Factors that shaped the development and ongoing functioning of municipal and NFP seniors’ campus continuums and their ability to offer wrap around care for older adults (as described by campus senior leadership and organizational partners) were carefully considered and organized into three overarchingthemes and eight sub-themes:
- Campus Evolution:
- legacies
- windows of opportunity
- organizational structure and capacity
- Campus Design and Functions:
- intentional physical and social design
- campus service mix, amenities and partnerships
- Ability to Offer Wrap Around Care:
- policy rigidities and enablers
- human resources shortages and innovation
- funding limitations and opportunities
A. Campus Inception and Development
In describing their campus inception—the “why”—participants noted a number of factors relating to their historical legacies of serving unmet need and key windows of opportunity that supported their evolution into full continuums of care. In the case of participants that were partners of a campus, they were asked to describe their own organization’s history with the campus including factors that led to their involvement with the campus and their ongoing contributions to campus life. Please refer to Appendix B for supporting quotes to each theme.
i. Organizational Legacies—Addressing Unmet and Changing Needs. Campus participants in this study described long organizational histories of caring for seniors and older adults with disabilities in need (e.g., local housing, care). Participants from the newest municipal campus (Georgian Village) and the most mature municipal case study (Spruce Lodge) noted legacies of helping vulnerable populations dating back to the late 1800’s starting as municipal “Houses of Refuge” (public and charitable organizations providing for social care, food, shelter and protection to the homeless or destitute) prior to becoming “Homes for the Aged” and evolving into broader spectrum seniors’ campuses.
Participants of the three NFP and the mature northern municipal campus described having deep ties to faith communities that recognized gaps in the system for local seniors, particularly those with specific cultural, religious and/or linguistic backgrounds. The mature NFP campuses—Radiant Care Pleasant Manor and Shalom Village—began as community driven enterprises where faith leaders sought to address housing and care needs within the contexts of their respective Mennonite and Jewish religious and cultural heritage. Pleasant Manor began its journey in the 1970’s when a collective of Mennonite churches developed independent seniors’ housing to address local housing needs for seniors in their community. Shalom Village began as a Home for the Aged in a setting that respected Jewish culture and Kashrut (dietary laws). The northern mature municipal campus, Au Château, and the newest NFP campus, Bruyère Continuing Care, while not faith-based campuses, benefited from strong foundational support and ongoing relationships with the Catholic Church (e.g., advocacy, access to resources) and the Francophone communities in which they operated. Au Château began as a district Home for the Aged to meet the needs of Francophone seniors in their district and foundational staffing was provided by Catholic Nuns and a priest who resided and presided over their onsite parish. Bruyère Continuing Care, an official designated French Language provider, began its evolution as a hospital run by the Sisters of Charity in the late 1800’s that has since evolved to include LTCHs, community-based care and most recently seniors’ housing.
Participants from mature campuses described the 1970’s to the 1990’s as a time when many seniors in residential LTC often had lighter care needs than that which was offered in those settings currently (e.g., many were still driving yet in need of light monitoring, care, or simply safe affordable shelter). Campus participants attributed expansion into full continuums (mixed-income housing options, community-based care supports for seniors and LTCHs) as a means to address the widely varying levels of needs of seniors and adults with disabilitieswishing to age in their communities (local and/or faith-based). Since that time, campus and partner participants alike highlighted that acuity and complexity of care for residents in their LTCHs had increased over time as well as in their supportive housing (SH) and Assisted Living Services (ALS) programs. Many noted that long wait lists for LTCH placement contributed to sometimes having residents on their ALS programs in seniors’ housing that have higher needs than what was in their LTCHs.
Participants from the municipal campuses in this study noted that where provincial law sets certain requirements on municipalities to offer LTCH options (separately or jointly) in southern Ontario, the expansion into continuums was not a legal requirement. However, municipal participants noted that co-locating a range of mixed housing and community support options in addition to having a LTCH in one physical location was considered important and a responsibility to their community members (taxpayers) in alignment with municipal “seniors’ strategies” which include focused attention on seniors’ housing with supports. Campuses were also noted to meet broader goals and commitments to developing Age-Friendly Communities.
Participants from the NFP campuses similarly noted that expansion into seniors housing and additional community services was a natural extension of their mandates to serve their local and/or identified community (heritage/religious/linguistic). The newest NFP campus, as a hospital and provider of LTCH beds, highlighted the direct impact a lack of housing and care options was having on their own hospital bed use and estimated approximately a third or more of patients in one of their hospitals did not belong in hospital, but rather in a LTCH or supported in an ALS program. Each alternative was considered a lesser cost to the system and a senior’s wellbeing. (See Appendix B).
Participants from all campuses noted that expansion into continuums required strong visionary leadership (past and current founders, board members, local councils and administration) and attributed successful campus inception and development to a deep dedication to their local community, a willingness to take risks (e.g., financial, organizational), having political acumen (e.g., sitting at the ‘right’ tables) and being “shovel ready” when funding opportunities appear. (See Appendix B)
ii. Policy Changes Afforded Windows of Opportunity. Campus participants described expansion into a continuum as both purposive and opportunistic often affected by key windows of opportunity (funding, structural, political) to meet varied needs. Participants from the mature campuses highlighted stimulus funding for housing through a combination of federal, provincial and municipal grants and ongoing operating subsidies in the 1980’s and early 1990’s, greatly supported their expansion of affordable housing for independent seniors with light care needs and the development of “elderly persons” wellness centres, and SH programs. They further noted that expansion efforts became constrained by the mid–1990’s with a change in provincial government and focus towards building new LTCH bed capacity. (See Appendix B)
Study participants from newer campuses highlighted that in the last decade new federal and provincial capital funding opportunities and incentives across different levels of government and ministries helped to seed interest and ability to expand affordable housing offerings. (See Appendix B)
Participants from all of the campuses described how they leveraged existing infrastructure (e.g., LTCH) as an “anchor” from which to develop other housing options, supports and services and felt a goal of up to four or five lighter or more independent housing types per LTCH bed with ranges of services available would best address growing needs. Expansion into a full continuum of LTCH, mixed housing and community programs was often described by most as incremental and reliant on opportunistic funding incentives by government. In contrast, the newest municipal campus was able to develop all of the components across one period of time by capitalizing on a redevelopment opportunity for their aging LTCH. Participants from each of the newer campuses described benefitting greatly from discussions and site visits with more mature campuses to observe and gauge fit for their own context and roll-out.
Campus participants noted the importance of offering a blend of mixed-income housing options to address a wide array of seniors with varied financial abilities to pay. These included social housing (rent-geared-to-income), affordable housing (generally 80% of market value rent), market housing, and for most case studies, life lease agreements (See Table 1). All campus participants described affordable housing options as critical to ensure a lower threshold for low income seniors that do not qualify for social housing on campus but also could not afford to pay market rent.
The newest municipal campus offered an additional retirement home option as a means to address additional care needs along the continuum (e.g., on site nursing, three meals per day) than are available in assisted living programs (government funded ALS program is limited to a relatively small percentage of seniors’ housing residents (~20%) in most of the case studies). Campus participants described the retirement option as more expensive for residents and only possible for seniors with financial means, but that this was worth considering for the future to "fill a hole” in the expanded continuum while also providing a campus with a wider economic base to support fixed overhead costs, cost recovery for the subsidized units (well below market prices) and enhanced stability of the campus and its programs.
iii. Organizational Structure and Capacity to Expand. Campus participants described having similar corporate structures and governance arrangements with key entities of the campus (e.g., LTCH, housing, foundation) generally having their own respective boards or advisory committees with oversight through an overarching corporate board and cross pollination across the different boards and committees/councils. Campus corporate services (e.g., administration, human resources, finance) were largely centrally administered and viewed as a means to improve operating efficiency, sharing knowledge and skills across the organization and for standardizing global practices and policies affecting quality of care, service and cost.
Campus study participants each described (re)development and expansion activities as intensive and relayed the considerable upfront commitments of time, finances, partnership development and knowledge requirements. Examples provided included: conducting gap analyses, feasibility studies, business case development, community and government consultations, land procurement/acquisition/ zoning, draft designs/ renderings, arranging mortgages, and fund-raising as necessary to proceed with building a campus or campus addition. Campus study participants identified the value of existing infrastructure and the importance of having adequate cash reserves to put upfront and charge to campus development to be paid back over the life of the project. (See Appendix B)
Study participants from municipal campuses described benefiting from their ability to leverage internal resources for advice and assistance for campus planning and ongoing functioning as needed. Examples provided included seeking expertise from their procurement and property offices to help with capital development plans, human resources departments for advice on collective agreements, or the social services and housing departments for advice on identifying and meeting broader housing affordability issues, criteria to set-up such housing, and capital maintenance. Participants from NFP campuses noted, where possible, they leveraged in-house expertise across their respective components and would contact other organizations to seek advice (e.g., legal, content expertise) or help project manage to process as necessary. For example, the rural NFP had a sister site to share resources/expertise and the new urban NFP campus had two hospitals, two LTCHs, rehabilitation and seniors housing, from which to draw expertise.
B. Campus Design and Functions
In describing campus management and ongoing functioning—the “how”—campus study participants described a number of factors related to campus design, structure, service mix, amenities and creative partnerships. Where participants were partners of a campus, they were asked to describe their own organization’s involvement and contributions to the campuses and campus life.
i. Intentional Physical and Social Design. Campus study participants described the great efforts taken to ensure physical interconnectivity across campus components (e.g., covered above ground linkages, connecting corridors, cleared outdoor walkways). Such connectivity was noted as critical to the health and social well-being of seniors including opportunities for physical exercise through connecting corridors across buildings, greater ease of passage for those with mobility devices, and simply not having to put coats and boots on in –32C weather or above 32C in the summer). Sometimes the physical linkages were not as convenient as others (e.g., going to separate buildings through underground corridors) in which case campus sites worked hard to make these spaces appealing (e.g., local artwork), senior friendly (e.g., seating between areas) and purposeful (e.g., amenities to utilize space like hair salons, cafés). (See Appendix B)
Physical connectivity was also seen to provide and enhance opportunities across the campus for participation in spontaneous and planned activities, and address the potential for loneliness and social isolation. A mature municipal campus participant described careful consideration given to the redesign of a common room in their LTCH auditorium to make it more inviting to other residents of the broader campus (e.g., sky lights, wide screen television, a small pub, an ice cream parlor, ample seating) and a central area to attend collective programming and social events. Similarly, a participant from another mature municipal campus described recently converting a former greenhouse in their LTCH into a popular lounge area where, given the higher proportion of housing residents than LTCH residents, instituted a policy that housing residents need accompany a LTCH resident to enjoy the area with them. This has provided family and friends of LTCH residents a greatly desirable space to enjoy visiting in.
Study participants (both campus and partners) detailed how residents in campus housing appreciated, even demanded, freedom of movement across campuses to be able to socialize, check on relatives and friends, and volunteer with ease. This freedom was noted to also benefit clients attending on-site day programs, recovering patients in convalescent care in campus LTCH beds, and visiting family and friends of LTCH residents who wished to participate in recreational and social activities or simply seek a change of scenery. Case studies located in smaller towns were largely populated with people from the local community and tended to have multiple residents with shared histories (e.g., attended the same schools, religious institutions or service clubs). It was not unusual for many residents of a (semi)rural or northern campus to be related in some way (e.g., siblings, cousins, in-laws) or for campus staff to have family residing at the campus (currently or in the past). Participants noted benefits in having family and friends in close proximity including an increased ability to maintain kinship and support for one another.
Participants noted that while all campuses aimed to be inclusive, tensions could sometimes develop when offering mixed housing that crosses socio-economic spectrums and different abilities (e.g., physical, cognitive, developmental). They also noted that in marketing for different housing options that the use of different perks or finishes (balconies, appliances) could contribute to potential divides and some campuses either avoided these differences and or actively monitored for this. All campuses that made distinctions observed the issue tended to fade as residents of the campus participated in collective activities and got to know and look out for one another.
ii. Service Mix, Amenities and Partnerships. Study participants noted that co-location of the various campus components and consolidation of resources allowed for greater economies of scale from shared staff training to bulk purchasing of food and cleaning supplies. Campus participants also described such practices benefited the client, organization, and external companies. Case study sites often purchased and sold utilities back to residents at a significant discount to what they would otherwise pay individually. For residents, this removes the need for them to have to organize directly with external companies and avoid strangers in to set up the utilities. For utility companies, this helps to avoid any confusion in navigating installation across the campus and having one payer. In another example, study participants noted economies of scale in shared offering of the LTCH kitchen which extended within and beyond campus walls to the broader community (See Appendix B).
Campus staff noted contracting out for certain tasks (e.g., pharmacy services, the use of agency staff to cover personal support worker (PSW) or nursing shifts) were common, while others would be less practical (e.g., housekeeping and maintenance). One case study had contracted with a private company to manage the maintenance and housekeeping for the housing component of the campus as well as dietary services for the restaurant and retirement home. While the company offered good service, it was noted the contract was not renewed because, after being in operation for a number of years, the organization came to the realization that these areas could be managed in-house more efficiently and effectively.
Some campus participants also described a practice dubbed “contracting-in” where in-house staff provide additional service at time and a half for short-term projects instead of hiring an outside tradesperson unfamiliar with the residents to do the task (e.g., having internal maintenance staff install lighting during retrofits) with any potential savings rolled back into campus operations.
Campus respondents described the impact of their municipal and NFP contexts on the way they are able to operate and manage money. Municipal campus participantsdescribed levies as an important factor affecting their ability to build reserves into their operations. Municipal participants noted levies were used to maintain service (e.g., automatic door openers, elevators, damages from wear and tear) when housing contracts were complete and to address any shortfall in revenue in the future and to provide for often higher wages and benefits than other providers (NFP and for-profit). However, when campuses were able to accumulate a surplus “for a rainy day”, municipal campus participants noted that it is not always viewed as managing well, but as having levied too much and requiring continuous negotiation with the municipality. (See Appendix B)
Participants from NFP campuses also reported having to exercise caution around the amount and manner in which they would plan and fundraise or carry a surplus in order to maintain their charitable status (e.g., not making profit and reinvesting revenue into campus operations and care). (See Appendix B)
Municipal campus participants in smaller communities noted that municipal corporations very much need to work collaboratively with local community and the private sector around their offerings being careful to neither overstep the balance of the private sector in the communitynor be seen as in competition with them (e.g., housing, retirement homes). Participants from NFP campuses also reported working closely with private and public sector organizations to encourage the development of local echo-systems for the benefit of residents of their campuses and local community. (See Appendix B)
Campus and partner participants highlighted the need to be knowledgeable across a vast array of policies and legislation they operate within, some of which were common across all components, and others more specific and targeted to care setting. In offering a wide array of health and social care, campuses also worked with different ministries (e.g., Ministry of Health and Long-Term Care, Ministry of Municipal Affairs and Housing, Ministry of Community and Social Services, Ministry of Seniors Affairs and Accessibility). Campus participants of the newest NFP campus noted an additional level of accountability to an overarching hospital board and having to adhere to hospital-based policies. Please see Table 2 for an overview of Key Legislation and Policies in which Campus Components Operate in Ontario.
Table 2. Key Policies and Legislation Ontario Campus Continuums Operate Within
Campus Feature
|
Provincial Legislation or Policy
|
Independent Seniors Housing
|
· Residential Tenancies Act 2006.
· Housing Services Act, 2011
|
Assisted Living/ Supportive Housing
|
· Home Care and Community Services Act, 1994
· Assisted Living Services for High Risk Seniors Policy, 2011
|
Adult Day Programs
|
· Patients First Act, 2016
|
Wellness Centres
|
· Seniors Active Living Centres Act, 2017
|
Retirement Homes
|
· Retirement Homes Act, 2010
· Residential Tenancies Act, 2006
|
Long-term Care Homes
|
· Ontario Long-term Care Homes Act, 2007
|
Hospital
|
· A Public Hospitals Act, 1990
|
Foundation
|
· Canada Revenue Agency Guidelines
· Not-for-Profit Corporations Act, 2010
· Individual Gift Agreements with Philanthropists
|
Unions
|
· Labour Relations Act, 1995
· Collective Agreements
|
Common to All
|
· Building Code Act, 1992
· Employment Standards Act, 2000
· Fire Protection and Prevention Act, 1997
· Health Protection and Promotion Act, 1990
· Human Rights Code, 1990
· Municipal Regulations and By-Laws
· Personal Health Information Protection Act, 2004
· Quality of Care Information Protection Act, 2016
· Workplace Safety and Insurance Act, 1997
|
Source: https://www.ontario.ca/laws
|
Co-locating and coordinating a mix of community programs, services and supports was viewed by all participants as crucial to maintaining people in the community for as long as possible; however, the community support sector was quite diverse and described as poorly funded by comparison to other sub-sectors. Participants described offering a similar core set of programs, and services (see Table 3 for a summary) assigned by a care coordinator or case manager. Examples provided included lighter coping supports for independent living (active seniors who do not require care support but may get peace of mind from 24 hour security, and the option to purchase light housekeeping, programs and meals), to addressing higher levels of need through case managed services and ALS program supports (personal care, medication and meal monitoring). Some programs were staffed by the campus and others by community partners renting space such as Adult Day Programs (ADPs). The northern municipal campus was unique in their ADP offering for seniors in that they supported an off-site program in another community in need of seniors’ services, but none was offered, or potentially needed with the current array of support services.
Many campuses included basic service packages as part of their rental agreements (e.g., minimum purchase of congregate dining meals per month, telephone, cable) with an option to purchase additional services. Service packages were described as helpful mechanisms to monitor and address safety, well-being, social isolation and nutritional needs of seniors while also helping to off-set costs in provision of providing these programs onsite.
Table 3. Common Campus Home and Community Care Programs
Campus
|
Meals on Wheels
|
Day Program*
|
Active Living Centres/Wellness Programs**
|
Falls Prevention Programs/ Physio-therapy***
|
Congregate Dining
|
Supportive Housing/ Assisted Living****
|
Au Château (Municipal)
|
I & E
|
Not onsite
|
|
I & E
|
I & E
|
I
|
Georgian Village (Municipal)
|
|
I & E
|
I & E
|
I & E
|
I & E
|
I
|
Spruce Lodge (Municipal)
|
I & E
|
I & E
|
I & E
|
I & E
|
I & E
|
I & E
|
Bruyère Village (NFP)
|
I & E
|
I & E
|
|
I & E
|
|
I & E
|
Radiant Care Pleasant Manor (NFP)
|
|
|
|
I & E
|
I
|
I
|
Shalom Village (NFP)
|
E
|
|
I & E
|
I & E
|
I & E
|
I
|
* Programs that provide structured and supervised activities for frail and socially isolated seniors and individuals with cognitive impairment offered during the day, evening or overnight.
** A centre with programs and services that promote socialization, physical activity, friendships, community involvement and independent living.
*** Group exercises and falls prevention education to help seniors stay healthy and active.
**** Programs for a set number of clients in housing units (differed across campuses) deemed eligible for intensive case management and care coordination of personal care and other supports based on Standardized Resident Assessment Instruments (RAI-CHA).
|
I = Available Internally to Campus Residents = I; E = Available Externally to Local Community
Campus and partner respondents at each case study described campuses as being "more than a place to live” and having "a real village atmosphere.” Campuses were often described as "community hubs” with the ability to serve a broad range of seniors’ needs in one place with common areas for residents to gather, socialize, play cards, host meetings, enjoy planned events (e.g., congregate dining, line-dancing, barbeques, live entertainment, religious services), and access important amenities (e.g., gym memberships, libraries, restaurant/pub) without the need for transportation. Commonly described campus offerings are listed in Table 4.
Volunteerism by residents, local community, family members, and school placements was noted as playing a pivotal role in the ongoing functioning and vibrancy of all campuses. Volunteer opportunities ranged from direct resident contact (e.g., friendly visiting, delivering meals on wheels on site, helping at ADPs, portering/accompanying people to and from social activities) to event planning and fundraising committees (e.g., auto shows, barbeques, gardening, organizing golf tournaments, bazars) and/or formal committee membership (family councils in LTCHs). Volunteers were often seniors living in campus housing where proximity increased their ability to help. Campus participants also highlighted the many volunteer hours staff provide in extra-curricular events like dances or barbeques and picking up items for residents unable to get out.
Table 4. Common Shared Recreation, Amenities, Events and Volunteer Opportunities
Recreation Opportunities*
|
On-Site Amenities*
|
Events and/or Volunteer Opportunities*
|
· Bingo
· Pub nights
· Art classes
· Choir
· Line dancing
· Religious services
· Off-site outings
· Woodworking
· Shuffle board
· Wellness centres – gym, therapy pools
|
· Health related clinics/labs
· Hair Salon
· General store/Tuck Shop
· Community gardens
· Library
· Restaurant/Bistro/Café
· Laundry
· Common spaces for planned and spontaneous activities
· Hospitality Suites**
|
· BBQs
· Live entertainment
· Bazars
· Golf Tournaments
· Tuck Shop
· Friendly Visiting
· Family Councils
· Board Committees
|
*Offered at many campuses
** Hospitality suites on campuses are available in many campuses for a modest fee to accommodate visiting family and friends to increase access and affordability and promote visitors. Campuses without hospitality suites noted informal arrangements with their local hotel which provided discounts to guests specifically visiting residents of the campus.
|
Campus respondents described many unique partnerships, relationships and arrangements they developed to enhance opportunities for maintaining the health and wellness of their residents and for continued community and civic engagement across all components of the campus. Relationships with partners included, but were not limited to, working with representatives from different levels of government, local community organizations, onsite clinics, and academic partners. Please see Table 5 for examples of key partnerships with providers and local businesses (some with lease arrangements) at many of the campus study sites.
Table 5. Key Partnerships and Supportive Arrangements
Government Partners
|
Community Partners
|
Clinical Intervention Partners *
|
Academic
Partners
|
· Municipal (housing, paramedics)
· Regional (Local Health Integration Network homecare)
· Provincial (Ministry of Health and Long-term Care, Public Health, Ministry of Housing and Municipal Affairs, Infrastructure Ontario)
· Federal (Canadian Mortgage and Housing Corporation)
|
· Community Care Agencies
· Hospitals
· Community Health Centres
· Primary care
· Alzheimer Society
· Community Living (serves people with developmental delays)
· Mental Health Agencies
· Pharmacies
· Faith Communities
· Local Businesses
· Community Programs (choirs)
· Shelters
|
· Audiology
· Chiropody
· Denture care
· Primary care
· Phlebotomy lab
· Physiotherapy
· Pharmacy Services
|
· Colleges
· Universities
· School Boards
|
* Visiting clinics, contracted providers, adjacent health facilities or lease agreements
** Internships (e.g., PSW, RPN, RN, Recreation, Culinary), research opportunities and volunteer opportunities (e.g., high school/co-op)
|
C. Ability to Offer Wrap-Around Care:
In addition to many facilitating factors described above, participants at each campus described three common impeding factors that impact upon their ability to offer wrap around care across a full continuum: policy rigidities, human resources shortages, inadequate funding. These are shared below with resulting innovations and workarounds.
i. Policy Rigidities and Enablers. Participants described a broad basket of services and supports offered by campus continuums which provide both opportunity and ability to support people’s needs as they change or intensify—sometimes temporarily, sometimes permanently. Participants spoke about the ability of community programs like SH and ALS as providing great value to clients as their need for care and coping supports increased; however, they also noted current waitlists and capped budgets limited their ability to serve as many people as they potentially could, and to the degree of support clients required. (See Appendix B)
Campus respondents explained creative solutions they would undertake for “incidental” short-term use of the ALS program such as an individual returning from cataract surgery in need of only temporary support. Restrictions on admission also applied pressures where clients in great need were unable to be admitted to an ALS program, where others with similar needs already in the program could access supports. Campus respondents also described working with residents and informal caregivers to arrange “top-up” support when client needs exceeded what the program could offer to help bridge gaps in service or fill-in until LTCH placement—ideally on campus—became possible. (See Appendix B)
Participants noted many benefits of a continuum where residents requiring increasing supports could transition across campus programs and settings, facilitated by campus staff familiar with a resident, the quality of the experience for the person receiving care, their informal care giver(s), and staff was much higher than when residents needed to move permanently to another location. (See Appendix B)