It took a rogue virus to make it obvious that 20 or 30 dependent seniors in one area within a long-term-care (LTC) facility isn’t the best idea in the world. This begs the question of what approaches Ontario’s Long-Term Care COVID-19 Commission should consider as alternatives.
Our “nursing home” approach to LTC emerged in the 1960s, a time of great optimism that infirmities of old age could be solved (or at least managed) by the biomedical sciences. Part of that optimism has proven to be justified, and part not.
There’s little question that biomedical research and medical management have helped maximize health and function later in life. But when it comes to helping people who for physiological or cognitive reasons need help with basic activities of daily life, the picture is very different. It’s not the staff — most are good and caring. It’s that the “medical model” they’re trained in offers little to ensure meaningful existence for people with diminishing physical or cognitive abilities.
Most everyone knows this. No one aspires to go to a “nursing home.” People intuitively know that on taking up a “bed” one gives up deciding when to eat, what to eat (no junk food at age 95?), when to bathe, and so on. It’s such loss of ability to make decisions on common everyday interests that people resist.
And the more people that live together in a place they can’t leave, the more difficult it becomes to keep an individual’s unique interests in focus. Inspired leadership can hold such drift at bay, but with time the drift continues.
Such “total institutions” are dangerous places. Think of the Truth and Reconciliation Commission of Canada report on Indigenous children in residential schools, or exposés on previous generations of “mental hospitals” and “training schools,” as they were euphemistically called.
LTC facilities can’t escape such danger, try as they might. Current deaths from COVID-19 are a stark reminder, but we shouldn’t forget previous media reports on abuse, neglect or Wettlaufer-type murders that continued despite assurances “the system is strong.”
I know something of how difficult it will be to change existing LTC into something new. My early career was immersed in replacing large “mental hospitals” with community alternatives, and replacing “training schools” for children and adults with developmental disabilities with individualized community services and supports now in place. Both were resisted by strong interest groups arguing existing systems could be fixed. If we’d contented ourselves with such arguments, thousands of people with any number of disabilities and their families would have been sadly impoverished, as would society.
LTC-related interest groups will be no less resistant. But “total institutions” they are. To change the status quo requires a reimagined vision transforming “long-term care” into “networks of caring” that support seniors in living meaningful lives through to death. From prior system transformations, we know the following ingredients are essential:
First, focus on the individual. Maximize each person’s capacities and compensate for deficits, fostering a sense of success and self-respect. The more seniors can define their ambitions while recognizing their own limitations, the better for everyone.
Second, emphasize flexible resources tailored for the person. Start with approaches already successful such as home health care and funding for individuals to hire their own support personnel. They dramatically increase personal satisfaction and decrease demand for “residential beds.”
Third, help individuals and small groups develop supports for their LTC needs where they already live. Think, for example, of all the apartment complexes with aging residents preferring to “age in place.” Develop policies that encourage sharing the cost of hiring support personnel and nursing assistance as and when required — right where they already live.
Fourth, if congregate LTC-type housing is needed, small and dispersed is good. Encourage development of “community housing” models — each of a size where people can eat and meet around a dining room table. That reduces the risk of exposure to rogue viruses while retaining links with family, friends and others living nearby.
Critics are bound to argue such models aren’t cost efficient. As a well-known deputy minister once reminded me, that’s an argument for the status quo, and irrelevant to doing what’s best for people.
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