The urgent need to re-imagine older adult care in Canada
Over 7 million people, or about 19% of Canadians, are over the age of 65, a number that will jump to 25% by 2030.1,2 Most older adults wish to age in place in their home for as long as is possible. But it is not always feasible or realistic for everyone to do so.
A 2020 Ipsos poll of Canadians conducted for the National Institute on Ageing (NIA) and the Canadian Medical Association found that 85% of Canadians would like to avoid going to a nursing home.3 This is not surprising given the widespread problems that occurred at many long-term care (LTC) homes across the country throughout the COVID-19 pandemic.
Decades of underfunding and under-resourcing can no longer go ignored after the pandemic brought to light the long-existing gaps in Canada’s long-term care sector. The 2,076 nursing homes across Canada are nowhere near enough to keep up with demand, and more beds are absolutely needed, but Canada does not have to accept out-dated policies that encourage the traditional institutional model of nursing care. 4 The current models are not working for residents, their families and the LTC workforce. Better options do exist.
NEW INNOVATIVE MODELS OF LONG-TERM CARE ARE NEEDED
Innovative long-term care models have been developing for decades – the Butterfly model of care for persons with dementia, the Eden Alternative, and the Green House Project, are just a few examples. COVID-19 has put a spotlight on the LTC sector and has become a catalyst for a transformative approach to elder care.
A recent development in LTC innovation in Canada is the release of the two new national standards published by Canadian Standards Association (CSA) for the safer operation of nursing homes, and the Health Standards Organization (HSO) for the delivery of reliable and high-quality LTC services, respectively. This comes nearly two years after a commitment from the federal government to develop new standards for LTC to help ensure older adults get the best possible care.
In this policy brief, we overview a few of these innovative models with examples of where these facilities and programs are operating in Canada.
The Small Nursing Homes Model and Quebec’s Maisons des aînés
The non-traditional small-home LTC model has attracted more attention in recent years even though the small household design like the Green House Project (GH) model in the United States has existed for two decades. The GH-type model consists of small, residential-like houses, each accommodating 10-12 older adults. Every resident has their own private room and bathroom, a shared kitchen, access to outdoor space, and a communal space for residents, staff, and residents’ families. Unlike most institutional LTC facilities, there are no nursing stations, no long hallways, and no set mealtimes.
The personal care worker or nurse providing care in the GH home is called a ShahbazAn ancient Persian term meaning guardian falcon. These individuals provide patient care and carry out household tasks such as preparing meals and doing laundry.5 Even with more household duties, care providers in the GH home spend an average of 4.2 hours of direct care per resident per day,6 which is in line with the new HSO standard recommendation of a minimum of 4.1 hours of direct care.7 Currently LTC residents in Ontario, for example, receive an average of 2.75 hours of direct care per resident per day, which the Ontario government has promised to increase to 4 hours per resident per day by 2024-2025. This increase, while an improvement, would now fail to meet the new standard of minimum direct care hours with residents.
In accordance with the small nursing home model, the new CSA Group Standard recommends resident bedrooms be designed to accommodate a single person. Research suggests this model helps contain the spread of communicable diseases, as is illustrated in a study published in the Journal of Post-Acute and Long-Term Care Medicine which shows that non-traditional small nursing homes like GH homes had fewer COVID-19 cases and deaths during the earlier waves of the pandemic.8
The Quebec government unveiled a Green House-like concept in 2018 called maisons des aînésElders’ houses in English. and has plans to open 46 of these small, residential-style homes that are expected to accommodate 3,480 people.9 The initiative was first unveiled before COVID-19, but with Quebec’s LTC residents experiencing the highest number of deaths during the earliest waves of the pandemic, the heightened impact on residential and long-term care centres (CHSLDs) motivated Premier Francois Legault’s Coalition avenir Quebec (CAQ) to make this a priority promise during the 2022 Quebec provincial election. The construction of the first homes in Lévis, Sherbrooke and Rivière-du-Loup are now underway.10 Capital costs continue to plague the expansion of GH homes in the United States and Quebec is no different. Ballooning costs of building materials and labour in Quebec have pushed some to suggest delaying or even ending the project entirely.
The Eden Alternative and Saskatoon’s Sherbrooke Village Model
The Sherbrooke Village Model is another small home LTC concept. The village model centres around nine to 10 residents living together in houses with their own private rooms and bathrooms. The houses are attached to the “village” or neighbourhood, by an internal street. The internal street provides residents with the safety to walk about and access such services and amenities like a hair salon and farmer’s market.
The Sherbrooke Village Model sowed the seeds that led American geriatrician, Dr. Bill Thomas to reimagine a different kind of nursing home and design the Green House Project.11 There are many similarities between the two models besides the small home concept, including qualified care providers – which the village model calls daily living assistants – who take on additional responsibilities like housekeeping and medication administration.15
The village model has been operating under Saskatoon’s Sherbrooke Community Centre since 1999. The centre is also a registered Eden Alternative home and has incorporated Dr. Thomas’ Eden Alternative philosophy into its vision and is dedicated to creating a better quality of life for older adults in LTC.
Combined with the village model, the Eden Alternative focuses on deinstitutionalizing the medical model of LTC and driving a culture change where older adults direct their own care and have the autonomy to decide how to spend their time.12
Insufficient evidence exists to determine how the Sherbrooke Community Centre fared during the earlier waves of COVID-19 and thus cannot determine if the model had a protective effect. However, the first resident tested positive for COVID-19 in late December 2020, and the facility managed to hold off an outbreak until January 2021 as the first of the vaccines were administered to residents and staff.13 To put it into perspective, thousands of LTC residents, mostly housed in larger facilities, died of COVID-19 before Sherbrooke had a single positive case.14
CareTO is a new approach to improve care and the quality of life for residents in Toronto’s 10 city-run nursing homes. Unveiled by the City of Toronto in 2022, the CareTO pilot program launched at Lakeshore Lodge LTC Home last summer. The program reaps the best bits of innovative models to transform LTC in Toronto, including a home-like experience, access to safe outdoor environments, person-centred care, flexibility of choices in diet and mealtimes, and a resilient, competent, and healthy workforce.
Sunnybrook Health Sciences Centre supports implementation of the project and will develop a set of recommendations to enable the adoption of CareTO to the other nine city-run LTC homes.15
The program components follow the guidelines of the new HSO standard. For instance, the standard recommends LTC leaders employ equity, diversity, and inclusion practices and demonstrate a commitment to cultural safety and humility.16 Supporting equity, diversity, and inclusion is a hallmark of CareTO. The program is designed to be flexible and adaptable to the multicultural and multilingual population of Toronto.
The program is jointly funded, with $16 million invested over five years – $12 million from the province of Ontario, and the remainder from the City of Toronto – including funding for 272 new positions.17
CareTO is focused on major improvements in staffing and additional training and education to respond to the complex needs of residents and the evolving culture change at the nursing homes. Hiring will include personal support workers, nurse practitioners, rehabilitation assistants, and janitorial and cooking staff. The program is also aiming to achieve Ontario’s target of four hours of direct care hours per resident per day.18
An independent evaluation of the program will be conducted by the Wellesley Institute after the 12-month pilot is completed.19 We look forward to the release of the recommendations and evaluation of the pilot project in 2023.
MOVING THE SYSTEM FORWARD
There are more than 52,000 Canadians waiting for placement in an LTC home.20 Governments are promising to add more beds and build more homes, but sticking with the traditional institutional nursing home model is not the way forward. To build a better older adult care system and provide a higher quality of care, Canada must implement new models of both LTC and community care.
There is no perfect model to implement, but there are similar concepts among each model that reappear again and again, such as a comfortable home-like environment, a meaningful quality of life for residents, and enabling support working conditions for staff. These components supported with the appropriate infrastructure design create positive and safe experiences for everyone inside and reduce the spread of infectious diseases.
However, adoption of more innovative models across the country will not occur without leadership from the federal government and a substantial investment in LTC infrastructure and the older adult care workforce.
Throughout the pandemic, shortages of personal protective equipment, stressful working conditions, and the death of residents and colleagues have negatively impacted long-term care staff physically, mentally, and emotionally. While a problem before COVID-19, staff shortages at these facilities are growing significantly worse every day and are compounding the detrimental impact to staff remaining in the sector. The federal government, in collaboration with the provinces and territories, should immediately act on its commitments to train up additional personal support workers, raise wages, and ensure health benefits and sick days are available to individuals working in the long-term care sector. A resilient and supported health workforce is a pillar of the new Agreements in Principle to Improve Health Services provinces and territories have begun to reach with the federal government.
The release of the new national standards for LTC in Canada is a positive development. However, a nursing home’s adherence to the standards is voluntary across the country. The federal government has encouraged provincesAt time of writing, Quebec is the only province that has committed to legislate LTC homes to be accredited against the standard. and territories to make the standards mandatory for nursing home accreditation, but implementation has not been backed with any new funding. The federal government previously allocated $4 billionThe Fall 2020 Economic Statement committed $1 billion through the Safe Long-Term Care Fund and Budget 2021 included $3 billion over five years to Health Canada to support provinces and territories to ensure standards are applied and permanent. to LTC through the Shared Health Priorities and Safe Long-term Care Fund.
According to an NIA/Telus survey, 91% of Canadians intend to do everything they can to stay active and maintain their optimal health and independence as they age. 21, 22 Moving into a LTC home should not mean an end to one’s independence and dignity. All levels of government owe it to our older adult population to shore up resources to meet the challenges of Canada’s growing and aging population.
To learn more about HealthCareCAN’s recommendations to support a pan-Canadian approach to better ageing at home and in long-term care, we encourage members and stakeholders to download our policy booklet and our 2023 pre-budget submission to the federal government.
Lauren W. Cohen, Sheryl Zimmerman, David Reed, et al. 2016. Health Services Research. The green house model of nursing home care in design and implementation. 51(1): 353-377.
Sheryl Zimmerman, Barbara J. Bowers, Lauren W. Cohen. 2016. Health Services Research. New evidence on the green house model of nursing care: Synthesis of findings and implications for policy, practice, and research. 51(Suppl 10): 475-496. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338207/
Health Standards Organization. 2023. Long-term care standards.