East of England

Population Health Research Hub

EoE PHResH

Our launch webinar:COVID-19 in Care Homes –A Regional Response

9th June 2020

Tweet today@eoe_PHResH#eoe_PHResH

AGENDA

COVID-19 in Care Homes: A Regional ResponseTuesday 9th June 2020: 16.00 – 17.00

16.00 – 16.10 Introducing the EoE Population Health Research HubProf Carol Brayne, Director, Cambridge Institute of Public HealthIan Wake, Director of Public Health Thurrock

16.10 – 16.20 Using research evidence to support the delivery of care in response to COVID-19 in Care HomesProf Claire Goodman, Centre for Research in Public Health and Community Care,University of Hertfordshire

16.20 – 16.35 Guidance on COVID-19 in Care Homes Dr Smita Kapadia, Public Health England – East of England

16.35 – 16.45 Sharing Local Learning & Findings:Essex SARS-CoV-2 Care Homes SurveyAnna Starling, Essex County CouncilLocal Authority Responses to COVID-19 in Care Homes in the East of EnglandDr Tara Berger-Gillam, Public Health England – East of England

16.45 – 17.00 Question & Answer Session and What’s Next?

East of England

Population Health Research Hub

EoE PHResH

Introducing the EoE Population Health Research Hub

Prof Carol BrayneDirector, Cambridge Institute of Public Health

Ian WakeDirector of Public Health, Thurrock

East of England Population Health Research Hub

EoE PHResH

Aim: A regional hub of public health practitioners and researchers in the East of England who address regional population health challenges and inequalities through collaborative networking and action

Objectives:1. INFORM: by catalysing research in response to local challenges

and increasing the visibility and accessibility of population health research

2. STIMULATE: action by increasing the utility of population health research within the region through translation and evaluation

3. FACILITATE: dialogue and links with expertise, the transfer of knowledge and evidence, and the development of new research collaborations within the region

PHE East of

England

ADPH East of

England

Servicebased

practitioners

Academia

Our partners include:

COVID-19: Our Hub Actions

COVID-19 Research in the EoE

Research BitesRapid Evidence Reviews

& Syntheses

Hub Newsletter

Coming Up:

Mapping Academic Skills & Capacity for Support

Include, but are not limited to the following:• Immunity after COVID-19: a briefing

• Interventions to mitigate the spread of COVID-19 in the community: a rapid review

• What models have been used to separate the management of patients who would normally be in hospital, with COVID-19 and those without COVID-19, in other countries? An Options Appraisal

• What are the mental health impacts of infectious disease epidemics on relatives and informal carers of affected individuals, and on relatives of health workers? What interventions are available to support them?

• Systematic review of guidelines for the management of intensive care during the COVID-19 pandemic

VISIT OUR WEBSITE: https://adph.org.uk/networks/eastofengland/eoephresh/

Connect with the Hub

Visit our Website: Email Us:

Dr Angelique Mavrodarisangelique.mavrodaris@phe.gov.uk

Caitlin Grantcaitlin.grant@phe.gov.uk

Follow Us:@eoe_PHResH

Subscribe to our Newsletter:

https://adph.org.uk/networks/eastofengland/eoephresh/

https://adph.org.uk/networks/eastofengland/newsletter-

signup/

East of England

Population Health Research Hub

EoE PHResH

Using research evidence to support the delivery of care in response to COVID-19 in Care Homes

Prof Claire GoodmanCentre for Research in Public Health and Community Care, University of Hertfordshire

Using research evidence to support the delivery of

care in response to COVID-19 in Care Homes

Claire Goodman

Centre for Research in Public health and Community Care UH

Lead Ageing and Multimorbidity theme NIHR ARC East of England

Background

Prof Mary DalyCOVID-19 and care homes in the UKhttps://www.gtc.ox.ac.uk/news-and-events/news/covid-19-and-care-homes-in-the-uk/

PLANNING• March 3rd NHS action plan• April 15th Action plan for adult social care• May 15th Care home specific plan TESTING• Late March testing for NHS• May 11th portal for care homes testingDEATHS• March 5th First death reported• April 20th Care home deaths included in statisticsPPE• May 15th Specific guidance for care homes and new

route to access supplies for care homes

Care homes hiding in plain sight….

https://ltccovid.org/2020/05/14/the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/

• COVID-19 exposed gap in data intelligence and prioritisation of needs

• Need for linked routine health and social care data with information from care homes, available in real time.

• During pandemic lacking data = difference between a rapid, effective response and high infection and death rate.

• Post COVID -19 collated, accessible data on residents’ health and service use could support planning & care tailored to residents’ needs,

• DACHA Study design, develop and implement a minimum dataset for UK care homes, report 2024.

• A MDS as a resource, not just regulation or cost containment..

• Making care homes part of a data system a priority post-COVID

History

• Care home staff initiated WhatsApp group

• Not sustainable membership> 256 participants

• Sector driven questions triggering research based resources for care specific issues

Example earlyquestions:

Apart from Personal Protective Equipment …….

- Isolating people who walk with purpose? How can it be done?

- When is restraint ethically defensible and what type?

- People coming in and out of hospital/community. Who is high risk for introducing COVID? Who is not?

- Anticipating decline and getting meds organised in time.

- Managing stressed and potentially grieving relatives remotely

- When is it okay to hug a resident?

From rapid review to heuristics

Alternatives to physical comfort

When residents don’t understand social distancing

Uncertainty around residents’ care

Dealing with multiple deaths

Supporting families at a distance

Hydration

Questions sharedRapid review of

research evidence & CH studies

First drafts & internal review

Reading level

Frontline staff Feedback on what

works

Presentation for multiple formats

(app, hard copy) & track use

Top Tips for Tricky Times: Supporting staff following multiple deaths in care home

environments

1. It is okay to grieve. Sometimes grief felt by staff is as real as the grief of residents’ family.

2. Time to talk about feelings and emotions is important for staff. Managers can support staff to do this in

one to one meeting.

3. Other ideas include a time of reflection, sharing stories and memories with each other.

4. Note what you did well in caring for the resident. That might be especially important when family can’t

be present.

5. Some staff may be new to experiences of death – they might need more support.

6. Could staff use a bereavement support line? Or make links with local hospices; staff could benefit from

the expertise they offer.

7. Rituals that involve gatherings won’t be immediately possible. Plan a Memorial Day to remember the

residents who have passed away in the past 12 months.

8. The effects of grief can accumulate rather than lessen with each death. Experiencing many deaths in a

short space of time can be overwhelming and lead to prolonged grief. It might feel unreal.

9. Staff can experience ‘compassion fatigue’. It shows as emotional and physical exhaustion. It can

impact on being able to care for residents and on relationships with colleagues. The above tips can help

manage this.

Author: Kathryn Almack

28th May 2020

Top Tips for Tricky Times

Work supported by NIHR ARC East of England, NIHR ARC Kent, Surrey and Sussex. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Top Tips for Tricky Times:

Providing physical comfort and reassurance to care home residents during COVID-19

1. How doll therapy can help: Dolls can have positive effects, improve a resident’s mood and calm

them.

2. Personal: Each resident should have their own doll to keep in their room.

3. Life-like: Soft texture and open eyes.

4. Ownership: Do not take dolls away but be aware if a resident becomes tired from looking after a

doll.

5. Person-Centred: Dolls may not be suitable or wanted by all residents. Dolls should be left out for

residents to choose.

6. Contamination: to reduce cross-contamination and confusion, important staff know which doll

belongs to which resident.

7. Attachment Residents may like them one day but not the next.

8. Concerns: Staff and relatives may worry residents are being treated like children. Reassure them

that dolls can be a source of comfort.Top Tips for Tricky Times

Elspeth Mathie and Frances Bunn 27.05.2020

Work supported by NIHR ARC East of England, NIHR ARC Kent Surrey and Sussex NIHR. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Very specific

Harwood RH, O’Brien R, Goldberg SE, Allwood R, Pilnick A, Beeke S, Thomson L, Murray M, Parry R, Kearney F, Baxendale B. A staff training intervention to improve communication between people living with dementia and health-care professionals in hospital: the VOICE mixed-methods development and evaluation study. Health Services and Delivery Research. 2018;6(41).

NB Not for reproduction final versions not yet available

Summary

Collaborative: changing research focus from what ‘ought to be done to ‘how it can best be done’ with care homes

Work in progress: 8 top tips reviewed by frontline staff with changes, now with designer

“Live” documents

Not a substitute for other sources of guidance

Found little care home specific “implementation ready” research evidence.

Helping pressurised staff organise their thinking might also :

Reassure staff they are not missing something

Be a resource for staff to use with inexperienced and junior staff

Top Tips for Tricky Times University of Hertfordshire Claire Goodman, Kathryn Almack, Frances Bunn, Angela Dickinson, Melanie Handley, Elspeth Mathie, Andrea Mayrhofer, University of East Anglia Tamara Backhouse, Diane Bunn, Anne Killett, University of Kent Ann-Marie TowersClaire Goodman, Elspeth Mathie, receive support from the National Institute for Health Research (NIHR) Applied Research Collaboration East of England (EoE). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Care Home Care WhatsApp and Covid-19 Care platform foundersWren Hall Anita Astle, Royal Derby Hospital Professor Adam Gordon, Nottingham & Nottinghamshire CCG David Ainsworth, PerCurra at Home Gill Heppell, Landermeads Care Home Ros Heath, Sears Healthcare Dr Richard Adams, The Manor Residential Home Hitesh Chavda, NHS Mansfield & Ashfield CCG and NHS Newark & Sherwood CCG Donna Nussey, My Home Life and National Care Forum Professor Julienne Meyer

DACHA is funded by the National Institute for Health Research (NIHR) Health Service Research and Delivery programme (HS&DR NIHR127234) and supported by the NIHR Applied Research Collaboration (ARC) East of England. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.DACHA is a collaboration between the Universities of Hertfordshire, Cambridge, East Anglia, Newcastle, Leeds, Nottingham, Kent, Exeter, The Health Foundation, NIHR ARC East of England & National Care Forum

Thank you!

c.goodman@herts.ac.uk

@HDEMCOP @DACHA_Study

East of England

Population Health Research Hub

EoE PHResH

Guidance on COVID-19 in Care Homes

Dr Smita KapadiaPublic Health England – East of England

Public Health management of COVID-19

in care homes for the elderly

A collaborative effort!

Dr Smita Kapadia

PHE EOE Health Protection Team

09 June 2020

For PHResH

Overview

Controlling outbreaks

• Reflections on our journey in the East of England

Guidance

• General principles of management

• Key interventions

Contact Tracing (T&T)

Road to recovery….

Priority settings

Vulnerable residentsHigh incidence of

transmission & deaths

Complex health care landscape

Availability of testing & PPE!

IPC skills & workforce

Latest numbers by UTLA

Controlling outbreaks: reflections from the EoE

• Care Homes Group

HPT & LA

• Joint SOP on outbreaks

Care Home cells (LA & CCGs)

• Ongoing management & follow up

Two-way communication

COVID-19 care home outbreaks reported to PHE

20th April 2020

Key guidance documents

Regional:

• PHE East of England HPT Care Homes SOP V4

• CRC local guidance documents

National:

o COVID-19: how to work safety in care homes (PPE focus):

https://www.gov.uk/government/publications/covid-19-how-to-

work-safely-in-care-homes

o COVID-19: adult social care action plan:

https://www.gov.uk/government/publications/coronavirus-covid-19-adult-

social-care-action-plan

Case definition: community settings

Community case definition

• New continuous cough

or

• High temperature

or

• A loss of, or change in, normal sense of taste or smell (anosmia)

*Atypical presentations in elderly residents*

What constitutes an ‘outbreak’?

• “A care home reporting one case or death in a resident or staff

with respiratory symptoms, or fever will be entered as COVID-19

Situation, regardless of laboratory confirmation.”

• HPT is alerted to outbreaks by various sources:

o Care home staff or management

o GPs and Practice Nurses

o Local authorities

o CCGs and community IPC teams

o Cluster detection, e.g. via FES & NEW* post code cluster alerts!

Outbreak management

- Notification to PHE

- Initial risk assessment & Infection Control advice

- Advice on interpreting guidance (there are so many!)

- Swabbing! (symptomatic & asymptomatic)

- Safe handover to LA cells for follow–up management

HPT RiskAssessment

Care Home Inform PHE Health Protection Team

(HPT)

Care Home Update Capacity Tracker

HPT Contact LA hub to Arrange Testing of all

symptomatic residentsand handover follow-up to local cell as per

joint SOP [ref]

CCG/LA Hub to Initiate Whole Home Testing

Via DHSC Portal or locally agreed

arrangements (refer to DHSC letter and SOP)

Suspected Outbreak 1 or More Residents or Staff

Whole Home Testing RequestedNo Symptomatic Residents

DHSC National Portal/ Local process

Care Home Residents and

Staff Swabbed

Symptomatic and Whole Home Swabs

Local Laboratory

Pillar 2 Laboratory

Results to HPT

Results to Local Swabbing

Service

As per National Process

Care Home to Advise Resident /GP/CCG

IPC

Advise Care Home of Results

Care Home Swabbing Process East of England 12-5-20 v4.2

Symptomatic Care Home Residents Swabbed

https://www.gov.uk/guidance/coronavirus-covid-19-getting-tested

PPE advice on a page!

Clinical

Gloves

Plastic

Aprons

Fluid

Resistant

Mask

Eye

protection

Period of use Single use Session of care

Direct contact with

resident ✔ ✔ ✔Assess

risk

Resident coughing

(within 2m) ✔ ✔ ✔Assess

risk

No direct resident

contact ✗ ✗ ✔ ✗

Communal areas✗ ✗ ✔ ✗

Summary : Complex situations / settings…..

- Schools, Care homes, homeless hostels, work places – offices, food

production/packing/other industry/essential infrastructure, Hospitals

PHE’s role:

- Undertake individual risk assessments, work with LA, NHS & other colleagues

- Make judgement calls! (yes that’s why we are here!)

- IMTs only where absolutely essential

- Make appropriate use of local and national SOPs

- Keep updated (constantly!!!)

Road to recovery?....☺

- Integrating contact tracing into the existing suite of Public Health actions

- Raising awareness on guidance for employers on staff-isolation, as part of test & trace

- Care Home support plan by Local Authorities

- Investing in workforce & digital innovation

COVID-19 care home data outputs

Frequency Disseminated to

Table showing number of care homes

reporting a suspected or confirmed

outbreak to PHE (East of England)

Daily

PHE

NHS E/I

DsPH

LA Heads of Public Health

LA Consultants in Public Health

LA/CCG Care Home cells

Line list of named care homes reporting

a suspected or confirmed outbreak

(East of England)

Daily

PHE

NHS E/I

DsPH

LA Heads of Public Health

LA Consultants in Public Health

Graph showing suspected or confirmed

outbreaks by day and principal context

Table showing new and total care home

outbreaks by upper tier local authority

(East of England)

Daily

East of England Dashboard

Access provided to PHE staff and

external stakeholders (e.g. LAs)

Weekly number and percentage of care

homes reporting an outbreak (LA,

regions and PHE Centres)

Weekly

https://www.gov.uk/government/statist

ical-data-sets/covid-19-number-of-

outbreaks-in-care-homes-

management-information

New Guidance

Letter issued 5 June – Guidance on Aftercare needs for Covid19 patients

https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0388-after-care-needs-of-

inpatients-recovering-from-covid-19-5-june-2020.pdf

Letter issued by DHSC 5 June – Extension of eligibility to access whole care home testing from 07 June

2020

050620 Factsheet -Care Home Testing Expansion.pdf

2020-06-05_Extension of eligibility for whole care home testing.pdf

Acknowledgements

• Members of the Care Homes Support Group

• Lynsey Emmett (Sr Scientist, Field Epidemiology Services, East of England)

• LA & NHS colleagues for their input & support in managing outbreaks

East of England

Population Health Research Hub

EoE PHResH

Sharing Local Learning and Findings:

Essex SARS-CoV-2 Care Homes Survey

Anna Starling Essex County Council

Anna Starling and Dr Eleanor White

Essex Care Home Testing Pilot

• April - 22% of care homes in England reporting an outbreak.

• London study found 40% residents positive, 43% of whom reported as asymptomatic.

• Whole care home testing pilot to better understand situation in Essex.

Essex Care Home Testing Pilot-Background

• 15 of 290 care homes in Essex were recruited during week commencing 26 April 2020.

• Residents were eligible for swabbing regardless of symptoms, care home staff were

eligible if they considered themselves fit for work.

• Swabbing - 1st and 14th May 2020 by a locally commissioned service.

• Care home manager interviews

Essex Care Home Testing Pilot-Methods

Essex Care Home Testing Pilot-Results

Staff:

Total staff: 632

Total swabbed: 471

(74.5%)

Residents:

Total residents: 462

Total swabbed: 443

(95.9%)

Results:

Positive: 8 (1.7%)

Void: 4 (0.8%)

Asymptomatic

positive: 8

(100%)

Symptomatic

postitive: 0

(0%)

Results:

Positive: 23 (5.2%)

Void: 6 (1.4%)

Symptomatic

postitive: 2

(8.7%)

Asymptomatic

postitive: 21

(91.3%)

Total swabs

performed: 914

• None of the residents who were asymptomatically-positive developed symptoms in the 14

days following swabbing, as reported by care home managers.

• The staff members who had positive swab results were re-swabbed between days 9-11,

the repeat swabs were all negative.

• Staff member data is pending.

Essex Care Home Testing Pilot-Results continued

• Symptoms are insensitive method of detecting Covid-19 in care homes.

• The infectivity of those who are asymptomatically positive remains unknown.

• There is a continued need for use of PPE for personal care.

What does this mean for future testing in care homes?

Essex Care Home Testing Pilot-Discussion

East of England

Population Health Research Hub

EoE PHResH

Local Authority Responses to COVID-19 in Care Homes in the East of England

Dr Tara Berger-GillamPublic Health England – East of England

Methods

• Registrars recruited from EoE local authorities using regional registrar networks.

• Additional input sought via direct email from local authorities with no registrar presence.

• Conversations took place via Skype between 5th and 26th May 2020.

• Data recorded using modified Donabedian framework.

• Data recorded in a table and sent to respondents for validation and permission to share.

Responses from 6 local authoritiesKey findings:

• Aims. Setting up structures and ongoing management of care homes. Some LAs reported a focus on proactive identification and prevention of outbreaks.

• Structures. LAs are generally operating a care homes outbreak cell, but vary in who leads. Often collaborative between ASC, PH and CCGs. In some areas lead by PH, in others, PH attend in an advisory capacity. Some are firmly established, while others are still setting up structures.

• Processes. LAs are in regular telephone contact with homes. Most are using RAG rating. All have established regular communications with homes.

• Outputs. One LA reports commissioning an additional 400 community beds within 5 days, and establishing a provider hub within 2 days. Key activities for LAs are: coordinating access to PPE and testing; providing or interpreting guidance for homes.

Results

Challenges:• Working between agencies, including

understanding different structures and managing data-sharing

• Lack of clarity surrounding testing availability and processes. Lengthy turnaround time

• Interpretation of guidance

• Availability of data from PHE

• Limited IPC capacity

Challenges & Opportunities

Opportunities:• Cross-agency working accelerated

• Development of clear data flows

• Learning from other agencies

• Building on good pre-existing relationships with homes

• Shift in focus to prevention

East of England

Population Health Research Hub

EoE PHResH

Question and Answer Session

Please write your questions in the Q&A section of the Webinar

East of England

Population Health Research Hub

EoE PHResH

Next Steps

Tweet today@eoe_PHResH#eoe_PHResH