The post-pandemic future: We will stop warehousing older people in care homes
Samir Sinha is director of geriatrics, Sinai Health System and University Health Network
Canadians got a shocking dose of reality in June, when we found out that 81 per cent of the country’s deaths from Covid-19 had taken place in long-term care homes, which are government subsidized, and retirement homes, which are regulated by the government, but operate under a private pay system. This news shouldn’t come as a surprise. In 2016, older Canadians began to outnumber younger Canadians for the first time in our history, yet our country has nine times as many pediatricians as geriatricians; in a country of 84,000 doctors, I’m one of only 304 geriatricians. Canada is not prepared to meet the needs of an aging population, and this is clear when we look at the physical set-up of our long-term care homes. Covid provides an opportunity to reimagine how we look after our aging population.
Our original sin is rooted in the fact that when we established medicare over 50 years ago, most of us didn’t live beyond our 60s. So we never thought much about long-term care when we designed our universal health care system. On average, Canada spends 30 per cent less of its GDP on long-term care than comparative industrialized countries. In our underfunded system, corners are cut. We’ve designed buildings that crowd people into two-, three- or four-bed rooms—a disaster in the making when it comes to infection control. These places also typically have shared bathrooms and narrow, cramped hallways. The other challenge is that nearly 70 per cent of people living in long-term care homes have dementia, and 50 per cent have what we call behavioural issues. That includes wandering, which makes it even harder to isolate these people in an outbreak.
Ontario’s long-term care homes traditionally experience about three times more respiratory infectious-disease outbreaks than retirement homes. That’s because retirement homes offer mostly single-bed accommodation. In order to be able to live in a retirement home in Ontario, you have to spend between $1,500 and $12,000 a month. If you have that kind of money, you’re not going to leave your home to live with a roommate.
So how can we ensure our homes are safe for all? We can design them so that more people can live in single-bed rooms, with enough space to spread them out in the event that they need to be isolated. We can also embrace an alternative model, called the Green House Model, where instead of housing, say, 240 people in a big tower, you have individual homes with about 12 people per home. Each person has their own bedroom and bathroom, and the group shares a kitchen and a living area.
Fundamentally, Canada needs to rethink its whole strategy in regards to our aging population. Our country spends 87 per cent of its long-term care dollars on warehousing older people in care homes, and only 13 per cent on enabling home- and community-based care. Meanwhile, according to the Canadian Institute for Health Information, 22 per cent of Canadians in care homes could easily remain in their own homes with community support. A nursing home is often a last resort; given the choice, most of us would prefer to age in our homes. It costs about $182 a day to house a high-needs person in a long-term care home, compared to about $103 a day to provide at-home care. Imagine if we had that extra money to spend on more home care, as well as more day programs, meals on wheels and transportation. When you allow community agencies to be flexible and work in partnership with families, often they can do a heck of a lot more for a heck of a lot less. A shift to home care would save taxpayer money from being wasted building unnecessary beds—not to mention set us up for success in the event of an infectious outbreak.
Are we going to need more nursing homes in the future? Absolutely. If a person doesn’t have close friends or family nearby, they’re at greater risk of loneliness and depression. They might benefit from a communal setting. Others may have health issues that require more than a few check-ins here and there. The government can decide that whenever they build a new long-term care bed, it’s going to be in a spacious home with single rooms and a more comfortable setting. It’s time that we finally reorient our entire system to be in line with what all of us want—to age with comfort, safety and dignity in a place that feels like home.