Guiding Principles and Planning Assumptions – Visitor Policies and Access

Angie Szumlinski
October 22, 2020

In a recent publication in the Journal of Post-Acute and Long-Term Care Medicine, there was a discussion regarding finding the right balance on opening visitation in nursing homes and distinguishing between family caregivers and social visitors. The information is interesting and summarized below for your reading pleasure. The link for the complete article is also included if you would like to review the information in its entirety.

Family Caregivers Versus General Visitors

  • Must differentiate between “family caregivers*” and “general visitors”. Residents substitute decision makers and their families should have the authority and autonomy to determine who is essential to support them in their care.
  • Although socialization is certainly important, family caregivers* as partners in care should be prioritized to support resident health and well-being.
  • Family caregivers also help ensure that all residents receive culturally safe and appropriate care, especially for LGTBTQ2S and indigenous residents and/or those with language barriers.
  • Although family caregivers are used frequently, it is important to recognize that approximately 15% of all caregivers are not related to their care recipients including some who may be privately hired.
  • The importance of identifying family caregivers* is that they are not accessing the nursing home primarily for social reasons but rather to provide services and care such as assistance with feeding, medical decision-making and management of responsive behaviors among residents living with dementia.
  • Substitute decision-makers should make this determination for incapable residents.
  • Initially each resident should be supported in allowing the reintroduction of at least 2 family caregivers and these individuals should receive a caregiver identification card or badge.

*Family caregivers are those individuals who assume essential caregiving responsibilities for a spouse, family member or friend who needs help because of limitations in their physical, mental or cognitive functioning, and are essential to meeting the needs of residents especially in the face of chronic staffing shortages.

Restricted Access – Balance the Risks

  • Restricted access to visiting must balance the risks of COVID-19 infection with the risks of social isolation to resident health, well-being and quality of life.
  • Strict, blanket “no visitor” policies were enacted early on during the pandemic.
  • It is essential that we focus on the considerable detrimental effects of the ongoing lockdown of nursing homes and restricted access to family caregivers and general visitors.
  • Many residents have experienced severe and potentially irreversible functional and cognitive declines, deteriorations in physical and mental health, severe loneliness and social isolation, worsening of responsive behaviors and increased use of psychotropic medications and physical restraints.
  • Many residents have died alone without family present to support end-of-life needs.
  • Theses negative outcomes have raised concerns that the risks associated with ongoing blanket visitor restrictions outweigh the benefits associated with preventing COVID-19 outbreaks in nursing homes.
  • These restrictions may also be violating the autonomy of residents and their right to make informed and risk-based decisions which prioritize their access to visitors over the risks of them contracting COVID-19.
  • There is now a much better understanding of public health guidance and recommendations including universal masking as well as increased access to testing for the general public which will further reduce the risk of COVID-19 being introduced into nursing homes.
  • As partners in care, most family caregivers may already be trained and experienced in infection control and PPE procedures because other infectious outbreaks are not uncommon in nursing homes.

Equity over Equality

  • Visitor policies must prioritize equity over equality, recognizing that a “one size fits all” approach is neither optimal nor practical.
  • Equality would mean giving all nursing home residents the same access to visitors.
  • Equity means giving nursing home residents the right amount of access they need to maintain their health and well-being.
  • Visitor policies should not prioritize the convenience of the nursing homes over the best interest of their residents in receiving the care and support of family caregivers and visitors.
  • Nursing homes must reserve the right to create and implement visitor screening protocols consistent with local public health guidance and procedures for visits that maintain the safety and well-being of all residents and staff.
  • Blanket implementation of policies should be avoided and instead, policies uniquely supporting family caregivers and general visitors should be both flexible and compassionate, recognizing that some of the new conditions and procedures surrounding visiting may not work for all residents, family caregivers and visitors.
  • Provide flexibility around the timing of visits, the location of visits, the length or frequency of visits, absolute restrictions on physical contact, etc.
  • Family caregivers and general visitors must e able to receive the necessary PPE to facilitate these visits from the facility.
  • It is important that ample PPE supplies are available as a lack of supply could restrict access to visitors and negatively impact resident quality of life.

4. Transparent, Accessible, Evidence-Based Communication and Direction

  • Governments, public health authorities and nursing homes must provide regular, transparent, accessible and evidence-based communication and direction about visitor policies and access.
  • Many nursing home residents and their families and friends have grown increasingly frustrated about a lack of transparency and regular communication regarding the development and implementation of visitor policies and restrictions.
  • It is important that we be transparent about who is responsible for decision-making, which evidence and metrics are being used to develop and monitor responses to visitor policies and what are the timelines and outcomes for progression and regression of phased responses.
  • If visitor restrictions are required, they should be implemented in a transparent manner with the same open and clear communication provided to residents as well as their family caregivers and family members.

5. Data Related to Re-Opening Nursing Homes

  • Collect and report data on COVID-19 cases as it relates to reopening in collaboration with local health authorities and public health units.
  • It is true that it is less difficult to impose restrictions than it is to remove them.
  • Public Health and governmental authorities should be actively working to use modeling and evidence to remove visitor restrictions as quickly as possible as regional community prevalence declines.
  • The Resident Assessment-Minimum Data Set 3.0 is completed quarterly and with change in condition. This information can assist in assessing the impact of both restricted visitor access and the reintegration of visitors on resident health and well-being.

6. Feedback and a Process for Rapid Appeals

  • There appear to be marked inconsistencies in how regional visitor policies are being interpreted and implemented.
  • Residents, family caregivers and visitors in all jurisdictions need access to a feedback and appeals process.
  • Recognizing that ombudsmen and existing nursing home complaint and support lines do not function as arbitrators in these situations, homes should create a mediating appeals mechanism consisting of nursing home staff and members of existing resident and family councils to assist in resolving disagreements around visitor policies and the designation of family caregivers.

Remember, at the end of the day it is what you do that makes you special. Thank you for the continued care of your residents, families, and staff, stay well, stay safe, and stay tuned!

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