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 across three overarching themes and organized into eight resulting sub-themes:
A. Campus Inception and Development:
ii. windows of opportunity
iii. organizational structure and capacity
B. Campus Design and Functions:
i. intentional physical and social design
ii. campus service mix, amenities and partnerships
C. Ability to Offer Wrap Around Care:
i. policy hurdles and rigidities
ii. human resources shortages and inequalities
A. Campus Inception and Development
In describing campus evolution, most case studies developed into a continuum incrementally over time with all six currently offering a broad spectrum of community-based health and social supports, mixed-income housing options and LTCH beds for seniors and older persons with ongoing care needs in one geographic location. Further enabling factors as described by case study respondents (campus providers and partners) are presented below.. Please refer to Appendix B for supporting quotes to each theme.
i. Organizational Legacies – Addressing Unmet and Changing Needs. Campus Respondents in this study described long organizational histories of caring for seniors and older adults with disabilities in need (e.g., local housing, care). Respondents from the newest municipal campus and the most mature municipal case study 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.
Respondents 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 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. The Mennonite campus 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. The Jewish campus began as a Home for the Aged in a setting that respected Jewish culture and Kashrut (dietary laws). The northern mature municipal campus, and the newest NFP designated Francophone campus, while not faith-based, 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. The northern municipal campus 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. The newest NFP campus, 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.
Respondents 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 respondents attributed expansion into more fulsome continuums as a means to address widely varying levels of need for seniors and adults with disabilitieswishing to age in their communities (local and/or faith-based). Since that time, campus and partner respondents 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.
Respondents 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 respondents noted that co-locating a range of mixed housing and community support options including LTCH options in one physical location was considered both a responsibility to their community members (taxpayers) aligned with municipal “seniors’ strategies” but also met broader goals and commitments to developing “Age-Friendly Communities.”
Respondents 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 continuum, originally a hospital and LTCH provider, highlighted the direct impact a lack of housing and care options was having on their 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 in the community. These alternatives would not only improve seniors’ well-being, but create system efficiencies. (See Appendix B). Case study respondents across all six case studies (3 municipal and 3 NFP) emphasized the bedrock of campus inception to expansion was visionary leadership (past and current founders, administration, board members, local councils and faith communities), with political acumen (e.g., sitting at the ‘right’ tables; working collaboratively community partners) and willingness to take risks (financial, organizational).
ii. Organizational Vision and Readiness for Windows of Opportunity. Respondents noted expansion to broad care continuums required capitalizing on opportunistic policy windows and government incentives (e.g., development and redevelopment funding) and being “shovel ready” when they arose. Respondents from 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 new policy directions towards developing LTCH bed capacity. (See Appendix B)
Study respondents 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)
Respondents 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. They 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 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 each of the four components of campus continuums being investigated in this study across one period of time by capitalizing on a redevelopment opportunity for their aging standalone LTCH. Respondents from each of the newer campuses described benefitting greatly from discussions on lesson learned and site visits with more mature campuses to observe and gauge fit for their own context and roll-out.
Campus respondents noted the importance of offering a blend of mixed-income housing options to address important issues around access and availability for varied financial abilities to pay. Options included social housing (subsidized rents for low income individuals), affordable housing (generally 80% of market value rent), market rent housing, and for most case studies, life lease agreements (residents own their own units but must sell back to the organization when moving or in the event of death).[1] (See Table 1) All campus respondents identified access to affordable housing options as critical, noting that many low income seniors were just above the threshold to qualify for the limited supply of social housing on campus but could not afford to pay even “fair” market rent. One mature NFP campus demonstrated great commitment to social housing in keeping rent geared to income options for one of their legacy buildings past the required timeline by the municipality to do so.
The newest municipal campus developed a retirement home option for those with means as an additional offering to address higher care needs along the continuum (e.g., on site nursing, three meals per day) than are available by government funded assisted living (ALS) programs that are limited to a relatively small percentage of seniors’ housing residents (~20%) in most of the case studies. Campus respondents described retirement home options as only possible for seniors with financial means, but that this was worth considering 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 respondents 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.
Respondents noted campus development activities “were not for the faint of heart” and described them as highly resource intensive to undertake (e.g., capital, time, finances) from idea to implementation. Leveraging existing campus infrastructure (e.g., number of licensed LTCH beds), organizational capacity (e.g., internal expertise for feasibility studies, land procurements, partnership development, renderings, project management) and adequate cash reserves to put upfront against campus (re)development were described as key enabling factors for expansion opportunities. (See Appendix B)
Municipal campuses and larger NFP organizations were described by respondents as more able to draw upon in-house knowledge, expertise and capital to manage campus planning, development and ongoing functioning as needed (e.g., human resources departments for advice on collective agreements, procurement and property offices to help with capital development plans). This minimized the need to contract out for required skills and project management. Securing funding posed challenges, even for large campuses, as funders could have difficulty understanding the interconnectedness of the multiple components within a coherent continuum of care and projects needing to be “value-engineered” to work within set limits and timelines.
B. Campus Design and Functions
Campuses were described by campus and partner respondents as being “more than a place to live” and having “a real village atmosphere” They highlighted the importance and intentionality of interconnected campus components as a means to offer diverse opportunities for social and civic engagement by campus residents and local community. Campuses further expanded access to health and social networks through intra and inter-organizational coordination of services, offering important onsite amenities and development of creative partnerships to improve integration of services both vertically and horizontally. Key enabling factors to campus design and function are described below:
i. Intentional Physical and Social Design. Campus architectural built environment was attributed as a key factor to the “vitality” and ongoing functioning of campus life and activities. Each campus noted intentional strategies to ensure physical (e.g., covered above ground linkages, connecting corridors, cleared outdoor walkways) and social (e.g., shared programing, shared amenities, common rooms) interconnectivity across campus components. Such connectivity was considered critical to the health and social well-being of seniors to facilitate planned and spontaneous opportunities for physical exercise (alone, with staff, friends and/or family), and ability to socialize with others in different areas of the campus. Safe linkages provide greater ease of passage for patrons, particularly those using mobility devices or with vision impairment. They also reduce seasonal risks for heat exhaustion with high temperatures in the summer, or simply not having to put coats and boots on deep cold in the winter. Where physical linkages were not as convenient as others (e.g., going to separate buildings through underground corridors) campuses worked hard to make these spaces appealing (e.g., local artwork), senior friendly (e.g., seating between areas) and purposeful (e.g., spaced utilized for hair salons, cafés) to promote their use. (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. Respondents of a mature municipal campus described careful consideration given to the redesign a large 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 respondent 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.
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 residents in the (semi)rural or northern campus to be related in some way (e.g., siblings, cousins, in-laws, grandparent) to other residents or with a campus staff (past or present). Respondents noted benefits in having family and friends in close proximity including an increased ability to maintain kinship and support for one another. Proximity, freedom of movement across campus buildings, and familiarity to campus staff and programs were all noted to promote greater uptake of onsite respite opportunities (ADPs, respite LTCH bed) by informal caregivers and greater opportunity for visits if onsite placement of a spouse/sibling/friend to the campus LTCH occurred.
Respondents noted that while all campuses aimed to be inclusive in their programing and offerings to potentially all residents, tensions could sometimes develop when offering housing that crosses socio-economic spectrums and different abilities (e.g., physical, cognitive, developmental). They further noted that different housing options that provide enhanced finishes or selling features (balconies, appliances) could contribute to potential divides; some felt these were necessary to attract seniors willing to pay extra for these features and offset costs for the lower cost rentals, while others felt offering the same to all avoided unnecessary distinctions of disparities. Proactive strategies described by campuses to address these issues included the development of tenant advisory boards to work together in developing communal activities (e.g., potlucks hosted in different common rooms across the campus) and enhancing opportunities for leisure, social engagement or volunteering regardless of income or abilities (e.g., communal libraries, garden spaces, party rooms, billiard rooms), shared amenities (e.g., worship space), and community wide activities open to campus residents and local community (e.g., live entertainment, special events, religious services).
All campuses noted socio-economic distinctions tended to fade as residents of the campus participated in collective activities and got to know and look out for one another. Respondents further noted that collective activities and shared spaces were also important mechanisms reduce the potential for loneliness and social isolation not only for campus residents, but also for clients attending on-site day programs, recovering patients in convalescent care in campus LTCH beds, and visiting family and friends of LTCH residents wishing for opportunities to involve engage or simply seek a change of scenery. Commonly described campus offerings (recreation, events, amenities) are listed in Table 2.
Table 2. Common Shared Recreation, Amenities, Events and Volunteer Opportunities
Recreation Opportunities* |
On-Site Amenities* |
Events and/or Volunteer Opportunities* |
· Wellness centres – gym, therapy pools
· Health related clinics/labs | · General store/Tuck Shop
· Common spaces for planned and spontaneous activities
· Hospitality Suites**
· BBQs |
*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.
ii. Service Mix, Amenities and Partnerships. Campuses were described as having the ability to coordinate access to a continuum of care in one geographic location for high needs and often underserved populations. In contrast to service-by-service delivery approaches where clients have to navigate multiple services and providers on their own, campuses were designed to consolidate resources to offer “one stop shopping” where clients receive help to access the most appropriate services and supports from a continuum inclusive of community supports, housing options, and LTCH beds The blend of independent living and housing with supports was viewed as crucial to maintaining individuals with a range of lower to higher needs as independently in the community for as long as possible. Specifically, legacy supportive housing (SH) programs in Ontario (pre 2011), assisted living services (ALS) programs (2011 onward), cluster care (CC) and retirement home (RH) living were all noted as beneficial options to access progressive levels of support but not requiring LTCH level care. Respondents identified issues with current long-term care waitlist practices for clients needing to transition out of housing to onsite LTCH beds – to be discussed later – which had campus staff stretching their SH, ALS and RH programs to try and bridge time to secure an onsite LTCH bed and avoid the need for a client to move off campus to another LTCH.
Campuses offered 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 government funded 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, yet none was offered, or potentially needed given the current campus configurations. Many campus respondents expressed concern that by comparison to other sub-sectors the community support services (CSS) sector was poorly funded. When delivering CSS services or partnering to do so, this disparity could impede abilities to serve more people in need (wait lists) or raise fees as program expenses increased. 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 (e.g., daily security checks), well-being (e.g., gauging gait or cognition during programs), social isolation (e.g., opportunities to dine with others) and nutritional needs of seniors (e.g., healthy meals with no meal preparation required), while also helping to off-set costs in provision of providing these programs onsite.
Table 3. Common Campus Home and Community Care Programs
I = Available Internally to Campus Residents = I; E = Available Externally to Local Community |
Campus |
Meals on Wheels |
Day Program* |
Active Living Centres/Wellness Programs** |
Falls Prevention Programs/ Physio-therapy*** |
Congregate Dining |
Supportive Housing/ Assisted Living**** |
(Municipal)
I & E |
Not onsite |
|
I & E |
I & E |
I |
Semi-Rural (Municipal) |
|
I & E |
I & E |
I & E |
I & E |
I |
Small Urban Mature (Municipal) |
I & E |
I & E |
I & E |
I & E |
I & E |
I & E |
Urban (NFP) |
I & E |
I & E |
|
I & E |
|
I & E |
Rural Mature (NFP) |
|
|
|
I & E |
I |
I |
Urban Mature(NFP) |
E |
I & 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).
Co-location of the various campus components and consolidation of resources were described as allowing for greater efficiencies and maximizing economies of scale which benefited clients and provider organizations(e.g., bulk purchasing for the entire campus; maximizing use of existing infrastructure to the broader community). For example, case study sites often purchased and sold utilities back to campus 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, it was noted to help avoid any confusion in navigating installation across the campus and having one payer. In another example, study respondents 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). Some campus respondents 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 respondentsdescribed levies as an important factor affecting their ability to build reserves into their operations. Municipal respondents noted levies were used to maintain service (e.g., automatic door openers, elevators, damages from wear and tear) when housing contracts were complete, to address any shortfall in revenue and to provide 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 respondents 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)
Respondents 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 respondents in smaller communities noted that municipalities need to work collaboratively with the local community and the private sector, being careful to neither overstep the balance of the private sector nor be seen as in competition with them (e.g., housing, retirement homes). Respondents 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 respondents 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 respondents 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 4 for an overview of Key Legislation and Policies in which Campus components operate in Ontario.
Table 4. 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 |
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
Volunteerism by campus 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 bazars) and/or formal committee membership (e.g., tenant councils, family councils in LTCHs). Respondents noted volunteering provided seniors, particularly those living in campus housing, an important sense of purpose and natural opportunities to socialize and reduce loneliness and isolation Proximity increased their ability to help. Campus respondents 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.
Innovative campus partnerships and arrangements with community organizations, government bodies, academic institutions, local providers (medical and non-medical) and local businesses enhanced campus offerings and helped them to serve as “community hubs” for which the broader community is encouraged to share in programs, supports, amenities and events. Co-location with partner organizations often mitigated the need for travel for campus residents and local seniors affording savings in transportation costs, and built important on-site linkages to clinical and non-clinical services (e.g., primary care, audiology, blood labs; banking hours/machine; libraries; general store; pharmacy services, social programing; restaurants). An important practical limitation for campuses was as their scope grew – so too did issues with a lack of parking for clients, staff, visitors, and volunteers. 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 |
· 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 | · Community Health Centres
· Community Living (serves people with developmental delays)
· Community Programs (choirs)
· Pharmacy Services
· Colleges |
* 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:
Respondents at each campus described three common factors that impact upon their ability to offer wrap around care across a full continuum: policy rigidities, human resources shortages, inadequate funding.
i. Policy Hurdles and Rigidities.
While all campuses conceptually have the ability to offer a full continuum of care to support people’s needs as they change or intensify – sometimes temporarily, sometimes permanently – each campus operated under and across multiple policies, legislation and sectoral standards that could pose barriers to do so seamlessly. An issue that emerged across all case studies was the management of LTCH waitlist policies, which in Ontario are under the control of the local regional government and applied using an equity lens for all in need of a bed across the province. Priority status is not given to residents living in campus housing for a LTCH bed on their campus. While legislative provisions are made for spousal reunification in LTCHs if one person is already in a LTCH bed (in the context of this study – a LTCH bed on campus), respondents noted that no such provisions are made for onsite priority of other family members living on campus (adult children with physical, cognitive or developmental disabilities) who would benefit from being in close proximity. Respondents highlighted that in cases where campuses provide for specific cultural/religious/ linguistic needs, clients in campus housing with these backgrounds (e.g., Francophone speaking; Jewish heritage) “in principle” seniors in campus housing had a greater chance of getting into the onsite LTCH, but would often wait long periods of time on the list for an opening.
Campus respondents expressed that while they understood the value and importance of equity-based policies for LTCH placement, they pointed to the lack of priority status as “incongruent” with the purpose and perceived benefits of care continuums to maintain a person in their community of choice. Respondents noted the continuum was the draw for many seniors to move to a campus despite being informed at time of application and entry there would be no guarantee that an onsite LTCH bed would be available if and when spaces opened at time of need. Mature campus respondents further noted this practice was counter to campus founders’ original intentions to support people across transitions at the most frail and vulnerable point in a resident’s life and for those that had been in campus housing prior to the change in wait list policies, moving across all components of the campus was an expectation. (See Appendix B)
Campus respondents described resulting consequences of transitions from campus seniors’ housing to an external LTCH setting as including increased burden for frail partners/family/ friends to attempt to monitor and maintain connection (e.g., transportation costs and energy for traveling distances), and severed relationships with familiar staff and settings.
Campus partners acknowledged and sympathized with these concerns, yet also described experiences of their community-dwelling seniors and caregivers in great need of a LTCH bed. They described off-site seniors as not having the same level of monitoring, support and access to services and amenities available to those in campus housing waiting for a bed making their needs equally and potentially more pressing to prevent additional stress or burnout by caregivers. Campus and partner respondents both noted that the campus interconnectivity and amenities supported uptake to their programs (e.g., Adult Day Programs, Wellness Programs, Congregate Dining, Volunteering) and enhanced transition experiences to LTCH placement with greater familiarity of setting, and ability to maintain social relationships (visitors across the components). (See Appendix B)
For individuals arriving to the campus LTCH from hospital or community as a “crisis placement” (a term that indicates an inability for people to manage independently at home and/or those with a distressed caregiver), campus respondents noted that, after having been rehabilitated, some of the placements had the potential for lower intensity care elsewhere on campus. They noted that few opportunities were available to shift such residents into campus housing programs for a “trial” without losing their LTCH bed, and no assurances to be next on the LTCH waitlist if the shift was unsuccessful. Study respondents noted frustration that some people can end up receiving care in the “wrong” places and additional observations that some “crisis placements” appeared to be in less need of higher level LTCH care than some seniors receiving support and care on their ALS programs.
While campus respondents had little control over funding restrictions or LTCH placement waitlists, they were able to manage their internal wait lists for housing – with some restrictions on rent-geared-to-income – to help residents move across other campus settings (e.g., life-lease to supportive housing) based on need and already being on campus – not chronology. Internal wait lists were also described as helpful when considering entry of a life partner or disabled adult child to campus housing from the community when their spouse/parent moved to the campus LTCH home from the community. (See Appendix B)
ii. Human Resources Shortages. Human resources shortages experienced by campuses ranged from PSWs and nurses to culinary and allied staff. These shortages were noted as a more prominent concern in the north and rural regions, but in all cases by comparison to stand-alone community programs and LTCHs, campus challenges were less acute. All campus respondents indicated that provision of in-house PSW care was preferred by housing residents to provide greater reliability and staff familiarity. External community support service agencies, which are also impacted by PSW shortages, were noted by respondents as being less reliable and consistent as in-house PSWs. Francophone campuses expressed that shortages are further impacted by an inability to find bilingual staff. At the time of data collection, some campuses were exploring becoming sole contracted providers for the provision of all government funded PSW services for campus residents. (See Appendix B)
Respondents from municipal and NFP campuses described a number of strategies to ensure coverage for required services and accountability agreements including: i. the use of external agency staff to cover shifts which for some could become expensive (e.g., equivalent to paying staff at overtime rates); ii. strategic contracting with another community support agency to provide care on a semi-regular basis as a means to better plan for and cover vacation and sick time for staff in different areas of the campus, avoid paying overtime, and prevent staff burnout; iii. hiring developmental services workers (DSW) instead of PSWs for one ALS program to provide an additional level of training for the increasing acuity of community residents with health and social care needs; iv educational placements and internships with students from local colleges and universities (health care, maintenance, culinary) to host, train and potentially hire new staff. (See Appendix B)
Campus respondents described relatively low staff turnover in administrative positions (some had 20 – 30 year histories) but greater fluctuation for front-line LTCH staff. Despite higher pay rates in LTCHs for these positions than in the community, some campus respondents described a trend of staff transferring into housing positions citing the attractiveness of lower ratios of patient to staff being lower (e.g., 1-1 vs 1-10). Campus respondents also described a historical trend of staff moving to hospitals where PSWs are paid similar wage rates as the LTCH sector pays registered practical nurses (RPNs), making it tough for campuses to compete. Respondents from the northern municipal campus noted that recruitment was particularly difficult in the north and remote communities as compared to their urban counterparts.
iii. Funding Limitations. At the time of data collection, respondents noted that budgets for community support services (CSS) in Ontario had not increased for approximately a decade (prior to the 2018-19 budget). In contrast, respondents noted increases in hospital and LTCH funding over the same period. Campus and partner respondents described frustration that CSS were “treated as less essential to other healthcare offerings despite their value and ability to offer high level care at the same or lower cost than if they were to be placed in institutional long-term care.” [CR1]. (See Appendix B)
Community-based ALS programs were described as able to provide enhanced support to people in lower care settings (their own apartments) – often delaying or avoiding the need for placement to LTCH. Respondents noted that ALS programs experienced policy rigidities through a 2011 policy that limited the intensity level of clients they were formally able to serve (those with moderate care needs) when in practice respondents noted that campus ALS programs often supported people with a range of moderate to high needs. They did so through a range of services and supports on campus and partnering with the regional authority for nursing and other professional care services to address client preference to live and die in ones’ own home when adequate support was available to do so. Funding limitations impacted the nimbleness of ALS programs to respond to need and forced the creation of waitlists for some case study sites. (See Appendix B)
Campus respondents described experiencing stress when seniors in need were unable to be permanently brought onto their ALS programs due to funding constraints creating waitlists. Campus respondents described creative solutions they would undertake for more “incidental” short-term use of the ALS program by non-ALS seniors (e.g., otherwise independent individuals returning from cataract surgery in need of only temporary support). In cases where clients’ needs exceeded the support ALS could offer, campus respondents described working with residents and informal caregivers to arrange private pay options (campus staff or outside agency) to “top-up” services, or to help bridge gaps while waiting for a LTCH bed. (See Appendix B)
Respondents noted that social and affordable housing offered on campuses were essential, but expensive to offset, particularly given the growing number of seniors in need of subsidized housing. Campuses used market rent and life lease, in for the newest municipal campus, retirement home living options as a means to do so. Additional strategies under consideration by some campuses included expansion to offer fair market NFP retirement home living as a means to both subsidize low-income housing, and to extend care continuum offerings (e.g., access to a nurse), noting that careful attention would be paid to reinvest any surplus back into the campus – a key factor to meeting NFP and charitable status. The newer municipal retirement home options included the ability to offer short term stays (one to three months) for seniors in need of seasonal help (e.g., winter stay to avoid risk of falls/snow shoveling), or a trial stay for permanent consideration. These options were noted as addressing organizational needs (suite capacity) and system needs (assisting hospital discharge planning with transitional alternatives to convalescing or LTCH placement).
Campuses utilized additional opportunities to secure funds for programs and services including fundraising events; however, for those without formal foundations, fundraising could be disruptive to other administrative activities. As discussed earlier, small revenues could also be generated through the inclusion of minimum service packages as part of rental agreements separate with direct reinvestment of funds in campus programs.
[1] Life lease housing properties are not owned by residents but rather provide the right to occupy the property and an “interest” in that property in exchange for a lump sum payment up-front, with monthly maintenance fees and property tax payments. Residents own their own units but must sell back to the organization when moving or in the event of death (76).