Maintaining Resident Social Connections During COVID-19: Considerations for Long-Term Care

Abstract

Worldwide, long-term care (LTC) homes have been heavily impacted by the coronavirus disease 2019 (COVID-19) pandemic. The significant risk of COVID-19 to LTC residents has resulted in major public health restrictions placed on LTC visitation. This article describes the important considerations for the facilitation of social connections between LTC residents and their loved ones during the COVID-19 pandemic, based on the experiences of 10 continuing care homes in Alberta, Canada. Important considerations include: technology, physical space, human resource requirements, scheduling and organization, and infection prevention and control. We describe some of the challenges encountered when implementing alternative visit approaches such as video and phone visits, window visits and outdoor in-person visits, and share several strategies and approaches to managing this new process within LTC.

Introduction

Long-term care (LTC) homes worldwide have been heavily impacted by the coronavirus disease 2019 (COVID-19) pandemic. In Canada, LTC has been hit particularly hard with estimates as of June, 2020 suggesting that up to 85% of COVID-19 deaths are LTC residents (Hsu et al., 2020). The severity of disease in this population has led to significant public health restrictions. In Alberta, Canada, this included strict visitation restrictions ordered by the Chief Medical Officer of Health, effective March 20, 2020 and still largely in place at the time of this writing in mid-July, 2020 (Office of the Chief Medical Officer of Health, March 20, 2020). These restrictions denied entry to all visitors into continuing care homes, except for end-of-life circumstances or those deemed an essential visitor; essential visitors were allowed entry only in exceptional circumstances where a resident’s care needs could not be met by staff (Office of the Chief Medical Officer of Health, March 20, 2020).

Since the start of the COVID-19 pandemic, researchers and clinicians have noted the importance of maintaining social connections for LTC residents in light of visitation restrictions (Edem & Friss Feinberg, 2020; Eghtesadi, 2020; Ruopp, 2020; Simard & Volicer, 2020). To our knowledge, no articles have been published describing the experience of facilitating social connections between hundreds of LTC residents and hundreds of family members, an enormous undertaking previously non-existent in pre-pandemic LTC settings where families could simply visit loved ones as desired. This article describes important considerations for the facilitation of social connections of LTC residents, based on the experiences of 10 continuing care homes in Alberta, Canada during the COVID-19 pandemic.

Setting

CapitalCare is one of the largest public continuing care organizations in Canada, operating since 1963. It provides care to 1,400 older adults or people with disabilities living in 10 care homes, as well as over 300 people living in the community who attend day programs. CapitalCare also provides palliative care, and short-stay restorative care for patients who no longer need acute care. Homes range in size from 111 to 276 beds.

Considerations for Social Connections

Technology

One of the most commonly promoted methods for maintaining social connections during COVID-19 is through technology. The care homes encountered several challenges to the rapid use of technology to facilitate connections between residents and family. First, was the availability of tablets or phones capable of facilitating video conference calls. Although all homes had a small number of tablets, several were older and could no longer update video conference apps to new versions required to facilitate video calls. Older tablets had pixelated or choppy images during video visits making it hard for residents to see family. New tablets were required to support new versions of video call software and enable high quality connections.

Several of the homes were constructed decades ago and as such, lack Wi-Fi and internet infrastructure. Although Wi-Fi is available in all of the homes, the strength varies by location and, particularly in the older brick buildings, is not strong enough in resident rooms to enable video calls. This means that residents must be assisted to building locations with sufficient signal strength for a video call.

A final technological challenge is the skill of both residents and family members to use technology in a meaningful way. Not only do most residents not own their own devices, many live with dementia and become confused during video calls. Most residents are not able to make calls themselves, either because they do not understand the technology, or because they lack the manual dexterity to complete the necessary steps on touchscreens. Most residents require a staff member to start the call and often remain with the resident for the call to maintain focus or to physically hold the device. Residents often do not have the physical strength to hold a tablet at face level, nor do many have the manual dexterity to set up a tablet on a stand. Many family members, themselves older adults, have not used video call apps before and require tutorials from the home staff on how to download, open and login to a video call. Video calls on tablets also present challenges for residents with visual or hearing impairments as the volume and screen size is often insufficient for their needs.

Socioeconomic disparities across residents and their families may result in differential access to phone and video technology. Since the start of the pandemic, some family members have purchased tablets or cell-phones for personal use by their loved ones in LTC. Families without resources to purchase personal-use technology rely on the home-provided technology, which is shared across all residents.

Physical Space

Window visits are offered to family members. Window visits involve bringing residents to a main floor, external window where family members can see and interact with the resident from outdoors. Window visits require access to large, main floor windows that are easily accessible to families from outside. Most of the homes have only a small number of these spaces available and few are located directly on the neighbourhood (unit) where the resident lives. In the older LTC homes, units were designed like hospitals, with long hallways containing numerous, multi-person rooms. In the newer LTC homes, neighbourhood models are used where small cohorts of residents live in “houses” or “neighbourhoods” designed to mimic homes, rather than hospitals. Because the older homes have multiple floors and are larger than newer homes, staff must assist residents further to and from visit areas. Window visits also require a mechanism of communication between the resident and family member through the window. Often this is a telephone or, for some family members, written cards or whiteboards held up to the window.

Outdoor in-person visits have been permitted between residents and two family members in Alberta since May, 2020 (Office of the Chief Medical Officer of Health, April 28, 2020). Outdoor visits require a safe, comfortable physical location where a resident can be brought to meet with family, while maintaining physical distance from others outdoors. In Edmonton, Alberta, one of the northernmost cities in Canada, weather is often cold and residents require additional clothing or blankets to be kept warm. The unpredictability of the weather also creates challenges and sometimes visits must be canceled or rescheduled due to poor weather conditions. Several of the homes have purchased outdoor tents to help facilitate outdoor visits while keeping residents from sun or rain exposure. Staff must remain nearby during outdoor visits in the event that residents have difficulty and need to end the visit early or require other assistance from staff. Visits require family members wear face masks and maintain two meters of physical distance, which can be confusing and distressing for some residents living with dementia, as well as their families. Any resident or family member can encounter problems with outdoor visits, as face masks can make it difficult to hear or read facial expressions.

Human Resource Requirements

The human resources required to facilitate social connections between residents and families during the COVID-19 pandemic cannot be understated. LTC staff are required to participate in all aspects of the social connections, including: intaking requests and scheduling visits (described below), assisting residents to locations for visits, setting up video visits and maintaining resident focus and participation, training family members on the use of new technology, and cleaning equipment after visits are finished. These are roles that did not exist prior to the pandemic and were therefore not part of staff job descriptions or part of the staffing resources for LTC homes.

The homes have addressed the human resource component in several ways. First, recreation therapy teams have lead the work to facilitate resident-family connections. These team members have good relationships with families and are well suited to help support the work of connecting residents and families. The time teams spend facilitating social connections varies across the homes, with Recreation Therapists spending between 25% and 80% of their time on this work, and Recreation Therapy Assistants spending 20% to 70% of their time on social connections. This comes with an opportunity cost, however, as these staff are not spending this time engaging residents in recreation activity.

The work of connecting residents and families is not solely the job of recreation staff. Other staff support this work. Departments and program areas that have been impacted by COVID-19 have had staff redeployed to help facilitate social connections. Volunteer coordinators, staff from the day programs and members of the rehabilitation teams, have been redeployed to help manage the volume of requested resident social connections.

Scheduling / Organization

The unfortunate reality is that family cannot simply “connect” with a resident when they wish. The limited availability of both technology and staff require visits be scheduled to ensure they occur and run smoothly while balancing the needs of the homes, the residents and the family. Scheduling also helps to ensure equity of access to connections across residents. Families submit requests through a central telephone line or central email address. Requests are forwarded to designated home staff, who use a shared calendar to schedule visits based on resident preferences, site capacity and family preferences. These staff also manage internal requests for connections from residents. Providing person-centred care creates scheduling challenges. Residents, many of whom live with dementia, have times of day that are better or worse for visits. Knowing each resident well and finding a time that will optimize their family connection is another important aspect to scheduling social connections. Scheduling must also account for the other rhythms of LTC life, including mealtimes, bath times and other resident activities.

Communication is an important and time-consuming aspect of organizing social connections for residents. Nursing staff on neighbourhoods must be made aware of the residents who will be leaving the neighbourhood for visits each day. This often requires advanced notice so nursing staff can ensure those residents are out of bed, dressed, had an opportunity to use the bathroom and have eaten prior to their visit. Communication with family is also a key aspect of social connections. Family must not only be made aware of their connection date/time, but also the method of connection and any important details related to that method, for example, like bringing and wearing masks during outdoor visits.

Infection Prevention and Control

Infection prevention and control is always part of LTC life, but is heightened during the pandemic. Staff must ensure that tablets and telephones are thoroughly cleaned between each resident use. Following outdoor visits, staff must clean resident wheelchairs and hands before assisting them to their neighbourhoods. If blankets were provided to residents, they must be laundered between uses, and outdoor seating areas must be cleaned between visits. Heightened precautions for staff also create human resource challenges when trying to facilitate social connections. For example, a staff member whose primary role is facilitating social connections may come down with a sore throat or cough and therefore be self-isolating for up to 14-days. This highlights the importance of taking a team approach to facilitating social connections in LTC, to ensure that social connections can continue even with staffing changes.

Table 1 outlines some of the key advantages and disadvantages associated with the visit types described above.

Table 1.

Advantages and Disadvantages of Visit Types.

Visit type	Advantages	Disadvantages
Phone calls	Most residents are familiar with formatAll LTC homes have telephonesAll family members have telephonesFamilies that live far away can connect	Talking without visual cues can be difficult for both resident and familyCan be difficult for residents with poor hearingNot all residents have a telephone in room, so calls must be made in more public spaces, limiting privacySome residents are unable or do not communicate verbally, or are deafSome residents become confused about who they are speaking withThorough infection control required between uses
Video calls	Residents and family can see each otherFamilies can share other things on screen like pictures or engage in activities like cookingMore than one person can visit on the screen either from the same location, or from different locations via group chatsFamilies that live far away can connect	Require tablets or computers for family and LTC homeRequire understanding of video calling apps for family, residents and staffRequire consistent apps for both parties involvedResidents may become confusedRequires strong internet accessSome residents do not respond to a screenThorough infection control required between uses
Window Visits	Does not rely on technologyResidents and family can see each other live, in-personCan use multiple cues to communicate with residents: phone speakers, whiteboards, pictures, physical and facial expressions	Requires availability of physical spaceCommunication through window can be challengingTransporting residents through the building to a window during an outbreak may be problematic or prohibitedInfection control of window is required if touched by residents and familiesSome residents are confused why families cannot come inside
Outdoor Visits	Does not rely on technology	Weather-dependent
	Residents and family can see each other live, in-person	Require availability of outdoor space
		Transporting residents through the building during an outbreak may be problematic or prohibited
		Mask-wearing regulations make communication difficult
		Families are unable to touch, assist, and hug the resident
		Some residents are confused about physical distancing and mask requirements

Discussion

This paper described some considerations for facilitating social connections during the pandemic, based on the experiences of 10 continuing care homes. We recognize that these experiences are regionally specific and may differ based on the severity of COVID-19 across communities. For better or worse, LTC organizations worldwide have been forced to change the way they operate. Staff have stepped up to provide not only immediate care needs in the face of the pandemic, but also to care for the social and emotional wellbeing of residents in the wake of significant visitation restrictions. These visitation restrictions have resulted in enormous changes to the organization of social activities in LTC.

Based on these experiences, we have several recommendations:

1. LTC residents require simple technology that enables them to independently make connections. For example, a wall-mounted tablet screen where residents could simply press an image of their family member to make a video call.

2. LTC residents require technology that is appropriately modified for their unique needs. For example, large screens with easy-to-use visuals, loud-speakers or audio that connects directly to hearing aids.

3. LTC homes require robust technological infrastructure to support ongoing virtual connections. In older buildings, this may include things like wall-mounted Wi-Fi extenders.

4. LTC homes need adequate staffing to facilitate meaningful, frequent social connections. For a home with 100 residents, two full-time staff dedicated to connections, and a part-time scheduling assistant would be required at a minimum to provide most residents with one 30-minweekly visit; four full-time staff would be ideal. The additional estimated cost for the minimum staffing compliment is $10,561 USD each month.

5. LTC homes should encourage families of residents, during the move-in process, to identify ways to connect with residents besides in-person visits.

6. LTC homes should promote the use of technology among family members. This can be accomplished by engaging family in technology-based activities or games, and by encouraging communication online, for example, by conducting online Resident-Family Councils and care conferences, or providing email newsletters.

7. LTC homes should establish a plan for managing visits in the event of future public health visitation restrictions. This may include: identifying scheduling app software, incorporating visitation activities into staff job descriptions, and outlining visitation policies and best practices.

Maintaining social connections is essential to the health and wellbeing of LTC residents (Jing et al., 2016; Kiely & Flacker, 2003; Moyle et al., 2015). Although social connections no longer look like they did in the past for LTC residents, and may not for some time in the future, strategies such as those described above help to keep residents and families connected, while supporting resident safety and security during this uncertain time.