Questions/Answers

The State Reference Center for Elderly Health Care (CREASI) is an outpatient reference unit 2with 22 years of experience assisting frail elderly and those at risk for frailty. At the beginning of COVID-19 pandemic, North American and European data showed the vulnerability and lethality of older people as a challenging problem. The question was: how to maintain outpatient care for the frail elderly, with chronic health conditions as social isolation was recommended? Furthermore, how to deal with an unprecedented scenario? As soon as the challenge was launched, the unit's team discussed possible intervention strategies based on the accumulated experience and available resources. Thus, the target population was selected: elderly patients assisted by CREASI; Older residents of Long-Term Care Facility (LTCF); health and other strategic sectors workers/professionals. The main objective was to mitigate the impact of COVID-19 on the target population. The specific objectives were: • to minimize COVID-19 morbidity and mortality; • to avoid lack of assistance of non-communicable diseases and injuries (NCDI) in the population assisted by CREASI; • to develop COVID-19 surveillance actions in LTCF; • to test and advise workers from health and other strategic sectors; • to rehabilitate elderly people with COVID-19 sequelae after hospital discharge (later on) For this, CREASI had been restructured itself into 4 work fronts: 1. Reorganized the appointments into telemonitoring, teleconsultation and personal assistance (for clinical complications) for elderly patients; 2. Organized and coordinated the Intersectorial Committee on monitoring Long-Term Care Facilities in the state of Bahia (ICMLTCF); 3. Took part in the implementation and managed the Testing and Reception Center (TRC) for workers from health and other strategic sectors; 4. Installed a Post-COVID Rehabilitation Clinic (PCRC).

Historically responsible for elderly outpatient care, CREASI was adapted to maintain the care of vulnerable elderly people and reduce morbidity and mortality due to COVID-19. Innovatively, it monitored 218 LTCFs in Bahia state and implemented a testing center for health and strategic workers/professionals. Gradually, it incorporated information and communication technologies used during the pandemic as hybrid treatment options, as in the example of the teleconsultation to bedridden elderly. The remodeling experiences still remain, with the possible flexibility, considering the pandemic's waves.

Historically the population assisted at CREASI are elderly people with chronic diseases with impaired functionality and quality of life. In this way, the care reorganization during pandemic met goals "3.4" and "3.d” linked to SDG 3 – Health and well-being. By maintaining specialized geriatric-gerontological outpatient care through the inclusion of digital technologies in the regular follow-up of cases, it was possible to guarantee the assistance with risk management of problems. On monitoring LTCF, the following actions were carried out: health surveillance actions, identifying and monitoring suspected or confirmed cases; articulations for testing and assistance support, collaborating in the contingency of outbreaks in these institutions; and educational actions. Through TRC, it collaborated with early diagnoses, following testing protocols for health and other strategic sectors workers/professionals, as well as, in special situations, others, like residents of LTCF, school students and young people in conflict with the law. The PCRC acted on the rehabilitation and risk management of post-COVID sequelae in the elderly. Therefore, alignment is based on care to reduce morbidity and mortality also due to NCDI, reduce health inequities, invest in early diagnosis and rehabilitation for life. This experience became a legacy for new challenges.

To fight the pandemic, despite the resizing of its human resources, the work fronts reorganization promoted the reduction of inequities, reinforced the health care, collaborated to maintain family and professional ties during social isolation, expanded the use of digital technologies aiming to promote improvements in the quality of life of frail elderly people and their families, giving social sustainability to the proposal. Longitudinal monitoring of older people improves health surveillance actions, reducing health problems and consequently costs with exams, hospitalizations and rehabilitation, as well as costs with supplies, medications and caregivers.

In the course of the experience, partnerships were established between municipal and state government instances which, despite political-party divergences, were successful in confronting the pandemic with regard to governance and public administration. This partnership was highlighted in the national media, unlike the scenario over other states in the country. In this process, there was also the professionals interchange, which certainly contributed to the confrontation of historical problems of public administration regarding the structuring of human resources. At the state level and also within CREASI, articulations were carried out to reduce bureaucracy, facilitating the flow of requests for supplies and equipment, access to medicines, scheduling appointments and building service flows. As actions were implemented, previously invisible needs were showed up, which mobilized the team to reinvent new processes or services were implemented, as happened with the Pos-COVID Rehabilitation Clinic. Thus, more LTCF were monitored, more elderly benefited, more public servants and LTCF workers diagnosed, in addition to minors in conflict with the law (symptomatic or symptomatic contacts) and students (to analyze the possibility of returning to classes), who did not belong to the initial target population.

Although there was a concern to take care of everyone, the population aging is a feminized process. Outpatient data from CREASI indicated that 74% are women and at least 35% of them are single, divorced or widowed, many of them living alone or with low social and family support and therefore presenting risk factors associated with health problems, as well as functional impairment. So, they could accumulate more risks related to COVID-19, demarcating the relevance of the actions carried out. There is also the feminization of health workers, which was also present in 63% of the public served by TRC.

Frail elderly people are usually invisible, especially those living in LTCF. COVID-19 suspected cases was found in 81.2% of the 218 LTCF mapped. From Apr/2020 to Oct/2021, approximately 6,200 LTCF older residents were monitored. COVID-19 infection was diagnosed in 1,704 (27.5%) of them. The lethality rate was 11.1%. These numbers are lower than those reported in the international media. During the same period, 3,962 older patients were assisted (teleconsultation and personal assistance) by CREASI, whose COVID-19 mortality was 2.0%. For health and others strategic sectors workers/professionals, ensuring access to testing at the TRC brought security to this exposed population. From Apr/2020 to Oct/2021, 43,129 exams were performed (13% positive). In addition, 2,980 medical consultations were held 10 days after COVID-19 (positive RT_PCR) diagnosis, to ensure a safe return to work. Even more, for those workers presenting stress symptoms related to the pandemic and its uncertainties, 1,507 psychological support sessions were held. It is understood that all interventions carried out promoted successful results in relation to the objective of minimizing the impacts of the pandemic and leaving no one behind. Furthermore, this experience managed to generate greater government visibility about LTCF.

The first step was a meeting with the unit's teams, which was based on the reorganization of CREASI into 4 major work fronts: 1. Outpatient Care: reorganization and resizing of outpatient care with a priority focus on telemonitoring and teleconsultations, maintaining a team to perform health appointment for clinical complications (Mar/2020); gradual and programmed return to the hybrid and in-person modality, based on sanitary recommendations (Sep/2020); 2. ICMLTCF: meeting to implement the committee published in the official gazette (Mar/2020); mapping of all LTCF in Bahia; dimensioning and setting up teams, organization of the work process; establishment of flows and technical-operational criteria, carrying out telemonitoring activities; training and intersectoral network articulations (Apr/20 to Oct/21); 3. TRC: implementation of physical structure and logistical organization for in-office, drive-thru and even home/institutional collection of nasal swab; Sizing and assembling the team work; organization of testing schedule (Monday to Monday, morning and afternoon); collection flow and protocols for communicating tests results; scheduling medical appointments to assess conditions for returning to occupational activities; start of examinations and psychological support (April, 2020). The service remains until today, but with reduced demand, after population vaccination; 4. PCRC: project design with elective criteria for access and assistance; dimensioning and setting up the team, acquisition of equipment and therapeutic resources (May/21); start of appointments (Jun/21). It is still working. CREASI has a monitoring department to evaluate the unit's data, including building process and result indicators, generating health information. Periodic newsletters on the LTCF and reports on the TRC were also prepared.

Outpatient care: Need to look after all elderly enrolled in CREASI, despite the reduced number of professionals forwarded to other fronts. ICMLTCF: Need to consolidate mapping of LTCF and build bonds with managers for greater reliability in data collected. TRC: Comply with an explosive demand in the first months, with a stressed and insecure public in the face of the pandemic and a team equally insecure due to the risks of virus exposure. These setbacks were overcome by teleconsultation; drive-thru modality; fixed teams to establish a trusting relationship with LTCF; development of integrative and complementary practices in care intervals.

Public department had not a consolidated LTCF list, once some of them do not pay taxes or receive public funding. However, the goal of ICMLTCF was leaving no one behind. Once the ICMLTCF's job was recognized, LTCF has begun to spontaneously seek the Committee. This fact was reverberated nationally as a successful strategy, and the team took part in meetings to talk about the experience. The strategies of testing, psychological support, medical appointment for safe return, to reduce the stress of the professionals who remained at work, highlighted a special care of this exposed population, also of unknown precedent nationally.

There was not enough time for the countries initially affected by COVID-19 to publish their successful initiatives to be reproduced. The process was planned, executed, monitored and evaluated continuously, based on the 22 years of experience in implementation of new services. Regarding the PCRC, implemented more recently, it was inspired in a state hospital, which focused on respiratory rehabilitation. The team visited the installations and discussed with the hospital's team. The implanted service model was adapted to better rehabilitate the elderly, which demand is about sarcopenia, depression and anxiety, more than respiratory sequelae

The use of information and communication technologies in health approaches by digital media was permanently incorporated into the performance of the geriatric-gerontology clinic, keeping its limits and possibilities, considering the complexity of the cases. The importance of the lightweight technology used is reaffirmed, which was the bond formed between the care team and the elderly population assisted in the unit, as well as in the follow-up of LTCF, a device that facilitates the approaches of educational and therapeutic actions in health.

The ICMLTCF experience inspirated non-governmental organizations in Brazil (e.g., National Front for Strengthening LTCF) and internationally (e.g., University of East Anglia/UK), through participation at online scientific events especially about actions aimed to LTCF older residents. Currently, CREASI collaborates with an international research, coordinated by the University of East Anglia, about the governmental and non-governmental strategies to mitigate the COVID-19 pandemic in low- and middle-income countries, serving as a basis to illustrate the conceptual tool adopted in methodology. From the governmental point of view, it served as a subsidy for the Municipal council of Salvador/BA and the National Congress (Chamber of Deputies) to propose the institution of new policies, which is being awaited. Futhermore, the Bahia State Health Department (SESAB, in Portuguese) implemented a specific commission to respond the questions raised by the monitoring of LTCF during the pandemic with the municipalities.

Considering the digital health technologies used and the lightweight technologies of health management based on therapeutic bonds, the experience model can be widely transferred and adapted in contexts of primary and specialized health care for the elderly, especially when overcoming geographic access barriers or the functional limitations and restrictions of patients with immobility or reduced mobility. The care for workers' health is always an experience to be shared in other contexts, adapting it selves to the challenges and needs found. Despite of periodic monitoring of LTCF (daily or every three days if suspected or not, respectively) had been changed into training actions for managers, LTCF teams and also for the Family Health Strategy's teams (in the territories which contains LTCF), after the elderly population has received total vaccination (three doses), the experience can be adapted to any other outbreak in collective households or even for possible injuries that could impact the elderly's independent life. The maintenance of service to the public must never be interrupted and this is CREASI's second experience, having been the first in 2009, when there was a fire and the elderly began to be cared for in rented containers during a 18 months rebuilding.

The CREASI maintenance budget (US$ 3,700.00/month) was used. As usual, salaries, electricity, water and telephone expenses were assumed by SESAB in addition to supplies and equipment related to pandemic, due to economies of scale. Approximately 130 professionals from different areas worked on the four fronts to fight the pandemic. The physical space had rooms adapted from CREASI and other units in the complex, in addition to 02 containers to house the TRC, in the parking lot. The CREASI computer network (123 desktops and 21 printers) and government or free software were used. Tablets and cellphones were bought for teleconsultations.

Considering the changes implemented in the pandemic, CREASI strengthened itself as a point of elderly health care, as part of the national policy for the elderly. During 22 years of experience, CREASI got a society recognition, what is translated as a strong political force for the sustainability over time. There are specific financial resources to fight the pandemic, which will be extinguished at its end. However, the actions incorporated into CREASI already have the unit's maintenance budget funded by the State government.

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CREASI has a monitoring and evaluation department, which monitors institutional indicators and integrates the initiative's team. The department subsidized the construction of newsletters and management reports that provides information about the organization, work processes, activities carried out and results achieved. Periodically analyzed, these data and indicators contributed to institutional decisions. The CREASI Ombudsman was also made available to receive complaints, suggestions and praise from the population served. The evaluation of civil society was carried out via demands from defense citizen rights organizations (Public Ministry and Public Defender’s office of the state of Bahia).

The indicators used are quantitative metrics. In outpatient care, including PCRC: percentage of procedures performed, absenteeism, deaths by COVID-19; in TRC: number of exams performed, positive cases and return to work; in LTCF: telemonitoring carried out, positive cases and deaths by COVID-19. It was based on the outpatient database of CREASI, as well as the monitoring teams of ICMLTCF and TRC. For assistance, access to programs was used, such as the Hospital Monitoring System, Medical Monitoring System and Information Management System. For LTCF and TRC, online electronic spreadsheets with encrypted access were used.

The engendered efforts provided successful results, considering the objectives of protecting life and minimizing the impact of COVID-19 on the target group. The outpatient care managed to maintain care for 3,962 elderly people, including PCRC. At TRC, 43,219 RT-PCR exams were performed, with 13% positive. There were more than 20,000 telephone calls in the period to the 218 LTCF monitored, having estimated 6,200 elderly people, of whom 1,704 (27.5%) confirmed for COVID-19 with 11.1% of lethality. In the ICMLTCF, in addition to the visibility and wide dissemination of experience, the success was: to consolidate the list of existing institutions in Bahia, whose data were outdated and unreliable; systematically monitor suspicious and confirmed situations; foster the governmental planning of health actions aimed at this public in the municipalities of Bahia. In October/2021 it was changed into a governmental commission to support health actions at the LTCF. The TRC, by offering support to health and strategic areas professionals, with assurance of testing, early diagnosis and counseling, demonstrated the importance of institutional efforts aimed at worker health. PCRC showed that the most impacting COVID-19 sequelae for older patients are sarcopenia and mood disorders, requiring insertion in psychological services and supervised physical activity.

CREASI is part of the organizational structure of SESAB, which means that its scope is statewide, and must serve the 417 municipalities of the state of Bahia. The State Council for the Elderly is one of two ways by which civil society participates in public management, and it is CREASI that represents SESAB in this Council. Normally, CREASI relates to several departments within SESAB itself. However, during the pandemic, the organizational ties were tightened by various reasons, such as exchange of public servants; availability of equipment and supplies; publication of ordinances and bulletins; borrowing and adaptation of physical spaces; networking, among others. However, the demands taken on by CREASI in the pandemic brought the need for coordination with public institutions from other areas, such as justice, human rights, citizen protection, education, and strategic sectors such as traffic department, public security and police. Many professionals from CREASI are members of the Brazilian Society of Geriatrics and Gerontology, a scientific institution that endorsed some decision-making processes and participated in training. The communication between the stakeholders is done informally by phone or email or formally through documents sent by the Electronic Information System of the state government or by presential or virtual meetings.

The collaborative spirit is a basic feature of CREASI's management, which immediately called up the team to discuss about the possibilities to take part in the task-force to fight against pandemic. Some of them stayed at CREASI, working as usual or in some work-fronts; others were temporally moved on to support others health services out of CREASI. Despite occasional resistance, they strongly engaged in the services for which they were assigned. As partnership is a well-established belief in CREASI and a fundamental part of running the public service for the implementation and success of the proposed actions, all teams did not hesitate calling others stakeholders to help in different ways: Nursing school, Justice and Human Rights and different sectors of SESAB to monitor LTCF; fire department and regional nuclei to check LTCF that didn't answer the calls; Public Ministry to call LTCF managers for their responsibilities; State Regulatory Center to hospitalize seriously ill seniors by COVID-19; Mobile Urgence Service to transfer elderly to hospital; various health and others strategic services to have the list of workers to test for COVID-19; Central Laboratory to process the collected samples; SESAB's communication sector for publicizing the Post-COVID Rehabilitation Service, among others.

The main lesson learned is related to crisis management and the importance of a flexible organization. Despite the initial concerns, the teleconsultation brought greater capillarity and reach of its actions for elderly people living in distant cities. In fact, CREASI already performed remote monitoring, but has now incorporated remote assistance for those and for the bedridden elderly. Processes and flows with historical barriers were simplified or reduced bureaucracy, without compromising attention, evaluation or control, what encouraged questions about their relevance. Appointment scheduling via messaging app, previously unavailable, is being gradually incorporated. Some medicines usually supplied for 30 days, were supplied to cover a longer period, what will be tried to keep. The collaboration of several independent sectors, whose work together became essential to meet the demands of the pandemic, raised the possibility of maintenance of these partnerships. LTCF are now better trained to deal with future localized outbreaks diseases and are better understanding the importance of legalizing their documentation. The importance of a careful and accessible leadership provided security for the team and contributed to facing individual fears and the growth of the collective spirit. By developing these adaptive skills, the team feels more open to taking on new challenges.