The Future: Nursing Homes

The Issue

Nursing homes have long been seen as grim and sterile, but during the COVID-19 pandemic, they’ve also been fatal. 1.3 million individuals living in nursing homes around the world have died from the virus. Globally, the fatality rate for people with COVID-19 is estimated at 3.4 per cent. In Canada, it’s 7 per cent, but the fatality rate for LTC (long term care) residents is as high as 29 per cent.

While elderly people and those with pre-existing conditions are high-risk populations, the infection’s rapid rate of spread is also due – as described in the EthicScan blog “Nursing Homes Ethics and Solutions” ( May 5,  2020) — to the way nursing homes are designed, funded and managed. Here we pose two questions.

  1. What are the key principles governing necessary change—both design and operational?
  2. What are the forecasts and outlooks according to eldercare nurses, facility designers, and health-care providers?

Nursing Homes and COVID

More than half of all COVID-19 deaths to date in Canada have been LTC facility residents and workers. Most deaths have been in Quebec and Ontario, although there have been several hot spots across the country. To date, Canada has the highest reported national proportion of COVID-19 deaths for LTC residents in the world, with 85 per cent of total COVID-19 deaths; the majority of whom are women. Comparable countries report percentages ranging from 29% (Australia) to 35% (U.S.) to 54% (England and Wales). 

People living in LTC are particularly vulnerable and more likely to experience severe disease or death from COVID-19 due to age, frailty, co-morbidities, less robust immune systems and the lack of prevention (vaccine) and treatment. About 40 per cent of home-care senior patients and 60 per cent of nursing home patients in Canada are in the top risk category for COVID-19 mortality due to age and underlying conditions such as renal failure, heart failure and liver disease. Many nursing homes in Ontario and Quebec have each registered 20 or more deaths. Federal data shows 94 per cent of COVID-19 deaths in Canada so far are from people aged 60 or older, and 62 per cent are from people aged 80 or older.

There are an estimated 700,000 seniors in Canada, 500,000 living in homes (home care circumstances) and 200,000 in nursing homes, senior’s homes, and long-term care (LTC) facilities. Seniors in home care are only there because they’ve got a family member supporting them. Otherwise they would be in a nursing home because they have comparable health conditions ⁠— it’s the family that is keeping them in place.

Residents have greater and more complex care requirements than ever before. Many are over 85 years old. Dementia is a major contributing factor to admission. LTC facilities have fewer regulated nurses, fewer clinical educators, fewer recreational therapists and aides, fewer social workers, and fewer physio and occupational therapists than ever before. This has a dramatic impact on the unregulated workforce, which is responsible for up to 80-90% of all point of care.

Before the 1980s, most patient care was provided by regulated nurses. Changes since then to staff mix and inadequate staffing levels have meant that workloads in the LTC sector are unsustainable for care providers and unsafe for residents. COVID-19 has exploited these long-standing vulnerabilities and exposed cracks in the foundation of an already-struggling LTC sector. 

A lot of nursing home buildings, built in the 1960s and 1970s — and not to the highest standards then — are at the end of their usefulness. Most rooms have two or four beds that are placed in close proximity; sinks and windows can be hard to access; and dated systems require surfaces to be frequently touched.  Despite the dramatic increase in complexity of individual patient care needs of residents, up to 80-90% of care is provided by unregulated care providers whose training and requirements vary across the country. Of Canada’s more than 400,000 regulated nurses, fewer than 15% work in LTC. Staff levels and skill sets have not kept pace with that complexity.

With this increase in acuity compounded by insufficient staffing and staff mix levels, staff at care homes report increased workloads and decreased quality of work-life. Despite this, many unregulated care providers maintain employment in more than one LTC setting, partially because compensation is insufficient. Improved compensation, improved staffing levels and improved staffing ratios to ensure the “right provider at the right time” could all contribute to more favourable work environments. In turn, research shows that more favourable work environments could lead to better quality of care, more effective teamwork, and less care left undone. 

Once COVID-19 is detected in staff or residents, self-isolation of contacts means staffing shortages are exacerbated. This increases patient ratios as patient illness and acuity also increase. In many facilities, there is no reserve of care staff and no contingency if a significant proportion of staff is not working due to illness, isolation or other factors. The lives of unregulated care aides during COVID-19 are complicated by:

  • (a) family pressures or threats of eviction from landlords;
  • (b) poor access to personal protective gear (PPG); and
  • (c) many do not have sick benefits, as many employers opt for part-time and casual staff to reduce benefit costs.

Enhancement Worthy Forecasts: Design

Admittedly, it is not easy to restructure or anti-COVID-inoculate nursing homes that have already been built. Nonetheless In the face of coronavirus, several experts have been rethinking how nursing home design and function could be enhanced. Here’s what they suggest:

  • Give each resident more space: Reducing the standard clusters of 40-50 residents to 12 people maximum, each with their own room, would help limit virus transmission while allowing for more targeted and intimate care. 
  • Discontinue double-bedded, semi-private rooms: as the easiest way to help mitigate prevention and spread of COVID-19 or any other contagion.
  • Add transitional short term stay units: Complement longer-term stay facilities with transitional care and short-term stay space. For example, home-care, family-respite needs as well as for patients who no longer need to be in the hospital but aren’t ready to fully integrate back into independent living. Benefits include:
    • (a) hospitalized patients can recuperate in a more secluded setting while still socializing with friends and family;
    • (b) patients can readily access or be under the supervision of a nearby hospital or other institution; and
    • (c) less health-compromised relatives can be chosen and allowed to visit in order to reduce infection, prevent the spread of the virus, and mitigate the isolation that comes from a nursing home lockdown.
  • Offer future residents larger, outdoor-connected, units well-suited for sheltering in place: The ability to have outdoor connectivity to a small terrace or Juliet balcony becomes really important to the sanity, health and wellness of many an individual resident during a pandemic. 
  • Diversify services offered: A pavilion-like facility of individual rooms or cluster of outdoor cottages can offer diverse services and benefits:
    • (a) family members can visit patients, primarily elderly people, while they receive medical treatment;
    • (b) patients can receive continuing care without exposing themselves to infections and viruses in hospitals; and
    • (c) residents have a more restful space that promotes healing.
  • Design more flexible spaces: Build flexible-use spaces for multiple-age groups, both young and old together, capable of being reconfigured to best serve that moment (for instance, putting all infected patients in one wing to limit the virus’s spread).
  • Choose LTC design and construction answers for the worst case: then you’ll be a lot better off for those more minor epidemics, like the flu every fall.
  • Consider campus and community designs where you don’t have to close down an entire community to enact strict infection control measures: For example, “pocket neighbourhood” designs that house residents in smaller, 16-20 bed self-contained neighborhoods. This involves grouping residents in 12-unit homes with private rooms and bathrooms, decentralized dining and other features that could help with infection control protocols.
  • Work with new materials that are either antimicrobial or are easily cleaned: For example, copper (which is already anti-microbial) in fabrics and solid surfaces can help make flooring, furniture, accessories, countertops, cabinets, handrails and doors more resistant to germs and pathogens like the novel coronavirus. 
  • Anticipate air filtration and purification considerations: they may become more important in senior living design, possibly driven by future changes in air quality codes.
  • Choose ergonomic technologies: they allow residents to navigate communities without pressing buttons or grabbing handles. This could be accomplished through:
    • (a) motion controls, which are already in use in the senior living industry,
    • (b) voice controls, like the ones seen in Amazon’s Alexa product, (or other Smart Speakers) and
    • (c) motion-sensitive intercoms.

 Enhancement Worthy Forecasts: Operations

While it’s uncertain how or when the COVID-19 pandemic will end, the disease’s unique pressures will continue to shape how senior living communities are designed, operated and monitored for years to come. Here is a selection of choices and forecasts from geriatric service stakeholders and experts. They are drawn from a literature review and interviews as part of an EthicScan webinar dealing with this sector:

(a) Give centre stage to active collaboration among professionals in health-care, legislative experts and industry specialists, coming together and working jointly to create new standards which will result in positive change.

(b) Expand virus testing of patients, caregivers and visitors in LTC facilities beyond current federal recommendations of testing only symptomatic individuals. Feed that data back to physicians and nurse practitioners to help identify most at-risk cases in order to manage them in, and throughout locations in the community. 

(c) Enhance infection protection and control standards, including dedicated isolation space, access to available PPE equipment, staff training, and transparency in reporting infection rates. The (U.S.) Hospital Improvement Innovation Network (HIIN), for example, has created effective measures that successfully have reduced the number of infections in hospitals.

(d) Radically alter normal socialization operations to prevent or limit the spread of COVID-19, such as:

  • i. canceling certain group activities and communal dining in favor of in-room entertainment
  • ii. offering meals on delivery, and
  • iii. sheltering a facility’s resident population in their rooms to protect them and give them peace of mind during a pandemic. 

(e) Improve compensation, staffing levels, and staffing ratios to ensure the “right provider at the right time” services which will contribute to a more favourable nursing home work environment. 

(f) Adopt remote communication technology (such as Zoom and Skype) as a tool to overcome social isolation and safely maximize interaction with the outside world. This includes new ways to remotely connect residents with family members, visiting friends, physicians and other health-care workers. The benefits include:

  • i. virtual socialization,
  • ii. tech-support should a TV or Wi-Fi go down and
  • iii. a clear communication system in place so that residents can get quick answers to questions.

(g) Provide more spaces that can be used for a variety of levels of care and various purposes, such as interim housing for staff, intermittent respite-care for those living at home, and step-up-step-down convalescent care to and from hospital. 

(h) Facilitate all-important, in-person visits with the help of dedicated “clean room” technology whereby residents would meet with their loved ones or friends in two adjacent rooms separated by a glass partition and equipped with an intercom system or even mobile phones. Staff would then sanitize the room after each use.

(i) Provide a specialized dedicated room for telemedicine sessions, or even just a cart with video conferencing technology that can be rolled throughout the facility, especially for residents showing more recent interest in digital technology at the encouragement of COVID-savvy grandchildren.

(j) Use less artificial, fluorescent light which is known to decrease levels of melatonin, a hormone which controls our circadian rhythms. When this “body clock” is interrupted, it affects sleep, hormones levels, and blood pressure; compromises the immune system; and can increase the risk of developing illnesses like depression and diabetes. Using design to boost the psychological health of nursing home residents could be more of a priority at many of these spaces.

(k) Apply a healthy design “archiceutical” approach to nursing home design. This includes

  • i. light therapy through an abundance of windows,
  • ii. placing structures in natural landscapes, and
  • iii. decorating with mood-enhancing colors like blue or yellow, all of which can contribute to healing.

(l) Remove unhealthy elements from existing buildings. Materials that generate gases, like glues and paints, should be eliminated so residents aren’t inhaling toxins (particularly since COVID-19 attacks the lungs). Heating systems that overproduce static ionic electricity in the air are another concern, as they harbor pathogens and affect breathing.

(m) Redefine community in the sense that populations of all ages live together in a blended community environment. When the elderly spend mixed time with school-aged children during the day:

  • i. the children love it as do the elderly,
  • ii. it enhances residents’ mental acuity; and
  • iii. it addresses some of the more systemic issues of eldercare such as isolation, loneliness, and mental health, which can be detrimental to physical health as well. 

(n) Apply robots, drones as well as remote health monitoring or bedside telemetry to help alleviate the burden on some care provider staff (for functions like carrying equipment, sterilization tasks, and expediting testing).

Conclusion

None of these many design and operational changes come cheap, and many nursing homes already operate on “razor-thin profit margins.” Implementing wide-scale changes to the industry would mean acknowledging the importance of not only design on mental health but also mental health on overall wellness. Many geriatric care specialists agree this means reprioritizing the elderly and their role in a vibrant society. Most significantly, necessary LTC reform would require a massive overhaul of the health-care system. It’s a lot, to be sure, but if anything is going to jump-start a revolution in our approach to eldercare, it’s a disaster.

Further Reading

CNN – Covid-19 is ravaging nursing homes. Government records show why:
https://www.cnn.com/2020/04/24/us/nursing-homes-coronavirus-invs/index.html

Modern Health Care – Independent Commission Reviews Nursing Homes COVID-19 Response:
https://www.modernhealthcare.com/government/independent-commission-review-nursing-homes-covid-19-response

Senior Housing News – How Covid-19 Is Shaping the Future of Senior Living Architecture and Design:
https://seniorhousingnews.com/2020/04/07/how-covid-19-is-shaping-the-future-of-senior-living-architecture-and-design/

Fast Company – Nursing home design is deadly, here’s how to change it:
https://www.fastcompany.com/90484506/nursing-home-design-is-deadly-heres-how-to-change-it

World Health Organization – Infection Prevention and Control guidance for Long-Term Care Facilities in the context of COVID-19:
https://apps.who.int/iris/bitstream/handle/10665/331508/WHO-2019-nCoV-IPC_long_term_care-2020.1-eng.pdf

Energetic City – How Canada’s nursing homes can be fixed to avoid repeat of COVID-19 outbreak:
https://www.energeticcity.ca/2020/05/how-canadas-nursing-homes-can-be-fixed-to-avoid-repeat-of-covid-19-outbreak/

CTV News – ‘Where the tragedy really lies’: The crisis in Canada’s long-term care homes:
https://www.ctvnews.ca/health/coronavirus/where-the-tragedy-really-lies-the-crisis-in-canada-s-long-term-care-homes-1.4927328

The Washington Post – Canada’s nursing home crisis: 81 percent of coronavirus deaths are in long-term care facilities:
https://www.washingtonpost.com/world/the_americas/coronavirus-canada-long-term-care-nursing-homes/2020/05/18/01494ad4-947f-11ea-87a3-22d324235636_story.html

The Globe and Mail -Lawsuits over COVID-19 handling in nursing homes raise questions about standard of care:
https://www.theglobeandmail.com/canada/article-lawsuits-over-covid-19-handling-in-nursing-homes-raise-questions-about-2/

Forbes – The Grim Post-COVID-19 Future For Nursing Homes:
https://www.forbes.com/sites/howardgleckman/2020/05/04/the-grim-post-covid-19-future-for-nursing-homes/

TV Ontario – Disturbing insights into long-term care from a former inspector:
https://www.tvo.org/article/disturbing-insights-into-long-article-care-from-a-former-inspector

David Nitkin

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