies, social isolation has been found to increase risk of dementia, depression, and the risk of hospitalization among older people (National Academies of Sciences, Engineering, and Medicine, 2020). To maintain social connections in emergency contexts, frequent contacts with family members should be promoted (Cranley et al., 2020). This can be done by embracing digital technologies, which showed to have positive impacts on older people’s health and social needs (CDC, 2020).

These suggested actions align with the major categories discussed by survey participants when mentioning the main challenges faced by LTCF. These refer to management, governance capacity building, quality of care and protecting and safety measures.

Table 2 shows the key actions which, according to respondents and to the evidence discussed in this session, are needed to improve LTCF responses to health emergencies. To understand the relevance of the measures proposed, a distinction between levels of responsibilities has been specified when reporting the key areas of actions. This could help the implementation and the division of tasks, which is often confusing due to the role that different actors play in the LTC sector.

As this paper suggests, there is still much to be done to strengthen the structure of LTCF and enable the LTC sector to better face public health emergencies. The fact that the fragile structure of LTCF is common to many countries shows the urgency of strengthening and redesigning the LTC sector. Firstly, to ensure it can cope with emergency situations, it is necessary to focus on its managerial and structural aspects. Towards this aim, the accountability, ownership, and responsibility of each actor involved in the LTC sector need to be clarified. As a next step, it is also necessary to develop contingency plans and ad-hoc measures to protect older residents during emergency contexts.

Table 2 wants to serve as a conclusion by summarizing the key actions that should be taken to mitigate future health risks among older people living in LTCF. It also wants to shed light on what needs to be improved in LTCF in the short term, to address the main challenges the LTC sector is currently facing, such as lack of ownership and accountability.