Zannat Reza: When you think of long-term care, what words come to mind?
Large, institutional, impersonal.
More hospital than home, right?
Well, almost a hundred percent of Canadians want to stay in their homes as long as possible.
But the reality is, some people need a higher level of care.
What if I told you that there's an alternative?
There's a growing movement for a culture change that involves a push towards small care homes, where residents can have a more personalized experience.
This is the basis of the Greenhouse Project in the US, which has pioneered this concept.
These ideas are starting to take hold in Canada, and today, we'll hear from someone who's put this into practice.
I'm Zannat Reza.
Welcome to The Future Age podcast, where we explore bold ideas and creative solutions in reimagining life as we get older.
If you're new to our podcast, check out some of our earlier episodes on the future of women's health, how caregiving impacts the economy, and designing communities to help us live longer, healthier lives.
For today's show, I spoke to Dawn Harsch about the company she founded, ExquisiCare, which was recently acquired by SE Health.
ExquisiCare has three small care homes in Edmonton, Alberta, with plans to expand into Ontario.
Each home has a small number of residents and focuses on a more comfortable and personalized experience.
As well as integration into the community.
Dawn started by explaining how she came up with her vision.
Dawn Harsch: The inspiration for ExquisiCare started, I guess, when I was a young nurse doing my nursing training.
And I worked as a healthcare aide.
And I worked in a hospital and specifically on the dementia unit.
And that dementia unit at that point in time probably had fifty residents per unit.
And at that time they were called patients.
One bathroom, six beds, shared wards, separated by curtains, concrete walls, concrete floor, tattered curtains.
And I was just really struck by the fact that these are our elders, you know, some of the individuals at that time, this was thirty some years ago, had fought wars, and I just thought this is not okay.
This is not the way we should be treating our elders, our parents, our grandparents, people that really created this country.
It just seemed like an institutionalization of our parents.
And people typically, you see when they go into traditional long-term care, there's a very sharp and rapid decline because it's not a place where people go to live.
It's a place where people go to die.
After my nursing degree, I actually did an MBA.
And created a business plan for what I thought could be an alternative to institutional long-term care.
At the core of everything we do at ExquisiCare is a belief that we should not be institutionalizing our elders.
And that's what we do in this country.
Zannat Reza: And so maybe you could give some examples of what that means, that you don't want to institutionalize our elders.
What are those features or services that make it more like home?
Dawn Harsch: It's not even more like a home.
It is a home.
It looks, feels, acts, smells completely different from what you would see as a traditional nursing home or traditional long-term care.
They are custom built, residential, currently ten bedroom.
You can go up to twelve and still fit the model.
But these are stand alone residential homes.
And when I designed them and when I sort of visioned it out, the homes are built with the residents in mind first.
If you look at traditional long-term care, it's built with what's best for the nurses, what's best for the doctors, what's best for the funders.
And so that's why you have one hundred bed facilities with one shared RN and these long hallways, because that's better for sight lines so that that one RN can see down the hallway to see her fifty patients here and fifty patients there.
ExquisiCare homes, again, residential estate homes.
Every resident has their own bedroom, their own attached en suite bath.
Which is a privacy and a comfort thing, but it's also infection prevention and control.
So during the pandemic, we had zero cases of COVID in any of our homes, zero deaths from COVID.
And that's a testament, not only to the physical setup and the physical design of the homes, but also the ability to control who's coming in and out of that home.
They look like every other house on the street.
You walk up, you really wouldn't know the difference between an ExquisiCare home and their neighbor.
And that sense of belonging that comes to the elders by truly living in a neighborhood.
And some of our neighbors, they support the homes just like neighbors should.
Through the years, we've had neighbors that pop over and say, oh, I hear that there's a bunch of seniors who live here and I play the guitar.
I'm retired.
Can I come over and play the guitar for them?
Of course you can.
Another lady contacted us once and said, my children really don't have access to their grandparents, but I would love for them to interact with the seniors here.
It was a beautiful thing.
Of course your children can come play in the yard.
You know, when you walk into the home, you will often smell the roast or the cinnamon buns cooking.
And sometimes the elders, who are able to, will even help in preparing that meal.
So it gives them purpose.
The nursing station is sort of hidden in what would otherwise be a butler's pantry.
So there's not this clinical area that's front and center in the homes because it's designed for the senior.
And then we fit in as care providers.
Zannat Reza: You've talked about the physical design of the home and that it fits right into a neighborhood.
So describe a little bit more about, you walk in, what do you see?
Dawn Harsch: So our homes still meet all the building specifications and codes of those larger care facilities.
So we are just as fire safe and just as safe as those bigger facilities, but it looks and feels like a home.
So you walk in, you'll see a staircase, there's a sitting area off to the left.
Big, beautiful, open concept kitchen with another sitting area.
All the elders will eat round one, sometimes we separate it into two tables, family style.
And the staff eat with the residents and they eat what the residents are eating.
So part of that model is we make our meals together and we enjoy them together.
So the benefit to the staff eating with the residents is it encourages socialization and that feeling of family.
But the elders who are suffering with dementia will also mimic or model the behavior that they see in their care providers in terms of how to eat.
There's a commercial elevator in all the homes, but it looks very residential because there's bedrooms on the upstairs, the main floor, and some of the homes do have bedrooms on the lower level as well.
Everybody has their own bathing unit.
And then oftentimes in the lower level there is therapeutic tub as well.
There's usually an office downstairs, but again, the staff areas, the work areas are hidden because this is the elder's home.
Zannat Reza: How many staff do you typically have?
Dawn Harsch: So there's two staff twenty-four seven always, and then there's other staff that come and go.
So every day during the day, there's two staff for ten clients, one of which is a nurse.
The other is a healthcare aide.
Evenings and nights, there's two HCs, but there's always a nurse on call.
In addition to that staff, there's a nurse manager for each pod.
And a pod of homes is three to four homes.
So that nurse manager is another set of eyes on those residents.
There's also an activity coordinator, so she does recreation therapy.
We have a physician who visits the home once every other week.
And some of the homes will have a third staff over the dinner hours, specifically our homes that are for individuals with dementia.
Zannat Reza: So tell me about some of the other innovations you've made at ExquisiCare.
Dawn Harsch: I think one of the biggest innovations that we have at ExquisiCare is less of an innovation, and more of a throwback to allowing caregivers to spend their time caring for the client.
And so when I designed sort of the job descriptions at Exquisite Care and compared that to traditional long-term care, and typically she or he is pushing around a med cart, handing out meds for fifty to a hundred people.
There's no job satisfaction in that.
You would have an RN who's doing a lot of paperwork, who spends no time with the residents unless the resident has fallen or has died.
And so if you look at why people go into health care, and particularly elder care, they do that because they want to spend time with the seniors.
They want to make a difference.
And so when I looked at sort of the job description of what it means to work in an ExquisiCare home, I wanted to make sure that we were creating an environment where people can come to work and feel like they did what they wanted to do, they feel like they're making a difference in the lives of their elders.
So the, the LPN, which we also call the elder guide, she's doing frontline clinical work.
She's also managing her small team of staff.
She's interacting with the families.
And with only ten clients, she's able to truly make a difference.
She's able to anticipate the needs of that resident and do something about it before it becomes a problem.
The health care aides, they're doing some meal prep, they're doing some laundry.
It kind of feels like going from their home to the elder home and helping with them.
And so because of that, we have very low staff turnover.
We pay people well, we get them fair market wages.
We allow them to do what they were meant to do.
And you have a lot of job dissatisfaction, because the people are terribly overworked, in traditional long-term care, where they become very task based.
So, you know, feed them, change them, bath them, get them to the dining room to eat, do that all over again.
We are relationship focused.
We're focused on the relationship with that elder.
I love it when I walk into the homes and I see the staff sitting down and looking at a photo album with the resident, that's what we have time to do.
And having that close relationship with the elders is really, I think the key factor in the ExquisiCare success.
When we're dealing with people and we're dealing with elders, it's that human connection that they crave.
And that's what we give them, is that human connection, that physical touch, not only between the staff and the clients, but between the clients themselves too.
With only ten residents per home, we see some really tight bonds happening with the elders and the families.
Which is beautiful.
Zannat Reza: Can you share a memorable success story or moment that exemplifies the positive atmosphere and environment of a small care home?
Dawn Harsch: You know, there's been so many through the years that it's hard to nail that down.
The one that sticks in my mind is actually from my very first resident.
And I think Jack was probably ninety-four when he came to live with us.
He had been previously living in a big institutional long-term care facility.
Jack had mild dementia, so he was forgetful.
He was in a shared room and he ended up unfortunately with a roommate that because of his dementia was quite aggressive.
And poor Jack got, he got beaten up quite badly.
And so the family said, you know, that's it.
We just want what's best for dad.
We want him to live in a comfortable home.
So in his other care facility, Jack was losing weight.
He was in a wheelchair.
He was in incontinent products because he was deemed incontinent.
He couldn't walk because of course in this long, long, long hallways at this big facility.
They just put them in a wheelchair.
Jack came to us and we parked that wheelchair and he didn't use it until he was about two weeks away from passing.
And he lived with us for four years.
He was not incontinent.
He needed to go to the bathroom every two hours and the staff made that happen.
He gained twenty pounds within the first two months of living with us.
Because we sat at the table, we gave him what he wanted to eat.
We gave him time to eat.
After two days, the son came to me and he said, you know, if dad lives another week, this move was worth it for us, 'cause like we got our dad back.
I have many, many stories like that, but Jack really stands out in my mind, 'cause he was our very first resident.
Zannat Reza: That's such a powerful and memorable and touching story.
I love that.
With all the benefits that you've outlined, why aren't we seeing more small care homes?
Dawn Harsch: That's a great question.
And you know, it's all about the funding model.
Because our funding model doesn't fit with traditional long-term care government funding models, that's why.
I would love for this to be government funded.
Zannat Reza: Homes like these ones are not yet a funding priority throughout Canada.
This is evident in Ontario, where the government is developing thirty thousand new long-term care beds by 2028 based on design standards that favor larger institutions of up to thirty-two person units and some shared rooms.
The good news is that other provinces are making headway.
Quebec has committed to creating fourty-six new homes called Maison des Années inspired by the Green House model.
Nova Scotia, PI, the Northwest Territories, and Nunavut have either adopted or are in the process of requesting approval for small care home design principles as a standard.
Dawn Harsch: I think what needs to happen from a government perspective is really to look at the funding model, because the current funding model fits when you've got a hundred or two hundred bed facilities, and it doesn't fit for small care homes.
So either we change the funding model so that small care homes are fully funded, that's option A.
Option B is the funding can follow the patient.
And what that does is it gives individuals, elders, and their families the option to choose where they want their funding to go.
And maybe that's a small care home.
Zannat Reza: In addition to funding models, which are the largest barrier, there are other challenges involved in spreading small care homes across Canada.
Existing legislation, policy, and regulatory requirements were developed to favor larger and more institutional settings.
I asked Dawn for her perspective on what it would take to change political will and get governments to accept the benefits of building small care homes more widely.
We're talking about changing the mindset of government.
What's it going to take?
Do people need to rally or lobby in front of the government building to say, hey, listen to us.
This is what we want.
We know the benefits of small care homes.
We want this.
Dawn Harsch: Maybe.
Yeah, maybe that is what it's going to take.
I don't know what it's going to take because I've been lobbying for years.
And we're getting there, but it takes so long to change something that's so ingrained.
I mean, we've been institutionalizing our elders in this country since the Second World War.
And if you look at the history of long-term care, that's when it started.
You know, individuals were losing their sons to the war.
So suddenly, what used to happen was the children would take mom and dad in with them.
Well, that couldn't happen anymore 'cause there was no more children.
And so it became sort of the way of caring for elders in North America, more so than the rest of the world.
And so, yeah, lobbying, I think people need to say we're not happy with the status quo.
And we're seeing that a little bit.
There certainly is some change to the landscape.
Alberta did release that small home capital grant, which was great.
It's a great first step.
Zannat Reza: What are some challenges in bringing small care homes to residential neighborhoods?
Dawn Harsch: We've had an issue, I guess, in the past where we've gone into a residential community and that community didn't have a zoning bylaw or a category that fit what we did.
Some of them would call ExquisiCare or small care homes group homes.
But what we see with group homes is there's a bit of a negative connotation, that people think group home and they think mental health or they think troubled youth or even a halfway house for individuals coming out of prison.
And so working with a couple of communities, and they haven't done it yet, but they are in the process of creating a new zoning category for something called a community care home.
I'm advocating with the province of Alberta to come up with some building codes specific to small care homes.
The way the building codes work is there's a provincial oversight that says this is the building code for X.
But then each municipality interpret that building code sometimes differently.
I'd love to see not only a provincial, but maybe even a national building code, for small care homes.
Because what that will do is that'll give assurance to the families and the individuals living in those small care homes that you're going to get a standard level of safety and security regardless of where you are in the province or in the country.
Zannat Reza: When we're thinking about building small care homes, how long does it typically take?
Dawn Harsch: Building small care homes, we've got it down to about eleven months.
We used prefab walls in our last build.
And so the way that works is we used a great company here in Edmonton.
They kind of built the house off site.
And we pour the foundation and then the house goes up in three days.
When you compare that to a larger, more institutional care facility with like five hundred beds, the building code, the design, all the pre work, and then even getting that building up, you're, you're looking at years, like three to five years to build something of that nature.
We can get our building permit, our design and the home up and running within a year.
And so it's a much faster way for municipalities and provinces to get care into the communities where it needed.
Because again, the small care homes are ideally suited, not only for cities, but they can also go out into rural areas where maybe there isn't a huge population, maybe they only need ten or twelve beds.
We are doing some exploratory work with First Nations as well, and how we can bring the small care home model to First Nation.
Because it's a very unique situation in First Nations communities, often being very northern with different health, different weather challenges.
And so working with a specific builder, who would build small care homes in First Nations communities that are windproof, moldproof, waterproof, and movable.
And so having these small care homes in the First Nation communities, I think is very important.
Those elders don't want to leave their community and come to the big city.
But the challenge is how do we build them when sometimes there's only an ice road to get up there.
And so we're looking at some really unique ways to bring small care homes to very remote communities, including indigenous communities.
So I'm pretty excited.
Zannat Reza: And what's your vision for the future?
Dawn Harsch: I would love to see hundreds of these across Canada in every neighborhood.
The other thing that I'll say, though, is that they're not the only option.
I believe in choice, and I think this is a choice that some seniors would love.
Some people may want that bigger care facility.
But my vision is for small care homes to be the main way that we provide care to seniors.
What we give to families is that peace of mind, knowing their mom or dad is only one of ten in this home.
And if they call that home, they're going to talk to Trish, who is their elder guide, which is that nurse that works Monday to Friday in the home.
And Trish knows mom and dad exceptionally well.
She's not going to have to say, Oh, I haven't seen them.
I don't know.
Let me check with the staff.
So that accountability.
And Trish loves her elders.
You know, the ten clients that she has in that home, she knows them exceptionally well.
Zannat Reza: My last question is something that we ask every guest, which is, if you could wave a magic wand and make one radical but realistic change to improve our society's well being, what would it be?
Dawn Harsch: It's a really hard question.
What I see in Canada, the US, is there's such polarizing opinions and such polarized sides of the political spectrum, is it's hard to get anything done.
It's tough with our political processes to actually get meaningful change implemented.
And you need to look at small care homes.
It's radical.
It's different.
And getting governments to adopt that, takes more than a two or a four year commitment to make these meaningful changes in terms of how we care for seniors.
So, love to see a government that commits to this and somehow embeds it in their policy, that this is gonna be the way we do things, even if they're no longer in power.
Zannat Reza: Thanks to Dawn for sharing the story of ExquisiCare and for her efforts to bring more small care homes to communities across Canada.
Thanks for joining us for this episode.
To learn more and for transcripts, go to TheFutureAge.ca.
Listen to new episodes by following us wherever you get your podcasts.
And if you're liking our podcasts, leave a review on Apple or Spotify.
And be sure to share it with your friends, family and colleagues.
The Future Age is brought to you by SE Health, a not for profit social enterprise that provides the best care, inspires innovation, and impacts how people live and age at home.