There are 38,000 people waiting for a spot in long-term care homes in Ontario alone and the government is preparing to build hundreds of facilities to meet demand, but some say we should also be reshaping how care is offered.
"I would really challenge those that are investing in this to look at alternatives that are out of the box," said Tammy Allison, who runs a small long-term care home in Monclova, Ohio. "You can do long-term care differently and you can do it better. And we feel like we're doing that."
Many traditional nursing homes follow an institutional model and are designed to care for dozens of residents at a time.
They often have large dining rooms and a single serving time for meals, for example, and a common complaint among care workers in Canada is that they hardly have time to get residents up and dressed every morning. In 2017, the union Unifor had a campaign to raise awareness that workers only had six minutes per person on average to get residents up, dressed and to the dining room for breakfast.
In many long-term care homes, Mary Nicodemus would be awakened by 7 a.m. for breakfast. But that's not the case at her nursing home in Monclova. It's after 10 a.m. and Deanna Webb is doing Nicodemus's hair before making her some coffee and breakfast.
"Everybody gets up at different times during their lifetimes," said Webb, a caregiver at the home, where her official title is Elder Assistant. "Some people were night people and some people were morning people. And then you never know what type of night they had. They might have been up all night long, couldn't sleep or something, so we let them sleep in."
It's a model of nursing home care that allows people to live life in retirement as close as possible to the way they did in their adult lives. It starts with the building — small homes with just 10 or 12 seniors living in them — and extends throughout all aspects of life there.
Each resident has their own room and bathroom.
There are no long hallways or seniors in wheelchairs sitting around a nurse's station so they can be monitored. Almost nothing inside these homes looks like a hospital or institution.
Mary's home is one of five in their own little subdivision about 20 minutes southwest of Toledo run by a not-for-profit, Otterbein Senior Senior Lifestyle Choices. Called Green House Project homes, they are built based on a not-for-profit model of care that started 17 years ago. There are more than 70 of these neighbourhoods either running or being built in the U.S., and operated by different organizations.
Another resident, Annette Coker, lived in a traditional nursing home after a car accident left her unable to care for herself. She was one of the first to call and get on the list for this neighbourhood when it was being built, because she said she wanted out of the institutional model of care.
"I really love the fact that we have our own room, but I like it more because it's like your home," she said.
"We get home-cooked meals. We get a really good relationship with the girls, and we actually get to meet with our other elders and talk and have good company."
WATCH | Annette Coker describes how the Green House Project home is different from her previous nursing home:
Different care and a different job description
Staff turnover has been found to be lower in Green House Project-type facilities than in other kinds of long-term care homes in the U.S. Webb has worked other places, but says she plans to retire here herself.
"What I like about Otterbein and this small house is it's 10 people to a house and it's two aides," she said. "You have more time to spend with the elders. Because everybody is different, and it recognizes that."
This means Webb might prepare a different breakfast for all 10 seniors living in the house every morning. Some like eggs, others opt for waffles, and that's built into the workflow.
Webb cooks while the other caregiver on duty tends to the needs of other residents.
The building's design recognizes that the kitchen is the heart of a home, as well as the joy a favourite meal brings at any age. There's no large dining room, just a dining table in the middle of the home next to the kitchen where residents can watch their food being made.
Menus for lunch and dinner are set by the aides in consultation with the seniors. The aides also do the laundry. Residents who want to help with these daily chores do.
The structure is flat, which means even people with more managerial jobs, like Tammy Allison who runs the neighbourhood in Monclova, help out with things an administrator might not normally be expected to do.
"I don't spend my day in an office," said Allison, whose official title at this home is Guide, but at most other places would be something more administrative like Director of Care.
"I might be helping one of our elder assistants put groceries away, or sitting with somebody so she can finish the last touches on a meal, or throwing a load of laundry into the dryer.
"So it really, truly does feel like a family. We all just kind of jump in and work together."
In Canada, Ontario alone had 38,000 people on the waiting list for a spot in long-term care as of May 2021, and has begun a widespread request for development proposals to build new homes.
Even after COVID-19 showed how difficult infection prevention and control can be in shared rooms in long-term care, new homes will be allowed to be built with semi-private rooms and shared bathrooms, according to the Ontario Ministry of Long-Term Care. Rather than building more institutions designed to house large groups of seniors, some say the Green House Project model has advantages that include more personalized care and a healthier living arrangement.
More than a decade before the pandemic, infection control was one of the reasons Jill Wilson said her former boss was enthusiastic about the Green House Project homes model when he first found out about it.
"He came from a family that also oversaw long-term care," said Wilson, now president and CEO of Otterbein Senior Lifestyle Choices. "And he came back [after visiting one] and he said, 'This is the best thing I've ever seen for two reasons. Number one, for the well-being of the people that we serve. And number two, infection control."
WATCH | Jill Wilson talks about her initial reluctance to embrace the idea of smaller care homes, and what changed her mind:
In a country that has had widespread community transmission of COVID-19, Green House Project homes fared exceptionally well compared to their more traditional, larger counterparts.
A report in the Journal of the American Medical Directors Association in January concluded that, "Nontraditional Green House/small nursing homes (NHs) have better outcomes than traditional NHs in numerous areas; evidence now demonstrates they have lower rates of COVID-19 and COVID-19 mortality than other NHs as well. As such, they are an especially promising model as NHs are reinvented post-COVID."
The Green House Project says its own data shows the difference in infection numbers continued throughout 2021.
These statistics, and the care provided in the Otterbein home, offered families comfort when they were locked out due to isolation measures during the pandemic.
Sue McCloskey dropped off care packages throughout the pandemic and would visit her mother Helen Anson at the window. The separation was hard, but McCloskey says she was comforted knowing her mother had her own room and the small facility was following protocols "very, very carefully."
Anson, 89, lived with her daughter until about seven years ago, when McCloskey knew her mother needed more care than she could provide.
"I knew her routine. I knew what she liked and didn't like," McCloskey said. "And it was tough, it was tough to make this decision. But after I came in here and felt warm and invited, we knew that this was the right move for her."
Cost of caring in small homes
Cost is often cited as a barrier to changing the traditional care models in nursing homes.
At Otterbein Monclova, 60 to 70 per cent of the seniors who live here are covered by the U.S. government aid program Medicaid. That aid is about the same amount the U.S. government would pay for those seniors to live at any other home — about $220 US a day in Ohio.
Others pay privately — at a premium of about $350 US a day.
For comparison, the Ontario government pays $187.73 Cdn for care per resident per day. On top of that, residents pay between $60 and $90 a day for room and board, depending on the type of room they are in.
The difference in care is substantial, however.
Ontario residents get about two hours and 45 minutes of direct care per day, with the province promising this will increase to a target of four hours of care by March 2025.
Otterbein Monclova isn't a perfect home and has had citations for issues such as delays getting residents care even with its high staffing ratio, and other complaints including concerns about wound care. It has also not been immune to staffing shortages that have plagued the industry throughout North America, especially with regard to registered nurses, who can often get big bonuses if they land a job at a hospital in the U.S. But in total, the home's residents get four hours and 15 minutes of care per day, according to Medicare data.
Advocates for the Green House Project model of care say it can work for the suburbs, rural areas, and downtown areas as well.
Just a couple blocks from the Canadian border in Detroit, Mich., the top two floors of a three-storey building make up another Green House Project home.
The first floor houses a day program where more seniors from the community come to do activities and get medical care. The second and third floors each house a self-contained care home, complete with its own kitchen, dining room and staff caring for 10 seniors.
Many of the 20 seniors who live upstairs choose to spend much of their time downstairs socializing.
WATCH | Wenona Breazeale gives CBC's David Common a tour of a Green House Project home in Detroit:
"We get a lot of referrals," said Wenona Breazeale, the guide at this Detroit Green House Project home.
"A lot of people who want to come to the Green House. We get people from other counties and other states. They come here and they're like, 'When I retire, when I have to go into a home, this is where I want to be because it's so homelike, it's so personal.'"
And what draws people to the smaller care homes is that it's like a real home, said Monclova Green-House resident Helen Anson.
"It's more homey, the table with people sitting there chewing and chatting, and that really caught my eye," she said.
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With files from David Common