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International Review of Innovations to Protect Nursing Home Residents from Infectious Diseases such as COVID-19

This report reviews the international community’s experience with the COVID-19 pandemic in nursing homes, which has varied substantially across different countries. It focuses on the experiences of some countries that have had relatively few deaths in their residential care facilities: how they prepare for pandemics in general, how they responded to the COVID-19 pandemic and how their long-term care infrastructure improved outcomes. It also covers international experts’ recommendations for improving how nursing homes and assisted living facilities respond to infectious disease. The report concludes that the relatively successful countries’ responses to the pandemic align with the expert recommendations. 

spinner image Older Asian woman in nursing home wearing a mask
Getty Images

Pre-Planning for Pandemics

Countries with lower COVID-19 rates in residential care settings tended to have mandatory prevention measures for nursing homes in place, along with strong community prevention measures and access to PPE.  Hong Kong, Singapore, South Korea and Taiwan had previous pandemic experiences, particularly with SARS in 2003, that motivated them to create emergency plans that they deployed early in response to COVID-19. Nursing homes were part of these plans and had immediate access to PPE. In addition, the countries had aggressive testing, contact tracing, and quarantining measures that their populations largely followed. About mid-way through 2020, Hong Kong and Taiwan reported no COVID-19 deaths in nursing homes and Singapore and South Korea reported less than 20 each.  All four countries had started their infection control measures by February 2020.


Other countries were able to minimize COVID-19 deaths in nursing homes likely due to their infrastructure – physical and institutional. A report comparing the Canadian provinces of British Columbia (BC) and Ontario asserts that the differences in their nursing home COVID-19 death rates are due to BC having responded earlier and having had better coordination among the public health, hospital and LTSS (long term services and supports) sectors. As of September 2020, Ontario had 5,965 resident cases and 1,817 deaths in its nursing home population, whereas BC had 466 cases and 156 deaths. Ontario’s facility resident infection rate was 7.6 percent, compared to 1.7 percent in BC. BC also put more resources into its LTSS system in terms of funding and care hours per resident – 3.25 hours of care per day per resident versus 2.71 hours in Ontario. In terms of preventing transmission, only 24 percent of rooms in BC are shared, versus 63 percent in Ontario, and, BC restricted workers to one facility starting in March 2020, whereas Ontario waited until April.

The county of Denmark is also reviewed as a case study. It has fared better than many other European countries because of its better nursing home environments and better prepared staff. 

Expert Guidance

The ideas that experts and researchers have about how to mitigate the impacts of pandemics converge in several themes, outlined below; the experiences of countries that had fewer COVID-19 deaths in their nursing homes confirm these ideas.

Planning and Rapid Response – Develop a national coordinating system that: can be immediately responsive to pandemics; is data driven; is on hand at facilities for immediate implementation; includes teams with geriatric expertise.

Infection Control and Quality Assurance – Ensure adequate pandemic monitoring in nursing homes and assisted living residences; share monitoring results with the health care sector; ensure adequate stockpiles of PPE; test everyone entering a facility and give them hands-on training about infection control; limit transfers from hospitals during pandemics. 

Integration of Health and LTSS – Ensure that residents continue to receive essential prevention, treatment, rehabilitation, and palliation services; upgrade clinical services in nursing homes; develop methods of treating LTSS residents in the primary, secondary (hospital/acute), and tertiary (specialist) care settings. 

Scale Up Collaboration – Networks of facilities sharing evidence-based metrics to establish common improvement initiatives lead to better performance. 

Prioritize Residents – Involve residents in decisions about visitors; help them socialize and connect with family using technologies; maintain and plan for palliative care plans and advanced care directives.

Workers – Secure sufficient staff and restrict staff to working in one facility (which can be incentivized with adequate wages); provide a living wage, benefits, stable employment; empower and mentor them; inform them about infection control and the pandemic; consider psychological support for staff. 

Environmental Design to Reduce Virus Spread – Private rooms; outdoor spaces; designated spaces for community members to meet with residents; separate areas and staff for residents with symptoms; meals and break rooms for staff (to limit their exposure in the community).

Suggested citation: Reinhard, Susan C., and Jane A. Tilly. LTSS Choices: International Review of Innovations to Protect Nursing Home Residents from Infectious Diseases Such as COVID-19. Washington, DC: AARP Public Policy Institute, May 25, 2021.

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