Response to the human tragedy in care home facilities

Staying in your home has proven to be a safer option during COVID-19. Older adults can more easily isolate in their own homes than in a congregate living setting of a care home facility, whether that be a retirement home or long-term care home. 

Ninety-six per cent of people dying of COVID are 60 years and older. Care homes residents account for 56 per cent (3,858 of 6,884) of all COVID deaths in Ontario. These facts also reveal who should be vaccinated. 

Although Ontario has 56,500 older adults living in private retirement homes and 78,000 living in publicly-funded long-term care homes, the other 94 per cent of the 2.5 million people in Ontario 65 years and older live in other types of accommodation. Few older adults prefer moving into care homes, and many are looking for ways to stay in their own home for as long as possible. 

Younger people often unknowingly harbour ageist attitudes, thinking it is best to do things for older adults, rather than enabling older adults with the tools to continue living independently. Unfortunately, these attitudes have become entrenched in Canadian health and social legislation, including in the understanding of ‘care’.

The Canadian Institute for Health Information (CIHI) in August 2020 reported that most older adults want to live at home for as long as possible, and that more of them could. 

Care homes admit individuals who are quite frail, or those living with dementia. CIHI reviewed the health status of people admitted in care homes over a one-year period. The project found that, among those living in care homes, about one in nine new admissions “could potentially have been cared for at home, provided they had access to ongoing home-care services and supports.”

We cannot separate the health and social aspects of living as frail older adults. When we are frail, we have a spectrum of health events (from acute episodes to more complex, long-term conditions) and we require a spectrum of approaches (from single interventions to long-term health-promotion interventions), where distinctions between health and social aspects of life are largely meaningless.

As the per cent of Ontarians who are 60 years of age and older increases, more older adults are living with complex and long-term conditions. This requires a new approach in the distribution of finite health resources: that is, what proportion of our tax dollars should be allocated to care homes versus a range of community services to assist with the tasks of everyday life, to help stay at home?  What’s more, care homes should be embraced as part of the community. For  example, their restaurant services can be enabled for meals on wheels and wheels to meals programs among people living in their own homes.

The Canadian health care system, and the Canada Health Act places hospitals as the topmost priority. While this choice was justified in the last century to meet the needs of a younger population, it is less appropriate today in the context of an aging population with complex and long-term conditions and disabilities. When the Canada Health Act was the core of the health-care system 60 years ago, older adults comprised eight per cent of the population. In 2021, older adults comprise 18 percent and in 2041 this will increase to 25 per cent.

Hospitals are designed to provide acute care to patients who need immediate medical interventions over a short, days or less, time period.  The culture in hospitals is substantially different from accommodation for people living in care homes. The short visit in the hospital involves patients receiving acute care, also known as skilled care. It comprises medical, nursing, or rehabilitative services, including help taking medicine, undergoing tests (IV’s, blood pressure, etc.), or other similar services. This care is generally performed by licensed nursing personnel and certified nursing assistants.

 Frail, older adults who have long-term conditions including dementia, diabetes, stroke, heart disease, lung disease live for months and years in residential settings, including their own home.

People living with these conditions can benefit from a range of services to assist with the tasks of everyday life, wherever they live. These tasks may include the six Activities of Daily Living, (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs include: eating, bathing, dressing, toileting, continence, and transferring (ability to get out of bed/chair). In general, if you cannot do two or more of these activities, or if you are living with dementia, you will most likely need assistance. This assistance is not always long, depending on your situation, and can be provided at home as well as at care homes or assisted living centres. 

IADLs include shopping, cooking, managing medications, using the phone and looking up numbers, doing housework, doing laundry, driving or using public transportation, and managing finances. These activities allow an individual to live independently in a community. Although not required to carry out ADLs, the ability to perform IADLs can significantly improve the quality of life. Often, support of one or two IADLs makes the difference between being able to stay at home versus moving to a care home.

The Ontario Ministry of Health plans for an “additional” $111 million in 2021-2022 for the High Intensity Supports at Home program to help people with high needs transition out of hospital to home. 

In October 2020, the Ministry announced a $461 million “temporary wage increase” for personal support workers in both home-care and long-term care settings during COVID-19. 

Recently, the Ministry said it was investing up to $20 million for a community paramedicine program to support older adults in their homes while they wait for a bed in long-term care. However, both the National Institute on Ageing and the Ontario Community Support Association recommend supporting people in their own home, rather than just as a temporary answer until older adults locate a space in a care home.

Supporting people to stay in their home is significantly less expensive than living in a care home. In Ontario, 38,000 people are waiting for a government-funded long term care home bed.

To address this waiting list, the Ontario government has promised to build 15,000 new long-term care beds and update 15,000 more. Given the incoming exponential increase of older adults, this plan, which will cost taxpayers billions of dollars, is not a long-term solution. This money could be better invested - at a lower cost - in adopting policies based on the principle that every citizen should have the right to choose where they live. Instead of deferring to outdated policies that have an “institutional’’ mindset, a successful aging-in-place philosophy should be used when building infrastructure.

By increasing emphasis on keeping older adults in their homes, such future investments will allow more people to age in the places of their choice. Aging in place, or staying in one’s home while getting older, is a worthy consideration that provides important benefits, including honouring dignity and independence, decreasing recovery times and reducing the risk of illness, enjoying companionship with loved ones, and promoting healthy aging.

Healthy aging is mostly about busting the myths of being old. Senescence, the normal biological process of aging, limits the maximal level of physical activity, but what does the science tell us about the effects of aging on the brain? Luck is required to avoid the diseases that cannot be prevented, notably Parkinson’s and Alzheimer’s; however, it is now recognized that the risk of dementia can be reduced by at least a third (as estimated by the Lancet Commission) by reducing stress, improving sleep, and by limiting the overuse of drugs both prescribed and self-prescribed, including avoiding cigarettes. There is also strong evidence that all that we know about preventing heart disease, including physical activity, reduces the risk of dementia.

Perhaps most interesting of all is the risk of isolation and the benefit of social engagement, ideally in paid or voluntary work – the more challenging the better – thanks to the brain’s enduring potential for neuroplasticity. 

We should value equipping older people with the opportunity to remain in their own homes, rather than relegating them to being passive recipients of ‘care’. The older adult demographic is looking for a life that enables them to play an even more important role in meeting society’s challenges and, as individuals, to live longer, together.

Larry W. Chambers has authored 175 articles and books concerning disease prevention (e.g. dementia), quality improvement in long-term care homes and innovative approaches for continuing professional development. He is research director of the Niagara Regional Campus, School of Medicine, McMaster University. Madeleine Smith is a medical student at the Niagara Regional Campus, Michael G. Degroote School of Medicine, McMaster University.