Supporting sustainable long-term residential care in Ireland: a study protocol for the Sustainable Residential Care (SRC) project

Long-term residential care (LTRC) in Ireland

While the definition and systems of long-term residential care (LTRC) differ across countries, it generally refers to long-term care given to people who reside in a residential setting. In Ireland, LTRC forms a central component of the care of older people. In 2019, an estimated 32,000 people lived in LTRC settings, of whom 94% were aged 65 years and older (Walsh et al., 2021). The total expenditure on LTRC in Ireland in 2019 was almost €2 billion, making it one of the largest components of total health and social care spending (Walsh et al., 2021).

Existing LTRC homes differ along several domains including the form of ownership with three main categories – public (Health Service Executive (HSE)), voluntary (private ‘not-for-profit’) and private (‘for-profit’). Public and voluntary institutions were the predominant providers of residential care up to the early 2000s. Since then, the private sector has become the dominant provider, in part driven by tax incentives introduced to encourage an increase in private provision, and in part by the establishment of the Nursing Homes Support Scheme (NHSS, ‘Fair Deal’) which provided increased financial security for the sector. Meanwhile, public providers were affected by fiscal constraints, public employment ceilings and regulatory requirements for upgraded facilities (Mercille, 2018; Wren et al., 2017). In 2020, beds in privately owned care homes constituted 78% of all LTRC beds (HIQA, 2020a). In recent years, a number of international private operators have entered the Irish LTRC market with foreign capital having acquired part, or all, of eight of the largest 15 private operators in the country in recent years (Kehoe, 2021). Under the Health Act (2007), all LTRC homes must register with the Health Information and Quality Authority (HIQA) and comply with the conditions and requirements set by HIQA (Wren et al., 2017). HIQA can inspect homes for registration purposes and to ensure quality standards.

The majority of LTRC in Ireland is privately provided but publicly funded (Walsh et al., 2021). The NHSS, a statutory scheme for LTRC that confers access to residential support for those who require it, was established in 2009. At the end of 2019, approximately 73% of LTRC residents were funded under the NHSS. Those funded through the NHSS are required to make a co-payment for care based on an assessment of income and assets (including the family home) (Wren et al., 2017); the co-payment is up to 80% of assessable income and up to 7.5% (per annum) of the value of any assets above €36,000. Those in receipt of the NHSS can access care in any public, voluntary or private care home that is participating in the NHSS scheme. The average cost of providing an NHSS-funded bed per annum is €61,021, with the State contributing 69% of the costs (Walsh et al., 2021).

COVID-19 and the LTRC sector

The LTRC sector has been significantly impacted by the coronavirus disease 2019 (COVID-19) pandemic. A significant proportion of LTRC settings internationally have reported COVID-19 outbreaks, with high rates of morbidity and mortality and high rates of staff absenteeism (European Centre for Disease Prevention and Control, 2020). In many countries, COVID-19 deaths in LTRC residents accounted for over half of all COVID-19 deaths (Comas-Herrera et al., 2021). Countries such as Australia (75%), Canada (59%), Belgium (57%) and the Netherlands (51%) had particularly high proportions of COVID-19 deaths occurring amongst LTRC home residents (Comas-Herrera et al., 2021). The percentage of people diagnosed with COVID-19 who died from the illness (case fatality rate) in LTRC settings was also found to be much higher than in the community, with case fatality rates of 36% in the UK in 2020 (Dutey-Magni et al., 2021). Research from Canada found that the COVID-19 fatality rate in LTRC residents was 13.1 higher than the rate for community-living adults older than 69 years (Fisman et al., 2020). Ireland also saw very high rates of COVID-19 infections and mortality amongst LTRC home residents. From March 2020 to end of November 2021, 62% of COVID-19 deaths were linked to outbreaks in nursing homes, with 4.1% linked to other community hospital and long stay settings. Due to the older age and high level of morbidity among residents in LTRC settings, the impact of a COVID-19 outbreak can be significant; in addition, the movement of LTRC staff across homes can contribute to the spread of the virus (McMichael et al., 2020).

Factors associated with outbreaks in the LTRC sector

Since the beginning of the pandemic, a number of studies have been undertaken looking at the factors associated with COVID-19 outbreaks in the LTRC sector, with wide-ranging and somewhat conflicting results. In Ireland, limited analyses have taken place on the subject. An analysis of COVID-19 outbreaks in LTRC homes between March and November 2020 found that the probability of an outbreak was positively associated with increasing incidence in the community close to the home and to the number of beds in the home (HIQA & HPSC, 2021). No relationship was found between ownership type (e.g. public, private) and the probability of an COVID-19 outbreak (HIQA & HPSC, 2021). Relative to the first wave of COVID-19 in Ireland (1 March to 1 August 2020), there were fewer outbreaks in LTRC settings in the second wave (2 August to 21 November 2020) and when they did occur, they tended to be smaller in terms of the number of people infected (HIQA & HPSC, 2021).

The factors associated with COVID-19 outbreaks in LTRC differ across countries. In England, for example, Shallcross et al. (2021) found an increased probability of outbreaks in LTRC homes that were for-profit (relative to those that were not-for-profit), in homes where there was frequent employment of agency nurses or carers, and in homes that reported difficulties in isolating patients. A US study found that larger staff size was linked to a higher number of COVID-19 cases in 2020; however, staffing quality measures (including direct care staff-to-resident ratios and skill mix), were not significant predictors of COVID-19 cases or deaths (McGarry et al., 2021). Abrams et al. (2020) examined the characteristics of LTRC homes in the US with COVID-19 cases in the early months of the pandemic and found that larger size, urban location, greater percentage of African American residents, non-chain status, and state were significantly related to the increased probability of having a COVID-19 case. Ownership type was not found to be significantly related (Abrams et al., 2020). A study from Italy examined the relationship between geography, size, design, organizational characteristics, and implementation of infection prevention and control measures and the extent of COVID-19 outbreaks in LTRC homes between March and May 2020 (Cazzoletti et al., 2021). They found that incidence of outbreaks was not significantly associated with any of the variables, except for geographical region.

To date a small number of review studies have been undertaken seeking to collate existing studies which have examined the factors associated with COVID-19 outbreaks in the LTRC sector. For example, a literature review including 18 studies examining the relationship between the ownership status of LTRC homes and their outcomes during the early months of the pandemic noted that the majority of studies found an association between ownership status and effectiveness in response to the pandemic (Kruse et al., 2021). However, this association was attenuated when other factors (including size, staff shortages and regional spread of COVID-19) were included in the analysis. A later systematic literature review examined the associations between LTRC home ownership and COVID-19 outbreaks, infections and mortality and included 32 studies across five countries (Bach-Mortensen et al., 2021). The review found that private (for-profit) homes did not consistently have an elevated risk of COVID-19 outbreaks; however, such homes did tend to have higher rates of infections and deaths. Seeking to explain this finding, the review found that private (for-profit) ownership was associated with shortages of personal protective equipment (PPE) (Bach-Mortensen et al., 2021). The review concluded that the variation in COVID-19 outcomes was not explained by ownership type alone and that other factors related to staffing, size and resident characteristics are also associated with poorer outcomes. The research outlined in this protocol will build upon this international literature to identify those factors most associated with COVID-19 outbreaks and deaths in LTRC in Ireland.

State response to COVID-19 in the LTRC sector

Many observers have argued that there was insufficient priority placed on safeguarding the LTRC sector at the beginning of the pandemic in Ireland (Pierce et al., 2020) and internationally (Comas-Herrera et al., 2020; Grabowski, 2020). An Expert Panel on Nursing Homes was convened in 2020 to examine the LTRC sector’s response to the pandemic. In a report, the Expert Panel highlighted that “at the beginning of the pandemic, efforts were made to ensure that sufficient acute hospital capacity was available, which included discharging patients who were medically fit where possible, including discharges of patients to nursing homes” (Frazer et al., 2020). This prioritisation of acute hospitals was also seen in terms of discharging patients, some of whom had COVID-19 symptoms, into LTRC, and the initial rationing of PPE in the LTRC setting.

The COVID-19 pandemic raised a number of challenges for the LTRC sector in Ireland due to the frailty of LTRC residents, the close contact needed between carers and residents, and the physical layout of many LTRC homes. Consequently it was necessary for the State to take a more proactive role in LTRC settings which included providing PPE, testing, clinical advice, staff and preparation and implementation of COVID-19 action plans (Department of Health, 2020). Privately owned LTRC settings have no formal clinical governance links with the HSE (HIQA, 2020b) and consequently the additional measures required to contain the spread of COVID-19 were difficult to implement in these settings in the early stages of the pandemic (Pierce et al., 2020). It became necessary for the HSE to provide staffing and infection control support for the LTRC sector in response to the pandemic, prompted by an emerging wave of infection. From April 2020 to December 2021, the HSE administered the Temporary Assistance Payment Scheme (TAPS), providing private and voluntary care homes up to €60,000 per month (initially €75,000) for cleaning/infection prevention and control, social distancing and isolation facilities, and recruiting and training staff. TAPS became one of the key elements of the State’s response to the pandemic in LTRC and was the largest injection of funds specifically targeting private LTRC homes to date. In this analysis. we will examine the extent to which TAPS was used, prevented future COVID-19 outbreaks, and could be leveraged in future funding mechanisms within the sector.

Rationale for the study

Both Irish and international research has repeatedly found that most older people prefer to remain in their own home as they age (Abramsson & Andersson, 2016; Fox et al., 2017). However, even with significant home care supports, there are some older people who will require residential care when their care needs can no longer be met in the home or community (HIQA, 2016). Despite measures aimed to facilitate people to remain within their own home, the demand for such care in Ireland is likely to increase significantly in the coming years due to the projected increase in the number of older people (Walsh et al., 2021).

The COVID-19 pandemic brought to the fore deficiencies in the LTRC sector in Ireland and beyond. The Expert Panel on Nursing Homes identified a number of concerns about the sector (Frazer et al., 2020) including a lack of an overarching governance structure within the sector, both within public and private homes. In addition, the Expert Panel’s report noted that there were issues with the current funding model which failed to recognise and compensate for the complex needs of some people within the LTRC setting (Frazer et al., 2020); currently NHSS funding is not linked with frailty, morbidity, or cognitive impairment rates of a home’s residents. Also highlighted was the need to define staff ratios and skill mix and reduce the disconnect between regulation and oversight in the private LTRC sector in Ireland. A number of recommendations to ensure the provision of safe, quality care for Ireland’s ageing population were made by the Expert Panel (Frazer et al., 2020). The research detailed in this protocol seeks to build on the analysis and recommendations from the Expert Panel to ensure a sustainable LTRC sector in Ireland.

Objective 1 - Overview of LTRC in Ireland

Objective 1 will describe and analyse the characteristics of LTRC homes across Ireland and discuss how the sector has evolved in recent years.

Objective 2 - Examination of COVID-19 in LTRC

Objective 2 will examine the association between LTRC home characteristics and COVID-19 outbreaks and deaths. In doing so the analysis will identify if particular types of homes were more or less likely to experience a COVID-19 outbreak and deaths.

Objective 3 - Sustainability of LTRC

This objective seeks to identify current challenges to the LTRC sector and provide recommendations on policies to inform sustainability in the sector.

First, a review of the funding models, regulations and governance structure that currently exist in Ireland will be undertaken. Working with all knowledge users on the project, this will draw upon recent analyses of the sector including the Expert Panel on Nursing Homes Report (Frazer et al., 2020) and the Department of Health’s ‘A value for money review of nursing home care costs’ report (Department of Health, 2021). We will also identify what funding models, regulations, and governance structure are identified as best practice in other jurisdictions that could be used to ensure high quality and safe care for LTRC residents in Ireland.

Second, we will examine the largest investment into LTRC homes undertaken during COVID-19, the Temporary Assistance Payment Scheme (TAPS). This scheme was introduced in April 2020 to aid private LTRC homes. Up to €75,000 per month was initially provided for cleaning/infection prevention and control, social distancing and isolation facilities, and recruiting and training staff. We examine the extent to which TAPS was used and whether TAPS was associated with lower rates of COVID-19 outbreaks and deaths.