how one long-term care home used design to foster belonging
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when a new long-term care home opened its doors in arnprior this month, it was a project eight years in the making.
redeveloping the grove nursing home has been in the works since 2013, when arnprior regional health made a business case to the province, arguing there were not enough ltc beds in the town to serve the population.
“we wanted to create a smaller ‘seniors village.’ we wanted a more home-like atmosphere that did not have an institutional feel,” said eric hanna, the president and ceo of arnprior regional health, who retired at the end of september.
when the old grove opened in 1981 on the edge of arnprior next to a swath of old-growth forest known as gillies grove, it was not unusual for a new resident to drive themselves to the home, said hanna.
fast forward 40 years, and life expectancies have changed. ltc residents are older and more frail than in the past. back then, the average length of stay was five years, said hanna. now, provincewide, the average stay is about 18 months. across ontario, about 70 per cent of ltc residents have some form of dementia.
the new grove is a small piece of a very large and constantly evolving puzzle.
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ontario’s ltc commission estimated 96,000 additional ltc beds will be needed in the province by 2041, meaning an average of 4,800 new beds need to be built every year over the next 20 years.
but it does not appear the province is making that kind of headway. last may, the financial accountability office, the province’s fiscal watchdog, reported ontario will not meet its goal of building 15,000 new beds by 2024 and estimated only 8,251 new beds will be in service by the end of the 2023-24 fiscal year. the office projected the province will not reach 15,000 beds until the 2025-26 fiscal year.
about a third of the beds in ontario’s 623 ltc homes are also up against a deadline, with licenses for about 26,000 beds set to expire on june 30, 2025. a license typically lasts for 30 years, and is transferable with some limits when operators decide to get out of the business or expand. but if these beds are not updated to current standards in less than four years, some of them could close.
many of the province’s ltc homes have not caught up with the design changes needed to suit a more frail population that is more likely to be suffering from memory loss.
meanwhile, the pandemic has underlined the need to update homes and design them to better prevent outbreaks of infectious disease.
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a paper, published in august 2020 in the canadian medical association journal, found of the 10 homes with the highest death rates in the early part of the pandemic, seven were for-profit homes with older design standards and chain ownership. homes where residents shared ward rooms were one of the major issues.
“home design has an impact on resident quality of life and quality of care,” noted the province’s ltc commission in its 322-page final report released last april.
“in an infectious disease outbreak, these impacts are heightened, particularly in homes with ward-style accommodations and shared washrooms, which can make it difficult to implement infection prevention and control measures.”
the old grove was a sprawling one-storey red brick building. the new grove has two floors and is designed around three “neighbourhoods” of 32 residents each.
in the first months of construction, some things were changed in the new grove in response to the pandemic. ventilation was upgraded, plastic laminate was replaced with solid surfaces and some carpet in living spaces was replaced with sheet vinyl. a glass screen was added to the reception desk, said architect wendy brawley, who designed the new grove.
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the old grove had been built according to design standards set in 1972. the new grove is designed according to standards set in 2015. the old grove had 60 residents. the new grove has 96, adding 36 residents.
this is not a random number. divide 96 by three to get 32. in 1999, the province established the concept of “resident home areas’” for ltc homes — smaller, self-contained units of 32 residents within a home form a more intimate and familiar living space.
resident home areas are still the foundation for ltc design standards in ontario. residents in the new grove have been divided into three “neighbourhoods.” while the 60 residents in the old home all shared a dining room, living room, sunroom and “spa” bathroom, now only 32 residents share each facility, said brawley.
the new grove has ensuite bathrooms accessible to residents in wheelchairs, while the old grove did not.
in the new grove, 60 per cent of suites have one occupant and the remainder have two.
even the suites for two are more like a two-bedroom unit, said brawley. the two residents share only a vestibule and washroom. each resident has their own separate space with a wall separating the two spaces.
more importantly, each resident has his or her own window.
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“there were suites inside the old grove where a resident had to look over the feet of another resident to see outside,” said brawley.
marilyn colton is the chair of the friends and family council at the grove. she is also a retired ltc administrator and proponent of “person-centred care,” a model that rejects assembly line care and encourages residents to make their own choices and express their preferences. residents are encouraged to use the skills they had in their working lives, for example.
“in this model, the resident sets the day, not the staff. some people might not want breakfast. they might just want a cup of coffee. that’s all right. residents are involved in the operation of the home,” said colton. “if a woman did a lot of cooking in her life and she wants to help peel vegetables, she can do that.”
design is critical, she said. smaller neighbourhoods will help to facilitate person-centred care. so will other features of the new grove, such as residents being able to open the windows in their rooms, which they couldn’t do in the old grove.
“that’s the way it should be. it fosters independence and autonomy,” said colton.
technically speaking, the new grove is a “redevelopment” of the old grove, with an additional 36 beds. it is built on land left in a bequest about 50 years ago only steps away from the old grove. the arnprior community raised about $4 million of the $29.2 million cost of the new grove through fundraisers, lotteries and major donations.
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while many ltc homes in small towns are lucky enough to have room to redevelop on their current grounds, this is difficult for others in cities who have to acquire new land, said lisa levin, the ceo of advantage ontario, which represents the province’s not-for-profit senior care.
the grove was also up against increases in the cost of labour and materials during the course of the pandemic. the new grove is 78,000 square feet, but some 7,000 square feet were scaled back in the final design, including replacing solariums with seating areas with windows, said hanna.
“anyone who has tried to build a deck in the past two years has seen firsthand the spiralling cost of construction materials. this has been further exacerbated by material chain issues and limited availability of construction trades in eastern ontario,” said brawley.
costs have been a moving target for many organizations building or redeveloping homes. a recent estimate pegged the infrastructure costs of redeveloping an ltc bed at between $212,000 and $268,000. but cost pressures are moving that higher.
the cost estimates for the grove were higher than the budget before going to tender, but design changes helped arnprior regional health stay on budget. the changes were incorporated into a fixed-fee contract with the general contractor.
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“we had all of these great ideas. but it all came down to what we could afford,” said hanna. “the ministry set minimum standards. in some cases, we went over. but there are financial realities.”
in august, grey county council pressed pause on redeveloping grey gables, an ltc home in markdale, after a cost estimate update found a 42 per cent increase since the project had been approved in 2019. grey gables was one of two redevelopment projects in the pipeline for the county. if both projects went ahead, the county faced borrowing nearly $90 million over a 25-year term.
provincial design standards can also change. in april, the ltc commission called on the province to update the 2015 standards.
designs in the drawing board include showers in ensuite washrooms and changing finishes from laminated to solid to accommodate electrostatic cleaning technology.
some non-profit homes are taking matters into their own hands and voluntarily increasing standards, said levin. but those that want to add a chapel or gathering space often find the province won’t approve the design because it goes above and beyond existing standards, she said.
in the 1980s, grassroots organizations could build homes with the help of loans from canada mortgage and housing corp. and the province, said levin. now, many struggle because they don’t fall into the category of either housing or infrastructure.
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“i’m happy for the people of arnprior. but we need more support from the federal government in terms of loan guarantees. if we’re going to reach the targets the government wants us to reach, we’ll need more support.”
jlaucius@postmedia.com
by the numbers:
79,000: approximate number of ltc beds in ontario
30,000: number of existing beds in need of redevelopment
26,000: number of existing beds whose licenses will expire on june 30, 2025
20,161: number of new beds in the development pipeline, according to the ontario ministry of health and long-term care
15,918: number of redevelopment beds in the pipeline
timeline: a short history of building long-term care homes
pre-1991: long-term care falls into three categories: nursing homes, municipal homes for the aged and charitable homes for the aged. design standards had been introduced in 1972, but they only covered those in the nursing home category. the standards permit four beds to a room with a wash basin and flush toilet.
1993: all ltc homes are brought together under one ministry and one piece of legislation. but the legislation does not address building design and different structural classifications continue to exist.
1998: structural classifications are introduced.
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1999: minimum design standards are introduced. the province starts to tie capital funding to a set of design standards. these standards include “resident home areas,” contained units that allow for a more home-like environment, with a maximum of 32 residents to a home area. only single and double rooms are permitted.
2009: designs standards are refreshed and the long-term care design manual is introduced.
2014: ontario changes the construction funding subsidy it provides to ltc operators, with the goal of redeveloping 35,000 older beds by 2025.
2015: the current long-term care manual is introduced.
2017: the ontario liberal government commits to building 5,000 new ltc beds.
2018: the provincial progressive conservative government pledges to build 15,000 new beds within five years.
2020: ontario premier doug ford announces his government will add 30,000 ltc beds over the next 10 years and will be investing $1.7 billion in ltc homes in the next five years.
2021: ontario’s ltc commission recommends the province update the 2015 ltc design manual as soon as possible to include allowing sufficient space for cohorting residents in case of an outbreak, as well as design solutions to facilitate palliative care and updating heating, ventilation and air conditioning systems.
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