Please click on each link to sequentially access Parts I, II and III

White Paper—University of Toronto Centre for Design + Health Innovation

Stephen Verderber, Arch.D., RA, NCARB
ACSA Distinguished Professor
John H. Daniels Faculty of Architecture, Landscape and Design
Director, Centre for Design + Health Innovation
Adjunct Professor, Institute for Health Policy, Management and Evaluation (IHPME)/
Dalla Lana School of Public Health
University of Toronto

In 2021, the Provincial Government of Ontario committed an unprecedented $1.75 billion over five years to strengthen and modernize the Long-Term Care (LTC) network in Ontario. This policy decision was driven by the urgency to respond to the expanding COVID-19 pandemic. It is a governmental commitment with potentially major ramifications for LTC, which many Ontarians had long been advocating. In early 2021, Jacobs Canada hosted an interdisciplinary Roundtable event. It drew together leaders from the architectural, direct care provider, and home eldercare sectors to focus on how this planned investment can be most thoughtfully and successfully implemented. Recommendations were put forth: 1. Current insufficient freedom of choice exists among the general public in being able to self-select among various LTC facility locations; 2. Better system-wide planning is needed in anticipation of the growing number of aged individuals with cognitive impairments in need of viable LTC options; 3. Greater infrastructural connections, i.e. walkability, transit, are needed between a LTC facility and its neighborhood and broader urban context; and 4. New public policies are needed to foster the construction of genuinely therapeutic LTC residential care facilities.

Purpose and Aim—Actionable recommendations were outlined in a brief report from the Jacobs Canada Roundtable participants, Re-Imaging Eldercare in a Post-COVID-19 Ontario. The Centre for Design + Health Innovation at the University of Toronto was a co-author. This report was presented to the leadership of the Ontario Ministry of Long-Term Care (MLTC) in February 2021. It ecommended: 1. Avoid haphazard overbuilding in response to the current pandemic; 2. Foster viable mechanisms to elicit community feedback in the form of grassroots-level consultations to identify the best capital investment strategies; 3. Develop an alternative facility compliance and monitoring system quasi-autonomous from currently in-use Ontario MLTC standards; 4. Identify evidence-based best practices in site selection, facility programming, and architectural and landscape design, i.e. a 2.0 version of the 2015 Provincial minimum construction standards for LTC homes to upgrade infection control best practices; 5. Implement asset management best practices; 6. Establish upgraded facility procurement metrics; 7. Focus on creating LTC homes—residences—versus housing the maximum number of beds on a single site; and 8. Balance 24/7 residential care with at-home senior care services. In the Spring of 2021, the Ontario Association of Architects (OAA) joined this effort as a collaborating co-sponsor with the aim of fostering its members’ furthered knowledge of the inner profundities of an evolving building type, and to reassess current policy challenges associated with LTC facility procurement in the Province.

Methodology—Three streams of architectural research have evolved in recent decades: Research for Design; Research into Design; and Research Through Design. Each paradigm has evolved its own theories, assumptions, hypotheses, methods and academic literature. The method adopted for this White Paper adheres to the Research for Design paradigm and as such consists of: Part I— An analysis of global case studies of recently built LTC residential care facilities; Part II— The distillation of site planning, architectural and landscape design considerations, and Part III—A literature review in support of Parts I and II. Key underlying concepts are: Autonomy; Individuality and Dignity; Privacy; Satisfaction; Self-Actualization; Room Personalization; Therapeutic Activities; Socialization; Security, Safety, and Infection Control; Ambient Environment; Noise Abatement; Well-Being and Health Status; Staff Well-Being and Functional Performance; Offsite Prefabrication; Person-Nature Affordances; Ecological Sustainability; Leadership/Stewardship; Facility Procurement Best Practices.

The methodology consisted of a broad review of published, peer-reviewed quantitative and qualitative investigations and essays. The first step consisted of a keyword search to identify potentially relevant peer-reviewed publications. Forty-five key words were used, referring to LTC resident and staff outcomes, i.e. wayfinding behavior, engagement with nature and landscape, infection control and COVID-19, medical errors, pain, stress, sleep patterns, privacy, personal autonomy, room personalization, involuntary and involuntary relocation impacts. A protocol established by Verderber et al. (2021) with respect to a comprehensive review of the literature on hospital-based ICU/CCU built environments guided these cross-searches using combinations of key words and phrases through the JSTOR and Google Scholar databases and further searches combing multiple databases including EBSCO, ScienceDirect, PsychINFO, MEDLINE, Ovid, ProQuest, PubMed, Web of Science, Science Digest, and NIH Public Access. This search included any study or article that alluded or referred to the LTC healthcare physical built environment in its title or abstract, published between January 2005 and June 2022. The decision was made at the outset to include both empirical and qualitative research investigations, as well as relevant theoretical and opinion essays, in order to broadly capture the scope, depth, and nuance of a rapidly evolving subject. The initial search phase yielded 347 primary sources, subsequently reduced in a second stage assessment to 279 peer-reviewed sources. These met or exceeded the team’s benchmark for rigor. In the third-stage assessment, these sources were further examined and reduced to a compendium of 218 sources (reported below).

The research team carefully screened three types of sources: (1) empirically based studies that examine the role and impact of the built environment or natural environment on resident, staff, and/or family outcomes; (2) qualitative studies that examine these same relationships; and (3) theoretical essays that examine the relationship between nursing best practices and administrative policies, and the planning and design of 24/7 LTC residential environments. Non-peer-reviewed white papers, research reports, minimum standards guidelines publications and books on this subject were eliminated in the first wave of the screening process. The final compendium was then structured into nine content categories deemed by the research team to best capture the current state of the art and science. The 2005–2022 period witnessed numerous significant advancements including the emergence of consensus on the single-bedroom and adjacent personal hygiene space as more healthful than traditional semi-private rooms. Specifically, also addressed are the virtues of smaller-scale residential units, multigenerationality, a homelike aesthetic and ambiance, privacy, dignity, space personalization, noise and daylighting controls, and engagement with nature/landscape.

Specifically:

Part I—Case Studies in Long-Term Care Residential Facilities. Twenty-five case studies are presented built since 2005 (with one exception—2003). They represent a continuum from the fewest number of beds on-site to the most. Four size-based categories were identified. Each case study is examined for its landscape and urban context, functional program, engagement with nature, and lastly, any opportunities for offsite-prefab manufacturing. They provided examples of design excellence to be translated into Part II.

Part II— Fifty Design Considerations. These considerations are based on salutogenic and biophilia-related design concepts drawn from the literature and the case studies. They are written and formatted for ease of use by architects, landscape architects, interior designers, planners, engineers, sustainability specialists, physicians, psychiatrists and allied therapists, gerontologists, nurses and caregiver support staff, long-term care administrators and organizations in the for-profit and not-for-profit sectors, Boards of Directors, federal and provincial government, private philanthropy, grassroots advocacy organizations, elected officials, and health policy specialists.

The design considerations were inspired by the work of Christopher Alexander and his colleagues, co-authors of A Pattern Language: Towns, Buildings, Construction (London: Oxford University Press, 1977, and subsequent editions). The genius of this enduring method is that an individual pattern is nested within other patterns, and here, connected by hyperlinks that form a relational web-network. Alexander’s approach was the inspirational basis for Wikipedia, and since, many other software algorithms, including Agile, Extreme Programming, and Scrum. Ironically, its full acceptance lagged, initially, but it remains on the radar in the planning and design professions 45 years later.

As with that first generation of patterns (1977) this compendium sets out normative propositions supported by evidence, and as such each is accompanied by one or more citations drawn from the environment and aging literature. These are normative assessments and after each, relevant design considerations are cited with a link provided. This compendium is equally inspired by the Ontario Long-Term Care Home Bill of Rights, and its 27 guiding provisos which assert that every resident has the right to experience and directly benefit from:

“1. Respect and dignity; 2. No abuse: 3. No neglect; 4. Proper care; 5. Safe and clean home: “You have the right to have a safe and clean place to live in;” 6. Citizen’ rights; 7. Knowing your caregivers; 8. Privacy: “You have the right to privacy;” 9. Participation in decisions; 10. Personal belongings: “You have the right to keep personal things in your room. This is your home. As in any home, it is important to have personal items around that are special to you or make you feel more comfortable;” 11a. Plan of care; 11b. Consent to treatment; 11c. Care decisions; 11d. Privacy and health information; 12. Independence: “You have the right to get help to become as independent as you can. For example, you have the right to get help to improve your ability to walk or go to the bathroom on your own;” 13. Restraint; 14. Communicate and visit in private; 15. Visitors during critical illness; 16. Designated contact person; 17. Raising concerns; 18. Friendships: “You have the right to make friends and to spend time with them. You have the right to be involved in any activities offered at the long-term care home, if you wish;” 19. Lifestyle and choices: “You have the right to live your life in the manner you wish;” 20. Residents’ council; 21. Intimacy: “You have the right to be alone with your spouse or a person who is important to you;” 22. Sharing a room: “You have the right to share a room with another resident, so long as you both agree and space is available at the home;”23. Personal interests; “You have the right to do things that interest you and things that are important to you, either inside or outside the home;” 24. Written policies; 25. Your money; 26. Going outside: “You have the right to go outside to enjoy nature, fresh air, and outdoor activities whenever possible. If the home has a protected area, no one can stop you from using it;” and 27. Bringing people to meetings. What can I do if my rights are violated? Getting legal help and information.”

Community Legal Education Ontario (2022). Bill of Rights for People Who Live in Ontario Long-Term Care Homes. CLEO. https://www.cleo.on.ca/en/publications/everyres.

The intent is for architects and others to build upon these design considerations. It is hoped the reader will view each design individual design consideration as a hypothesis. The compendium’s nine thematic categories are: Site Context and Spatial Organization (1); Private Realm (2); Shared Realm (3); Biophilia and Nature Connectivity (4); Circulation and Navigation (5); Support Amenities (6); Sensory and Environmental Support (7); Offsite Prefabrication (8); Total Environment (9).

Part III—Typology/Bibliography: 2005-2021—Recent and Future Design Trends. A comprehensive review of the literature on long-term care from January, 2005 to the end of 2021. The first wave search culled nearly 350 citations and of this total, 272 citations were retained and are categorized as follows:

1.Community-Based Aging in Place (43 citations): 1a. Immediate Neighborhood and Urban Environment; 1b. Aging in Place in One’s Existing Home; 1c. Multigenerational Dwelling Strategies. 2. Residential Units and Residentialism (38 citations): 2a. Design Considerations and Case Studies; 2b. Sense of Place and Well-being; 2c. Prefab Modular Opportunities in LTC Residential Environments; 2d. Personal Space and Cultural Factors. 3. Nature, Landscape, Biophilia and the Aged (34 citations): 3a. Biophilia and Related Theories; 3b. Design Considerations and Case Studies; 3c. Therapeutic Gardens; 3d. Dementia and Nature Engagement. 4. Dementia Care Special Units—SCUs (35 citations): 4a. Cultural Factors and Dementia SCUs; 4b. Immediate Living Spaces; 4c. Influence of the Built Environment; 4d. Design Innovations and Case Studies. 5. Facility Closure and Resident Relocation (28 citations): 5a. Cultural Factors in Relocation; 5b. Voluntary Relocation; 5c. Involuntary Relocation—Adverse Outcomes; 5d. Improving the Relocation Process. 6. The Expanding Role of Family Engagement (10 citations): 6a. Family Engagement—Case Studies; 6b. Family Engagement—Facility Design. 7.Infection Control, Well-Being, and COVID-19 (40 citations): 7a. Safety and Infection Control; 7b. Lighting, Noise, and Indoor Air Quality; 7c. Covid-19. 8. Ecological and Cost-Effective Facility Procurement (13 citations): 8a. Sustainable-Resilient Strategies, and 9. Recent Design Trends and Prognostications (31 citations): 9a. The Green House Model; 9b. The Future.

The current situation might be summarized as a confounding triad of challenges:

1. The Current Minimum Design Standards are Obsolete—The state-of-the-art in design for aging is not necessarily reflected in the most recent minimum design manual for LTC homes in Ontario. This becomes clear as one peruses the most progressive case studies reviewed in Part I (below). There are excellent exceptions in Canada, of course, yet these are still relatively few and far between.
    
2. New Facility Procurement Funding Mechanisms are Sorely Needed—The conventional PPP procurement mechanism is flawed and unsuited to current realities. It is a process often at odds with itself. New metrics need to foster improved local municipal fiscal participation in this process. A critical point has been reached where exorbitant land costs have made it nearly impossible to build in walkable, connected neighborhoods without the help of local government.
    
3. Consumers Have Unacceptably Limited Choice—The for-profit sector has little incentive to build anything above and beyond the “minimum standard” because it has been disincentivized to do so. Anything it builds fills up instantaneously. More than 38,000 individuals are currently on waiting lists in Ontario, eager to get in anywhere as close to home as possible. Net effect: the general public lacks the freedom to compare the architectural design quality of various options and LTC provider organizations know this.

The hope is for this White Paper to be taken into advisement for incorporation into an update of government-mandated minimum standards for the design and construction of long-term care homes in the Province of Ontario.

The older adult population in Canada is projected to grow significantly over the coming decades. As of 2018, individuals age 65 and older made up 17.4% of the Canadian population. Projections estimate that by 2068, this percentage will grow to between 21.4% and 29.5%. 1 Between 2016 and 2021 alone the over 65 population in Canada grew by nearly 1 million. The situation now requires a dedicated all hands on deck effort on the part of the Canadian healthcare and political systems. A main priority among seniors is housing because it encompasses other age-related concerns such as social isolation, physical accessibility concerns, geographic remoteness from everyday amenities, financial constraints and socio-cultural factors. Of particular relevance to those whose responsibility and focus is the built environment, social isolation, lack of access to support amenities, and counter-therapeutic conditions in everyday residential life are of concern. Ineffective social networks are a challenge with one recent longitudinal study reporting approximately 18% of individuals over the age of 60 in Canada live alone, with 43% of these respondents reporting that they feel lonely (Image 1). 2

In 2019, a British Columbia Centre for Disease Control report on social isolation addressed the impact on seniors. Housing is key in fighting social exclusion, although age-appropriate housing for this age demographic is still not a priority for most municipalities. 3 The scientific literature on loneliness among older adults living in LTC facilities is also scarce. One study explored loneliness in senior housing communities and found that 42.7% of residents were moderately lonely and 26.6% were severely lonely, using the Hughes scale. 4 Across studies, loneliness is correlated with a decline in function with respect to activities of daily living, negative impacts on subjective health and an increase in the risk of depression, incontinence, hypertension, vision impairment, and higher mortality. 5 It is clear that social isolation and inadequate functional support is a current and growing public health issue.

In Canada, several models of housing for older adults exist nationwide. Collectively they provide tiers for delivery of care that can be tailored to an individual’s specific needs. In general, these consist of independent living, assisted living, long-term care, and hospice care, with respite care serving as a temporary option at all four levels to provide caregiver relief. Independent care options involve minimal professional assistance, while assisted living is suited for older adults able to make decisions but yet require everyday support due to their physical and functional health challenges. 6 Long-term care is designated for medically complex individuals who require 24-hour nursing care. Hospice care is for those who are at the end of life and who require symptom management and is one of the multiple care options at this stage of life. 7 

As for Covid-19, the 627 long-term care (LTC) homes in the Province of Ontario have struggled since the onset of the pandemic in early 2020. As of March 2021, 55% of Ontario deaths from Covid-19 had occurred in LTC homes and countless families had lost their loved ones. A Toronto Star investigative article reported on a statistical (multiple regression) analysis that compared for-profit (FP) versus not-for-profit (NFP) homes, showing that the main predictive factor associated with higher LTC home mortality was whether a home housed 3 or 4 residents in the same bedroom—not who owns and operates that home. This study, first, identified whether each FP and NFP home housed multiple residents in a single bedroom. Data were compiled from 510 (out of 625) homes. Municipally owned homes were excluded because they receive extra funding from municipal taxes. Mortality rates were documented as of 1 March, 2021. Since that date vaccinations have significantly reduced deaths. The number of Covid deaths was divided by the total number of residents (beds) per site to determine a mortality rate for each home. The multiple regression analysis was used to examine these data, controlling for ownership type and if the presence of 3 or more residents per bedroom was associated with higher mortality. Ownership type was not linked with the outcome (p value = 0.43). However, room overcrowding was found to be strongly associated with higher mortality (p value = 0.002).

This finding is consistent with the Canadian Institute for Health Information's conclusion, in a report presented to the Marrocco Commission. It found no such association between home ownership type and higher mortality. NFP homes are generally newer than many FP homes in Ontario. The policy implication is clear: private versus public ownership is not a cause per se of higher mortality. Instead, a main determinant of higher mortality is architecturally-based—namely, overcrowded bedrooms. Three or four residents breathing the same air, the same bath-shower room, and associated social space with little opportunity for contact with nature and the outdoors, is a major cause:

“We need to urgently replace the 31,000 Ontario LTC beds located in homes with three-to-four-person bedrooms. Replacing those older homes will cost about $10 billion (CAN). Raising money and rebuilding those homes will be faster with everyone engaged—both NFP organizations and FP corporations. We also know this is about more than buildings. We need to continually monitor quality in LTC and ensure more hours of care from full-time staff, who are better trained and better paid and supported by effective management and leadership. Assuring sufficient resources to protect and care for LTC residents represents our society’s value for life when we are old and infirm and when the preferred option of home care is not safe or appropriate….no one should profit by skimping on care to vulnerable seniors. Every dollar provided for care is reviewed by government to ensure that it goes to providing care—these dollars cannot be diverted for profit. Companies (already) achieve profit from co-payments that residents provide for room and board.” 8

Many of the case studies presented in Part I (below) feature all-private bedrooms, and others, semi-private (2 person) bedrooms while none feature 3 or 4-person bedrooms. Suffice to say, the adverse outcomes associated with overcrowding in Ontario LTC homes warrants attention as soon as possible. Two years into the pandemic the provincial death toll had reached 4,311, according to the Ontario Ministry of Long-Term Care (MLTC). By Spring 2022, the Ministry reported an increase in LTC home outbreaks (a sixth wave), in 115 or 18.4% of the 627 facilities in-province. 9   These LTC homes, also called nursing homes, continuing care facilities, and residential care homes, provide a wide range of medical and personal care services for individuals with medical or physical needs who require access to 24-hour nursing care, personal care and other therapeutic and support services. The proportion of private and publicly owned LTC homes in Canada varies by jurisdiction. Overall, 54% of LTC homes in Canada are privately owned and 46% are publicly owned. Due to their varying size, the proportion of beds by ownership type can differ from the number of homes, by ownership type. Of the 627 licensed LTC homes in Ontario, 16% are publicly owned, 57% are owned by private for-profit organizations, and 27% are owned by private not-for-profit organizations.

A Roundtable was organized by Jacobs Canada in January of 2021, following meetings of an interdisciplinary panel of care providers, medical professionals and architects. This group recommended early-actionable issues for the Ontario Provincial Government to weigh as it responded to the LTC home crisis:

• Balance investment in LTC homes, and home-based care programs, with successful hybrid programs that support diverse medical and personal care needs.

• Transition LTC programs out of large institutional settings into residentially-scaled, smaller homes in support of dignified aging.

• Explore proven home-care models such as Southlake@Home, an innovative transitional bundled care program in northern York Region that is driving positive outcomes.

• Adopt evidence-driven design strategies to ensure LTC residential settings prioritize home-like qualities, maximize mobility, a higher quality of life, and human dignity.

• Ensure investment planning is undertaken at the provincial LTC network level to deliver material benefits across the entire LTC sector. 10

It is a triad of challenges:

• Current Minimum Design Standards are Obsolete—The state-of-the-art in design for aging is not reflected in the minimum design manuals for LTC homes in Ontario. This becomes abundantly clear as one peruses the twenty-five case studies in Part I (below). There are excellent examples in Canada, of course, yet these are still relatively few and far between.
   
• New Facility Procurement Funding Mechanisms are Needed—The conventional PPP procurement mechanism is flawed and poorly suited to the LTC home industry. It is often at odds with itself. New approaches to foster local municipal fiscal participation are needed. A chokepoint has been reached where exorbitant land costs are making it nearly impossible to build in walkable, connected neighborhoods without fiscal help from local municipal government.
   
• The Consumer has Unacceptably Limited Choice—The industry has little incentive to build anything above and beyond the minimum standard because it has been disincentivized to do so. Anything it builds fills up instantaneously. More than 38,000 individuals are currently on waiting lists in Ontario, eager to get in anywhere close to home. The general public lacks the freedom or knowledge to meaningfully compare the architectural design quality of various options and the industry knows this (Image 2).

In the Greater Toronto Area (GTA) alone there are 36 LTC homes, housing 5,878 beds with an average of 163 beds per site. Across Canada, private investors are investing in this sector unlike ever before. 11  But do these shareholder-driven corporations care more about residents’ health needs then the financial return on their investment? The population living in the 627 licensed LTC homes in Ontario have similar proportions of those who exhibit depressive symptoms (57.3%), exhibit aggressive behaviors (44%), low social engagement (62.2%), and are treated with antipsychotics (25.1%) and antidepressants (57%). Ontario residents’ antipsychotic drug usage is almost the same (25%) as the Canadian average. Improving LTC home resident health and decelerating their declining health not only benefits older adults but can also lower caregiver job stress.

Evidence-based research on the health-promoting benefits of therapeutically designed LTC built environments remains insufficient. Ontario’s Enhanced Long-Term Care Home Renewal Strategy plans to update those LTC beds structurally classified as “B,” “C,” and “Upgraded D”, which were based on 1972 design standards from the Nursing Home Act Regulation by using the updated 2015 Long-Term Care Home Design Manual. This update addressed transforming “institutional-like” environments into “home-like” environments” and changing four-person bedrooms with shared washrooms into one to two-person bedrooms with en suite washrooms (Ministry of Health and Long-Term Care, 2017). This manual focuses on safety, proximity, and the availability of outdoor spaces, as well as minimum views to outdoor spaces from bedrooms and dining rooms. And the associated outdoor spaces should include “grade level spaces, balconies, and roof-top terraces” (Ministry of Health and Long-Term Care, 2015), yet there are no formal requirements for these salutogenic and biophilia-related design features. 

Meeting the minimum design standards never was and now definitely is not enough. The four-tier LTC Bed Structural Classification in the Province of Ontario is currently:

New Beds—Beds that comply with the 1999 LTC Facility Design Manual, 2002 LTC “D” Retrofit Facility Design Manual or the 2009 or 2015 LTC Home Design Manual.

“A” Beds—Beds that substantially comply with the 1999 LTC Facility Design Manual.

“B” Beds—Beds that substantially exceed the structural standards of the 1972 Nursing Homes Regulation Act.

“C” Beds—Beds that meet the structural standards of the 1972 Nursing Homes Act Regulation.

Upgraded “D” Beds—Beds that do not meet the structural standards of the 1972 Nursing Homes Act Regulation but were upgraded under the 2002 D Bed Upgrade Option Guidelines (by spending a minimum of $3500/bed on approved improvements to benefit resident health, safety, and well-being).

In January, 2022 the Providing More Care, Providing Seniors, and Building More Beds Act, 2021 and its Schedule 1: Fixing Long-Term Care Act, 2021, was placed under review for approval by the Ontartio Government. Politically mired amid the depths of the Covid-19 pandemic, Ontario’s LTC Covid-19 Commission was mandated to investigate how and why the coronovirus had spread so virulently throughout LTC homes Province-wide. Also, actions to mitigate its further transmission (and future infectious diseases), and how the LTC network had facilitated its rapid spread. It was approved on 9 Decemeber 2021 as Ontario Bill 37, Providing More Care, Protecting Seniors, and Building More Beds Act, 2021, having received royal assent. When it is proclaimed into force (a date yet to be determined), Bill 37 will repeal the Long-Term Care Homes Act , 2007, and replace it with this new Act. Bill 37 generlly maintains the staus quo set out in the 2007 Act while it makes incremental changes relating to staffing and care, accountability, transparency, enforecement, and licensing.

In terms of Bill 37 having any direct impact on modernizing Ontario’s network of LTC homes: 

“The Minister is now permitted to directly restrict a license application through developing a licensing policy based on the public interest. The policy will have to consider the effect that issuing a license would have on the concentration of ownership, control, or management of LTC homes, and the balance between non-profit and for-profit LTC homes in a specific area, or in the province generally. If the Minister has developed a policy that sets the number of beds required in the province, and where the beds under a license application are needed, the Director may decide whether individual applications are covered by the policy and whether the restrictions in the policy apply. Alternatively, where no policy has been implemented, the Minister may make a restriction in a particular application for a license to provide accountability, the Act will allow stakeholders the ability to request that the Minister review the Director’s decision to issue or not issue a license. Under the previous legislation, a person that gains a controlling interest in a LTC licensee by any method is required to obtain the approval of the Director. However, the new Act provides that the regulations may override this requirement. It remains to be seen whether this discretion is to facilitate integrations or amalgamations. Furthermore, licensees will be required to ensure that every person in a leadership position receive training, the substance and frequency of which will (presumably) be set out in the regulations.” 12

It remains to be seen what this new LTC Act will mean for the built environment of LTC homes across Ontario. Suffice to say, the state-of-the-art in international LTC design trends has clearly moved far beyond the minimum design standards currently in place in Ontario. As of January 2022, as mentioned, there were more than 38,000 qualified individuals on waiting list for acceptance in Ontario LTC homes and this list is growing. While waiting for admission, these individuals are being cared for at home, in hospitals, and in other ad hoc settings. The situation is so dire that the Ontario Ministry of Health has initiated and oversees a bridge-building type it now refers to as a “Transitional Care Facility.”

Too many LTC homes in Ontario are architecturally obsolete. Updated operational standards will be ineffective if the residence itself is functionally obsolescent and of unsuitable design quality, i.e. counter-therapeutic. This is compounded by the fact that Ontario’s LTC minimum design standards have barely been tweaked since the late 1990s. Many of the problems that currently plague the facility procurement system stem from current funding mechanisms. LTC homes are funded and regulated by the provincial government with these sources of facility suppliers—local municipalities, the charitable NFP sector, and FP private sector developers. The current effort (2022) by the Canadian Standards Association (CSA) to update the standards it issued just two years ago points to the major impact Covid-19 has had on this sector. 13  And chronic past underfunding by the government has placed a disproportionate burden (read, opportunity) for the private sector to take over more than ever.

White Paper Background—The Provincial Government of Ontario has committed an unprecedented $1.75 billion over five years to strengthen and modernize LTC in Ontario, driven in large part by the need to respond to COVID-19. This financial commitment has the potential to bring about a paradigmatic shift in LTC, which many Ontarians had long been advocating for. In early 2021 Jacobs Canada hosted the aforementioned interdisciplinary roundtable event that brought together healthcare leaders from the architectural, direct care provider, and eldercare infrastructure sectors to focus on how this planned investment can be most thoughtfully and meaningfully implemented: 1. An absence of choice exists in selecting among various LTC facility options; 2. Better planning is needed in anticipation of the growing number of aged individuals in Ontario; 3. Greater connectivity is needed between a LTC facility and its neighborhood/urban context; and 4. New policies are needed to foster the construction of user-attuned, therapeutic 24/7 residential care facilities.

These recommendations centered on: 1. Avoid haphazard overbuilding in response to the current pandemic; 2. Fostering viable mechanisms to elicit community feedback in the form of grassroots-level consultations to identify the best capital investment strategies; 3. Developing an alternative facility compliance and monitoring system autonomous from current MLTC standards; 4. Identifying evidence-based best practices in site selection, programming, architectural and landscape design—a 2.0 version of the 2015 minimum construction standards to include infection control best practices; 5. Implementing asset management best practices; 6. facility procurement centered on evidence-based design; 7. Focusing on homes—residences—versus meeting mere bed count targets; and 8. Policies that balance 24/7 with in-home-based services. In the Spring of 2021, the Ontario Association of Architects (OAA) joined this effort as a collaborating sponsor in order to foster its members’ furthered knowledge of the inner profundities of an evolving building type.

Methodology—Three broadly defined streams of research in architecture exist: Research for Design; Research into Design; and Research Through Design. Each type has evolved its own protocols, methods and standards. The method adopted here is Research for Design: A comprehensive literature review, an analysis of case studies of recently built LTC residential care facilities, and the articulation of site planning, architectural and landscape design considerations. Key concepts: Autonomy; Individuality and Dignity; Privacy; Satisfaction; Self Actualization; Room Personalization; Therapeutic Activities and Socialization; Security, Personal Safety, and Infection Control; Ambient Environment; Noise Abatement; Well-Being and Health Status; Staff Well-Being and Functional Performance; Offsite Prefabrication; Person-Nature Affordances; Ecological Sustainability; Leadership/Stewardship; Facility Procurement.

The methodology consisted of a broad review of published, peer-reviewed quantitative and qualitative investigations and essays. The first step consisted of a keyword search to identify potentially relevant peer-reviewed publications. Forty-five key words were used, referring to LTC resident and staff outcomes, i.e. wayfinding behavior, engagement with nature and landscape, infection control and COVID-19, medical errors, pain, stress, sleep patterns, privacy, personal autonomy, room personalization, involuntary and involuntary relocation impacts. A protocol established by Verderber et al. (2021) with respect to a comprehensive review of the literature on hospital-based ICU/CCU built environments guided these cross-searches using combinations of key words and phrases through the JSTOR and Google Scholar databases and further searches combing multiple databases including EBSCO, ScienceDirect, PsychINFO, MEDLINE, Ovid, ProQuest, PubMed, Web of Science, Science Digest, and NIH Public Access. This search included any study or article that alluded or referred to the LTC healthcare physical built environment in its title or abstract, published between January 2005 and June 2022. The decision was made at the outset to include both empirical and qualitative research investigations, as well as relevant theoretical and opinion essays, in order to broadly capture the scope, depth, and nuance of a rapidly evolving subject. The initial search phase yielded 347 primary sources, subsequently reduced in a second stage assessment to 279 peer-reviewed sources. These met or exceeded the team’s benchmark for rigor. In the third-stage assessment, these sources were further examined and reduced to a compendium of 218 sources (reported below).

The research team carefully screened three types of sources: (1) empirically based studies that examine the role and impact of the built environment or natural environment on resident, staff, and/or family outcomes; (2) qualitative studies that examine these same relationships; and (3) theoretical essays that examine the relationship between nursing best practices and administrative policies, and the planning and design of 24/7 LTC residential environments. Non-peer-reviewed white papers, research reports, minimum standards guidelines publications and books on this subject were eliminated in the first wave of the screening process. The final compendium was then structured into nine content categories deemed by the research team to best capture the current state of the art and science. The 2005–2022 period witnessed numerous significant advancements including the emergence of consensus on the single-bedroom and adjacent personal hygiene space as more healthful than traditional semi-private rooms. Specifically, also addressed are the virtues of smaller-scale residential units, multigenerationality, a homelike aesthetic and ambiance, privacy, dignity, space personalization, noise and daylighting controls, and engagement with nature/landscape.

Impact—The Covid-19 crisis in LTC homes is by no means isolated to Ontario or Canada. A recent feature in the New York Times, “Nursing Homes Are in Crisis: We Can’t Look Away Any Longer” by Jay Caspian Kang, eloquently laid out the current sad state of affairs. He summarized parts of a nearly 600-page report recently issued (April 2022) in the U.S. by the National Academies of Sciences, Engineering and Medicine. It argues for comprehensive changes in the industry. It calls for “all private bedrooms and bathrooms…and the construction of smaller facilities that would more closely resemble family homes.” This massive in-depth report also calls for fundamental changes in federal (US) funding mechanisms, a fundamental change in the way labor is conceptualized in LTC settings, and in how society cares for its infirm aged in general. Caspian, in his NYT piece, interviewed Betty Ferrell, palliative care expert and Chair of the expert committee that authored and released this landmark report:

“Most people don’t think about nursing homes, and most people don’t go to a nursing home until it’s their moment in time where suddenly their parent is there. It is a for-profit industry that has not had enough oversight and regulation, and has not had any level of transparency. For the nursing home industry to continue as it is now—being able to profit in such a significant way without providing quality care—is outrageous. I don’t think we can look away any longer.” 14 

National Academies of Sciences, Engineering, and Medicine (2022). The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press, https://doi.org/10.17226/26526.

Chapter 6 (pp. 303-356) of this report, “Nursing Home Environment and Resident Safety” addresses the role of the physical environment. Table 6.2 “Importance of Sensory Perceptions in the Nursing Home Setting” addresses the value of positive visual stimulation, appealing sounds, tactile environments inviting touching, and aromatic odors as key to residents’ decoding their physical setting in a positive way. The subsection “The Physical Environment” (pp. 329-356) is of particular interest to architects, landscape architects, other design professionals, engineers, health policy specialists, FP and NFP provider organizations. This shopworn adage is apropos in Canada right now, “Think globally but act locally.” The hope is for this White Paper to be taken into advisement for incorporation into an update of the government-mandated minimum standards for design and construction of LTC homes in the Province of Ontario.

1. Statistics Canada. Population Projections for Canada (2018 to 2068), Provinces and Territories (2018 to 2043). http://www.statcan.gc.ca/n1/pub/91-520-x/91-520-x2019001-eng.htm.

2. Perissinotto, C, Stijacic, Cenzer I & Covinsky K. (2012) “Loneliness in older persons: A predictor of functional decline and death. Archives of Internal Medicine, 172(4), 1078-1083.

3. Lubik, A & Kosatsky, T. (2019). Is mitigating social isolation a planning priority for British Columbia (Canada) municipalities? British Columbia Centre for Disease Control. http://www.bccdc.ca/Our-Services-Site/Documents/Social Isolation Report 17Sept2019.pdf.

4. Taylor H, Wang Y, and Morrow-Howell N. (2018). “Loneliness in senior housing communities,” Journal of Gerontological Social Work, 61(2), 623-639.

5. Tilvis, R, Laitala, V, Routasalo, P. et al. (2011). Suffering from loneliness indicates significant mortality risk of older people. Journal of Aging Research. 12(4), 534781.

6. Government of British Columbia (2020). Supportive Housing and Assisted Living. Victoria: British Columbia. http://www.gov.bc.ca/gov/content/family-social-supports/seniors/housing/supportive-housing-and-assisted-living.

7. Verderber, S and Refuerzo, B (2020). Innovations in Hospice Architecture, Second Edition. London: Routledge.

8. Bell, Robert & Wodchis, Walter (2021). Long-term care deaths related to residents per room. Toronto Star, 15 March. https://www.thestar.com/opinion/contributors/2021/03/15/privately-owned-long-term-care-is-not-associated-with-increased-mortality.html.

9. LeBlanc, Erin (2022). Ontario reports 18% of LTC homes in outbreak due to COVID, Toronto Star, 13 April. https://www.thestar.com/news/gta/2022/04/13/ontario-reports-18-of-ltc-homes-in-outbreak-due-to-covid.html.

10. Letter sent to then-Minister of LTC Merilee Fullerton, co-signed by Ansar S. Ahmed, Diana Anderson, Arden Krystal, Stephen Verderber, Shirlee Sharkey, William Egi, Santiago Kunzle and Paul Moyer, 19 February 2021.

11. Lanthier, N. (2022). Investment in seniors housing soars despite pandemic’s negative impact. The Globe and Mail. 22 March.  https://www.theglobeandmail.com/business/industry-news/property-report/article-investment-in-seniors-housing-soars-despite-pandemics-negative-impact/ 

12. Ngan, Henry, Fenech, Benjamin & Case, Harry M. (2022). What you need to know about Ontario’s Fixing Long-Term Care Act, Borden Ladnew Gervais LLP. https://www.lexology.com/library/detail.aspx?g=f8b8f448-45a7-4092-98b7-f6f4dd0a416a.

13. Wall, D. (2020). Old buildings, design standards plague Ontario LTC system, says architect. Daily Commercial News. 8 June. https://canada.constructconnect.com/dcn/news/projects/2020/06/old-buildings-design-standards-plague-ontario-ltc-system-says-architect.

14. Kang, J. Caspian (2022), “Nursing homes are in crisis. We can’t look away any longer.” The New York Times, 14 April. https://www.nytimes.com/2022/04/14/opinion/nursing-homes-crisis.html.

Many thanks to all the firms who granted permission to reproduce their drawings and photo images. Many thanks to Jacobs Canada and the Ontario Association of Architects (OAA), whose combined financial support and consistent level of engagement made this project a reality. At the OAA, thanks to Adam Tracey and Sara Trotta and the entire leadership team at the OAA. At Jacobs, Ansar S. Ahmed, Dr. Diana Anderson, and Matthew Holmes, all of whom painstakingly stuck with this initiative from its inception in the Spring of 2021 and throughout the weekly project meetings over a period ten months. In point of fact, it was Jacobs Canada who convened a symposium on this topic in January 2021, an event that provided the spark for this project. It was Diana Anderson who visualized this as an opportunity to make a statement on behalf of, and to, the architectural community in the Province of Ontario and beyond on the urgent need to revisit this building type in the context of Covid-19. Thanks to the graduate students in the Architecture and Health Thesis-Year Research/Design Studio at the University of Toronto during the 2021-2022 academic year: Lucy Yang, Indu Bose, Yi Chen, Ashlin Lithgow, and Yifan Wang. They were able to effectively collaborate as a team on identifying and documenting the case studies, and generating the first generation of the 50 LTC design considerations. Thanks to Shirley Chan and Kristina Dinevska, who both helped to shepherd the OAA/Jacobs/University of Toronto contract agreement through multiple administrative hurdles. Special thanks to Lucas Siemucha, Catherine DelaCruz and Umi Kobayashi, my three hard-working Research Assistants—they worked with me patiently from May 2021 to May 2022, beginning with assembling a comprehensive thematic bibliography on this topic. Thanks to Alexander Ponomaroff and Sara Elhawash, who constructed this web page. Research funding was also provided by the University of Toronto Daniels Faculty of Architecture, Landscape and Design. 

Note: Stephen Verderber has not received any compensation from any long-term care corporation at any time.

Citation: Verderber, Stephen (2022) Reimagining Eldercare in a Post-Covid-19 Ontario and Beyond. Toronto: Centre for Design+Health Innovation White Paper, 16 May 2022. University of Toronto.

Copyright, 2022, Stephen Verderber and the University of Toronto