MC COVID-19 Governmental Response to the COVID-19 Pandemic in Long-Term Care Residences for Older People: Preparedness, Responses and Challenges for the Future

MC COVID-19 Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future

Greece Costis Prouskas Aktios

MC COVID-19 WORKING PAPER 07/2021 Contents

1. DESCRIPTION AND ANALYSIS OF THE ROLE OF THE RESIDENTIAL CARE SECTOR FOR THE OLDER-AGE POPULATION 3 1.1. The historical trajectory of LTC 3 1.2. Current arrangements in LTC 4 1.3. Debates around the development of a LTC system 12 1.4. LTC governance 18 1.5. General functioning of the residential care system 21 2. DESCRIPTION OF THE EVOLUTION OF THE PANDEMIC IN THE GENERAL SOCIETY AND IN THE RESIDENTIAL CARE AND HEALTHCARE SECTORS MORE SPECIFICALLY 24 2.1. General description of the epidemic: detection, scope and some data 24 2.2. The eﬀects of the epidemic on the healthcare system 27 2.3. The epidemic in public and political debate 30 3. DESCRIPTION AND ANALYSIS OF THE MEASURES ADOPTED TO ADDRESS THE IMPACT OF THE PANDEMIC ON THE RESIDENTIAL CARE SECTOR FOR THE OLDER-AGE POPULATION 32 3.1. Background of preparedness for the Crisis 32 3.2. The General Impact of the Epidemic on the Residential Care Sector and Policy Responses 37 3.3. Analysis 46 3.4. Examples of developments in speciﬁc care homes 49 CONCLUSION 53

REFERENCES 54

MC-COVID19 text of institutionalized older-age care (age Project Coordinators: Coordination mechanisms in Corona- group that appears particularly vulnerable Eloisa del Pino Matute virus management between diﬀerent in this epidemic context), in Spain as well Francisco Javier Moreno-Fuentes levels of government and public policy as in the rest of the EU-15. This study fo- sectors in 15 European countries cuses on the articulation of resources be- Research Team: tween health and social policies, and aim Gibrán Cruz-Martínez The political and administrative manage- to contribute to improve the effectiveness Jorge Hernández-Moreno ment of the healthcare crisis provoked by of the decision-making process and cru- Luis Moreno the COVID 19 is a key issue in preventing cial aspects in the ﬁght against the pan- Manuel Pereira-Puga the spread of the disease. The Mc-COVID demic. Findings also aim to be useful to Roberta Perna 19 project is set to analyse the socio-san- inform other public policy sectors involved itary co-ordination procedures in the con- in crisis-related situations. https://www.mc-covid.csic.es/

How to cite this publication: Prouskas, C. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Greece’, MC COVID-19 working paper 07/2021. http://dx.doi.org/10.20350/digitalCSIC/13695 Costis Prouskas 1. DESCRIPTION AND ANALYSIS OF THE ROLE OF THE RESIDENTIAL Aktios CARE SECTOR FOR THE OLDER-AGE POPULATION1 [email protected] 1.1. The historical trajectory of LTC

Greece was the ﬁrst Balkan country to gain full independence from the Ot- toman Empire in 1830. Initially the independent territory was only a small part of what is now considered to be Greece. Areas like Crete, the Ionian islands, central Greece, Epirus, Macedonia, Thrace and the Dodecanese were gradually incorporated, up to the late nineteen forties, with the exception of Cyprus which gained its own independence in 1960 (Press and Information Ofﬁce, Republic of Cyprus, 1995).

Greece, after the revolution against the Ottomans and the ﬁght for independence, became successively an absolute and then a constitutional monarchy (Clogg, 1992; Kokkinos, 1972), and a republic from 1968.

The country was involved in almost every war that took place in the region, including the 1897 war against Turkey, the Balkan Wars (1908 -1912), World War One (1914-1918), the Catastrophe of Asia Minor (1921-1922), World War Two (1940-1944), the Civil War (1944-1945), and the Turkish invasion of Cyprus (1974).

Most of these wars and tension periods inﬂuenced the development of the newly founded Greek state. For example, 70 percent of the land was added after the Balkan wars. The catastrophe of Asia Minor, as well as the Young Turks Movement in Turkey caused the resettlement in Greece of over one million refugees from Asia Minor and the Black Sea (Kokkinos, 1972;). Ac- cording to the censuses of 1907 and 1928, the population of Greece more than doubled (from 2631,9 thousand to 6204,6 thousands respectively) (National Statistical Service of Greece, 1991).

The Second World War led to large numbers of people dying in battles and from famine. The ﬂourishing Jewish community of Northern Greece was virtually annihilated (Clogg, 1992).

1 These events influenced the country, and its development in many ways. This series of reports is one of the Economic underdevelopment, bankruptcy and political instability stopped research results of the Mc-COVID-19 project, “MC-COVID19: Coordination adequate planning and development of educational, social, and develop- mechanisms in Coronavirus ment policies and services. management between different levels of government and public policy sectors in 15 European countries”, The problems and the political instability of the 1950’s and 1960’s, caused funded by the Spanish National by the wounds of the civil war, large scale migration and the Palace’s inter- Research Council (CSIC) within the ference with the democratically elected government reached their peak in CSIC-COVID-19 programme, as well as 1967 with a military coup. This contributed to a further disorganisation of of the GoWPER project, “Restructuring the Governance of the Welfare State: the social services, and of the weak administration system in general. The Political Determinants and Implications restoration of democracy in 1974 which followed the Turkish invasion of for the (De)Commodification of Risks”, Cyprus, as well as the public vote against the restoration of the monarchy CSO2017-85598-R Plan Estatal de opened a new chapter in the history of the modern Greek state (Clogg, Investigación Científica y Técnica y de Innovación. 1992).

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Finally, from the late 1980s large number of immigrants from Albania, Eastern European countries, and ethnic Greeks from Albania, Romania, the Black Sea (Pontic Greeks), as well as from Russia and Ukraine, settled in Greece.

To summarise, over the course of the last century the Greek population has experienced ﬁve major wars, at least four resettlements (refugees from Asia Minor, Alexandria, Constantinople, Albania/Black Sea) and mass em- igration to Germany, the United States of America, Australia, Canada and, in recent years, France, Italy and England (for political and educational reasons). The Greek population also suffered ﬁve years of German Occupa- tion, three military dictatorships, and a Civil War and went bankrupt several times from the inception of the state.

The circumstances above mentioned help explain Greece being poorer and slower than some other European countries in the development of a comprehensive system of health and social services for all of her citizens, including those over the age of 65.

The modern Greek state started with poor resources and the need to deal with the repercussions of wars, cholera, and absent and destroyed infrastructure.

The 1960’s, saw many more facilities for older people begin operation. Most of the residential units currently operating are licensed under an 1980’s law. According to the Ministry of Labor report, in 2020, approximately 300 Long Term Care Units were licensed in Greece with an average of 45 beds in each. Of these 53% are private (for profit) and the remainder (not for profit) are operated by NGO’s and the Church (Ministry of Labour, 2020). The country has no publicly owned elderly care facilities. Services provided in registered units include nursing and medical care, hospitality services and some recreational activities. Elderly care units operate under the supervision of the Social and Welfare Services of the Regions. The 2007 law set specifications and standards of operation as far as buildings and staffing is concerned. In general terms, the state and the insurance funds do not pay for the cost of staying in care units with fees being paid by the elderly person and/or their family. The current legal framework does not include any quality indicators and quality standards (Government Ga- zette, 2007).

1.2. Current arrangements in LTC

The Greek state is the main mechanism for ensuring social well-being and the redistribution of economic resources. It is also the exclusive insurance institution and through three mechanisms i) the social security ii) social care and iii) health care, it supports the social security system.

After the fall of the dictatorship of the colonels/junta in 1974, the process of normalization of political life and the modernization of the basic institutions began, part of a general process of achieving Greece’s accession

◂ back to table of contents GREECE ℅ 5 to the European Community. In this context, the construction of the state that includes the law and welfare is included. (Stathopoulos, 2005, Rapti, 2007).

Even though there has been a growing awareness amongst Greek governments of possible problems associated with the rapidly increasing number and proportion of elderly people in the Greek population, there has been no overall national plan for the development of health and social services for elderly people. Some programmes were initiated by service providers such as local authorities and NGOs, and wider policy measures are currently under review by the Ministry of Labour and Social Solidarity.

Long-term care in Greece is based on a mixed ‘quasi-system’ of services, comprising formal (public and private providers) and informal elderly care.

Formal Care providers include:

a. Primary Health Centers (Local) b. Hospitals (State, Regional and University) c. Day Care Centers d. Counseling Centers e. Rehabilitation centers f. Private Clinics g. Private Hospitals h. Elderly Care Units i. Services from Non-Governmental / Non-Proﬁt Organizations (e.g. The Red Cross, Alzheimer centres) j. Home Care Services by various care providers (Public, Private, Non-Governmental)

As far as informal care is concerned, the primary responsibility for the ﬁnan- cial and practical support of family dependants rests squarely and legally on the family and plays the dominant role in the provision of long-term care for older people, and this constitutes the main determining feature of the Greek long-term care system. (Kagialaris et al., 2010, Ziomas et al., 2018)

Ministry of Labour and Social Solidarity

The Ministry of Labour and Social Solidarity is the government department responsible for social policy programmes. The very small Ofﬁce for the Care of The Elderly has the following tasks:

a. Research and assessment of problems and needs, b. Studies of current forms and methods of care for healthy and chronically ill elderly people, and c. Approval of relevant programmes.

The main axis of all Governments in their policy towards older people in previous decades, has been the emphasis on providing pension support (Sextant, 1998).

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1980 saw some change in the direction of Public Policy with the development of the Open Day Care Centres for Older People (KAPI) in over 230 local authorities. In addition, several programmes e.g. KEFI, Help at Home were initiated focusing primarily on isolated elderly.

In the ﬁeld of health care, the National Health System failed to provide resources for the development of primary health care, thus increasing the load on hospitals and an increase in costs, though more recent developments are seeing greater stress on Primary Health Care (Loizou, 1991, Yfantopoulos, 2006, Pierakos, 2013).

Pension Schemes/Insurance Companies

The National Health System is similar to that of other European Continen- tal countries. Basically, treatment, other than emergency hospital care, is provided through the social insurance fund to which individuals contribute.

On January 1, 2017, the Uniﬁed Social Security Institution (EFKA) was created. It included 9 insurance companies, 4.2 million insured and 2.6 million retirees. The Social Insurance Institution (IKA) and the Agricultural Workers Fund (OGA) which until then had been the most signiﬁcant state insurance funds, plus others, joined EFKA from 1.1.2017.

Through EFKA, all services and regulations are uniﬁed for all policyholders. Two important developments in public health insurance are, on the one hand, the abolition of health visa requirements and the creation of a digital personal insurance account, where every citizen is able to follow his “insurance” course.

The Social Insurance Institution (IKA) that had covered almost the 70% of the population was the main fund for urban workers until 2011 and had tried to develop fully functional primary health care services with an action plan for the creation of primary health care teams in every region. Part of the job description of those teams would also be the promotion of preventive medicine and a healthier lifestyle as well as other more comprehensive health services. (Prouskas, 2000).

The Agricultural Workers Fund (OGA) provided a minimum pension to the elderly and widows and basic access to health services. It was a non-con- tributory scheme, with inadequate funds. (Prouskas, 2000, Yfantopoulos, 2006). OGA changed its name to Organization of Welfare Beneﬁts and So- cial Solidarity (OPEKA) that now provides the beneﬁts of OGA.

The National Organization for the Provision of Health Services (EOPYY) is a Legal Entity under Public Law which is now the main buyer of health services in Greece. The Organization was established by law 3918/2011 and started its operation on January 1, 2012, initially under the supervision of the Ministries of Labour & Social Insurance and Health & Social Solidarity in order to provide health services through a single national body. It was then placed solely under the supervision of the Ministry of Health (Pierakos,

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2013). Health Services that previously were provided by IKA, OGA or other insurance funds, are now provided by EOPYY.

Generally, no pension scheme or insurance company covers nursing home care expenses. They do, however, cover hospitalisation, pharmaceutical and part of rehabilitation and examination expenses.

Available State Services

Hospitals (Geriatric Units)

Rural areas have a higher proportion of people over the age of 60 than urban areas. In 1981, people over 75 in the islands of Northern Aegean Sea accounted for 8.5% of the local population, but by 2011 (the last de- mographic census), this had increased to 29%.

Hospital beds are concentrated mainly in the metropolitan areas of Athens, and Thessaloniki even though University hospitals exist in Ioannina, Alexan- droupolis, Irakleion, Patras and Larissa. While there are also non university regional hospital units.

There are a limited number of psychiatric hospitals with geriatric units e.g. the “Gemeleion” department of the Dromokaition Psychiatric Hospital in Attica, operating since 1988 as a Department of Short-term care for people over 65 years. The department focuses: a) on the examination and treatment of patients, and b) on efforts to channel patients, after their stay in the ward, either to their families or to respective psychosocial rehabilitation units (https://www.dromokaiteio.gr/, 2020).

Psychosocial Rehabilitation Units

The Psychosocial Rehabilitation Units provide various degrees of protection to people with chronic mental illness of different ages through accommodation, treatment and support in order to support their stay in the community. There is no limit to the time of their stay in it. Among the people who can be accommodated are people who need psycho-geriatric care and patients with end-stage dementia. The purpose is to maintain the quality of life and relieve the family of the burden of ongoing care (Greek Government Ga- zette, 2018).

Regional/Rural Health Centres

One of the basic tasks of the National Health System concerns the decen- tralisation of services. Regional primary care health centres were created and strategically placed. However, many of them are still inadequately staffed. Only some of them have managed to create an extended network of community service provision. In general, the network of Primary Health Centers and rural clinics is insufﬁcient, and patients are required to repeat medical examinations and procedures and wait in queues. This increases the cost of care, burdens the secondary and tertiary health care and

◂ back to table of contents 8 ℅ MC COVID-19 increases the operating costs of the NHS. (Pierakos, 2013). The main advantages is that chronically ill elderly people can easily get their medica- tions prescribed without having to go to private clinics or public hospitals, and develop a relationship of trust with their doctor, even if he or she is not typically a family doctor.

Regional and Municipal Services

Local Authorities and Regional Governments

Another provider of social welfare programmes is the Local Authorities and the Regional Governments. They are responsible for the assessment of local needs and the initiation of several measures. Both regional and municipal authorities have the jurisdiction to operate nursing homes, medical centres as well as Open Day Care Centres (KAPI). Regional governments are also responsible for the licencing and supervision of Long Term Care facilities such as nursing homes.

Community Mental Health Centres

These services are organised by the psychiatric departments of the university hospitals. They employ health professionals specialised in Mental Health care, and are able to give directions and information regarding mental health problems (Stathopoulos, 2007). The Mental Health Centers are the heart of community mental health care. Their purpose is the prevention and treatment of mental disorders, contributing to the psychosocial rehabilitation of the mentally ill, to psychosocial care and counseling interventions in the community. Their services include crisis intervention and home care (https://www.psychargos.gov.gr/, 2020).

Municipal Medical Centres

Municipal authorities such as those in the Greater Athens and Thessaloniki areas began operating local medical centres. However, these centres are not afﬁliated with the National Health System, are not staffed by full-time health professionals and do not provide complete coverage of health care needs (Stathopoulos, 2007).

Open Day Care Centres (KAPI)

The primary scope of these Centres was to contribute to the harmonization of family and working life, fsupporting family members, especially working women, who are usually in charge of the care of dependent elderly family members. The Centres are small day care structures and operate to cover the working hours of family members (Kotaridi, 2007).

The KAPI programme was initiated in the early 1980’s by an NGO, the Red Cross and then the Ministry of Health and Welfare. The responsibility for running the Open Day Care Centres was passed to local authorities in 1995, and since then, several municipalities have supported initiatives

◂ back to table of contents GREECE ℅ 9 to improve the quality of life of elderly people and their carers. In 1998, the government obtained funding through the European Union to fund a pilot programme for two years of home care services for elderly people in over 140 municipalities, to be organised and run by each municipality. The “Kapodistrias” legislation project, aimed to give the local government and the local societies the capacity to raise and administer their own funds (Prouskas, 2000).

They are small local centres dedicated to meeting the needs of the elderly local community. For example, KAPIs should provide social work for home bound elderly people, physiotherapy, meals on wheels, instructions and care on medical and nursing issues, as well as psychological support and leisure activities (trips, visits to archaeological sites, swimming etc.) (Sextant, 1998; Loizou, 1991). They were considered to be the spinal cord for the creation and co-ordination of services for elderly people with their further development benefiting the community (Kalligeri-Vithoulka, 1996; Walker and Maltby, 1996). However, the programmes lack organisation and co-ordination, as well as services such as psychological support, and preventive medicine. In many instances the lack of appropriate space and facilities is an added problem. In addition, KAPIs need constant financing from the local authorities, which is often problematic, originally due to the small size of authorities. Though Local authorities now are larger, more powerful, and able to obtain and manage their own funds, the years of the economic crisis 2008-2018 saw a serious cut back in L.A. funding which impinged on staffing.

Care at Home

The ﬁrst home care service launched in 1984 to meet the needs of the elderly at home was the “Help at Home” programme of the Gerontological Department of the Red Cross. (Triantafyllou & Mestheneos, 1993)

The Help at Home Program has been successfully tested and implemented, with the aim of providing home care for the frail elderly, especially the weak or lonely, to improve quality and maintain their autonomy and independence by providing psychological support, consulting, nursing and assistance services (eg. paying bills, shopping, cooking, cleaning). (Lyberaki, 2018)

Greek Orthodox Church

The Ottoman laws which prohibited the confiscation of ecclesiastic property resulted in the Greek Orthodox Church having tremendous financial assets. As an institution its position in Greek society has been, and continues to be, one of great influence. At present, the church runs a service network for elderly people. Nonetheless, these services, no matter how well intended, rather depend on the enthusiasm of the volunteers. They do not take place under a more generic plan, and thus they are not part of the infrastructure of or coordinated with national Social Services. It is worth noting that the financial position of the Church could enable the creation of permanent

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Free dinners and Social Groceries

Until the 2008 economic crisis, free dinners were a service mostly provided by the Greek Orthodox Church. In most cases they were staffed by a priest and by a number of volunteers. Even today, they provide free lunch and dinner to the poor and to people over the age of sixty. Everyone is eligible and has the right to access these services. Sometimes, the volunteers take over duties such as visiting elderly people at home, assisting them with shopping and accompanying them to the doctor.

Municipal authorities organized services in order to help residents of their cities most affected by the economic crisis and austerity measures. Servic- es of a “social grocery” were created which provided free groceries, deter- gents, frozen products, clothes, home appliances, toys, etc. for families and elderly people facing serious ﬁnancial problems.

Dementia Day Centres

Founded in 1997, the Dementia and Alzheimer’s Day Centres provide psychological support for demented people and their families. They are non-governmental centres, working in co-operation with the local authorities, that aim to expand community services including cognitive and De- mentia detection tests. The purpose of the Dementia and Alzheimer’s Day Centers is the daily - systematic monitoring of patients, their employment in activities, and their socialization. They also provide assistance for medical, social, insurance and legal problems. Through pharmaceutical or non-pharmaceutical approaches (mental exercises, psychotherapeutical groups, multisensory activities), social services and other services, they try to reduce the burden on the family and improve their quality of life and that of the demented. (www.alzheimerathens.gr, 2020)

Private Sector

The private sector in Greece provides hospital care and nursing home care for elderly people. Organised private initiatives for the care and support of elderly people at home are minimal. Since 2000, there has been some development of private domestic and home care services, a nursing at home service, a meal delivery service for elderly people, and accompanying services.

Elderly Care Units

Elderly Care Units in Greece are operated by the state, charities, the church, and the private sector. A number of institutions with variable standards and varied admissions requirements provide nursing care for elderly people. Perhaps not surprisingly, the status of nursing homes in Greece is quite problematic and services are to a great extent privately owned.

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Almost none of the public or private social insurance agencies offers ﬁnan- cial assistance towards the costs of nursing home placement. Furthermore, due to the small number of beds in the public hospitals, hospitalisation of an elderly person is permitted for only a few weeks. (Prouskas, 2020).

Thus, the caregiving family of the elderly person has to meet all associated expenses without any financial support from the state, since retirement income is usually insufficient to cover the costs in the contemporary Greek market of nursing homes (Prouskas, 2020). Since the health care system provides no assurance or support to the families of the elderly, these families have to face their problems on their own. This heavy burden constitutes a major stress factor in the lives of the caregivers and their role typically becomes more difficult and complicated, not less (Sextant, 1998, Lyberaki, 2018).

Way back in 1981 the Greek Statistical Agency reported less than one nursing home bed for every one hundred patients over the age of sixty-ﬁve in need of residential care ie. an elderly person unable to perform vital ADL (Dontas, 1981). A major problem is rooted in there being no law describing in detail the prerequisites that a nursing home must meet before obtaining a licence. Between 1984 to 1989 no licenses were given for the creation of new facilities. Consequently, many hotels started functioning as Homes for the Aged, creating confusion in the public since there was no assurance and information available regarding the licensed and unlicensed institutions (Prouskas, 2000).

In addition, the fact that the nursing homes were very closely related with asylums created a public suspicion as to their professional function. The absence of any support from the state to either caregiving families or nursing homes made matters worse.

Until the ends of the 90’s no action had been taken for the creation of new beds. However according to the report of the Social Protection Committee (2002), data from the Ministry of Health (2019) and GCHA / PEMFI2, the coverage of beds in Elderly Care Units increased by 40% between 2000 and 2019.

This situation improved after Law 1136/2007 was issued, that stipulates the “Conditions for the establishment and operation of Elderly Care Units by for-proﬁt and non-proﬁt entities” (Greek Government Gazette, 2007).

2 Greek Care Homes Association (GCHA/ Since only a small percentage of those in need of Long Term Care are in PEMFI). PEMFI, established in 1974, residential care, the number of dependent elderly and disabled people in represents all legal structures in the community is high. The issue of families caring for dependent elderly Greece that host elderly people and their employees. One of its main aims people will be discussed further on. is to assist the Greek state and the European institutions in the formulation Other Available Services of realistic policies concerning Long Term Care, mainly for the vulnerable group of older people in closed care There are a number of small scale elderly care services, in the form of pilot structures. (www.pemﬁ.gr, 2020) programmes, or run by volunteers.

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Rehabilitation centres: Private nursing homes and clinics (small hospitals) are the venues for rehabilitation programmes. Again however, these lack specialisation, planning, and development. Some insurance companies pay some of the fees for private practitioners (speech therapists, occupational therapists).

Respite Care: In some cases hospitals are used by family members as a form of emergency respite care. Nursing and residential homes often fulﬁl this function as well, especially during the summer months and vacation periods.

1.3. Debates around the development of a LTC system

Role of the Family and Informal Care

The lack of a comprehensive system of service provision for elderly people in Greece generally left them in a disadvantaged position (Gournas, Madianos and Stefanis, 1992). In earlier decades, families supported one another at various life stages, and informal family care and support has always been critical. Poverty was strongly related to age, with older people more likely to live in poverty than younger people (Tsakloglou and Panopo- ulou, 1998). In recent years, after the economic crisis, this changed as unemployment and lower wages meant that many older people were relatively better off. However, this did not mean that there were resources to cover the costs of residential care. Unemployment rates amongst older women 50 plus suggest that some lost their jobs and others, especially on low salaries, left jobs to undertake care work in the family ie for grandchildren and older relatives.

The Greek constitution makes the child of an elderly person responsible for his/her welfare and support. This reﬂects an established trend in Greek society. The Greek family is in both ideological and relative terms the central social institution.

The role of family and kinship is very signiﬁcant, and this reciprocity of gifts, services, and support occurs beyond the context of the narrow nuclear family. As mentioned before, childless people can make provision for this care in period of need by offering gifts to cousins, nephews, etc. The absence of alternatives, as far as welfare state support and services are concerned, contributes to the formation and endurance of such support networks. This, along with the fact that life patterns are changing, people are living longer with chronic illnesses, makes the life of carers of older people in Greece more stressful and care more demanding.

The traditional domestic role of women in Greece helps explaining why carers assume the responsibility of looking after the elderly person without state support. In recent surveys, carers appear not to expect more services to be provided by the state. They admit to feeling uncomfortable with the idea of having strangers walk into their home and take care of their parents. What they would expect and wish for however, is ﬁnancial assistance. Many

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Table 1. Older people: population categorised by age group

Greece Total Population 10.816.286 %

60-69 y.o 1.134.045 10,5%

70-79 y.o 1.017.242 9,4%

80+ y.o 583.334 5,4%

Total pop. over 60 y.o. 2.734.621 25,3%

Source: ELSTAT, 2011

carers of elderly people in Greece say that they would prefer to have their dependent parents/spouses at home, and receive income support from the government in order to meet their needs in ways that they feel would be more appropriate (Sextant, 1998, Eurofamcare, 2006, OECD,2011, Sakelariou 2015). A considerable proportion of those with good incomes have turned to the use of foreign immigrants as a solution to the problem of care at home for an elderly person (OECD, 2011).

As shown in Table 1, according to the latest census of the Greek population in 2011 (www.elstat.gr, 2020) the population over 60 years constitutes 25% of the population. The Hellenic Association of Geriatrics and Geron- tology (Ε.Γ.Γ.Ε. / HAGG) forecasts that in 2030 people age over 65 will be about 30%. OECD’s report shows that care for demented people burdens almost 70% of the caring families.

Living and Household Conditions

In Greece, the main care obligations for elderly dependent people falls upon their families. However, after the 2008 economic crisis care provided by the family became much more difﬁcult. Households with older people spend proportionally more of their income on health (Eurostat, 2019). The out -of -pocket expenditure as shown in Figure 1 is nearly 40% and just 20% lower than the State Health expenditure.

The multigenerational households that provided support to elderly members have tended to break up, mainly due to changes in lifestyle, as well as the result of the massive urbanisation that Greece experienced in earlier decades (Prouskas, 2000). Poulopoulou-Emke (1999) and Sakelariou (2015), argue that the family and family caregivers are the most important providers of elderly care. Caregivers are heterogeneous in terms of age, gender, relationship and cohabitation with the dependent person.

According to Dalaka (2014), the shrinkage of the so-called welfare state as a consequence of the economic crisis, observed in EU members such as Greece, lead to a constant shift in the volume of care provided from formal (State and Private Sector) to informal structures. That way, relatives

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TotalState Exp % Total OOP Exp % Private Insurance % OOP % 60,70% 60,50% 58,70% 57,70% 57,60% 40,90% 40,90% 40,60% 39,10% 38,80% 37,10% 36,80% 36,40% 35,10% 34,90% 4,40% 4,00% 3,90% 3,80% 3,80%

2014 2015 2016 2017 2018

Figure 1: Health Care Expenditure 2014-2018. Source: ELSTAT, 2020

shoulder the main responsibility for care of dependent elderly people, either themselves or with the help of paid caregivers (many of whom are informal).

As shown in Table 2 (ELSTAT, 2020), Greece’s population at risk of poverty in 2015 is 12% higher than the EU27, when the exit from austerity was announced. By 2019, it decreased by 5.7% (from 35.7% to 30%), but still remains higher than the European average. In 2019, 12.2% of those in poverty were people over 65 years, and 8.9% were retired, 2% less than in 2015.

Important data appear in Table 3 (ELSTAT, 2020) regarding the population living with material deprivation. Despite the decrease in the population living in material deprivation, from almost 40% to 30% in the period 2014- 2019, the percentages remain high. Almost 35,7% of minors and 28.3% of the elderly over 65 y.o, lack materials such as heating, TV, and even basic food (chicken, red meat, vegetables, fruits). The correlation between deprivation and age groups is of high importance, because due to high unemployment after 2010, older retirees were called on to help their children, their children’s families or even their grandchildren ﬁnancially. But even after the ﬁnancial crisis, 1/3 of adults 18-64 years old do not seem to be able to pay rent and bills for goods such as electricity and water.

Material deprivation and lack of adequate income for living, burdens families who have to care their elderly parents or relatives, especially those who need constant medical care, medication and 24-hour supervision and care.

According to Table 4 (ELSTAT, 2020), which refers to rooms per household, 46.5% of the population lives in houses with 3 rooms (including the living room). The second highest percentage (24.3%) are those who live in a house with 4 rooms. Only 7.3% live in houses with more than 5 rooms. Re- garding the rents, they have now reached 340 Euros on average for a house with 3 rooms in Athens, not including the costs for electricity, water and / or

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Table 2. Population at Risk of Poverty, Greece

2014 2015 2016 2017 2018 2019

Total in Euros 4608 4512 4500 4560 4718 4917

Greece 35,7 35,6 34,8 31,8 30

EE27 23,8 23,7 22,5 21,6

65+ 14,70% 13,70% 12,40% 12,40% 11,60% 12,20%

Pensioners 10,80% 9,70% 9,50% 8,70% 8,90%

Source: ELSTAT 2020

Table 3. Population (%) Facing Material deprivation 2014-2019, Greece

Age Groups 2014 2015 2016 2017 2018 2019

Total pop. % 39,5 39,9 38,5 36 33,5 30,2

0-17 41,9 44,5 42,3 38,3 39,3 35,7

18-64 40,1 41,5 39,6 36,6 34,2 30,7

65+ 35,7 34,9 34,4 32,3 30,8 28,3

Source: ELSTAT 2020

Table 4. Living Conditions: Number of rooms per household (%), Greece

Rooms 2015 2016 2017 2018 2019

1 3,8 3,7 3,7 3,2 3,3

2 19,9 19,8 19,9 18,8 18,6

3 48,7 47,5 47,5 46,7 46,5

4 20,4 21,6 21,5 24,1 24,3

5 5,5 5,5 5,3 5,7 5,6

6+ 1,7 1,9 2,1 1,5 1,7

Source: ELSTAT 2020

telephone. As a conclusion, a family that is called to “host” and take care of an elderly person, most likely to live in a house with 2 rooms and a living room, which affects the quality of life and health of both family members and the elderly, as well as the relationships between them.

Regarding the elderly population over 65 y.o. living alone (Table 5, ELSTAT, 2020), it is reasonable to expect its increase, since the elderly population

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Table 5. Distribution of population aged 65 and over by type of household (single person)

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Total 18,6 17,6 19,1 23,5 24,2 23,9 24,1 24,6 24,4 24,1

Men 6,1 6,1 7,1 11,7 12,6 11,9 11,8 12,7 11,7 11,6

Women 28,6 26,9 28,8 33,0 33,5 33,5 34,0 34,2 34,7 34,3

Source: EU-SILC survey, Eurostat, 2020 is constantly growing. The last decade saw an increase of almost 6% in the total population aged 65+, living alone.

The percentage of women living alone over 65 years of age is clearly higher (34.3%) compared to that of men (11.6%). Both men and women show a similar increase of 5-6% from 2010 (6.1%, men and 28.6% women) to 2019 (11.6% men and 34.3% women). This can be explained by three factors:

a) Women’s life expectancy is higher (84.4 years for women and 79.3 years for men) b) The population of men over 65 years is smaller (18.2%) than that of women (21.3%) c) Men over the age of 65 may be more dependent or seeking more care than women of the same age. Though women’s greater longevity means more women need care.

The caregivers’ opinion

Caring for elderly people requires social interaction to meet social, economic, psychological and social needs. The existing public social and health services to support elderly people and their caregivers are limited. As already reported, a large proportion of long-term care is of an informal nature and provided by the family. Thus any attempt to estimate the total cost of care will fail, unless the cost of informal care is taken into account. It should also be taken into account that the proportion of elderly people residing in institutions and the proportion of families receiving formal care at home is very low (MoH, 2005).

The state hospitals are widely used by elderly people and their caregivers. Experience shows that the long stay of some elderly people in a state hospital structure is due to or prolonged due to the lack of alternative services for the elderly and carers. (Triantafyllou & Mestheneos, 1993, Prouskas, 2000,2020).

There were an estimated 8.500 beds in private LTC units in 2005. Prouskas (2000) mentions that until then there were many unregistered small elderly care units (care homes), so the total number comes from calculations. Since then, the growth rate of beds has been exponential. As mentioned in section 1.2, beds capacity increased over 40% in the last 15 years (by

◂ back to table of contents GREECE ℅ 17 almost 14.000 beds). According to the OECD (2011) report, in Greece 8.7% of the population declared that they were informal care givers.

Families are in a constant dilemma about caring for elderly parents. Stud- ies, as early as that of Pitsiou (1986), highlight the importance of maintaining family ties for good mental and physical health and the well-being of elderly people. Prouskas (2012, 2020) states that the decision to choose between home care and admission to an Elderly Care Unit is not easy. Fami- lies are governed by a confusion between emotional and logical arguments.

On the one hand, they are stressed by the emotional ties with the person in need of care, by the social pressure to care but also pressure from relatives. On the other hand, they have to face the demands of care, the psychological burden and the frictions inside the family arising from the fatigue of caring (burn out) as well as the reactions to the elderly due to their mental functioning or psychological transitions.

The following table (Table 6) contains results from a national survey report, conducted by Triantafyllou, Mestheneos, Prouskas et al. (2006) for Euro- famcare (https://www.uke.de/extern/eurofamcare/deli.php, 2020) on the opinions of family caregivers about caring.

Table 6. Caring: The Caregivers’ opinion

Caregiver’s opinions %

Cope satisfactorily 83,20%

Caring is worthwhile 90,70%

Have a good relationship with the person they look after 91,70%

Have support from family and friends 52,50%

They enjoy their families support 75,10%

Feel their job as carers is appreciated 80,40%

Their health is good or excellent 67,70%

Rank their life’s quality from good to very good 50,20%

They will continue caring in the future 70%

Believe that care is very demanding 55,10%

Admit that care provision causes problems among family members 13,40%

Feel that care causes ﬁnancial problems 27,80%

Feel trapped in their caring role 30,70%

Face problems with family and friends, due to care 22,80%

They receive help from several support services 36,30%

Care provision negatively aﬀects their health status 27,60%

Source: Eurofamcare, 2006

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The majority (over 80%) considered that the care they offer is worthwhile and appreciated, that they have a good relationship with the dependent person and work well together, even though the caring process is demanding (55%). But there are negative aspects. At least 60% face ﬁnancial issues and need social support services. 35% faces problems in their personal relationships -with family or friends- caused by caring and 30,7% feel trapped in their role as a caregiver.

In the same report statistics showed that only 25% of the elderly people receiving care were independent and lived alone: 60% lived with their partner and another 54% reported living with their children. The degree of depend- ence was high. The majority of elderly people needed help with household chores, with arranging their medical issues and taking their medication. More than 50% needed help with personal care while they also needed help with ﬁnancial support (52.5%) and management (79,2%) .

Care Sharing

In the developed, industrialized countries of Europe the post-war social contract between capital and labor which supported state beneﬁts, was based on national regulatory gender differences that reserved the role of career and employment for men and that of caregiver and housewife for women. Yet women have traditionally been an important part of the civil service working in social sectors as teachers, nurses or paid caregivers (Prouskas et al, 2012). However, the need for exclusive care for elderly people at home by the rest of the family and the growth of caregiver roles by women of working age intensiﬁed their inability to access the labour market and, therefore, increased the female unemployment/non-employment rates (OECD, 2011).

Care for elderly people is mainly offered by spouses (approximately 30%) and adult children (30%-40%), 80% of whom are women. The percentage of women caring remains one of the highest among European countries. The usual age of women is 40-55. They are burdened, on one hand by the demands of work and their own family, and on the other hand by the need to care for their parents. In families with more than one child, the care of elderly people is taken over by the child that lives closest. Although women take more care of the family, men feel equally obliged or affected. Men more often provide ﬁnancial assistance, transport, shopping, dealing with authorities, while women are more involved in personal care. (Kostaridou- Efkleidi, 1999, 2011; OECD, 2011,2018, Prouskas et al, 2012, Lyberakou 2018)

1.4. LTC governance

It should be stated at the outset that there is no universal statutory scheme for LTC in Greece nor comprehensive formal long-term care services that guarantee universal coverage. LTC (including prevention and rehabilitation services) has been an underdeveloped policy area. There is no speciﬁc model of organizing Long-Term Care: identiﬁable are combinations that

◂ back to table of contents GREECE ℅ 19 are relevant to the “EverCare” model (a personalized approach and holistic approach) and the “GuidedCare” model -but this is not a central management policy choice. A common point of the two models is the importance of nurse-caregivers, cooperation with the treating physician, connections with the local community and the National Health System (Pierakos 2013, Ziomas et al. 2018, Prouskas, 2020).

The issue lies in the non-coverage of Long- Term Care by state insurers. Thus, regarding the Long-Term Care of the Elderly, day hospitalisation expenditure is not justiﬁed, nor has it been costed, while the costs of medical care, medicine and other therapeutic costs are justiﬁed (e.g., physiotherapy, occupational therapy) both by the state insurance funds and by those private insurance companies operating in Greece. Non coverage also ap- plies to other Long-Term Care Units such as psychiatric structures, treatment centers etc..

The state’s involvement in this policy area is rather limited, while governance and organisational arrangements are grossly inadequate. The state ﬁnances and controls the National Health System, ie Health Centers, Hospitals, etc. and the social services mentioned above, ie the home care program, the social beneﬁts (social assistance allowances and pen- sions).

The rest of the state social structures for older people are funded and con- trolled by the Regions and the respective Municipal Authority. The Regions also license and control the Elderly Care Units in their operational and health activities. The main changes introduced into the health system have focused on the work and role of the central state.

There are actions concerning funding, with common new trends in service delivery and the emergence of hybrid systems. These trends can be sum- marized as follows:

1. Variations in the systems of public supply. 2. The retreat of the state as a direct service provider of health (in paral- lel with a shift from hospital to primary care) where private providers traditionally play a more important role. 3. Rearrangements in the regulation of relations between the three main institutions of the health care system - the state, the health funds or associations of health care providers, and the private doctors involved in the “health market”.

Existing studies distinguish three basic modes of coordination (or “ideal” modes of regulation) between the above bodies:

(a) the exercise of hierarchical control by the state, or in other words, the state hierarchy, (b) collective bargaining, where the Contracting Parties shall interact, on equal terms, with a view to the development of collective agree- ments, and

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(c) the competition agreement, with rivalry between individuals or groups and therefore more selective and unstable relationships. (Petmetzi- dou et al, 2015, Rothgang, 2009)

Both the State and its bodies and private initiatives have developed a set of bodies for the delivery of cash benefits, materials and services for the elderly. In the public sector, cash benefits relate to retired but uninsured elderly people; health care and financial support for the elderly with disability level of more than 67%; exceptional financial assistance in cases of emergencies; and rent subsidy for lone persons or couples over 65 years old facing economic problems.

The average pension is 882 euros per month (713 euros main pension, 169 euros supplementary). According to Ministry of Labour, Social Security & Social Solidarity’s display of pension beneﬁts, about 1,5 million elderly people aged 71 to over 90 years old receive a pension of no more than 880 euros. Those aged 85 to over 90 do not receive more than 650 euros on average. 34% of pensioners receive over 1000 but not more than 1150 euros on average

The benefit policy cannot meet the real needs of destitute elderly people since the benefit amount is usually quite small while ineffective bureaucratic procedures have unsurprisingly, made the whole process more difficult.

Beneﬁts in kind relate to the provision of clothing, medicines and food to helpless or destitute elderly people and are administered either through their local church, through the Red Cross or other Third Sector organizations. Overall, in addition to the State, local authorities, the church and various charities have contributed to the care of the needy and vulnerable by cover- ing many state malfunctions and inadequacies.

In Greece there are no “intermediate institutions” i.e., medical or convales- cent homes, to complete treatment after a hospital so that there can be a full recovery. Concerning LTC, the State is just an observer and a regulator for LTC providers. With the exception of the local Day Centers and community or home care programmes, mentioned previously, the State is absent in the provision of LTC Units.

Of the total 14571 beds in LTC units, almost 50% are based in the Attica Region (Athens, Piraeus and the suburbs), with 47% provided by not-for-profit organisations and 53% by the private sector. A list of 295 operating El- derly Care Units can be found in the 2019 records of the Ministry of Health. Amongst these 294, 145 are for proﬁt (Private Sector) and 148 are run by the church or an NGO (Third Sector- non for proﬁt). The one characterized as a Public Entity is an ecclesiastic foundation without operational authorization. There are 30 unauthorized Units in the Private and Third Sectors. The reasons for non registration are either due to bureaucratic reasons, as they have to wait for the regional administrative bureaus to publish the operating authorisation, or they are church institutions that started as humanitarian institutions or asylums (elder care charities) with an initial authorization which has never been renewed since then.

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Table 7. Gazettes of the Greek Government referring to Long Term Care

Year Gazette/Law No Title

1972 29/1118 Legislative Decree (L.D): On private enterprises for the care of elderly or disabled persons with chronic diseases

1972 223/770 L.D: Conditions for the establishment and operation of private care companies for elderly or disabled persons with chronic diseases

1977 134 Amending Decision (A.D): Amendment of the conditions for granting loans through the Commercial Banks for the construction, extension and completion of private clinics and training facilities as well as care facilities for elderly or disabled persons, mentally disabled and disabled children

1978 180 Ministerial Decision (Min. D.): Granting of pre-approval authorisation for the purpose of taking out loans for the building of nursing homes

1979 55/877 Replacing and supplementing provisions of Law 1118/1972 and regulating related matters

1979 204/Presidential Decree 692 Presidential Decree (P.D.): Conditions for the establishment and operation of private enterprises for the care of elderly or disabled persons or persons with chronic diseases

1979 922 Min. D.: The purpose of determining the supporting documents required for the granting of authorisation for the establishment and operation of private care undertakings for the elderly and those suﬀering from mobility and temporary authorisation

Min. D.: On how to set up the Committees for the establishment and operation of private care enterprises for the elderly and for persons with mobility disabilities

1995 213/2345 L.D.: Organised Social Welfare Protection Services and other provisions

1996 455 Min. D: Conditions for the establishment and operation of Elderly Care Units (MFI) by private individuals (for-proﬁt)

2007 1136 Min. D.: Amendment and supplementation of ministerial decisions “Conditions for the establishment and operation of Elderly Care Units by for-proﬁt and non-proﬁt entities.

2011 32/3919 L.D: Principle of professional freedom, abolition of unjustiﬁed restrictions on access to and pursuit of professions

2011 Amendment and supplementation of 1136/2007 and 2190/2009

2012 38 Cabinet Acts: Structural Labour Market Arrangements

1.5. General functioning of the residential care system

The institutional framework for the establishment and operation of the For-Proﬁt Long Term Care Units is determined by legal provisions and ministerial decisions referred to in the Government Gazette Sheets (FEK) as shown on Table 7.

During the dictatorship (1969-1974), the Greek Junta published two legislative Decrees in 1972, which included the “Nursing Houses for the very

◂ back to table of contents 22 ℅ MC COVID-19 old” under the supervision and control of the Ministry of Social Services. The ﬁrst (Law 1118/72) descriptively set out a clear framework for basic operating conditions within units, the pre-requirements for installations, the ﬁnancial-accounting directives, the sanctions and the licensing of the Nursing Units. Until then, as mentioned earlier, the Housing and nursing Units operated without legal permission under laws concerning their charity status and social assistance.

The second Legislative Decree (Law 770/72) set out clearly and in detail spatial, economic and administrative operations, e.g., sq.m./bed for a capacity of 50 and 100 beds, classiﬁcation of room class according to number of beds, etc. but without setting any prerequisites for the quality of the services provided.

The 1975 Constitution of the Hellenic Republic laid the foundations for the expansion of social policy and the safeguarding of individual and social rights.

The ﬁrst laws that set clear quality characteristics was Law 877/1979 and the Presidential Decree no. 692 of 1979 when the restructuring of health services began under the general planning for the establishment of the Na- tional Health System. It is clearly stated that Elderly Nursing Units are units that care for elderly people and must provide them with:

• healthy, safe and comfortable living; healthy and adequate nutri- tion; continuous care and individual cleanliness combined with regular medical monitoring; offering and facilitating employment, entertainment and psychological assistance, the provision of physiotherapy or kinesitherapy services; ability to perform religious duties as well as the respect and interest to be given to human values, regardless of the physical and mental condition of the person being treated.

They also modiﬁed previous legislation, to clarify and tighten the quality conditions for housing, food, hygiene, nursing and medical requirements, safety regulations and for the supportive and rehabilitation services provided.

The license to operate an elderly care unit was provided by the Directorate of Public Health and Social Welfare of the Region of the area where it is located. The law regulated issues relating to the building and hotel infrastructure of the units, the characteristics of the rooms, bathrooms, galleys, the level of services provided, security as well as the staff employed.

In Law 2345/1995 the name changes from “nursing homes” to “Elderly Care Units”.

Since then, the legislative changes that were made - with the last one taking place in 2012) mainly concerned the conditions of licensing (surfaces/ person and buildings), human resources requirements and changes in labour provisions.

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Table 8. Comparison between the legislation of 1996 & 2007 for LTC units, Greece

1996 2007

Administrative Personnel • 1 Administrative Oﬃcer • 1 Administrative Oﬃcer

Doctors • 1 doctor/100beds, 2hours/day • 1 doctor, 2 hours/day

Nursing Personnel • Head Nurse • 1 Head Nurse or 1 nurse assistant with head nurse responsibilities

Morning Shift • 1 nurse or 1 nurse assistant for at least 25 beds. • 1 social caregiver per 25 or 15 beds • Another one is added after the addition of 11 • +1 for every 11 beds more or more beds.

Evening Shift • 1 nurse personnel assistant for at least 25 beds. • 1 nurse or 1 nurse assistant • Another one is added after the addition of 11 • 1 social caregiver per 25 or 15 beds or more beds. • +1 for every 11 beds more

Night Shift • 1 nurse personnel assistant for at least 30 beds. • 1 nurse or 1 nurse assistant for 35 beds • Another one is required after the addition of 11 • 1 social caregiver for every 35 beds or more beds. • +1 for every 17 beds more

Special Personnel • 1 Physiotherapist /50 beds • 1 Physiotherapist or 1 Gymnast for 2 hours/day • 1 Social Worker/100 beds • 1 Psychologist or 1 Social Worker for 2 hours/day • 1 Psychologist/100 beds, 2hours/day or 4h/day for more beds • 1 Occupational Therapist/100 beds, 2hours/day or 4h/day for more beds

Assisting Personnel • 1 cook (chef de cuisine) • 1 cook (chef de cuisine) or Sus-chef • 1 sus chef for evening shift • 1 cleaning assistant/25 beds • 1 cleaning assistant/20 beds • 1 doorman for LTC units with more than 100 beds

Source: Government Gazette No. 455 & 1136

Although relevant ofﬁcial statistical data concerning both the demand and supply of LTC services/facilities are not available, all the indications are that formal care is available to only a small number of beneﬁciaries. The Eurostat data show that in 2015 (ELSTAT, 2016) for every 100,000 inhabitants there were only 17 long-term care beds in nursing and residential care facilities; this was the lowest ratio among the EU Member States.

The majority of LTC Units and services for elderly people are located near to urban areas. Almost 50% of them can be found in Athens- leading to a geographically unequal development (Athens contains 40% of the Greek population). This implies that access to long-term care is heavily dependent on where the elder person lives, which constitutes one of the main barriers to accessing LTC services, especially for those living on the islands and in isolated rural areas. (Ziomas et al., 2016, 2018).

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There are several other barriers that have been identified concerning access to and availability of long-term care services (including home care services). According to the latest available data (European Quality of Life Survey 2011 – Eurofound, 2012), more than 80% of long-term care service users in Greece experienced difficulties with availability (e.g. waiting lists, lack of services), while over 70% of service users experienced difficulties over access (e.g. because of distance or opening hours). One example of this is that the care services provided through the public day-care centres for the elderly and the ‘Help at Home’ programme are available only on weekdays, in the morning and early afternoon, and for up to 8 hours per day.

In addition, most of the existing public formal long-term care services entail rather strict eligibility criteria, that makes them inaccessible to many persons in need of such care. As Tinios (2017, p.104) argues, ‘those left out are probably the majority of those who need long-term care; they would be excluded either de jure through the exclusion criteria or de facto through the limited places available’. It should also be underlined that, despite the fact that disability is one of the main factors driving the demand for long- term care services, the capacity of such services in Greece falls far short of meeting the needs of people with disabilities, the great majority of whom are aged 65+ (Ziomas et al., 2018).

As Ziomas (Ziomas et al., 2018, p.9) argues “552,700 people aged 65+ reported difﬁculty with personal care activities, while almost 2/3 of them needed assistance. Although these data are not up to date, they reveal that disability is prevalent among older age groups, and thus demand for long- term care services is likely to increase.” The ‘closed’ institutions for the disabled of all ages are found to be inefﬁcient and with serious shortcomings, to the detriment of patients.

The Greek Association of Alzheimer’s Disease and Related Disorders (2017) mentions that the existing community-based long-term care services for the disabled and for elderly people with Dementia with/without Alzheimer’s remain strongly limited. Overall, there is an urgent need to increase the system’s capacity, so as to meet the demand for long-term care services. That constitutes the most profound challenge in this policy area. Still, and most importantly, action to increase the system’s capacity should go hand in hand with efforts to ensure sufﬁcient quality of long-term care services provision.

2. DESCRIPTION OF THE EVOLUTION OF THE PANDEMIC IN THE GENERAL SOCIETY AND IN THE RESIDENTIAL CARE AND HEALTHCARE SECTORS MORE SPECIFICALLY

2.1. General description of the epidemic: detection, scope and some data

The new coronavirus pandemic Sars-Cov-2 appeared and spread in Greece from 26 February 2020 onwards. The majority of cases in the early days were related to people who had travelled to Italy for business and to a group

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Table 9. Cases by Sex and Age until 31 May 2020, Greece

Cases Fatal cases Cases treated in ICU

Number (%) Number (%) Number (%)

All 2719 100 175 100 13 100

Male 1499 55,1% 123 70,3% 9 69,2%

Female 1220 44,9% 52 29,7% 4 30,8%

≥65 576 21,2% 133 76,0% 8 61,5%

40–64 1139 41,9% 39 22,3% 5 38,5%

18–39 844 31,0% 3 1,7% 0 0,0%

0–17 160 5,9% 0 0,0% 0 0,0%

Source: NHPO, 2020

of pilgrims who had travelled to Israel and Egypt, and subsequently their contacts. (www.reuters.com, 2020, www.eody.gov.gr 2020)

Table 9 refers to the general population data as presented in the NHPO’s ofﬁcial report of 31 May 2020. It is clear that the highest level of mortality occurs in the over-65s and especially in men, who make up 51.4% of covid-19 deaths. In contrast, women over the age of 65 appear to be less diseased in both the general population and over-65s, with the mortality rate almost half that of men, at 24.6%.

From 27 February 2020 to 31 May 2020 confirmed cases and deaths due to Covid-19 were kept to very low numbers. Greece was among the countries with the lowest mortality rate due to Covid-19, with only 175 deaths despite the 2915 confirmed cases., i.e. 6% of confirmed cases. Following the opening of the borders at the end of June, the daily number of confirmed cases reported includes those detected following checks at the country’s entry gates. In addition, a total of 3,562 recoveries had been announced by 26 July. (www.civilprotection.gr, 2020)

The government adopted strict containment measures during the ﬁrst quarter of 2020 to delay the spread of coronavirus, including (as seen below ordered by date):

(i) 26th of February (1st Covid-19 patient): Suspension of leaves for health workers (ii) 27th of February 2020: Cancelation of carnival festivals, (iii) 5th of March 2020: Requisition of all the available beds provided by Hotels, Private LTCs, Nursing Homes & Hospitals in case of state of emergency, (iv) 8th of March 2020: – Suspension of Elderly Day Centers (KAPI),

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– The forbidding of school excursions for at least 2 weeks – Athletic matches were to take place behind closed doors (v) 10th of March: – school closures – Disposal of conﬁscated ethyl alcohol, to the state for processing and preparation of antiseptics (vi) 12th of March 2020: Suspension of the operation of courts, gyms, cinemas and theatres as well as night clubs (vii) 13th of March 2020: Closure of cafes, restaurants, libraries, museums etc. (viii) 14th of March 2020: Decision for a daily live update of the public given by Dr. Sotirios Tsiodras (Ministry of Health) and Mr. Nikolaos Chardalias (General Secretariat for Civil Protection) (ix) 15th of March 2020: – Interruption of transportation (arrivals, departures) for Italy, Northern Macedonia, Spain, Albania (x) 16th of March 2020: – Mandatory quarantine for international visitors and Greek nation- als returning from abroad (xi) 18th of March 2020: Closure of commercial stores (xii) 23rd of March 2020: National lockdown that restricted all but essential movement and economic activity

Health authorities recommended that travelers who had returned from affected areas or people who have been in contact with them, remain under house restrictions for 14 days, the maximum incubation period of the virus.

After the conﬁrmation of the ﬁrst three cases in Greece on 27 February 2020, all Carnival events in the country were cancelled and by 10 March there had been a total of 89 cases in the country mainly the travelers from and the pilgrims returning from Israel and Egypt. The health and state authorities issued recommendations and guidelines to protect the population, while the measures taken up to then were local and included the individual closure of school units and the suspension of cultural and artistic events in the affected areas (particularly Ilia, Achaia and Zakynthos).

On the 10th of March, due to the occurrence of cases of the virus in different parts of the country and the non-compliance of containment measures by citizens, it was decided to close all levels of education in the country and then, on March 13th, to suspend the operation of cafes, bars, museums, shopping centres, sports facilities and restaurants. On March 16th, all shops were closed and all congregations of all denomination and religions were suspended. Bakeries, supermarkets, pharmacies, private health services and a number of other businesses remained open. From the 16th of March onwards, daily television brieﬁngs were introduced by the Ministry of Health on the evolution of the pandemic in Greece and the government’s emergency decisions to tackle it, which were stopped at the end of May but restored in mid-July. The total cost of the measures announced by the government to support the economy, businesses and workers was 24 billion

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euros, equivalent to 14% of the country’s GDP (FEK,2020, www.imf.org, 2020).

As of 6 a.m. on the 23rd of March 2020, quarantine measures were im- posed on trafﬁc and the movement of citizens throughout the territory, with speciﬁc exceptions. On April 4th, it was decided to extend the restrictions until the 27th of April, and on 23 April an extension was announced again until 4 May. Since 4 May, the government’s plan for the gradual de-escalation of emergency measures was implemented, with the lifting of restrictions on travel and the resumption of private businesses.

2.2. The effects of the epidemic on the healthcare system

Starting on 16 March, the Hellenic Ministry of Health introduced a daily afternoon live televised briefing with updates on the progression of the pandemic in the country and the government’s emergency measures, hosted by Professor Sotiris Tsiodras MD, the health ministry spokesman on the coronavirus pandemic, and the Deputy Minister for Civil Protection and Cri- sis Management, Nikos Hardalias, with occasional appearances of other government officials. From the beginning of May, the live televised briefings were held three times a week, while a daily COVID-19 report by NPHO3 on the progression of the disease in the country was published online. On 27 May, after 72 days, the televised briefings ended, while the daily NPHO reports on the daily number of new cases and deaths continued. From mid-July, weekly televised briefings by Deputy Minister Hardalias, focusing solely on operational issues, were re-introduced.

At the end of January 2020, thirteen basic and alternate reference hospitals were designated by the Greek Ministry of Health by Health Region and equipped with a negative pressure chamber to deal with cases of the virus in the country.

The Hellenic Ministry of Health has formed a 3-member committee responsible for the review and employment of all the donations in support of the National Healthcare System during the COVID-19 pandemic. On May 7th, 2020, Health Minister Vasilis Kikilias announced that donations, worth about 90 million euros, came from organisations, companies and individuals, as well as other states such as China and the United Arab Emirates. Forty million euros were spent for medical equipment (ICU monitors, ven- tilators, ICU beds). Twenty-four million two hundred thousand euros were spent for personal protective equipment (face masks, surgical aprons, pro- 3 tective uniforms, medical overshoes). Finally, there was 12.5 million euros The National Public Health in cash deposits. Organization (EODY/NPHO) is a legal entity of Private Law under the supervision of the Minister of Health. Human Resources It is established under the Law 4633/2019 and it is the universal The Greek Ministry of Health announced the recruitment of doctors, nurs- successor of the pre-existing Centre es, laboratory staff and other health professionals to deal with Covid-19. for Diseases Control and Prevention (KEELPNO/HCDCP), which was In April 2020, the third month of the pandemic in Greece, the Minister of abolished by the Law 4600/2019. Health stated that 3,337 health professionals had been hired to meet the

◂ back to table of contents 28 ℅ MC COVID-19 needs of the 7 Health Regions of Greece. More speciﬁcally, 402 doctors, 2935 nurses and other staff were recruited by April to meet the emerging needs (skai.gr, cnn.gr, 2020). In August 2020, the recruitment of 400 doctors of various specialties with a notice to be made public in September was announced by the Deputy Minister of Health Vasilis Kontozamanis. Half of them were to take up duties in the Intensive Care Units (ICU). At the same time, social welfare centres, hospitals and health centres throughout the country as well as the National Public Health Organisation continued constantly recruiting. However, because, as the latest epidemiological data show, with the corovirus continuing to be of growing concern, the Govern- ment remained ready to make additional new recruitments of staff (e-dimo- sio.gr, 2020).

Hospitals

On 29.01.2020 (covid19.gov.gr), the Minister of Health, Vassilis Kikilias, designated Covid-19 reference hospitals in all seven Regional Health Au- thorities of Greece (RHA). Reference hospitals and ambulance crews were supplied with gloves, special masks and uniforms. Special insulation cham- bers were also established in each Health Region. The thirteen (13) reference hospital are listed below:

(i) 1st RHA: Base: Athens General Hospital (A/GH) for Chest Diseases “Sotiria”, Alternate: AGH “Evagelismos” (ii) 2nd RHA: Base: University Hospital (UH) “Attikon”, Alternate: Elefsi- na GH “Thriasio” (iii) 3rd & 4th RHA Base: Thessaloniki UH ACHEPA, Alternate: UH of Al- exandropolis, Ptolemais GH “Bodosakio” (iv) 5th RHA: Base: Larisa UH, Alternate: Lamia GH (v) 6th RHA: Base: Patras UH “Panagia Voitheia”, Alternate: Ioannina UH (vi) 7th RHA: Base: Herakleion UH, Alternate: Chania GH “Aghios Geor- gios”

Intensive Care Units

In Greece, the NHS ICU departments had 565 functional beds before the crisis. By the end of March, the Ministry of Health had increased the number of intensive care beds available in the NHS from 565 to 870 and, by April 2020, to 952, of which more than 250 were for COVID-19 patients only. Private and military hospital beds were made available to the public health care system. This includes 350 intensive care beds in private hospitals and their conversion to Enhanced Care Units (ΜΕΘ). The plan stated that the number of ICU-for COVID-19 only-would increase to 400 (with the development of new beds and the transfer of patients who are not coronavirus infected to Intensive Care beds in private hospitals). In addition, it was planned in the next phase (until mid-July 2020) to increase intensive beds only for COVID-19 to 1,000. This was to be done by creating ICU in special containers in Covid-19 reference hospitals, the development of intensive beds in surgical rooms and resuscitation areas and the

◂ back to table of contents GREECE ℅ 29 further exploitation of the private sector and military hospitals (kathimerini. gr, eody.gov.gr,2020).

Mobile Covid-19 Check Units

The ﬁrst Mobile Health Units (COMY) were announced by the Minister of Health on April 8th, 2020. The mobile Health Units are motorised units car- rying medical personnel (nurses and physicians) to perform on-site assess- ments and evaluation and provide medical and nursing care in high-risk areas and in health and welfare units with chronic patients who cannot have access to medical centres and hospitals due to their chronic conditions. These units were on the roads after a few days to carry out checks and tests on the population, mainly on the basis of geographical and epidemiological criteria. These Units were used again for the second wave of cases (healthmag.gr, 2020, eody.gov.gr, 2020) and their operation expenses are fully funded by the Administrative Reform Programme under the EU Partnership Agreement 2014-2020.

Laboratories

With Covid-19 infections and suspicious cases increasing rapidly in the country, it was decided to increase the number of laboratories that carry out molecular checks related to Covid-19.

Since 12.03.2020, the laboratories of the hospitals “Atticon” and Univer- sity Hospital of Larissa started performing tests for the new virus, bringing the number of laboratories to 7 (Pasteur, EKPA, AUTH, PAGNI, UnHosp of Rio, Atticon, Larissa) (tovima.gr, moh.gov.gr., 2020). Instructions from the NPHO and the Ministry recommended that the general public stay at home and stated that only those who show severe symptoms and on the instruc- tion of their doctor should come to hospitals for the test. This measure was of double importance: (a) due to a lack of staff, the country’s hospitals could not cope with the high demand that would occur in regular outpatient clinics and the lack of laboratories would make it impossible for the system to meet the requirements and (b) it restricted the movement to hospitals so as to not spread the virus within hospitals (to staff and patients) but also among those coming for examination.

Over time, private laboratories began to do molecular checks at a high cost (150-300 euros). The cost has been reduced to around 50 euros, as more hospitals run tests and have been enhanced with personnel and equipment.

Medical and self-protection equipment

The sharp increase in demand for products related to prevention and individual protection against Covid-19 led to an increase in prices and to the creation of an artiﬁcial shortage of materials. Especially in the ﬁeld of LTC, prices per piece almost quadrupled in masks, while there was a tripling of prices in disinfectants.

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In mid-April 2020, the government took measures to control the market for pharmaceutical and medical equipment. In order to ensure the adequacy of personal protective and personal hygiene equipment, importers were required to submit to the competent authority data on their stocks in surgical masks, antiseptic solutions and wipes. In the event of failure to submit or submission of an incorrect declaration by them, the penalty was a ﬁne (EUR 1 000 – 100 000) and seizure of the unreported items. The purpose of the registration of the above mentioned items was to supervise the market as to the adequacy of the products in question and to monitor their selling prices in order to avoid the phenomena of proﬁteering and unfair practices.

Electronic Patient Register COVID-19

On 13/4/2020 the COVID-19 Patient Register was launched. Its creation allows the monitoring of patients diagnosed with COVID-19 by treating physicians in order to ensure the continuity of their care. Doctor-patient communication is ensured through teleconsultation. In addition, remote prescription for medication was introduced. This way, cooperation between NPHO and the General Secretariat for Civil Protection (GSCP)4 became easier and more effective.

Psychological Support Lines

In Greece, the provision of telephone psychological support during the crisis of the SARS-CoV-2 coronavirus pandemic and the risk of COVID-19 infection, was an initiative taken by the Psychiatric Clinic of the University of Athens (UoA). It started operating immediately after March 10th, 2020. In its ﬁrst operational phase, it was manpowered by Professors of Psychiatry, Psychologists, as well as volunteers -internal and external partners- of the Clinic. The experience of this initiative was the starting point for the dis- cussion of its expansion with the cooperation of the General Secretariat for Public Health. It was developed into a Statewide Psychosocial Support Line “10306”, that was launched on 4.04.2020, with the involvement of the Federation of Psychosocial Rehabilitation and Mental Health Institu- tions “ARGO”. It still operates and provides anonymous and conﬁdential information on the psychosocial consequences of Covid 19 and psychiatric, 4 psychological and social support. The General Secretariat for Civil Protection (GSCP) is a subdivision of the Ministry of the Interior and was 2.3. The epidemic in public and political debate established pursuant to Article 4 paragraph 1 of the Law 2344/1995 (Greek Government Gazette A’ 212). Due to the zero death rate of LTC Units’ residents, the public debate that The GSCP’s mission is to design, took place between January and June 2020 in Greece was not particularly plan, organize and coordinate actions aimed at LTC – unlike in the rest of Europe – but rather at the National regarding risk assessment, prevention, Health System and the Third Age in general. The political and social debate preparedness, information and response to natural, technological or that concerns health care and the Third Age can be summarised as follows: other disasters or emergencies, to coordinate rehabilitation operation, Public Health System inadequacy to monitor the above actions and to inform the public on these issues. Moreover, it organizes and supervises The Greek public health system had deteriorated and shrunk due to extend- the Civil Protection Volunteerism ed austerity in the Greek economy. Shortages or the lack of human and System.

◂ back to table of contents GREECE ℅ 31 health and technical equipment in public hospitals (General or University) had been repeatedly reported. For years, there was no recruitment of doctors and health workers. The operation of hospitals and regional medical centres, even specialised units that were to be of high importance under the current circumstances, had stopped. Finally, there was an insufﬁcient number of ICU beds whereas many of the existing units remained closed or without the necessary qualiﬁed staff and equipment.

The “next-day” of the economy

Employers and employees were concerned about the impact on the economy at a micro and macro level due to the closure of a wide variety of businesses to avoid congestion, the increase in the infectious load and the transmission of Covid-19. Unfortunately, there is no research on Greek citizens’ opinions about the crisis and its management. The measures taken highlight a new working model, that of ‘distance work’, where applicable, and ‘special purpose permits’ (for those who should not work due to other health conditions, or because the business is not operating due to quarantine). These “out of work permits” were subsidized. Despite the government legislation, in an attempt to prohibit dismissals of employees, many were anxious about their return to their job and whether it would still be available.

Quarantine control measures

The severity of the control measures during quarantine was an issue. Quar- antine as a means of controlling the spread of coronavirus was generally accepted. Moreover, public transportation was reduced. Leaving home had to be done in a justiﬁed way by sending a text message to number “13033” or writing out a form, which for elderly people and in combination with strict controls did not make living in quarantine easy. In addition, the government directive to avoid contact between children and elderly people and the closure of schools contributed to many working parents facing difﬁculties.

Technological development and e-government

The closure of schools and universities created problems in the course of the academic year. The Ministry of Education decided that courses would be done online through video conferencing platforms and on March 15 this was ofﬁcially announced (https://www.minedu.gov.gr/, 2020). Schools started ﬁrst and were later followed by Universities and other educational centers.

Concerns were raised about how the online lesson would be conducted, who would handle the platform and how young students would attend les- sons in cases where the parents were working and the children were at home with the grandparents. Also, how students who did not have comput- ers and internet access would attend classes. In some schools, laptops or tablets were given to those students from poorer families, which had to be returned when the schools opened. Students and teachers had to get used to the new reality and methods of teaching, without any preparation.

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The fact that the networks in many universities could not support such courses is one of the first difficulties that appeared. The closure of many public services has prompted the government to develop e-government and public service systems. In this way, both the bureaucracy and the hassle of long waits were reduced and the congestion outside the public services and the risk of transmission of Covid-19 was limited. In addition, the newly developed services continued to operate after quarantine. There were difficulties for those who were unaware of the new features, could not adapt to them, were not in areas where the new systems were installed or did not have access to the Internet. Most importantly, as analysed below, it was difficult for elderly people to be serviced in provincial cities and villages.

Older people (Third and Fourth Age)

The measures taken during and after the quarantine had a negative impact on older people. Even though their health and survival were prominent in public announcements and media coverage, their daily routine and social ties and contacts were severely affected. The daily routine of many older people used to include morning shopping, church congregations, meetings with friends, taking care of the grandchildren and these activities were limited or interrupted due to house restriction during quarantine. The lack of home care services, as well as digital illiteracy in older ages, resulted in to further isolation and a possible increase in depression or cognitive deterioration.

The attitude of some clergy, that Covid-19 does not spread within church premises and during religious ceremonies, resulted in a large proportion of religious older people attempting to attend church congregations without the necessary personal protection measures (masks). As mentioned before, the government had to forbid all religious activities, which due to Greek Orthodox Easter would have placed older people in grave danger.

All of the above, as well as their vulnerability, the high degree of mortality in the elderly population and the rhetoric of “individual responsibility” by the government and the media, lead a large part of society to be stigmatised and marginalised.

3. DESCRIPTION AND ANALYSIS OF THE MEASURES ADOPTED TO ADDRESS THE IMPACT OF THE PANDEMIC ON THE RESIDENTIAL CARE SECTOR FOR THE OLDER-AGE POPULATION

3.1. Background of preparedness for the Crisis

Greece’s geomorphology, geographical location, its internal and international commercial routes, mean that diseases can easily be transferred from the mainland to the islands and vice versa, causing epidemics of infectious diseases.

In the 19th century, Europeans regarded the Ottoman Empire and Egypt as a last frontier for the control of epidemics. For this reason, in 1851

◂ back to table of contents GREECE ℅ 33 fourteen countries, including Greece, launched international health conferences to exchange information and solutions to prevent the spread of cholera, plague, and yellow fever from the East to Europe (Gardikas, 2018).

In Greece, quarantine measures were implemented by the beginning of the Revolution and subsequently under the administration of Governor Ioan- nis Kapodistrias. A more systematic network of quarantines and infectious cleansers for protection, mainly against the risk of plague and cholera, was developed by the country after 1845. Unlike other countries with a developed commercial sector, such as Britain, the Greek governments and people, thanks to the memory of the cholera epidemic experience of 1854, supported the maintenance of quarantine. Refugees from the Caucasus in 1919 and from Minor Asia and Pontos after 1922 passed ﬁrst through the country’s pesthouses.

Greece’s first attempt to organize a health service was made in 1833 and the first relevant service was named “Health Department” or “Health Police” and belonged to the Ministry of the Interior. In 1920, the Greek government supported the foundation of the Pasteur institute with French help and philanthropic funding – an important step in developing modern Public health laboratories. In 1914 the Health department became the “Di- rectorate of Public Hygiene and Public Perception” and three years later it was seconded to the Ministry of Care and Public Perception. During this period, the first recruitments of hygienists took place during the second cholera epidemic in 1911 and of health regional doctors and vaccinators in 1914. In addition, the first “lunatic asylums”, lepers’ sites, sanatoria, infectious disease hospitals, pesthouses, the first smallpox and rabies clinic of Athens were founded and operated. Subsequently, in order to deal with the adverse effects on Public Health caused by the Minor Asia disaster in 1922, the Directorate-General for Public Hygiene was established under the Ministry of Hygiene, Welfare and Perception, followed in 1931 by the establishment of Regional Health Centres and the School of Health Visitors and Nurse Sisters in 1937. (Sidiropoulou, 2009)

Cholera

Among the biggest epidemics to hit the new independent Greek state at middle of the 19th century, was cholera that made its appearance in Pirae- us in 1854, which was transmitted by the crews of the French and British ﬂeets, who had sieged and isolated Piraeus and Athens during the Crimean War. The inhabitants of Athens and Piraeus ran in panic to the villages of Attica to escape. In Athens, 20,000 inhabitants remained, - the poorest and 1,000 of them died of cholera between October and December 1854. It is estimated that in Greece the victims of the cholera epidemic of 1854 were more than 3,000 (Gardikas, 2018, Pyrgiotakis, 2020).

The Spanish ﬂu

Documentation for the appearance of the Spanish ﬂu in Greece is quite limited. The national and local press, death certiﬁcates and some medical

◂ back to table of contents 34 ℅ MC COVID-19 documents are the only sources for this pandemic. In Greece, the Spanish ﬂu appears in the summer of 1918, (again) in Patras. The city was quar- antined. Nevertheless, in less than 5 months, eight hundred people lost their lives. The rest of the country took strict prevention measures, such as closing schools and local quarantines. However, the ﬂu spread rapidly. Skyros island experienced the greatest tragedy: one third of its inhabitants died. Thessaly and Western Macedonia were the most affected. Athens was hit, later, by the so-called “second wave” of the pandemic, that of autumn 1918. Of the 9,296 deaths in 1918, 57.6% were males and just 42.4% females (Tsoukalas, 2015, Bournova, 2020, Charalabidou, 2020, Pyrgio- takis, 2020).

Dengue fever

The dengue fever epidemic took the form of a pandemic and even affected the then Prime Minister Eleftherios Venizelos. The epidemic broke out in two waves, the ﬁrst in the autumn of 1927, and the second and strongest in August 1928. The second wave quickly took the form of a pandemic, mainly in the southern regions of the territory. Some prefectures of northern Greece remained almost unaffected by the disease. It was the most serious dengue epidemic in Europe. To deal with it, the health services issued instructions to doctors and citizens, proposing ways to protect themselves from mosquitoes, which are the main carriers of the virus that causes dengue fever. Much of the work on new health policies produced during the last years of the 1920s is a product of pressure from the dengue pandemic. The culmination of these policies was the founding of the Athens School of Health in 1929 (Kyriopoulos, 2008).

Malaria

The great malaria epidemic in 1942 was the last malaria epidemic throughout Greece and was linked to the conditions under war and occu- pation. Malaria was mainly endemic in the countryside and was part of the everyday life of rural populations. While killing their children, frequent exposure to disease parasites over the years ensured them a level of immune but weakened them and made them less productive. The “an- ti-malarial struggle”, which began systematically at the end of the 19th century, followed the methods tested internationally and included drain- age, spraying, usage of quinine and, a gentler method, the planting of eucalyptus trees, imported from Australia for its hydrophyllic nature. How- ever, environmental interventions proved to be effective and extremely costly. That is why, when the use of DDT was introduced in Greece by UNRRA health workers in 1946, Greeks who saw the disease reduced to 10% within a year, adopted the use of DDT instantly. However, the remaining outbreaks of malaria were persistent. Systematic surveillance of the disease was required throughout the country, with laboratories and workshops that, after American assistance, were able to secure the country’s own post-war economic development. Thus, Greece’s release from malaria was both a prerequisite for and a result of economic growth. (Gardikas, 2018)

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Tuberculosis

During 1925-1929, European tuberculosis mortality rates were generally high. Greece was among the first six European countries with the highest mortality rates. 35,000-40,000 patients aged 18-40 died each year. By 1930, tuberculosis deaths reached 1,000,000, with an increasing mortality rate from 16% to 18% in the five years 1925-1929. In Greece three types of treatment took place: a) hydrotherapy, b) calmtherapy c) aerotherapy. In 1905 the establishment of the sanatoria began, where calmtherapy and aerotherapy were mainly combined. Later, more specialized methods through pharmacotherapy or surgical procedures were followed as the Greek scientific community emerged and followed European medical approaches. The most important result from these difficulties came through an understanding of the communicability of tuberculosis, leading to the “social medicine” movement that required specialized spaces for the treatment of infectious diseases of the respiratory system. This movement, supported by philanthropists made it possible to reduce the disease, but also initiated a dialogue on the construction of a National Health System of Greece based on international standards.

Since 1980, many laws endeavored the modernization of the public health system. Nowadays, the network of public health services is structured at national, regional and prefectural level and Greek legislation on the protection of public health against communicable diseases includes a wide range of areas affecting health, such as the adoption of the International Health Regulation, legislation on the declaration of infectious diseases and epidemiological surveillance, legislation on the control of the health market and health service providers, legislation on water, food, environmental hygiene and standards for vaccination (Sidiropoulou, 2009).

In the 90s’ and millennial Greece, outbreaks of poultry and swine inﬂuenza viruses - Inﬂuenza A(H7N9) and A(H1N1) - as well as respiratory control coronaviruses such as MERS and SARS, were treated, which did not result in epidemic situations, since the NHS, in cooperation with the HCDCP5 and the Government Agencies, was able in a timely manner to inform the public of their risk and to check travellers coming from countries where the disease was on the rise.

5 Due to the frequent occurrence of epidemics worldwide, HCDCP and the Hellenic Centre for Diseases Control Ministry of Health cooperate in launching guidelines about the prevention and Prevention (KEELPNO/HCDCP). and treatment of infectious diseases. Among those guidelines four are of The Hellenic Centre for Diseases Control and Prevention, HCDCP (Greek: importance here: Κέντρο Ελέγχου και Πρόληψης Νοσημάτων, ΚΕΕΛΠΝΟ) was Greece’s a. The Guide for the “National Action Plan to Tackle the Influenza Pan- public health organization until 2019. It was based in Athens, Greece, and demic”, with the first published in 2005 for the treatment of H5N1, was named “HCIDC” (Hellenic Centre renewed on the basis of WHO and EU guidelines until 2009 when for Infectious Diseases Control) up to H1N1 first appeared (HCDCP committee, 2005,2009). 2005. HCDCP was replaced in 2019 b. In 2007 the Scientific Committee for Hospital Infections of the HCD- and its full successor is the National Public Health Organization (NPHO/ CP issued the “Guidelines for the Diagnosis and Empirical Treatment EODY). of Infections”, to be shared in all Hospital and Clinical Units of Greece

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given the concern raised by the resistance of viruses due to the over- consumption and over-prescription of antibiotics. c. In 2015 in the context of the implementation of the Ministerial De- cision (FEK 388/18-2-2014) on the basis of which each hospital should draw up an Internal Regulation for the control of antimicro- bial resistance and hospital infections, the Commission developed “Guidelines for the drafting of the Rules of Procedure for the Preven- tion and Control of Infections in Health Service Areas”, a standard of Rules of Procedure for Greek hospitals. This standard mainly deﬁnes the role of human resources, explains infection control surveillance indicators by which hospital practices will be assessed, and guidelines are given on control and prevention measures and the rational use of antibiotics. d. In 2019 the Ministry of Health and the National Council for Public Health published the “NATIONAL ACTION PLAN FOR PUBLIC HEALTH” (NAP-PH), developed by the General Secretariat for Public Health (GSPH). In the context of the reconstruction of public health services the NAP-PH adopted the main priorities of the WHO, to achieve the key strategic objectives relating to the reduction of social ine- qualities, improving health for all and participatory governance for health. It has seven (7) main axes of actions, selected using the main criteria of their mental burden, their economic consequences and the resources of the health system, as well as the emergencies caused by international economic and political circumstances. Axis 6 describes the exact plan for health emergencies as set out by the International Health Regulations (IHR) for cross-border threats and communicable diseases. (www.moh.gov.gr, 2020).

A common feature of all above directives is the attention they pay to:

1. Cooperation between various Governmental Bureaus, Ministries, Health and State Departments 2. Personal protection measures (use of masks, gloves, protective glasses and special suits if necessary) as well as to hand hygiene 3. Working environment and equipment sterilization 4. General population information campaigns or precaution measurements and 5. Systematic training for all the above.

Similar measures were proposed by the NPHO and government sources to deal with Covid-19.

Until now, there have been no speciﬁc references to prevention and response measures in the LTC Units. Due to the population they serve, LTCUs must follow instructions and provisions relating to (a) hospital/clinical environments and (b) health regulations addressed to the community. This is because LTCUs in Greece are open care structures so on the one hand they are clinical environments and on the other hand the population they serve is integrated and can act freely within the community when they are outside the Unit of residence and through visiting contacts. Thus, with regard

◂ back to table of contents GREECE ℅ 37 to infectious diseases in particular and health regulations in general, they are no different from a primary care clinic. No matter what, LTC Units are obliged to follow every public health regulation that is taken. Many of the measures taken during the present pandemic of Covid-19 are the result of all the above historical experiences and good co-operation and the sharing of information among the directors and managers of the LTCUs as well as the ethical and correct behaviour of the working staff.

It is therefore clear that the lack of specialised regulations and government guidelines for the LTCUs in the treatment of epidemic infections affecting Public Health at both clinical and community level makes the work of LTCUs more difficult to implement and open to criticism from public opinion and the media. The first time the government mentioned the announcement of measures to prevent and treat the spread of infectious diseases specifically for LTCUs, was on the 28th August 2020, with the statement that they will be certified by the National Public Health Organisation (NPHO) specialists. Until then, measures to deal with Covid-19 were only mentioned in Minis- terial Decisions.

3.2. The General Impact of the Epidemic on the Residential Care Sector and Policy Responses

Government and Regional Policies for LTC Sector

The ﬁrst ofﬁcial guidelines for Long Term Care units were announced in March 2020.

First, there was an advisory notice concerning public rights of visitation to the Units. It originated with the Ministry of Health and was distributed by the Regional Authorities on the 14th of March 2020.

On the same day, an Act of Legislative Content was published in the Gov- ernment Gazette issue 64, under which the State could commandeer the human resources (caregivers, nurses, nursing assistants, doctors, etc.) as well as the equipment (beds, rooms, isolation rooms, respirators, sanitary material) of the private Primary and Secondary Health Units including Long- Term Care Units.

On 24.03.2020 the National Public Health Organisation (NPHO) announced the General Guidelines for precautionary measures against Covid-19, which were ofﬁcially adopted by the Ministry of Health on 07.04.2020.

They concerned, in particular, personal protection and hygiene measures in the event of a case of coronavirus. More speciﬁcally, the NPHO page states:

Medical and nursing staff

• All health service personnel are to be alert for possible symptoms consistent with respiratory infection (e.g., cough, respiratory distress)

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and measure their own temperature daily before starting work. The measure concerns medical and other staff as well as external partners. (www.eody.gr, 2020) • All staff, as well as external partners, must wear a simple surgical mask • Removal from work in case of symptoms compatible with infection with the new coronavirus or in case of contact with a conﬁrmed or suspected case is mandatory. • Training and the proper use of personal protective equipment with emphasis on the application and removal process of the following should be provided: – Surgical Mask – High Respiratory Protection Mask FFP2, FFP3 – Protective robe – Gloves – Eye Protection – Face Shields • Systematic observance of cleaning, disinfection of premises and surfaces and safe management of infectious waste should be recorded • A list of exposure risk and removal conditions was published (NHPO, 2020) as shown in the following table.

Visitors

On March 24th 2020, visitors were banned from residential care. The only exception referred to relatives of residents that were in a near-death condition. But even in such a case, entrance was prohibited if they had symptoms compatible with respiratory infection (e.g., fever, cough, respiratory distress). The LTC Units would have to update families regarding their admitted relative via video conferencing, SMS, phone or other alternatives.

Residents

• Assessment for possible symptoms of respiratory infection prior to admission and stay at the Unit was required. • Daily surveillance at least twice a day for Covid-19 symptoms (fever, cough, respiratory distress) became mandatory. • In the case of a resident with symptoms of respiratory infection, all measures to prevent spreading should be applied: – isolation in a single room with individual toilet – strict restriction of movements to what is strictly necessary by ap- plying a simple surgical mask if it is tolerated – proper use of personal protective equipment by the nursing staff – application of basic, contact and droplet precautions in all cases of respiratory infection by an unknown causative agent. In addition, application of airborne precautions in cases of suspected infection with an airborne pathogen – in each room alcoholic antiseptic solutions, liquid soap in each sink and hand towels, foot-moving closed buckets, tissues

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Table 10. Exposure risk & Removal conditions. Greece, 2020

Close contact with Covid-19 patient who wore a mask

Health monitoring for 14 days Remove for working place Risk factors for the health service staﬀ Exposure risk after the exposure of the asymptomatic staﬀ

Without Self protection Equiment Medium Active Stay in workplace

Without surgical or FFP 2, FFP 3 mask Medium Active Stay in workplace

Without eye protection Low Self monitoring Stay in workplace

Without gloves or protective robe Low Self monitoring Stay in workplace

Fully equiped with Self Protecting gear Low Self monitoring Stay in workplace but using the surgery mask instead of FFP 2 or FFP 3

Close contact with Covid-19 patient WITHOUT mask

Health monitoring for 14 days Remove for working place Risk factors for the health service staﬀ Exposure risk after the exposure of the asymptomatic staﬀ

Without Self protection Equipment High Active Removal from workplace for 7 days after the last contact Without surgical or FFP 2 or FFP 3 High Active Removal from workplace for 7 days after the last contact Without eye protection Medium Active Stay in workplace

Without gloves or protective robe Low Self monitoring Stay in workplace

Fully equiped with Self Protecting gear Low Self monitoring Stay in workplace but using the surgery mask instead of FFP 2 or FFP 3

Source: EODY/NPHO

– Hand Hygiene – respiratory hygiene and use of a simple surgical mask by the patient if this is tolerated – cleaning and disinfection of premises and surfaces, disposal and collection of infectious materials – Suspension of non-essential activities such as gymnastics, group activities, staying in their rooms, etc. – Avoiding meals in common areas and preferably serving in the room – Avoiding unnecessary personal care services (shaving, haircut, etc.) – Suspension of non-urgent or unnecessary visits by external partners (doctors, therapists etc) – In a suspected or conﬁrmed COVID-19 case, the resident needs to be transferred to a health service provider. The Ambulance service, the NPHO and the reception Hospital shall be immediately

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informed in order to take all necessary measures to prevent and control the spread of the infection. – In the case of the death of a patient with suspected or conﬁrmed COVID-19 infection, the instructions of the EODY on the management of dead bodies are followed.

Management & Logistics

• Ensuring and reporting the adequacy of all necessary infrastructure for the application of hand and respiratory hygiene • Maintaining access to personal protective equipment for the staff • Posting of printed instructions on the 5 steps of hand hygiene and the correct procedures for the application and removal of personal protective equipment upon entry into the Unit or isolation room • Installing closets with personal protective equipment, immediately before entering the patient’s room • Placing of a closed, foot operated, trash-can in the room to dispose of personal protective equipment before leaving. • Providing exclusive staff at each shift for the care of a conﬁrmed case of Covid-19 • Providing uninterrupted operation in case of critical personnel absence (numeric and qualitative) • Immediate declaration of suspected or conﬁrmed cases to the NHPO phone lines whether they concern a patient, health professionals or other personnel.

LTC Sector Policies and Impact

Prouskas and Goudoumas ran a survey among nursing home directors in the ﬁrst 6 months of 2020 (Prouskas, 2020). A questionnaire was administered to a large sample of 61 managers and/or owners of LTC Units from all regions of Greece. The percentage of completed questionnaires (21%) compared to the total number of units (n=295), as well as the coverage areas of the respecting units allows a claim for it being a representative sample.

The questionnaire consisted of 165 questions divided into 7 Sections and 34 Sub-sections. Questions related to operational issues, pandemic han- dling, measures and incidents, residents and family reaction, personnel attitudes towards the disease, company ﬁnances and inspections by authorities. The analysis of the questionnaire shows the general impact of the pandemic on the residential care sector.

According to the survey conducted, 44% of the LTC Units that did not already have them, developed health risk protocols following the above measures. 52% had protocols or internal regulations which were readjusted with additions regarding the threats from Covid-19. The remaining 3% had no protocols and did not form any, but this is likely to have been corrected due to the development of the situation and frequent checks by the health authorities. Isolation rooms in case of a Covid-19 outbreak, were increased in 54% of the Units.

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As to what procedures they would follow if there were a Covid-19 outbreak, 72% replied that they would follow the standard treatment procedure as deﬁned by the EODY but also they would take additional measures. Finally, 28% said they would only follow the EODY procedure.

LTC Sector Measures

Most LTC Units (44%) received the ﬁrst updates on the risks of Covid-19 in February 2020. Only 8% started to be updated from December 2019 and 28% in January 2020. However, 3% were updated about the measures in April, i.e 2 months after the ﬁrst cases in Greece, but this was when the MoH decided to adopt the General Precautionary Measures for LTC Units.

When asked about the information source regarding the measures to be taken for Covid-19, 82% of those questioned answered that they were mainly informed by the media and the Internet. The percentage of information coming from government sources, i.e. the central government, the regional authorities and the NPHO, reached 90%. Another 21% included GCHA as a source of information.

Most of the measures proposed by the Ministry of Health and the NHPO were already being followed in the Long-Term Care Units, due to the vulnerability of their older residents. Masks, gloves, disinfectant liquids and soaps as well as various methods of disinfection of the premises were essential for living within the Units and before the appearance of Covid-19. There- fore, the answers by all the Units were 100% for adopting these measures as well as single-use handkerchiefs in the rooms and the bathrooms. The vast majority of these measures will continue after the Covid-19 pandemic. Moreover, more than 50% of the Units were supplied with shoe covers, face shields, single use suits for the medical staff (medicals, nurses and caregivers), but less than 20% stated that they are likely to use them after the pandemic. Most of these materials were not in use before. A minority of the Units had not had a contract with a disinfection company (almost 40%), but due to the situation they took the decision to co-operate with one. More than 65% of the Units were disinfecting the Units using their own resources.

The overall results indicate that government agencies had been slow to take action on Covid-19 in the area of long-term care. According to the results of the survey, 60% of the Elderly Care Units in Greece had already started to take emergency precautions earlier. 24% of them took the measures before the virus appeared in Greece. Only 7% took action after government instructions or during lockdown.

In order to better control the situation, the LTC Units took additional protection and precaution measures which were not mentioned in the ofﬁcial state brieﬁngs. These measures were later adopted by the Government through the intervention of the Greek Care Home Association and discus- sions with relevant authorities such as the Directorates of Public Health of the Regions and later the Competent Committee of the MoH.

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• Restricting tenants to their rooms • Prohibition of group eating in the dining room • Maintenance of air conditioners • Temperature measurements of staff • More frequent temperature measurement of all tenants (more than three times per day) • Installation of antiseptics outdoors of the unit • Increase in doctors’ visits

Impact of the Epidemic on the Residents and Relatives

Greek LTC Units are basically small to medium-sized enterprises with an average capacity of 60 beds. Only 9% exceed 100 beds and just 2% of them can host more than 200. A quarter of the Units have a capacity of not more than 80 beds. The situation emerging due to Covid-19 was negative for their occupancy rates. Most Units stated that admissions for 2020 were reduced compared to the same period (January-May) of the previous year. More than 45% of the Units reported a large reduction in occupancy. An almost similar proportion (43%) mentioned that their occupancy remained the same. 10% of the participants stated that they saw an increase in the occupancy rate during January to May of 2020.

Departures of residents for reasons related to Covid-19 occurred in 11% of units and not for more than 5 residents per unit. In most cases, it was the decision of the relatives to take the resident home and the reason was ﬁnancial, arising from the pandemic and quarantine and less because of their concern about staying in a Long-Term Care Unit.

With the exception of the Personal Protection directives and the visitation ban, the Government did not take any other serious measures for the protection of LTC Units in the ﬁrst semester of 2020. The LTC Units had to face the Covid-19 “ﬁrst wave” by themselves.

The degree of acceptance and adjustment to the measure appears to have been positive. By the answers of the managers and administrators of the Long-Term Care Units it seems that the level of the adjustment difﬁculty was divided almost 50% among the residents. Eventually, more than 75% of the residents accepted the lack of a visits, which clearly affected the good per- formance of the Units in terms of precaution and service provision.

However, a difficulty emerged within the Units. Given the fact that within most Elderly Care Units are many people with Dementia, Alzheimer’s disease or other neurodegenerative diseases that affect their cognitive functionality and behavior, less than 25% were able to follow “easily” the implementation of personal protection and prevention measures. Most of the tenants found it difficult (30%) or very difficult (21%).

Another factor that has to be taken into account is the psychological effects of all measures on the psycho-emotional state of recipients of long- term care services. Especially those for whom the expression of emotions is

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Serie1

40% 40%

17% 3% 0%

Non Cooperative Little Medium Enough Very

Figure 2: Relatives’ Cooperation rate. Source: Prouskas, 2020

difﬁcult due to cognitive decline or limited functionality. The unit managers were also asked to respond to this either through their own impressions or through the information received from the unit professionals.

The following Table (Table 11) shows that the most commonly occurring impact was psycho-emotional instability, followed by sadness and feelings of loneliness. Also, a large number - almost a third of tenants - experienced stressful feelings and felt excluded. However, psychosomatic or behavioural disorders and other purely psychiatric indications remain low (from 5 to 10%).

The majority of the relatives (62%), despite their fears – caused by high levels of mortality and unpleasant developments in other European countries- accepted the ban on visitation. All of them considered that the suspension of their rights to visit was of “high necessity”, but also that it “lasted too long” (50%). They deemed that the measure was necessary even though a large proportion of them (36%) did not completely understand the urgency and the long duration of the visitation’s ban (27%). Just 22% disagreed with the measure’s continuation. The general agreement and acceptance of the measure was demonstrated by their level of co-operation. On a ﬁve scale, from “non-cooperative” to “very cooperative, 80% of the relatives were reported as “sufﬁciently” or “very cooperative” in the opinion of the Units’ directors or managers. Only 3% percent of the relatives were found to give “Little” cooperation (Figure 2).

Table 12 shows that although relatives largely trust the place of hospitality and care of their loved one, they do not cease to feel guilt and sadness. That’s usually because they think they’ve left the elderly person alone. Stress, caused by the feeling of abandonment, affects 65% of relatives.

Probably good cooperation also comes from the alternative means of communication offered by the Units. Due to new technologies, the LTC Units

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Table 11. Residents’ psycho-emotional state during the quarantine and the visitation ban

Psycho-emotional or Psycho-somatic State Percentage

Psycho-emotional transitions 46%

Sadness 38%

Loneliness 33%

Stress 33%

Exclusion/Marginalisation 31%

Nothing referred 20%

Nothing Noticed 18%

Isolation indications 16%

Depression 13%

Sleep disorders 10%

Behavioural disorders 10%

Psychosomatic Disorders 8%

Aggressive behaviour 5%

Psychiatric Symptoms 5%

Eating disorders 5%

Source: Prouskas, 2020

Table 12. Psychological impact of visitation ban on relatives. Greece, 2020

Psychological impact on relatives Yes No

Sadness 55% 45%

Guilt 67% 33%

Anxiety for resident’s life 48% 52%

Anxiety for resident’s psychological condition 65% 35%

Anxiety for resident’s QoL 28% 72%

Anxiety for the resident’s Health condition 53% 47%

Nervousness 48% 52%

Source: Prouskas, 2020

residents were able to communicate with audiovisual media (videoconferencing applications) (Table 13). Almost 75 % of the residents, in all units, used these methods to communicate with their family. One third of the units (34%) mentioned that 51-75% of residents used videoconferencing in addition to a simple telephone call, while 15% of them said that the percentage exceeded 75%.

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Table 13. Communication alternatives

Communication Alternatives Percentage (%)

Videocalls via mobile 85%

Videocalls via laptop or PC 72%

E-mail 25%

Phone 97%

Source: Prouskas, 2020

Impact upon LTC Units

Over 90% of the units participating in the survey employ the specialties required by law (doctors, nurses, nursing assistants, administration ofﬁcers). Very few employ additional specialist therapists e.g. speech or occupational therapists (5% and 15% respectively). It is important to mention that not more than 60% of the Units employ psychologists and fewer employed social workers (48%).

In 84% of the units in the survey, their employees were molecularly tested for Covid-19 at least once. Most of the tests (47%) were conducted after the lockdown. Just 1/3 of the participants stated that the testing took place during the quarantine. The tests were mainly conducted by the units of NHPO (62%) and by Private Laboratories or Hospitals (29%).

Concerning personnel, 65% of the Units replied that their human resources remained the same, while 25% noted an increase in numbers for reasons related to Covid-19. The results showed that the 97% of the employed staff and the external partners accepted “to a large extent” or “fully” the measures taken for precaution against and treatment of Covid-19. About a tenth of the nursing staff left to be employed in the Public Sector.

Other factors that burdened the LTC sector are shown in Table 14. All units seem burdened by the increase in the price of products, the increase in medical services, the increased prices of laboratory tests related to Cov- id-19 and the inability to ﬁnd sanitary and personal protective equipment. Occupancy reduction was reported by 66% of the Units. Reduced demand was reported by 62%.

Furthermore, there was an increased expenditure in sanitary and personal protection materials. 97% of the Units increased their expenditure for masks, gloves, nurse suits, single use suits, diapers, incontinence bed pads, disinfection and personal hygiene materials.

The Long-Term Care Sector in Greece seems to have been ﬁnancially damaged by the pandemic and its consequences. Not only were they not supported by a central government mechanism (lack of grants, increased

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Table 14. Burden Factors on LTC Sector due to Covid-19 pandemic, Greece

Burden Factors Percentage (%)

Increased prices of sanitary material 95%

Diﬃculty to ﬁnd sanitary and PPE 92%

Reduction of ﬁnancial incomes 82%

Exam fees related to Covid-19 75%

Increased product prices 74%

Reduction of occupancy 66%

Reduction of potential customers 62%

Diﬃculty to ﬁnd Human Resources 56%

Lack of subsidies 39%

Withdrawal of human resources 33%

Increased prices for laboratory tests 25%

Increase in prices for medical services 18%

Increased tax liabilities 11%

Increased insurance contributions 11%

Source: Prouskas, 2020

taxation, continuous state controls and increased safety conditions), but they faced a sharp increase in their costs due to reduced outﬂows (reduced occupancy, cases of checkouts). The average loss is 25%, while some Units reported 40-50% proﬁt loss. Only the 10% reported the same income as for the previous year in the same period.

3.3. Analysis

The increase of the elderly population in Greece is rapid. An impressive percentage of people over 65 y.o are in need of Long-Term Care. Statistical- ly, it looks like older people will spend a quarter of their life in poor health, which makes it necessary to develop both prevention services, as well as the establishment of further health services including rehabilitation units, and long-term care, both at home and in institutional structures.

The LTC sector in Greece is still in its development phase, both in terms of market and internal operations. Factors such as aggressive competition, or lack of any central plan for healthy development to properly meet the needs of local populations, have led to “scissors scale” phenomena e.g., obvious inequality between very large or small units in the same area. The State plays the role of supervisor and does not consider the sector as an area working under special conditions and capabilities but integrates it into the wider health and welfare sector. However, the Greek Long-Term Care Units

◂ back to table of contents GREECE ℅ 47 for Elderly People are not included in national lists of state funding, making them accessible to the wider population, thus creating market distortions and essentially forcing them to remain in the private or Third sectors’ initiative. Pricing is determined by the owners or managers of the Units, depend- ing on the customer audience to which they refer or want to attract. This means that an elderly person whose pension is on average EUR 750-800, will have to be helped to meet out-of-pocket expenses from family members (most commonly children), relatives or even friends. This reduces the op- tions for a unit of choice for residence, or it means that an elderly person is forced to stay home with the help of a personal caregiver with difﬁculties in supervising the latter and uncertain care conditions.

The above factors are warning signs of the difﬁculties faced for the sustain- able development of the Long Term Care sector. Incentives need to be given to modernize the existing Units (facilities and equipment) and improve the quality of services offered, while also encouraging the development of new services and forms of housing and living. In addition, a form of ﬁnancing should be established to cover at least part of the cost of nursing home admission, especially for those who do not have the resources to use this services but are in need of it.

Establishing a categorization of Care Units into levels of provided care, such as autonomous and semi-autonomous living, residential care and Special- ized Elderly Care Units, is crucial for moving to the next stage of the LTC sector’s development. This planning should be done in such a way as to allow the further specialization of Units in matters of care (e.g. Dementia, Alzheimer’s Disease, encephalopathies, pain management), the operation of Day Care Centers for elderly people within the Units, the encouragement of community approaches and home assistance programs. Planning may also include the developmnent of a formal, independent and certified Audit Mechanism that will formulate official standards for the Quality of Services and a Certification of Elderly Care Units.

Furthermore, emphasis should be placed on the community dimension of Long-Term Care Units and their de-stigmatisation. In the last decades, efforts have been made in this direction by moving away from asylum-based approaches through continuing education and training of health and care professionals, and by adopting methods for maintaining the sociability as well as social inclusion of the elderly residents. A promotion of the possibilities and advantages of the Long-term care industry may be achieved by informing and raising the awareness of stakeholders and the public and by the promotion of research. Already, through the application of new technologies, it is easier to create networks and provide intergraded care.

Focusing more on the coronavirus outreach period, the LTC units were not subsidised by the Government to overcome their needs and difﬁculties and only a few of the governmental measures (remote work ability, the prohibition of redundancies at the time of the virus’ intense outbreak etc.) applied to them. Through the Attica Regional Authority’s initiative and in cooperation with the Greek Care Homes Association (GCHA/PEMFI), a small quantity of

◂ back to table of contents 48 ℅ MC COVID-19 masks (200 pieces) and sanitizers (8 litres) were distributed to local units as a donation during the period that drugstores either had no materials or had increased their prices too. However, there was no government initiatives to overcome the lack of protective equipment and materials in case of virus spread within the Units. On the other hand, in case of an increased spread of Covid-19 cases, Long Term Care Facilities would have been very useful in supporting NHS and cover its needs for beds for chronic patients or even asymptomatic covid patients.

Creation of new protocols, or upgrading existing ones, offered a sense of security to tenants’ relatives and employees at regional and state administration level. This has strengthened the prestige of the country’s LTC sector and positive results might be expected at a variety of levels. Already, in dis- cussions in the Region of Attica on the design of measures for the expected outbreak, the president of the Greek Care Home Association was an equal interlocutor.

The difficulty in finding skilled or unskilled carers continues to exist and intensified in this pandemic. The process of care is physically tedious and can often cause psychological burdening if appropriate preventive and protective measures are not taken, but also if appropriate training is not given. Unfortunately, in Greece, following the global phenomenon, nurses and nursing assistants do not easily choose to work in Elderly Care Units. Even when workforce demands due to Covid-19 increased, carers and nurses hardly ever chose to work in a care-home. The selective information that has been provided by the press and by the television news bulletins, who chose the cultivation of fear instead of highlighting positive outcomes in the sector in Greece compared to other countries in Europe or even worldwide, has contributed to that. This therefore leads the sector to turn towards alternative sources for their work force such as nurses and nursing assistants among the refugee and immigrant populations.

Despite the difﬁculties mentioned above, the Greek LTC sector, exceeded expectations during the outbreak of the Covid-19 pandemic. The Greek El- derly Care Units managed to work together and overcome obstacles and bureaucratic impediments. With an occupancy of 97.5% (13,613 residents), until the end of the lockdown only two deaths were recorded due to covid-19, whereas there were only 13 (less than 0,001%) cases in 2 of the 300 units of the country.

Despite the risks, 65% of the LTC Units stated that their nurses or caregivers remained in position. In several Units the staff even increased in numbers. No employee was reported as infected by Covid-19 and in August 2020, 100% of them appear negative in molecular test results.

The fact that the LTC market in Greece is still small, gives a variety of prospects for growth of the sector. The foundations can be laid for a well-developed sector, more customer-orientated, that integrates well with other existing services and takes into account the needs of all the stakeholders (residents, employees, managers, owners and inspectors) thus achieving

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Table 15. Units’ Proﬁle

Operating years Licenced Capacity m. Occupancy

Unit A 6 to 10 Yes 116 88

Unit B Over 20 Yes 42 38

Unit X 11 to 15 Yes 125 76

Table 16. Proﬁle of ECUs’ managers

Educational Level Field of Profession Position in ECU Duration (years)

Unit A PhD Health Sciences Legal Representative Over 10

Unit B Master’ s Economics Manager/Director 1 to 3

Unit X Bachelor Not Mentioned Manager/Director 1 to 3

the equilibrium between Quality of Care and Quality of Life (Prouskas in various conferences 2015,2017,2020),

3.4. Examples of developments in speciﬁc care homes

In Greece the overall covid-19 death rate in the Elderly Care Units was minimal, almost 0% for the a’ semester of 2020. For the purposes of this case study, a Unit in which cases occurred will be compared with two other Units in the same area.

• Unit A is an example of good practices that prevailed facing a possible Covid-19 threat; it has been operating for 6 to 10 years, is licensed has a capacity of 116 and an occupancy, at the time of the survey, of 88. • Unit B, is an example of good practice, without any operated reported threat, and has been operating for more than 20 years, is licensed and has a capacity of 42 and an occupancy of 38 • Unit X, the unit where there have been fatal cases, has been operating 11-15 years, is licensed and has a capacity of 125 and an occupancy of 76 (Table 15).

The manager of Unit A has a PhD in Health Sciences and an experience of over 10 years. The managers of Unit B and X hold a Master and a bachelor’s degree respectively and have been in that position between 1-3 years (Table 16).

Regarding the Covid-19 information, all three representatives were quickly informed (January and February 2020). As far as information is concerned,

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Table 17. Comparison of protective measures

Personal Protection & Hygiene Measures Unit A Unit B Unit X

Mask constantly Yes Yes Yes

Gloves constantly Yes Yes Yes

Glasses (eye protection) No No No

Face shields Yes Yes Yes

Shoe covers Yes Yes No

Hats Yes No No

Nurse suit (fabric) Yes Yes Yes

Single use suits Yes Yes Yes

Crème soaps in residents’ rooms Yes No Yes

Crème soaps in nurse station and/or oﬃces Yes Yes Yes

Antiseptic in residents’ room Yes No No

Antiseptic in nurse stations or wagons Yes Yes Yes

Single use hand towels in residents’ rooms Yes No No

Single use hand towels in nurse station or wagons Yes Yes Yes

Steam cleaners Yes Yes No

Disinfection by private company Yes Yes Yes

Disifentction by own means Yes Yes Yes

Disinfection both by a company and by own means Yes Yes Yes

Antiseptic in outer spaces Yes Yes Yes

the main source was the Internet. Unit A relied on the publications of the scientiﬁc community and the Unit’s medics. Unit B used information from the mass media and the Regional Authority. Unit X, unlike the other two, appears to have underestimated the afternoon brieﬁng held daily by government bodies and representatives of the NHPO.

As far as the Covid-19 related protocols Unit X and Unit A belong to the majority of Greek LTC Units that had protocols for dealing with infectious diseases and health hazardous conditions and/or made speciﬁc additions related to the present situation. Also, according to its director, Unit X took action when the seriousness of the situation began to be understood, before the relevant directives were announced by the Region. This, again, is in line with the majority (59%) of LTC in Greece, as mentioned in a previous section. It has to be mentioned that 44% of the Greek LTC Units did not have an internal protocol before, they developed it due the Covid-19 situation.

Unlike Units A & B, Unit X did not increase the number of isolation rooms. The survey results show the same strategy was followed by 39% of the total LTC Sector. On some occasions this is allowed by the legislation according

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Table 18. Comparison of Extra Protection Measures

Unit A Unit B Unit X

Dining only into rooms No Yes Yes

A/C maintenance Yes Yes Yes

A/C special ﬁlters Yes Yes No

Staﬀ Temperature Measurement Yes Yes Yes

Visitor Temp. Meas. Yes Yes Yes

Residents Frequent Temp Meas. Yes Yes Yes

Protective glass to the oﬃces Yes Yes No

Increased Doctor visits Yes Yes No

Alternative meetings (with relatives) Yes Yes Yes

Limitation of persons/oﬃce No No Yes

Restriction in the room No Yes No

to the number of residents and the total capacity. In Units X case, this was a mistake.

Similar basic protection measures were followed by the three Units concerning the continuous use of gloves and masks and the temperature measuring of staff, residents and visitors. Unit A took the best protective measures. There were precautions for personal hygiene rules, personal protection, antiseptic methods (by own means and in cooperation with a specialised company). Precaution measures were also taken for the health protection of the residents. But, unlike Units B & X, Unit A did not follow the dining restriction. Even if none of the three Units used eye protection goggles, they did use full face shields and masks. Unit X took the same measures as Unit B, but despite the known situation, they decided not to increase the doctors’ visits. (Table 17 and Table 18).

Infectious diseases, accidents and their complications and complications caused by dysfunctions of the neuromuscular system are parameters for measuring the quality of health and quality of life (Yfantopoulos, 2006). Gastroenteritis, Inﬂuenza, Respiratory Diseases, Falls and Bonefractures and Aspirations were measured during the period of quarantine. . Due to increased personal protection measures, that were taken because of the pandemic more than 50% of the Units experienced reductions in infectious or transmitted diseases. As shown in Figure 3, there was an increased degree of reduction in respiratory and gastrointestinal infections (51% and 54% respectively). Inﬂuenza cases were also reduced to 62% of the LTC Units.

In the LTC units studied, Unit A -that took the strictest measures- record- ed “Signiﬁcant Reduction” in Gastroenteritis, Inﬂuenza and Respiratory

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80% 74% 69% 70% 64% 70% 62% 61% 60% 54% 50% 46% 38% 40% 36% 36% 31% 30% 26% 30% 20% 10% 2% 2% 0%

Falls Influenza Aspirations Gastroenteritis Bone-Fractures

Respiratory Diseases

Reduction No difference Increase Other diseases or medical situations

Figure 3: Appearance of Infectious Diseases in LTC Units. Greece. Source: Prouskas, 2020

disease cases and “Reduction” to Falls and Bone Fractures. Unit B noted “No differences”. Unit X noted “Signiﬁcant Reduction” in Gastroenteritis. On the other hand, both Unit B and Unit X noted “no differences” in Respiratory Diseases (Table 19).

As far as visiting hours are concerned, all three Units stopped the visits of relatives. Units A and X stopped the visitation as a precaution before the Region authorities made the decision. Unit B kept the visitations until the last minute and stopped it when it was mandated by the regional authority. Entry was also denied to external partners.

As far as admissions are concerned, 15% of the Units stopped admissions due to fears of coronavirus inﬁltration and spread. Most of the Units in the survey (62%), including Units A and B, followed the NHPO protocol on admissions, i.e. molecular control of the person to be admitted to the Unit before the admission, then accommodation in an Insulation chamber or Temporary Nursing Room and molecular control before the persons’ transfer to their room of residence. A small, yet signiﬁcant proportion of the units (20%) in the survey performed only one check before admission. So did Unit X.

In Unit X, the virus inﬁltrated through members of staff. Three employees claimed to be asymptomatic but tested positive in the molecular tests carried out by an NHPO team during quarantine. The Achilles heel of Unit X seems to be in the late response to the onset of symptoms.

In a similar case, Unit A also reported a symptomatic employee (n=1) who said he/she had symptoms associated with Covid-19. Unit A took immediate action and placed the employee on sick leave. He was also asked to

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Table 19. Appearance of Infectious Diseases (Comparative)

Respiratory Bone Gastroenteritis Inﬂuenza Falls Aspirations Other Disease Fractures

Signiﬁcant Reduction Unit A Unit A Unit A Unit X Unit X Unit X

Reduction Unit A Unit A

No Diﬀerence Unit B Unit B Unit B Unit B Unit B Unit A Unit A Unit X Unit X Unit B Unit B Unit X Unit X

Increase None None None None None None None

Signiﬁcant Increase None None None None None None None

be tested immediately and after examined by the NHPO testing unit, he was found negative to SARS-Cov-2. It is possible that following the protocol and removing the employee from the shift, may have prevented a possible spread, if the employee was infected.

Checks were carried out on the tenants of Units A and X. In Unit A (in which the workers showed symptoms) as well as in Unit X molecular tests were performed by the NHPO testing unit. Unit’s A tenants were not found positive. In Unit X, eleven (n=11) residents were found to be Covid-19 positive and were taken to the Hospital. Most of them were women. Of the 13 con- ﬁrmed cases of Covid-19 only two (n=2) died.

CONCLUSION

Watching closely the negative development of the pandemic in other countries, as well as the instructions of the global scientiﬁc community as re- ﬂected in the guidelines of the World Health Organization, timely measures were taken which were welcomed and then incorporated into the directives of the Region of Attica, the EODY and the Ministry of Health.

The outstanding outcome is the result of their timely reaction and the initiatives and early measures that they introduced as well as the government early reaction and measures that kept low rates of covid-19 infections in the community. It is also the result of their managers working together within the Greek Care Home Association, as well as the Association’s communication and cooperation with Regional Authorities and the Government.

The decisions that were made by the Units’ owners or managers for isolation of the units, regular checks of employees and residents, increased

◂ back to table of contents 54 ℅ MC COVID-19 protection measures and close observation of employee and residents’ temperature and possible symptoms were also correct. It seems that many Units took these precautions even before they were adopted by the national bodies. The experience and training of the Units directors, the information they received from the scientiﬁc community, as well as the horrible outcome in Units across the world that were published in the media may be the reason for this timely reaction and the positive outcome.

The cooperation of relatives and residents in the decision to restrict visiting hours was also of tremendous importance. If the visitation remained open, the exposure to the virus might have had devastating consequences.

The “ﬁrst wave” of the pandemic was effectively halted in the Long-Term Care Units in Greece, not without ﬁnancial impact on the Units and with tremendous psychological and social consequences for families, residents and employees. Time has been earned in order to design a, better, common, solid strategy and to make the necessary adjustments to “heal wounds” and effectively deal with Covid-19 in the future.

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