{"paper_id":"4910d77a-88d3-434a-ab52-69486d7d1d30","body_text":"Understanding the Contribution of Primary and Community Services to Health System Resilience During the COVID19 Pandemic in Aotearoa, New Zealand: A Qualitative Interview Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding the Contribution of Primary and Community Services to Health System Resilience During the COVID19 Pandemic in Aotearoa, New Zealand: A Qualitative Interview Study Vanessa Burholt, Janine Wiles, Alison Schneller This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4756850/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Dec, 2024 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background The COVID-19 pandemic, an unprecedented event, exposed varying levels of preparedness across health systems. This study examines the resilience of primary health and community services in Aotearoa New Zealand, focusing on their response to the needs of unpaid caregivers and older care recipients during the pandemic’s first waves. The objective is to inform future disaster preparedness and enhance health system resilience. Methods A multidisciplinary research team conducted qualitative research involving semi-structured interviews with service providers (SPs) who provided primary or community home-based services, care, support or information to older people and/or their caregivers across Aotearoa New Zealand. Views were sought from five service provider groups: national organisations, Māori, Pacific, or rural providers and dementia services. Data were collected between July 7 and October 4, 2020. Interviews focused on innovative practices, resources, and organizational settings. Notes from interviews were revised and validated by participants. Thematic coding and analysis were performed using NVivo 14 software to identify key themes and strategies. Results Twenty SP staff (Chief Executive Officers and representatives) from National (4), Māori (3), Pacific (5), rural (4), and regional dementia service (4) providers) were interviewed. Participants had 0-21 years in post (Mean=7.37, SD=6.56). Telephone interviews lasted 30-45 minutes. Government support, coordination by Civil Defence Emergency Management groups, and regional communication influenced SP resilience. Challenges included access to personal protective equipment (PPE), staffing, identifying vulnerable people, digital access, and accessing residential care facilities. Innovative practices and remote communication were essential for service continuity. Conclusions Aotearoa New Zealand managed COVID-19 effectively, but the pandemic exposed areas for improvement in health system resilience. Examples of absorptive and adaptive resilience in SPs’ and government responses highlighted both strengths and weaknesses. Insights from these experiences can inform transformative resilience, necessitating long-term strategic changes to address vulnerabilities and enhance capacity, ensuring the health system’s robustness and sustainability for future crises. emergency preparedness health system resilience community services older people COVID-19 Aotearoa New Zealand Figures Figure 1 Background COVID-19 was categorised as an unexampled event, beyond the individual or collective experience of health systems [ 1 ]. In general, it is unreasonable to expect organisations to be prepared for specific unexampled events. However, some health systems exhibited more resilience than others during COVID-19 pandemic, demonstrating that there are different levels of preparedness for the unexpected in general. Some health systems suffered substantial (human) losses through COVID-19, others witnessed organisations slowly or suddenly ‘fail’. Similar harms can be avoided in the future by learning about the capacity of some primary health and community services to rebound after unanticipated events, informing disaster preparedness and health system resilience [ 2 ]. This article draws on the experiences of primary health and community services responding to the needs of unpaid caregivers and older care recipients during the first waves of the COVID-19 pandemic in Aotearoa New Zealand to share relevant strategies and issues and contribute to future readiness to deal with similar events. Health System Resilience Resilience has been defined as the process of effectively negotiating, adapting to, or managing significant events, stresses or trauma. At the microlevel, assets and resources facilitate the capacity for personal resilience, individual adaptation and ‘bouncing back’ in the face of adversity [ 3 ]. At the macrolevel, system resilience is operationalised as sustaining “operations under expected and unexpected conditions, by adjusting functioning prior to, during, or following changes, disturbances and opportunities”[ 4 ]. In health care systems, resilience is “the capacity to adapt to challenges and changes at different system levels, to maintain high quality care” [ 5 ]. Healthcare systems feature assets and resources such as service delivery; a health workforce and ‘invisible’ workforce of unpaid caregivers; health information systems; access to essential medical products, vaccines and technologies; health systems financing; and leadership and governance [ 6 ]. A resilient health system requires a well-integrated range of organisations with good understanding of the diverse needs of clientele which are able to monitor the situation, learn and change practices, strategies, or protocols to anticipate future events and improve [ 5 ]. Overall, resilience, from the macro to the micro level of society is the result of the interaction between innovation, resources, and processes during times of disruption or instability [ 7 – 12 ]. Health system resilience can be understood as absorptive, adaptive, and transformative [ 13 ]. Absorptive Resilience is the ability of a health system to withstand and manage the immediate impacts of a shock without major changes to its structure or functioning, maintaining core functions and services, utilizing existing resources, and implementing emergency measures to buffer impact. Adaptive Resilience refers to a health system’s capacity to adjust and reorganize in response to changing conditions and new information during a crisis, including learning and evolving practices to improve response and recovery efforts, optimizing resources, and making flexible decisions to address emerging challenges. Transformative Resilience is a health system’s ability to fundamentally change its structure and operations to better cope with future shocks and stresses, including long-term strategic changes addressing underlying vulnerabilities, enhancing system capacities, integrating innovations, and improving overall system robustness and sustainability. Each type of resilience plays a crucial role in ensuring health systems survive and thrive in the face of crises. In the first year of the COVID-19 pandemic we would expect to observe examples of absorptive and/or adaptive health system resilience. Longer term, establishing best management practices in country-level responses to COVID-19 is vital for transformative resilience, informing future strategies and polices, and improving national preparedness to mitigate the effects of future unexampled events. Exploring the practices and experiences of discrete segments of national health care systems, such as service delivery and health workforces in primary health and community services, can inform future disaster preparedness and health system resilience [ 14 ]. The Context: Aotearoa New Zealand Health System Aotearoa New Zealand has an estimated population of 5 million people. At the time of the 2023 Census, the population comprised 67.8% European, 19.6% Māori (indigenous population), 17.3% Asian and 8.9% Pacific peoples [ 15 ]. The country is founded on Te Tiriti o Waitangi (the Treaty of Waitangi), a contractual relationship between the British Crown and Māori. The health system is thus committed to active protection to achieve equitable health outcomes for Māori. Aotearoa New Zealand has an ageing population, and the health system is reliant on the unpaid contributions of caregivers. A majority of physical, emotional and practical support for sick, disabled or older people is provided by unpaid caregivers [ 16 ], with approximately 480,000 people providing regular care for someone with an illness or disability [ 17 ]. The Aotearoa New Zealand health system is publicly funded (through taxation) and primarily government-operated; users do pay a charge for access to primary care. There is a complementary private health sector that offers additional services and often faster access to elective surgeries and specialist care. The Ministry of Health (MoH) is responsible for overall policy direction, regulation, and coordination of the health system. Historically, the country was divided into District Health Boards (DHBs), which managed and delivered health services within specific geographic areas. As of July 2022, these DHBs have been replaced by a centralized organization known as Health New Zealand (Te Whatu Ora). The health care system has a strategic role to play in promoting health equity [ 18 ]. It aims to provide universal access to essential health services, ensuring that all residents, regardless of income or residential address, can receive necessary care. Although the health system has focussed on improving conditions for groups who have had fewer opportunities [ 18 ], health inequities are widening: Māori, Pacific peoples and those with lower socioeconomic status experience much higher levels of chronic disease, higher morbidity and lower life expectancy [ 18 ]. At the time of this study, services and support for caregivers was provided through primary care, DHBs funded community services (e.g. Needs Assessment Support Coordination, home help), and non-governmental organisations [ 19 , 20 ]. interRAI-Home Care (interRAI-HC) - a standardised geriatric assessment tool – is mandated to determine the level of support required by older adults living in the community [ 21 ]. Services available to older people living in the community and deemed eligible include home help, personal care, medication management, transportation assistance, social support, or housekeeping, health monitoring and rehabilitation services. Other services include respite care for primary caregivers, and day programs. While many services are free at the point of use (e.g. homecare services), some, such as appointments with General Practitioners (GPs) and prescription medications, require a co-payment. Subsidies are available to reduce these costs for low-income individuals and families, and regions. Long-term care (and respite) is provided in aged residential care (ARC) facilities, which are managed by private companies or non-profit organizations. Aotearoa New Zealand faces challenges related to healthcare workforce shortages, impacting service delivery and wait times. Before the COVID-19 pandemic, research demonstrated that bureaucratic obstacles [ 20 ], difficulties navigating health and social care systems [ 19 , 22 ], discrimination in health care services [ 23 ], the challenge of English as a second language [ 24 ], geographic location or area deprivation [ 25 – 27 ], and limited access to digital services [ 26 , 28 ], created barriers to accessing health resources for many unpaid caregivers and care recipients. Unexampled events and disasters such as the pandemic have the potential to widen inequities in access to the health system. Between April-September 2020, Te Hiringa Hauora / the Health Promotion Agency established a working group to develop approaches to address needs of older people as part of the Ministry of Health’s COVID-19 response. People aged 70 and older were issued with specific instructions to restrict social interactions (Table 1 ). For Māori and Pasifika communities, the age threshold for being considered ‘older’ was ≥ 60 years recognizing of the earlier onset of age-related health conditions and lower life expectancy in these populations. The working group highlighted gaps in support for unpaid caregivers to older people, particularly for those living in rural areas, supporting people living with dementia, and of Māori and Pacific ethnicity. This led to the development of a research study Health Equity And Wellbeing Among Older People’s Caregivers During COVID-19 [ 29 ]. The study of health service (service provider) resilience is a sub-study within this project. Purpose Our objectives are to: Explore support to, and coordination of primary health and community services provided by the Government and its Ministries. Examine community health and social care service providers’ (SPs) strategies or protocols concerning provision of services, assets, and resources, innovative practices, and communication methods. Assess barriers and challenges to achieving a resilient health system as perceived by SPs. Methods Our research team comprised three social scientists with PhDs and expertise in gerontology (VB), human geography (JW), and health and organisational communication; three nursing researchers with PhDs and specialties in physiotherapy, palliative care and spirituality; Māori and Pacific community researchers; and research assistants. The principal investigator (female) and a research fellow (female) collected the data (VB, DB) and one author (VB) coded the data which was validated by JW. Three of the authors (VB, JW and AS) contributed to analysis of the data, and reporting findings. Interviews and Recruitment Recruitment of SPs and data collection took place between 7th July and 4th October 2020, during which time regions in Aotearoa New Zealand moved between four Alert Levels (Fig. 1 ). Throughout all levels, healthcare providers were required to adhere to stringent infection prevention and control measures, including the use of PPE, physical distancing, and hygiene practices to protect both patients and healthcare workers (Table 1 ). Thirty organisations were identified across Aotearoa New Zealand. Via email and phone call, we approached organisations of varying size providing services to unpaid caregivers, people living with dementia, or older people during alert levels 2–4. We purposively approached a range of a) national organisations (6); b) Māori providers (13); c) Pacific providers (11); d) rural providers (5); and e) local or regional dementia services (4). Table 1 Description of restrictions for the general population, older adults, primary care, community care and residential and nursing aged care facilities during COVID-19 Alert Levels in Aotearoa New Zealand 2020 General Population Older people Primary Care Health & Disability Community Services Residential care facilities 1. Contact tracing of cases. General hygiene practices. Public health campaigns to raise awareness. Normal activities with caution: advised to remain vigilant about hygiene and physical distancing. No restrictions, use of telehealth where appropriate, safety and hygiene practices. No restrictions, use of telehealth where appropriate, safety and hygiene practices. Normal visiting, health screening and infection control practices. 2. Physical distancing in public and workplaces. Limits on gatherings. Encouraged to work from home where possible. Heightened tracing and testing. Closure of schools and non-essential businesses considered. Caution going out and attending small gatherings. Encouraged outdoor activities and exercise avoiding crowded places and maintaining physical distancing. Mixed model of in-person and telehealth consultations, with in-person visits following public health guidelines. Most services delivered with safety measures, including social distancing and hygiene practices. Controlled visitor access with restrictions, such as limited visitor numbers and health screening. 3. Strict physical distancing and restrictions on public gatherings. Closure of public venues. Schools and childcare centres open only for children of essential workers. Essential services open, non-essential businesses and services closed. Travel restrictions within regions. Stay home and limit outings. Use support networks for essential supplies and medications. Short walks and outdoor exercise permitted, with physical distancing. Limited visits: visitors to adhere to strict hygiene and physical distancing protocols. Primarily via telehealth, with in-person visits allowed for urgent cases following strict safety measures. Essential services, some non-essential services with strict safety measures. Restricted visitor access, with some allowances for close family members under controlled conditions. 4. Stay at home, except for essential personal movement. Severe restrictions on travel and movement. All gatherings cancelled, and all public venues closed. Schools and educational facilities closed. Only essential businesses and services open. Avoid all non-essential outings. Indoor exercises, short walks (only if necessary) maintaining physical distancing. Utilize support networks for essential supplies. No visitors allowed. Prioritized pandemic response. Operated for urgent and essential services only. Routine consultations moved to telehealth wherever possible. Essential services with significant restrictions. Non-essential services paused. Strictly no visitors, except for end-of-life care. Stringent infection control measures. The semi-structured interview schedule has been described elsewhere [ 29 ]. In this article we draw on participants’ responses to question topics concerning innovative practices such as new services, resources, and outreach activities. In addition, we examine the organisational and external settings (health system infrastructure), in which the innovative practices were implemented. We took notes during the interview on a grid with column headings following the structure of the interview topic guide, supplemented by immediate post-interview reflective journaling, and revision of the notes into a coherent summary [ 30 ]. Participants were sent the revised note grid to verify and/or amend and to return to the research team within one week along with examples of innovative resources mentioned during the interview [ 31 , 32 ]. Analysis NVivo 14 software facilitated a rapid deductive thematic coding to an a priori framework of concepts based on the sections of the interview. Table 2 shows the thematic codes that are used in this article. Results Participants’ Characteristics Twenty SP staff were interviewed: participants included CEOs and their nominated representatives from National organisations (4); Māori providers (3); Pacific providers (5); rural providers (4); and local or regional providers focusing on dementia (4). Participants had been in post from 0–21 years (Mean 7.37 SD 6.56). Telephone interviews lasted 30–45 minutes. Table 2 Thematic coding structure. Ordinate and Subordinate Codes Notes Organisational level SP changes in care and support during COVID19 Innovative practices In person Face-to-face contact Crises, new assessment and referral Emotional and practical support Informational support Remote working No direct contact with clients Arts, leisure, entertainments and culture Checking in and checking up Also, relationships and communication Crises, new assessment and referral Emotional and practical support Informational support Challenges with delivering support by service providers Challenges with workforce or employees SP new operating procedures SP relationships and communication with clients Social structural and cultural level Availability and suitability of facilities and services Specialists, hospital and residential care Coordination of services Designation of services Non/Essential services Government support to SP Structural support and services that worked well Macrolevel: Health System Support and Coordination of Services Government Support Live daily COVID-19 briefings were presented by Aotearoa New Zealand Prime Minister Jacinda Ardern and Director-General of Health Dr Ashley Bloomfield, beginning in March 2020. The briefings were a key source of information support for the SPs; the frequency of briefings became more sporadic after June 2020, when the situation stabilized. In addition to informational support, financial and practical support from the government, Ministries of Social Development (MSD), Health, (MoH), and Business, Innovation and Employment (MBIE) enabled organisational resilience for SPs. Co-ordination of services between SPs was managed by sixteen Civil Defence Emergency Management (CDEM) Groups, each comprising committees of elected councillors from within regional boundaries working in partnership with emergency services, lifeline utilities, DHBs, health and care service providers, and government departments. Some government ministries played specific roles supporting SPs. MSD provided wage subsidies for staff and honoured contracts although many SPs could not meet service targets while face-to-face contact was prohibited. MSD also funded specific service innovations proposed by SPs as necessary for clients (e.g. food packages or digital technology). SPs stated that the funding from MSD was easy to apply for and funds were obtained rapidly, one SP noted trust around their spending was helpful. MoH provided funding for COVID-19 specific services, and helped SPs develop policies fulfilling the Health and Safety at Work Act 2015 requirements for employers to take all practicable steps to mitigate risk and protect employees from workplace hazards. National SPs were in regular direct contact with the MoH or MSD (depending on the focus of their services) for briefings and updates. Information from these meetings was cascaded down to staff, and experiences of frontline workers and local SPs were passed up to the Ministries. MBIE provided extensive resources, templates, and guidance documents to help SPs implement human resource policies, such as risk assessment, health monitoring, flexible working arrangements, leave and absences management, employee wellbeing and support (e.g., Employee Assistance Program), and wage subsidy scheme. The goal was to ensure that workplaces remained safe, employees were supported, and SPs could navigate the operational challenges posed by the pandemic. The Māori Health Directorate, Pacific Future Fund and MoH provided funding for innovative services and activities targeting Māori and Pacific communities. Regional Coordination CDEM worked in collaboration with other government agencies and SPs to identify ‘vulnerable’ individuals in need of additional support to include on the Civil Defence list (see also ‘challenges’ below). Vulnerability was considered on basis of age, health conditions, disability, or other factors that made it difficult to manage independently. People on the Civil Defence list were prioritized for receiving essential services, such as grocery deliveries, prescription medication, regular communication ‘check ins’ and ongoing welfare ‘check ups’. In practice, this meant that SPs identified ‘vulnerable’ people, and were responsible for providing their essential services. One Pasifika SP noted although there was a lot of collaboration with Civil Defence who provided a list of service providers, it was still difficult to “decipher who was doing what in the community – finding who had the right support for a particular situation” (SP04). This sentiment was echoed by others. Locally, there were differences in communication, leadership and coordination of services provided by DHBs. One SP noted leadership from the DHB was absent at the pandemic outset, another SP did not receive any direct contact from their DHB despite sending summaries of their activities. Yet there was evidence from several SPs of good communication and support from DHBs. One SP said, “the support our DHB has offered us cannot be faulted, when we went into Level 3 lockdown our day program services were in question, and the viability of the organisation looked very uncertain. The quick and decisive decisions made enabled us to keep all of our staff engaged and fully paid.” (SP07) Distribution of PPE to frontline healthcare workers, hospitals, and other essential services was co-ordinated by MoH. Centralized distribution was meant to ensure that PPE was allocated based on priority needs, focusing on healthcare providers, aged care facilities, and other critical sectors. While this worked for some organisations, other SPs encountered difficulties. Several had to lobby MoH directly, or via MSD, to get PPE released to them. There were examples of collaboration between organisations at the national and local level. For example, the Chief Executives of national SPs collaborated to share information. Extant and new collaborations within Districts also facilitated coordination of services and information. One SP noted strong relationships with other health and care providers in the locality assisted with planning responses to restrictions and solving problems. Mesolevel: Service Provider Procedures and Strategies The essential services regime allowed some premises to keep operating during COVID-19 (see Table 1 ). In March 2020 essential services included DHBs and their facilities; any person employed or contracted as a doctor, nurse, pharmacist, paramedic, kaiāwhina, a social worker, aged (residential and nursing) care and community workers and paid caregivers more generally; hospitals, primary care clinics, pharmacies, and care facilities. The classification of essential services changed the second time that the country entered Alert Level 4 in August 2020 and included social and community-based services supporting persons to maintain critical well-being. Only organisations deemed ‘essential services’ were able to continue face-to-face services with clients, with the appropriate PPE protocols in place. There were also variations in the approaches taken by national organisations versus local organisations that served a smaller or specific population. National SPs developed emergency plans and distributed these to local organisations. In most organisations this process had previously been devolved to local organisations, but during the pandemic it became apparent that these had not always been completed. The national SP essential workforce required new health and safety training, but as one noted “with everyone in lockdown we needed to completely change the way we trained our people” (SP11). For example, “donning and doffing” (how to put on and take off PPE) was especially important, so training teams created videos to be utilised by all staff whenever or wherever they were. One national SP delivered PPE to letterboxes of staff and/or clients all over the country; another adapted day to day business operations, limiting the need for staff to enter client’s homes by developing a triage process. When staff needed to enter a client’s home they delivered care differently enabling physical distancing whenever possible. Digital applications were used more extensively, for example, to provide client information, alerting to additional risks (e.g., an unwell client), and co-ordinating visits. Some national SPs implemented telehealth procedures, checklists, or standard questions to assist teams assessing clients’ issues. Development of new strategies and procedures by national SPs was not universal. One local SP noted ‘disappointment’ in the leadership of a national SP, feeling that the local provider was “left to fend for itself” (SP05). In contrast to national SPs, the strategic response of local SPs tended to focus on meeting their clients most pressing needs with a dwindling workforce (see ‘challenges’ below). Some changed the focus of their work. For example, one SP switched to the provision of personal care only, dropping housework; as they noted, “clients can live with mess, but not without being washed” (SP16). A rural SP suspended a policy which prohibited staff being involved in financial transactions: helping clients obtaining medications or groceries during Level 4. A Pacific SP designated as a non-essential service during Level 4 put all other work on hold to manage an 0800 number and help clients complete ‘welfare’ forms. Available through Government websites, these were used to apply for financial aid, access essential services, and receive support (e.g., Wage Subsidy Scheme; COVID-19 Leave Support Scheme); Emergency Benefit; Rent and Housing Support; Food and Essential Services Support; and Health and Disability Support). Microlevel: Innovative Practices and Communication with Clients Innovative practices were developed and delivered remotely or in person. Informational support, emotional and practical support, and support for crises, new assessment, or referral were delivered by both means, whereas ‘checking in and checking up’, and ‘arts, leisure, entertainment and culture’ were delivered remotely. Informational Support SPs were often seen as trusted and central sources of information. For example, one noted, “we established an 0800 number so that older people and caregivers could phone up for trusted information, as digital literacy and navigation of multiple sources of information could be difficult.” (SP07). Remote informational support included material about COVID-19 or the protocols relating to the different levels of social restriction, and the use of PPE. Some SPs made sure that information was available in the appropriate and accessible format for their clients (e.g. large font size, audio formats, or translated to meet language needs). Other SPs provided information on how to access health and care support, or what support could be provided, or ‘advice’ such as how to maintain mental, physical and spiritual health, keep connected and support a person at home. Some SPs provided practical support by providing digital devices (see below), and also provided written instructions about how to operate them. There were examples of in-person information support. One SP described support workers delivering information about COVID-19 along with the services to clients. In-person informational support was particularly important in Pasifika communities where one SP trained volunteers to deliver COVID-19 and vaccination information in various Pacific languages. Practical and Emotional Support In-person practical support included financial support (e.g. food vouchers, energy bills, broadband plans, pre-paid phone cards), food parcel delivery, digital devices such as tablets, mobile phones and laptops, care packs, or firewood. There were also innovative supportive practices for unpaid caregivers who could not go out, such as pharmacy or medication pickups, and grocery shopping and delivery. Often practical support was tailored to particular groups. For example, one SP produced a new ‘companion’ card for unpaid caregivers to use when in public, explaining the caregiver had to be accompanied by the care recipient with dementia. A Māori SP provided care-packs including essentials required to keep people well in overcrowded houses, such as, blankets, pillows, and utensils to facilitate cooking outside. Both Māori and Pacific SPs paid electricity bills and delivered wood for fires (for heating and cooking), along with food parcels and food vouchers as they were aware that many of their clients could not afford to pay bills. SPs also devised ways of providing in-person emotional support to unpaid caregivers, for example through driveway visits, chats through windows or on poches, and a staff choir that sang outside clients’ homes. While some SPs had to suspend face-to-face support to clients, service delivery was adapted and practical and emotional support was delivered by phone, email, and video calls. This included online/video conference caregiver support groups, groups for people living with dementia, and exercise classes. One SP delivered Cognitive Stimulation Therapy to people with dementia via online video link [ 33 ], while another SP set up a closed Facebook page to enable disability clients who managed their own care via an Individualised Funding model to share experiences. Remote emotional support via telephone was provided to an unpaid caregiver when a care recipient was critically unwell and hospitalised. New Assessments, Referrals and Crises New assessments were mostly conducted remotely. SPs described how more triage was undertaken over the phone; a Registered Nurse would carry out a phone assessment or medication review and the organisation would liaise with the GP and pharmacy. Another SP explained that between March 25th to June 30th, 2020, the interRAI Contact Assessment was managed over the phone as a rapid (approximately 20 minutes) temporary alternative to the interRAI-HC assessment. In anticipation of carer crises, some national SPs developed emergency plans for unpaid caregivers to complete. This provided a written record of preferences and needs of care recipients, if the caregiver became ill (or passed away). One national provider encouraged use of a ‘Lifetube’ stored inside the fridge so first-responders could easily find essential information. In-person support was mostly provided for crises and emergencies. For example, SPs described referring care recipients to emergency home-based or relocated to residential care when caregivers passed away during restrictions. As part of driveway chats (see above) SPs also undertook ‘welfare checks’ and if issues were identified they refers clients on to hospital-based services or GPs. One SP transported clients to medical appointments with both driver and passenger wearing full PPE. Arts, Leisure, Entertainment and Culture Many SP were concerned disruption to routines would be detrimental to their clients, and unpaid caregivers would struggle to find things to do. In response they developed entertainment resources delivered by email or hosted online. For example, one SP sent a daily newsletter to unpaid caregivers, featuring joyful and funny content, and links to virtual activities for people with dementia, like train journeys and art gallery tours. Some SPs collaborated with expert organizations to deliver online art groups and themed meetings, while others created their own arts and crafts classes or distributed digital devices with preloaded games. Due to the lack of access to and difficulty using digital devices among people with dementia, one SP created and hand-delivered 300 photocopied activity booklets. Other SPs also developed, delivered or mailed hard copies of entertainment resources, tailoring them to the severity of dementia or cultural context. (i.e. for Māori and Pasifika clients). While most of the ‘hard copy’ entertainment packs were developed for unpaid caregivers of people with dementia, two SPs noted that they delivered hard copies of entertainment activities to the homes of clients who did not have email. Communicating and Maintaining Relationships with Clients As most face-to-face services were moved to contactless services, ‘checking in’ became a virtual care modality and provided a sense that ‘someone was there’. On the other hand, ‘checking up’ referred to contact intended to ascertain the wellbeing of clients. Many SPs were unable to visit clients and were restricted to remote contact only, especially in the first lockdown. Many talked about the strategies they adopted to maintain communication with clients, ranging from regular telephone calls, texts, emails, or video calls to instant message or group conversations. Some focused on establishing how much contact clients would like so that they were neither isolated, nor overwhelmed. SPs felt it was important to “be a voice on the end of the phone, giving re-assurances and connecting people with other services” (SP13). Some SPs relied on telephone calls only, others tried to ascertain the status of digital connectivity and whether clients could receive emails. SPs perceived that ‘checking in’ was particularly important for some client groups. For example, to help maintain routines for unpaid caregivers supporting a person with dementia, one SP phoned on the day that they would normally go to a day programme. Phone calls to older Pasifika people and caregivers were also perceived as essential with one Pacific SP noting that verbal communication was much better than leaflets. Regarding ‘checking up’, some service providers made phone calls to all their clients for wellbeing checks, while another received a request from a GP practice to call all their clients over 70. Some SPs noted that their support workers staff were worried about clients and would often take it upon themselves to check up on them in their own (unpaid) time. One SP noted that there were more welfare checks during COVID-19 than prior to the pandemic. Challenges There were four main challenges identified by SPs relating to staffing, identifying ‘vulnerable’ older people, digital access and access to aged residential care. Difficulties associated with accessing PPE at the outset of the pandemic are noted above. Staffing During the pandemic the SP workforce shrank, with more than 30 per cent of staff on unplanned leave at any one time. Staff were unable to work if they were unwell or had been exposed to COVID-19. SPs noted others were educating children at home which impacted on their ability to work, and some took leave to manage burnout, exhaustion, and grief. Social restrictions designed to reduce the risk of contracting COVID-19 for particular groups also impacted the workforce. For example, older volunteers were asked to step down as they were unable to attend face-to-face activities or deliver ‘meals on wheels’. One rural SP noted many of their support workers had respiratory issues that were attributed to coal smoke in the town. SPs noted staff worried about transmission of COVID-19 between clients’ homes and their private abode. Consequently, some support workers were unwilling to extend their bubble and would only work with existing clients. Others, especially Māori SPs, faced challenges recruiting new staff to fill vacant roles, attributing this to the low status and undervaluing of homecare work. One SP reported the public accused their workers of spreading COVID and flaunting lockdown rules; they resolved this by obtaining fluorescent vests marked ‘essential worker.’ SPs also noted challenges with travelling across regional boundaries to deliver home-based health and care services to clients when alert levels varied by region. Essential workers were provided with contradictory advice about moving across boundaries and there were inconsistencies between agencies involved in the policing of regional borders. Identifying ‘Vulnerable’ People As noted, CDEM groups created a list of ‘vulnerable adults’ that were prioritized to receive services during the pandemic, based on age, health conditions (e.g. cardiovascular disease, respiratory issues, diabetes, and cancer), disability (e.g. physical, sensory, intellectual, or mental health disabilities limiting ability to access essential services or comply with public health measures), and social isolation, dependence on services, ethnic and cultural factors (e.g. Māori and Pasifika communities). The list relied on the identification of vulnerable adults by SPs. However, the combination of criteria used by SPs to identify vulnerable adults varied significantly. For example, one SP prioritized individuals living alone with dementia, another focused on those over 85 with high-level needs. Some used more elaborate criteria. For example, one had sufficient information prior to the pandemic to categorise all their clients as home alone, living with spouse, or living with others, and could also consider their access to services and transport, health of the care recipient and their primary caregiver, geographical location, and digital access. Factors like social isolation, disability, and economic hardship were weighted variably (or not considered) by other SPs. Inconsistencies meant that, for instance, a couple in their 90s with one partner caring for the other with dementia might be prioritized by one SP but overlooked by another, contributing to unequal service delivery. Identifying vulnerable people relied on the SPs’ community connections and knowledge of clients prior to COVID-19. While some SPs knew their clients and were able to respond appropriately, others had less community engagement and could not respond to changing needs. Furthermore, there was little or no familiarity with people who developed a need for care after the onset of the pandemic. Unless unpaid caregivers proactively contacted SPs, they were in danger of being overlooked for inclusion on the Civil Defence priority list. As criteria were not always applied consistently to old and new clients, the ‘type’ of older people and caregivers receiving home-based services varied across different SPs and regions. Digital Access Digital access was a challenge for both staff and clients of SPs. There was great variation in digital literacy within both groups. During levels 3 and 4 when many staff worked at home, SPs had to upskill the workforce in relation to using digital equipment, apps, and systems. Many SPs delivered training in telehealth, video conferencing, and using the range of smartphone features. Some SPs noted staff were either not interested or unwilling to use digital technology, or there was competition between household members to use digital devices at home (e.g., for education or work as well as recreation). Other SPs did not have appropriate digital hardware or software for staff. This was especially relevant in organisations which employed older staff or relied on older volunteers: many did not have an internet connection, laptops, computers or printers at home. Some staff knew how to use mobile phones only for calling or texting. While essential services were able to purchase laptops for staff who needed them, SPs that were (originally) designated as non-essential services did not receive funding to rectify this. Consequently, where possible, digitally literate staff used their own personal computers and phones for work purposes. Others solved the issues by using telephone calls as the main form of communication between staff, and with clients. The proportion of clients with digital access (and digital literacy) also varied between organisations. SPs estimates of the proportion of their clients that had an email address ranged from 30 to 90%. Some SPs adopted a policy to connect to clients by phone, others noted they were unable to support those who were not connected digitally. Digital access was particularly difficult for certain groups such as rural people, people living with dementia, and older Pasifika. One rural SP noted difficulties for clients accessing online resources because of lack of network coverage; while a SP who primarily worked with people living with dementia noted that around 40% of clients lived alone, and most only used a landline. Cognitive impairment precluded some people with dementia from using digital devices. Another SP noted that Pacific older people without phones or who forgot to charge phones were difficult to contact. Some SPs attempted to address digital inequities by providing training and resources. One SP provided training for unpaid caregivers to use video conferencing, another delivered a computer course for older people during Alert Level 1 and 2 (June to Aug 2020). The training and distribution of laptops before Alert level 3 restrictions in August 2020 facilitated better communication with clients during lockdown. Access to Aged Residential Care Facilities SPs identified a challenge relating to clients’ changing circumstances during the pandemic, particularly the need to access ARC when a caregiver was no longer able to provide support at home, needed respite from caring, or in emergencies. This was extremely difficult during Alert Level 4, when the most stringent restrictions were in place. One SP noted that after a caregiver passed away emergency ARC was required for a person living with dementia. The SP was ‘literally kicking the door’ as staff would not admit them. The SP threatened to phone the Human Rights Commissioner before the issue was resolved. Another SP noted that rest homes would not accept new residents to provide caregivers with respite without following rules that were often unacceptable to the caregiver and care recipient. The process involved the person obtaining a clear Polymerase Chain Reaction (PCR) COVID-19 test while isolating at home (separate from the unpaid caregiver) for 48 hours, and then on entering ARC being isolated from others in the facility. Discussion The government has received acclaim from some commentators for their exemplary handling of the pandemic, often described as the ‘gold standard’ of management [ 34 , 35 ]. Others comment on the swift implementation of epidemiological strategies which led to Aotearoa New Zealand being free of community transmission for over 100 days, and earned the country a top spot in the COVID-19 Performance Index rankings [ 36 ], However, there is little evidence on the resilience of the health system. Establishing best management practices in country-level health system responses is vital to improve national preparedness to mitigate the effects of other future unexampled events. In exploring absorptive, adaptive and transformative health system resilience [ 5 ] we start by discussing positive contributions and move on to consider gaps and challenges undermining resilience. Aotearoa New Zealand government acted quickly and decisively with strict lockdown measures, clear communication strategies, activating emergency response plans and designating essential workers [ 37 ]. These were examples of absorptive resilience, withstanding and managing the immediate shocks of COVID-19 without major changes to structure or functioning. However, most responses to the pandemic provided examples of adaptive resilience: adjusting and reorganizing responses to the changing conditions. The government adapted to the new situation by providing support and protection for healthcare workers [ 38 ]. This included good governance, the provision of PPE, and financial aid to individuals and businesses. The latter mitigated some of the economic impact of the pandemic for financially vulnerable older adults and caregivers, and helped preserve jobs, especially in the community care sector. SPs modified service protocols, enhanced telemedicine services, and redistributed resources to vulnerable people by remote or face-to-face means. This was facilitated by rapid adoption of digital health solutions and temporary fixes, including telehealth services and apps that helped with rapid information about clients and coordination of care workers. Some SPs led community initiatives to support vulnerable populations, ensuring access to essential services and reducing social isolation. Active involvement and leadership from Māori, Pasifika and rural communities ensured culturally appropriate responses and better outreach to these populations. Many SPs sustained a high level of risk management as they navigated each alert level change, scaling up or down as required by the environment and advice of the time. These positive aspects of health system resilience highlight the importance of leadership, community involvement, robust communications systems, good data management, collective and individual trust and a well-prepared healthcare system in managing public health crises. Despite these positive aspects, there were also gaps identified. Our research highlights challenges and limitations in the health system, such as inconsistencies in the identification of vulnerable individuals, coordination challenges, communication breakdown, staffing issues, and geographic and socio-economic barriers. Co-ordination of services between SPs and the identification of ‘vulnerable people’ was managed by the CDEM groups. However, coordination between multiple organizations was often difficult, leading to delays or gaps in service delivery. Although the priority list of vulnerable people aided the distribution of support to some, there was lack of a unified framework or standard guidelines for identifying and prioritizing vulnerable populations. Health agencies primarily focused on medical vulnerability, while social service organizations placed greater emphasis on economic and social factors. Māori and Pasifika organizations, as well as other community groups, often had their own criteria for vulnerability, reflecting the unique needs and circumstances of their populations. Ability to identify individuals depended on the level of information held by organisations prior to the pandemic. As a result, SPs used varying criteria to identify vulnerable individuals, leading to inconsistencies and some people being overlooked. New service users faced additional barriers to accessing services if they were not already known to SPs, especially if they were unable to identify which SPs they should contact. SPs identified other barriers to delivering services. Some regions or communities had better resources and networks, while others were disadvantaged by border controls, resulting in uneven distribution of support. This meant that inequities in access to services were amplified for those in rural or remote areas [ 39 ] as people often faced greater challenges in receiving timely support. Māori and Pacific SPs reported on developing innovative services for their communities. However, these were typically delivered in areas with high proportions of specific cultural population. For Māori, Pasifika, and migrants living in less intensive concentrations of culturally distinct groups, cultural and language barriers may have impeded effective outreach and support [ 40 , 41 ]. In addition to language difficulties, communication breakdowns between the government and society were often due a preference for face-to-face information or digital access. Some older people and unpaid caregivers did not have had access to reliable communication channels (e.g., phone or internet) to request help or receive updates. Some SPs tried to remedy this by providing digital training, equipment, or ‘data’ (i.e., prepaid vouchers or plans) to unpaid caregivers and older people. While the government recognized a digital divide in certain segments of society [ 42 , 43 ], there was little attention given to the limited digital literacy and access experienced by many health and community care staff, and the subsequent workforce challenges encountered by SPs. Staffing issues were apparent across most SPs, and were also noted as a factor influencing the supply of services in 29% of countries surveyed by WHO in 2020 [ 37 ]. In Aotearoa New Zealand, some staff shortages were attributed to their digital access and digital literacy influencing their ability to work from home, and the age of some employees and volunteers. Staff also faced additional caring or educational responsibilities, illness, and increased stress, or were safeguarding family; similar issues for front-line community health and social care staff have also been reported elsewhere [ 44 – 46 ]. Most SPs reported being overstretched during the pandemic and, some initiated triage systems to reduce pressures on staff (also tried elsewhere [ 47 , 48 ]). Most community care workers experienced both increases and changes to their workload due to staff shortages, which has also been documented internationally [ 37 , 45 , 48 , 49 ]. Difficulties recruiting staff to replace the depleted critical workforce of health and care community staff were reported in this study and elsewhere [ 50 ]. Some SPs provided digital training and equipment for staff while others lacked the financial resources or knowledge to do this. Other countries facing staff shortages employed different tactics such as recalling inactive health and care workers, or fast-tracking trainees to provide childcare for essential health care workers [ 38 ]. These are important strategies for health care systems to develop a broader capability and draw on a wider pool of potential staff in anticipation of future emergencies [ 51 ]. Some of the issues identified in this study, such as workforce sustainability and digital access, were systemic issues that were not addressed sufficiently before the pandemic. In 2020, prior to the pandemic, the health and disability system was already experiencing serious issues, with a workforce under pressure and high stress levels. A report noted “persistent shortages already exist in a number of workforces and rural areas generally find it more challenging than urban areas to recruit and retain staff” [ 51 ]. Subsequently, significant structural change resulted in the establishment of two new health system organisations (Te Whatu Ora - Health New Zealand, and Te Aka Whai Ora - Māori Health Authority b ). However, a Health Workforce Plan 2023/24 focuses primarily on health professionals and does little to address community care workforce issues [ 52 ]. This means that the inequities apparent in the ‘value’ ascribed to community care staff during the pandemic persist. Community care workers were overlooked as ‘essential workers’ during the Alert Level 4 lockdown, and PPE provisions for this sector were neglected. Similarly, today, strategies for recruitment and retention, and training for staff development in areas such as digital and data literacy focus on health professionals rather than the broader community care sector. The community care sector has been pushed to breaking point and has not recovered from the effects of the pandemic on the workforce. Without further transformational work in the health system, the community care sector lacks resilience, and its precarious situation means it is unlikely to be able to deal adequately with future emergencies [ 53 ]. To achieve transformative resilience in health systems we recommend the following. A Unified Framework to Inform a ‘Priority List’ : develop national standards for identifying and supporting current (e.g., through administrative datasets) and new vulnerable individuals, ensuring consistency across regions and organizations Adequate Workforce Capability, Capacity, and Support : strategies for recruitment, retention of community care workforce, and ‘diversity’ in the workplace (e.g., a reserve pool of inactive workers) so that in the event of disasters there are people that can step-in and help. Enhanced Coordination of Emergency Planning : establish clear roles and responsibilities for all service providers to avoid duplication of effort; and ensure service providers have local emergency response plans, are digitally enabled (i.e., have sufficient resources to facilitate home-based working in times of emergency), and have access to emergency facilities (such as residential care facilities and hospitals). Effective Communication : address digital exclusion of older people, caregivers and staff within service provider organisations; develop multi-channel communication strategies to reach all segments of the population, including translations from a single or central point to avoid misinformation concerning complex concepts and instructions. Conclusions While Aotearoa New Zealand is justifiably considered to have done well in preventing the worst impacts of Covid-19, there are lessons that can be learned about health system resilience. This unexampled event provided challenges for the health system and there were good examples of absorptive and adaptive health system resilience in the actions of SPs and Government responses. Knowledge gleaned from these observations of absorptive and adaptive resilience and barriers and challenges to resilience could contribute to Transformative Resilience. This requires long-term strategic changes to address the vulnerabilities and enhance capacity to improve the health system’s robustness and sustainability in the future, especially regarding preparedness for future crises. Abbreviations ARC: Aged Residential Care CDEM: Civil Defence Emergency Management DHB: District Health Board GP: General Practitioner MBIE: Ministry of Business, Innovation and Employment MoH: Ministry of Health MSD : Ministry of Social Development PPE: Personal Protective Equipment SP s: Service Providers Declarations Ethics approval and consent to participate The study was approved by the University of Auckland Health Research Ethics Committee (Ref AH21966). Consent to participate in the study was obtained from all participants. Availability of data and material The datasets generated and/or analysed during the current study are not publicly available as restrictions apply to the availability of these data due to sensitivity (i.e. Māori data sovereignty). These restrictions have been ratified by the Auckland Health Research Ethics Committee (AHREC) at the University of Auckland. Data will be made available from AHREC ( [email protected] ) on reasonable request. Competing interest The authors declare that they have no competing interests. Funding This work was supported bythe Health Research Council of New Zealand (20/1380) as a 2020 COVID-19 Equity Response Community Action Grant Health Equity and Wellbeing Among Older People’s Caregivers During COVID-19 . Authors’ contributions VB and JW contributed to the conception and design of this study and collected data along with AS. All authors contributed substantially to the analysis and interpretation of data, drafting and critical revision of the manuscript. Acknowledgments We acknowledge the Named Investigators on the study that are not listed as authors: Deborah Balmer (DB), Rosemary Frey, Moema Gregorzewski, John Parsons, Teuila Percival, Rangimahora Reddy, Mary Simpson. We are grateful to our community partners Alzheimers New Zealand, Alzheimers Northland, Age Concern New Zealand, TOA Pacific, and Carers Alliance as members of the Advisory Group and Rauawaawa Kaumātau Charitable Trust Advisory Groupfor guiding the research; Mary Roberts from Moana Research and Pare Mehafrom Rauawaawa Kaumātua Charitable Trust for help recruiting participants. Authors’ information Vanessa Burholt (BSc, PhD, FAcSS) is Professor of Gerontology in the School of Nursing/School of Population Health, Faculty of Medical and Health Sciences, a Co-Director of the Centre for Co-created Ageing at the University of Auckland, and concurrently Professor of Gerontology at Swansea University, United Kingdom. Over 29 years, Vanessa has undertaken and overseen transdisciplinary research on ageing and dementia, incorporating biological, psycho-social, environmental and social policy perspectives drawing on critical interactionism to explain the complexity of aging. She was the Principal Investigator on the study Health Equity and Wellbeing Among Older People’s Caregivers During COVID-19 . Janine Wiles (BA(Hons), MA, PhD)is an Associate Professor in Population Health, Faculty of Medical and Health Sciences, at the University of Auckland. She is a geographer and gerontologist, and uses a critical positive ageing framework. Her research encompasses three disciplinary areas: social/health geographies, critical social gerontology, and community health. Alison Schneller (BA, MA, LLB, LLM, PhD) was a research assistant in the School of Nursing, Faculty of Medical and Health Sciences, at the University of Auckland, at the time of the study. She has a research background in sociology and law. She is currently Principal Advisor Mental Health and Addiction Sector at Te Hiringa Mahara / Mental Health and Wellbeing Commission. Footnotes a Kaiāwhina describes non-regulated roles in the health and disability sector. 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Te Whatu Ora – Health New Zealand. Health Workforce Plan 2023-24. Wellington, New Zealand: Te Whatu Ora – Health New Zealand;2023. Perrott A. COVID-19 pushed the health system to breaking point: HQSC. New Zealand Doctor - Rata Aotearoa. 2022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Dec, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 24 Jul, 2024 Editor assigned by journal 22 Jul, 2024 Submission checks completed at journal 22 Jul, 2024 First submitted to journal 17 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4756850\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":331184846,\"identity\":\"d2dfc29b-1390-419f-8f09-37458c38427e\",\"order_by\":0,\"name\":\"Vanessa Burholt\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"University of Auckland\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Vanessa\",\"middleName\":\"\",\"lastName\":\"Burholt\",\"suffix\":\"\"},{\"id\":331184848,\"identity\":\"c4c69fd4-8037-4bcd-91eb-daa62d7ed642\",\"order_by\":1,\"name\":\"Janine Wiles\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Auckland\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Janine\",\"middleName\":\"\",\"lastName\":\"Wiles\",\"suffix\":\"\"},{\"id\":331184850,\"identity\":\"8c561c6d-3854-482c-b3b5-b46b6d54a5ba\",\"order_by\":2,\"name\":\"Alison Schneller\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Auckland\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Alison\",\"middleName\":\"\",\"lastName\":\"Schneller\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-07-17 14:15:23\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4756850/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4756850/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12913-024-12078-6\",\"type\":\"published\",\"date\":\"2024-12-24T15:57:50+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":62799398,\"identity\":\"e118b29f-4f0f-4890-b9e4-860ab2fe4119\",\"added_by\":\"auto\",\"created_at\":\"2024-08-19 15:40:59\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":138567,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e2020 Timeline for COVID-19 Alert Levels in Aotearoa New Zealand and Auckland Region.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4756850/v1/ff8cea224407f2e26121f7cf.jpeg\"},{\"id\":72640700,\"identity\":\"fd5b1ec9-310f-4c6f-addb-7931029b5dc0\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:08:49\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":949277,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4756850/v1/36a0e7c7-89b6-4f2e-b3e2-2c229a40bb7a.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Understanding the Contribution of Primary and Community Services to Health System Resilience During the COVID19 Pandemic in Aotearoa, New Zealand: A Qualitative Interview Study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eCOVID-19 was categorised as an unexampled event, beyond the individual or collective experience of health systems [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. In general, it is unreasonable to expect organisations to be prepared for specific unexampled events. However, some health systems exhibited more resilience than others during COVID-19 pandemic, demonstrating that there are different levels of preparedness for the unexpected in general. Some health systems suffered substantial (human) losses through COVID-19, others witnessed organisations slowly or suddenly \\u0026lsquo;fail\\u0026rsquo;. Similar harms can be avoided in the future by learning about the capacity of some primary health and community services to rebound after unanticipated events, informing disaster preparedness and health system resilience [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. This article draws on the experiences of primary health and community services responding to the needs of unpaid caregivers and older care recipients during the first waves of the COVID-19 pandemic in Aotearoa New Zealand to share relevant strategies and issues and contribute to future readiness to deal with similar events.\\u003c/p\\u003e\\n\\u003ch3\\u003eHealth System Resilience\\u003c/h3\\u003e\\n\\u003cp\\u003eResilience has been defined as the process of effectively negotiating, adapting to, or managing significant events, stresses or trauma. At the microlevel, assets and resources facilitate the capacity for personal resilience, individual adaptation and \\u0026lsquo;bouncing back\\u0026rsquo; in the face of adversity [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. At the macrolevel, system resilience is operationalised as sustaining \\u0026ldquo;operations under expected and unexpected conditions, by adjusting functioning prior to, during, or following changes, disturbances and opportunities\\u0026rdquo;[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. In health care systems, resilience is \\u0026ldquo;the capacity to adapt to challenges and changes at different system levels, to maintain high quality care\\u0026rdquo; [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eHealthcare systems feature assets and resources such as service delivery; a health workforce and \\u0026lsquo;invisible\\u0026rsquo; workforce of unpaid caregivers; health information systems; access to essential medical products, vaccines and technologies; health systems financing; and leadership and governance [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. A resilient health system requires a well-integrated range of organisations with good understanding of the diverse needs of clientele which are able to monitor the situation, learn and change practices, strategies, or protocols to anticipate future events and improve [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Overall, resilience, from the macro to the micro level of society is the result of the interaction between innovation, resources, and processes during times of disruption or instability [\\u003cspan additionalcitationids=\\\"CR8 CR9 CR10 CR11\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eHealth system resilience can be understood as absorptive, adaptive, and transformative [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Absorptive Resilience is the ability of a health system to withstand and manage the immediate impacts of a shock without major changes to its structure or functioning, maintaining core functions and services, utilizing existing resources, and implementing emergency measures to buffer impact. Adaptive Resilience refers to a health system\\u0026rsquo;s capacity to adjust and reorganize in response to changing conditions and new information during a crisis, including learning and evolving practices to improve response and recovery efforts, optimizing resources, and making flexible decisions to address emerging challenges. Transformative Resilience is a health system\\u0026rsquo;s ability to fundamentally change its structure and operations to better cope with future shocks and stresses, including long-term strategic changes addressing underlying vulnerabilities, enhancing system capacities, integrating innovations, and improving overall system robustness and sustainability.\\u003c/p\\u003e \\u003cp\\u003eEach type of resilience plays a crucial role in ensuring health systems survive and thrive in the face of crises. In the first year of the COVID-19 pandemic we would expect to observe examples of absorptive and/or adaptive health system resilience. Longer term, establishing best management practices in country-level responses to COVID-19 is vital for transformative resilience, informing future strategies and polices, and improving national preparedness to mitigate the effects of future unexampled events. Exploring the practices and experiences of discrete segments of national health care systems, such as service delivery and health workforces in primary health and community services, can inform future disaster preparedness and health system resilience [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003ch3\\u003eThe Context: Aotearoa New Zealand Health System\\u003c/h3\\u003e\\n\\u003cp\\u003eAotearoa New Zealand has an estimated population of 5\\u0026nbsp;million people. At the time of the 2023 Census, the population comprised 67.8% European, 19.6% Māori (indigenous population), 17.3% Asian and 8.9% Pacific peoples [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. The country is founded on Te Tiriti o Waitangi (the Treaty of Waitangi), a contractual relationship between the British Crown and Māori. The health system is thus committed to active protection to achieve equitable health outcomes for Māori.\\u003c/p\\u003e \\u003cp\\u003eAotearoa New Zealand has an ageing population, and the health system is reliant on the unpaid contributions of caregivers. A majority of physical, emotional and practical support for sick, disabled or older people is provided by unpaid caregivers [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e], with approximately 480,000 people providing regular care for someone with an illness or disability [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe Aotearoa New Zealand health system is publicly funded (through taxation) and primarily government-operated; users do pay a charge for access to primary care. There is a complementary private health sector that offers additional services and often faster access to elective surgeries and specialist care.\\u003c/p\\u003e \\u003cp\\u003eThe Ministry of Health (MoH) is responsible for overall policy direction, regulation, and coordination of the health system. Historically, the country was divided into District Health Boards (DHBs), which managed and delivered health services within specific geographic areas. As of July 2022, these DHBs have been replaced by a centralized organization known as Health New Zealand (Te Whatu Ora).\\u003c/p\\u003e \\u003cp\\u003eThe health care system has a strategic role to play in promoting health equity [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. It aims to provide universal access to essential health services, ensuring that all residents, regardless of income or residential address, can receive necessary care. Although the health system has focussed on improving conditions for groups who have had fewer opportunities [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e], health inequities are widening: Māori, Pacific peoples and those with lower socioeconomic status experience much higher levels of chronic disease, higher morbidity and lower life expectancy [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e At the time of this study, services and support for caregivers was provided through primary care, DHBs funded community services (e.g. Needs Assessment Support Coordination, home help), and non-governmental organisations [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]. interRAI-Home Care (interRAI-HC) - a standardised geriatric assessment tool \\u0026ndash; is mandated to determine the level of support required by older adults living in the community [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eServices available to older people living in the community and deemed eligible include home help, personal care, medication management, transportation assistance, social support, or housekeeping, health monitoring and rehabilitation services. Other services include respite care for primary caregivers, and day programs. While many services are free at the point of use (e.g. homecare services), some, such as appointments with General Practitioners (GPs) and prescription medications, require a co-payment. Subsidies are available to reduce these costs for low-income individuals and families, and regions. Long-term care (and respite) is provided in aged residential care (ARC) facilities, which are managed by private companies or non-profit organizations.\\u003c/p\\u003e \\u003cp\\u003eAotearoa New Zealand faces challenges related to healthcare workforce shortages, impacting service delivery and wait times. Before the COVID-19 pandemic, research demonstrated that bureaucratic obstacles [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e], difficulties navigating health and social care systems [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e], discrimination in health care services [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e], the challenge of English as a second language [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e], geographic location or area deprivation [\\u003cspan additionalcitationids=\\\"CR26\\\" citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e], and limited access to digital services [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e], created barriers to accessing health resources for many unpaid caregivers and care recipients. Unexampled events and disasters such as the pandemic have the potential to widen inequities in access to the health system.\\u003c/p\\u003e \\u003cp\\u003eBetween April-September 2020, Te Hiringa Hauora / the Health Promotion Agency established a working group to develop approaches to address needs of older people as part of the Ministry of Health\\u0026rsquo;s COVID-19 response. People aged 70 and older were issued with specific instructions to restrict social interactions (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). For Māori and Pasifika communities, the age threshold for being considered \\u0026lsquo;older\\u0026rsquo; was \\u0026ge;\\u0026thinsp;60 years recognizing of the earlier onset of age-related health conditions and lower life expectancy in these populations. The working group highlighted gaps in support for unpaid caregivers to older people, particularly for those living in rural areas, supporting people living with dementia, and of Māori and Pacific ethnicity. This led to the development of a research study \\u003cem\\u003eHealth Equity And Wellbeing Among Older People\\u0026rsquo;s Caregivers During COVID-19\\u003c/em\\u003e [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. The study of health service (service provider) resilience is a sub-study within this project.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eOur objectives are to:\\u003c/p\\u003e \\u003cp\\u003e \\u003col\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eExplore support to, and coordination of primary health and community services provided by the Government and its Ministries.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eExamine community health and social care service providers\\u0026rsquo; (SPs) strategies or protocols concerning provision of services, assets, and resources, innovative practices, and communication methods.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eAssess barriers and challenges to achieving a resilient health system as perceived by SPs.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eOur research team comprised three social scientists with PhDs and expertise in gerontology (VB), human geography (JW), and health and organisational communication; three nursing researchers with PhDs and specialties in physiotherapy, palliative care and spirituality; Māori and Pacific community researchers; and research assistants. The principal investigator (female) and a research fellow (female) collected the data (VB, DB) and one author (VB) coded the data which was validated by JW. Three of the authors (VB, JW and AS) contributed to analysis of the data, and reporting findings.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eInterviews and Recruitment\\u003c/h2\\u003e \\u003cp\\u003eRecruitment of SPs and data collection took place between 7th July and 4th October 2020, during which time regions in Aotearoa New Zealand moved between four Alert Levels (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Throughout all levels, healthcare providers were required to adhere to stringent infection prevention and control measures, including the use of PPE, physical distancing, and hygiene practices to protect both patients and healthcare workers (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThirty organisations were identified across Aotearoa New Zealand. Via email and phone call, we approached organisations of varying size providing services to unpaid caregivers, people living with dementia, or older people during alert levels 2\\u0026ndash;4. We purposively approached a range of a) national organisations (6); b) Māori providers (13); c) Pacific providers (11); d) rural providers (5); and e) local or regional dementia services (4).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDescription of restrictions for the general population, older adults, primary care, community care and residential and nursing aged care facilities during COVID-19 Alert Levels in Aotearoa New Zealand 2020\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eGeneral Population\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOlder people\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePrimary Care\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHealth \\u0026amp; Disability Community Services\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eResidential care facilities\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eContact tracing of cases. General hygiene practices. Public health campaigns to raise awareness.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eNormal activities with caution: advised to remain vigilant about hygiene and physical distancing.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eNo restrictions, use of telehealth where appropriate, safety and hygiene practices.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eNo restrictions, use of telehealth where appropriate, safety and hygiene practices.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNormal visiting, health screening and infection control practices.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePhysical distancing in public and workplaces. Limits on gatherings. Encouraged to work from home where possible. Heightened tracing and testing. Closure of schools and non-essential businesses considered.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCaution going out and attending small gatherings. Encouraged outdoor activities and exercise avoiding crowded places and maintaining physical distancing.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMixed model of in-person and telehealth consultations, with in-person visits following public health guidelines.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eMost services delivered with safety measures, including social distancing and hygiene practices.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eControlled visitor access with restrictions, such as limited visitor numbers and health screening.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStrict physical distancing and restrictions on public gatherings. Closure of public venues. Schools and childcare centres open only for children of essential workers. Essential services open, non-essential businesses and services closed. Travel restrictions within regions.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStay home and limit outings. Use support networks for essential supplies and medications. Short walks and outdoor exercise permitted, with physical distancing. Limited visits: visitors to adhere to strict hygiene and physical distancing protocols.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePrimarily via telehealth, with in-person visits allowed for urgent cases following strict safety measures.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eEssential services, some non-essential services with strict safety measures.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eRestricted visitor access, with some allowances for close family members under controlled conditions.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStay at home, except for essential personal movement. Severe restrictions on travel and movement. All gatherings cancelled, and all public venues closed. Schools and educational facilities closed. Only essential businesses and services open.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAvoid all non-essential outings. Indoor exercises, short walks (only if necessary) maintaining physical distancing. Utilize support networks for essential supplies. No visitors allowed.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePrioritized pandemic response.\\u003c/p\\u003e \\u003cp\\u003eOperated for urgent and essential services only. Routine consultations moved to telehealth wherever possible.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eEssential services with significant restrictions. Non-essential services paused.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eStrictly no visitors, except for end-of-life care. Stringent infection control measures.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe semi-structured interview schedule has been described elsewhere [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. In this article we draw on participants\\u0026rsquo; responses to question topics concerning innovative practices such as new services, resources, and outreach activities. In addition, we examine the organisational and external settings (health system infrastructure), in which the innovative practices were implemented.\\u003c/p\\u003e \\u003cp\\u003eWe took notes during the interview on a grid with column headings following the structure of the interview topic guide, supplemented by immediate post-interview reflective journaling, and revision of the notes into a coherent summary [\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. Participants were sent the revised note grid to verify and/or amend and to return to the research team within one week along with examples of innovative resources mentioned during the interview [\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAnalysis\\u003c/h2\\u003e \\u003cp\\u003eNVivo 14 software facilitated a rapid deductive thematic coding to an \\u003cem\\u003ea priori\\u003c/em\\u003e framework of concepts based on the sections of the interview. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e shows the thematic codes that are used in this article.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eParticipants\\u0026rsquo; Characteristics\\u003c/h2\\u003e \\u003cp\\u003eTwenty SP staff were interviewed: participants included CEOs and their nominated representatives from National organisations (4); Māori providers (3); Pacific providers (5); rural providers (4); and local or regional providers focusing on dementia (4). Participants had been in post from 0\\u0026ndash;21 years (Mean 7.37 SD 6.56). Telephone interviews lasted 30\\u0026ndash;45 minutes.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eThematic coding structure.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e Ordinate and Subordinate Codes\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNotes\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOrganisational level\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSP changes in care and support during COVID19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eInnovative practices\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIn person\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFace-to-face contact\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCrises, new assessment and referral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEmotional and practical support\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInformational support\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRemote working\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo direct contact with clients\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eArts, leisure, entertainments and culture\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChecking in and checking up\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAlso, relationships and communication\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCrises, new assessment and referral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEmotional and practical support\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInformational support\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChallenges with delivering support by service providers\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChallenges with workforce or employees\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSP new operating procedures\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSP relationships and communication with clients\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSocial structural and cultural level\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAvailability and suitability of facilities and services\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSpecialists, hospital and residential care\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCoordination of services\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDesignation of services\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNon/Essential services\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGovernment support to SP\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eStructural support and services that worked well\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMacrolevel: Health System Support and Coordination of Services\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eGovernment Support\\u003c/h2\\u003e \\u003cp\\u003eLive daily COVID-19 briefings were presented by Aotearoa New Zealand Prime Minister Jacinda Ardern and Director-General of Health Dr Ashley Bloomfield, beginning in March 2020. The briefings were a key source of information support for the SPs; the frequency of briefings became more sporadic after June 2020, when the situation stabilized.\\u003c/p\\u003e \\u003cp\\u003eIn addition to informational support, financial and practical support from the government, Ministries of Social Development (MSD), Health, (MoH), and Business, Innovation and Employment (MBIE) enabled organisational resilience for SPs. Co-ordination of services between SPs was managed by sixteen Civil Defence Emergency Management (CDEM) Groups, each comprising committees of elected councillors from within regional boundaries working in partnership with emergency services, lifeline utilities, DHBs, health and care service providers, and government departments.\\u003c/p\\u003e \\u003cp\\u003eSome government ministries played specific roles supporting SPs. MSD provided wage subsidies for staff and honoured contracts although many SPs could not meet service targets while face-to-face contact was prohibited. MSD also funded specific service innovations proposed by SPs as necessary for clients (e.g. food packages or digital technology). SPs stated that the funding from MSD was easy to apply for and funds were obtained rapidly, one SP noted trust around their spending was helpful.\\u003c/p\\u003e \\u003cp\\u003eMoH provided funding for COVID-19 specific services, and helped SPs develop policies fulfilling the Health and Safety at Work Act 2015 requirements for employers to take all practicable steps to mitigate risk and protect employees from workplace hazards. National SPs were in regular direct contact with the MoH or MSD (depending on the focus of their services) for briefings and updates. Information from these meetings was cascaded down to staff, and experiences of frontline workers and local SPs were passed up to the Ministries.\\u003c/p\\u003e \\u003cp\\u003eMBIE provided extensive resources, templates, and guidance documents to help SPs implement human resource policies, such as risk assessment, health monitoring, flexible working arrangements, leave and absences management, employee wellbeing and support (e.g., Employee Assistance Program), and wage subsidy scheme. The goal was to ensure that workplaces remained safe, employees were supported, and SPs could navigate the operational challenges posed by the pandemic. The Māori Health Directorate, Pacific Future Fund and MoH provided funding for innovative services and activities targeting Māori and Pacific communities.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eRegional Coordination\\u003c/h2\\u003e \\u003cp\\u003eCDEM worked in collaboration with other government agencies and SPs to identify \\u0026lsquo;vulnerable\\u0026rsquo; individuals in need of additional support to include on the Civil Defence list (see also \\u0026lsquo;challenges\\u0026rsquo; below). Vulnerability was considered on basis of age, health conditions, disability, or other factors that made it difficult to manage independently. People on the Civil Defence list were prioritized for receiving essential services, such as grocery deliveries, prescription medication, regular communication \\u0026lsquo;check ins\\u0026rsquo; and ongoing welfare \\u0026lsquo;check ups\\u0026rsquo;. In practice, this meant that SPs identified \\u0026lsquo;vulnerable\\u0026rsquo; people, and were responsible for providing their essential services. One Pasifika SP noted although there was a lot of collaboration with Civil Defence who provided a list of service providers, it was still difficult to \\u0026ldquo;decipher who was doing what in the community \\u0026ndash; finding who had the right support for a particular situation\\u0026rdquo; (SP04). This sentiment was echoed by others.\\u003c/p\\u003e \\u003cp\\u003e Locally, there were differences in communication, leadership and coordination of services provided by DHBs. One SP noted leadership from the DHB was absent at the pandemic outset, another SP did not receive any direct contact from their DHB despite sending summaries of their activities. Yet there was evidence from several SPs of good communication and support from DHBs. One SP said,\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;the support our DHB has offered us cannot be faulted, when we went into Level 3 lockdown our day program services were in question, and the viability of the organisation looked very uncertain. The quick and decisive decisions made enabled us to keep all of our staff engaged and fully paid.\\u0026rdquo;\\u003c/em\\u003e (SP07)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e \\u003cp\\u003eDistribution of PPE to frontline healthcare workers, hospitals, and other essential services was co-ordinated by MoH. Centralized distribution was meant to ensure that PPE was allocated based on priority needs, focusing on healthcare providers, aged care facilities, and other critical sectors. While this worked for some organisations, other SPs encountered difficulties. Several had to lobby MoH directly, or via MSD, to get PPE released to them.\\u003c/p\\u003e \\u003cp\\u003eThere were examples of collaboration between organisations at the national and local level. For example, the Chief Executives of national SPs collaborated to share information. Extant and new collaborations within Districts also facilitated coordination of services and information. One SP noted strong relationships with other health and care providers in the locality assisted with planning responses to restrictions and solving problems.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMesolevel: Service Provider Procedures and Strategies\\u003c/h2\\u003e \\u003cp\\u003eThe essential services regime allowed some premises to keep operating during COVID-19 (see Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). In March 2020 essential services included DHBs and their facilities; any person employed or contracted as a doctor, nurse, pharmacist, paramedic, kaiāwhina,\\u003csup\\u003ea\\u003c/sup\\u003e social worker, aged (residential and nursing) care and community workers and paid caregivers more generally; hospitals, primary care clinics, pharmacies, and care facilities. The classification of essential services changed the second time that the country entered Alert Level 4 in August 2020 and included social and community-based services supporting persons to maintain critical well-being. Only organisations deemed \\u0026lsquo;essential services\\u0026rsquo; were able to continue face-to-face services with clients, with the appropriate PPE protocols in place.\\u003c/p\\u003e \\u003cp\\u003eThere were also variations in the approaches taken by national organisations versus local organisations that served a smaller or specific population. National SPs developed emergency plans and distributed these to local organisations. In most organisations this process had previously been devolved to local organisations, but during the pandemic it became apparent that these had not always been completed.\\u003c/p\\u003e \\u003cp\\u003eThe national SP essential workforce required new health and safety training, but as one noted \\u0026ldquo;with everyone in lockdown we needed to completely change the way we trained our people\\u0026rdquo; (SP11). For example, \\u0026ldquo;donning and doffing\\u0026rdquo; (how to put on and take off PPE) was especially important, so training teams created videos to be utilised by all staff whenever or wherever they were. One national SP delivered PPE to letterboxes of staff and/or clients all over the country; another adapted day to day business operations, limiting the need for staff to enter client\\u0026rsquo;s homes by developing a triage process. When staff needed to enter a client\\u0026rsquo;s home they delivered care differently enabling physical distancing whenever possible.\\u003c/p\\u003e \\u003cp\\u003eDigital applications were used more extensively, for example, to provide client information, alerting to additional risks (e.g., an unwell client), and co-ordinating visits. Some national SPs implemented telehealth procedures, checklists, or standard questions to assist teams assessing clients\\u0026rsquo; issues.\\u003c/p\\u003e \\u003cp\\u003eDevelopment of new strategies and procedures by national SPs was not universal. One local SP noted \\u0026lsquo;disappointment\\u0026rsquo; in the leadership of a national SP, feeling that the local provider was \\u0026ldquo;left to fend for itself\\u0026rdquo; (SP05).\\u003c/p\\u003e \\u003cp\\u003eIn contrast to national SPs, the strategic response of local SPs tended to focus on meeting their clients most pressing needs with a dwindling workforce (see \\u0026lsquo;challenges\\u0026rsquo; below). Some changed the focus of their work. For example, one SP switched to the provision of personal care only, dropping housework; as they noted, \\u0026ldquo;clients can live with mess, but not without being washed\\u0026rdquo; (SP16). A rural SP suspended a policy which prohibited staff being involved in financial transactions: helping clients obtaining medications or groceries during Level 4.\\u003c/p\\u003e \\u003cp\\u003eA Pacific SP designated as a non-essential service during Level 4 put all other work on hold to manage an 0800 number and help clients complete \\u0026lsquo;welfare\\u0026rsquo; forms. Available through Government websites, these were used to apply for financial aid, access essential services, and receive support (e.g., Wage Subsidy Scheme; COVID-19 Leave Support Scheme); Emergency Benefit; Rent and Housing Support; Food and Essential Services Support; and Health and Disability Support).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMicrolevel: Innovative Practices and Communication with Clients\\u003c/h2\\u003e \\u003cp\\u003eInnovative practices were developed and delivered remotely or in person. Informational support, emotional and practical support, and support for crises, new assessment, or referral were delivered by both means, whereas \\u0026lsquo;checking in and checking up\\u0026rsquo;, and \\u0026lsquo;arts, leisure, entertainment and culture\\u0026rsquo; were delivered remotely.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eInformational Support\\u003c/h2\\u003e \\u003cp\\u003eSPs were often seen as trusted and central sources of information. For example, one noted, \\u0026ldquo;we established an 0800 number so that older people and caregivers could phone up for trusted information, as digital literacy and navigation of multiple sources of information could be difficult.\\u0026rdquo; (SP07).\\u003c/p\\u003e \\u003cp\\u003eRemote informational support included material about COVID-19 or the protocols relating to the different levels of social restriction, and the use of PPE. Some SPs made sure that information was available in the appropriate and accessible format for their clients (e.g. large font size, audio formats, or translated to meet language needs).\\u003c/p\\u003e \\u003cp\\u003eOther SPs provided information on how to access health and care support, or what support could be provided, or \\u0026lsquo;advice\\u0026rsquo; such as how to maintain mental, physical and spiritual health, keep connected and support a person at home. Some SPs provided practical support by providing digital devices (see below), and also provided written instructions about how to operate them.\\u003c/p\\u003e \\u003cp\\u003eThere were examples of in-person information support. One SP described support workers delivering information about COVID-19 along with the services to clients. In-person informational support was particularly important in Pasifika communities where one SP trained volunteers to deliver COVID-19 and vaccination information in various Pacific languages.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePractical and Emotional Support\\u003c/h2\\u003e \\u003cp\\u003eIn-person practical support included financial support (e.g. food vouchers, energy bills, broadband plans, pre-paid phone cards), food parcel delivery, digital devices such as tablets, mobile phones and laptops, care packs, or firewood. There were also innovative supportive practices for unpaid caregivers who could not go out, such as pharmacy or medication pickups, and grocery shopping and delivery.\\u003c/p\\u003e \\u003cp\\u003eOften practical support was tailored to particular groups. For example, one SP produced a new \\u0026lsquo;companion\\u0026rsquo; card for unpaid caregivers to use when in public, explaining the caregiver had to be accompanied by the care recipient with dementia. A Māori SP provided care-packs including essentials required to keep people well in overcrowded houses, such as, blankets, pillows, and utensils to facilitate cooking outside. Both Māori and Pacific SPs paid electricity bills and delivered wood for fires (for heating and cooking), along with food parcels and food vouchers as they were aware that many of their clients could not afford to pay bills.\\u003c/p\\u003e \\u003cp\\u003eSPs also devised ways of providing in-person emotional support to unpaid caregivers, for example through driveway visits, chats through windows or on poches, and a staff choir that sang outside clients\\u0026rsquo; homes.\\u003c/p\\u003e \\u003cp\\u003eWhile some SPs had to suspend face-to-face support to clients, service delivery was adapted and practical and emotional support was delivered by phone, email, and video calls. This included online/video conference caregiver support groups, groups for people living with dementia, and exercise classes. One SP delivered Cognitive Stimulation Therapy to people with dementia via online video link [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e], while another SP set up a closed Facebook page to enable disability clients who managed their own care via an Individualised Funding model to share experiences. Remote emotional support via telephone was provided to an unpaid caregiver when a care recipient was critically unwell and hospitalised.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eNew Assessments, Referrals and Crises\\u003c/h2\\u003e \\u003cp\\u003eNew assessments were mostly conducted remotely. SPs described how more triage was undertaken over the phone; a Registered Nurse would carry out a phone assessment or medication review and the organisation would liaise with the GP and pharmacy. Another SP explained that between March 25th to June 30th, 2020, the interRAI Contact Assessment was managed over the phone as a rapid (approximately 20 minutes) temporary alternative to the interRAI-HC assessment.\\u003c/p\\u003e \\u003cp\\u003eIn anticipation of carer crises, some national SPs developed emergency plans for unpaid caregivers to complete. This provided a written record of preferences and needs of care recipients, if the caregiver became ill (or passed away). One national provider encouraged use of a \\u0026lsquo;Lifetube\\u0026rsquo; stored inside the fridge so first-responders could easily find essential information.\\u003c/p\\u003e \\u003cp\\u003eIn-person support was mostly provided for crises and emergencies. For example, SPs described referring care recipients to emergency home-based or relocated to residential care when caregivers passed away during restrictions. As part of driveway chats (see above) SPs also undertook \\u0026lsquo;welfare checks\\u0026rsquo; and if issues were identified they refers clients on to hospital-based services or GPs. One SP transported clients to medical appointments with both driver and passenger wearing full PPE.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eArts, Leisure, Entertainment and Culture\\u003c/h2\\u003e \\u003cp\\u003eMany SP were concerned disruption to routines would be detrimental to their clients, and unpaid caregivers would struggle to find things to do. In response they developed entertainment resources delivered by email or hosted online. For example, one SP sent a daily newsletter to unpaid caregivers, featuring joyful and funny content, and links to virtual activities for people with dementia, like train journeys and art gallery tours. Some SPs collaborated with expert organizations to deliver online art groups and themed meetings, while others created their own arts and crafts classes or distributed digital devices with preloaded games.\\u003c/p\\u003e \\u003cp\\u003eDue to the lack of access to and difficulty using digital devices among people with dementia, one SP created and hand-delivered 300 photocopied activity booklets. Other SPs also developed, delivered or mailed hard copies of entertainment resources, tailoring them to the severity of dementia or cultural context. (i.e. for Māori and Pasifika clients). While most of the \\u0026lsquo;hard copy\\u0026rsquo; entertainment packs were developed for unpaid caregivers of people with dementia, two SPs noted that they delivered hard copies of entertainment activities to the homes of clients who did not have email.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCommunicating and Maintaining Relationships with Clients\\u003c/h2\\u003e \\u003cp\\u003eAs most face-to-face services were moved to contactless services, \\u0026lsquo;checking in\\u0026rsquo; became a virtual care modality and provided a sense that \\u0026lsquo;someone was there\\u0026rsquo;. On the other hand, \\u0026lsquo;checking up\\u0026rsquo; referred to contact intended to ascertain the wellbeing of clients.\\u003c/p\\u003e \\u003cp\\u003eMany SPs were unable to visit clients and were restricted to remote contact only, especially in the first lockdown. Many talked about the strategies they adopted to maintain communication with clients, ranging from regular telephone calls, texts, emails, or video calls to instant message or group conversations. Some focused on establishing how much contact clients would like so that they were neither isolated, nor overwhelmed. SPs felt it was important to \\u0026ldquo;be a voice on the end of the phone, giving re-assurances and connecting people with other services\\u0026rdquo; (SP13). Some SPs relied on telephone calls only, others tried to ascertain the status of digital connectivity and whether clients could receive emails.\\u003c/p\\u003e \\u003cp\\u003eSPs perceived that \\u0026lsquo;checking in\\u0026rsquo; was particularly important for some client groups. For example, to help maintain routines for unpaid caregivers supporting a person with dementia, one SP phoned on the day that they would normally go to a day programme. Phone calls to older Pasifika people and caregivers were also perceived as essential with one Pacific SP noting that verbal communication was much better than leaflets.\\u003c/p\\u003e \\u003cp\\u003eRegarding \\u0026lsquo;checking up\\u0026rsquo;, some service providers made phone calls to all their clients for wellbeing checks, while another received a request from a GP practice to call all their clients over 70. Some SPs noted that their support workers staff were worried about clients and would often take it upon themselves to check up on them in their own (unpaid) time. One SP noted that there were more welfare checks during COVID-19 than prior to the pandemic.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eChallenges\\u003c/h2\\u003e \\u003cp\\u003eThere were four main challenges identified by SPs relating to staffing, identifying \\u0026lsquo;vulnerable\\u0026rsquo; older people, digital access and access to aged residential care. Difficulties associated with accessing PPE at the outset of the pandemic are noted above.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStaffing\\u003c/h2\\u003e \\u003cp\\u003eDuring the pandemic the SP workforce shrank, with more than 30 per cent of staff on unplanned leave at any one time. Staff were unable to work if they were unwell or had been exposed to COVID-19. SPs noted others were educating children at home which impacted on their ability to work, and some took leave to manage burnout, exhaustion, and grief.\\u003c/p\\u003e \\u003cp\\u003eSocial restrictions designed to reduce the risk of contracting COVID-19 for particular groups also impacted the workforce. For example, older volunteers were asked to step down as they were unable to attend face-to-face activities or deliver \\u0026lsquo;meals on wheels\\u0026rsquo;. One rural SP noted many of their support workers had respiratory issues that were attributed to coal smoke in the town.\\u003c/p\\u003e \\u003cp\\u003eSPs noted staff worried about transmission of COVID-19 between clients\\u0026rsquo; homes and their private abode. Consequently, some support workers were unwilling to extend their bubble and would only work with existing clients. Others, especially Māori SPs, faced challenges recruiting new staff to fill vacant roles, attributing this to the low status and undervaluing of homecare work. One SP reported the public accused their workers of spreading COVID and flaunting lockdown rules; they resolved this by obtaining fluorescent vests marked \\u0026lsquo;essential worker.\\u0026rsquo; SPs also noted challenges with travelling across regional boundaries to deliver home-based health and care services to clients when alert levels varied by region. Essential workers were provided with contradictory advice about moving across boundaries and there were inconsistencies between agencies involved in the policing of regional borders.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec22\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e\\u003cem\\u003eIdentifying \\u0026lsquo;Vulnerable\\u0026rsquo; People\\u003c/em\\u003e\\u003c/h2\\u003e \\u003cp\\u003eAs noted, CDEM groups created a list of \\u0026lsquo;vulnerable adults\\u0026rsquo; that were prioritized to receive services during the pandemic, based on age, health conditions (e.g. cardiovascular disease, respiratory issues, diabetes, and cancer), disability (e.g. physical, sensory, intellectual, or mental health disabilities limiting ability to access essential services or comply with public health measures), and social isolation, dependence on services, ethnic and cultural factors (e.g. Māori and Pasifika communities). The list relied on the identification of vulnerable adults by SPs. However, the combination of criteria used by SPs to identify vulnerable adults varied significantly. For example, one SP prioritized individuals living alone with dementia, another focused on those over 85 with high-level needs. Some used more elaborate criteria. For example, one had sufficient information prior to the pandemic to categorise all their clients as home alone, living with spouse, or living with others, and could also consider their access to services and transport, health of the care recipient and their primary caregiver, geographical location, and digital access. Factors like social isolation, disability, and economic hardship were weighted variably (or not considered) by other SPs. Inconsistencies meant that, for instance, a couple in their 90s with one partner caring for the other with dementia might be prioritized by one SP but overlooked by another, contributing to unequal service delivery.\\u003c/p\\u003e \\u003cp\\u003eIdentifying vulnerable people relied on the SPs\\u0026rsquo; community connections and knowledge of clients prior to COVID-19. While some SPs knew their clients and were able to respond appropriately, others had less community engagement and could not respond to changing needs. Furthermore, there was little or no familiarity with people who developed a need for care after the onset of the pandemic. Unless unpaid caregivers proactively contacted SPs, they were in danger of being overlooked for inclusion on the Civil Defence priority list. As criteria were not always applied consistently to old and new clients, the \\u0026lsquo;type\\u0026rsquo; of older people and caregivers receiving home-based services varied across different SPs and regions.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec23\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eDigital Access\\u003c/h2\\u003e \\u003cp\\u003eDigital access was a challenge for both staff and clients of SPs. There was great variation in digital literacy within both groups.\\u003c/p\\u003e \\u003cp\\u003eDuring levels 3 and 4 when many staff worked at home, SPs had to upskill the workforce in relation to using digital equipment, apps, and systems. Many SPs delivered training in telehealth, video conferencing, and using the range of smartphone features.\\u003c/p\\u003e \\u003cp\\u003eSome SPs noted staff were either not interested or unwilling to use digital technology, or there was competition between household members to use digital devices at home (e.g., for education or work as well as recreation). Other SPs did not have appropriate digital hardware or software for staff. This was especially relevant in organisations which employed older staff or relied on older volunteers: many did not have an internet connection, laptops, computers or printers at home. Some staff knew how to use mobile phones only for calling or texting. While essential services were able to purchase laptops for staff who needed them, SPs that were (originally) designated as non-essential services did not receive funding to rectify this. Consequently, where possible, digitally literate staff used their own personal computers and phones for work purposes. Others solved the issues by using telephone calls as the main form of communication between staff, and with clients.\\u003c/p\\u003e \\u003cp\\u003eThe proportion of clients with digital access (and digital literacy) also varied between organisations. SPs estimates of the proportion of their clients that had an email address ranged from 30 to 90%. Some SPs adopted a policy to connect to clients by phone, others noted they were unable to support those who were not connected digitally.\\u003c/p\\u003e \\u003cp\\u003eDigital access was particularly difficult for certain groups such as rural people, people living with dementia, and older Pasifika. One rural SP noted difficulties for clients accessing online resources because of lack of network coverage; while a SP who primarily worked with people living with dementia noted that around 40% of clients lived alone, and most only used a landline. Cognitive impairment precluded some people with dementia from using digital devices. Another SP noted that Pacific older people without phones or who forgot to charge phones were difficult to contact.\\u003c/p\\u003e \\u003cp\\u003eSome SPs attempted to address digital inequities by providing training and resources. One SP provided training for unpaid caregivers to use video conferencing, another delivered a computer course for older people during Alert Level 1 and 2 (June to Aug 2020). The training and distribution of laptops before Alert level 3 restrictions in August 2020 facilitated better communication with clients during lockdown.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec24\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAccess to Aged Residential Care Facilities\\u003c/h2\\u003e \\u003cp\\u003eSPs identified a challenge relating to clients\\u0026rsquo; changing circumstances during the pandemic, particularly the need to access ARC when a caregiver was no longer able to provide support at home, needed respite from caring, or in emergencies. This was extremely difficult during Alert Level 4, when the most stringent restrictions were in place. One SP noted that after a caregiver passed away emergency ARC was required for a person living with dementia. The SP was \\u0026lsquo;literally kicking the door\\u0026rsquo; as staff would not admit them. The SP threatened to phone the Human Rights Commissioner before the issue was resolved. Another SP noted that rest homes would not accept new residents to provide caregivers with respite without following rules that were often unacceptable to the caregiver and care recipient. The process involved the person obtaining a clear Polymerase Chain Reaction (PCR) COVID-19 test while isolating at home (separate from the unpaid caregiver) for 48 hours, and then on entering ARC being isolated from others in the facility.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe government has received acclaim from some commentators for their exemplary handling of the pandemic, often described as the \\u0026lsquo;gold standard\\u0026rsquo; of management [\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. Others comment on the swift implementation of epidemiological strategies which led to Aotearoa New Zealand being free of community transmission for over 100 days, and earned the country a top spot in the COVID-19 Performance Index rankings [\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e], However, there is little evidence on the resilience of the health system. Establishing best management practices in country-level health system responses is vital to improve national preparedness to mitigate the effects of other future unexampled events. In exploring absorptive, adaptive and transformative health system resilience [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e] we start by discussing positive contributions and move on to consider gaps and challenges undermining resilience.\\u003c/p\\u003e \\u003cp\\u003eAotearoa New Zealand government acted quickly and decisively with strict lockdown measures, clear communication strategies, activating emergency response plans and designating essential workers [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e]. These were examples of absorptive resilience, withstanding and managing the immediate shocks of COVID-19 without major changes to structure or functioning. However, most responses to the pandemic provided examples of adaptive resilience: adjusting and reorganizing responses to the changing conditions.\\u003c/p\\u003e \\u003cp\\u003eThe government adapted to the new situation by providing support and protection for healthcare workers [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. This included good governance, the provision of PPE, and financial aid to individuals and businesses. The latter mitigated some of the economic impact of the pandemic for financially vulnerable older adults and caregivers, and helped preserve jobs, especially in the community care sector.\\u003c/p\\u003e \\u003cp\\u003eSPs modified service protocols, enhanced telemedicine services, and redistributed resources to vulnerable people by remote or face-to-face means. This was facilitated by rapid adoption of digital health solutions and temporary fixes, including telehealth services and apps that helped with rapid information about clients and coordination of care workers. Some SPs led community initiatives to support vulnerable populations, ensuring access to essential services and reducing social isolation. Active involvement and leadership from Māori, Pasifika and rural communities ensured culturally appropriate responses and better outreach to these populations. Many SPs sustained a high level of risk management as they navigated each alert level change, scaling up or down as required by the environment and advice of the time.\\u003c/p\\u003e \\u003cp\\u003eThese positive aspects of health system resilience highlight the importance of leadership, community involvement, robust communications systems, good data management, collective and individual trust and a well-prepared healthcare system in managing public health crises. Despite these positive aspects, there were also gaps identified. Our research highlights challenges and limitations in the health system, such as inconsistencies in the identification of vulnerable individuals, coordination challenges, communication breakdown, staffing issues, and geographic and socio-economic barriers.\\u003c/p\\u003e \\u003cp\\u003eCo-ordination of services between SPs and the identification of \\u0026lsquo;vulnerable people\\u0026rsquo; was managed by the CDEM groups. However, coordination between multiple organizations was often difficult, leading to delays or gaps in service delivery. Although the priority list of vulnerable people aided the distribution of support to some, there was lack of a unified framework or standard guidelines for identifying and prioritizing vulnerable populations. Health agencies primarily focused on medical vulnerability, while social service organizations placed greater emphasis on economic and social factors. Māori and Pasifika organizations, as well as other community groups, often had their own criteria for vulnerability, reflecting the unique needs and circumstances of their populations. Ability to identify individuals depended on the level of information held by organisations prior to the pandemic. As a result, SPs used varying criteria to identify vulnerable individuals, leading to inconsistencies and some people being overlooked. New service users faced additional barriers to accessing services if they were not already known to SPs, especially if they were unable to identify which SPs they should contact.\\u003c/p\\u003e \\u003cp\\u003eSPs identified other barriers to delivering services. Some regions or communities had better resources and networks, while others were disadvantaged by border controls, resulting in uneven distribution of support. This meant that inequities in access to services were amplified for those in rural or remote areas [\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e] as people often faced greater challenges in receiving timely support. Māori and Pacific SPs reported on developing innovative services for their communities. However, these were typically delivered in areas with high proportions of specific cultural population. For Māori, Pasifika, and migrants living in less intensive concentrations of culturally distinct groups, cultural and language barriers may have impeded effective outreach and support [\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn addition to language difficulties, communication breakdowns between the government and society were often due a preference for face-to-face information or digital access. Some older people and unpaid caregivers did not have had access to reliable communication channels (e.g., phone or internet) to request help or receive updates. Some SPs tried to remedy this by providing digital training, equipment, or \\u0026lsquo;data\\u0026rsquo; (i.e., prepaid vouchers or plans) to unpaid caregivers and older people. While the government recognized a digital divide in certain segments of society [\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e], there was little attention given to the limited digital literacy and access experienced by many health and community care staff, and the subsequent workforce challenges encountered by SPs.\\u003c/p\\u003e \\u003cp\\u003eStaffing issues were apparent across most SPs, and were also noted as a factor influencing the supply of services in 29% of countries surveyed by WHO in 2020 [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e]. In Aotearoa New Zealand, some staff shortages were attributed to their digital access and digital literacy influencing their ability to work from home, and the age of some employees and volunteers. Staff also faced additional caring or educational responsibilities, illness, and increased stress, or were safeguarding family; similar issues for front-line community health and social care staff have also been reported elsewhere [\\u003cspan additionalcitationids=\\\"CR45\\\" citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e]. Most SPs reported being overstretched during the pandemic and, some initiated triage systems to reduce pressures on staff (also tried elsewhere [\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e]). Most community care workers experienced both increases and changes to their workload due to staff shortages, which has also been documented internationally [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eDifficulties recruiting staff to replace the depleted critical workforce of health and care community staff were reported in this study and elsewhere [\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e]. Some SPs provided digital training and equipment for staff while others lacked the financial resources or knowledge to do this. Other countries facing staff shortages employed different tactics such as recalling inactive health and care workers, or fast-tracking trainees to provide childcare for essential health care workers [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. These are important strategies for health care systems to develop a broader capability and draw on a wider pool of potential staff in anticipation of future emergencies [\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eSome of the issues identified in this study, such as workforce sustainability and digital access, were systemic issues that were not addressed sufficiently before the pandemic. In 2020, prior to the pandemic, the health and disability system was already experiencing serious issues, with a workforce under pressure and high stress levels. A report noted \\u0026ldquo;persistent shortages already exist in a number of workforces and rural areas generally find it more challenging than urban areas to recruit and retain staff\\u0026rdquo; [\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e]. Subsequently, significant structural change resulted in the establishment of two new health system organisations (Te Whatu Ora - Health New Zealand, and Te Aka Whai Ora - Māori Health Authority\\u003csup\\u003eb\\u003c/sup\\u003e). However, a Health Workforce Plan 2023/24 focuses primarily on health professionals and does little to address community care workforce issues [\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e]. This means that the inequities apparent in the \\u0026lsquo;value\\u0026rsquo; ascribed to community care staff during the pandemic persist. Community care workers were overlooked as \\u0026lsquo;essential workers\\u0026rsquo; during the Alert Level 4 lockdown, and PPE provisions for this sector were neglected. Similarly, today, strategies for recruitment and retention, and training for staff development in areas such as digital and data literacy focus on health professionals rather than the broader community care sector. The community care sector has been pushed to breaking point and has not recovered from the effects of the pandemic on the workforce. Without further transformational work in the health system, the community care sector lacks resilience, and its precarious situation means it is unlikely to be able to deal adequately with future emergencies [\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eTo achieve transformative resilience in health systems we recommend the following.\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eA Unified Framework to Inform a \\u0026lsquo;Priority List\\u0026rsquo;\\u003c/b\\u003e: develop national standards for identifying and supporting current (e.g., through administrative datasets) and new vulnerable individuals, ensuring consistency across regions and organizations\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eAdequate Workforce Capability, Capacity, and Support\\u003c/b\\u003e: strategies for recruitment, retention of community care workforce, and \\u0026lsquo;diversity\\u0026rsquo; in the workplace (e.g., a reserve pool of inactive workers) so that in the event of disasters there are people that can step-in and help.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eEnhanced Coordination of Emergency Planning\\u003c/b\\u003e: establish clear roles and responsibilities for all service providers to avoid duplication of effort; and ensure service providers have local emergency response plans, are digitally enabled (i.e., have sufficient resources to facilitate home-based working in times of emergency), and have access to emergency facilities (such as residential care facilities and hospitals).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eEffective Communication\\u003c/b\\u003e: address digital exclusion of older people, caregivers and staff within service provider organisations; develop multi-channel communication strategies to reach all segments of the population, including translations from a single or central point to avoid misinformation concerning complex concepts and instructions.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eWhile Aotearoa New Zealand is justifiably considered to have done well in preventing the worst impacts of Covid-19, there are lessons that can be learned about health system resilience. This unexampled event provided challenges for the health system and there were good examples of absorptive and adaptive health system resilience in the actions of SPs and Government responses. Knowledge gleaned from these observations of absorptive and adaptive resilience and barriers and challenges to resilience could contribute to Transformative Resilience. This requires long-term strategic changes to address the vulnerabilities and enhance capacity to improve the health system\\u0026rsquo;s robustness and sustainability in the future, especially regarding preparedness for future crises.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eARC:\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003eAged Residential Care\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eCDEM:\\u003c/em\\u003e\\u0026nbsp;\\u003c/strong\\u003eCivil Defence Emergency Management\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eDHB:\\u003c/em\\u003e\\u0026nbsp;\\u003c/strong\\u003eDistrict Health Board\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eGP:\\u003c/em\\u003e\\u0026nbsp;\\u003c/strong\\u003eGeneral Practitioner\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eMBIE:\\u003c/em\\u003e\\u0026nbsp;\\u003c/strong\\u003eMinistry of Business, Innovation and Employment\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eMoH:\\u003c/em\\u003e\\u0026nbsp;\\u003c/strong\\u003eMinistry of Health\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eMSD\\u003c/em\\u003e:\\u0026nbsp;\\u003c/strong\\u003eMinistry of Social Development\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ePPE:\\u003c/em\\u003e\\u0026nbsp;\\u003c/strong\\u003ePersonal Protective Equipment\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eSP\\u003c/em\\u003es:\\u0026nbsp;\\u003c/strong\\u003eService Providers\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was approved by the University of Auckland Health Research Ethics Committee (Ref AH21966). Consent to participate in the study was obtained from all participants.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and material\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and/or analysed during the current study are not publicly available as restrictions apply to the availability of these data due to sensitivity (i.e. Māori data\\u0026nbsp;sovereignty). These restrictions have been ratified by the Auckland Health Research Ethics Committee\\u003c/p\\u003e\\n\\u003cp\\u003e(AHREC) at the University of Auckland. Data will be made available from AHREC (ahrec@auckland.ac.nz) on reasonable request.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis work was supported bythe Health Research Council of New Zealand (20/1380) as a 2020 COVID-19 Equity Response Community Action Grant \\u003cem\\u003eHealth Equity and Wellbeing Among Older People\\u0026rsquo;s Caregivers During COVID-19\\u003c/em\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eVB and JW contributed to the conception and design of this study and collected data along with AS. All authors contributed substantially to the analysis and interpretation of data, drafting and critical revision of the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe acknowledge the Named Investigators on the study that are not listed as authors: \\u0026nbsp;Deborah Balmer (DB), Rosemary Frey,\\u0026nbsp;Moema Gregorzewski, John Parsons,\\u0026nbsp;Teuila Percival, Rangimahora Reddy,\\u0026nbsp;Mary Simpson. We are grateful to our community partners Alzheimers New Zealand, Alzheimers Northland, Age Concern New Zealand, TOA Pacific, and Carers Alliance as members of the Advisory Group and Rauawaawa Kaumātau Charitable Trust Advisory Groupfor guiding the research;\\u0026nbsp;Mary Roberts from Moana Research and Pare Mehafrom Rauawaawa Kaumātua Charitable Trust for help recruiting participants.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; information\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eVanessa Burholt\\u003c/strong\\u003e (BSc, PhD, FAcSS)\\u0026nbsp;is Professor of Gerontology in the School of Nursing/School of Population Health, Faculty of Medical and Health Sciences, a Co-Director of the Centre for Co-created Ageing at the University of Auckland, and concurrently Professor of Gerontology at Swansea University, United Kingdom. Over 29 years, Vanessa has undertaken and overseen transdisciplinary research on ageing and dementia, incorporating biological, psycho-social, environmental and social policy perspectives\\u0026nbsp;drawing on\\u0026nbsp;critical interactionism to explain the\\u0026nbsp;complexity of aging.\\u0026nbsp;She was the Principal Investigator on the study\\u0026nbsp;\\u003cem\\u003eHealth Equity and Wellbeing Among Older People\\u0026rsquo;s Caregivers During COVID-19\\u003c/em\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eJanine Wiles\\u0026nbsp;\\u003c/strong\\u003e(BA(Hons), MA, PhD)is an Associate Professor in Population Health,\\u0026nbsp;Faculty of Medical and Health Sciences,\\u0026nbsp;at the University of Auckland. She is a geographer and gerontologist, and uses a critical positive ageing framework. Her research encompasses three disciplinary areas: social/health geographies, critical social gerontology, and community health.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAlison Schneller\\u003c/strong\\u003e (BA, MA, LLB, LLM, PhD) was a research assistant in the School of Nursing, Faculty of Medical and Health Sciences,\\u0026nbsp;at the University of Auckland, at the time of the study. She has a research background in sociology and law. She is currently\\u0026nbsp;Principal Advisor Mental Health and Addiction Sector\\u0026nbsp;at\\u0026nbsp;Te Hiringa Mahara\\u0026nbsp;/ Mental Health and Wellbeing Commission.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFootnotes\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003ea\\u0026nbsp;\\u003c/sup\\u003eKaiāwhina describes non-regulated roles in the health and disability sector. Kaiāwhina is a Māori\\u0026nbsp;language\\u0026nbsp;term that embodies the core essence of a workforce that is passionate, resilient, diverse, skilled and committed to supporting hauora (holistic wellbeing) outcomes.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003eb\\u0026nbsp;\\u003c/sup\\u003eLegislation was passed in February 2024 to disestablish the Māori Health Authority - Te Aka Whai Ora on 30 June 2024.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003ePeat G, Olaniyan J, Fylan B, et al. Mapping the resilience performance of community pharmacy to maintain patient safety during the Covid-19 pandemic. Res Social Adm Pharm. 2022;18(9):3534-3541. doi:10.1016/j.sapharm.2022.01.004\\u003c/li\\u003e\\n\\u003cli\\u003eRoberts A. Building resilience macrodynamic constraints on governmental response to crises. In: Comfort LK, Boin A, Demchak CC, eds. 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BMJ Open. 2020;10(12):e041622. doi:10.1136/bmjopen-2020-041622\\u003c/li\\u003e\\n\\u003cli\\u003eBourgeault IL, Maier CB, Dieleman M, et al. The COVID-19 pandemic presents an opportunity to develop more sustainable health workforces. Hum Resour Health. 2020;18(1):83. doi:10.1186/s12960-020-00529-0\\u003c/li\\u003e\\n\\u003cli\\u003eHussein S, Saloniki E, Turnpenny A, et al. COVID-19 and the Wellbeing of the Adult Social Care Workforce: Evidence from the UK. The Personal Social Services Research Unit, University of Kent: Canterbury, UK. 2020.\\u003c/li\\u003e\\n\\u003cli\\u003eOffice of the Auditor-General. Co-ordination of the All-of-Government Response to the Covid-19 Pandemic in 2020. Wellington, New Zealand: Office of the Auditor-General;2021.\\u003c/li\\u003e\\n\\u003cli\\u003eTe Whatu Ora \\u0026ndash; Health New Zealand. Health Workforce Plan 2023-24. Wellington, New Zealand: Te Whatu Ora \\u0026ndash; Health New Zealand;2023.\\u003c/li\\u003e\\n\\u003cli\\u003ePerrott A. COVID-19 pushed the health system to breaking point: HQSC. New Zealand Doctor - Rata Aotearoa. 2022.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"emergency preparedness, health system resilience, community services, older people, COVID-19, Aotearoa New Zealand\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4756850/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4756850/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe COVID-19 pandemic, an unprecedented event, exposed varying levels of preparedness across health systems. This study examines the resilience of primary health and community services in Aotearoa New Zealand, focusing on their response to the needs of unpaid caregivers and older care recipients during the pandemic’s first waves. The objective is to inform future disaster preparedness and enhance health system resilience.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA multidisciplinary research team conducted qualitative research involving semi-structured interviews with service providers (SPs) who provided primary or community home-based services, care, support or information to older people and/or their caregivers across Aotearoa New Zealand. Views were sought from five service provider groups: national organisations, Māori, Pacific, or rural providers and dementia services. Data were collected between July 7 and October 4, 2020. Interviews focused on innovative practices, resources, and organizational settings. Notes from interviews were revised and validated by participants. Thematic coding and analysis were performed using NVivo 14 software to identify key themes and strategies.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTwenty SP staff (Chief Executive Officers and representatives) from National (4), Māori (3), Pacific (5), rural (4), and regional dementia service (4) providers) were interviewed. Participants had 0-21 years in post (Mean=7.37, SD=6.56). Telephone interviews lasted 30-45 minutes. Government support, coordination by Civil Defence Emergency Management groups, and regional communication influenced SP resilience. Challenges included access to personal protective equipment (PPE), staffing, identifying vulnerable people, digital access, and accessing residential care facilities. Innovative practices and remote communication were essential for service continuity.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAotearoa New Zealand managed COVID-19 effectively, but the pandemic exposed areas for improvement in health system resilience. Examples of absorptive and adaptive resilience in SPs’ and government responses highlighted both strengths and weaknesses. Insights from these experiences can inform transformative resilience, necessitating long-term strategic changes to address vulnerabilities and enhance capacity, ensuring the health system’s robustness and sustainability for future crises.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Understanding the Contribution of Primary and Community Services to Health System Resilience During the COVID19 Pandemic in Aotearoa, New Zealand: A Qualitative Interview Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-08-19 15:40:55\",\"doi\":\"10.21203/rs.3.rs-4756850/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2024-07-24T11:03:05+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-07-22T09:53:49+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-07-22T09:53:24+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Health Services Research\",\"date\":\"2024-07-17T14:13:57+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"d08157c1-6def-42ff-82ca-23cb2ffd751b\",\"owner\":[],\"postedDate\":\"August 19th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-12-30T16:03:28+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-4756850\",\"link\":\"https://doi.org/10.1186/s12913-024-12078-6\",\"journal\":{\"identity\":\"bmc-health-services-research\",\"isVorOnly\":false,\"title\":\"BMC Health Services Research\"},\"publishedOn\":\"2024-12-24 15:57:50\",\"publishedOnDateReadable\":\"December 24th, 2024\"},\"versionCreatedAt\":\"2024-08-19 15:40:55\",\"video\":\"\",\"vorDoi\":\"10.1186/s12913-024-12078-6\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12913-024-12078-6\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4756850\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4756850\",\"identity\":\"rs-4756850\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}