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A U.S.-based movement aims to put seniors in smaller groups with better amenities, and Premier François Legault wants to adopt it on a mammoth scale – but complex questions of cost and logistics must be sorted out first

Illustration by Pui Yan Fong

In the 10th decade of her life, Vera Altman found herself living like a student in a college dorm, sharing a room with another woman who kept her up at night. The Farash Tower, the main residence of Jewish Senior Life, her elder-care provider in Rochester, N.Y., used to be the kind of accommodation many aging people live in: large, impersonal and institutional.

Seniors didn’t have private rooms, there were few common areas, and everyone had to eat at the same time. The poor health of her roommate led to sleep deprivation for Ms. Altman, since staff had to enter their room so frequently.

“They had to come in at night and take care of her. Every night this would wake me,” Ms. Altman said in a recent interview on the eve of her 101st birthday.

That changed when she and scores of other residents relocated to one of three cottages Jewish Senior Life built in 2017, using the Green House model, a concept that sees seniors living in smaller groups, in a home-like setting, with single-occupancy bedrooms and showers. Instead of 7 a.m. wake-ups, residents could get out of bed when it suited them.

“Everybody said they thought they went to heaven,” Ms. Altman said.

Vera Altman, 101, shows visitors her room at the Jewish Senior Life centre in Rochester, N.Y. In her chair, she uses a tablet to play games; in the hall, registered nurse Tracy Hanel gives her a hand. Fred Lum/The Globe and Mail

Around her room were discrete signs that the cottage wasn’t just her home but also a place of medical care for dependent seniors. The ceiling housed an overhead track for the lift to transfer residents with mobility issues. An alcove near the door hid a wooden cabinet for medications, with a shelf where nurses could place a laptop to access medical charts.

Nearby, in the sunlit open kitchen and dining area, caregivers helped nine residents in wheelchairs eat lunch at the communal table. Mary Ann Roesch, an 85-year-old former teacher, said the cottage was more serene than her previous shared-room arrangement. “It’s more home-like. Communal dining. You pretty well know the people on your floor.”

Quebec hopes its long-term care residents will soon experience something similar – the province is in the midst of an ambitious drive to duplicate this type of nursing home, which could serve as a template for other provinces and transform long-term care in Canada.

The U.S.-based Green House model is the best known proponent of a movement that aims to eradicate the indignities of institutional living through smaller-scaled forms of elder care that are designed to accommodate the needs of residents.

While some homes in British Columbia, Ontario and the Maritimes have adopted this approach, no one has made as big a commitment as Quebec. Premier François Legault’s government plans to open 46 facilities, known as Maisons des aînés (French for elders’ houses), housing 3,480 people. About 2,600 beds are to be ready by the end of the year.

A private single-occupacy suite and a family room stocked with toys and games are shown at a long-term care facility in Laval, Que., that is testing out the new features Quebec plans to adopt. Evan Buhler/The Globe and Mail

The initiative was unveiled before COVID-19, but the pandemic has brought urgency to the need for better long-term care residences. At a coroner’s inquest into the impact of the pandemic on Quebec care homes, witnesses last year recalled how, even before the coronavirus, their ailing, aging parents had to live in grotty, crowded facilities.

“They call it a living environment. It’s more like a zoo,” Sofie Réunis testified about placing her mother who had dementia into a place with shared rooms, blaring TVs and staff oblivious to the stress this caused.

More than 6,500 long-term care residents in Quebec have died from causes linked to COVID-19 since the pandemic started. Residents in Green House-style facilities, by contrast, have fared better, studies show, since private rooms and the small-scale living arrangements help contain the spread of infection.

Quebec will build and operate the MDAs on public budgets – unlike Ontario, which plans to create 30,000 beds and upgrade another 28,000, but using prepandemic standards that still allow double rooms and allocating new beds to some of the same for-profit operators with the worst COVID-19 track records.

With a Quebec election to be called on Aug. 29 at the latest, Mr. Legault can be expected to mention on the campaign trail that the Maisons des aînés are a major achievement of his government. Constructions of the first homes, in Lévis, Sherbrooke and Rivière-du-Loup, will be completed “soon,” a Health Department spokeswoman said, without giving a specific date. However, the project is facing hard questions about its soaring capital costs, now nearing $3-billion, the outlying locations of the new homes, and whether the 3,480 beds will even be enough, considering there are currently 4,160 people waiting for a spot.

Still, those who’ve studied the Green House model, such as Laval University professor Philippe Voyer, who helped design the MDAs, say it offers the potential for improved care. “Long-term care is an environment that is very, very stagnant, which is still very static in terms of modernizing practices,” he says. “But fortunately, in the last 15 years, we have started to have more scientific research, to be able to do more, to do better.”

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At the Jewish Senior Life centre in Rochester, the large dining table is designed to give residents and staff more room to sit together and form community bonds.Fred Lum/The Globe and Mail

Mary Ann Roesch, 85, heads back to her room with certified nursing assistant Ashley King. Fred Lum/The Globe and Mail
Susan Adams-Price, a manager at the Rochester home, visits one of the private bathrooms. Fred Lum/The Globe and Mail

The seeds for this new approach to elder care were planted three decades ago in Saskatchewan.

In 1987, Suellen Beatty was a nurse who had just completed a master’s in gerontology and the environment from the University of Saskatchewan. The Sherbrooke Community Centre in Saskatoon hired her to design its new long-term care facility. At the time, provincial guidelines called for a very impersonal type of nursing home, with up to 60 residents per ward. “I was heartbroken,” Ms. Beatty recalled in an interview. “Nobody who has a choice lives like that … places that are like this are prisons, sanatoriums or mental hospitals, places where people didn’t go by choice.”

Sherbrooke, which is run by a registered charity, started to move away gradually from those standards, at first completing two units of 20 residents each in 1993.

Ms. Beatty conducted focus groups with seniors receiving home care. They told her they would rather die than move to a nursing home. “So I said to them, ‘If you could design it so that it was acceptable for you, what would it be like?’” Their input helped shape Sherbrooke’s Village Model, where residents live in groups of 10 in bungalows connected by a covered street. Sherbrooke had an agreement to house military veterans in one village. For the other, they had sponsorship from a local charity, the Kinsmen Foundation.

As the Sherbrooke villages took root in Saskatoon, in the U.S., Bill Thomas, a geriatrician from Ithaca, N.Y., looked for better ways to care for elders. He was marked by an encounter with a long-term care patient who had a minor medical issue. “Doctor, I am so lonely,” she told him, making Dr. Thomas realize she needed more than clinical care. He began advocating what he called the Eden Alternative, emphasizing the well-being of elders to counter the helplessness and boredom of nursing home life.

In the fall of 1998, Ms. Beatty met Dr. Thomas at an Eden Alternative training session in Minnesota. She showed him photos of the Sherbrooke villages, got him to tour the site a few summers later – “and he said, ‘Oh my goodness, this is it!’”

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One of the Green House cottages in Rochester.Fred Lum/The Globe and Mail

The Sherbrooke villages led to Dr. Thomas’s formulation of the Green House, his reimagining of a more intimate, compassionate type of care home, focused on residents’ needs, rather than the assembly-line atmosphere of big institutions.

The first opened in 2003 in Tupelo, Miss. Green House became a not-for-profit that has worked with local partners to launch homes from Portland, Ore., to Pompano Beach, Fla.

Its footprint in the U.S. remains small, with 359 sites in a country with an estimated 15,600 nursing homes.

Green House facilities are divided into units called “homes” of 10 to 12 elders living in a self-contained ward. Architecture isn’t, however, the sole departure from traditional care, Green House senior director Susan Ryan said in an interview.

Staffing is reconfigured to ensure there’s a consistent team that keeps a close connection with the elders.

This includes expanding the role of personal-care workers, the staff who usually assist nurses with basic tasks such as weighing residents or taking blood pressure.

Under the Green House model, their responsibilities also include meal preparation, housekeeping and laundry, to create deeper bonds with their charges.

“You get to know what they like to eat, what they like to do, you build a relationship with them … it’s more intimate,” said Susan Adams-Price, director of Person-Centered Care at the Rochester facility.

The approach also helps identify potential problems. “We are able to intervene much earlier rather than wait for things to get more full blown and out of control,” Ms. Ryan said.

The model comes at a higher cost, at least in Quebec. The average cost of servicing a public long-term care bed in the province in 2021 was $108,114. The estimated cost for an MDA bed will be $125,000, according to Seniors’ Minister Marguerite Blais, and $143,800 when including maintenance expenses.

Ms. Beatty says it can be challenging convincing others to adopt the small-home approach.

“We’ve had visitors from everywhere in the world, as far away as Japan. And you know, it’s just the willingness of people to change, especially when you’re asking them to inconvenience themselves. It’s a hard sell.”

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A Red Cross volunteer walks through a mobile hospital set up in Montreal's Jacques-Lemaire Arena in April, 2020, for COVID-19 patients from long-term care centres. Per capita, Quebec had more nursing-home deaths in the pandemic than any province.Christinne Muschi/Reuters

Canadian Armed Forces members take a training session in Montreal in April, 2020, before deploying to the Quebec seniors’ residences hit hardest by COVID-19. Ryan Remiorz/The Canadian Press
Flowers lie outside Residence Herron in the Montreal suburb of Dorval in May of 2020. Quebec would launch a coroners’ inquest into deaths and neglect of residents here. Graham Hughes/The Canadian Press

Even before the pandemic, Quebec’s long-term care system faced challenges. Among Canadian provinces, Quebec has the fewest long-term care beds per capita. The national average is 29 beds per 1,000 people aged 65 and older. Quebec’s ratio is 24.

And while the province spends more now for long-term care, once adjusted for inflation and the increasing number of seniors, funding actually shrank by 14 per cent over the past two decades, according to former health minister Réjean Hébert.

The coronavirus starkly exposed the flaws in this system. Quebec had the highest rate of COVID-19 deaths in nursing homes in Canada during the first wave of the pandemic.

The government wasn’t oblivious to the poor conditions. Already, in 2003, the Quebec Health Department issued ministerial directives outlining that nursing homes weren’t just places for medicine but were also places for living.

But they remained underfunded, unhappy places. By 2016-2017, the government of Liberal premier Philippe Couillard faced drawn-out outrage about nursing homes cutting corners by only giving residents a bath every two weeks.

In the 2018 election, elder care was the hot topic at the first televised party leaders’ debate, with an audience member asking the candidates why her 83-year-old husband had to live in a nursing home with inedible food, foul-smelling hallways and sweltering rooms.

Mr. Legault was able to reply with a specific proposal. Elder care was a significant element of the CAQ electoral platform, with the Maisons des aînés, presented as a “generational” project. “We owe that to our elders,” he said.

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Quebec Premier François Legault.Jacques Boissinot/The Canadian Press

Prof. Voyer of Laval has been paying attention to the Green House Project since its beginning. He has a keen interest in new ways to care for people with dementia, since up to 80 per cent of Quebec long-term care residents have major cognitive problems. Wandering residents with dementia in poorly staffed facilities are a challenge when trying to control infectious diseases, he said.

He tracks innovations such as the gated villages for Alzheimer’s patients in the Netherlands, or Norway’s use of cameras and sensors to monitor sleeping seniors, and he has toured Green House sites since the early 2000s.

In 2017, he helped set up pilot projects that turned two nursing homes in the Quebec City area, CHSLD Ste-Monique and CHSLD Faubourg, into specialized facilities for people with Alzheimer’s. Staff were trained to be more flexible and respectful of residents. The interior design recreated a home-like ambience.

As a result, Prof. Voyer said, families reported that their elders appeared more peaceful, staff were less likely to wake residents in the night to give them medication and the use of physical restraints dropped by half.

When the government announced its recent plan to create more long-term care beds, it asked Prof. Voyer to help design the new MDAs. He suggested something similar to Green House sites.

The basic MDA elements, the maisonnées, French for households, are self-contained wards of 12 residents, with their own bedrooms and showers. There are Quebec-specific touches. Instead of rooms surrounding a common area, the typical floor plan is L-shaped, with the kitchen and dining room tucked into the elbow of the L.

Every two households are serviced by a “backstage” – a separate wing for medical and administrative functions. Prof. Voyer said it was a compromise since MDAs haven’t gone as far as their Green House counterparts in removing nursing stations.

Once the pandemic hit in 2020, the design had to be tweaked to provide better infection prevention and control. More hand-washing sinks. Better ventilation. Space for staffers to don personal protective equipment.

“It will be like being at home. There won’t be a medication cart circulating around,” Ms. Blais, the minister for seniors, told the Globe. “The care will be personalized. Residents will get up at the time of their choice, go to bed at the time of their choice.”

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Marguerite Blais is Quebec's minister in charge of seniors and informal caregivers.Jacques Boissinot/The Canadian Press

The cost of the project has grown, from an initial estimate of $1-billion for a first phase with 30 MDAs to $2.4-billion for 46 facilities. Now the latest estimate for the 46 sites has jumped to nearly $2.8-billion, according to SQI, the provincial agency managing infrastructure projects.

In a statement, SQI attributed the problem to the overheating of the construction sector after the end of pandemic lockdowns, labour shortages and higher building materials’ prices. But the cost has drawn criticism from opposition parties, as has the proposed locations of the MDAs, 85 per cent of which are in ridings held by the governing CAQ party, mostly in suburban or outlying regions, such as the Laurentians, the Lower Saint-Lawrence or the Magdalen Islands.

Opposition politicians accused the CAQ of ignoring the Montreal area, where nursing homes suffered the highest pandemic death toll.

According to Ms. Blais’s office, the selection of the MDA sites was based on a 2018 statistical analysis forecasting the growth of the elderly population in the next decade. That approach came under criticism last month by Quebec Auditor-General Guylaine Leclerc, however, who says the time frame of the analysis is too short and its scope doesn’t take enough factors into account.

While the MDAs will initially add 2,600 more beds, there are already more than that number of people on waiting lists, Ms. Leclerc said. As of June 29, there were 4,160 people on waiting lists.

To address needs where MDAs aren’t planned, the government wants to renovate 25 nursing homes rated E (“very high level of degradation and defect”) on its index of infrastructure conditions.

The work will include as many MDA features as possible, though some locations will have fewer because of lack of space.

Tender documents show that Quebec plans to spend $439-million to provide 1,200 MDA-style beds to replace seven facilities in Montreal. However, it will take four to seven years to complete those projects.

A lunch gathering, nursing station and emergency-signal panel at CHSLD Val-des-Brises in Laval, Que., a pilot project for many of the features Quebec’s MDAs will adopt. Evan Buhler/The Globe and Mail

A preview of what will be built can be found north of Montreal, in Laval, at CHSLD Val-des-Brises, one of the last regular nursing homes completed before the introduction of the MDAs. Here, local officials decided to try a different tack and, in consultation with Prof. Voyer, built a 232-bed nursing home configured like an MDA. They were able to steer away from the traditional template because Val-des-Brises is a pilot project for a different way of completing long-term care sites. The four-storey structure was built by a private developer who is renting it on a 15-year lease to the Laval health authority.

The residents, who have moderate to severe cognitive troubles, live in self-contained households of 11 laid out around a common space with a dining area and an open kitchen. Not all bedrooms have their own showers but officials say that’s not necessary because some residents with dementia are unable to get clean by themselves.

Like Green House facilities, Val-des-Brises strives to be a more attentive, humane place. The bedroom entrances are differentiated by distinctive wall colours to help residents with cognitive impairments find their way. Common spaces are brightly lit by large windows to encourage people to socialize outside their rooms.

Gladys Leclair, a gregarious night owl who was one of the first residents to move in, relishes sleeping in until 9 or 10 in the morning in the new facility. Her daughter, Susan Carignan, said it was a relief to see Ms. Leclair settled in a place that respects her habits.

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Gladys Leclair looks out her window at Val-des-Brises.Evan Buhler/The Globe and Mail

Marie-France Dubois, the assistant director for elder care, said Val-des-Brises heeds the residents’ daily rhythms and preferences, and places no limits on family visiting hours. Residents will not be woken up in the night to check incontinence diapers. The risk management is also different. Giving residents more agency means having to be more vigilant to the potential dangers of having them in a kitchen, or letting them outdoors. Workers at Val-des-Brises need to be more invested and to know the residents more closely, she says. “These are new ways of doing things. We need people with open minds.”

That’s not always easy to find. Initially, only half of the facility could be occupied because of staff shortage. In fact, some asked to be sent back to traditional homes because they were more used to working in the old system. The current occupancy rate is 60 per cent.

To address the staffing issues, Ms. Blais has announced a $2.9-billion plan to hire more personnel, and put in place more personalized care, the kind of tenets championed by the Eden Alternative and the Green House Project. The province is not ready, however, to expand the job description of orderlies and turn them into Green House universal workers who handle cooking and housekeeping in addition to basic care.

“We haven’t reached that point yet. You know, we also have unions. There are all kinds of negotiations around,” she said.

Samir Sinha, director of health policy research at the National Institute on Ageing, cautioned that Quebec won’t reap all the benefits of creating smaller homes if it settles for half measures in staffing.

Despite his reservations, he said it’s promising that the government has moved toward a type of nursing home that coped effectively with the pandemic. Dr. Sinha is part of a project to define long-term care national standards. He said one group, the Canadian Standards Association, is developing draft standards recommending that new facilities be built like small homes, with single bedrooms and bathrooms. Those guidelines could become a launchpad for national standards.

Prof. Voyer said the localized deployment of the Quebec MDAs will allow regional officials to fine-tune the new practices.

The Maisons des aînés, “won’t be like a magic wand,” he said. Better care won’t happen overnight. “It certainly won’t be quick. It’s going to happen very slowly.”

A better way for seniors: More from The Globe and Mail

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Illustration by Tim Boelaars

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Earlier this year, four experts in Canadian health care explored the 10 biggest ways our system could be made better for patients and more cost-effective to the public. Read the full Fixing Health Care series here. Below are some of the highlights.

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