Innovative models pave the way for safe, high-quality long-term care homes

It has taken the devastating impact of COVID-19 for governments to pay heed to decades-old warnings from seniors and disability advocates about the need for long-term care reform.

Reacting to the continuing wave of deaths, the Ontario government has announced more money for additional long-term care beds and a commitment to provide a minimum of four hours of direct care for each long-term care resident by 2025. Further changes are expected in the wake of the second interim report by Ontario’s Long-Term Care COVID-19 Commission, which called for more accountability and focused inspections to ensure each facility is capable of preventing and containing outbreaks.

However, advocates hope for far more than basic infection control, minimum standards of care and more beds.

An April 2020 report from the Canadian Centre for Policy Alternatives states that while safety is the priority now, “We must make sure that we build on the existing research while drawing lessons for the future that allow us to do more than provide a safe environment for all those who live, work and visit in long-term residential care.”

But what does high-quality and patient-directed long-term care look like in practice? And is it feasible in Ontario, with its mix of dense urban and sparsely populated rural settings, for-profit homes and public institutions and diverse cultural and linguistic groups?

Experts say there’s no one single solution but point to innovative models to implement or learn from. One promising alternative that is drawing international attention is The Green House Project in the U.S. This small nursing home model is demonstrating remarkable success in not only limiting infections and deaths from COVID-19 but also in providing improved quality of life for its residents, resulting in better health outcomes and life satisfaction and reduced healthcare spending overall.

According to a Green House Project handout, from February to June last year, 95 per cent of its small homes were COVID-free, with only four deaths among the 2,788 patients living in the small homes.

Meanwhile, Ontario’s 623 registered nursing homes reported 1,465 deaths in 308 outbreaks during that same period. As of Jan. 7, in the midst of the second wave, the death toll has risen to 2,909 residents, demonstrating an urgent need for further transformation of Ontario’s nursing homes.

Susan Ryan, a nurse and senior director of The Green House Project, attributes its success to a non-traditional approach to care: smaller environments with private rooms, continuity of care and richer relationships with fewer care providers and access to the amenities of home, including being able to go outdoors freely and allowing residents to prepare their own food.

The typical Green House Project home is a self-contained residence with 10 or 12 private rooms, each with a private bathroom.

Ryan describes how “each of those rooms is centered around a hearth area, kind of an open concept where we have the centralized dining and kitchen, so that you’ve got an open kitchen where meals are prepared, where you’ve got access to food 24/7. And the living room just really invites socialization and the opportunity to connect with people in the home. Because it’s so much smaller, it really gives the opportunity to build relationships.”

She says that the family dining table that is integral to the design of each of its homes – rather than the typical dining hall with multiple tables seen in most nursing homes – is particularly important for people with dementia who do better in familiar environments.

The laundry and most other chores are decentralized, meaning they are done in the home, with residents contributing when they can. Ryan says there are typically two direct caregivers for every 10 residents. “Those caregivers are also doing the cooking; they’re doing the cleaning. They’re doing the laundry right along with the care.”

This has significantly reduced the traffic of workers in and out of the home and between facilities, which is important for infection prevention and control. In contrast, in Ontario’s nursing homes, particularly early on in the pandemic, care providers worked at multiple sites.

Ontario nursing homes, particularly in the for-profit industry, continue to contract out entire services such as laundry, food and security, which brings additional people into the buildings.

Studies have shown that while the caregivers, who are typically certified nursing assistants (known in Ontario as personal support workers), have expanded responsibilities in Green House Project homes, they still spend more time in direct care activities and engaging directly with residents than in traditional nursing homes.

Ryan notes that having fewer residents and consistent staff means better relationships, which she says is central to good care. For example, she says that when staff members know the residents well, “they are better able to early-detect when somebody’s just not right (with respect to their health) and it translates into better outcomes – and not just from a quality-of-care perspective but really a quality-of-life perspective.”

When family members were prohibited from visiting during the early days of the pandemic, Ryan says staff had “relationships with the residents and their family members. And so, they were able to communicate with them and say, ‘Don’t worry,’ and be able to say, ‘Hey, your mom’s great today … and let’s do some Facetime.’”

With respect to the financial feasibility of such a model, studies suggest that “while perhaps counter to prevalent beliefs … it is possible to provide a high quality of life and care through The Green House model at a net profitability and return on investment comparable to large, traditionally structured nursing facilities.”  

A published review of the financial implications of the model found the increased costs of more direct care were offset by decreased administrative and management costs. Further savings are found in hospital expenditures, as Green House Project residents require fewer hospital resources, using approximately USD $1,300 to $2,300 less in total Medicare and Medicaid costs compared to traditional nursing homes over a one-year period.

The most expensive aspect of the model is the square footage provided to each resident – which is a significant barrier to implementation in Ontario, particularly in locations such as Toronto and other urban centres where space is limited.

Pat Armstrong, a York University researcher who has studied long-term care homes in Canada, the U.S. and Europe for more than a decade, says that while “in the city there’s not much space, period,” there are ways to adapt the concept to urban areas.

“There’s no question that we need smaller spaces within those big places,” she says. “The huge 35-person units we have here – we all would agree that that’s not very conducive to care.”

One example Armstrong points to is The Dorothy Macham Home, a Toronto facility built to look like a one-storey home that houses 10 veterans with moderate-to-severe dementia. The non-institutional setting offers individual rooms and outdoor garden space as well as specialized care for advanced dementia but is supported by the resources of the Sunnybrook hospital next door.

Armstrong also wants to diversify our understanding of what “home” means in the context of long-term care. “What I hear over and over and over again is these places are their homes … but everybody has a different idea of home.”

She suggests that larger nursing homes could dedicate entire floors or units to a specific cultural focus to meet the needs of a population and design the look and feel of the unit to fit what the residents see as home.

Armstrong also notes that “You can get not only economies of scale in a bigger place but you can have more flexibility” in larger facilities, allowing for a wider range of entertainment and access to various types of therapists that can be employed full-time in a bigger institution.

And Armstrong shoots down the notion that home care is the solution. “We talked to a residence council here in Toronto about whether it is better being (in long-term care) than being at home. And they unanimously said yes.

“They said they had company and ‘even if I don’t like all of the people, there are people, and if I was at home, I’d be all alone.’” Armstrong adds that activities were also a priority, even if they were minimal because they felt that if they were at home, they would just be watching television.

Armstrong says she ultimately doesn’t have a preference for Green House Project homes over other alternative models, such as the Butterfly Model or Montessori homes, which have shared principles. But there are urgent lessons to be learned for improving our current system: “The central one is more staff, more autonomy for the staff. More attention to the social and the emotional rather than focusing on tasks and the medical. And comfortable physical environments.” Most importantly, she wants the future of long-term care to “go in the direction of standards and not standardization.”

“It’s about adjusting the care to fit the population and not just the population but the individuals,” she says. “And all of that requires particular kinds of conditions of work. It requires more staff. It requires a recognition of skills. As we like to say in our project, the conditions of work are the conditions of care.”