Ads for retirement homes often feature an older couple relaxing in comfortable surroundings, playing a board game or enjoying a meal with friends. They look well — and young for their age — with broad smiles and perfect silver hair.
These ads offer worry-free, active retirement living at its fullest, complete with delicious and nutritious food. It looks like a wonderful lifestyle choice.
But is it really a lifestyle choice? Or, is it imposed upon older adults by fragmented and under-resourced primary and community care services?
Assisted living
In Canada, retirement homes (also known by other names like assisted living) are increasingly for-profit living facilities for older adults. They offer a variable range of services paid for by residents. Across Canada, monthly fees range from $1,600 to over $6,000 for spaces ranging from 300 to 600 square feet.
In Ontario, where monthly fees for retirement homes average almost $4,000, at least two services must be provided, such as meals and medication administration, with additional services often available at extra cost.
Some homes (for extra fees) offer services geared towards people with cognitive impairment, and others provide nursing and personal care to those who require physical support. Yet, these privately paid services are often not enough.
A 2017 study in the Hamilton Niagara Haldimand Brant region of Ontario showed that up to 40 per cent of retirement home residents receive publicly funded home care services, in addition to those purchased from the home. In almost one-third of these cases, retirement home residents or their caregivers said they would be better off living elsewhere, such as in long-term care (LTC) homes, where they can receive 24-hour access to nursing and personal support services.
In Ontario, retirement homes are almost exclusively private facilities offering accommodations and some paid care services for less frail seniors, and they operate under less stringent regulations by the Ministry for Seniors and Accessibility.
In contrast, LTC homes provide 24/7 nursing care for more dependent individuals and are regulated and subsidized by the Ministry of Long-Term Care. Retirement homes typically feature private suites or apartments, whereas LTC homes have more institutional and less private accommodations.
A recent review of research showed that the opportunity for greater social interaction in retirement homes is an important consideration for some, and consistent anecdotal reports suggest that many residents have a boost in health and well-being after moving into a retirement home.
However, the primary drivers of relocation are concerns over age-associated decline in health, coupled with uncertainty over being able to access services — such as assistance with property upkeep, medications or personal care — in their current home.
Unmet health-care needs
We still have a limited picture about what happens when someone moves into a retirement home. In contrast to the LTC sector, for which we have relatively rich information sources at the national level, there is almost no information on retirement home residents.
What we do know paints a mixed picture. For example, retirement home residents living with dementia, and who can afford specialized memory care services, are less likely to move to a LTC home. In contrast, retirement home residents receive far fewer primary care visits than those in LTC homes, and are more likely to visit the emergency department, be hospitalized and experience prolonged hospital stays.
Clearly, the service and health-care needs of retirement home residents are not being met, nor were these being met in the community, compelling the move to a retirement home in the first place.
In Canada, under-resourcing of home- and community-care sectors imposes limits on where an older person can reside as their health declines, though more choices are available to those living in larger cities and able to pay for expensive private home care. Canada spends substantially less per capita on home and community-care than the OECD average.
Despite evidence that the medical needs of retirement home residents have been growing more complex, the role of primary care medical providers is not regulated, nor is there much incentive to practice in these settings. Retirement homes look like primary care deserts, with residents often having no meaningful access to their previous primary care provider due to mobility limitations in transportation to off-site clinic locations.
Retirement home residents are more likely to be hospitalized and experience accelerated functional and cognitive decline without access to co-ordinated, senior-friendly primary care. Reliance on the limited access to community-based primary care clinics is inadequate because outside primary care providers often can’t know the environment or staff in the retirement home.
Common issues, like falls, can go unaddressed given that there is no one on site to do a sufficiently thorough medical falls risk assessment. Dehydration related delirium (confusion) that could be addressed on site can instead lead to hospital admission and premature institutional care.
Designed for institutionalization
Our health-care system seems designed to foster premature institutionalization. The retirement home sector attempts to fill a care and service gap in the community, but is progressively less able to do so as resident care needs become more complex and exceed what they can afford out of pocket.
The solution requires that publicly funded and integrated home and community services be made accessible to older people regardless of where they chose to live, whether in a retirement home or in the private residence where they have lived for years.
Specific attention is required for community dwelling older people with cognitive difficulties, many of whom could continue aging in place with minimal assistance for nutrition, medication management and surveillance of chronic medical conditions.
Interprofessional primary care (teams that include multiple health professionals such as doctors, nurse practitioners, dietitians and social workers) would have greater capacity to support older people with complex health issues. Such teams must be made available to prevent hospitalization and its often disabling consequences.
Since many residents have limited capacity to travel to office visits, providing on-site access to primary care in retirement homes is simply fulfilling the promise of the Canada Health Act that reasonable access to insured health services is provided to all Canadians.
More home care and better access to robust primary care services will better meet the needs of older adults in the community, optimize their health and independence, and reduce the huge strain on our hospitals and caregivers. They will also allow older people greater choice over — and ability to afford — whatever lifestyle they prefer.