The future of long-term care: Integrating age-friendly living into urban communities

With seniors making up nearly one-fifth of Canada’s population today (Statistics Canada, 2024), there has been tremendous attention of late around age-friendly cities. Age-friendly cities are an important part of public health and public policy. They fall short, however, when it comes to addressing the complexity of our current demographic shift. Older adults are living longer and with increasingly complex health profiles. And while supporting aging in place at home is the foremost goal, most adults over the age of 85 require home and healthcare services (Statistics Canada, 2021).

Long-term care plays a pivotal role in meeting these needs today and will continue to play a pivotal role in the future as demand continues to grow. The system is not without its challenges, however.

In Ontario, as in other parts of the country, one of the foremost challenges is the exodus of long-term care homes from urban areas. In populous cities, land is scarce, and the costs associated with its purchase, development and operation have become prohibitive for most providers. At present, the provincial per-bed-per-diem cannot raise sufficient funds to subsidize the premium of urban development.

As a result, long-term care providers are moving out of the city, building siloed structures often apart from established neighbourhoods. Not only does this compound current and persistent issues of resident placement and displacement outside of their communities, but it also exacerbates the social isolation of people living in care homes.

While it may be a widely held ideal that everyone has a right to the city, long-term care and other forms of higher needs housing have a long history of marginalization in public health and policy making.

Now, with renewed government investment in long-term care across the country, there is an important opportunity to rethink urban aging or risk a new generation of buildings with the same old problems. With that said, is it even possible to create the socio-spatial conditions necessary for urban long-term care? The ecology and resilience of our cities, it would seem, depends on it. 

In Canada, not unlike other countries, ever-pressing demands for affordable housing coupled with land shortages have prompted many urban cities to adopt inclusionary zoning policies. Policy outcomes include an increasing number of mixed-income housing developments that support the strongly-held political goal of mixité sociale (Mallach & Calavita, 2010: 100). In many parts of the city, these developments are part of larger master plans transforming underused parcels of urban land into new mixed-use, transit oriented communities.

In the pursuit of age-friendly cities and aging-in-place, arguably one of the biggest oversights in these communities and the policies and plans that support them is seniors supportive housing and long-term care.

This is not for lack of design. In fact, an urban long-term care home within a mixed-use development is – conceptually at least – possible. But it requires a bespoke understanding of long-term care design and the intricacies involved in integrating its many specific systems and standards with those of other uses that have far less stringent requirements.

The scheme depicted here is one such example, developed with the intent to offset land and development charges, consolidate infrastructure and reduce construction costs, contribute to intensification of the urban core rather than urban sprawl, and create a sustainable, supportive environment for urban aging.

In this concept, the long-term care home occupies the upper three levels of a four-storey podium. A void in the podium produces two secure gardens for long-term care residents. Each long-term care floor, as shown, can meet all the requirements of the current long-term care design standards. Two towers rise above the podium, one each dedicated to independent living and/or life lease and the other to market and/or affordable housing. As with any urban development on a constrained site, roof planes double as outdoor amenities for tower residents. Entrances to the long-term care, retirement and residential components are located at grade. Each entrance occupies its own side of the podium, reinforcing its identity within the larger block. Together with street-oriented retail functions, they create an active perimeter and ground floor condition.

Mixed-use development is by no means a new idea in city-building. Land scarcity and development costs are driving new, integrated models across many sectors. Think urban schools for instance. When it comes to long-term care, the conceivable benefits are equally if not more substantial.

Research among residents has found time and again that loneliness and idleness are chronic in long-term care settings. The planning and design of these buildings, preoccupied with creating a safe, comfortable, home-like environment, often undervalue residents’ need for stimulus. In our more than 40 years in this sector, we’ve swapped many anecdotes with providers around what sights and spaces long-term care residents enjoy most. More often than not the boisterous eclipses the bucolic. Windows overlooking playgrounds and school yards are favourites as are entrance lobbies and lounges where people and cars can be seen coming and going.

Mixed-use, multi-generational developments like the one depicted here offer older adults in residential care the possibility of so much more. They are busy, vibrant places set in busy, vibrant communities that offer easier access to health and community support services as well as important civic and social infrastructure that encourage participation among residents, however passive. More importantly, they offer a housing continuum that supports aging in place and the co-location of family households that creates a sense of security among residents and facilitates family visits and family caregiving. And they support the principles of reverse inclusion, inviting stronger community connections and a larger volunteer presence within the home, all of which, we know, contributes to greater place attachment, sense of belonging and quality of life.

What’s more, the benefits aren’t just one way. The long-term care sector is experiencing extreme staff shortages, exacerbated in recent years by the pandemic and an aging workforce. Integration rather than isolation makes employment more attractive, as does the co-location of services like child care, fitness centres, and grocery stores.

So… why haven’t we done this yet?

The short answer: new agreements would need to be developed between the ministry and the private sector to make this level of integration not only possible but functionally and financially feasible. A vertical ownership stratification, as is done in private residential development, is one possible pathway. The challenge lies in developing the legal framework that considers the intricacies of this kind of public-private partnership, and in having the courage to test it.

But it can be done. Naturally, creating policies and programmes that incentivize market residential projects, similar to those for affordable housing, could help.

Ultimately, it’s time to shift the long-term care sector in Canada from being reactive to proactive. This starts with rethinking age-friendly cities and the policies and plans that support them, the evolution of mixed-use communities and the people who live there, and how we can create conditions that help them lead healthy, active, engaged lives into and through their older years.


Alexandra Boissonneault is Associate, Research and Communications at Montgomery Sisam Architects and a PhD Candidate at Toronto Metropolitan University.

Santiago Kunzle is principal at Montgomery Sisam Architects.


References

Mallach, A., & Calavita, N. (2010). Canada: Social Inclusion in a Market-Driven Polity. In A. Mallach & N. Calavita (Eds.), Inclusionary Housing in International Perspective: Affordable Housing, Social Inclusion, and Land Value Recapture (pp. 79-121). Lincoln Institute of Land Policy.

Statistics Canada. (2022). A portrait of Canada’s growing population aged 85 and older from the 2021 Census. Retrieved from https://www12.statcan.gc.ca/census-recensement/2021/as-sa/98-200-X/2021004/98-200-X2021004-eng.cfm

Statistics Canada. (2024). Demographic estimates by age and gender, provinces and territories: Interactive dashboard. Retrieved from https://www150.statcan.gc.ca/n1/pub/71-607-x/71-607-x2020018-eng.htm

 

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