Considerations for Resuming Visiting for Older Adults in ... · Visiting Restrictions & Older Adults in Hospitals and Congregate Settings 3 guest. Google shows the definition of visitor

Considerations for

Resuming Visiting for Older Adults

in Hospital and Congregate Settings

amid COVID-19

FINAL

June 12, 2020

Special thanks to the following for sharing their documents and ideas:

The Hospital for Sick Children

North East Specialized Geriatric Centre / Health Sciences North

Visiting Restrictions & Older Adults in Hospitals and Congregate Settings 1

INTRODUCTION

In May 2020, the NSM SGS program released a discussion paper entitled “The Need for a Multi-

Dimensional Strategy to Address the Care of Older Adults & Their Caregivers in COVID-19”.

Within that paper, a strategy is proposed to better support the breadth of needs of older adults

and their caregivers during COVID-19. The strategy is based on four dimensions:

Dimension 1 – COVID-19: The Disease

Dimension 2 – Urgent Non-COVID Issues

Dimension 3 – Impact of COVID-19 Restrictions

Dimension 4 – Broader Impact of COVID-19

Dimension 3 includes a focus on the impact of social isolation in older adults, including

recommendations regarding the lifting of visiting restrictions for older adults in hospital and

congregate settings. COVID-19 visiting restrictions were implemented in these settings in mid-

March and have had a significant impact on the health and well-being of older adults and their

caregivers. On June 11 2020, the government updated Directive #3 and released guidelines to

begin re-opening RHs and to resume visiting in LTCHs and other congregate settings.

With much research already underway on this topic prior to the provincial announcements on

June 11, the NSM SGS program thought it would be helpful to share the information with local

health service providers to support planning and discussion around policies and practices

related to older adults.

CONSIDERING THE ENVIRONMENT

Recent news and social media has been focused on the COVID-19 imposed visiting restrictions

across hospitals and congregate settings. It is with great relief and excitement that we see new

Ministry direction emerging!

The Importance of Restrictions

One of the fundamental considerations in the delivery of health care is safety. This is especially

true today. Health care providers continue to be focused on the most immediate concern of

COVID-19 – protecting individuals by reducing the spread.

Reducing spread is especially critical in older adults. Global, national and provincial reports

have highlighted the impact of COVID-19 on older adults. The impact has been greatest in

congregate settings like LTCH and RH settings. In an examination of international trends 1, it was

found that across 13 countries, the overall share of COVID-19 deaths that could be attributed to

care home residents ranged from a low of 19% in Hungary to a high of 62% in Canada. Key

1 Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N and Fernández J-L (2020) Mortality associated with

COVID-19 outbreaks in care homes: early international evidence. Article in LTCcovid.org, International

Long-Term Care Policy Network, CPEC-LSE, 3 May 2020. https://ltccovid.org/wp-

content/uploads/2020/05/Mortality-associated-with-COVID-3-May-final-1.pdf

https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-3-May-final-1.pdf

https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-3-May-final-1.pdf


findings from a June 4 2020 national LTCH report 2 show:

An estimated case fatality rate of 36% (range 20 to 42%) among residents in Canadian

long-term care homes.

Deaths in long-term care residents currently represent up to 85% of all COVID-19 deaths

in Canada.

Visiting restrictions reduce the risk to older adults by limiting contact with potential symptomatic

and asymptomatic individuals from the community. In so doing, the restrictions reduce

morbidity, mortality and associated costs to the health care system. At June 7 2020, the

National Institute on Aging LTC COVID-19 Tracker 3 reported 416 affect homes, 9,430 COVID-19

positive cases and 1,932 deaths in Ontario. These volumes are overwhelming. The number of

COVID-19 related cases and deaths would likely have been much worse if facilities across the

province had not implemented strict visiting restrictions in mid-March.

Implications:

It will be integral to continue to protect older adults in hospital and congregate

settings through thoughtful and strategic visiting policies. Finding the right balance

for ‘safety’ will be critical – protection from the disease vs the impact on the health

and well-being of the older adult. This balance will become more difficult to find in

the coming weeks with the concurrent direction to open LTCHs and RHs to

admissions.

A Commentary on “Visitors”

Before we go too far in this document, there is a need to address the value of visitors. Visitors are

incredibly important to the health and well-being of older adults in hospitals and congregate

settings. In addition to supporting their physical, mental and emotional health, “visitors” are their

voices, their advocates and their essential partners in care.

To promote safety during COVID-19 a blanket approach to visiting restrictions was implemented,

limiting visitors to exceptional circumstances. There are several important pieces to consider in

this. First, because of restrictions, the vast majority of older adults have been alone, separated

from family and friends. While Ministry direction did allow visiting in exceptional circumstances

many organizations restricted all visitors.

Second, in implementing a blanket approach, the health system treated all visitors the same.

While all visitors to hospitals or congregate settings may be “outsiders” to the operations of the

organization, one could argue that not all are visitors by definition. According to Meriam-

Webster, a visitor is one who visits. The word is synonymous with caller, drop-in, frequenter and

2 Amy T. Hsu, Natasha Lane, Samir K. Sinha, Julie Dunning, Misha Dhuper, Zaina Kahiel, Heidi Sveistrup.

Report: Understanding the impact of COVID-19 on residents of Canada’s long-term care homes – ongoing

challenges and policy responses. p.2. International LTC Policy Network (June 4 2020).

https://ltccovid.org/wp-content/uploads/2020/06/LTCcovid-country-reports_Canada_June-4-2020-1.pdf

Accessed 7 Jun. 2020. 3 NIA Long-Term Care COVID-19 Tracker. https://ltc-covid19-tracker.ca/ Accessed 7 Jun. 2020

https://ltccovid.org/wp-content/uploads/2020/06/LTCcovid-country-reports_Canada_June-4-2020-1.pdf

https://ltc-covid19-tracker.ca/


guest. Google shows the definition of visitor as being “a person visiting a person or place,

especially socially or as a tourist”. While many of the visitors within hospitals and congregate

settings may be ‘callers’ or ‘social drop-ins’, most are close family and friends who are important

to an older adult’s sense of meaning and purpose. Still others are essential caregivers. The role

they play in delivering care may be equal in importance to that provided by formal health

service providers. In many cases, it may be more important. We, in truth, shut the door to not

just visitors, but to important care partners and essential caregivers.

Third, in pediatrics the physical presence of parents and guardians is an expectation. Many

would argue there should be a similar expectation in the case of older adults and their

caregivers, especially when the abilities of older adults are impaired and they rely of their

caregivers for support.

Finally, in higher risk settings like hospitals and congregate settings, movement has been limited

in and out of the building for months for both visitors and older adults. The only movement in/out

has been staff and essential workers. As such, new initial cases in these settings since April

started with community-transmission (someone bringing it in). Visitors are at equal risk to

acquiring COVID-19 in the community as staff and essential workers. Precautions have been put

in place (i.e. screening, PPE, testing, etc.) to reduce the risk of community-transmission.

Implications:

Exceptional circumstances will continue. Organizations need to consider how to

incorporate this into policy to ensure all older adults have access to, at minimum

essential caregivers, at all times.

Policy and practices need to once again enable the important role of caregivers.

It would be important to build in and recognize the various types of visitors (essential

caregivers, important care partners, visitors) and align roles, expectations and

restrictions accordingly.

Expectations and limitations placed around parents and guardians in pediatric

environments should be comparable to expectations and limitations for older adults

and their essential caregivers, especially when the abilities of the older adult is

impaired and they rely on that caregiver for support.

The precautions and training established to reduce the risk of community transmission

from staff/essential workers to older adults could be applied to essential caregivers.

Appreciating the Impact of 3 months of Restrictions

The Experience of the Older Adult

As per the Regional Geriatric Program of Toronto’s Senior Friendly 7 toolkit, social engagement is

defined as an “involvement in meaningful activities with others and maintaining close, fulfilling


relationships”4. Social isolation and loneliness, which can occur when social engagement is

compromised, can affect 5:

Physical health contributing to problems like early mortality, strokes, elevated blood

pressure and malnutrition

Mental health, leading to issues like depression, anxiety and increased risk of substance

misuse and suicide; and,

Functional status, with impact including functional decline as well as physical and/or

cognitive deterioration.

In a recent publication, people with dementia in care homes in the UK and Wales are ‘switching

off’ amid reduced medical care and family visits 6. England and Wales have seen an 83% and

54% increase respectively in deaths from dementia and Alzheimer’s Disease. Local leaders link

the increase to several causes including, “isolation, the reduction in essential care as family

carers cannot visit, and the onset of depression as people with dementia do not understand

why loved ones are no longer visiting, causing them to lose skills and independence, such as the

ability to speak or even stopping eating and drinking”. In a survey of 128 care homes by that

region’s Alzheimer’s Society, they found 79% reported the lack of social contact was negatively

impacting the health and well-being of residents with dementia with families reporting their

loved ones were feeling confused and abandoned. 79% is a shocking statistic, not because it is

so high but because it is seemingly low – begging the question whether health care providers

are appreciating the relationship between social contact and health and well-being.

Implications:

The loss of both usual routine/activities and usual caregivers (staff and families)

coupled with a reduction in the availability of staff (due to staff shortages, additional

time required for PPE) AND up to three months of social isolation has taken its toll on

many older adults. For family and friends, any deterioration will be upsetting and

maybe surprising, especially for those that have had limited virtual contact. Early

visits will likely be an emotional time for all.

The Experience of Family and Friends, including Essential Caregivers

“The familiar faces of family and friends are gone, and carers are behind masks and

can’t touch or comfort the residents,” he said. “Yvonne has lost her sparkle, she’s in a

world she doesn’t understand. The staff at the care home are doing an amazing job

looking after the residents, but we’ve only got video calls to keep in touch, and Yvonne

4 RGP Toronto Senior Friendly 7 Toolkit, p.79 https://www.rgptoronto.ca/wp-content/uploads/2018/04/SF7-

Toolkit.pdf. Accessed 6 Jun. 2020. 5 RGP Toronto Senior Friendly 7 Toolkit. https://www.rgptoronto.ca/wp-content/uploads/2018/04/SF7-

Toolkit.pdf. Accessed 6 Jun. 2020. 6 Extra 10,000 dementia deaths in England and Wales in April. The Guardian, Published June 5, 2020.

https://www.theguardian.com/world/2020/jun/05/covid-19-causing-10000-dementia-deaths-beyond-

infections-research-says Accessed 6 Jun. 2020.

https://www.rgptoronto.ca/wp-content/uploads/2018/04/SF7-Toolkit.pdf




https://www.theguardian.com/world/2020/jun/05/covid-19-causing-10000-dementia-deaths-beyond-infections-research-says



doesn’t always understand them. If lockdown continues, I’m really fearful my wife won’t

be able to recognise me at the end of all this.” 7

Older adults rely on social engagement with their family and friends and vice versa. It is

important to shared meaning and sense of purpose. The news and social media have been

filled with stories of families desperate to visit loved ones in hospitals and congregate settings.

Standing at windows hoping to see each other. Connecting via technology. While many have

appreciated any opportunity for contact, they will all tell you it has not been enough.

Within the NSM region, our team and partners noted increased stress among caregivers who

were anxious to visit their loved ones in person. Caregivers experienced anxiety, guilt, worry and

fear. With the passing of time, frustration and anger became increasingly evident. For many,

fears were exacerbated by the military report, which raised concern about the quality of care in

five Ontario LTCH settings. While this report heightened awareness, it also became seen

mistakenly by many as a reflection of the situation present in all homes across the province.

Implications:

While most family and friends will just be happy to return, some will come back into

facilities fearful, cautious, observant (especially given the military report) and maybe

even angry. Staff should be prepared to deal with this variety of feelings and

emotions.

We need to think about how to welcome family and friends back, how to re-engage

visitors safely, how to allow essential caregivers to resume their roles and how to re-

build any relationships that may have been damaged through the imposed

restrictions.

The Impact on the Health Care System

Family and friends are critical partners. In some congregate settings, essential caregivers are

considered extended family of the setting. In hospitals and congregate settings, these

individuals attend to the needs of the older adult and contribute to their health and well-bring:

Improved function and cognitive status by promoting activity, supporting mobilization,

providing relevant cognitive stimulation.

Improved nutrition and hydration status by encouraging fluids, bringing food from home

and supporting feeding in those that may require assistance.

Early identification of changes in medical status by noticing subtle changes in baseline

abilities.

Reduced loneliness, anxiety and depression through social engagement.

Through this support, they help reduce unnecessary ED visits as well as hospital and LTC

admissions.

7 Extra 10,000 dementia deaths in England and Wales in April. The Guardian, Published June 5, 2020.

https://www.theguardian.com/world/2020/jun/05/covid-19-causing-10000-dementia-deaths-beyond-

infections-research-says Accessed 6 Jun. 2020.




The loss of visitors in hospital and congregate settings has likely affected the health and well-

being of some staff due to the loss of relationships and daily support. Some staff are new to the

settings and may not be familiar to/with the families and friends of the older adults. Amid

COVID-19, less availability of staff coupled with limited visitors means staff may, at times, have

made difficult decisions to prioritize care needs, sometimes delaying usual care in favour of

other clinical priorities. Those in LTCHs have felt the weight of the military report and the

associated public response. Many feel ‘beat up’ and undervalued despite their efforts to

provide the best care possible within the current circumstances. Staff may also be tired

because of staffing shortages, the loss of support from visitors, additional IPAC requirements and

general system stress from COVID-19. Finally, visitors are being re-introduced to an environment

that has changed with new policies and practices in place. Together, these will all affect the

quality of interaction between staff and visitors

Implications:

The mental and emotional health of staff has been impacted by COVID-19. As we

transition them from their most current norm to yet another new norm that includes

the re-introduction of visitors, consideration should be given to assessing, monitoring

and supporting their mental and emotional health and well-being.

Staff will need to be prepared for visitor re-introduction. This will include the need for

clear communication around policies and practices.

CONSIDERING MINISTRY DIRECTION & THE WORK OF OTHERS

Appendix A highlights some of the key ideas regarding visitors within provincial directives,

guidance documents and communication (at June 12, 2020). Appendix B provides a summary

of approaches to visitors from other jurisdictions and sectors. Together these offer lessons to

guide planning and next steps.

Common Themes

Provincial documents and approaches from other jurisdictions and sectors share many common

themes that can be used to guide visitor policy and practices:

Evidence of phasing, with initial phases starting with outdoor visits.

Reference to essential visitors or caregivers.

A requirement for adherence to (and education regarding) IPAC protocols, inclusive of

hand hygiene, physical distancing and PPE.

Regular screening and the passing of screens to gain entry.

The importance of developing policy to support practices.

Maintaining visitor logs to support contact tracing.

Many of these are addressed within the most recent provincial documents.

Implications:

These common themes provide a good foundation to support the development of

policies and practices for visitors of older adults in hospitals and congregate settings.


Opportunities

In reviewing all documents, including the most recent provincial ones, there are some interesting

observations and ideas that may help inform the development of policies and practices:

The concept of a visit does not take into account the breadth of a relationship between

the older adult and his/her family and friends.

o Contact for 30min in an outdoor setting with a requirement to maintain physical

distance is reflective of a social drop-in. While it will be sufficient for some, most

will struggle to be limited to this type of interaction.

o Directive #3 defines essential visitors as including a person performing essential

support services (e.g., food delivery, inspector, maintenance, or health care

services (e.g., phlebotomy)) or a person visiting a very ill or palliative resident. In

the directive, essential visitors are the only type of visitors allowed when a resident

is self-isolating or symptomatic or when a home is in outbreak. The Resumption of

Visitors in LTCHs document uses the term essential family caregiver and defines

that as people capable of providing caregiving support (feeding, social support,

etc.) and who had done this in the home prior to COVID-19. This document does

not reference essential visitors. What is clear is that if a home enters outbreak, all

non-essential visits cease, which would include those by essential family

caregivers. As such, we continue to hold the door shut to even the older adult’s

most important people.

o Providing clarity in terms and roles would be helpful. As noted in the bullet above,

the Resumption of Visiting in LTCH document uses the term essential family

caregivers as part of priority in-home visiting in phase 2. There would be benefit

to: further categorize this broad group; limit the volumes/designate individuals to

better control flow and support training/education; and align roles, expectations

and restrictions with outbreak phases. Of note, one organization required picture

identification from designated essential caregivers as they noted cards/badges

were being passed between family and friends.

While the documents take a phased approach to resumption of visiting, the focus of

phasing is tied to the outbreak status of the setting:

o While there is an assumption the reference is to COVID-19, there may be other

types of outbreaks that occur and clarification within policy may be important.

o A standard provincial date for the resumption of visiting is set for June 18th. While

direction considers the status of the home, it does not consider the status of the

community of the phase of regional re-opening. There may be merit to engage

the ministry in conversation around a phased approach that considers these

conditions to enhance safety. If this is coupled with a categorization of visitor

types/associated roles there could be an earlier and safer return of essential

caregivers (vs all visitors) in regions where community spread remains a concern.

In alignment with government directions, there should be information provided around

IPAC protocols, including hand hygiene, physical distancing and PPE. Consideration

could be given to mandatory orientation and ongoing training for essential caregivers as

well as return demonstrations to ensure appropriate practice. Some jurisdictions have


developed FAQ documents, used visual signage (i.e. posters) as reminders, and

implemented signed agreements with essential caregivers that clarify roles, expectations

and outcomes should roles and expectations not be met.

Directive #3 indicates that LTCH policy must clearly state that if the home is not able to

provide surgical/procedure masks, no family visitors should be permitted inside the home.

The Resumption of Visitors in LTCHs document states that visitors are responsible for

bringing their own face coverings and that LTCH are to provide surgical/procedure

masks and masks to outdoor visitors without one.

o To optimize support for outdoor visits, the LTCHs should consider securing and

appropriately laundering cloth face masks to support, at minimum, outdoor visits

should surgical/procedure masks be in limited supply.

o While it is important to protect PPE, it may be important to develop a strategy

that does find a way to make available surgical/procedure masks to support

visitors within the home.

Implications:

There are numerous lessons that can be learned from other jurisdictions and sectors

that could help inform the development of policies and practices for visitors of older

adults in hospitals and congregate settings.

SUMMARY OF RECOMMENDATIONS FOR CONSIDERATION

The following are recommended for consideration and discussion in the development of visiting

policies and practices as they pertain to older adults in congregate settings:

Collaborating to Achieve ‘Right Care, Right Time, Right Place’

Organizations must determine the right balance for their individual organization. They must

consider whether they can achieve ‘right care right time, right place’ in regard to:

Their level of risk readiness;

The organization’s ability to support visitors (i.e. sufficient space to support physical

distancing, access to PPE, ability to support additional screening and tracking/logging of

visitors, etc.); and,

The local level of COVID-19 risk and defined phase of community re-opening.

Ideally, a coordinated and consistent approach to regional and/or sector plans, processes and

practices should be considered to help support communication and clarity. All plans should be

developed and implemented in collaboration with local health units and in alignment with

Ministry direction and guidance.

Building a Supportive Environment

Preparing & Welcoming Family & Friends

Family and friends will be anxious to visit their loved ones. Most will have had some virtual

contact but some will have had none. Rebuilding relationships with visitors, including

essential caregivers will be important. The goal should be to create a good first encounter,


without overwhelming either visitors or the older adult. In addition to provincial guidelines

(i.e. min 30min visits, one visit/wk./resident, masks and physical distancing, etc.), the following

is offered for consideration:

o Have knowledgeable staff dedicated to outdoor visiting areas to answer any

questions that may arise (i.e. health of the older adult, changes to visiting policy and

practices, etc.) and to provide oversight to the interactions (in case reminders

regarding safety best practices are required). It will also be important for these staff

to monitor and address signs of overstimulation or fatigue in the older adult.

o Develop FAQ questions and use visible signage (as appropriate) to address safety

best practices and changes to visiting policy and practices.

o In advance of initial visits, send communication regarding the process, the

experience (i.e. what will they see, etc.) and expectations during the visit (i.e.

screening, can they bring food or gifts, etc.). It may also be important to consider

including general commentary on the fact that the abilities of the older adult may

have changed from the last in-person visit. It would be helpful to have someone

available to answer questions prior to the visit if required.

o Provide information around ways to re-engage and interact with the older adult.

These strategies should consider the impact the COVID-19 restrictions on their loved

one and could include ideas to stimulate social engagement, cognitive function,

mobility/activity and nutrition/hydration status.

o Find a way to safely celebrate and welcome visitors back to the hospital or

congregate setting. Consideration should be given to re-building any damaged

relationships and demonstrating the value and importance of family and friends as

partners in care.

Supporting Staff

While many will be excited to see the return of visitors, it is important to consider the pressures

facing staff. The following is offered for consideration:

o Provide communication regarding new policies and procedures, including posting

and circulating materials as appropriate. Everyone should be clear on the plan prior

to the arrival of the first visitors.

o Engage staff in conversation around what the re-introduction of visitors will look like

within the setting and support them (in advance) to address situations that may arise

(i.e. what should they expect to see, what questions visitors may have, timelines/next

steps, how to address situations that may arise like a break in physical distancing,

etc.)

o Designate an individual(s) as a resource for staff should any questions or issues arise.

o Assess and monitor the mental and emotional health and well-being of staff over the

coming months. This could be done through brief staff surveys or individual targeted

staff conversations. Through regular monitoring, issues can be addressed early,

proper supports can be put in place and/or links can be made.

o Visitors will take additional staff time and focus, especially in the early days as visitors

will require education around safety best practices. If possible, schedule extra staff


(or redeploy leaders or other staff) as ‘Visitor Champions’ to help support some of

these additional needs.

Policy & Practice Considerations

Developing a Family Presence Policy

Organizations could use this opportunity to develop a policy that meets short-term needs

related to COVID-19 but lays the foundation for evolution to a more fulsome family presence

policy that recognizes family and friends as integral partners in care.

Incorporate Exceptional Circumstances

All organizations are encouraged to ensure that regardless of outbreak status, there is within

the policy clear guidelines that allow for targeted visits in exceptional circumstances,

including end-of-life visits for COVID+ older adults.

Address Other Outbreaks

Ensure the policy recognizes that COVID-19 is one disease that can lend to an outbreak but

that there are others as well. Clarification may be required within policy around whether

actions differ if one or both are present within the organization.

Defining Visitors

The term visitor should be defined in policy. Consideration should be given to including and

defining types of visitors in hospital and congregate settings. This would give greater ability

to designate essential caregivers, allowing them to continue to play an important role for

older adults if ever the outbreak status of an organizations changes. Three types are

proposed for consideration:

o Essential Caregivers – in the most recent provincial LTC documents, essential [family]

caregivers are defined as people capable of providing caregiving support (feeding,

social support, etc.) and having provided this support in the LTCH home prior to

COVID-19. It is difficult to define and quantify ‘caregiving support’ as the importance

of support will be subject to the needs and perceptions of the older adult. What may

be more important is building a process that allows the older adult or his/her SDM to

designate the individuals that they consider ‘essential’. To keep volumes

manageable, consideration should be given to limiting the number of designated

essential caregivers (i.e. to two individuals per older adult).

o Important Care Partners – family or friends who come to the setting to provide

support to the older adult and are important to their sense of health and well-being.

o Visitors – extended family or friends who come to the facility for the sole purpose of a

social drop-in.

Roles, expectations and restrictions should be aligned with visitor types. These could be

further aligned with outbreak status, similar to how recent provincial documents have

allowed for in-home visits by essential family caregivers in LTC ahead of other visitors. It

would also be important to consider continuity in language in reference to pediatrics and

parents/ guardians and older adults and their essential caregivers.


Roles & Expectations of Visitors

In addition to provincial direction to date (i.e. masks, hand hygiene, physical distancing,

screening, visitor log, etc.), policies and practice could include the following:

o Family and friends should only be allowed into one hospital/congregate setting.

There should not be travel/visits between facilities.

o If they are able to tolerate masks and use them appropriately, older adults could

wear masks when visitors are present.

o Commentary should be included related to bringing gifts or food/drink in the facility

as well as access to common areas, cafeterias and bathrooms.

o Masks – there should be a balance between preserving PPE, promoting safety and

facilitating contact with family and friends:

While cloth masks are recognized as effective, effectiveness is based on them

being clean. If sufficient supplies exist, providing surgical/procedure masks for

both indoor and outdoor visits could be a consideration.

If surgical/procedure masks are limited:

For outdoor visits, if the visitors are not arriving with masks, settings

could secure and launder cloth face masks to support the visit.

For indoor visits, it will be important to develop a creative strategy to

make surgical/procedure masks available to support visitors.

o The timing and volume of individuals arriving on site to spend time with older adults

may need to be managed to limit volumes and ensure physical distancing. New

Brunswick, as an example, is only allowing 10% of residents a visitor on any given day

in the early stages. If this is adopted, scheduling will be critical and a plan should be

in place for those that arrive without a scheduled appointment.

o Screening of older adults (residents, family and friends) does include recognition of

assessment of both typical and atypical symptoms. It is important to remember that

older adults may present WITHOUT an elevated temperature.

Additional Roles & Expectations of Essential Caregivers

Essential caregivers should be designated, with identity confirmed via picture identification

(if the staff are not familiar with the individual) prior to admission. They should follow staff

protocols for screening and testing. They should receive an initial orientation and ongoing

training/education regarding IPAC, including hand hygiene, physical distancing and PPE.

Return demonstrations for PPE could help ensure proper procedure is followed in donning/

doffing.

If Possible: Enhance the Approach to Phasing, Including Consideration of Community Spread

Provincial direction clearly outline a phased approach to the resumption of visiting. If

possible and appropriate, the phases could be more structured, aligned with visitor types

and better recognize the importance of community spread. This would need to align with

provincial direction and be developed in collaboration with public health. For example:

o Level 1 (Red) – COVID Outbreak in the facility and/or high/moderate community

spread:


In an organizations-specific outbreak, visitors should be restricted. Essential

caregivers could be allowed with tight restrictions:

- Maximum two designated essential caregivers per older adult, identified

by the older adult or SDM in collaboration with a representative from the

unit and the attending provider. Only one would be allowed in the facility

at a time.

- Signed contract with an agreed schedule and clear expectations/

boundaries. If not met, designation could be revoked.

- Be required to follow staff screening guidelines. All screening must be

passed to enter/remain on-site.

- Be required to complete similar training/ongoing education to staff

regarding IPAC, including hand hygiene and PPE with return

demonstration required. PPE would be defined based on organization

policy and clinical scenario.

If high/moderate community spread, the facility should be closed to all

visitors, except essential caregivers who could be allowed with tight

restrictions (as above).

o Level 2 (Orange) – No COVID cases in the facility + small community spread:

Essential caregivers only, with implementation of tight restrictions (see Level 1).

Permitting of outdoor visits with important care partners. Based on the space

available, could have more than one care partner as long as physical

distancing can be maintained. Masks and hand hygiene required.

o Level 3 (Yellow) – No COVID cases in the facility + no new community cases in the

last 14 days:

Essential caregivers and important care partners only with restrictions and

precautions in place in alignment with best practices and organization policy.

Permitting of outdoor space visits with visitors. Based on the space available,

could have more than one visitor as long as physical distancing can be

maintained. Masks and hand hygiene required.

o Level 4 (Green) – Pandemic clear

Essential caregivers, important care partners and visitors with restrictions and

precautions in place in alignment with best practices and organization policy.

CONCLUSION

The purpose of this discussion paper is to provide health system leaders with some thoughts for

considerations in developing policies and practices related to the resumption of visiting for older

adults in hospitals and congregate care settings amid COVID-19. It is not comprehensive, nor is

it complete. We hope it will:

Highlight key considerations related to older adults and their caregivers for consideration

in planning.

Emphasize the important role the Ministry and public health will play in providing


direction to begin to safely resume visiting.

Promote discussion in local regions around a phased, coordinated and consistent

approach to resume visiting that optimizes the safety, health and well-being of older

adults, their family and friends, health care providers and the community.

Encourage organizations to consider current and future needs and work toward a “new

normal” family presence policy that embraces the role of family and friends as partners

in care.


APPENDIX A

Summary of Ministry Direction Regarding Visitors at June 12, 2020

The following summarizes key or interesting considerations related to visitors within provincial

directives, guidance documents and communications.

Source Highlights Directive #5 for Hospitals

within the meaning of the

Public Hospitals Act and

LTCHs within the meaning of

the Long-Term Care Homes

Act, 2007 8

April 10, 2020

For LTCHs only, all staff and essential visitors must wear surgical/procedure

masks at all times for the duration of full shifts or visits, regardless of whether

the home is in outbreak or not.

This is to be implemented in conjunction with all other requirements

contained in Directive #3 dated April 8th 2020 or as amended.

COVID-19 Guidance: Long-

Term Care Homes 9

Version 4

April 15, 2020

Essential visitors include a person performing essential support services (e.g.,food

delivery, maintenance, family providing care services, and other health care) or

a person visiting a very ill or palliative resident. If an essential visitor is admitted to

the home, precautions must be taken as outlined in Directive #3 for Long-Term

Care Homes under the Long-Term Care Homes Act, 2007.

Guidance for Mask Use in

LTCH and Retirement Homes 10

Version 1

April 15, 2020

Essential visitors must wear a surgical/procedure mask at all times while in

the home. Any essential visitor in contact with a resident who has COVID-19,

should also wear appropriate PPE in accordance with Directive #1 and

Directive #5.

Essential visitors entering the home are expected to provide their own

surgical/ procedure masks and/or PPE as required (unless there are existing

arrangements with the home).

Every effort should be made to conserve masks and other supplies used as

PPE within a home. These supplies should be provided to support the safety

of staff, essential visitors and residents, but at no times should be overused

or used where not warranted.

COVID-19 Guidance: Hospice

Care 11

Version 1

May 7, 2020

Visitors should not be permitted in hospices, except for essential visitors.

Essential visitors include a person performing essential support services or a

person visiting a patient nearing the final days of their life.

Physical distancing, hand hygiene (washing hands or using hand sanitizer)

and respiratory etiquette (coughing or sneezing into sleeve/bend of arm)

8 Ontario Ministry of Health. April 10, 2020. Directive #5 for Hospitals within the meaning of the Public

Hospitals Act and Long-Term Care Homes within the meaning of the Long-Term Care Homes Act, 2007.

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/public_hospitals

_act.pdf Accessed 6 Jun. 2020. 9 Ontario Ministry of Health. April 15, 2020. COVID-19 Guidance: Long-Term Care Homes.

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_long_term_care_guid

ance.pdf Accessed 7 Jun. 2020 10 Ontario Ministry of Health. April 15, 2020. Guidance for mask use in long- term care homes and

retirement homes.

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_guidance_ltc_retirem

ent_homes.pdf Accessed 6 Jun. 2020. 11 Ontario Ministry of Health. May 7, 2020. COVID-19 Guidance: Hospice Care.

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_hospice_care_guida

nce.pdf Accessed 10 Jun. 2020.

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/public_hospitals_act.pdf

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/public_hospitals_act.pdf

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_long_term_care_guidance.pdf

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_long_term_care_guidance.pdf

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_guidance_ltc_retirement_homes.pdf

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_guidance_ltc_retirement_homes.pdf

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_hospice_care_guidance.pdf

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_hospice_care_guidance.pdf


should be reinforced to all staff and essential visitors and patients, if

applicable.

Hospices should conduct active screening for COVID-19 symptoms of all

staff and essential visitors entering the hospice. Must pass screening to gain

entry. Symptom screening should include twice daily assessments (at the

beginning and end of the visit or shift), including temperature checks.

Additional precautions for essential visitors: screening (including typical and

atypical symptoms), only allowed to visit the one patient they intended to

visit, wear a mask for the duration of the hospice visit, wear appropriate PPE

if visiting someone who is COVID+

The visitor’s name, contact information and patient they visited should be

collected to facilitate follow-up in case an outbreak/case is detected.

Directive #3 for Long-Term

Care Homes under the Long-

Term Care

Homes Act, 2007 12

May 23, 2020

Long-term care homes must be closed to visitors, except for essential visitors.

Essential visitors include a person:

o Performing essential support services (i.e. food delivery, phlebotomy,

maintenance, family or volunteers providing care services and other

health care services required to maintain good health); or,

o Visiting a very ill or palliative resident.

If an essential visitor is admitted, the following applies:

o They must be screened on entry for symptoms and exposures for

COVID-19, including temperature checks. Admission is only allowed if

screening is passed.

o They must attest to absence of typical and atypical symptoms.

o They must only visit the one resident they are intending to visit, and no

other resident.

o They must wear a mask while in the home, including while visiting the

resident that does not have COVID-19.

o If they are to be in contact with a resident who is suspect or confirmed

with COVID-19, appropriate PPE should be worn in accordance with

Directive #5 and Directive #1.

COVID 19 Guidance:

Congregate Living for

Vulnerable Populations 13

Version 1

May 28, 2020

In one Ministry document,

congregate living settings and

institutions are defined as

including homeless shelters,

group homes, community

supported living, disability-

specific

communities/congregate

settings, short-term rehab,

hospices, other shelters. This

Only staff and essential visitors who have no symptoms associated with

COVID-19 and who pass screening are permitted within congregate

settings. Essential visitors, like staff, should have twice daily screenings.

Essential visitors must notify a supervisor immediately if they develop signs

and symptoms of COVID-19. Administrators of settings are required to notify

public health or any known or suspected COVID-19 cases in essential

visitors.

Policies should be developed to limit non-essential visitors. These policies

should also provide a definition of an essential visitor. It is suggested these

could include for example, individuals providing support services (i.e. health

care services), a parent/guardian or a person visiting a very ill or palliative

resident.

Essential visitors should receive general and ongoing education , instruction

and training about disease transmission and prevention. There should be a

training program for essential visitors which includes instruction and training

on the safe use, limitations, conservation, proper maintenance and storage

of supplies and equipment including alcohol-based hand-rub and PPE.

12 Ontario Ministry of Health. May 23, 2020. Directive #3 for Long-Term Care Homes under the Long-

Term Care Homes Act, 2007.

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/LTCH_HPPA.pdf

Accessed 7 Jun. 2020. 13 Ontario Ministry of Health. 28 May 2020. COVID-19 Guidance: Congregate Living for Vulnerable

Populations. Version 1



document specifically excludes

adult correctional facilities.

All staff and essential visitors should wear non-medical masks while in the

setting for the duration of their shift or visit. Staff providing direct care

should consider PPE (“non-medical masks are not defined as PPE”) based

on the nature of the planned interaction with the resident and his/her

known health status.

COVID-19 Testing for Long-

Term Care Home Staff 14

Communication to LTCH

Licensees

May 31, 2020

It is intended that all LTC home staff be tested, at reasonable intervals, a

minimum twice in the month of June. LTC homes should continue testing

residents based on COVID-19 Provincial Testing Guidance.

Testing for LTC home staff will include all individuals working in the LTC home

(e.g., front-line workers, management, food-service workers, contracted

service providers, etc.).

COVID-19 Guidance: Acute

Care 15

Version 5

June 5, 2020

Acute care settings must conduct active screening for COVID-19 symptoms

on everyone entering the facility.

It is currently recommended only essential visitors be allowed into the

facility. Examples of individuals who could be determined by the hospital as

essential visitors include those visiting:

o A patient who is dying or very ill;

o A parent/guardian of an ill child or youth;

o A visitor of a patient undergoing surgery; and/or,

o A woman giving birth.

Recommendations for

Regional Health Care Delivery

During the COVID-19

Pandemic: Outpatient Care,

Primary Care, and Home and

Community Care 16

June 8, 2020

Patients, clients, and essential caregivers/visitors should wear a mask for

source control (cloth or surgical/procedural) and should be encouraged to

bring their own if possible

Directive #3 for Long-Term

Care Homes under the Long-

Term Care

Homes Act, 2007 17

June 10, 2020

Active screening of all visitors which includes twice daily symptom screening

and temperature check. The screening must be passed to gain entry.

Homes must have a visitor policy in place that is compliant with the

Directive and guided by applicable policies. At minimum, visitor policies

must:

o Be informed by the ongoing COVID-19 situation in the community and

the home and be flexible to be reassessed as circumstances change.

o Be based on principles such as safety, emotional well-being, and

flexibility and address concepts such as compassion, equity, non-

maleficence, proportionality (i.e., to the level of risk), transparency

and reciprocity (i.e., providing resources to those who are

disadvantaged by the policy).

o Include education about physical distancing, respiratory etiquette,

hand hygiene, IPAC and proper use of PPE.

o Include allowances and limitations regarding indoor and outdoor

visiting options.

14 Ontario Ministry of Health. May 31 2020. Communication to LTCH Licensees. COVID-19 Testing for LTCH

Staff. 15 Ontario Ministry of Health. June 5 2020. COVID-19 Guidance: Acute Care. Version 5 16 Ontario Ministry of Health. June 8 2020. Recommendations for Regional Health Care Delivery During the

COVID-19 Pandemic: Outpatient Care, Primary Care, and Home and Community Care 17 Ontario Ministry of Health. May 23, 2020. Directive #3 for Long-Term Care Homes under the Long-

Term Care Homes Act, 2007.


Accessed 12 Jun. 2020.



o Include criteria for defining the number and types of visitors allowed

per resident when the home is not in an outbreak. When the home is

in an outbreak, only essential visitors (as defined below) are permitted

in the home.

o Include screening protocols, specifically that visitors be actively

screened on entry for symptoms and exposures for COVID-19,

including temperature checks and not be admitted if they do not

pass the screening.

o Include visitor attestation to not be experiencing any of the typical

and atypical symptoms.

o Comply with the home’s IPAC protocols, including donning and

doffing of PPE.

o Clearly state that if the home is not able to provide

surgical/procedure masks, no family visitors should be permitted inside

the home. Essential visitors who are provided with appropriate PPE

from their employer, may enter the home.

o Include a process for communicating with residents and families

about policies and procedures including the gradual resumption of

family visits and the associated procedures.

o State that non-compliance with the home’s policies could result in a

discontinuation of visits for the non-compliant visitor.

o Include a process for gradual resumption of family visitors that

stipulates:

Visits should be pre-arranged.

Family visitors to begin with one visitor at a time.

Must only visit the one resident they are intending to visit, and no

other resident.

Family visitors should use a face covering if the visit is outdoors. If

the visit is indoors, a surgical/procedure mask must be worn at all

times.

Family visits are not permitted when: a resident is self-isolating or

symptomatic, or a home is in an outbreak.

o Specify that essential visitors:

Be defined as including a person performing essential support

services (e.g., food delivery, inspector, maintenance, or health

care services (e.g., phlebotomy)) or a person visiting a very ill or

palliative resident.

Providing direct care to a resident must use a

surgical/procedure mask surgical/procedure mask while in the

home, including while visiting the resident that does not have

COVID-19 in their room.

Who are in contact with a resident who is suspect or confirmed

with COVID-19, must wear appropriate PPE in accordance with

Directive #5 and Directive #1.

Are the only type of visitors allowed when: A resident is self-

isolating or symptomatic, or a home is in an outbreak.

LTCHs must keep families informed about COVID-19, including frequent and

ongoing communication during outbreaks. Signage must be clear about

COVID-19, including signs and symptoms of COVID-19, and steps that must

be taken if COVID-19 is suspected or confirmed in staff or a resident.

Resuming Visits in LTCHs 18

June 11, 2020

Provides guidance to LTCHs and is intended to supplement the updated

Directive #3. To the extent that anything in the document conflicts with the

18 Ontario Ministry of LTC. June 11 2020. Resuming Visits in LTCHs. https://files.ontario.ca/mltc-resuming-

visits-long-term-care-homes-en-2020-06-11.pdf Accessed 11 Jun. 2020.

https://files.ontario.ca/mltc-resuming-visits-long-term-care-homes-en-2020-06-11.pdf

https://files.ontario.ca/mltc-resuming-visits-long-term-care-homes-en-2020-06-11.pdf


Directive, the Directive prevails, and LTCHs must take all reasonable steps to

follow the Directive.

Visitors are not allowed in the LTCH if the home is in outbreak.

The LTCH is to develop procedures for the resumption of visits and a process

for communicating these with residents, families, visitors and staff, including

but not limited IPAC, scheduling and any setting-specific policies including:

sharing information on IPAC, wearing a mask, movement within the home,

approach to dealing with non-adherence to home P&P (including

discontinuation of visits).

A list of visitors is to be maintained.

Visitors must pass screening prior to each visit, attest that they have tested

negative within the last 2wks and not positive since (LTCH not responsible for

testing)

Must comply with IPAC protocols including proper use of surgical/

procedure mask – face covering if outdoors and surgical/procedure mask if

indoors. Face masks to be worn at all times. Visitors responsible for bringing

own face coverings, LTCH to provide surgical/procedure masks and masks

to outdoor visitors without one.

Visitor is defined as any family member, close friend or neighbour. They can

also be essential family caregivers. Essential family caregivers are those

people capable of providing caregiving support (feeding, social support,

etc.) and has done this before in the home prior to COVID-19.

Phase 1 – June 18 start - outdoor visiting

One visitor/resident at time, visit scheduling required to ensure physical

distancing and staff coverage, visits can be time limited but cant restrict

<30min, equitable access to visits must be provided for all residents; allow

for one visit min/wk per resident; staff support transfer of residents in/out of

home;

Phase 2A – start one wk after lifting emergency orders - outdoor visiting

expanded

Similar to Phase 1 but up to 2 visitors at a time

Phase 2B – start one wk after lifting emergency orders - indoor visiting for

essential family caregivers only

Similar to Phase 1 + one visitor at a time, procedure required to escort

visitors to homes, no overcrowding in room, min one visit/wk/per resident

but for essential family caregivers on agreement with home for more

frequent schedule should be permitted

Phase 3 – at max one month after limiting emergency measures - outdoor

visiting and indoor visiting expanded

Similar to Phase 2 + up to 2 visitors as long as physical distancing can be

accommodated, can regulate number of visitors

Reopening RHs 19

June 11, 2020

Re-opening should take place in a gradual, phased manner that meets the

health and safety needs of residents, staff, and visitors. Additionally, to

ensure maximum resident and staff safety, a RH co-located with a LTCH will

adopt LTCH visitation policies if those policies are more restrictive

Visitors not allowed if on outbreak

Required to dedicate area for indoor/outdoor visits with staff to maintain

highest IPAC standards prior/after visits

RH plans need to consider access to adequate testing/plan in place,

adequate PPE; IPAC standards including essential cleaning and

disinfection; physical distancing – able to facilitate and protocols to support

Visitors can only visit designated indoor/outdoor areas, suites

19 Ontario Ministry of Health. June 11 2020. Reopening RHs. https://files.ontario.ca/msaa-reopening-

retirement-homes-en-2020-06-11.pdf Accessed 11 Jun. 2020.

https://files.ontario.ca/msaa-reopening-retirement-homes-en-2020-06-11.pdf

https://files.ontario.ca/msaa-reopening-retirement-homes-en-2020-06-11.pdf


Can start June 18.

Screening, attestation re negative testing, IPAC, masks (like LTC)

# visitors/resident/day determined by home, visits need to be scheduled

and can be time limited

Resuming Visits in Congregate

Settings 20

June 11, 2020

An essential visitor is generally a person (including a contractor) who

performs essential services to support the ongoing operation of a service

agency or is a person considered necessary by a service agency to

maintain the health, wellness and safety, or any applicable legal rights, of a

resident.

Although the direction on non-essential visitors does not place a blanket

prohibition on all visitors, it is intended to greatly limit entry into the

congregate living setting to help prevent transmission of COVID-19 and to

protect residents and staff during the outbreak. The role that families, visitors

and loved ones play in providing caregiving and emotional supports is

important in the quality of life for those living in congregate living settings. To

support visits while protecting residents and staff, the ministry is proposing

resumption of personal visits, provided they take place outdoors and are

guided by some key principles.

20 Ontario Ministry of Children Community & Social Services. June 11 2020. Resuming Visits in Congregate

Settings. https://files.ontario.ca/mccss-resuming-visits-in-congregate-living-settings-en-2020-06-11.pdf

Accessed 11 Jun. 2020.

https://files.ontario.ca/mccss-resuming-visits-in-congregate-living-settings-en-2020-06-11.pdf


APPENDIX B

Other Jurisdictions & Sectors

North East Specialized Geriatric Centre / Health Sciences North

Health Sciences North has established a Family and Caregiver Presence (Visitor) Policy Working

Group. The North East Specialised Geriatric Centre is involved in that work. Within that Working

Group, a process is being established to ensure essential visitors are identified and that there is

an internal process for communication regarding essential visitors.

With the goal to achieve family care partner/presence and participation in a manner that is

safe for patients and staff, a decision guide is being developed. The guide will help staff decide

whether a visitor is essential. Essential visitors include support persons as well those supporting

individuals at the end of life or those requiring emergency/unplanned surgery. Support persons

include, for example, those supporting communication, ambulation and/or cognitive

impairment. It also includes those providing emotional support or those requiring training to

support discharge.

Pediatrics & Toronto’s Hospital for Sick Children

Pediatrics offers an interesting lens for consideration. Similar to providing care for older adults,

the world of pediatrics values, recognizes and promotes the importance of family and friends in

meeting the daily needs of their population.

Since the start of the outbreak, HSC has put visiting restrictions in place to protect the health and

well-being of their children while recognizing the essential role of family. The following measures

are in place:

One adult is allowed to accompany a child to the hospital. Inpatients staying overnight

are allowed two designated adult caregivers to take turns in providing care but only one

is allowed in the building at any time.

Designated caregivers are provided with a badge and must present the badge and

picture identification at screening to gain entrance.

Siblings under 18 and other visitors are not allowed at this time. No individual under age

18 is permitted, unless they are the parents.

Family members are provided with Level 1 masks by the organization. Family of

inpatients are asked to wear masks if they are unable to maintain a 2m distance within

the room.

Children over 6 are now masked if they are able to wear if safely and tolerate it.

Screening occurs prior to entry. Family of inpatients who stay overnight are screened

daily on the units.

IPAC training occurs with designated caregivers.

Prince Edward Island

PEI is currently limited to outdoor visits only:

Designated spaces only, cleaned between use, "hosted" visits, maximum of 1 hour


2 designated visitors per resident, may visit together or separately

Hand hygiene and physical distancing required (non-medical mask required if physical

distancing might not be maintained, i.e. cognitive impairment)

Scheduled ahead of time

Palliative visits are permitted at the bedside with 6 designated visitors per resident, who may visit

together or separately. Hand hygiene and physical distancing is required.

In the next stage, likely starting June 26 the following will apply:

Outdoor visits will continue with the same conditions applying except that individuals are

allowed 6 designated visitors per resident, with a maximum of 2 visitors at a time

Indoor visits will be added in designated spaces only (not bedside or in common rooms).

These areas will be cleaned between use, "hosted" visits, maximum of 1 hour. 2

designated visitors per resident will be allowed and they can visit together or separately.

Hand hygiene and physical distancing will be required (non-medical mask required if

physical distancing might not be maintained, i.e. cognitive impairment). Visits will be

scheduled ahead of time.

Palliative visits would continue as per present practice

New Brunswick

Outdoor Visits at Facility (started June 5, 2020):

2 visitors per resident at a time

Physical distancing (area must have sufficient space for distancing)

Appointment ahead of time

Number of visits at one time limited to respect the current “gathering” guidelines

Palliative Visits in LTCF (new policy, June 5, 2020):

Palliative Performance Scale score of 30% or less are eligible for visitors and bed ridden (if

PPS 20% or less, 2 visitors may visit at one time)

Resident may select 10 members of their immediate family/friends, to visit one at a time

(unless support is required)

Facility should be provided a list of these individuals.

Out of province may apply for exemption to cross border (call 1-800-863-6582)

Indoor visits expected to start June 19.

Visits may occur within the facility, and will be subject to maximum visitation capacity

limits (10% of residents per day)

Resident must select 1 visitor, they will be the only visitor permitted to enter the facility

during this phase

10% of residents can have 1 visit per day (for example, a 100-bed facility would have 10

visits per day). Assumption that every resident may have 1 visit every 10 days

Active screening of visitors, mandatory mask use, hand hygiene, disinfecting high-touch

areas are some of the mandatory measures to mitigate the risks


Saskatchewan

On June 3, 2020 the Saskatchewan Health Authority (SHA) expanded criteria for compassionate

reasons related to visitation restrictions in both hospitals and LTCH settings 21. To support this work

a Family Presence Expert Panel was established with representation from patients, families,

public health and IPAC experts. They have developed and published guidance and FAQ

documents, a family presence commitment statement, a family presence poster and posters

outlining visitor items and restrictions. The family presence commitment statement outlines the

roles of both health service providers and the family with information around who to contact for

more information.

Within the context of these documents:

Compassionate care includes, but is not limited to end-of-life care, major surgery,

intensive care/critical care, or a care partner aiding in clinical care (at the discretion of

the patient's care provider).

Under the concept of compassionate care, older adults can have a designated family

member or support person if their quality of life and/or care needs cannot be met

without that person’s assistance. This has been further clarified:

o The support person can include a loved one, friend, religious/spiritual care

provider, paid caregiver, or other support person of the patient/resident’s

choosing.

o Inpatients, outpatients, emergency/urgent care patients can designate one

support person. In LTC settings, two individuals can be designated but only 1 can

visit at a time.

o Assistance is considered required in those with compromised comprehension,

decision making or mobility due to disability or onset of a medical condition (for

example but not limited to: mobility, hearing, speech including communication

barriers, compromised cognitive functioning (i.e. mental illness, intellectual

disability, dementia), visual or memory impairment).

o Determination is made by the attending physician and unit manager/ charge

nurse in consultation with the designated support person(s).

Screening, including temperature check and questionnaire, is required prior to entry with

visitors required to perform hand hygiene and wear a medical grade mask if tolerated.

Other PPE may be required based on the circumstances.

Visitors are not permitted in waiting rooms or common areas.

Food and beverages are permitted to be brought into facilities with certain guidelines

defined.

LTCHs are now allowing outdoor visitation. Visiting must be arranged in advance and

more than one visitor is allowed as long as physical distancing can be maintained

21 Saskatchewan Government. Visiting SHA Facilities. https://www.saskatchewan.ca/government/health-

care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-

issues/2019-novel-coronavirus/visiting-sha-facilities?fbclid=IwAR04Qpp8FGq-

V5naM3zOuipB6yKzW2nbTXCFzu0kgrRASJjVKQJIdEMHBlo Accessed 7 Jun. 2020.

https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-coronavirus/visiting-sha-facilities?fbclid=IwAR04Qpp8FGq-V5naM3zOuipB6yKzW2nbTXCFzu0kgrRASJjVKQJIdEMHBlo





(exception: family members from same household). If it cannot be maintained, masks

are to be worn and hand hygiene performed.

Quebec

The province of Quebec website has a page specifically dedicated to informal and family

caregivers during COVID-19. 22 This website recognizes the value of informal caregivers, outlines

what to expect in the changing environment and addresses the importance of IPAC measures

like hand hygiene and PPE. Within this site, they also clearly outline key definitions and processes

to support the role of informal caregivers.

Informal caregivers are now able to provide assistance or significant support to an individual

living in a facility, as long as they comply with specific conditions and precautions.

Informal caregivers are considered those who provide, or who would like to provide,

significant assistance and support to a loved one to meet their needs and contribute to

their integrity and well-being. Examples of support included: helping with meals,

supervising and being attentive to the person’s overall condition, supporting various daily

or recreational activities, assistance with walking and/or providing moral support and

comfort.

The term “significant support” is defined as a “regular basis, every day or several times a

week” with the key being that the support of the caregiver is contributing to their loved

one’s integrity and well-being.

More than one informal caregiver may be authorized to provide support to the same

person in a facility but only one is allowed in the facility at any given time.

Informal caregivers decide themselves when they will visit and the length/frequency of

visits. They must comply with visit conditions within the facility. They may receive an

arrival and departure time to minimize contact with others.

They are required to sign a consent form stating that their decision was informed and

voluntary, they understood the risks of infection and that they promise to adhere to the

precautions to maintain the safety of residents, themselves and others in the facility.

They are required to self-monitor for symptoms and are not allowed to enter the facility if

they are COVID+ or if they have been in contact with an individual who is COVID+. A 14-

day isolation period is required and they must test negative to gain re-entry.

Informal caregivers need to sign a register to facilitate contact tracing, if required.

They are allowed to provide care and support to only one person. In some facilities/

circumstances there are no exceptions to this rule. In others, it is possible if two people in

the same unit receive regular, significant support from the same informal caregiver.

They must wear clean clothes when they go to the facility. They are not allowed to bring

clothes or other items from home (i.e. purses, lunch bags, documents) and if they do,

they will be prevented from bringing them home.

They are encouraged to minimize travel outside their homes to reduce risk.

22 Province of Quebec website. https://www.quebec.ca/en/health/health-issues/a-z/2019-

coronavirus/caregivers-during-the-covid-19-pandemic/ Accessed 10 Jun. 2020

https://www.quebec.ca/en/health/health-issues/a-z/2019-coronavirus/caregivers-during-the-covid-19-pandemic/

https://www.quebec.ca/en/health/health-issues/a-z/2019-coronavirus/caregivers-during-the-covid-19-pandemic/


Within the facility, movement within the facility is limited with no access to common

areas and physical distancing required. Directions are provided around which

bathrooms are allowed for use.

New Zealand

On May 13, 2020 New Zealand 23 moved into Alert Level 2 24 status (Level 4 = lockdown)

signifying the disease was contained with the risk of community transmission remaining. While

many precautions remained in place (i.e. physical distancing, border controls, testing, isolation

and contact tracing of those unwell), their society began to re-open. Gathering sizes were

increased from 10 to 100. Gyms re-opened with restrictions. Restaurants and businesses

opened, as did schools and day cares with physical distancing required. Museums, theatres

and public spaces re-opened with a requirement to maintain records to support contact

tracing.

Within Alert Level 2 there were specific guidelines for aged care providers 25, including guidelines

for family visiting. At an Alert Level 4 or 3 family visits were limited to essential visitors (i.e.

palliative cases) with all visits scheduled and full precautions taken during the visit (i.e. screening,

hand hygiene, PPE, physical distancing). At an Alert Level 2 visiting was allowed, including

general family visits and non-essential service visits. These visits were managed in a controlled

way and precautions put in place. For example:

Visits were limited to designated visitors with a limit to the number of visitors allowed at

one time. Appointments and sign-ins were required. There were limits to the length of

the visit and/or the visit location based on the health status of the older adult and the

number of other visitors in the facility.

Health screening was completed on all visitors prior to entering the facility.

Visitors were required to follow the facility’s IPAC measures, including hand hygiene,

physical distancing and appropriate use of PPE.

23 New Zealand Ministry of Health website. https://www.health.govt.nz/ Accessed 7 Jun. 2020. 24 On June 8, 2020 New Zealand moved to Level 1 status 25 New Zealand Ministry of Health. COVID-19: Aged Care Providers. https://www.health.govt.nz/our-

work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-resources-health-professionals/covid-

19-health-sector-providers/covid-19-aged-care-providers Accessed 7 Jun. 2020.

https://www.health.govt.nz/

https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-resources-health-professionals/covid-19-health-sector-providers/covid-19-aged-care-providers



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Considerations for Resuming Visiting for Older Adults in ... · Visiting Restrictions & Older Adults in Hospitals and Congregate Settings 3 guest. Google shows the definition of visitor