Nursing Homes — Providing dignified care

Covid has exposed failings in nursing home care around the world. It is clear that funding, regulation, oversight, and staffing need to change to provide our elders with the dignified care they deserve.

Covid has exposed many shortcomings in government, business, and society. One of the biggest failings has been in nursing homes. In the UK the share of Covid deaths taking place in care homes ranges from 20%-40% depending on region of the country. In the province of Quebec nearly 70% of Covid deaths are in nursing homes. The same tragic story of Covid taking hold of nursing homes, seniors dying without their families at their sides, and staff struggling to cope is repeated across the world.

The challenges that nursing homes present in a pandemic are well known. Many older people with chronic health conditions living together, sometimes in tight conditions, with staff moving from one facility to another is a recipe for infection outbreaks to take hold. So what can we learn from this mess? How can we provide dignified quality care to seniors who require the care that nursing homes should provide?

Where care can’t be provided at home because seniors have complex needs or it can’t be provided cost effectively, nursing homes are there to help. When a home can’t be cost effectively modified for homecare to work, where a senior is too frail to live alone, or where the healthcare needs are too complex for homecare, nursing homes provide a key support for seniors. The challenge we face as society, is that we don’t adequately build, staff, fund, or regulate these vital facilities.

This blog is targeted at Canada, however, the solutions proposed could be applicable in the UK or other developed economies.

Capacity

Stories of families waiting to get their loved ones into nursing homes either in the community where the senior lives or closer to relatives are not new. So are stories or married couples being split up and sent to different nursing homes due to a shortage of rooms. Any Canadian medical professional working in a hospital is also familiar with the term ‘bed blocker’, which typically means a senior who has been admitted to hospital but is now ready to be discharged into a nursing home, but no nursing home room is available. This leaves the senior stuck in a hospital bed, while someone else can’t get their surgery or be admitted to hospital as their bed is ‘blocked’.

What is surprising about all this, is that it is not as if the number of seniors and forecasts of those needing nursing home case can’t be predicted with a good degree of accuracy. Statisticians, healthcare planners, and even life insurers have a pretty good idea of how many seniors needing nursing home care there will be in the future. Unfortunately, governments and society have not adequately planned for the increasing number of seniors, particularly those requiring nursing home support.

This is a shortcoming that can be fixed. Governments need to use forecast data on demand for nursing homes and develop capacity to ensure that stories of bed blockers or families waiting months for nursing home beds for the loved ones are no longer the norm. With reliable estimates of demand governments can work with nursing home providers to ensure that there is capacity where and when it is required. I realise that this is easier said than done, I will get to funding all this later. However, pointing out that forecasting demand is possible and governments that fail to do this are letting us all down.

Coordination

Living in the UK even before Covid struck, the news was filled with stories of the lack of coordination between the NHS hospitals and nursing homes, resulting in bed blockers and seniors falling through the cracks. The same stories will be familiar to Canadians.

Part of the problem of coordination between hospitals and nursing homes would be fixed by more capacity. Meaning, with more free nursing home spaces it would be easier for hospitals to find suitable space for seniors once they are ready to be discharged. However, to ensure that seniors and their families don’t fall through the cracks resulting in bed blockers, couples being split up, or seniors getting inadequate care more coordination between hospitals and nursing homes is required.

I propose that a sort of AirBnB or Expedia for nursing homes be developed. All regulated nursing homes in a province would be required to create profiles on the platform, along with photos, services, care specialisation, room availability, and estimated time for a room. While a bit morbid, nursing homes should also be able to forecast, with a degree of accuracy, death rates and hospitalisation rates for their residents, thus future room availability.

Armed with the system, hospitals would also be required to have a dedicated ‘placement’ unit to facilitate seniors being discharged from hospitals into nursing homes. This unit would be notified as soon as someone was admitted who may require nursing home care upon discharge. At this point the team would start planning for the senior’s discharge, working with them and their family to find a suitable nursing home. They would be able to use the database of nursing home availability to shortlist potential homes, then once a home was selected, start working with that home to facilitate the senior’s hospital discharge. By starting this process as soon as an at risk senior was admitted, the problem of bed blockers would be reduced and the transition to a nursing home would be smoother for the patient.

Staffing

Staffing in nursing homes has been a challenge for as long as I can remember. There has been a shortage of Registered Nurses, care aids, and Doctors specialising in geriatrics. Many of the staffing challenges are down to poor planning, lack of funding, and lack of social prestige for those working in nursing homes. Perhaps this will change post-Covid, with many viewing front-line care workers as heroes, however, more needs to be done.

Firstly, the pay offered to Registered Nurses, Registered Psychiatric Nurses, and Licensed Practical Nurses working in nursing homes needs to be equalised with those working in hospitals. We can’t expect qualified nurses to seek employment in nursing homes when they may get paid more with more ‘prestige’ when working in a hospital setting. Specialist training pathways should also be created for nurses to pursue education with a focus on nursing homes / geriatrics. This would enable nurses to develop their careers and increase their pay with a focus on nursing home care.

The hiring of care aids is one area that has been extensively covered during Covid, particularly, the trend for care aids to work at multiple nursing homes. This practice has been traced to many Covid outbreaks in nursing homes as care aids bring the virus from one facility to another. One reason for care aids working at multiple facilities is the lack of full-time care aid jobs. For instance, it has been reported that the increase in the minimum wage in Ontario and Alberta led many nursing homes to eliminate full-time jobs with benefits, sick pay, pensions, and vacation to a part-time and casual employment model, without these perks. For a care aid to continue to earn the same amount of money many were forced to work at multiple facilities. The lack of sick pay and vacation has also been reported to have led some financially insecure care workers to come to work while feeling sick, resulting in Covid outbreaks.

Care aids are often the lowest of the low on the medical worker pecking order. They generally receive low pay, are held in low esteem by society, are often immigrants, and largely female. If anything good has come of Covid it is a realisation that these people are saviours, often putting themselves at risk to care for our parents and grandparents. Let’s hope that this hero status is retained once things return to normal. But what can be done to address the failings that Covid has exposed around care aids?

The profession of ‘care aid’ is currently unregulated in most provinces, which means that anyone can be hired to do the role. While much of the work of care aids could be deemed ‘basic’ such as dressing, feeding, bathing, and cleaning, these frontline healthcare workers also spot infections, monitor deterioration in cognitive ability, or muscle wasting — flagging changes to nurses and Doctors. There are colleges that offer care aid training programs across Canada, with programs lasting about 30 weeks, however, perhaps more is required.

To raise the status of the profession care aids should become a regulated profession, perhaps Registered Care Aid, with a professional association behind it. The education for Registered Care Aids could remain largely as it is today, 30 weeks full-time, including a 7 week onsite practicum. Graduates of the programs would then have a sit a standardised Registered Care Aid qualifying exam to ensure a high and common standard of competence for the profession. Finally, very clear and accessible career pathways for holders of the Registered Care Aid qualification towards Licensed Practical Nurse, Registered Psychiatric Nurse, and Registered Nurse should be created. This would enable those Registered Care Aids who want to progress their careers to benefit from recognition of their prior-learning and work experience should they decide to pursue further nursing education.

Finally, and crucially, the practice of care aids working at multiple nursing homes should be prohibited. Even before Covid it should have been clear that people working with vulnerable individuals at multiple sites increases the risk of infections spreading — Covid has made that glaringly obvious. To do this, nursing homes will have to increase the number of full-time roles that they offer, which will increase costs. However, nursing homes are often where society’s most frail and health compromised seniors live, basic steps to prevent inflection outbreaks should have always been the norm — now they will have to be.

These solutions all make sense and should improve the care provided in nursing homes. But one key are has been left unaddressed, how do we pay for it all?

Funding

Funding for nursing homes in Canada is a mix of provincial government funding and self-funding, with the provincial government paying for hospitals. In the UK local government pays for nursing homes along with self-funding, while the central government funds hospitals. In both countries there is pressure on funding nursing homes. The cost of nursing homes is only forecast to increase as the number of seniors grows, while the budgets allocated to nursing homes struggles to keep up.

Paying for the construction and operation of more nursing homes, along with more qualified full-time staff won’t be cheap. I propose a few ways that society can pay for nursing homes to ensure that quality care is provided to our seniors. It involves a mix of government, private sector, non-profit, and self-funding, which should provide flexibility to deliver the care that seniors need where and when the need it.

• Government Funding — Like governments fund hospitals and public healthcare, a basic level of nursing home care should be available to all. However, the level of government funding would be means tested, meaning it would be reduced for those seniors with more means that those that are poorer. At the basic level low-income seniors in Canada benefit from Old Age Security (“OAS”), the Guaranteed Income Supplement (“GIS”), and possibly the Canada Pension Plan (“CPP”). In my proposed model, any senior in a nursing home would have to pay 90% of their OAS, GIS, and CPP to the government in return for government funding of nursing homes. This means that a senior with no assets or CPP who is eligible for c. $18,000 in GIS and OAS would pay $16,200 a year for their nursing home, leaving $1,800 for extras. This is nearly $2,500 less than it currently costs to have a standard room in an Alberta government run nursing home. Which is why better off seniors who also may get CPP benefits would need to pay 90% of these benefits. Under this model seniors paying 90% of their GIS, OAS, and CPP may just cover the costs of the current basic care model, which we know is not good enough.
• Self-Funding — Seniors with higher retirement incomes and assets would be expected to pay more for care, however, they would also have the ability to pay for enhanced services. To pay for more full-time and better qualified staff and more capacity to benefit all seniors, wealthier seniors in nursing homes would be expected to pay 75% of their retirement income above CPP, GIS, and OAS up to incomes of $40,000 to pay for their care. This would provide all seniors with a basic level of care that is better than today, providing possibly 50% more funding than the basic care that is currently provided. Also, all seniors moving into nursing homes would be expected to liquidate assets as required to generate income to fund their care, meaning selling homes, cars, and other assets with proceeds held in pension style funds to pay for care. If you are not living in your house or driving you don’t need a house or car, you should be using the proceeds of your house to pay for your housing in a nursing home.

Construction & Operation

In order to expand the number nursing home rooms, the construction and operation of nursing homes should be opened up to government, non-profits, and companies. This would enable private and charitable capital to be used alongside government money to build sufficient nursing home capacity to match demand. The operation of nursing homes should also be open to different types of organisations. As long as a nursing home meets agreed government minimum standards it should be able to receive the same government funding regardless of if it is government, non-profit, or for-profit.

This model will provide seniors with choice, while benefitting from high-minimum standards. It will also reduce the need for governments to take on debt to fund all the construction of new capacity, with private companies assuming some of the burden. Just like housing, seniors with more means could pay more for enhanced services or rooms, however, there would be minimum standards that all seniors would benefit from.

New nursing homes should also be developed within communities where a large number of seniors already live, using excess public lands, and be built enabling mixed communities and a continuum of care in mind.

Many Canadian cities are faced with situations where there are underused elementary or junior high schools in neighbourhoods that were once home to young families, but are now much older. This often means that students are bussed to these underused schools because there is not enough money to build schools in their newer local neighbourhoods. Imagine a situation where seniors villages were built on the school grounds of some of these schools, with the former school being repurposed as a community hub. Schools and land would be sold to to health authorities, non-profits, or companies to develop seniors villages. The funds raised from selling surplus schools and land would go to local school boards for new school construction.

For example, a former school could serve as a mixed use facility bringing benefits to the local community and seniors. It could have a gymnasium, community kitchen, library, community centre, medical centre, rehabilitation centre, and be gathering place for the wider community. Schools often have great gymnasiums that could be used for community sports activities, seniors fitness, and programs to bring kids and seniors together for social and physical activity. The school library could be open to the neighbourhood, something many neighbourhoods now lack, perhaps offering language, reading, and computer programs for the local community. Importantly, the seniors living at the seniors village could not only participate in the activities and programs, they could volunteer. This volunteering and sense of purpose could provide many seniors with a way to still feel valuable and contribute to their community, brining a wealth of mental health benefits. The ownership of the school and costs for redeveloping would come from the entity that develops the seniors village, however, operating the community hub could be passed to a local charity or community association.

With the former school acting as the central hub of new seniors villages, some of the school grounds would be used to develop varying levels of seniors living. This would include seniors apartments and townhouses for independent living, assisted living facilities where a low level of care and support is provided, and a nursing home with higher levels of support. Importantly, residents of the seniors village would have the ability to use all the services of the village regardless of what style of housing they required, creating more of a community feeling. The housing would be closely linked to the school / community hub making it accessible to all who live there.

Regulation

A high level of regulation with minimum standards that ensure seniors get dignified quality care is key for any system to work. Once the standards are set regular oversight is also required. What this means is that government inspectors should visit facilities, unannounced at least 4 times a year for each facility, with those previously found below some standards receiving more visits. Recent press reports found that some Canadian nursing homes had not had inspections for over a year. This is not acceptable.

Regulations should cover the design of nursing homes, staffing levels, and costs to ensure that seniors get the care required. While I accept that there are currently regulations in place that cover some of this, they will need to be updated to reflect the changes that I propose.

Improving the availability and care provided by nursing homes is something that the Covid crisis has exposed. As a society we can no longer ignore what we have all known was a challenge. Seeing seniors left to die as staff abandoned homes due to a lack of personal protective equipment, staff shortages, and Covid outbreaks out of control in nursing homes means this problem can no longer be ‘out of sight out of mind’. We need to change the way nursing homes are staffed, funded, and regulated. This won’t be cheap, but it is possible. Please let us not miss this opportunity to do something better.