Pandemic effect: Long-term care homes

TEXT Robert Davies, Director and Principal, Montgomery Sisam Architects

During the COVID-19 pandemic, long-term care homes have seen a significant share of superspreading events around the globe. According to Canada’s National Institute on Aging, as of early May, 82 percent of deaths from COVID-19 have occurred in the country’s long-term care homes. This is the highest proportion of deaths in long-term care settings among 14 countries.

Why is this happening, and what can we do about it? Is it possible to mitigate the biological science of an outbreak with building science?

Long-term care is licensed and regulated by the provinces, and is largely funded through public money. It has always stood apart from other types of health care—for example critical care, acute care, rehabilitation care—through a set of regulations and guidelines which insist that the design emphasizes a home-like experience over a clinical one.

People in long-term care are referred to as residents, not patients. The architectural language of these settings includes town squares, neighbourhoods and spas. It considers rooms to be small houses lining a street. These notions reinforce the concept that long-term care facilities are intended to be scaled-down versions of regular community life.

It may come as no surprise that there is disparity in the existing building stock for long-term care homes across the country. While many homes meet current standards, there were also many built prior to the current standards which still have three to four residents sharing a room and bathroom, and where congregating spaces are smaller and more crowded.

When a home declares an outbreak, the infected residents become patients. Just like the rest of us, they need to be isolated. This is not always possible in the older homes as they are presently configured. In addition to physical isolation, mechanical systems should be designed to a higher standard, to allow for negative pressure to isolation rooms. In extreme cases, the provision of oxygen is necessary to avoid a trip to the hospital.

The challenge will be to find the right balance between designing long-term care homes as a residential setting, and providing the clinical conditions necessary to battle a pandemic.

An increase in funding will also be needed to overcome several characteristics of superspreading events—which include enclosed spaces with poor ventilation, close proximity between people, and poor infection control behaviours. Older homes will need to be replaced. Operating dollars will need to increase to improve staffing levels—allowing for proper protocols for hygiene, and to overcome the pattern of some operators who hire part-time workers to reduce costs. These workers may hold positions at two or three long-term care homes to make ends meet, thereby increasing the chances of spreading disease.

Currently, operational funding is provided by the provinces based on the number of licensed residents at each home. Capital funding is based on an established daily rate for each resident over a 25-year period, and begins to flow to the operator once construction has been completed. In our experience, neither of these amounts have kept pace with actual costs of operating homes and rebuilding the older stock of buildings.

Funding is deployed differently by the three types of long-term care operators. Each municipality is required to run long-term care homes by statute, and these agencies have the ability to draw on tax revenue to bolster operating funds, and assist in the cost of rebuilding. Charitable and not-for-profit homes often use fundraising to add to their operating and capital projects budgets. Private or for-profit homes, however, are generally in business to provide profits to their shareholders, and tend to work with the amounts provided by the provinces for both operating and capital costs.

We know that all Ministries of Health are looking at the vulnerability of long-term care homes to pandemic outbreaks very carefully. We expect to see a measured and thoughtful response, by way of updated design standards, in good time. Hopefully this will be paired with a revisiting of funding models for long-term care.