When Liisa Jaakkimainen first walked into Suomi-Koti—a nursing home in Toronto—something felt oddly familiar. “It was like walking into Finland,” says Jaakkimainen, a Toronto-based family physician whose mother had been transferred to Suomi-Koti from another nursing home in Ottawa.
Although her family had no qualms about the care their mother received in Ottawa, the advantages of being in a culturally specific nursing home like Suomi-Koti were hard to ignore. These included having Finnish speaking front-line staff, a kitchen that served Finnish food, and regular activities specific to Finnish culture. One instance that really stood out for Jaakkimainen was during a traditional Finnish Christmas dinner organized by the home. “My mother was tapping her hands to music,” she says. “She hadn’t done that in years!”
Jaakkimainen also noticed that her mother, who suffered from advanced dementia and has since passed away, was more alert and engaged after being transferred to an environment reminiscent of her native land. Their family waited more than five years for a bed at Suomi-Koti to become available, and statistics like this are unfortunately becoming increasingly common in Ontario.
Nursing homes (also referred to as long-term care homes) are residential facilities that provide around-the-clock care to seniors who are unable to care for themselves independently at home. Currently, the Ontario Ministry of Health and Long-Term Care website does not formally list all its nursing homes by ethnicity, but previous reports have estimated that between 50 and 60 ethnic-specific homes exist. Like Sumoni-Koti, they are all not-for-profit nursing homes that cater their services to a specific ethnicity or culture.
It’s clear that there is a high demand for these types of homes in the province, especially with its aging multicultural population. So why aren’t there more of them?
How long can the wait be?
Wait times for nursing homes in Ontario have been steadily increasing for years, with recent estimates suggesting that an additional 199,000 beds will be needed by 2035 in order to accommodate the province’s growing aging population. And while the provincial median time for placement into a nursing home is 133 days, people who hope for placement in an ethnic-specific home tend to wait much longer.
In fact, a 2016 report by the Wellesley Institute indicated that residents who apply to ethnic-specific nursing homes in the Greater Toronto Area had to wait approximately six months longer than those who applied to mainstream (non-ethnic) homes (538 days versus 357 days for a basic bed). In some ethnic-specific homes nine out of ten applicants who were placed in those homes waited more than 3,000 days, with anecdotal evidence from previous media investigations reporting instances where seniors wait up to 12 years before being placed into an ethnic home of their choice.
What are the benefits of having ethnic-specific nursing homes?
There is evidence to suggest that ethnic minority residents living in mainstream nursing homes tend to have poorer outcomes compared to the rest of the residents. Studies conducted in the United States, mostly studying Hispanic and African-American populations, demonstrated poorer quality of life, more pressure ulcers, less social engagement and poorer documentation of advanced directives. Rates of anti-psychotic drug use and the actual treatment of pressure ulcers, however, were not different.
Unfortunately, few studies have been conducted to compare ethnic versus mainstream nursing homes. One study in Australia compared Greek and Italian residents with dementia who lived in either an ethnic-specific or mainstream nursing home. They found that residents living in ethnic-specific homes had better verbal communication with other residents, and lower anti-psychotic medication prescription rates.
Aside from the Wellesley Institute report noted above, which only evaluated wait times, Canadian-specific data on this subject is limited. Health Quality Ontario reports nursing home performance across the province using a number of different quality indicators, and although data on ethnic-specific homes is reported on its website, there is no composite or comparative report available.
Residents living in an ethnic-specific home likely also benefit from having a sense of cultural safety and familiarity, though this has not been documented in the academic literature. Through previous news reports, they have applauded these homes for allowing them to communicate in their native languages, enjoy their own cuisine and participate in culturally specific activities.
Does it all come down to funding?
Like any other area in health care, funding may be a contributing factor to the limited availability of ethnic-specific nursing homes. The funding needed to operate any nursing home in Ontario is standardized and comes from a combination of government subsidies proportional to the number of beds in each home, and monthly accommodation costs paid by each resident (as of July 2018, $1,848.73 for basic rooms, $2,228.63 for semi-private rooms and $2,640.78 for private rooms). Depending on the nursing home, however, actual operating costs can exceed what is provided through these two sources. This is often the case for ethnic-specific nursing homes, which require additional funding to support their mandate of providing culturally sensitive activities and services.
This is true at Dom Lipa, a 66-bed nursing home in Etobicoke that caters to the Slovenian community. Maria Muhic, a 94-year old resident who has been living there for the past 10 years and is currently president of its resident council, was among the initial group that helped establish the nursing home over 30 years ago, along with her husband and other members of the Slovenian community in Toronto. She recalls acquiring the financial support, land rights and even physically laying the brickwork of what eventually became the home itself. According to Muhic, the goal was to create a place “like home” where Slovenian immigrants could spend their aging years.
Applicants can wait more than 1,900 days for a bed at Dom Lipa as it is currently the only Slovenian nursing home in the province. Despite long wait times, having only a single ethnic-specific nursing home for any given ethnicity tends to be the norm.
However, for the Chinese community, two non-profit organizations currently operate seven ethnic-specific homes within the greater Toronto area, more than any other single ethnicity in the province. The Mon Sheong Foundation opened its first senior’s residence in 1975, and has expanded to operate three nursing homes servicing a total of 457 residents. Tim Kwan, chairman of the foundation, attributes the rapid growth of the organization to both the size of the Chinese community and a strong demand for nursing homes. “We’re quite large in the Greater Toronto Area so that the demand is there, there’s no over-reaching,” says Kwan.
The other Chinese organization is the Yee Hong Centre for Geriatric Care, which operates four homes in the province with a total of 805 beds. Unlike Mon Sheong, Yee Hong has a few dedicated units for other ethnicities as well (Japanese, Filipino, South Asians), but still primarily services the Chinese community. Joseph Wong, founder of Yee Hong, thinks that his organization’s growth stems from a mandate to build communities, rather than isolated nursing homes. Since its inception, Yee Hong has offered a continuum of services to the Chinese community, including recreational and social services, meal deliveries and senior community housing. “In order to serve seniors properly, you need to serve them with the appropriate language and culture, and you want to create a community atmosphere,” says Wong.
Currently, each of the nursing homes operated by both Mon Sheong and Yee Hong have upward of 4,000 residents on their wait lists. Even if they have enough funding to build a home, its construction also depends on government approval. The last time additional nursing home beds were approved by the government was in 1999 (20,000 new beds), but the current Ontario government has announced plans to introduce more than 30,000 new beds over the next decade. How these beds will be allocated is not completely clear, but both Mon Sheong and Yee Hong are hopeful that some of them will be allocated to their homes.
Another group that might take advantage of the opportunity for new beds is the South Asian community. Even though South Asians make up the largest proportion of Ontario’s visible minority population (26.9 percent, 2016 Ontario Census), there are currently no culturally specific nursing homes serving their community. Maher Hussain, CEO and clinical director of South Asian Canadians Health & Social Services, thinks that a strong cultural tradition might explain the lack of South Asian nursing homes. “In South Asian culture, the parents prefer to be with their children, and the children prefer to keep their parents with them,” says Hussain.
Gurpreet Malhotra, CEO of Indus Community Services, adds that the many sects within the South Asian community might make it difficult to create a nursing home that is uniformly appropriate for all its members. However, Malhotra is confident that a home can be built to accommodate all these different cultural groups, and is currently in consultation with the government to establish a nursing home for South Asians. “If it has a culturally appropriate focus on the South Asian community, it will be welcoming in that regard,” says Malhotra.
Building more homes may not always be the solution
Considering that the development and operation of a nursing home is expensive, some smaller ethnic groups may not have enough local fundraising support, regardless of demand.
“Ethno-specific homes are great for communities that have strong community power,” says Seong-gee Um, a researcher at the Wellesley Institute. “In reality, it’s not possible to have ethno-specific homes for every ethno-cultural community in Ontario, so it might make more sense to think about how to accommodate diverse linguistic and cultural needs in our mainstream homes.” For this reason, Um suggests that future research should target improvement initiatives within existing mainstream nursing homes, where many ethnic minority residents end up residing.
This was the focus of a recent report conducted by the Ontario Centres for Learning, Research and Innovation in Long-Term Care (CLRI), which makes a number of recommendations on how mainstream nursing homes can create a more culturally sensitive environment for its residents. This includes hiring executives and front-line staff from different cultural backgrounds and collaborating with cultural community groups.
“How can each individual home, despite their cultural status, improve their care delivery by addressing the cultural needs of individual residents?” asks Tammy Cumming, manager of the Ontario CLRI program hosted at the Schlegel-UW Research Institute for Aging (RIA). “It’s more about the individual residents, wherever they’re located.”
These recommendations perhaps speak to a broader philosophy of care that extends beyond the management of ethnic minority populations. “What it comes down to is a matter of providing truly person-centered care, no matter who the person or group of people living in a long-term care home,” adds Kate Ducak, a project officer at the RIA.
As the current Ontario government plans on expanding nursing home beds across the province, having a mandate to provide person-centered care would certainly be beneficial to all residents, regardless of ethnicity. It will also be of great interest to many ethnic communities how much of this funding will be used to support the creation of more ethnic-specific nursing homes.
A previous version of this article used the term “average” when describing wait times for some ethnic nursing homes, rather than “nine out of ten.”
Correction: This article has been updated to reflect the fact that the CLRI program is hosted at the Schlegel-UW Research Institute for Aging (RIA), and that Kate Ducak is a project officer at the RIA.