managing covid-19 in the community
TRANSCRIPT
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Managing COVID-19
in the Community
Public Health Operating Guidelines for DHBs, PHOs, and Providers
Version 0.1
November 2021
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Consultation
Dr Nick Chamberlain, Chief Executive Northland DHB Ministry for Social Development
Caring for Communities Committee NRHCC Operations
ICCC Clinical Advisory group Reconnecting New Zealand, Self & Community Isolation
Keriana Brooking, Chief Executive Hawke’s Bay DHB Pacific Leaders Forum
Mid-Central COVID-19 Community Navigators Therapeutic Tag Technical Advisory Group
Ministry of Health Clinical Advisory Group
Authorised
Authoriser Date Signature
Robyn Shearer
Acting Chief Executive
Abbreviations
Abbreviation Full Name
DHB District Health Board
PHO Primary Health Organisation
PHU Public Health Unit
MoH Ministry of Health
AMB Ambulance Service
POL Police
IPC Infection prevention and control
MIQF Managed isolation and quarantine facility
NCTS National Contract Tracing Solution
NTS National Telehealth Service
BCMS Border Control Management System
PMS Patient Management System
HSPP Health System Preparedness Programme
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Contents
1. Background ................................................................................................................................4
2. Principles ....................................................................................................................................5
3. Operational Guidelines ..............................................................................................................6
3.1. Organisational responsibilities ..........................................................................................6
3.2. Regional coordination function .........................................................................................8
3.3. An individual tests positive for COVID-19 .........................................................................8
3.4. Initial assessments .............................................................................................................9
3.5. Logistics .......................................................................................................................... 12
3.6. Workforce ....................................................................................................................... 13
6. Funding .................................................................................................................................... 14
7. Health Information Systems and Communications................................................................. 15
8. Continuous Improvement ....................................................................................................... 16
Appendix A: Managing COVID-19 in the Community Landscape ................................................ 17
Appendix B: Considerations for home quarantine ...................................................................... 18
Appendix C: COVID-19 Signs and Symptoms............................................................................... 24
Appendix D: Pulse Oximeters: Community Care and MIQ .......................................................... 25
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1. Background
Whakatauki He aha te mea nui te a o? He tāangata, he tāangata, he tāangata
What is the most important thing in the world? It is the people, the people, the people
Context Since the implementation of Aotearoa New Zealand’s COVID-19 elimination strategy, almost all COVID-19 positive people have been managed through dedicated quarantine facilities. This has included managing their health needs, accommodation support, welfare, and any broader needs.
As Aotearoa New Zealand’s vaccination rate increases, we are moving into a new phase where we will be managing COVID-19 more flexibly in the community. Aotearoa must be ready for coordinated and responsive delivery of quarantine support options when cases arise.
In this new phase, when a person is confirmed positive for COVID-19, the requirement for them to quarantine remains and is necessary to contain the spread of the virus and keep our wider community safe. Depending on the level of illness, home quarantine may be a good option for an individual.
The model of care described as COVID-19 in the Community (‘home quarantine’) has been implemented in many parts of the world. Aotearoa New Zealand has incorporated the lessons from locations such as Australia and Canada into this first iteration of a home quarantine model.
Other options will still be available including placement in a managed facility if necessary, and if severely unwell, hospital level care.
Purpose and development approach The Managing COVID-19 in the Community Operating Guidelines (Operating Guidelines) provides guidance on managing COVID-19 positive people and whānau in the community. These Operating Guidelines treat the COVID-19 positive individual and whānau as a household cohort.
This first iteration focuses on a co-designed public health response. Future iterations will include more comprehensive detail on the social and welfare response, as well as lessons from implementing these guidelines.
The Operating Guidelines are designed to empower District Health Boards (DHBs), Primary Health Organisations (PHOs), and health and community care providers to develop a flexible regional response to manage COVID-19 positive people and whānau safely, effectively, and equitably in the community. The Operating Guidelines work to support the appropriate balance of; centrally supported, regionally delivered, locally led health and well-being.
The health and social welfare sectors are encouraged to provide feedback on the usability and utility of these Operating Guidelines. to [email protected] Attn: Operating Guidelines Managing COVID-19 in the Community.
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2. Principles Supporting COVID-19 positive people and whānau to remain at home when safe and appropriate to do so. COVID-19 in the Community can be an effective way to provide high-quality, sustainable, and equitable care.
The model for managing COVID-19 positive people and whānau in the community has been
designed with a whole of system approach to:
● recognise and respond to the obligations of Te Tiriti o Waitangi partnership
● ensuring that COVID-19 positive people and whānau are given every opportunity to quarantine in a location of choice, within the boundaries of safety to self and others.
● ensure equity of access and support is person and whānau-centred
● ensure safe, high quality care is flexible tailored to the induvial and whānau needs
● embrace the natural care and support relationships already in place for many people with their health and social networks
● embrace existing interorganisational collaboration, whilst concurrently fostering new collaboration opportunities.
● effectively balance centralisation with local flexible empowerment – Centrally supported, regionally delivered, locally led
The model of care principles are informed by an integrated support pathway, or continuum.
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3. Operational Guidelines Figure 1 Managing COVID-19 in the community overview
3.1. Organisational responsibilities The thoughts and emotions experienced by an individual as they receive a positive test result are unique to the individual. Some will be overwhelmed with fear or anxiety, whilst others who are asymptomatic may be shocked. The initial minutes and hours after receiving a positive test result are crucial to the safety and wellbeing of the individual, whānau, and community.
There are several organisations across Aotearoa with a role and responsibility to keep that
COVID-19 positive individual, whānau, and community healthy and safe. Table 1 sets out the responsibility expectations of key organisation types. How these organisations work collaborative around the COVID-19 positive individual and whānau is to be designed at a regional and local level. This enables regional and local ownership, empowerment, flexibility, and collaboration.
Table 1 Stakeholder responsibilities
Stakeholder Responsibilites
Public Health Unit Oversight and management of the public health pathway of managing COVID-19. Public health pathways business-as-usual, with clinical support from primary care and specialist and hospital services.
• Notification of positive result
• Conduct the initial COVID-19 positive public health assessment
• Conduct initial clinical, social, welfare, and cultural assessment
• Determine suitability for home quarantine
• Coordinate home contacts and close contact screening and if necessary tested for COVID-19
• Communicate positive result to individuals preferred primary care
provider and any relevant assessment information
• Report non-compliance to police as per existing protocols
• Complete assessment and processes around clearance from quarantine requirements
• Documentation and communications with relevant stakeholders
COVID-19-positive person and whānau
Work with health and Government partners to keep themselves and the community safe and healthy
• as active health partners
• providing up-to-date, accurate, and complete information
• complying with regulations.
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Community care organisations -including social developement, housing and NGOs
Points of contact for social, welfare, wellbeing, and cultural needs.
• Triage social, welfare, and cultural needs
• Identify refer to appropriate agencies or organsiations
• Communicate with primary care teams social, welfare or cultural needs which could impact on health status of individuals or whānau.
• Report any non-compliance of stay-at-home advice to local PHU
• Coordinating delivery of a ‘package of care’ for social, welfare and wellbeing, including where relevant cultural support.
Primary Care Teams – including general practitioners, district nursing
First point of contact for clinical management
• Contribute to/lead clinical assessment on enrolled patients, and where necessary unenrolled patients.
o Opt-in model for practices o enrolled patients o enrolled patients + o opt-out, with pathways available for non-COVID-19 related
management
• Obtaining consent to refer to social and welfare services
• Providing referral to social and welfare services
• Provide ongoing clinical management of both-COVID-19-and non-COVID-19 health issues
• Providing telehealth offerings, including afterhours as needed. o For ‘low-risk ’patients a virtual consultation is expected at
least every 2 days. o For ‘at risk ’patients, the primary care team is required to
contact the patient every day or more if required to ensure patient safety and connect with other members of the care team regarding any new or changing needs identified.
Primary Health Organisations
It is the responsibility of the PHOs to understand and support community health care providers implement these guidelines.
• Monitor the demand and returning of the items
• Disseminate pulse oximetry to primary care providers, or nominated distribution teams
• Maintain registries of distribution
• Ensuring adequate levels of PPE remains the responsibility of each individual practice and can be ordered via the existing PPE portal on HealthCare Logistics or Onelink
• New healthcare providers or providers that do not currently hold
adequate contingency stock, should email the Ministry of Health via: [email protected].
District Health Boards
DHBs will lead the implementation home quarantine and support the correct use of the patient pathways in primary care.
• Regional coordination and stakeholder engagement
• Ensures immediate welfare needs are met and allows time for other agencies, NGOs to become involved. Provide an initial and tailored multi-day ‘pack’ of common support items, where appropriate
• Building and maintaining a communication cascade, where relevant,
ensuring messaging is given and understood
• Ensuring socio-cultural needs are being met, including access to translation or interpretation services where required
• Quality and safety oversight through clinical governance o Point of escalation for clinical management, e.g., telehealth
triage, inpatient support
o Provide management and oversight of all high-risk unwell patients and non-enrolled patients
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• Ensure adequate daily reporting on risk and performance through to the Ministry of Health
• Distribute pulse oximetry to PHOs to disseminate to primary care or nominated distribution teams.
• Ensure electronic data capture and sharing occurs in alignment with privacy and security obligations
• Payment/reimbursement for costs incurred by Providers.
3.2. Regional coordination function To deliver services and care regionally and locally requires the establishment, or formalisation of a coordination function. As geographic regions develop processes for integrating health and social services an interim solution of regional coordination hubs is likely required. The preferred option for the initial organisation host for the regional coordination function is DHBs, due to both the legislated role of health in leading this aspect of the response, and due to the functions and relationships already well formed under the DHB structure. This may be virtual and may be coordinated by a DHB or other well-connected agency able to take this responsibility.
The regional coordination function will need to provide a whānau-centred connection with public health, primary care, community care, specialist and hospital care services, ambulance,
and welfare and well-being services. Table 1 above provides an expectation of stakeholder responsibilities and can be expanded upon depending on regional and local needs. How this is administered, and the delegation of roles and responsibilities will be dependent on whānau needs and preferences, existing care and support relationships, local provider capability and capacity, and acknowledgement of the required expertise and standard responsibilities of providers (for example, delivery of medicines). Introducing a community coordinator role will likely assist with stakeholder engagement and patient and whānau support. Issues that emerge regionally that cannot be resolved should be escalated to the Ministry of Health.
3.3. An individual tests positive for COVID-19
The Aotearoa New Zealand experience has shown that the likelihood of cases and contacts agreeing with isolation or quarantine arrangements is strongly influenced by the quality of the relationships that are established at the outset. It is important that upon first contact with the COVID-19 positive person and their whānau, they are made to feel safe, respected and understood.
From confirmation of a positive COVID-19 test result, public health services undertake assessment processes and connect with relevant professionals within the regional coordination function to gather information and complete initial assessments.
Within the regional coordination function, public health teams can access support to complete initial assessments and take responsibility for confirming suitability for home quarantine. Detailed considerations are available in Appendix B.
Figure 2 Regional coordination function
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The outcomes of these assessments help ensure that a care plan is developed detailing both clinical and non-clinical supports are in place. Individuals determined not suitable for home quarantine will be escalated by PHUs to a managed facility or hospital care as clinically required. The PHU will notify the primary care team of the positive result and hand over the monitoring to either the National Case Investigation Unit or the primary care team.
3.4. Initial assessments Across the regional coordination function, a four-part initial assessment must take place to ensure that critical actions are undertaken following notification of a positive case. The appropriately skilled, qualified, and informed professionals to undertake each part of the assessment suite may vary case-by-case and be determined by the situation.
Table 2: Initial assessment
Public health assessment
Initial clinical assessment of COVID-19 signs and symptoms
Clinical risk assessment for COVID-19 complications and management
Support and cultural needs assessment
As per usual processes for public health requirements and statutory responsibilities.
Initial assessment of current or emerging need for clinical support. (see Appendix C)
Health history and current medical needs.
Suitability of accommodation, safety, security, and essential needs. Whānau needs.
Secure and stabilise Identify primary and community care needs and relationships
Determination of suitability of place (see Appendix B) Care coordination for whānau Set-up activities (including essential supplies and technology)
Clinical risk assessment for COVID-19 complications and management1
The COVID-19 positive individual can be classified as ‘low risk ’or ‘at risk ’of complications.
At risk COVID-19 positive individuals are those that fall into any of the below six groups and require more intense clinical management:
1. Unvaccinated or second vaccination received less than 2 weeks before testing positive
2. Vulnerable children classified as an infant under 1 month; children less than 2 years born premature under 37 weeks; or any child with a comorbidity
3. Pasifika >39 years old, Māori > 44 years old, Other ethnicities >65 years old
4. Current medical history containing any of the following:
○ Pregnant, or within six weeks or giving birth ○ immunocompromised
1 The Ministry is actively preparing a more comprehensive tiered risk assessment clinical pathway
which will be available in future releases of these Operating Guidelines.
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○ active malignancy ○ hypertension ○ diabetes ○ ischemic heart disease ○ chronic kidney disease ○ chronic obstructive pulmonary disease (COPD) ○ asthma ○ stroke (CVA) ○ epilepsy ○ liver disease ○ mental health ○ addiction ○ frailty ○ smoker (tobacco or cannabis) ○ BMI>30 ○ CPAP use for sleep apnoea
5. Complex or dynamic circumstances with any of the following:
○ Social isolation, ○ geographical isolation (rural), ○ lack of transport, ○ unreliable phone or internet connection, ○ housing insecurity, ○ housing crowded or damp and cold, ○ requires carer support, ○ absence of a suitable caregiver, ○ disability support required, ○ family harm notifications, ○ health literacy support required, ○ requires a translator
6. Nil of the above apply but the individual is experiencing moderate or severe clinical signs and symptoms of COVID-19, see Appendix C.
Determining clinical care level
Guidance determining care level requirements are shown in Table 3 below. Anyone experiencing severe signs and symptoms requires urgent hospital care, Level Three. Most young and healthy adults experiencing no, or mild symptoms will initially require Level One clinical care. These individuals are initially low risk. Those individuals ‘at risk’ or experiencing moderate symptoms will require more regular clinical care and should receive Level Two care. Depending on social circumstances, home quarantine may be an option for those requiring Level One or Two care.
Table 3: Care Levels
Level One Level Two Level Three
Clinical Assessment
Asymptomatic or mild symptoms
Moderate symptoms Severe symptoms requiring acute or palliative care
Risk of complications
Low risk (e.g., fit young and healthy)
At risk of complications -
Feasible Care Setting
Home Quarantine Home Quarantine Hospital or Palliative Care
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Based on the three care levels the resulting service models of care are provided in Table 4.
Table 4: Service levels
Level One Level Two Level Three
Service delivery modality
Self-monitor with virtual contact every other day
Self-monitor with daily virtual health consultations with a primary care provider
Ongoing face-to-face acute hospital or palliative care
Self-monitoring frequency
Daily, more frequent if emergent concerns
At least twice daily pulse oximetry readings communicated to primary care team
Ongoing by hospital or palliative care staff
Escalation Via telehealth or 111 as symptoms deteriorate
Via telehealth or 111 as symptoms deteriorate
Per local protocol
Assessing and providing social, welfare, wellbeing, and cultural needs
In the initial hours following a positive COVID-19 result, individuals with high pre-existing needs require rapid wrap around support. Across the regional coordination function there must be an avenue for rapid assessment and response to the social, welfare, wellbeing, and cultural needs of the person and whānau quarantining at home. Once an individual’s need is identified, a community coordinator, via the regional coordination function, should be engaged to provide support for the COVID-19 patient and whānau during their time in home quarantine. This person could be a nurse, member of the local iwi, or other individual determined by the coordination function to be the most appropriate community coordinator.
This individual will work with the individual and whānau to capture existing community care needs (e.g., disability, mental health, aged care), as well as welfare and wellbeing relating to the new situation of quarantine. This will need to be a collaborative exercise across involved stakeholders. The following information should be collected and clearly documented to inform welfare and wellbeing support services.
● Current care or support needs relating to whānau support, disability, mental health, aged care, home and community support services, child development, and maternity.
● Household members (ages, medical conditions, ability to work or continue education from home, access to sick leave, special needs, ethnicity, and preferred language).
● Information on the housing situation (housing tenure, number of bedrooms and bathrooms, bed sharing, any potential challenges for isolation and/or quarantine).
● Ability to access what is needed to maintain an isolation/quarantine ‘bubble.’
Community
Coordinator
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● COVID-19 status and testing of household members (dates, results, symptoms, retesting).2
Welfare and wellbeing need for household contacts are to be met as part of managing COVID-19 in the community. This includes ensuring those that live in rural areas or a considerable distance from a GP practice, pharmacy, or hospital are adequately connected. Where practical, the community coordinator should utilise normal processes, with the support and cultural assessment identifying gaps.
Each community and support service are required to work alongside primary care teams to meet the needs of the person and whānau at home in quarantine.
The regional coordination function will need to consider the whānau-centred connection with public health, primary care, community care, specialist and hospital care services, and welfare and well-being services. This may be coordinated by a DHB or another well-connected agency within a region. The community coordinator helps to ensure these connections remain in place for everyone.
New social services measures introduced after the national Alert Level 4 period for COVID-19 provide a greater level of support to those impacted by COVID-19 in New Zealand. These social services may also be appropriate. Shared services known as C4C - Caring for Communities, through Ministry of Social Development (MSD), Kainga Ora, Oranga Tamariki, and other collaborating agencies will continue to be available to provide support services to any person/whānau requiring food, shelter or income support and meet their criteria.
3.5. Logistics Obtaining informed consent Prior to the COVID-19 positive individual receiving either home or facility quarantine, a registered health professional must obtain informed consent, per the Code of Health and Disability Services Consumers Rights (the Code). The steps to recording the outcome of the informed consent conversation are:
1. The clinician or an administrative support person must record in the patient management system (PMS) or medical record the person’s consent to adhere to the regulations of the quarantine setting.
2. A written consent form is preferable to be scanned into the PMS system and forms must be always held and transported securely (for example, in a locked cabinet/drawer, a tracked courier bag, or other secure container when transported between locations) then destroyed as securely as normal process. Or where this is not available verbal consent can be documented in the clinical notes.
Where a person is not competent to make an informed choice and give consent someone who has the legal right can make decisions on the person’s behalf; namely a legal guardian or someone who currently holds Enduring Power of Attorney for personal care and welfare.
Once all the options have been considered and the decision for home quarantine has been agreed the COVID-19 positive person or their legal guardian is to sign a patient commitment form. This must be explained in detail by either the primary care team or the PHU prior to signing and recorded on the patient PMS and BCMS.
2 All household contacts of a COVID-19 positive person require specific testing, education, and
monitoring, as per standard public health processes. This is coordinated by PHUs.
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Pulse oximeters for home quarantine
For successful implementation of managing COVID-19 patients in the community, there is a requirement for patients in Level Two care on home quarantine to self-monitor with a pulse oximeter. It is up to the patient to self-monitor their symptoms and to report recordings when followed up by their primary care team or PHU. A pulse oximeter will be provisioned to patients categorised as needing Level Two care. Pulse oximetry monitoring is not necessary for Level One low-risk individuals.
The delivery of pulse oximeters to Level Two Care patients is considered the responsibility of the primary care team via the PHO, where the DHB has sourced the pulse oximetry. The DHB will need to identify a suitably qualified and reputable company to manage the delivery (and any necessary maintenance) of pulse oximeter machines to nominated patients. See Appendix D for technical specifications regarding this equipment.
Personal Protective Equipment (PPE)
Ensuring adequate levels of PPE remains the responsibility of each individual practice and can be ordered via the existing PPE portal on HealthCare Logistics or Onelink.
New healthcare providers or providers that do not currently hold adequate contingency stock, should email the Ministry of Health via: [email protected].
3.6. Workforce To manage COVID-19 positive people and whānau in the community, a more diverse workforce may be engaged or required. Therefore, new roles and responsibilities may be shared across the system.
Support is needed to empower and enable the workforce to be safe and effective in their roles, and to ensure sustainability. Flexibility of traditional roles is encouraged, providing that the people engaged have the appropriate qualifications, competencies, and tools for their work. For example:
● access to clinical information and responsibility for clinical services must remain with those appropriately qualified to undertake these roles
● people providing in-person support to COVID-19 positive people or whānau within the household bubble need to be vaccinated, trained in IPC, provided with appropriate PPE, and monitored in accordance with public health requirements
● relevant health providers must have access to, demonstrate understanding of, and apply the supporting frameworks for allocating patients to the appropriate Level of care, such as the Clinical Risk and Management Decision Support Tool.
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6. Funding As per the current arrangement with DHBs and PHOs, primary care teams will invoice the PHO for services rendered and the PHO is to complete the payment.
The Primary and Community care commission modelling is progressing at pace. Funding estimates are working towards an initial 12-month period.
Key aspects of the commission modelling include:
● Equity loading and adherence to the agreed clinical model of care as foundational.
● General practice, community pharmacy, paramedic, ambulance, maternity, systems integration, and some equipment costs.
● Estimates on case numbers are based on expert advice from epidemiologists and the August Auckland Delta outbreak. Case estimates are based on up to 230,000 cases across a year, 630 per day.
● Unenrolled, complex, and high needs population estimates are incorporated into the model.
The funding model is undergoing a peer reviewing process and input from Ministry of Health Finance, and the DHB Chief Executive leads for primary care.
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7. Health Information Systems and Communications
Aotearoa New Zealand does not currently have a standardised and integrated IT solution for health and social services. DHBs will need to work with systems already in place. It is critical that information from key disparate systems is shared where possible. As an interim solution this will be accomplished via the use of the Border Clinical Management System (BCMS). Health providers will be responsible for inputting their assessments of each patient into their relevant medical records plus the BCMS. There is not currently an intent to enable BCMS to social and welfare providers.
In the immediate term, we need to utilise what is currently available nationally and at a regional-DHB level, which involves accessing the BCMS system for notification and assessment, supplemented by PMS systems to manage the broader clinical care pathway. The continuum of care from notification to release is as follows:
Within this continuum:
● PHU notifies person they have returned a positive COVID-19 test and determines whether a quarantine facility or home quarantine is appropriate; begins case investigation.
● Primary care providers receive patient notification via BCMS.
● GP performs assessment to determine level of care; updates BCMS accordingly.
● High risk persons referred to hospital, medium and low risk managed in the community; model of care captured in BCMS.
● Regular health checks as per risk rating; captured in BCMS.
● Clearance certificates post home or facility quarantine are to be completed by the PHU team and given to the patient for their records.
All health providers will require training on the BCMS. An e-learning module will be provided from the Ministry of Health via Health IT.
To arrange access to the BCMS system, please contact [email protected]. A training guide accompanies this document.
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8. Continuous Improvement
Working together should be anchored to a common purpose and centred around the people we are working to help. Working together means understanding, respecting, and valuing each other’s different roles, strengths, and contributions. It means recognising who is best placed to commission and deliver services. It also means seeking agreement to shared outcomes. Relationships containing high levels of trust are critical. Building and maintaining relationships should be a feature at all stages of the commissioning process. Interagency relationships that promote collaboration and coordination will be critical for the integration and connection of investments and services. This applies at all levels of support from centrally supported, regionally delivered, and locally led.
Insights should be used to determine need before the services are designed and used thereafter to deliver continuous improvements. Agreement on the level and type of insights that are needed and possible should be undertaken early in the commissioning process.
These early conversations should also canvas what constitutes a good outcome and how to measure it. Metrics used to measure ‘good ’should be focused on quality and results rather than quantity and should include transparency and rationale around what is evaluated and why.
High trust, low compliance contracts should be in exchange for willingness and commitment to share learning and address the challenge of how to capture insights and conduct evaluation.
Consistent with the Data Protection and Use Policy, collection and sharing of information should be done in ethical and responsible ways. This should include consideration of issues related to data access and the use, relevance, and quality of data about Māori, and Māori Data Sovereignty.
Contracts and funding approaches should allow flexibility for a test–learn–adapt approach.
The Ministry of Health is rapidly iterating the model for Managing COVID-19 in the Community, including considering all consultation feedback. Consultation not addressed in this first release will be considered and incorporated into subsequent iterations. Please provide feedback regarding this document to [email protected] Attn: Operating Guidelines Managing COVID-19 in the Community.
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Appendix A: Managing COVID-19 in the Community Landscape
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Appendix B: Considerations for home quarantine
Table 5: Minimum requirements for a dwelling to be used for isolation/quarantine
Dwelling
Safe and sanitary ● Access to potable running water ● Functional heating and lighting ● Functioning sewage disposal system ● Facilities are available for handwashing for staff who need to enter the
dwelling ● There is provision for safely disposing of household waste
Space and ventilation
● Outside space able to be accessed without traversing areas shared by people not sharing the ‘bubble’
● Reasonable access to an area for exercise ● Opening windows in living, bedroom, and bathroom areas ● No ducted ventilation (unless isolating/quarantining alone)
Privacy ● The residence/local accommodation is protected from unwanted public attention
Communication ● Cases and contacts have a reliable means of communication available (e.g., internet, landline, mobile phone)
Shared dwelling ● Cases and contacts have access to separate toilet and bathroom facilities ● The dwelling is of sufficient size to allow people to move around freely
while maintaining 2 meters physical distancing
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Table 6: Commitments to Te Tiriti o Waitangi
Commitment to Te Tiriti o Waitangi
We are committed to meeting obligations under Te Tiriti o Waitangi/The Treaty of Waitangi and achieving Pae Ora (Healthy Futures) for Māori, as set out in He Korowai Oranga (the Māori Health Strategy).
Public health officials are to discuss the needs of individuals confirmed as having COVID-19 and their close contacts or whānau, and where possible, could consider options.
It is important to get support from your PHUs local relationships with iwi and hapū, and Māori, Pacific, and other community providers to ensure strong links with the community and to support the individual and their whānau. Don’t assume the individual and their whānau have existing links in place for support.
Properly resourced kaupapa Māori health and disability services should be discussed and provided if needed, for the individual during their stay in local accommodation or MIQF as well as for any whānau remaining behind and staying in the home.
Ensuring equitable wellbeing, means providing the resources needed to support and protect the individual and the whānau’s wellbeing. (the local relationships with Māori, Pacific, and other providers (including engagement organisations) will be able to provide/ put support in place). Using the opportunity (that is the intense focus on the family caused by COVID-19) to make sure everything else is addressed and taken care of (i.e., health, wellbeing, welfare) to improve longer term outcomes for the individuals/family. This will prevent making at-risk populations more at-risk.
The considerations in the table (which are not exhaustive) should also apply to the whānau. For example, providing technology for an individual in local accommodation or MIQF to stay connected to whānau will not be effective if their whānau do not also have technology, support, and access to the internet with enough data. whānau wellbeing may also mean providing wraparound services, and referrals to providers and agencies to provide support.
These questions have been developed using the Ministry’s Te Tiriti o Waitangi Framework.
Is the individual and their whānau involved in the conversation at the outset and a relationship established?
Has information about isolation/quarantine, including on the implications and risk to health and wellbeing of any options, been communicated in a way that is meaningful to the individual and the whānau, framed by te ao Māori (the Māori world)?
Within the existing parameters (which may change), have different options (for example, isolating closer to home) been discussed with the individual and their whānau? Has the individual and their whānau been able to suggest additional options that the Medical Officer of Health may not have considered?
Have the individual and their whānau been actively involved as a partner in the decisions?
Is the whānau’s well being supported? (Who are not the confirmed case, and who are not moving to local accommodation or MIQF, enlist support from local Whānau Ora groups).
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Health needs of the entire household
Can the health needs of each member of the household be appropriately supported in a MIQF?
If the health needs for each whānau member differs, can the whānau members be transferred to different isolation/quarantine facilities to meet their individual needs, or do they need to (or wish to) remain together?
Availability and distance to travel to an MIQF
Can individuals with pre-existing /perpetuating medical or mental health needs be transferred across regions/facilities?
Consideration needs to be given to sharing of clinical notes, services, or clinicians the individuals are already engaged with, etc
Travelling short distances is preferable and the travel requirements specified within the MIQ Operations Framework will need to be met.
How far would the individual/whānau need to travel to the nearest (most appropriate) MIQF?
Will the individual/whānau be able to travel this distance? (Consider health and mobility needs and if the transport options available can accommodate these needs.)
Cultural considerations
Manaakitanga is a key value that needs to be displayed here.
Being required to move away from a person’s traditional whenua can be traumatic for Māori as that is their tūrangawaewae (for example, moving from their community/whānau to another geographical location).
For wellbeing purposes, people will need to have access to full support, including cultural support which might include virtual contact with whānau members and karakia.
Access to Māori security and support staff at the quarantine location is preferable, or staff who have experience working in partnership with Māori. All security staff will be trained in the appropriate IPC practices that they must follow to keep themselves safe, including practicing physical distancing and the correct and safe use of PPE.
Partnership between the medical officer of health, local DHB/PHU staff, and local iwi in decision-making around managed quarantine options is critical to Māori support of the approach.
Culture is an important determinant of health and wellbeing for Pacific peoples and their families. For many, this is reflected in their connections across extended multi-generational families, often in one household,
Will the household/family have ready access to appropriate cultural support if needed? (Health or social services workers that can speak their respective ethnic language if preferred and understand the culture of that ethnic group.)
Will the household/family have access to technology, internet, and phones to stay connected with other family members and community outside of isolation/quarantine, and to participate in online events that support their cultural and/or religious beliefs and values? (If online events are available, how individuals can be supported to engage in them.)
Will the household/family have access to an appropriate space in a MIQF to support practice of cultural or religious beliefs and values in a safe environment? (With consideration of IPC requirements.)
If safe and appropriate to do so, whether families from different but related households (extended family relatives) can be supported – and offer support to each other – in the local accommodation or MIQF?
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and connections in the local community through church, sport, and other activities. The complexities of language must be addressed including access to interpreter services.
Social and welfare needs of the entire household
Consider older carers who are caring for their older partners, and particularly carers of someone with dementia/cognitive impairment. In a lot of cases moving out of a familiar/safe environment would be detrimental to their health.
Disabled people may receive assisted/supported living services which cover a range of activities from a carer entering a person’s house for a few hours each week to help with household chores and activities to daily support with activities such as getting in and out of bed, toileting, getting dressed, and preparing food. Generally, carers also provide social and emotional support. There is a high degree of variability in terms of level of need for disabled people, and the level of assisted/supported living services required.
If a person requiring this form of assistance and care tests positive for COVID-19, officials anticipate that a carer may choose to enter MIQ with the person they care for (e.g., the carer may be a relative of the confirmed case). However, in some cases, they may not be willing or able to do this.
Properly resourced kaupapa Māori health and disability services should be discussed and provided if needed, for the individual during their stay in local accommodation or MIQF as well as for any whānau remaining behind and staying in the home.
Ensuring equitable wellbeing means providing any resources needed to support and protect the individual and the whānau’s wellbeing. The considerations in the table (which are not exhaustive) should also apply to the whānau. For example, providing technology for an individual in local accommodation or MIQF to stay connected to whānau will not be effective if their whānau do not also have technology, support, and access to the internet with enough data. whānau wellbeing may also mean providing wraparound services, and referrals to providers and agencies to provide support.
What is the size of the household?
Can the entire whānau be supported within a MIQF?
Aside from the case, does the whole whānau need to be quarantined? What does the whānau prefer?
Would entering a MIQF decrease the risk to the whānau? (Would confining the whānau to a hotel room increase the risk of onward transmission between them, compared to remaining in their home.)
How many, if any, dependent children are there in the household? Can they be appropriately supported within local accommodation or a MIQF?
Can the household be split across rooms/facilities, or do they need to remain together (e.g., for childcare reasons)?
Are there vulnerable members of the household that are at risk if they remain in close contact with other household members? (E.g., elderly people, a multi-generational household, pregnant people, people who are immune-compromised or have other pre-existing conditions that elevate their risk.)
Alternatively, are there vulnerable/dependent members of the household that will be at risk if they are separated from other whānau members?
Do members of the household have serious mental health needs that cannot be accommodated within a MIQF? (Noting that anxiety, distress, and changes in mood are normal responses to stressful situations and not reason to avoid quarantine in a MIQF.)
Do members of the household have disability support needs or accessibility requirements that cannot be met in a MIQF? (Disability support needs need to be met by suitably qualified and skilled support staff.)
Would any in the household experience trauma because of moving out of their home and changing their routine due to their disability related need? (e.g., Autism)
Are there external pressures, such as intense media scrutiny, that may affect the individual/whānau’s wellbeing?
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Does the individual or members of their whānau have any mental health needs that could be exacerbated by the quarantine itself?
Are any whānau/household members at risk of family violence and sexual violence? If yes, what is the safest isolation/quarantine option for them?
Would a change of circumstances increase the risk of harm from substance use, e.g., risk of withdrawal, disruption to recovery? If yes, can this risk be managed with appropriate support?
House type and space
Is the individual(s)/whānau’s home appropriate to self-isolate in?
Is there adequate space to physically distance between confirmed positive cases and other whānau members?
Are housing conditions adequate (e.g., warm, dry, healthy home)?
Housing density and proximity considerations – what is the risk that the household will come into contact with neighbours?
If concerns regarding housing type and space (such as those described above) have been identified, can these concerns be mitigated or alleviated with the appropriate supports and plans in place?
Children/young people
If the child/young person is in care or custody, Oranga Tamariki (or the provider approved under s396 that has legal custody of the child or young person under the Oranga Tamariki Act 1989) must be included in decision-making.
The starting point for children in care is that the decision needs to be based on the wellbeing and best interests of the child (refer United Nations Convention on the Rights of the Child (UNCROC) and the Oranga Tamariki Act).
In determining what is in the best interests of a child in care, start with determining how isolation/quarantine was able to be managed in the child’s usual home, rather than considering a MIQF the default option.
The ability of the local accommodation or MIQF to meet the needs of tamariki in care, and those caring for them (e.g., physical space, safe sleeping arrangements, space for breaks) if staff are caring for tamariki, specific needs of young people who might challenge the
Is the child/young person, or their parent/caregiver, subject to a court order requiring them to remain in a specific region? If yes, is the proposed location of quarantine within this region?
What are the needs of children in a whānau, and how can their needs be best met? (This is important given the role of guardians/caregivers in decision making and the support needs children might have.)
Does the child/young person require more than one adult caregiver, i.e., if they are to be cared for by staff, not their usual caregiver? Is this manageable within the proposed quarantine arrangement?
Does the child/young person have mental health needs, or disabilities? Where can these needs be best accommodated and supported? This could include anxiety, distress, trauma, substance harm, neurodiversity, and conduct disorders.
Does the child/young person have behavioural challenges that need to be managed while in isolation/quarantine, particularly challenges
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confines of local accommodation or a MIQF but cannot be dealt with like an adult who does the same thing.
around staying in one place? How and where can the child/young person be best supported?
Adherence and compliance risk
Adherence and compliance risk can be a challenge and additional support for providers may be needed for at-home isolation/quarantine. Involve the provider/carers in the decision making.
MIQ facilities may have limited numbers of accessible rooms.
Has the individual(s) or household indicated they will be unwilling to comply with the isolation/quarantine requirements if they were to self-isolate at home, including the requirement to remain at home and have no visitors?
Are there any whānau members, including children, who may struggle with complying with quarantine requirements if they were to self-isolate at home? Can this be appropriately managed in a home setting?
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Appendix C: COVID-19 Signs and Symptoms Table 7: COVID-19 signs and symptoms
Mild Moderate Severe
Symptoms
Feeling tired
Headache
Cough
Sore throat
Muscle aches
Runny nose
Nausea
Loose bowel motion
Loss of taste or smell
Mild symptoms plus one or more of:
Constantly fatigue
Worsening headaches
Worsening cough
Becoming short of breath with effort
Constant aches
Diarrhoea (frequent loose bowel motions)
Chills, fever
Abdominal pain
Vomiting
Rashes, swelling or blistering of toes
Intensifying symptoms or any of:
Difficulty breathing at rest, talking in short sentences or single words
Chest pain or pressure
Coughing up blood
Confusion, altered mental state or becoming difficult to rouse
Cold clammy mottled or pale skin
Worsening fatigue, profound exhaustion, fainting, falls
Dehydration (reduced oral intake and minimal urinary output in 12 hours)
Rapid deterioration of any sign or symptom
CHILDREN
Difficult to wake, floppy, or convulsions
Decreased oral intake, lethargy, persistent irritability
Signs
Mild fever <38 degrees
SpO2 > 93%
Fever of 38-39.9 degrees
Rising heart rate from normal baseline
Dropping oxygen saturations by 3% from baseline, or SpO2 < 92% or blue lips or face
Fever > 40 degrees
Respiratory Rate > 24, unexplained heart rate > 100
CHILDREN
Cyanosed or SpO2 < 90%, pale or mottled
Severe respiratory distress: Respiratory rate
● 60 if under 2 months
● >50 if aged 2-11 months
● >40 if aged 1-5yr
Fever > 38 for 5 days
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Appendix D: Pulse Oximeters: Community Care and MIQ
The Nonin Onyx Vantage 9590 Finger Pulse Oximeter is a small, lightweight, portable device indicated for use in measuring and displaying functional oxygen saturation of arterial haemoglobin (%SpO2) and pulse rate of patients who are well or poorly perfused.
It is intended for spot-checking of adult and paediatric patients on digits (fingers, thumb, toes) in a wide range of environments to include hospitals, clinics, long-term care facilities, skilled nursing facilities, emergency medical services, and home healthcare services.
Table 8: Technical Specifications Pulse oximeter: fingertip
Pulse oximeter: fingertip
1 General technical requirements
SpO2 and pulse rate monitor integrated into finger/toe clip.
Configurations required to apply to adults and children, and all skin pigmentations. Suitable for spot check.
SpO2 detection to include the range: 70–99%. SpO2 resolution: 1% or less.
SpO2 accuracy (in the range at least 70–99%): within ± 3%.
If equipment is capable of a wider SpO2 detection range, the accuracy over that wider range shall be stated.
Pulse rate detection to include the range: 30–240 bpm. Pulse rate resolution: 1 bpm or less.
Pulse rate accuracy within ± 3 bpm.
Suitable for detection in low perfusion conditions (as per ISO 80601-2-61, test method must be described).
Design must enable use in demanding environments, e.g., shock, vibration, and free fall tests as per tests in ISO 80601-2-61.
Available probe sizes must accommodate finger/toe thicknesses at least including the range 8–25 mm. Automatic correction for movement, ambient light artefacts (as per ISO 80601-2-61, test method must be described).
Display shows % SpO2, pulse rate, signal quality, sensor error or disconnect and low battery status. Enclosure to have ingress protection level IPX2 or better.
Any aspects of usability as per IEC 62366-1 must be described.
Automatic power-off.
Hours of continuous use, or number of tests, per battery set shall be stated.
Batteries must allow at least 2500 spot checks calculated at 30 s per spot check, or at least 12 hours of operation, or better.
Operated by internal battery. If rechargeable, batteries may be charged via USB connector or by external AC charger. Rechargeable batteries are preferred.
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2 Displayed parameters
SpO2, pulse rate, battery and system status and preferably signal quality.
3 Alarms Audible and visual alarms for sensor error or disconnected, system errors, low battery. Audible and visual alarms for low/high saturation and pulse rate.
4 Consumables Rechargeable and/or non rechargeable batteries: 2 sets.
5 Accessories Battery charger (AC or USB if relevant): 1 per equipment.
Replacement flexible cover for patient finger contact (if removable): 2 per equipment. Carry case and/or lanyard.
6 Documentation requirements (English language mandatory)
User: manuals, hard and soft copies, in English (mandatory) and other languages (preferable). Certificate of calibration and inspection (other means of assurance may be considered).
Troubleshooting separate manuals or as part of the user manual.
7 Primary packaging label
Name and/or trademark of the manufacturer.
Electrical power input requirements (voltage, frequency, and socket type) and safety use and storage (keep away from oil, grease and petroleum-based or flammable products as well as smoking or open flames).
Model or product reference.
Information for storage conditions (temperature, pressure, light, humidity).
8 Standards, for the manufacturer
Certified quality management system for medical devices (e.g., ISO 13485). General quality management (e.g., ISO 9001). Application of risk management to medical devices (e.g., ISO 14971).
9 Regulatory approval/ certification
Free sales certificate (FSC) or certificate for exportation of medical devices provided by the authority in the manufacturing country.
Proof of regulatory compliance, as appropriate, per the product’s risk classification (e.g., Food and Drug Administration [FDA] and/or Conformité Européenne [CE]).
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10 Standards, for product performance
Compliance to the following international standards or to regional or national equivalent (including the technical tests for safety and performance from accredited laboratory or third party) for:
IEC 60601-1 Medical electrical equipment – Part 1: General requirements for basic safety and essential performance.
IEC 60601-1-1 Medical electrical equipment – Part 1-1: General requirements for safety – Collateral standard: Safety requirements for medical electrical systems.
IEC 60601-1-2 Medical electrical equipment – Part 1-2: General requirements for basic safety and essential performance – Collateral standard: Electromagnetic compatibility – Requirements and tests. ISO 80601-2-61 Medical electrical equipment – Part 2-61: Requirements for basic safety and essential performance of pulse oximeter equipment.
ISO/IEEE 11073-10404 Health informatics – Personal health device communication – Part 10404: Device specialization – Pulse oximeter (if capacity for data connection to a computer is included).
IEC 60068-2-31 Environmental testing – Part 2-31: Tests –Test Ec: Rough handling shocks, primarily for equipment-type specimens.
IEC 62366-1 Medical devices – Part 1: Application of usability engineering to medical devices.
IEC 62133 – Secondary cells and batteries containing alkaline or other non-acid electrolytes – Safety requirements for portable sealed secondary cells. Part 1: Nickel, Part 2: Lithium.
11 Warranty 2 years with regards efficiency and quality of the product. Availability of accessories and spare parts for at least 2 years.