Transforming the hospital-style nursing home to a centre for living

Introduction

As health leaders look to reinvent service delivery models in a post–COVID-19 world, the aged care crisis must be a watershed moment to turn the tide on replacing outdated living environments with a better safer life for older adults and their caregivers. Frontline workers attained hero status during the pandemic, their experiences received much attention as the spotlight was shined on the rights of older persons, their families and direct care workers.

Long-term care homes during the pandemic were ground zero with high rates of infections and deaths before staff and residents were vaccinated. A repeat of this experience could be prevented if transformational changes are made to the long-term care system. The pandemic may be the turning point for eldercare renewal. With outdated infrastructure, funding and staffing challenges, the seniors care system is due for improvement.

A nursing home alternative

Before anyone had heard of the coronavirus, a movement had swept through the seniors’ living sector. It was embraced by transformational leaders who were committed to rebuilding hospital-style long-term care bed stock with new centres for living based on the household model. Rather than a long double-loaded corridor with dozens of residents, 10 to 14 older adults live in one self-contained home, each with their own private room and ensuite. The homes have their own front door, living room with fireplace, den, open kitchen, dining space and activity space with access to outside gardens. This decentralized model allows staff to be assigned to one home, improving continuity of care as they provide personal care, prepare food, and do housekeeping and laundry. While the design model was first created to ensure meaningful living, individual choice and life-long learning, the small home environment may in fact help control infections. Staff focusing on one self-contained home are less likely to introduce a virus to other residents living in different households. ¹

During the pandemic these non-traditional small house nursing homes had fewer COVID-19 cases and deaths. A seminal study published in March 2021 in JAMDA, the Journal of Post-Acute and Long-Term Care Medicine. ² The study analysed data from small-house homes and compared it to data from for traditional nursing homes between January 20, 2020, and July 31, 2020. Researchers noted that small-house homes are beneficial above and beyond the mere benefit of size, perhaps due to their private bedrooms and bathrooms, limited ancillary staff and fewer move-ins and deaths. Also noted is the potential advantage that small-size homes offer older adults with regard to psychosocial well-being. The article notes that families may be more able to have socially distanced outdoor visits and having consistent, universal staff may allow for the maintenance of social relationships.

As an innovative service delivery model of care, small homes likely had fewer cases of the virus because of the smaller numbers of older persons living together with limited contact with other seniors living in other households. Less people were coming in and out of the household reducing risk of exposure to an infection and with the small design model there is the ability to cohort small numbers of people should an exposure event occur. Additionally, the model helps older persons avoid some of the negative aspects of the pandemic: social isolation, loneliness and boredom.

The current state of eldercare is in need of transformation. In a 2021 survey sponsored by the Canadian Medical Association and the National Institute on Ageing, 96% of older Canadians said they would do everything possible to avoid going into an Long Term Care (LTC) home after seeing what has happened to residents of such facilities. ³ Among Organisation for Economic Co-operation and Development member countries, Canada fared worse with double the number of deaths in nursing homes during the first wave of the pandemic when 8 out of every 10 deaths took place in LTC settings. ⁴ Now that LTC staff and residents have been vaccinated, infections and deaths within LTC have been reduced to a trickle.

Non-traditional small nursing homes have better outcomes than traditional nursing homes in numerous areas; evidence during the first year of the pandemic demonstrated lower rates of COVID-19 and COVID-19 mortality. ⁵

Adopters of the small-home model report older persons experiencing superior customer satisfaction, better occupancy rates and higher direct care time. This research is the result of visionary leaders who have taken the built living environment to a new level of evidence to believe in the model, to revolutionize eldercare. ⁶

The role of health leaders

In the post-pandemic era, a rising tide of seniors will rely on health and social services in unprecedented ways; in response, the role of health leaders as eldercare change agents will be paramount. The LEADS in Caring Environment leadership capabilities provide a framework from which forward-looking health leaders will develop and adopt transformational change to the eldercare system. ⁷

Of the 5 domains in the LEADS framework – Leads Self, Engage Others, Achieve Results, Develop Coalitions, and Systems Transformation, the last domain shows the way leaders will advance the movement in 4 capabilities:

Demonstrate systems/critical thinking. They think analytically and conceptually, questioning and challenging the status quo, to identify issues, solve problems, and design and implement effective processes across systems and stakeholders.

The 4 leadership capabilities in the Systems Transformation LEADS domain applied to eldercare empowers the strategic ability to create the improvements needed. Fiscal, technological and human resource challenges have become the norm. Eldercare organizations are faced with the challenge of increasing turnover of staff coupled with shorter lengths of stay and increased care demands, which are indicators of the predicted rising tide of seniors being a reality. ⁷

Through Systems Transformation, leaders consider options for change and, through this reflection, decide to take action that achieves results. Success is dependent on engaging key stakeholders in collaborative planning and implementation as the eldercare system is transformed.

Changes in the eldercare sector will come from leaders transform the current infrastructure, health human resources, build capacity for the Baby Boomer demographic who will undoubtedly expect – and demand – a different journey than their parents experienced.

Rethink capital investment

The current outdated bed stock in Western countries is in need of replacement. The biggest challenge in replacing outdated nursing homes is finding the capital funding to pay for the building costs. Looking at policy direction in other jurisdictions points to potential solutions. In Australia, a bond program was introduced to create the economic conditions to encourage aged care innovation. Seniors contribute a refundable bond. The financial contribution covers their portion of the building costs of a new nursing home. When the senior passing way, the bond is returned to the estate and, in some cases, a portion of the interest. This financial formula has brought a cash infusion into the aged care marketplace to replace obsolete bed stock. Outdated institutional living environments are undesirable for the last few years of an older persons life coupled with the health outcomes of living with Alzheimer disease and related dementias. There is an equitable subsidy program for seniors and their families who cannot afford a bond or the monthly property fees.

Health leaders responsible for eldercare are well positioned to lead the transformational change needed to rebuild seniors’ living development projects. Choice, dignity and well-being are foundational elements for seniors’ residences based on best practices leading providers of programs and services that honour old age. Cash infusions are needed to transform nursing homes adding quality-of-life amenities such as hydro therapy pools for rehabilitative services led by physiotherapists focusing on re-enablement, emphasizing that the top predictor of longevity is mobility.

As capital infrastructure investments are made, existing bed stock will be replaced with new innovative living models reflecting the voice of older persons and their families, determining the type of home one would imagine living in should they one day require long-term care or assisted living. In rethinking the ageing journey, a reimagined nursing home experience will undoubtedly transform the dementia journey opening up new possibilities. This vision is a different lifestyle for seniors living in care. As the global news stories have depicted the impact on seniors living in nursing homes grappling with devastating outbreaks, public sentiment is shifting to create a new narrative where seniors thrive in a vibrant living environment. ⁸

When the next generation of nursing homes is designed, further disease-prevention architectural features warrant consideration including configuration features that are anti-microbial, negative air pressure and filtration systems that remove airborne toxins. Wearables, sensors, artificial intelligence and voice-activated technology will help reduce the need for high-touch surfaces and will improve resident-to-staff communication, anticipating the care needs of seniors before a person-generated request is made.

During the pandemic, older adults and their families, as well as employees, have supported each other, adopting new infection control practices. There is a commitment to following the new normal of prevention measures – the results will save lives of employees, their families and the older adults who have entrusted them with their care. ⁹

Recommendations

Five steps are recommended to solving the nursing home infrastructure crisis, all of which require transformational leadership to implement this revolutionary approach to eldercare.^10,11

Work with federal, provincial/territorial and municipal government and health authorities to develop comprehensive pan-Canadian national standards for long-term care and assisted living design guidelines. National standards must encompass the family and voice of recipients of care as partners with health providers to achieve a desirable home living environment setting.

Ready set build

The pandemic has put a spotlight on the senior living sector. Leaders embracing culture change are needed to bring about a new normal designing a better living environment for older adults. This outbreak crisis experienced in eldercare may be a watershed moment to turn the tide on replacing outdated buildings with a reinvented small household model, a better life. ¹² Now is the time for health leaders to lead this transformation.

Leaders have a voice to rethink how health resources are allocated to the elderly both by transforming LTC and AL living options and bolstering community services. Wishing to remain in their houses for as long as they can is the overwhelming sentiment of older persons, this can be achieved with the support and care provided by a well-coordinated eldercare system. Access to neighbourhood amenities and social connections will help ensure seniors are not isolated. ¹³

As federal and provincial governments plan budgets and program priorities, health leaders have a transformational responsibility to ensure priority is given to the rights of older persons. This is, after all, a matter of human rights.