Who will care for us?
I would have been nine or 10 at the time. On Saturday afternoons my parents, fulfilling their Christian duty, would take me along to visit seniors at the local old folks’ home in Battle, the little town in Sussex where the Battle of Hastings was fought and near which lived.I noticed even at that early age what a sad, depressing place it was, with 60 or 70 elderly people sitting on chairs around the walls of a large room, rarely talking, taking little interest in the world around them.More than 50 years later, my 80-year-old father-in-law entered a nursing home in Toronto. It was clean with cheerful surroundings and plenty of activities, including concerts, crafts and weekly outings to a neighbourhood swimming pool.
But in spite of the improvements, the quality of life for the residents didn’t seem all that different from those in the Battle infirmary 50 years ago. For the most part, people sat in the hallways, watching others go by, talking little, or else sat with a television blasting away, but which few were watching.
The mere mention of nursing homes gives many of us a feeling of unease. “I’m not going to end up in one of those places,” we swr, perhaps after seeing an elderly relative in the situation just described. Or else in our middle years we worry about what we’re going to do when our parents or other elderly relations can no longer look after themselves.
That worry has risen to almost panic pitch as we’re bombarded with statistics about the coming tidal wave of elderly in Canada. Just around the corner, by 2011, the number of Canadians over 65 will increase by 40 per cent to nearly five million. A truly mind boggling increase will occur in the over 80 group, which will almost double in size in the same period.
Where will we find the long term care beds for them? Who’s going to look after them – or us? If you were expecting an article on the need for more nursing homes, this isn’t it. Or if you were hoping to be reassured that today’s nursing homes are a completely different kettle of fish from yesteryear’s, and that you or your loved ones will enjoy your sunset years amidst a round of singsongs and cheery chat in a long-term care facility, forget it.
Even the experts have come around to the view that nursing homes are places you’re better to avoid – if you possibly can.
“Ideally,” says Catherine McDonald, in charge of long-term care for the western region of Newfoundland, “it would be great to get rid of nursing homes. As much as we try to deinstitutionalise the environment, I think we have a long way to go before we can provide a truly homelike atmosphere.”
Even in the best circumstances, she says, nursing home residents “lose privacy, lose the ability to make choices about things such as what they eat, the colour of their room, what soap they use. As wonderful as it sounds to those who think they’d like the protection of a nursing home, when they get there they realize a lot of things they took for granted – like keeping a pet – have been lost.”
A leading British expert even argues that nursing homes should be phased out altogether. “Going into a nursing home is dreaded by older people because there’s a huge difference between living in one’s own home and in an institution,” says Roger Clough, professor of applied social science at Lancaster University. People often enter nursing homes so as not to be a burden to their families, he says.
Clough’s suggestion: Most existing nursing homes should be converted to cluster housing, where older people could live in their own unit, receiving the services they need, while remaining nursing residences should provide a hospice like setting for the dying.
Without most of us noticing, the future predicted by Clough is already unfolding. Older Canadians are a darned sight fitter both physically and mentally than preceding generations. Today, only four or five per cent of Canadians over 65 end up in a nursing home (or long- term facility, as they’re often labelled these days) — a number some experts predict will actually decrease in coming decades.
The provinces, in fact, realized a decade ago they’d become “over-bedded”, and although nursing homes weren’t shut down, no more were built. In Ontario, for example, small non profit nursing homes have been quietly closing, says Mike Klejman, executive director of the Ontario Association of Non Profit Homes and Services for Seniors — usually because they can’t afford to bring their building up to modern standards.
“In the last 10 years,” he says, “Ontario lost 5,000 non-profit beds.” The total remaining, 67,000, represent nearly half of Canada’s 150,000 bed total.
The same scenario is unfolding in the private sector. “Nothing’s being built,” says Shelly Jamieson of the Ontario Nursing Home Association. “There used to be a feeling that an investment in shelter for the elderly would make you rich. It’s no longer so.”
Joy Calkin, the new president of Extendicare Inc., the nursing home giant, has been quoted as saying, “Why would Extendicare build for a wave when there’s a trough coming?” She sees a strong future for housekeeping and therapy services provided to people in their own homes.
But if not to nursing homes, where will people go?
As Newfoundlander Catherine McDonald spoke in her office at the Bay St. George Senior Citizens’ Home overlooking the ocean at Stephenville Crossing, one of the answers to that question stood right across the street: Emile Benoit House. It’s a modern low rise building consisting of 20 individual living units – similar to bachelor apartments – plus a common living area. The residents, the eldest aged 90, have their own private living quarters, but they gather to cook and eat one meal together every day.
Emile Benoit House – the first of its kind in the province thus far – is called congretive housing. It’s based on a New England experiment and its slogan is “independence through interdependence.” In other parts of Canada, similar schemes, sometimes called supportive housing, are springing up — often right alongside long-term care facilities.
The concept, says McDonald, is to provide a bridge between totally independent living and full time care. It’s a bridge many will not, in fact, have to cross because supportive housing – having their own units with housekeeping and other services available – will always answer their needs.
At Stephenville Crossing, in addition to the 126 bed nursing home, there are also 38 cottages for seniors who can look after themselves. When they can no longer manage without assistance, there’s always Emile Benoit, where residents get full custodial care.
And who decides who goes where?
That’s the other half of the revolution that’s been raging almost unnoticed.
With the Prairie provinces blazing a trail, and the rest of Canada sprinting to catch up, we seem to have opted firmly for one stop shopping when it comes to elder care.
If Mom, for instance, leaves the stove on once too often and appears to be unable to care for herself, it isn’t a case any more of her middle aged kids hunting for a suitable nursing home. She’ll probably be directed to an assessment unit – in Ontario they’re called Community Care Access Centres (CCAC) – where her needs will be carefully evaluated.
The goal, explains Kevin Mercer, director of the Waterloo, Ont., CCAC, is to keep the senior at home, perhaps with someone coming in to provide daily help. Supportive housing – usually apartment units with household and medical support – is a second choice, and a nursing home is now regarded as a last resort.
“The idea that everyone should end up in a nursing home is wrong,” says John Hirdes, a gerontologist at Waterloo University who is working on a 16 nation co operative study of geriatric assessment. “We need a grid of services. And the aim should be to keep people out of nursing homes as long as possible.”
The single entry agencies have their flaws – there have been stories of couples being split up, ending up in different institutions – but admission criteria are acknowledged to be fairer than in the past.
While the geriatric care debate continues, nursing homes, meanwhile, have changed beyond recognition. The major reason? Where just a decade ago the average age of admission was in the 70s, today the average age is between 85 and 90. No longer the “retirement homes” where Mom went to knit and chat, they more and more resemble chronic care hospitals, with IV drips, tube feeding and active dressings. And with half or more of the residents experiencing some form of dementia, security alarms on all exits have become part of the landscape.
And “long-term” care is rapidly becoming a misnomer. Average annual turnover in nursing homes stand at about 40 per cent, which means in any year nearly half the residents die or move to another institution, usually a hospital.
If that sounds depressing, it shouldn’t be. It simply means more and more people are staying healthy and independent and when Old Mortality comes calling, he’s likely to find them still living at home.