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Introduction

Residential aged care is an essential service that provides ongoing care to frail and vulnerable older people and some younger people with disability or complex health conditions. During the COVID-19 pandemic, a coordinated approach between the aged care, public health and primary care systems will support residential aged care accepting new residents from the community and from hospitals, as well as residents returning from a hospital stay following an acute admission for health issues (non COVID-19 related).

This will help to ensure:

  • vulnerable residents of RACFs receive appropriate clinical care and are protected
  • residents are admitted to hospital when medically necessary and can be safely and efficiently discharged into appropriate care, and
  • frail and vulnerable older people and younger people with disability or complex health conditions and their carers/families are supported throughout the process.

Purpose and audience

This document provides guidance and recommends strategies to ensure safe and efficient care of older people and younger people with disability or complex health conditions with COVID-19 and other conditions, during the COVID-19 pandemic.

This guidance aims to assist NSW Health Local Health District/Specialty Health Network (LHD/SHN) staff in geriatric services, inpatient wards, emergency departments, and patient flow managers, as well as staff in RACFs, by providing principles to inform best practice strategies for the care of patients and residents. Practice according to the three interlinked principles below will assist in providing safe, efficient care in an appropriate setting.

This document captures the knowledge of experienced professionals and provides guidance based on the available evidence at the time of completion. Local judgement and discretion may be required in the application of this guidance. Each LHD/SHN will use strategies according to need, capacity and feasibility.

Guidance may change as testing, transmission in the community and healthcare associated infection rates in hospital change.

This document should be read in partnership with the policy documents addressing infection control and outbreak management for COVID-19:

Background

There are approximately 81,000 residential aged care beds in NSW (GEN Data website, March 2020). Residential aged care in NSW is provided by:
  • 881 non-government RACFs in NSW (March 2020), regulated by the Aged Care Quality and Safety Commission (ACQSC)
  • 7 RACFs operated by NSW Health (regulated by ACQSC)
  • 63 Multipurpose Services with residential aged care operated by NSW Health (regulated by Australian Commission on Safety and Quality in Health Care).

The range of geriatric and specialised clinical care services offered to RACF residents varies between LHD/SHNs. Services may include outreach/in-reach teams, rapid response teams, hospital in the home (HITH), and acute/post-acute services. Many of these services have been scaled up to increase home and community-based care during the COVID-19 pandemic.

Principles for safe and efficient admissions into RACFs

  1. Ensuring the right care at the right time in the right place: residents are transferred to hospital when clinically indicated and consistent with their wishes and avoidable hospital admissions are minimised
  2. Protect vulnerable people: supporting efficient and safe admissions of new and returning residents to RACFs
  3. Communication to support COVID-19 strategies

Principle 1: Ensuring the right care at the right time in the right place – residents are transferred to hospital when clinically indicated and consistent with their wishes and avoidable hospital admissions are minimised

Key points

  • maximise and support safe and appropriate care in place to minimise avoidable hospital admissions
  • adapt and innovate models of care to safely support clinical needs and resource capacity
  • residents are transferred to hospital when clinically indicated and consistent with their wishes.

Applying Principle 1: Ensuring the right care at the right time in the right

In partnership with primary care, specialised LHD/SHN aged care outreach models:

  • provide proactive and timely access to aged healthcare that may reduce unnecessary hospital presentations and admissions
  • improve consumer experiences of care, and
  • are an effective strategy for keeping older people and younger people with disability or complex health conditions well in their homes (RACF).

LHD/SHN outreach services have existing clinical partnerships with local RACFs and General Practitioners (GPs), and provide a variety of general, acute and palliative care outreach services that support care of residents in place and minimise avoidable hospitalisations. It is recommended that aged care outreach teams provide multidisciplinary care including medical, nursing and allied health services as indicated and where possible.

GPs/GP VMOs remain the primary medical point of contact for residents.

Actions for local health districts
  • Augment existing outreach services to maximise care in situ and minimise hospital admissions during the COVID-19 pandemic, both for residents with COVID-19 and those with other health conditions.
  • Promote the available LHD/SHN supports and establish pathways for geriatric care with local RACFs during the COVID-19 pandemic.
  • Where available, work in consultation with other specialist outreach services including palliative care, heart failure outreach programs, renal supportive care, respiratory care etc.
  • Work with local RACFs to educate and support infection prevention and control practices where needed, including site visits.
  • Early engagement of aged care outreach teams to assist with discharge planning for residents admitted for COVID-19 and other conditions.
Actions for RACFs
  • Engage with LHD/SHNs to understand available clinical supports and pathways during the COVID-19 pandemic.
  • Develop processes to support screening for new/returning residents in line with the CDNA Guidelines.

Provide virtual care/telehealth

Virtual care models and technologies minimise the exposure of residents and healthcare professionals to COVID-19, support resource allocation and disruption for residents by enabling remote assessment, monitoring and care. LHD/SHNs use telehealth (including videoconferencing) within some existing services.

Actions for local health districts
  • Establish and/or augment clinical models that utilise telehealth and virtual care for the provision of clinical care to RACF residents (as part of the eHealthNSW Virtual Care strategy and related projects).
Actions for RACFs
  • Work with LHD services to implement virtual care models.

Secondary triage

Secondary triage is a ‘safety net’ model to minimise unnecessary transfers to hospital from RACFs. It is activated when a RACF requests a lower acuity transfer to hospital via Ambulance, outside of a GP or LHD/SHN outreach initiated request. The secondary triage is performed by an accredited Emergency physician via a telehealth consultation with RACF staff. A plan for the most appropriate clinical care is determined and may include consultation with or referral by the Emergency physician to LHD/SHN services, GP follow up, or transfer to hospital.

The secondary triage process applies automatically when certain criteria are met during a call to Ambulance/Patient Transport Services (PTS) from an RACF and operates 24/7. See Appendix 1 for information on the secondary triage process.

Actions for local health districts
  • Establish communication pathways and protocols with local RACFs to ensure escalation of less acute conditions is via GPs (primary contact) or LHD/SHN services.
  • Contribute to statewide evaluation of secondary triage model.
Actions for RACFs
  • Build awareness amongst care staff of secondary triage via information supplied by LHD/SHNs.
  • Maintain GP as primary point of medical care for residents.
  • Understand and utilise the clinical services offered by LHD/SHNs to support the care needs of residents in situ and avoid unnecessary hospitalisations.

Promote Advance Care Planning

Every RACF resident should have an Advance Care Plan or Advance Care Directive with regular updating at least annually, and if the person's medical condition changes. Advance Care Planning is part of routine practice and with the increasing impact of COVID-19, it is critical for clinical and RACF staff to proactively engage in these discussions with all residents/patients and carers/families.

Actions for local health districts
  • Support local RACFs to discuss Advance Care Planning and ensure Advance Care Planning information is current for all residents admitted to hospital, and for residents in a RACF where there is an outbreak. Use NSW Health’s guidance for health professionals.
  • Advance Care Plans, including decisions about whether hospitalisation is appropriate should be discussed and updated with all residents/persons responsible when admitted to hospital. Social Work may assist where available.
  • The development of, or changes to, an Advance Care Plan or Advance Care Directive during a hospital admission should be communicated to RACFs on discharge within discharge summaries.
Actions for RACFs
  • Advance care plans, including decisions about whether hospitalisation is appropriate, should be discussed and updated with all residents/persons responsible. End of Life Directions in Aged Care and Advance Care Planning Australia provide resources to support ACP in aged care settings.
  • Where the resident has capacity to make an Advance Care Directive, the NSW Government Advance Care Directive
    booklet and form should be used.
  • RACF staff should share ACP information with other services when a medical decision is required and/or when transferring care.
  • Endorsed NSW Ambulance Authorised Care Plans may be created by a resident’s medical or nurse practitioner to provide directions for treatment and to authorise NSW Ambulance paramedics to administer medications for specific and/or palliative conditions (authorised NSW Ambulance Palliative Care Plan).

Maximise community palliative care for RACFs

RACFs may need additional support to provide end of life and palliative care for residents confirmed as having COVID-19, particularly if there is an outbreak in the facility. People with COVID-19 can experience complex symptoms at end of life, including breathlessness and delirium.

If all palliative and supportive care needs can be met, care should be provided in the RACF if this meets the resident’s wishes. NSW Health palliative care, respiratory and geriatric services are available to provide specialist consulting and care as needed, particularly for complex cases. Specialist services will continue to work alongside GPs, who should continue to have a lead role in palliative care for many RACF residents.

The care plan and place of care should be kept under review. RACFs should provide access to oxygen if required as recommended in the clinical care plan and on specialist advice from palliative care. If a resident’s symptom management and distress/agitation escalate despite best management and cannot be managed in the facility, palliative care and primary care services should be consulted to consider the need for hospitalisation. The need for more sedation is an example when transfer to hospital may be recommended.

Actions for local health districts
  • Provide in-reach models of care to RACFs where possible, including telehealth as needed.
  • Support RACF staff to recognise and escalate when residents have increasing needs or are deteriorating.
  • Provide specialist palliative care, advice and education on care planning for complex needs of residents. Provide advice on medication, symptom management, use of oxygen and need for hospital admission including admission to Hospital in the Home (HITH) if appropriate.
  • Ensure reliable access to medicines and clinical equipment, such as supply of oxygen and syringe drivers, is available to meet clinical needs at end of life.
Actions for RACFs
  • RACF staff should provide a palliative care approach to caring for residents who are at end of life.
  • Establish clear escalation protocols to seek specialist clinical advice and criteria for transfer to hospital for deteriorating patients. Protocols should consider RACF workforce capability, skill mix and availability.
  • Ensure reliable access to medicines and clinical equipment, such as supply of oxygen and syringe drivers, is available to meet clinical needs at end of life.

Principle 2: Protect vulnerable people – support efficient and safe admissions of new and returning residents to RACFs

Key points

  • When a resident has been admitted to hospital and is ready for discharge, the treating team will medically screen and risk assess the resident for COVID-19 prior to discharge. The receiving RACF should undertake their own screening process when the resident is admitted.
  • RACFs should screen and risk assess all new and returning residents who are asymptomatic and not suspected of COVID-19. This includes medical screening and assessment of epidemiological risk factors. Depending on the risk assessment, the RACF may implement additional infection prevention and control measures on admission.
  • Processes for admissions/re-admissions to facilities where there is a current outbreak will be in line with relevant national guidelines on infection control and prevention and based on the advice of the local Outbreak Management Team.

Applying Principle 2: Protect vulnerable people - support efficient and safe admissions of new and returning residents to RACFs

Admission to RACF from the community including respite: COVID-19 not suspected and RACF does not have a current outbreak

New admissions from the community can be accepted if the person:
  • has no epidemiological risk factors including no overseas travel or contact with anyone who has travelled overseas in the last 14 days
  • has had no contact with anyone with confirmed, suspected or probable COVID-19
  • is not awaiting a COVID-19 test result, and
  • does not have any acute respiratory symptoms (cough, fever, sore throat, anosmia).

The COVID-19 case definition can be found on the NSW Health website.

An Aged Care Assessment Team (ACAT) assessment should be completed in the lead up to admission, however direct entry can be arranged in emergency situations.

Prior to admission, all residents must be medically screened by a medical practitioner (GP or hospital physician) for symptoms of COVID-19. The AHPPC recommends that no new residents with COVID-19 compatible symptoms should be permitted to enter a RACF, unless the person has recently tested negative for COVID-19.

As current swab PCR testing for COVID-19 can produce negative results until symptoms appear, a negative swab result does not necessarily mean a person is not infected (Guidance for people tested for COVID-19). Therefore, RACFs should individually assess the COVID-19 risk of each new and returning resident and implement the infection prevention and control measures deemed necessary.

The CDNA National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia provide guidance for infection prevention and control measures.

It is important that respite continues to be available, particularly emergency respite places. The same precaution should be exercised by RACFs in admitting a person for respite, as with permanent placement. An exit plan for return to the community should be discussed between the RACF, their carer/family and the assessment service (if involved).

Admission to RACF from the community: COVID-19 suspected or confirmed

If a person requiring admission to RACF is suspected of having COVID-19, the assessment service will liaise with home care package providers and/or LHD/SHN aged care teams to continue to support the person at home while awaiting test results. New residents should not be admitted to a RACF while awaiting test results.

People with a negative test result can be admitted to an RACF. However, RACFs should undertake their own screening and risk assessment of all new and returning residents for COVID-19. This includes screening for symptoms and epidemiological risk factors. Depending on the risk assessment, the RACF may institute additional measures on admission. The CDNA National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia and the Infection Control Expert Group COVID-19 Infection Prevention and Control for Residential Care Facilities provide guidance for infection prevention and control measures.

New/returning resident to RACF from hospital or Emergency Department and RACF does not have a current outbreak

There may be increasing numbers of acutely unwell COVID-19 patients as the pandemic progresses. To ensure that hospitals can be as responsive as possible, it is critical that patients who no longer require hospital care are efficiently discharged. Older people who are medically fit and ready for discharge but whose discharge is delayed are at risk of further deterioration and deconditioning associated with lengthy hospital stays.

Key points

  • Residents will have relevant COVID-19 screening as part of the ED triage process
  • The ED Medical Officer will undertake further COVID-19 screening with a full patient clinical assessment considering epidemiology factors; if indicated an oro-nasopharyngeal swab will be taken for a COVID-19 test
  • Patients who have had a COVID-19 test must not be discharged to their RACF without confirmation of a negative result under any circumstances
  • To minimise time in ED, the patient may require an admission to the ED / hospital short-stay unit or other hospital ward while awaiting the test result. Alternately, local pathways should be followed to request approval for a rapid COVID-19 test for patients not requiring hospital admission.

 

NSW Health has a risk management approach to discharging people to RACFs (see section 4.2.8 Safe discharge process from hospital below), which involves medical and epidemiological screening for COVID-19. This process aims to provide confidence that new and returning residents have been risk assessed for COVID-19 at the time of discharge. Screening for COVID-19 follows current NSW Health advice for aged care which is consistent with advice in the Australian Health Protection Principal Committee (AHPPC) statement and the CDNA National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia.

RACFs are also required to screen new and returning residents and may elect to implement additional infection prevention and control measures on entry.

LHD/SHN aged care outreach teams will assist with discharge planning and follow up, where available in the person’s geographic area. Otherwise discharge planning should follow usual processes.

Note: Hospital acquired functional decline (HAFD) in older patients can be significant: efforts should be made to prevent decline and to preserve function throughout the resident’s hospital admission through multidisciplinary input including allied health consultations (physiotherapists, occupational therapists, nutrition and dietetics, speech pathologists), as required. On discharge to the RACF, residents may require multidisciplinary rehabilitation to prevent further deconditioning and decline in independence and function.

Residents hospitalised with an illness unrelated to COVID-19

Residents hospitalised with an illness unrelated to COVID-19 will be returned to their usual RACF when medically appropriate, as per usual practice, if discharge screening shows no symptoms compatible with COVID-19 and there has been no contact with confirmed or suspected cases of COVID-19. LHD/SHN aged care outreach teams/specialised staff should be engaged as soon as possible in the hospital admission to assist with discharge planning if required (where available in patient’s geographic area).

Residents hospitalised for an illness suspected to be COVID-19

Residents hospitalised for an illness suspected to be COVID-19 will have a medical assessment in hospital including SARS-CoV-2 PCR testing. If PCR testing is negative, including the initial and a repeat PCR testing at least 24 hours later and no other respiratory infectious disease is suspected or has been ruled out, the resident can be de-isolated and discharged to RACF once the treating team has assessed them as medically stable for discharge.

Residents hospitalised and confirmed to have COVID-19

Transfer back to the aged care facility for residents who have been hospitalised with COVID-19 should be managed in line with the up-to-date CDNA guidelines.

Admissions/re-admissions to facilities where there is an outbreak

In circumstances when the facility has a current outbreak, decisions regarding admission/re-admissions should be in line with the relevant and up-to-date national guidelines on infection prevention and control. These include the CDNA National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia and the Infection Control Expert Group COVID-19 Infection Prevention and Control for Residential Care Facilities. Decisions should also be informed by the advice of the local Outbreak Management Team.

Carers/Families may wish to seek alternative arrangements until the outbreak is over. The LHD/SHN will assist in identifying alternate accommodation as needed. LHD/SHN aged care outreach teams/specialised staff may should be engaged as soon as possible to assist with discharge planning (where available) in the person’s geographic area, and Social Work should be engaged to provide support as needed.

Safe discharge process from hospital

Medical screening

The treating team will medically screen all returning and new residents to RACF for COVID-19 prior to discharge, regardless of the clinical reason for admission/ presentation. This includes screening for signs and symptoms compatible with COVID-19.

Epidemiological risk assessment

Individual risk is assessed by the treating team to determine potential exposure to COVID-19.

Testing

If a resident meets the criteria, they will be tested for COVID-19 prior to discharge. Note: SARS-CoV-2 PCR testing in asymptomatic people cannot be wholly relied on to indicate the person is COVID-19 negative. As testing is likely to produce negative results until the symptoms appear, a negative swab result does not necessarily mean a resident is not infected
(Guidance for people tested for COVID-19).

Discharge information

The treating team will communicate a resident’s COVID-19 screening result to the RACF, with an information sheet that explains the risk assessment. This is in addition to the usual discharge records. An RACF discharge letter template and information sheet is available on the NSW Health website and in Appendix 2. LHD/SHN aged care outreach teams/specialised staff will assist with discharge planning and follow up (where available in patient’s geographic area).

Discharge medication

Ensure the required medications are available at the RACF or are provided by the hospital pharmacy at discharge, as scripts from GPs and supply by community pharmacy may be delayed.

The safe discharge process will be reviewed when there are changes to COVID-19 testing, community transmission, or nosocomial infection rates in hospital.

Managing COVID-19 cases in RACFs

Management should be in line with the Commonwealth-NSW Protocol to support joint management of a COVID-19 outbreak in a RACF in NSW. Residents should be immediately isolated and infection control measures used as per the CDNA Guidelines for outbreaks in residential care facilities, Infection Control Expert Group COVID-19 Infection Prevention and Control for Residential Care Facilities, and the NSW Health Incident Action Plan for a public health response to a confirmed case of COVID-19 in an Aged Care Facility. Medical assessment and testing should be sought via the resident’s GP or LHD/SHN outreach service. If a resident tests positive to COVID-19, the Australian Government Department of Health (DOH) and the LHD/SHN Public Health Unit (PHU, phone 1300 066 055) must be notified. The PHU also notifies the Aged Care Quality and Safety Commission (ACQSC).

The RACF is supported in outbreak management by a public health response team led by the LHD/SHN PHU and RACF Incident Controller with key stakeholders, including the NSW State Health Emergency Operations Centre (SHEOC) Aged Care team.

During an outbreak of COVID-19, the Australian Government Department of Health facilitates access to Commonwealth support in sourcing a surge workforce, assisting with relocation of cohorts, and providing financial assistance.

Residents confirmed to be COVID-19 positive can remain in the facility as long as they can be appropriately isolated and receive the required level of clinical care. PPE requirements can be supported by accessing the national stockpile via the Australian Government Department of Health PPE process. State Government RACFs must access PPE through LHD processes. See Appendix 3 for the PPE required when caring for residents who are COVID-19 positive.

Clinical care in situ may be supported by LHD/SHN outreach services and/or virtual care. If the resident’s condition changes, a clinical and risk assessment is required to determine the best location to continue clinical care. This decision should be made in line with principles in the Protocol to support joint management of a COVID-19 outbreak in a residential aged care facility in NSW.

If transfer to hospital is required, the Ambulance service and receiving hospital must be notified of the outbreak/suspected outbreak verbally and through using a resident transfer advice form (available from CDNA Guidelines for outbreaks in residential care facilities).

During an outbreak of COVID-19, the Australian Government Department of Health facilitates access to Commonwealth support in sourcing a surge workforce in consultation with the NSW Health system, assistance with relocation of cohorts, and providing financial assistance.

Principles for determining the clinical care setting for a resident with COVID-19

Decisions regarding the clinical care setting should be in alignment with the principle of consumer-centred care in the Protocol.

Considerations:
  • Decisions to transfer to hospital will be made on a case-by-case basis and will be based on the clinical assessment and the wishes of the resident and their carers/families
  • Advance Care Plans and Advance Care Directives are in place and help guide the decisions regarding location of care
  • Most cases can be managed within the RACF: efforts should be made to facilitate this wherever possible utilising primary care (GP), LHD/SHN outreach teams and virtual care where available
  • Communication with the resident’s carer/family or person responsible is integral in deciding to transfer the resident, and they should be kept updated of the outcome
  • If transfer to hospital is required, the receiving facility and transport staff (Ambulance or Patient Transport Service) should be informed that the resident is a suspected or confirmed case of COVID-19 via discussion and use of transfer advice form (available from CDNA Guidelines for outbreaks in residential care facilities).

Transfers to hospital from RACF: non-COVID-19 related

RACFs should continue to seek medical advice through their associated GPs.

Except in the case of an acute emergency, the GP or RACF should access specialist telehealth advice (Geriatrician/GP VMO) prior to any transfer to hospital, where available. The objective is to provide clinical care in place where possible. Transfers to hospital should be pre-planned with the LHD/SHN team, considering the resident’s Advance Care Plan/Advance Care Directive. LHD/SHN outreach teams may liaise directly with the receiving Emergency Department and Ambulance/Patient Transport Service to arrange patient transfer if required.

If a major medical event or injury has occurred, Ambulance should be called as usual.

The transfer of residents to hospital (with prior Geriatrician/Specialist/GP VMO approval) will be managed as usual with Ambulance or Patient Transport Service. Lower acuity calls by RACF to Ambulance are subject to a secondary triage process to minimise avoidable transfers and redirect to LHD/SHN services or GPs for clinical care (see Appendix 1: Secondary Triage).

Principle 3: Communication to support COVID-19 strategies

Key point

  • Support admission strategies with accurate, timely and coordinated engagement and communication.

Applying Principle 3: Communication to support COVID-19 strategies

Communication with stakeholders, residents, their carers and families

Actions for local health districts

Advise local RACFs and GPs/primary care team of LHD/SHN services pertaining to the COVID-19 pandemic:

  • Confirm the clinical services available for geriatric and specialised aged care, including pathways and access to outreach services
  • Public Health Unit advice and support for outbreak management and infection prevention and control
  • How to contact LHD/SHN services.
Actions for RACFs
  • Understand the LHD/SHN services available, when and how to access
  • Lead and drive early and ongoing two-way communication with residents, families, staff, primary care team and LHD/SHN services throughout pandemic.
  • Provide technology to enable connection and communication between RACF residents and their carers/families during COVID-19 related visitor restrictions.

Appendices

Appendix 1: Secondary triage model

Appendix 2: Discharge to RACF: information and letter template

Appendix 3: PPE use in Aged Care: COVID-19

Coronavirus (COVID-19) – When to use personal protective equipment in aged care

Document information

Developed by

Aged Care Unit, Ministry of Health.

Consultation

  • Aged Care/Aged Health Communities of Practice, NSW Health
  • Australian Government Department of Health (NSW/ACT)
  • Clinical Excellence Commission.

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

Reviewed by

Aged Care Unit, Public Health Response Branch.

For use by

  • NSW Health hospitals
  • NSW Emergency Departments
  • NSW Ambulance
  • Patient flow managers
  • Local Health District aged care service managers and clinicians
  • Residential aged care facilities including SGRACFs, MPSs and non-Government RACFs.

Current as at: Friday 16 July 2021
Contact page owner: Health Protection NSW