Illustration by Tim Boelaars
The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly-funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services.
READ MORE • Fixing Health Care: 10 ways to transform Canada’s public health care systems • About the authors
The Problem: Seniors want to age independently in their communities, but they don’t receive adequate support
Ana’s favourite aunt Louise is 92 and has been slowing down for two or three years. She worries about Louise living alone in the old house she shared with Ana’s uncle until he passed away, but Louise did not want to move – there’s too many memories there for her.
Ana visited her nine months ago and was concerned that Louise’s house was messy and that she had very little food. She seemed to be living on toast, jam, and instant coffee. She had difficulty climbing stairs and had been sleeping on her living room couch. Ana also noticed that one bottle of Louise’s heart medication was empty, but she couldn’t remember when she had run out of it.
Ana called the local health authority and explained her concerns. They said Louise sounded like a candidate for home care. But when Ana went to visit her a couple of months after home care started, nothing seemed to have changed. Louise said that the home care worker was supposed to come four times a week but frequently missed the appointment. When the worker did come, the timing of the visit was never reliable. The workers were always different and she did not feel comfortable having a stranger help her with bathing.
Ana decided to talk to Louise about a nursing home. Louise was open to downsizing her house but frightened about going into a nursing home after the horror stories she heard during the pandemic. Ana isn’t sure how to get her aunt the support she needs. She wants to help Louise maintain her independence, but she’s worried that her aunt will become more isolated and that her current living situation might not be the best option for Louise’s health.
The Fix: Governments should recognize and encourage Naturally Occurring Retirement Communities (NORCs) as an important resource for helping seniors to live independently
Canadians are living longer than ever before, and seniors are the fastest-growing segment of our population. According to the latest census data, nearly 1 in 5 Canadians are between the ages of 55 and 64, which means a large segment of our population is close to retirement, while Statistics Canada reports that the number of Canadians over the age of 85 is expected to triple by 2046. Figuring out how to provide care to Canadians as they age is among the biggest challenges currently facing publicly funded health care.
While life expectancy in Canada has continued to increase in recent decades, survey research conducted by StatsCan in 2018 found that only one in three seniors in Canada were meeting the criteria for “successful aging,” which includes a low probability of developing a disease or disability, the ability to function well both cognitively and physically, and having an active social life with adequate community support. Living alone has been identified as a risk factor for seniors in not meeting the criteria for successful aging, StatsCan noted, “due to its association with lower social support and interactions” and the fact that it increases our susceptibility to “negative health outcomes in older age.”
In our current health care system, our response to the growing population of seniors has largely been focused on attending to the physical symptoms of aging, which we typically treat with increasing levels of care as these symptoms worsen over time. While hospitals, long-term care homes, and home-care services primarily focus on assisting seniors with the physical criteria for successful aging, social interaction and a sense of community have been lower priorities in our care strategy for seniors, despite being just as important to maintaining independence and cognitive wellbeing. This gap in the continuum of care for seniors is especially important to address for our oldest citizens – StatsCan data show that 28 per cent of men over the age of 85 live alone, compared to 58 per cent of women in the same age group, and that seniors living alone were also “more likely to report poor perceived health and social well-being.”
Of course, many Canadian seniors find ways to look after their own social well-being as they get older. Increasingly, urban seniors are choosing to live in vertical communities as a way to downsize from maintaining larger, single-family homes, or avoid paying the high costs of living in a retirement home. Toronto is a prime example of this trend, where more than 70,000 people over the age of 65 live in high-rise buildings. A 2020 report by the University Health Network in Ontario found that around 36 per cent of the city’s seniors reside in apartment buildings, and counted 489 high-rises in the city “where at least 30 per cent of the residents are over 65 years old.” This trend is sometimes referred to as “vertical aging,” though health care experts have also started to refer to these residential phenomena as naturally occurring retirement communities, or NORCs.
We believe the increased numbers of seniors living independently in these congregate settings have presented governments with an organic opportunity to standardize and improve the delivery of services for seniors. The state of New York, for example, has developed a system of criteria for determining when a NORC has come into existence (for example, when a building becomes home to a high enough number of residents above a certain age, it can be classified as a NORC). Once registered, these communities then become eligible for various types of public funding that, in concert with funds from other public and private entities, can be spent on delivering community programming, social services and health care in a more comprehensive manner. For example, in a functioning NORC, home-care co-ordinators can arrange for a single home-care agency to provide services to all seniors living in a particular building or may arrange for onsite, group-based activities requested by the community. By using the power of collectivity, NORCs can assist with the direction of services to older adults while also helping community members maintain their autonomy.
There are already a few examples of communities and residences that self-identify as NORCs in Canada, but determining what exactly makes for a NORC is still somewhat fluid. Early research from the U.S. on the subject defined NORCs as “housing developments that are not planned or designed for older people, but which over time come to house largely older people.” In our view, if provincial governments were to direct more attention to identifying and supporting NORCs, they could save money over time while also improving the system of care for seniors.
In 2020, Ontario spent over $73,000 on each of its 75,000 seniors in long-term care over the course of a year. In comparison, about 800,000 Ontarians are cared for at home annually, and the cost of this care, on average, is about one-third of what the province spends on nursing home residents. By taking advantage of the congregation of clients in a NORC, home care and community care services could be provided at a lower cost and in a better manner. NORCs have also been recognized as having a strong potential for supporting seniors’ independent living and delaying the need for seniors to be admitted to nursing homes. Research by Queen’s University has demonstrated that seniors living in NORCs report being healthier and less lonely, enjoy an improvement in physical performance, and have lower rates of emergency-room visits and hospitalization.
Already, some infrastructure for NORCs has started to appear in Canada – the Oasis program in southern Ontario, for example, was established to provide seniors living in NORCs with common spaces to gather for exercise, social activities, meal preparation and more. The program relies on collaboration between landlords and publicly-funded entities to ensure that gathering spaces and other services are made available to senior residents, but the program’s most defining feature is its emphasis on self-determination and independence. Residents are the main drivers of the programming made available to their age group, which helps to alleviate the risk of social isolation that can beset seniors.
NORCs can also employ digital networks to help seniors maintain independence and their links to the outside world. Volunteer services that provide support to seniors can be arranged through these online networks, along with food delivery, medical assistance and other local services. Throughout the pandemic, NORC Ambassador programs were established online to help seniors start community activities in their own buildings, while mobile vaccine teams helped to organize onsite COVID immunization services for seniors.
NORCs have the potential to be a catalyst for a new approach for governments in caring for Canadians as they age. These communities present us with an opportunity to place more focus on aging well and preventing decline for as long as possible, as opposed to catching up to decline when it inevitably arrives.
About the authors:
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former Deputy Minister of Health for Ontario, and former CEO of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
Illustration by Tim Boelaars
More from the Fixing Health Care series:
It’s time for therapy to be included in Canada’s universal health care system
What’s a pain point you’ve experienced in Canada’s health care system? Our experts want to hear from you.
Email your story to comment@globeandmail.com and one of our experts may feature it in a follow-up article along with a potential systemic solution. If your story is chosen, we will identify you by your first name and last initial. Please use “Fixing Health Care Reader Story” in the subject line.
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