The virus has certainly opened up a tantalising debate for residential aged care to stop locking people away and do what it takes to maximise frail lives. Not surprising when we look at how, even in a time of extraordinary effort, the virus has exposed that:
- people prefer not to live in residential aged care homes
- life enhancing technologies, buildings, supports and skills are seldom present
- they are not safe and infection safety is achieved by locking residents away for long periods
- they survived by subjecting poorly paid and equipped staff to significant risk and stress, and
- half of them weren’t viable even before the virus.
So, what would ‘good’ residential aged care look like? Leaders will need to know this before they will shift from the safe process of gradual improvement to the rapid transformation we really need right now.
For years we’ve asked residents to comment on our plans for new residential care, containing them to also being gradual improvers. Then last year Strathalbyn Aged Care asked residents and the community what it was they wanted to preserve or change if they became frail. They said, ‘I’m not going to be easy to care for, but just add discrete and loving care in a place that lets me live my current lifestyle. I don’t want to live in an institution, but I do want community at my doorstep. And don’t take away all that I love, or destroy my reputation.’
We gave the Strathalbyn Aged Care ‘co-designed brief’ to architects and asked what the building would look like. They said they really needed to design it with the client… hold onto your hats – they meant the resident not the provider.
But they identified seven foundation requirements to achieve the brief, none of which are present in the current residential care service model:
- a culture that doesn’t take away but adds whatever it takes to maximise a frail life by building resident skills and reputation
- rooms being more like houses with easy individual house access and function for families and home deliveries, with the whole development feeling more like housing and less like a carpeted hospital
- accepting that both short and long-stay residents and their families prefer more private space, and that the demand for “good” short-stay is about to escalate
- an extreme effort for the inclusion of families and community to enhance joy, care, and safeguard against abuse in ways that inspections and reporting never can
- a concierge service that creates a single point of contact for the resident, and offers a very wide range of health, care and lifestyle options … from both the provider and external ‘best of breed’ suppliers
- embedded enabling technologies that create larger-than-life benefits for frail people, and
- staff who are partners in driving the innovation, skilled in the new service models and free from the institutional service model that has reduced them to servants.
Our friendly architects also told us (off the record) that we might do better if the architects had a housing background, rather than a residential aged care specialisation.
All looks pretty obvious once the client is the resident. Surely with the amount of newbuild going on in the sector someone’s already done this. Not really. There is a move to serviced apartments and retirement villages adding care to their offering, with Life Care saying “it’s unlikely you’ll ever have to move again”. But the nearest is the unique, and completely ignored, Colton Court residential care in SA, which offers high-care residents a fully equipped home, with family and community coming in their front door and services in the back. Residents conduct most of their roles in their own ‘homes’ but wanted some modest community right on their doorstep. Just take a look at what residents bring with them to preserve their current lifestyle … spouses, cooking appliances, sewing machines, dogs, gardens, exercise equipment, furniture …the list goes on.
But it took the virus to show us how technology could add significantly to this frail life maximising.
The lessons on how older people in their own homes raced to adopt life-improving technologies during the pandemic contradicted so much of what we believed about them and the usefulness of technologies for them. The trick is going to be for providers to build their own narrative about why technology matters in their residential care. This ‘why technology matters’ narrative should grow from just being about the product to capturing the value of product and service ecosystems that share cost and create unique products, co-invention with the residents, and innovation-themed staff networks that test the boundaries in and out of organisations.
Anyone who has visited or lived in residential care knows that the staff are everything. They are usually caring and skilled in caring, yet rarely champions for maximising frail lives that these new service models will require. No amount of training will change them from doing what the institutional service model demands of them. Changing the model will. So if post-COVID residential care wants these champions, staff at all levels will need to work in spaces ‘owned’ by the residents, be partners in the organisations’ innovation efforts, be connected to others in and out of the organisation around learning and doing innovation, and trained in calling out and rejecting ageism.
Released from the shackles of the current service model, and ever close to the residents, staff can become a brand-new force for change in a sector that doesn’t have much force for change.
One of the most interesting questions during the pandemic has been to imagine safer residential care that lowers the risk to all residents without locking down the whole place. Smaller ‘group homes’ have been proposed, more homelike in both amenity and domestic role-possibility … but still requiring lockdown for safety.
Single home units isolate cross-infection risk and allow each resident and family to negotiate their level of social isolation and social distancing, just like older people do in their own homes.
So, would these ‘apartments for maximising frail lives’ be viable to build and run? Building more of what we already have certainly won’t be. Let’s prototype lots of iterations and see.
We might be able to use more domestic construction, or not increase the footprint as we exchange public for private space. We might achieve much higher quality of care, life and safeguarding while containing the costs, particularly if we stop excluding families and community. We could use different pricing structures for housing ownership, and a daily fee that allows people to buy more or less depending on their abilities, supports and changing conditions. People might even be happy to pay more if they liked what they were buying for a change. And better for investors to invest in products the market likes, than ones they hate.
We asked people of all ages would they choose ‘apartments for maximising frail lives’ or conventional residential aged care. Couldn’t find a single taker for the old model.
This is a transformation of a service for a very vulnerable group and the developing but highly regulated market mechanisms will need the support of a national transformation effort to succeed.
This effort will assemble the globally best technologies, co-inventors, building and product designers and innovation-ready provider clusters to land prototypes that could only come out of such a purposeful bringing together. It’s urgent that we start this work now before too much more residential care is built that will forever disappoint.
So, the virus certainly opened our eyes to the problems of low safety and quality in residential care by making it even worse during a time when they were under public scrutiny, and turned our minds to what should now be expected alternatives. Will we go there? Certainly, with some of the technology, but otherwise probably not. The sector will dine out on their near-zero infection success compared to other countries, forget the life impact it had on residents and staff, and resist the once-in-a-lifetime insights into what we are actually doing to vulnerable people.
The extreme ageism in residential care is largely unconscious and at the end of the day residential care will continue to be designed and run by mission-driven people who never live in them, with the virus now making this even less likely. Leadership with lived experience never was, and still isn’t, on anyone’s agenda.
A national investment in a globally sourced transformation effort on ‘apartments for maximising frail lives’ will be our best bet.
Mike Rungie specialises in the intersection between good lives and aged care. He is a member of a number of boards and committees including ACFA, Every Age Counts, Global Centre for Modern Ageing and GAP Productive Ageing Committee.Do you have an idea for a story?
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