How many nursing beds are needed in Canada to care for frail, elderly people with high care needs? That's a question policy-makers across the country are grappling with, given the aging population and especially the rapidly growing number of very elderly people over the age of 85.
Many people as they age eventually need some help with daily activities such as housework or shopping, but with some help they can stay in their own homes. Some people, though, particularly those who reach their 80s or 90s, or even 100, eventually need more help than that, such as help with getting in and out of bed, eating and using the toilet. When care needs are this great, admission to a nursing home -- or what are also sometimes called long-term care facilities or personal-care homes -- is usually the only option.
Should we really be talking about how many nursing-home beds are needed -- as politicians, media and health policy people all do? Or shouldn't the question be, "How many more homes are needed for frail, older people who need care?" One might argue that "bed" is just a manner of speaking, a way to simplify the language. But language does matter; it reflects assumptions and it limits thinking.
The language of "beds" fits with a medical model. It evokes images of institutions, people who are sick lying in beds and long, impersonal hallways. The idea of a "home" brings to mind entirely different images. The smell of homemade cooking, a favourite armchair, a window to look out of and watch people going by and, ultimately, the feeling of a place where one is comfortable and safe.
There have been considerable strides in the last few decades in making nursing homes feel less institutional. Older institutions have been refurbished so most, if not all, residents have a room to themselves, people are encouraged to personalize their rooms, and the staff is often very caring. Newer nursing homes sometimes consist of smaller units to create a more intimate feel. Yet, fundamentally, they are still institutions.
What if the starting point for thinking about nursing homes is to take the idea of the "home" seriously? Would the result be different?
Models that do just that exist, but they are still the minority. Some use the language of "villages," suggestive of a small, intimate community where everybody knows each other and looks after each other. In the Netherlands, a village has been created for people with dementia where they can shop, go eat in a restaurant, and live as normally as possible for as long as possible.
Other models offer self-contained housing units, each accommodating a small number of residents, akin to a group home. The emphasis is on recreating the home experience by being small-scale and home-like in layout and furnishings. The philosophy of care in these settings emphasizes people's dignity and right to continue to live life to the fullest, despite care needs.
The vast majority of older people want to age in place in their own home. When staying in their own home is no longer possible, should people not have the option of living in a home-like setting, rather than an institution? Would we not want that for our mother, father, grandmother or grandfather?
The crux of the matter is, of course, there are typically few choices. Elderly individuals and their family members are restricted by what is currently available. When a bed in a nursing home becomes available, there is not much choice but to take that option. And there is tremendous pressure on hospitals to discharge elderly people who can no longer go home to nursing homes -- they are sometimes called "bed blockers," yet another word that evokes many negative images.
We need a different philosophy to underlie nursing homes. And it starts with the language that is used. We don't need more nursing-home beds. What we do need are homes and care options so people have choices. We need creative thinking about what might be possible to accommodate diverse needs and preferences.
There are examples that can be built on, but there needs to be a willingness on the part of policy-makers to support innovative thinking. Elderly people themselves and family members need to speak up and voice their preferences. In thinking about new approaches, the question we have to ask is really quite simple: "Would I want to live here?"
Verena Menec is an expert adviser with EvidenceNetwork.ca and a professor in the Department of Community Health Sciences in the College of Medicine at the University of Manitoba. Her research focuses on aging.