Covid-19 HSE Clinical Guidance and Evidence

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Disability Services - Guidance for Residential and Group Home Facilities

Contingency Plan for Home Support Managers and Health Care Support Assistants and Disability Managers/Personal Assistance (CD19-123 001 / 08.06.20)

• Purpose of this document

• General Measures to reduce the risk of accidental introduction of COVID-19 to a client/service user

• Providing planned home care for people who have suspected or confirmed COVID-19

• Client Schedule of Service

• Home Support Contingency Plan

• Prioritisation Classifications

• Action Cards

• Appendix

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Purpose of this document

To advise Home Care Support Teams/disability support teams on actions to be taken during the Covid - 19.  This document identifies:

• A sample client schedule of service.
• Prioritisation classifications.
• Action cards for the Home Support Co-Ordinator and HCSA/Personal Assistant or other providers of care/support in the home eg specialist nurses, voluntary providers etc.
• Additional operational matters for consideration included in Appendix I.

The Home Support Contingency Plan also identifies prioritisation of patients/service users/clients which has been reviewed in the context of three different scenarios:

1. Normal service to continue
2. Reduction of homecare/home support service
3. Alternative provision of care/support services

Please note, this document does not deal specifically with;

• Alternative models of practice with respect to clinical/therapeutic interventions
• Behaviours that challenge
• Facilitating testing for COVID-19 for service users

These are being addressed specifically in separate guidance documents. Other supports in relation to mental health are accessible at www.yourmentalhealth.ie.

Implementation of contingency plans will be led at local level within each CHO in collaboration with Disability Managers & Service Providers. Operational issues such as Garda Vetting for volunteers will be addressed at this forum.

Compliance with GDPR is a legislative requirement and standards will continue to be observed.

General Measures to reduce the risk of accidental introduction of COVID-19 to a client/service user

Current information suggests that COVID-19 can spread easily between people and could be spread from an infected person even before they develop any symptoms. For these reasons we suggest greater attention to cleaning and general hygiene and recommended social distancing measures. All care/support staff are requested call their managers before they go to work if they have a cough, temperature or shortness of breath.

 The following are some general recommendations to reduce the spread of infection:

• Informing all staff of the signs and symptoms of COVID-19 and advise them of actions to take if they or any close family members develop symptoms and to follow HSE guidance. Guidance should be in keeping with most current information from HSE and Health Protection and Surveillance Centre.
• Careful attention to hand hygiene with provision of hand sanitiser
• Coughing / Sneezing into tissue / elbow crook
• Encourage clients/service users to cover their nose and mouth with a tissue if they cough or sneeze
• Maintain a distance of 1m or more for clients/service users other than when you are providing direct personal care.
• Regular infection prevention and control training for staff with emphasis on Standard Precautions (including hand hygiene) and including the appropriate use of personal protective equipment. (see more detail on this below)
• Avoid eating or drinking in the client/service users home
• Clients/service users and their families/friends  who are receiving care/support in their home should be advised to let the service provider know as soon as possible if they have a new cough, temperature or shortness of breath, new onset loss of smell, loss of taste or changes to taste they should be advised to contact their doctor right away to facilitate testing as appropriate.
• If you arrive at a client/service users’s home and find that they have a new cough, temperature or shortness of breath, new onset loss of smell, loss of taste or changes to taste you should leave the room if possible or otherwise maintain a distance of at least 1m (ideally 2m) or more if possible and call your manager. If the person is not distressed but is on their own call a family member or other contact person. If you find it necessary to remain with the person or to approach within 2 m to attend to a person in distress the risk can be reduced by applying the basic precautions outlined above.
• If neither you nor the person you are providing care and support to have symptoms of a respiratory like illness, then standard infection prevention and control measures are appropriate. More information about general infection prevention and control can be found in the information booklet for Home Helps/Home Support Workers and Personal Assistants which is available online at: https://bit.ly/2x52A2h

Providing planned home care for people who have suspected or confirmed COVID-19

• Homecare workers who are able to provide planned home care for people with suspected or confirmed COVID-19 can play a critical role in helping to manage the COVID-19 emergency. Homecare workers undertaking this role will require some additional training to manage the associated risks. The most critical element of managing this risk is to review key skills (especially hand hygiene) but there will also be a requirement for appropriate use of personal protective equipment (PPE)
• Guidance on the appropriate PPE for each task is outlined in guidance on the HPSC website. The guidance is based on the task performed in whatever setting the task is performed. 
• Note that PPE must be used correctly to provide protection. Instructional videos on putting on and removing items of personal protective equipment are available on the HPSC website and should be followed.
• Staff providing planned care in the home for clients with COVID-19 should practice putting on and safely removing PPE before they visit the client’s home. Some details are provided below. New personal protective equipment is required for each person cared for. In some instances re-use of eye protection following cleaning may be necessary but eye protection will probably be required infrequently in most care settings. It is essential that used personal protective equipment is discarded into a disposable waste bag. This waste bag should be placed into a second waste bag, tied securely and kept separate from other waste within the home. It should be left for 72 hours before removed.
• Additional details on use of PPE (please refer also to guidance and instructional videos on the HPSC website https://bit.ly/3eL7LFC

Use of surgical masks

• Surgical masks should be worn by healthcare workers when providing care to individuals within 2m of a patient, regardless of the COVID-19 status of the individuals.
• Surgical masks should be worn by all healthcare workers for all encounters, of 15 minutes or more, with other healthcare workers in the workplace where a distance of 2m cannot be maintained
• If using a surgical mask, it should be snugly fitted to your face so that it completely covers the mouth and nose. Masks should not be touched or handled during use. If the mask gets wet or dirty from secretions, it must be replaced immediately with a new clean, dry mask. The mask should be removed using the appropriate technique Guidance for Health and Social Care Workers Who Visit Homes, V1.0 19/03/2020 HSE Health Protection Surveillance Centre www.hpsc.ie Page 7 of 8 – that is, do not touch the front, but instead untie it. Discard the mask after use into a waste bag and perform hand hygiene. Masks should not be reused. Respirator masks are only recommended for a small number of tasks (or example suctioning the respiratory tract). Eye protection (goggles or visor): It is unlikely you will require goggles for home care situations.

Putting on and removing PPE

• PPE should be put on and removed in the most practical place that can be identified. This may be in a hallway or separate room. If there is no hallway or other room, PPE should be put on and removed at a distance of 1 to 2 m from the client. It is essential that the correct sequence and procedure is followed for putting on and removing PPE as follows:

Putting on PPE

1. Clean the hands.

2. Put on a disposable plastic apron or where necessary for the task a surgical gown (see guidance).

3. Put on a surgical mask, secure ties/straps to middle back of head and neck. Fit flexible band to bridge of nose. Fit snug to face and below chin.

4. Put on gloves–and if wearing a gown pull gloves up over the cuffs of the gown.

Removing PPE In the client’s room

1. Remove gloves (avoid touching outside of gloves and dispose in waste bag).

2. Clean the hands.

3. Remove apron (or gown in required) by pulling from the back and avoid touching the front and dispose in waste bag directly outside the client’s room

4. Grasp and lift mask ties from behind the head and remove mask away from your face.

5. Avoid touching the front of the mask and holding the ties only, discard in a waste bag.

6. Clean the hands.

Watch a video for non clinical staff on how to prevent the spread of infection:

http://tiny.cc/4ghonz

Watch a video on how to put on and take off personal protective equipment (PPE)

http://tiny.cc/uhhonz

Application

• Home Support Coordinators / Organisers, Home Support Managers,Disability Managers, Health Care Support Assistants (HCSAs), Personal Assistants.

Definitions

Guidance

• Each Home Support Office/disability service manager must have an updated client list obtained from the Public Health Nursing department/disability service provider. This should be compiled in priority order with the most dependent clients at the top of the list e.g. clients requiring hoisting and/or 2 person call, clients with no relatives/extended family support. This list will inform Managers in the event of a reduction in staff numbers and or in the event of an increase in demand for Home Support due to a large scale outbreak involving staff, carers or clients.
• The list should be as comprehensive as possible to include a checklist with the following items below in the example shown.  Client/service users schedule of support should be attached/ also available as client may be receiving supports in conjunction with other services i.e. private providers, IWA and other disability support providers etc.

Client Schedule of Service

Home Support Contingency Plan

This contingency plan is to support clients/service users receiving home care to remain at home. Due to the Covid - 19 pandemic there is a risk that normal service could be interrupted and therefore alternatives will have to be explored. The following scenarios have been discussed with the Public Health Nursing Service/Disability Services and are deemed the most appropriate to maintain the individual in their own home. It is acknowledged that it will be necessary to work in collaboration with a range of community volunteer organisations, hospital based specialist services where they exist and consideration must be given to the optimal and safe utilisation of these services. Meals on Wheels and the Alone monitoring service are just some of the available supports to enable individuals  to remain in their own home. Work is ongoing in this regard as part of the overall response in relation to Covid - 19.

Prioritisation Classifications

Patients/clients/service users who receive home care support have been prioritised into the following categories:

This prioritisation of individuals has been reviewed in the context of five different scenarios:

1. Normal service to continue.
2. Reduction of homecare/home support service
3. Alternative provision of care/support
4. Intercurrent non-covid related illness
5. COVID Infection

In scenario 4 and 5 the main role of the Home Support Managers and Disability Managers is to ensure that all those involved in the care of the individual are aware of current status. Any clinical decisions relating to clinical care will be made by primary care physicians and/or treating hospital Consultant in collaboration with the individual and their family

Scenario 1: 

• Normal service remains in situ; care is delivered as normal.

Scenario 2:

• There is a reduction in home care/home supports services due to impact of Covid - 19. The national context must be taken into consideration in this scenario. Taking account of the vulnerability and safety of the individual, family/friends and those known to the person may be able to provide support. There will also be the utilisation of volunteer community resources.  The resources normally allocated to patients/clients/service users in the priority categories 3 & 4 can be appropriately redistributed to those in priorities 1 and 2.

Scenario 3:

• Due to the impact of Covid - 19 the scenario may arise where it is not feasible to maintain an individual in their own home. In this case the following contingencies would be appropriate. Consideration must be given to the fact that those individuals in the Priority 1 and 2 groups are those who would be categorised as at high risk both in terms of contracting Covid – 19 and their complex support and care needs would make them especially vulnerable.

Scenario 4

• Vulnerable disabled patients can be prone to other non-COVID illness – e.g. those with high levels of disability are prone to UTIs.  While every attempt should be made to treat at home, it may be necessary to admit to an intermediate care facility for medical management / IV therapies. 
• It will be essential to nominate facilities within each region that can provide this type of care in a COVID- free environment, where possible.  It will be necessary to identify these facilities at regional level to expedite early management, appropriate treatment and safe discharge. Any recommendations in relation to same will be made by the individuals primary care physician/treating consultant.

Scenario 5

• This will be determined by the nature of the underlying illness and feasibility of full mechanical ventilation.  Based on the underlying condition, early engagement with the appropriate hospital based clinical service will be essential (for example those with complex neurological conditions).  In many instances it will be entirely appropriate to transfer patients for full medical assessment and care, including mechanical ventilation. 
• It will be important to engage with the hospital based management services where they are available to provide guidance.  In some instances, it may be appropriate to introduce advance care directives.  This should be undertaken in a sensitive manner with experienced  senior health care professionals at consultant  / experienced SpR level, or a senior nurse specialist in the relevant clinical discipline / in association with  palliative care services. The person case managing the individual in the community should have easy access to relevant clinicians involved in the clinical management of the individual.

Staff related Scenarios

1. In the case of an on duty Health Care Support Assistant (HCSA)/ Personal Assistant/Home Support Worker who advises their line manager that they have been informed by Occupational Health or Public Health of their contact with a known diagnosed case: The Line manager advises them to return home and refers them to Occupational Health for further advice. Advice should be in line with the most up to date information from the HSE/Health Protection Surveillance Centre
2. In the case of a Health Care Support Assistant (HCSA)/ Personal Assistant/Home Support Worker  who complains of symptoms during working hours please use the following steps:  – Before your next client contact, please contact your line manager via phone and your GP (and/or helpline). Follow the advice provided to you. Advice should be in line with the most up to date information from the HSE/Health Protection Surveillance Centre
3. In the case of an off duty Health Care Support Assistant (HCSA)/ Personal Assistant/Home Support Worker who advises their line manager that that they have been informed by Occupational Health or Public Health of their contact with a known diagnosed case:  The Line manager advises the HCSA/ Personal Assistant/Home Support Worker to remain off duty and refers them to Occupational Health for further advice. The line manager should be familiar with the most up to date recommendations from the HSE/Health Protection Surveillance Centre when advising staff in terms of testing, self isolation and return to work.

Client related Scenario 1:

• In the case of a HCSA/ Personal Assistant/Home Support Worker who arrives at a client’s home and is advised that either the client or a member of the client’s family residing in the property is in self-isolation:  Do not enter the premises and contact line manager to establish next course of action. A risk assessment of HCWs with potential workplace exposure to Covid - 19 will be undertaken. 
  https://www.hse.ie/eng/staff/workplace-health-and-wellbeing-unit/covid-19-guidance/ 

Action Cards

Home Support Co-Ordinator - Action Card

Scenario Outline

This prioritisation of individuals has been reviewed in the context of three different scenarios:

• Scenario 1:  Normal service remains in situ; care/support is delivered as normal.
• Scenario 2: There is a reduction in home care/home support services due to impact of Covid - 19. The national context must be taken into consideration in this scenario. Taking account of the vulnerability and safety of the individual, family / friends and those known to the person may be in position to provide additional support. There will also be the coordinated utilisation of volunteer community resources.  The Home Support resources normally delivered to individuals in the priority categories 3 and 4 can be redistributed to those in priorities 1 and 2 and optimal informal carer input will be required for priority 3 and 4 clients.

• Scenario 3: Due to the impact of Covid - 19 the scenario where it is not feasible to maintain an individual in their own home. In this case the following contingencies would be appropriate. Consideration must be given to the fact that those individuals in the Priority 1 and 2 groups are those who would be categorised as at high risk of contracting Covid - 19. Priority 1 individuals would be especially vulnerable.

Health Care Support Assistant/Personal Assistant/Home Support Worker- Action Card

Scenario 1

• Ensure you are aware of latest client/service user priority listing.
• Ensure you are aware of the latest update from your Line Manager.
• Report any issues in relation to Personal Protective Equipment PPEs and supplies to your Line Manager
• Report any issues from your client/service user caseload – e.g.  relative symptomatic of Covid-19.
• Ensure attendance at any training sessions/information sessions in relation to issues associated with Covid-19.

Scenario 2

• Adhere to guidance from your Line Manager.

Scenario 3

• Adhere to guidance from your Line Manager.

Appendix

Additional Operational Considerations

Operational

• Identify additional sources to strengthen workforce - staff available to work increased hours, volunteers and agencies who have been identified and approved to support existing resources.
• Identify any training requirements required by existing staff or support agencies and volunteers.
• As appropriate, make contact with the treating physician / specialist nurse where available, if the patient carries a diagnosis for which there is ongoing active management or engagement with hospital services as appropriate
• Identify any requirement for the timely supply of PPEs.
  • In the event of urgent replacement/redeployment, ensure replacement staff  are suitably trained.
  • Access to the house is available.
  • Introductions by HHO may not be available and therefore prior arrangement by phone with client/families to ensure HCSA is arranged.https://www.youtube.com/watch?v=_4l7qvh5p80&feature=youtu.be
• Ensure all updates from local and national co-ordination teams are communicated to staff. Staff are also to be advised to monitor HSE and HSPC communications for updates due to the evolving situation.

Administrative

• Review (and update when necessary) client/service user list and level of dependency and those clients who may require services daily, every three days or may be deferred to weekly care.
• Ensure that the list also contains details of the treating / managing hospital based clinical service 
• Identify any additional sources of support - availability of family members who may be able to provide care/support, contact details of local community groups.
• Compile alternative roster based into allocated teams or increased working hours as a further contingency measure.
• Ensure all workforce/volunteer contact details are up to date and all relevant staff are aware of this list.
• Review existing business continuity plan and update based on existing situation. Your line manager to be informed of current status. Liaise with Local Co-ordination Group regarding current situation and supply chain in relation to PPEs.
• https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/guidanceforhealthcareworkers/