It's time to give last rites to the worn-out medical/institutional model of long-term care. The swelling wave of grey baby boomers will not stand for it. It's time to develop long-term care that allows seniors, no matter what stage they are at, to live life to the fullest, to be the best they can be. Why not focus on everything residents can do, instead of on what they can't do?
Change has begun, but it needs to accelerate. During the past 25 years, numerous initiatives have emerged, changing the way long-term care is delivered. Examples include the Sherbrooke Community Centre in Saskatoon (nine-resident households), based on the Eden Alternative, and the Fisher Personal Care Home in Fisher Branch (10-resident households), based on the Chez Nous model, both built in 1999. They demonstrate that by providing home-like environments, especially for elders who have dementia, their quality of life significantly increases and drug use dramatically decreases.
The first step in developing a residential/household model is a commitment to creating facilities that are similar to normal homes, places where residents are surrounded by recognizable things and similar people. This means creating smaller individual homes or households. Based on the experience to date, 10-resident households seem to be effective, although a very successful Dutch facility has only six. The latter also provides seven different lifestyles based on the interests (professional, political, religious), preferences (music, art, food, hobbies), social or private activities, and daily routines of residents.
The household model ensures residents drive their own lives, as they did at home. Schedules are flexible. Residents get up, eat, participate in activities, and go to bed when they wish. Each household is served by a multi-skilled, self-managed, staff team that carries out the daily tasks and also befriends the residents. Meals are prepared in each household, providing cooking aromas and opportunities for residents to assist. The food is served family-style, giving residents choices. This results in heartier eating habits, better health, less food wastage, and a substantial decrease in food supplements and medication. The physical and cultural design reflects a sense of home: Residents move about with intent as they would in their own homes, eliminating the need for artificial features such as wandering paths and memory boxes. Remarkably, the household model is financially viable and sustainable. Studies show capital costs are similar, operating costs are lower, and the quality of services is superior.
In the past decade, numerous homes based on the Green House model have been constructed in the U.S. (They were developed by Dr. William Thomas who also started the Eden Alternative in 1994.) This model features clusters of free-standing homes with eight to 10 residents in each. Homes are run by self-managed, cross-trained teams who are dedicated to increasing the skills and capacities of the residents. This model has evolved and there is now an Urban Model Green House project, built near Boston in 2010. The facility consists of five floors with two 10-resident households per floor. The main floor contains numerous amenities as well as indoor access to other parts of the complex.
I am involved with an integrated model, currently in design in Calgary, that expands the household approach into a community model. Several multi-storey buildings will each contain a mixture of self-contained long-term-care households (10 residents each), supportive housing, independent living, and other forms of housing, thereby creating an integrated community. A main floor, with various recreational and commercial facilities, will connect the buildings.
In the U.K. and elsewhere, neighbourhoods and even cities are working to become more dementia-friendly. Ensuring the elderly live meaningful lives is becoming a human right.
Change can be painful, especially for those who have a stake in the current worn-out, long-term-care system. But only change can prevent the abuses and disasters we hear about in the news. We need government policy, at all levels, to drive change. We need to stop medicalizing old age, even dementia, and to stop drugging people in facilities. We need to normalize old age and its challenges, to start seeing the potential in people no matter how elderly. We need to start by creating comfortable home-like environments that we'll be happy to live in if and when our time comes.
Rudy Friesen, partner emeritus at ft3, was the architect for the first Chez Nous personal care home. At 72, he wants to change long-term care before he gets there himself.