In a few short months, COVID-19 has achieved what no individual, organization or advocacy group was able to do for decades: it has exposed the cracks in the way we care for our older adults. Before this pandemic, almost daily media reports described numerous problems in Canada’s long-term care facilities, but nothing changed.
Our long-term care and seniors’ facilities are now being called “death pits.” They account for more than 80 percent of COVID-19 deaths in Canada. We are hearing calls for every potential remedy from government ownership to more public funding to national standards to surprise inspections.
As a retired architect who has more than 40 years of experience designing facilities for older adults, who has served on boards of facilities and who has researched leading-edge initiatives around the world, I focus mostly on the built environment and the delivery of care. Although I see some merit in all the solutions being talked about, I believe they fail to address the fundamental problem: the need for pansystemic change.
We need a multipronged approach to caring for older adults. We need a system that is more humane, trustworthy, accountable, equitable, economical, integrated and resilient. There are better approaches out there, but their uptake has been slow. Decision-makers seem oblivious to them, perpetuating a broken system.
Unfortunately, governments are now being urged to fund upgrades of existing care facilities and the construction of new facilities based on obsolete standards. It is crucial that we fix the horrific problems that were identified long before the pandemic and that have mushroomed since it began.
A better model
Beginning in the 1940s, long-term care became medicalized and institutionalized, resulting in hospital-like facilities. They featured long corridors, or “horridors,” with shiny floors and glare lighting. Nurses’ stations were omnipresent, and there was an authoritarian staff hierarchy. Meals were prepared in commercial kitchens. Common areas were large and impersonal. Care delivery was hospital-like, too, with fixed schedules.
Sadly, most long-term care facilities are still like this. Not only that, but residents are isolated and segregated from the community and warehoused in quarters where disease spreads easily.
One viable alternative is the household model. It provides better quality of care for older adults in a more cost-effective way while giving them freedom of choice.
Household-type facilities are designed to operate like a family home. There’s usually a grouping of 6 to 10 residents around a living/dining area. Meals are prepared in a residential-type kitchen. A self-managed team stays with each household. They are specifically trained as universal care partners: they provide personal care, meal preparation, laundry, light housekeeping and companionship. Staff here feel more satisfied than those working in institutional-style facilities. Schedules are flexible and determined by the residents. This is especially important for people living with dementia since they need familiarity.
Because of its scale, the household approach can be incorporated into developments of any size. In suburban Rochester, New York, for example, two 10-resident homes are integrated into an existing residential neighbourhood. Ideally, two or more homes can also be integrated into large village-like communities that may include multiple levels of care, multigenerational housing, and mixed uses such as shops and services.
Studies show that these household-type facilities cost less to operate because less medication is used; in addition, less food is wasted. Costs to the health care system are reduced, too. There are fewer falls, pressure ulcers and hospitalizations because residents remain healthier.
The household approach is becoming the standard for new construction in Manitoba, where these facilities are being built at almost half the cost of medical-institutional facilities, according to architects involved in the projects. The shift is partially due to changes in the way the building code is being interpreted. Officials now see care facilities using the household model as different from hospitals, which would be governed by more restrictive (and more expensive) requirements.
Better approaches to long-term care are being called for by governments, families of people in long-term care, boomers (who are next in line) and the National Institute on Ageing (NIA). The NIA’s recent report Enabling the Future Provision of Long-Term Care in Canada describes new approaches and models of long-term care that promote person-centred and flexible care. This organization suggests that innovative evidence-informed models of care should be introduced “to shape an enhanced future for the provision of long-term care.”
The NIA report examines the Hogeweyk, a renowned facility in the Netherlands that provides care for older adults living with severe and extreme dementia. Opened in 2008, it is owned by the nonprofit Vivium Care Group. The Hogeweyk emphasizes familiar surroundings and quality of life, with residents grouped according to interests, backgrounds and values.
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The report also describes examples such as the Green House Project, a nonprofit organization with approximately 300 homes in the US. Its mission is to create “radically non-institutional” environments that result in “real homes, meaningful lives, and empowered staff.” The Green House Project, founded by Bill Thomas in 2003, was inspired by the Sherbrooke Community Centre in Saskatoon, which opened its first households in 1999.
Lessons from COVID-19
One of the most important factors in controlling COVID-19 has been the ability to cohort residents: to create smaller groupings of residents to improve infection control. Self-contained living units such as households accomplish this goal while still supporting relationships.
Susan Ryan, senior director of the Green House Project, told me in an email in May, “The Green House homes are doing quite well amid the pandemic. In many ways, this is a model that was made for this moment. The design features, as well as the consistent staffing and philosophy of person-directed care, combine to create truly synergistic transformation that mitigates the spread of infection.”
The Hogeweyk is reporting similar results. Eloy van Hal, senior advisor and a founder of the organization, wrote me in early May, “Although the Hogeweyk is not completely Corona-free anymore, it seems to be under control, in large part due to the small households of 6 to 7 residents and most staff working in only one or two households.” He added, “The household model like the Hogeweyk (or small suites) has a lower infection risk because it has the advantage of better controlling and preventing the pandemic.”
“There will come a time when we will see this pandemic in the rearview mirror. There will not come a time when we will return to the old normal,” says Robert Kramer, president and founder of Nexus Insights, an advisory firm that helps clients “rethink aging from every angle.” The new normal for long-term care must include at least two key considerations: small households and more personal space.
Small households that support relationships, provide infection control and have a stronger connection with community will be critical. Kramer predicts that seniors’ housing and care will change. “Whether it’s 60 units or 160, you’ll see small neighbourhoods that can easily isolate when an infectious disease strikes.”
Juniper Communities, a senior living organization with 22 facilities in the US, is reinventing itself based on its experience dealing successfully with COVID-19. Lynne Katzmann, its founder and president, said at the Senior Living Foresight virtual summit in April, “Cohorting is very important to give peace of mind, to assure safety but also to support building real strong relationships among small groups of people.” She also notes that Juniper’s nonhierarchical approach to staffing will become more so, and that staff will be retrained to become “true universal workers.”
It is also clear now that residents will require more personal space to reduce the psychological trauma of living in small rooms during lockdowns. Kramer observed at the April summit, “We now see a desire in design for larger personal spaces rather than having huge congregate spaces with tiny personal living spaces.”
A rethink of resident rooms in long-term care facilities could result in small suites with a bedroom (private space) and a living area (semiprivate space). This is already the case in a number of European long-term care facilities. In a recently completed project embedded in a small Dutch community, long-term care will be provided to residents in their small suites by the self-managed care teams of the healthcare organization Buurtzorg.
The COVID-19 pandemic has disrupted our lives and given us incentives — personal and societal, and moral and economic — to reshape long-term care. Let’s take full advantage of this opportunity. We can begin the process by dismantling and replacing our archaic systems. We need pansystemic change and we need it now — for Canada’s older adults, their families and their care partners, for Canadian society and potentially for ourselves.
This article is part of the Facing up to Canada’s long-term care policy crisis special feature.
For related content, check out the IRPP’s Faces of Aging research program.