In the past few years, the concept of aging in place has dominated discussions among researchers, health professionals, governments, and community service organizations as well as those of seniors and their families (Vasunilashorn, Steinman, Liebig, & Pynoos, Reference Vasunilashorn, Steinman, Liebig and Pynoos2012). The majority of older adults want to live outside of institutional care for as long as possible (Barrett, Reference Barrett2014; Chippendale & Bear-Lehman, Reference Chippendale and Bear-Lehman2010; Cutchin, Reference Cutchin2003; Simard & Dupuis-Blanchard, Reference Simard and Dupuis-Blanchard2011). However, both personal factors such as income, education, and health status – as well as community factors such as the availability of transportation services, appropriate housing, and informal and formal support – all play an important role in determining older adults’ capacity to age in place (Dupuis-Blanchard et al., Reference Dupuis-Blanchard, Gould, Gibbons, Simard, Villalon and Éthier2015; Rosenberg & Everitt, Reference Rosenberg and Everitt2001). Moreover, the advantages of remaining in the family home are sometimes questioned, at least for some older adults (Golant, Reference Golant2008).
For older adults with a loss of independence, access to appropriate services is imperative in determining whether aging in place is feasible. These services, however, are not always available in rural regions and in the preferred language of choice in official minority-language communities. These issues are particularly salient in the province of New Brunswick, which has the highest proportion of adults over the age of 65 years (Statistics Canada, 2017a) and is therefore among the first regions in the country to face the challenges of population aging. New Brunswick, like other Atlantic provinces, is composed of many rural communities with elevated numbers of seniors whose family members work outside the province, thus leaving these seniors dependent on local services to age in place (Dupuis-Blanchard, Beaudin, & Desjardins, Reference Dupuis-Blanchard, Beaudin and Desjardins2016). Moreover, health care investments are going mostly towards institutional care (Government of New Brunswick, 2017), such that community service organizations have few human or financial resources to invest in supporting home-based senior care.
Given the urgency of finding cost-effective and innovative solutions to providing community services for aging in place, novel solutions that take advantage of existing infrastructure are clearly needed. In the present study, we chose to explore the role that nursing homes could play in offering services to a non-traditional target population, namely seniors with loss of independence living in the community.
Nursing homes, also known as long-term care facilities, provide services and care for adults who require 24-hour supervision and care (Government of New Brunswick, 2009). In New Brunswick, nursing homes are independently owned by not-for-profit organizations with the provincial government providing the majority of the operating funds. The province counts 65 nursing homes distributed in rural and urban communities both in French- and English-speaking areas. Because of their presence in many communities around the province, it seems logical to investigate the possibility of nursing homes offering services outside of their mandate to seniors living in the community but needing some form of service or care.
Few studies have been carried out on the role of nursing homes as a support for aging in place. One New Brunswick study investigated the use of a nursing home’s shuttle bus to transport seniors living in a rural community to the shopping mall and grocery store in a regional centre. Despite the fact that a limited number of seniors used the shuttle service, it provided an essential service for participants to age in place although the long-term feasibility of the program was in doubt (Gould, Webster, Daniels, & Dupuis-Blanchard, Reference Gould, Webster, Daniels and Dupuis-Blanchard2016).
Most programs addressing the use of nursing homes as support for frail elderly adults living at home has involved the use of day programs (see Chan, Cheng, & Su, Reference Chan, Cheng and Su2008, for a review). In Canada, day programs as support for aging in place have been set up in multiple provinces. These include the Comprehensive Home Option of Integrated Care (CHOICE) program in Alberta (CapitalCare, 2017), the Program of Integrated Managed-Care of the Elderly (PRIME) program in Manitoba (Deer Lodge Centre, 2017; Winnipeg Regional Health Authority, 2017), and the community services offered by the North Renfrew Long-Term Care Centre (http://www.nrltc.ca/).
In this study, we took a different approach. Rather than describing existing projects, we used a sequential mixed-method approach (Creswell & Plano Clark, Reference Creswell and Plano Clark2010) to gain better insight into the possibility of nursing homes offering aging-in-place services beyond the traditional models within the province. Specifically, we investigated (1) which services nursing home administrators were interested in offering to seniors living outside the nursing home, and (2) the perception of nursing home administrators regarding the feasibility of providing such services.
Methods
Participants
Of the 65 nursing home administrators invited to take part in the study, 42 completed the online survey, a 65 per cent response rate. Of these, 10 agreed to a face-to-face individual interview. Participants who completed the survey were mostly aged 50–59 years of age (54.76%) followed by those aged 40–49 years (35.71%). Thirty-one per cent reported having 5–9 years of management experience while 21 per cent reported 1–4 years of experience. Twenty participants identified English as their native language, one identified French, and the others identified as bilingual. Over half of participants taking the online survey (66.7%) reported that the nursing home was in a rural community whereas half (50%) of the interview participants were from rural areas. All but one of the participants who agreed to an interview were between 50 and 59 years old, nine out of 10 had a university degree, and their experience in managing a nursing home was between 2 and 30 years with an average of 11 years.
Materials
We developed two data collection instruments on the basis of the current literature and the experience of the research team members on aging-in-place research. The first instrument consisted of a 16-item survey, which included questions related to the types of supports required by seniors to age in place and covered aspects related to physical, psychological, social, cultural, and spiritual services. Questions also addressed the resources required if such services were to be delivered outside of the nursing home. Responses to 13 items on the survey were in the form of a 5-point Likert scale, ranging from 1 = very unlikely to 5 = highly likely. The survey took approximately 20 minutes to complete and was available online in French and English using Fluid Surveys. At the end of the survey, participants were asked if they wanted to complete a face-to-face interview and contact information was provided. The qualitative semi-structured interview guide consisted of open-ended questions relating to the nursing home administrators’ perceptions regarding offering services for aging in place and the future role and vision of nursing homes. Interview participants were assigned pseudonyms, and individual interviews were recorded, lasting an average of 60 minutes. Sociodemographic questions were also included in both instruments.
Procedure
Once ethics approval was obtained (from the Université de Moncton and Mount Allison University), an email invitation was sent to all 65 nursing home administrators in the province of New Brunswick by the New Brunswick Association of Nursing Homes (NBANH). The email message contained information on the study, a link to the online survey, an invitation to participate in a face-to-face interview, and contact information for the principal investigator and a research assistant. Online data were collected during a two-month period, with one reminder email being sent by the NBANH. Qualitative interviews were conducted during a two-month time frame subsequent to the online survey’s being conducted. Data analysis consisted of open coding and then identifying themes related to the study objectives. Saturation was achieved for the qualitative portion of the study.
Results
Willingness to Offer Services in the Community: Quantitative Analyses
All participants (100%) agreed that nursing homes could offer services to seniors in their communities for aging in place. Administrators were asked to rate a series of items on how likely it was that their nursing home could offer this service to seniors in the community. Group means were compared using one-sample t-tests to the neutral value (3) on the 5-point Likert scale ranging from “very unlikely” to “very likely”. For the majority of items (12 of 16), the group means do not significantly differ from the neutral midpoint on the scale (Table 1). Therefore, the nursing home administrators were generally neutral regarding the possibility of offering new services to seniors in their communities. However, the likelihood of offering certain services such as educational and social activities where transportation was not necessary was significantly higher than the neutral point.
Table 1: One-sample t-tests on likelihood of offering expanded services to older adults in the community
Note. a Using Bonferonni correction, the criterion for significance used is p < .01. b Using Bonferonni correction, the criterion for significance used is p < .008.
In a second set of analyses, a series of paired sample t-tests were carried out to explore which services were more likely to be offered by nursing homes. Three groups of services were identifiable (Table 2): Some services, such as transportation and psychological support, were very difficult to offer, services allowing seniors in the community to participate in certain social or religious activities were already being offered, and educational services were perceived as relatively easy to offer.
Table 2: Paired sample t-test results to compare the perception of the possibility of offering each type of service
Note. a Each service is perceived as being significantly more susceptible of being offered than those indicated by the letters.
We conducted chi-square tests in order to compare differences in the perceived likelihood of nursing homes’ offering expanded services to seniors in the community between groups based on (a) nursing home size (< 70 and > 70 beds), (b) rural versus urban, and (c) language spoken in the nursing home (French or English). For these analyses, the responses of very unlikely, unlikely, and neutral were grouped together as “Unlikely” whereas the responses of likely and very likely were grouped as “Likely”. No significant results emerged, although there was an interesting trend observed given the New Brunswick context. Namely, although 79 per cent of mainly English-speaking nursing homes did not believe that they could provide services to francophone seniors, only 50 per cent of mainly French-speaking seniors felt that they could not provide services to anglophone seniors, χ2(1, n = 42) = 3.56, p = .06.
Nursing Home Services: Qualitative Analyses
The majority of nursing home administrators (pseudonyms are used in this article) we interviewed agreed that it was time to make changes to the nursing home model of care in order to respond to population aging. Most emphasized the importance of quality of life and the well-being of seniors.
I think, when we’re looking oftentimes at aging in place, we’re looking at long-term care. We’re looking at diseases that they can live with, that aren’t going to kill them, but they need some help, and some intervention, and some management or whatever. So it’s not just keeping [them] in their home longer, it’s having a quality of life that allows them to stay in their home. And I think people sometimes miss that connection. (Jill)
Although participants shared a vision of what a nursing home could be in the future or the services that they would like to offer, none had concrete plans of how this could be brought about. In terms of a vision of what the future could include, some administrators discussed the possibility of developing transitional care or assisted living units while others focused on service coordination and moving towards services for the community.
I think we are the best placed to coordinate efforts for aging in place … for the village; it does not mean do everything, but coordinate. It is something we can do, but when it will come to programming, we will need resources, and that’s when we can find out about the type of resources available. (Danny)
We are very proactive and we are starting, through the nursing home association – the collaborative – we are starting to become almost like the linchpin that’s keeping everyone together to start the dialogue, to start the education, to look at the possibilities, to start to shape the future. (Jill)
The lack of financial resources was mentioned by many as delaying the way forward. Some mentioned that the foundations established by their nursing home was providing funds to move ahead with some services to the community but that financial resources remained a major hurdle. The majority of participants reflected on the state of the province and the impact of population aging.
To me, there are two problems. One problem is, the [financial] mess that the province is in and everybody is looking – how can we save, how can we cut, how can we survive? The other problem is, and this is where I feel nursing homes can work, is in another 10 years, we’re going to be so inundated with seniors that we’re not going to know where to put them. If we make changes now and plan for that now, we can find a solution to that. (Annie)
Nursing Homes’ Presence in the Community
Most nursing homes have already established collaborations with the community where they are located. Although most nursing homes do not receive requests from community service organizations to provide services to seniors in the community, administrators agree that they are open to such a collaboration. In fact, Helen observed that “But usually, it’s us going out and taking the lead and reaching out.” Knowing that financial resources are limited, some community members and businesses have found ways to help and support the work of nursing homes.
The community’s very good. We had this volunteer fire department do a bottle drive for us in two of the communities, and the support’s very good. We’ve had donations, and we’re going to do a walk-a-thon. The last walk-a-thon we had we raised ten thousand dollars; our goal was 6. It was for a blanket warmer. (Helen)
Nursing homes also offer their boardrooms for community meetings and some have joint day-care centres for children. Volunteers also come to the nursing home to help with social activities and meals.
Administrators advised that many services are already available for aging in place. Over half of the nursing homes in the qualitative portion of the study explained that they offered transportation for seniors living in the community. One nursing home explained: “We have transportation. We bring them in, we give them a good bath with a hydrosonic tub process, and then they feel better about it, the home care feels better about it, and we’re providing a service” (Ivan). Another nursing home offers a shuttle to a nearby town once a week. Meals are also an important service component to aging in place. However, few provide meal delivery services at home. Some explained that it would be easier for seniors in the community to come to the nursing home for meals.
Despite the limited number of current services for aging in place, all participants in the qualitative portion of the study agreed that nursing homes could play a central role for aging in place. In fact, they identified themselves, the administrators, as those best placed to offer these types of services: “I guarantee that every nursing home knows their own community and knows what their community needs are” (Annie).
Nursing Homes of the Future
According to interview participants, the nursing home of the future will become a place where a number of services for seniors are available, including those for aging in place:
I think we’ll also have tentacles into the community doing different things for people in the community as they need them. So it’s going to be home care, meals, clinics, transportation – we can be a community help. We can bring people in our doors without having to live here and we can extend ourselves outside our doors. (Elise)
Other participants have a vision of including a community centre where people looking for services related to aging would come to the nursing home. Annie shared:
I have a vision of a nursing home on top of the hill that not only has resident long-term care beds like we have now, but a transitional unit which includes a rehab unit, which has a community centre that takes care of the social needs, medical needs, spiritual needs of all the seniors in the community.
Administrators also mentioned that care will become increasingly complex because seniors with a loss of independence will likely be staying longer in their homes. As a result, a smaller percentage of frail seniors will be using nursing home beds, and more services and care in the community will be needed. Most participants mentioned the need for a day centre where seniors could spend the day while receiving much needed services and care before returning home.
Although quantitative survey results indicated that few new services could be offered by nursing homes for aging in place, participants in the face-to-face interviews explained that they are willing to look at how to offer more services in the future. However, all interview participants agree that more human and financial resources would determine the extent of services offered.
It’s certain, there is an investment that is needed, maybe one year or six months, and after that we can start to close beds and recycle the funds. And we can do more, with $100,000 or $60,000 for a level 3 bed, that’s care for one person. With $60,000 in the community, we can provide a lot of care to more than one person. (Carol)
Only a few participants mentioned needing more space in their nursing homes to offer additional services.
Unanimously, participants agreed that collaboration with other service organizations is the first step towards providing additional services to seniors in the community. Elise commented: “I think we all need to get out of our little silos and start looking carefully at how we can contribute to our community.” Participants suggested that needs evaluations were needed while others attributed much importance to the need for a strategy on aging that would provide guidance. Most agreed that existing resources had to be utilized to eliminate duplication and costs.
Discussion
The goal of our study was to explore the possibility of nursing homes offering services to seniors in the community so that older adults who want to age in place receive needed support for activities such as housekeeping, home maintenance, meal preparation, grocery shopping, and transportation (Dupuis-Blanchard, Gould, Villalon, & Gibbons, Reference Dupuis-Blanchard, Gould, Villalon and Gibbons2014). Although results indicate that all nursing home administrators agreed that they could provide services for aging in place, only three types of services for older adults wanting to age in place were identified as possibly being offered: counselling, receiving community older adults for religious ceremonies, and receiving community older adults for social activities. Although important, these services are only a few of the many supports needed for older adults to age in place; moreover, they are mostly limited to areas where few nursing home human resources are required. Indeed, administrators confirmed that a lack of financial resources was preventing them from moving forward with offering services in the community.
We observed an interesting contrast related to transportation. Over half of the interview participants claimed that they already offered transportation to seniors in the community. However, activities not requiring transportation were more likely to be perceived as feasible on the survey. This issue is a critical one because access to transportation is of the utmost importance for aging in place (Dupuis-Blanchard et al., Reference Dupuis-Blanchard, Gould, Gibbons, Simard, Villalon and Éthier2015). The study by Gould et al. (Reference Gould, Webster, Daniels and Dupuis-Blanchard2016) confirms the importance of access to transportation in a rural setting for banking, pharmacy, and grocery shopping but also for the social connections between seniors using the shuttle service.
We expected differences between nursing homes and were surprised at the level of similarity regarding perceptions of administrators regarding what services could be offered. Of course, different results may be found when specific plans begin being developed and needed resources are identified. One important difference between categories of nursing homes was the possibility of offering services in one of the two official languages. Nursing homes where French was mostly spoken were somewhat more likely to be able to offer services in both official languages than were English-speaking institutions. (It should be noted that given the small sample size, statistically significant results were not obtained, although phi calculation yielded a medium [r = .29] effect size.) It is important to recognize the importance for seniors to communicate in their language of choice, especially when receiving services or care. In fact, when language is a barrier, there are more complications and less satisfaction with care, and communication breakdowns put both the senior and the employee at risk for unforeseen events (Bowen, Reference Bowen2015; Forgues & Landry, Reference Forgues and Landry2014). The challenge for many nursing homes and other employers is the availability of French-speaking employees and the retention of these bilingual staff (Forgues, Gaucher, Guignard Noël, Kabano, & Michaud, Reference Forgues, Gaucher, Guignard Noël, Kabano and Michaud2012).
The majority of nursing home administrators discussed the fact that the nursing home model of care needs to change to be sustainable for the future. There has been a proactive movement in New Brunswick in the past year or two by the Nursing Home Association of New Brunswick in order to prepare nursing homes for the future of care, which seems likely to be increasingly based within the community. In fact, during the course of the interviews, many participants cited “community” while describing their vision for the future of nursing home care. Nursing home administrators’ view of the future included nursing homes as community hubs for aging, a place where members of the community could obtain information on services available as well as delivery of those services. Despite the fact that nursing homes have established laudable collaborations within their communities and that some services are beginning to be offered in the community, long-term care facilities must have the appropriate human and financial resources in order to offer both traditional nursing home care and home services.
Even the government of New Brunswick, in its provincial aging strategy, recognized the need to be innovative as well as to provide adequate resources for new models of care to support aging in place (Government of New Brunswick, 2017). Indeed, given the increasing number of seniors who live alone in the community (Statistics Canada, 2017b) and the projected rates of dementia in this population (Alzheimer Society of Canada, 2017), it is likely that aging in place will not be feasible for a considerable number of individuals, particularly in the later stages of the disease. Thus, the challenge for governments, nursing homes, and communities is to develop adequate levels of care both for seniors living at home as well as for those who can no longer do so even with enhanced home services.
The current study does present limitations. Although the response rate to our study was good, the limited number of possible participants for both the quantitative and qualitative data collections limited the types of analysis we could perform and the interpretation of results. Also, the Nursing Home Association of New Brunswick held their annual general meeting a few months previous to our recruitment with the first author (SD-B) as the keynote speaker addressing the need to rethink the role of nursing homes. This could have introduced a bias whereby participants in the study felt they had to support the ideas presented in the keynote address. Despite these limitations, the study provides new insights into supporting aging in place with infrastructure already available in many communities. Our results suggest that nursing home administrators are supportive of expanding their services with appropriate resources and that solid collaborations are already established with community partners.
Conclusion
To support aging in place, provincial governments must implement cost-effective and innovative solutions. With nursing homes present in most communities, be it rural or urban, and likely speaking the most common language in their community, having nursing homes offering services for aging in place seems to be an economical and logical approach. Although human and financial resources need to be enhanced, the basic infrastructure is already in place, and nursing home administrators are supportive of this approach. With the number of older adults expected to increase at never-before-seen rates, it is imperative that supports be developed and implemented now so that our communities can meet the needs of this growing population of seniors.
