This past weekend, like many I sat riveted, watching the SpaceX Endeavor as it launched successfully and 19 hours later, docked with the International Space Station.
Like a phoenix rising from the fire of chaos raging across our planet, the Endeavor is a symbol of what is possible when vision meets believers, talent, and money.
Which brings me to an issue we cannot seem to solve: long term care.
The COVID-19 pandemic has pulled the curtains back on institutionalized care for seniors in Canada, the US, the UK and much of Europe. One cannot be blamed for wanting to close the curtains again as quickly as possible because what was exposed was not pretty. However, we would do further injustice to our seniors by allowing the curtains to fall again.
In Ontario and Quebec, the Canadian military was deployed to sort things out and provide care in long-term care homes ravaged by COVID-19. Over a week ago, the military released a report that, to the government’s credit, was quickly made public. The report, in true military fashion, cut to the chase and listed the atrocities found in the five homes in which they were called upon to serve. The report shocked the general public, causing a storm in the media and social media that has only been bumped by recent unrest elsewhere in the world. I should note that of the over 2,000 deaths in Ontario due to COVID-19, 83% of those were residents of long-term care, retirement or group homes—the vast majority in long-term care.
I was as distressed as anyone else by the military’s findings, but not at all surprised. The report was refreshingly candid; having never provided medical services in that setting, the observations were from those who were seeing long-term care for the first time. The authors talked about residents calling out for help repeatedly and not receiving any assistance. They observed people sitting in wheelchairs all day with no stimulation. Those of us who have visited long-term care residents or who have had loved ones who live there will think as I do: that’s par for the course. Understaffing will do that! Of course, the report went on to reveal people not being fed, food left on trays to rot, feces on the wall, and much, much more. COVID-19 pushed an already precarious situation over a cliff.
The report is tough but necessary reading.
On the upside, unlike Spain, the military did not find any residents dead in their beds. So, there’s that.
Our Ontario premier, minister of long-term care, and even Canada’s prime minister came on air to express their shock and outrage, with promises of inquiries and fixes. We won’t hold our breath. People have been calling for change for decades and it has yet to happen in any substantive way. Politicians up and down the line have known about the issues in institutionalized care—how could they not?—but senior care is not sexy. Caring about old people doesn’t win elections. Pipelines and climate change do, at least for now.
Before I get too political, let me explain a little about senior care in Canada, or at least, in Ontario, for my readers to the south of us.
Canada is a federation of provinces and territories, each of which is responsible for managing their own health care. Thus, we have more than ten health care systems operating independently across the country, each funded in part by the federal government. Each health care system is responsible for doctors, nurses, hospitals, institutionalized care, home care, and more.
In Ontario, our hospitals are chronically underfunded. One of the good things to come out of COVID-19 is that the wait times for ER have reduced dramatically as people with regular issues have been encouraged to stay away. Hospitals for once are not operating at over-capacity.
Ontario seniors have several options for living accommodations as they age, but much depends upon income. Subsidized apartments are available for seniors who cannot afford rent and who do not own their own homes. Those who own homes and wish to move into a setting that relieves them from the upkeep of a house and garden can choose to move into adult-living communities or independent living. Retirement homes may be the next stop when cooking, driving, or getting out to socialize or participate in activities becomes more difficult. Retirement homes typically offer greater availability of care options, although anyone living at home or in independent living communities has access to at-home care. When dementia or physical ailments mean more advanced levels of care are required, seniors move into assisted living, long-term care, or hospitals.
Of these various housing options, only long-term care and limited quantities of home care are funded by the provincial government. What this means to a resident is that the fees for long-term care are adjusted based on income; no one will be left on the street if they can’t afford care but may be offered a bed in a room with three other people rather than the private room. From what I understand, limited amounts of home care hours are available to people based on income. Again, no one will go without care, but care might mean two hours per week.
Retirement homes and assisted living are beyond the means of many (most?) Canadians. When searching recently for a place for a relative, I was shown a small room with a closet and a window for $2,300 per month, meals and activities included. A room with a compact fridge and space to microwave a meal or plug in a kettle would have been well over $3,000. That’s considered cheap. Fees in urban retirement homes for one-bedrooms can easily reach $4,000-$7,000 per month and higher.
Seniors over the age of 65 receive the Canada Pension Plan and also provincial retirement funds—in Ontario, it’s called Old Age Security. Unless one is living in the afore-mentioned subsidized seniors’ apartments, the combination of the two is not enough to live on and eat at the same time. Hence, some people who can no longer live at home due to their physical condition or dementia, and can’t afford home care or retirement homes, end up in a quad or double room in long-term care.
One more thing: due to the long waitlists for long-term care, thousands of seniors languish in hospitals while many with dementia who would benefit from increased levels of interaction and support end up in retirement homes rather than memory care. There are waitlists because the provincial government puts a limit on the number of “beds” that can be built. Existing homes that want to extend the number of beds cannot. They can renovate but cannot add a bed. The Ontario government recently increased the number of beds in an attempt to address the waitlist. The reason for the limit is that the government would need to pay more for funding each “bed” and to assist in building the residences, most of which are multi-story buildings.
And it’s all understaffed and underfunded.
Public homes are underfunded because they’re, well, public. Private homes can start to feel underfunded because the home is a business with owners who expect to at least break even and optimally, make a profit. If the profits do not meet expectations, residents can expect cheaper cuts of meat. PSWs are underpaid and overworked. The tenuous situation in long-term care was made worse by COVID when staff became ill or stopped coming to work from fear of being infected.
Now, some long-term care homes deal with their constraints better than others. Some private home operators are mission-driven rather than profit-driven, meaning that they put care above making money. In addition, lest one think that everyone in Ontario over the age of 65 is locked up in an institution, let me point out that of those aged 85-94 living in Canada in 2016, only 16.4% were living in long-term care or assisted living, translating into approximately 118,000 Canadians. (Conference Board of Canada, Sizing Up the Challenge, https://www.cma.ca/sites/default/files/2018-11/9228_Meeting%20the%20Demand%20for%20Long-Term%20Care%20Beds_RPT.pdf) According to this same report, the number of people in this age group is predicted to double by 2035, with 239,000 Canadians requiring accommodations in long-term care.
In 2035, I will be 72, not quite ready for long-term care. My hope is that I will be one of the 84% who never lives in long-term care. However, low income, low retirement savings and poor health are three conditions that could push me and others my age in that direction by 2045.
So what needs to happen?
I hate writing that “we need someone with vision to take leadership” because I’m of the mind that if you’re not prepared to do what you’re asking others to do, then don’t suggest it. “If not me, then who? If not now, when?” But I’m not the best person. We need an Elon Musk of health care. We need someone with vision, talent, believers, and money.
The media has been calling for the government to take over long-term care and make them public. Bring them in under the same umbrella as hospitals. There’s something to that suggestion; long-term care homes are really like hospitals but without the staff. Walk down the corridors of most long-term care homes and you’d think you’d mistakenly walked into the hospital instead. I have to come down on the side of NOT making long-term care homes government-run, however. If we did, I fear that every home would need a foundation to fundraise for it, just as all hospitals do. Did you know that most equipment in Ontario hospitals, including the actual BEDS, are purchased only as the result of hours of dedication on the part of volunteers, who raise millions of dollars to make sure patients have what they need?
Besides that, long-term care and retirement homes are already regulated up the wazoo by the government, so going public will not solve anything.
According to the same Conference Board of Canada report above, there are several costs to consider when thinking about how we can create more space in long-term care to accommodate current waitlists, future residents, and now social distancing as well—no more “four-to-a-room.” There’s the cost to build and equip the home, which amounts to billions of dollars. And then there’s the cost to provide care, which is approximately $75,000 per year, per bed (the industry refers to residents as beds). The question becomes: How might we better spend that money to provide care to seniors?
To do that, let’s take a look at care at the other end of the life spectrum: childhood.
In Canada, new parents receive paid maternity and paternity leave. They also receive the Canada Child Benefit, which can be as much as $500 per month on average, per child, until the child is 18.
How about we fund the care of seniors the same way we fund the care of children? We don’t like to think about spending all that money on seniors because their productive years are over. The average return on investment of putting billions of dollars into senior care pales in comparison to the potential of children if we invest in their futures. Children become future voters as well.
First, that’s ageism. Second, that’s narrow-minded.
What if the $75,000 spent “per bed” on long-term care residents was spent paying nurses and Personal Support Workers to provide home care, and paying them well? What if someone who broke a hip could be supported to live in a small group home embedded in the community with free care rather than being forced to live in long-term care because that was all they could afford? What if, in addition to government pensions, people received an additional $500 per month to fund home care, recreational therapy, occupational therapy, transportation, and activities, just as parents are funded for their children? And what if a family were given two years of paid leave to support a family member with complex care needs?
Not only is the investment in the person who is aging, but the investment is in that person’s family, which doesn’t need to choose between work and caring. The investment is in care workers, who, when paid properly, presumably have more money to spend and more to invest in their own children’s wellbeing. The investment is in our community, which would be better for having seniors embedded in the community either in their own homes or in small group homes with dedicated care workers rather than in a highrise, cut off from the community.
How do I see this unfolding in our current care infrastructure?
Immediately provide enough funding to long-term care to staff them properly and pay PSWs and other staff the wage they deserve. No more PSWs working at three different locations to make ends meet. Let families become a vital part of the care of their family members, starting now, even during COVID-19.
Then, assess the real care needs of those currently in long-term care. Those who need care but could live more independently if well-supported do not need to live in long-term care. Build small group homes to accommodate them in the communities. The way they throw up houses and apartments in the suburban area in which I live, I know these can be built quickly if government has the stomach for it.
Then, increase funding to those living in their own homes so that they have the appropriate level of care to remain there. Fund more housing models like Wellings, where people live communally in apartment buildings, each in their own well-appointed suite or apartment at various price points, with one meal per day and self-managed care. Provide funding that incentivizes families to care for their older family members.
The objective is to cut down on people moving into long-term care and retirement homes.
Once it is clear what the real need is for long-term care, renovate the spaces so that no one shares a room.
I was about to launch into how we must redesign our communities from the ground up so that the amenities we need are within easy walking distance and not a drive, thus benefiting families and seniors alike. And no, a gas station does not qualify as an amenity I’d like to walk to. But, I’ll save this topic for another time. Instead, I’ll leave you with this:
Yes, re-envisioning care for our older adults is a massive job. Sending Endeavor to the space station might seem easier than overhauling long-term care, but like a phoenix rising from the ashes, it’s what must be done. It’s overwhelming, I know. There is one small action that you can take, however, and you can do it today: when you see a senior, flash them a smile and a handwave. Yeah, I know, social distancing, blah blah. Plenty of seniors are out and about walking or sitting on their front stoop or outside their apartment buildings. Go for a walk, and if you see someone, look them straight in the (socially distanced) eye and say, “Hello!”
Part of the problem of re-envisioning old age is that the people who are in charge of that aren’t old; they are far removed from issues of ageing. But you can start now to promote understanding in your community, simply by a smile and a greeting.
Let’s start there.