The care home that’s more like home

At this Toronto LTC, a little extra government money has paid off handsomely for residents

In theory, they are decorating cookies.

Nobody’s really paying attention to food styling because, mostly, they are laughing. Six residents sit around the table at Etobicoke’s Lakeshore Lodge nursing home with three staff members and almost as many criss-crossing conversations. In preparation for pub night, James Armstrong offers recreation assistant Nathan Posteraro advance notice of his favourite drinks: “Usually gin and tonic. Sometimes port wine.”

Sharon Reed, the fashionista who prefers Merlot to Earl Grey during high tea, discusses her imminent volunteer shift in the downstairs gift shop, wearing a headband and just enough necklaces to look au courant.

Chubby Checker sings “The Twist,” playing low over a Bluetooth speaker. Then someone cranks Kool & the Gang’s1980 postdisco smash “Celebration” and the chair dancing begins, led by Sandra Racotchie in a white cardigan, arms waving.

The funding that helped lead to this moment of spontaneity became official four months ago, when Toronto City Council approved its 2022 budget with $4.1 million for the new CareTO program that aims to transform the way people live and work in longterm care.

Last week, to mark Seniors’ Month in Ontario, Mayor John Tory and Deputy Mayor Michael Thompson arrived for a check-in, asking residents if they’re seeing change. Many said yes, including Hector Ibbitson and William Lahey, as they ate mid-morning eggs, toast and cream of wheat — part of the home’s new flexible dining hours. A few told Tory the home still needs more staff. “They’re right,” a worker said quietly.

In his post-tour speech to residents and families, Tory called the new program the “single biggest new initiative in the city’s budget this year.

“You may ask, ‘What was the money for?’ Well, the money actually added staff,” Tory said. “I’ve listened as I’ve gone around today, and people have said we need even

more staff.”

As part of CareTO funding, Lakeshore Lodge hired 29 new permanent full-time “equivalent” staff, including 15 personal support workers (PSWs), a nurse manager, nurse practitioner and staff for food services, housekeeping and recreation, the city said. Instead of the typical daily staff-to-resident ratio of 1:12, the city said Lakeshore Lodge now has the budget for one PSW for each 8.6 residents.

The pilot will finish in early 2023 and — if it meets city council’s expectations and is added to all 10 city-run homes — the $4.1 million is expected to increase wages, pay for training and hire, in total, 272 permanent workers by 2025. (Another $12 million will come from the province.)

While the boomer generation is demanding new ways to live in the community — to avoid long-term care — a small but growing number of Ontario’s 627 nursing homes are trying to shed or at least diminish the entrenched institutional style of care.

Instead of the industry’s oldschool mindset that, at worst, viewed residents as beings to be merely “watered and fed,” as the saying goes, the Toronto program — created in consultation with residents, family members, staff, management, and unions among others — is training staff to focus on making deeper connections with residents.

It’s early days. Staff training began in April and so far, workers have finished roughly half of 27 sessions teaching a philosophy that, at its core, isn’t complicated.

Treat humans humanely. Foster friendships among residents. Learn the details of a person’s life, career, habits, culture, language, food and travels. What time do Mr. Ibbitson or Mr. Lahey like to eat? If they want breakfast at 10 a.m., it’s their right to choose instead of forcing a rigid schedule.

Sometimes it takes a bit of sleuthing. A former lawyer was restless at night, refusing to sleep — and lack of sleep can lead to health problems, including falls. Staff asked his family a lot of questions and learned that during his career, he always worked on his legal files in the evening before going to bed. So, workers gave him pens and paper at night. “Now he writes and then, he goes to sleep,” said Migena Lipo, a 20-year PSW at Lakeshore Lodge and one of the new program’s seven “peer-selected” coaches leading change.

Another resident resisted shower time. Lipo said a beleaguered worker asked for advice, then huddled with a colleague who, using the home’s new philosophy, had already found a solution.

The worker starts the showering process not with towels and soap, but a conversation. She sits nearby and listens as the woman tells stories from the days when she was busy and needed by her family. Soon enough, the resident relaxes, offering to braid the worker’s hair just as she did her daughter’s years ago. And she willingly goes to the shower.

These are the kind of stories that emerge whenever a long-term-care home makes an effort to shed the old ways. The industry calls it cultural transformation and it can have a lasting impact — that is, if the home has the ongoing support of its leaders and enough staff to properly spend time with residents.

At last Thursday’s “reflection day” training session, PSW Rashmi Mishra described the value for residents and staff of the time spent listening, instead of rushing from task to task.

“One resident, I offered her drinks and she said, ‘No, no, I don’t want to drink.’ I offered her food. She said, ‘No, no, no. I don’t want to eat.’ ”

Instead of giving up, Mishra had the time to sit with the woman. She asked about the photos of her daughter. The resident began speaking, talking of her daughter’s childhood paintings. As the conversation continued, Mishra offered her a drink, and she took it. She offered food, and the woman ate it.

“To be honest with you,” Mishra said, “that just gave me so much happiness.”

In the traditional nursing-home system, Tory told residents in a first-floor meeting room, certain time-consuming requirements may have existed for a reason but the focus on rigid rules “took away the individuality of the care that could be offered.

“Residents have had a life before coming to Lakeshore Lodge or any other long-term-care home,” he said. “And that was a life that had built up some likes and dislikes and some habits and some things that made them happy, brought them joy.”

It’s not just an exercise in kindness. Independent research shows that the residents living in the U.S.based Green House Project homes (small households) have deeper relationships with staff, fewer trips to the hospital emergency department and fewer pressure ulcers or urinary-tract infections — conditions that can be serious for older adults and costly to the health-care system.

Recent studies on COVID also found that the pandemic had a minimal impact on people living in non-traditional homes such as Green House, where roughly 10 residents have private rooms and washrooms and are known well by staff who work consistently in each home.

In 2018, Peel Region said its internal data on the Butterfly Model (one of several models that focus on relationships and the individual interests of residents) showed a drop in antipsychotic drug use, a lessening of falls and decrease in staff absenteeism. But during COVID, in 2020, Peel said the impact of government-imposed isolation from the lockdown led to a slight uptick in depression, falls, unexpected weight loss and pressure ulcers.

At Lakeshore Lodge, the impact of the CareTO program and its focus on what the staff call “holistic” care will be evaluated by researchers from Sunnybrook Health Sciences Centre and the University of Toronto. Jennifer Dockery, Toronto’s general manager of seniors’ services and long-term care, said the evaluations will include resident falls, staff absenteeism and satisfaction reports from residents or their families.

The lodge residents are now in charge of many decisions related to their living space, Dockery said, including new paint colours. When the green swatch chosen by residents looked hideously different once painted on the third-floor wall, she said the residents rallied for a redo — and got it.

Built 30 years ago, with large units of roughly 25 residents, Lakeshore Lodge is on the list of Toronto homes to be redeveloped over the next 10 years and as a result, Dockery said, the city won’t be tearing down walls to renovate.

Still, she said, residents called for improvements in flooring, seeking something that looks more like hardwood than hospital-style laminate. She added that the home can add new furniture in materials that look homier, but still meet requirements for disinfection and infection-prevention.

Dr. Samir Sinha, director of geriatrics for Sinai Health, said the oldstyle buildings can’t always be physically transformed, but enhancements of things like paint or flooring can make a difference. “It’s the software (the connections), not the hardware (the layout),” he said.

“I think the real emphasis of CareTO is on how care is being provided, and doing so in a relational way. Ultimately, at the end of the day, that’s what’s really going to transform the care experience.”

Toronto’s seniors advocate councillor, Josh Matlow, had a similar reaction after his visit last week. While the home still has an institutional footprint, Matlow said, “It’s the people who distract you from that in the most positive way. It actually makes the built environment less relevant.”

As Lakeshore Lodge moves forward, though, workers like Ashley Gibbs are still struggling with the impact of COVID.

Working on her master’s degree while holding down a job considered invaluable to most residents — managing their clothing in the laundry — Gibbs said the training helps.

“We’re learning how to be not just great workers, but great friends. And I think the emotional (piece) is front and centre because some of us are still hurting,” Gibbs said.

“We’re learning how to support the residents in ways that are not just physical. We’re learning how to address the emotional side and I think that’s what really is holistic care.”