Introduction
There are more than 90 million people who are over 65 years old living in Europe (European Union, 2020). While most of them live in private households, some choose freely to move into long-term care facilities (LTCFs) or are forced to because they need more support due to their frailty. In 2018, there were 156,316 beds in LTCFs in Europe. The highest ratios of beds per 100,000 inhabitants were recorded in the Netherlands and in Sweden and the lowest in Greece and Bulgaria (Eurostat, 2022). The estimated number of LTCFs in the European Economic Area was calculated as 43,000 in December 2019 (ECDC, 2021).
COVID-19 has heavily impacted the oldest population, with 58% of COVID-19-related deaths in those over the age of 80 (Rocard et al., Reference Rocard, Sillitti and Lena-Nozal2021). The estimated percentage of COVID-19 mortality in LTCFs in Europe was reported as ranging from 21 to 66% during the pandemic (Miralles et al., Reference Miralles2021). It is worth nothing that before the pandemic, LTCFs faced difficulties in securing funding and coordinating properly with health systems due to shortage of staff (World Health Organisation, 2020). Additionally, health care support for LTCFs may vary depending on the type of health care provider from primary health care (PHC) professionals to geriatricians or hospital units’ teams and the organization of the health care system (Panza et al., Reference Panza2018). The World Health Organization (WHO) described PHC as a whole-of-society approach to effectively organize and strengthen national health systems to bring services for health and well-being closer to communities. PHC provision is organized in Europe under different health systems models (Böhm et al., Reference Böhm2013) (Table 1).
Different European models of health systems regarding regulation, financing, and provision (Organization for Economic Co-operation and Development)
Adapted from Böhm et al. (Reference Böhm2013).
In Europe, the role of PHC in providing medical care to LTCFs varies considerably (Boeckxstaens and De Graaf, Reference Boeckxstaens and De Graaf2011). According to a study in seven high-income European countries, comprehensive care ranged 14–46% between LTCFs and general practitioners (GPs) (Doty et al., Reference Doty2020). At the beginning of the pandemic, the clinical pathways for COVID-19 patients in LTCFs were scarcely organized (Giri et al., 2021), although the WHO recommended early recognition and close monitoring of symptoms in residents and caregivers (WHO, 2022). The role of GPs in LTCFs during the pandemic has been poorly described and documented (Dykgraaf et al., Reference Dykgraaf2021). The aim of this study is to analyze the role of PHC in the clinical pathways for LTCF COVID-19 patients in 30 European countries in the early phase of the pandemic.
Methods
A retrospective descriptive study was performed in 30 countries (Figure 1). This article is part of the Eurodata study, which aims to describe the role of PHC during the COVID-19 pandemic in Europe (Ares-Blanco et al., Reference Ares-Blanco, Guisado-Clavero and Del Rio2023). In this study, the core research team was formed by six specialists in family medicine, preventive medicine, and public health, as well as a group of 45 national key informants from participating countries. The informants were invited through the European General Practice Research Network (EGPRN) and the European branch of the World Organization of Family Doctors (WONCA Europe). EGPRN is an organization of GPs and other health professionals involved in research in PHC and family medicine in Europe (EGPRN, 2022), and WONCA Europe is an academic and scientific society representing European GPs (Wonca, 2022). A presentation of the project took place at the EGPRN meeting in October 2021, and all the assistants were invited to participate. The main criteria for participation were either being a GP or having a background in GP, practicing in Europe during the pandemic and speaking English. All the key informants were health professionals and lead researchers in the different European countries represented in the study, mostly working in general practice, with the exception of the participants from Finland and Lithuania who were working in public health during the study period. Data were collected through an ad hoc semi-structured questionnaire intended to provide country-specific data about COVID-19 LTCF pathways from September 2020. The questionnaire was based on the clinical pathway described by the WHO (World Health Organization [WHO], 2020). Changes to the initial LTCF questionnaire were made by the core group before distributing it to all the key informants in October 2021. The questionnaire was circulated twice until a consensus was reached in November 2021, including a glossary with the definition of terms (Supplement 1). All the comments were included in a new version and all researchers provided feedback. An agreement was finally obtained in the second round. Three online meetings were organized to share the agreement and provide recommendations on how to collect the information from relevant and reliable official sources (Governmental guidelines—national and regional ones, scientific societies, medical consensus among clinicians). The sources are quoted in Supplement 2. The questionnaire was filled by one or two national key informants, and it was peer reviewed by a different national researcher before submitting it to the core group of researchers. They checked the national data to assure the data quality. The national information was collected between January and February 2022. Data analysis for qualitative variables was performed by organizing and transcribing the information from the questionnaires. The information was reviewed by the core group in March–April 2022. A national and international peer review was performed to assure the quality of the data. In cases where the information received was unclear, key informants were contacted to provide further details to complete the initial information.
Participation of primary health care in medical care for COVID-19 patients living in long-term care facilities in Europe.
Countries where primary health care (PHC) did not participate in providing medical care in long-term care facilities (LTCF). Poor: Countries where PHC rarely participated in providing medical care in LTCFs. Medium: Countries where PHC sometimes participated in providing medical care in LTCFs. High: Countries where PHC participated in providing medical care in LTCFs.
Variables were grouped in five blocs: (i) SARS-CoV-2 testing, (ii) contact tracing, (iii) follow-up, (iv) additional testing, and (v) moderate and severe cases (Supplement 1). An international peer review of all the national data was performed by the core group. If there were differences in interpretations, they contacted the national key informant to clarify the description. They also homogenized the language to facilitate the interpretation of the data. All decisions regarding the language were agreed on with the key informants. Once that results were aggregated, we shared it with the key informants to confirm the findings, and all agreed with the results. A final consensus with the information of each country was achieved between the core group and the key informants in May 2022.
Medical care was defined as the initial care provided, COVID-19 testing, COVID-19 contact tracing, supervision of isolation, and medical care including physical examination, follow-up, and complementary tests.
The degree of PHC involvement in the LTCF COVID-19 patients’ clinical pathways in the different countries was defined as (Figure 1):
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PHC was the main provider of medical care (high).
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PHC was not the main provider of medical care; however, they deserved some complementary services or, in case of shortage of LTCF workforce, they became the main provider (medium).
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PHC did not deliver healthcare to LTCFs except for specific issues (poor).
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PHC was not involved in the medical care of these patients (none).
Results
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1. The role of PHC
PHC was involved in caring for LTCF COVID-19 patients in 26 out of the 30 European countries that participated in the study, either exclusively or in collaboration with other departments. The role of PHC was predominant in 17 countries (Figure 1). Furthermore, LTCFs received extra support from COVID-19 teams and infectious disease or internal medicine specialists in five countries.
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2. The role of nurses in the LTCF
In Belarus, Belgium, Bulgaria, France, Israel, and Spain, nurses provided medical care alongside GPs or LTCF doctors. In France and Italy, nurses were responsible for performing antigenic tests and delivering the results to patients in Belarus, Bosnia and Herzegovina, Germany, Italy, Luxembourg, Spain, and Sweden. In Croatia and Spain, nurses worked with public health and PHC teams to conduct contact tracing.
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3. Detection of cases
Isolation rooms for COVID-19 patients were available in all countries (red zones). However, in Austria and Ireland, LTCFs directly established red zones, while, in others, it was organized by public health or PHC. SARS-CoV-2 testing took place in LTCFs in 11 countries and was provided by PHC in seven countries, while contact tracing was mainly conducted by public health services (Table 2). When COVID-19 positive patients were detected in LTCFs, infected cases could be isolated in special areas (red zones) under the supervision of the staff (mostly nurses), except in Austria, where practices varied between facilities.
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4. Care of COVID-19 patients
Management of COVID-19 patients in long-term care facilities in European countries
Countries with no primary health care implication were Belarus, Bosnia and Herzegovina, Israel, Portugal, Turkey, Ukraine.
A&E = Accident and Emergency Department; GP = general practitioner; PH = public health; PHC = primary health care.
COVID-19 outpatient clinic: Primary care clinic that take care of COVID-19 ambulatory patients and it is run by primary care staff.
Aligned primary care network: Network of PHC practices that provide integrated and coordinated care in the community.
*The test was not needed but it was performed routinely before going out the COVID-19 zone in the LTCF.
In most countries, if patients presented with suspicious symptomatology, they contacted GPs for medical care; symptoms’ follow-up was mostly carried out by nurses from LTCFs and PHC. If physical examination was needed, GPs performed it in the LTCF. In Italy, they counted on the additional support of the Unitá speciali di continuità assitenziale (special continuity care units) for assisting patients under PHC direction. These units performed physical examinations, lung ultrasounds, and blood gas analysis (in some regions) in LTCFs and prescribed pharmacological therapies in collaboration with GPs.
No additional testing was performed in LTCFs. Chest X-rays could be requested by GPs in 12 countries and performed in hospitals or COVID-19-specific centers. For phlebotomies, a GP request was needed in 22 countries. When patients’ conditions worsened, they were referred to the hospital by LTCF staff or GPs.
Discussion
This study describes the COVID-19 health care provided by PHC in LTCFs in 30 European countries. Nurses in LTCFs had an important role in the care of frail or old patients, testing, supervising isolation, and the follow-up of patients. PHC collaborated in the diagnosis and follow-up of COVID-19 in LTCFs. While many countries could perform SARS-CoV-2 testing and phlebotomies in LTCFs, chest X-rays were always taken in outpatient clinics.
In the European Union, the health care professionals involved in the care of LTCF residents are nurses, physiotherapists, and remunerated GPs at the national or regional level (Spasova et al., Reference Spasova, Baeten, Coster, Ghailani, Peña-Casas and Vanhercke2018). Before the pandemic, most of the Organization for Economic Co-operation and Development countries had developed some form of emergency preparedness protocols for their health systems but without special measures for LTCFs. However, after the pandemic, nearly all countries started including LTCFs in their plans (Rocard et al., Reference Rocard, Sillitti and Lena-Nozal2021). After the first wave, the need for changes in regulations, funding, and strategies to care for these patients also became more obvious (Werner et al., Reference Werner, Hoffman and Coe2020). In September 2020, SARS-CoV-2 testing was available in LTCFs of all the countries due to the implementation of the European Centre for Disease Prevention and Control (ECDC) guidelines (Adlhoch et al., Reference Adlhoch2020). The COVID-19 pandemic has been confronted with a dynamic transformation of health, social, and economic structures (Haldane et al., Reference Haldane2021). As is reflected in our results, two countries created specific organized networks to provide more integrated care: in Belgium, the coördinerend en raadgevend arts (CRA) was a specially trained consulting GP that coordinated medical care with the support of LTCF staff during the pandemic, and in the United Kingdom, the PHC network aligned with a group of practices that partnered with local communities at LTCFs to deliver care.
One review reported better nurse-to-patient ratios were associated with fewer cases, while nurse shortages were prone to cause COVID-19 outbreaks (Dykgraaf et al., Reference Dykgraaf2021). Proactive care from the nursing home staff, with regular communication and visits from their usual GP, seemed beneficial to LTCF residents (Sherlaw-Johnson et al., Reference Sherlaw-Johnson2018). Moreover, some countries (Estonia, Finland, Latvia, Luxembourg, Portugal, and Slovenia) promoted multidisciplinary teams to integrate PHC and LTCFs at the beginning of the pandemic (Rocard et al., Reference Rocard, Sillitti and Lena-Nozal2021). France provided a new incentive to increase GP visits in LTCFs, whereas Italy and Luxembourg implemented medical care 24 hours. Our results highlight the role of nursing staff in the care of COVID-19 patients, as well as the role of GPs in performing physical examination, testing, and follow-ups, to guarantee continuity of care and attend those patients who would not benefit additionally from being admitted to a hospital (Miralles et al., Reference Miralles2021). Indeed, nurses have played a key role in monitoring COVID-19 cases and contacting GPs in cases where patients’ conditions have worsened (British Geriatrics Society, 2020).
SARS-CoV-2 testing and phlebotomies were not available in LTCFs in all the countries, and some residents needed referrals to an outpatient or inpatient setting to access these tests. These results contrast with the recommendation from the WHO European Office to guarantee not only appropriate access to health care services in LTCFs but also an adequate provision of services in PHC (WHO, 2020). The results of our study show that hospital referral was recommended if severe COVID-19 was suspected; however, some other publications do not match our findings (Ouslander and Grabowski, Reference Ouslander and Grabowski2020; Ryan, Reference Ryan2022; Shoaee et al., Reference Shoaee2022). In a report of six European countries, patients were not referred to the hospital if the incidence of pneumonia and COVID-19 cases had risen and intensive care units would provide patients care according to age policy, which implied that LTCF patients would not have access to all the treatments available at that time (Miralles et al., Reference Miralles2021). Furthermore, some pre-pandemic studies did not show benefits for frail elderly patients with pneumonia whether to be treated in intensive care unit or not, as life expectancy and comorbidities would not assure the patient’s recovery (Dosa, Reference Dosa2006; Loeb et al., Reference Loeb2006; Tandan et al., Reference Tandan2020).
Strengths and limitations
To the best of our knowledge, this is the first detailed description of the role of PHC in the management of LTCF COVID-19 patients. This retrospective study spanning 30 European countries in the early stages of the COVID-19 pandemic has elucidated the interconnected roles and multilevel collaboration among PHC, LTCF, public health, and hospitals in the provision of care for elderly individuals during pandemics (Figure 2). A potential limitation could be the fact that all key informants were GPs. We did not consider to involve other kind of professionals who work in LTFC in the study (social workers, PHC nurses, or cases managers among others) as we wanted to collect the role of PHC in the COVID-19 clinical pathway in these facilities. Nonetheless, this bias was diminished by collecting information from publicly available official sources (Supplement 2) and also by the research background of key informants, GPs who belonged to the EGPRN of WONCA Europe.
Roles and multilevel connections among primary health care, long-term care facilities, public health, and hospitals to care for the elderly during the pandemic.
As the organization and the number of LTCF beds vary across Europe, it is not possible to make a direct comparison of the pathways. However, a detailed description and juxtaposition might carry valuable information for future decision-makers and stakeholders of the different health care systems. As these are official data, we cannot contrast whether all recommendations were followed in the different regions of each country. Palliative care statistics of LTCF patients has not been collected. As the situation of palliative care was very different among the regions and depended on the pandemic peak waves, the information could vary widely inside each country.
The representation of data from two countries corresponds to a specific region and not to the entirety of the country. In the case of Sweden, the data were obtained from the Västra Götaland region, and for the United Kingdom, the corresponding information is specific to England.
Implications for research and practice
Policies and further investment are needed to strengthen the coordination between PHC and LTCFs to improve patient-centered care (Figure 2). In addition, more research is required to examine the role of the different health care professionals involved in the care of LTCF residents, as well as qualitative research to explain the care preferences of the residents. Special care for LTCF residents should be established in future guidance when managing a pandemic.
Close collaboration between PHC professionals and nursing home staff is crucial for developing guidance on the management of COVID-19 to improve the comprehensive care of LTCF residents.
Further research is needed to understand the possible difficulties in separating the COVID-19 and non-COVID-19 residents and the capacity of LTCFs. Moreover, research related to all changes which took place in the management of care in LTCFs could provide relevant information for future pandemics. Additionally, it is necessary to describe the role of PHC in other diseases suffered by LTCF residents.
Conclusion
The role of PHC and nurses in LTCFs during the COVID-19 pandemic has been decisive in many European countries, and LTCFs must be integrated in health care strategies when managing a pandemic. In the future, it is essential to value and promote the role of PHC professionals on pandemic management strategies, including coordination and integrated care within the health system, regarding LTCF health care provision.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1463423623000312
Funding statement
This study was supported by the European General Practice Research Network (EGPRN) grant (2022/01). The publication was funded by Università di Modena e Reggio Emilia (Italy).
Competing interests
The authors have no competing interests to declare.
Ethics approval
Ethical approval was obtained from the Ethics Committee of the Hospital Universitario La Paz (Madrid, Spain), ID PI-5030. Additional ethical approval according to local laws was needed in Croatia (ethical approval from the Ethics Committee, School of Medicine, University of Zagreb: Ur. Broj: 380-59-10106-22-111/76; Klasa: 641-01/22-02/01).
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