Originally published at The Hamilton Spectator

It is well established that social engagement is a far greater determinant of a seniors’ well-being than the dimensions of hallways, bed rails and toenails.

The vision I have of my final home seems idyllic when I try to describe it. It’s a big red brick century home with a peaked roof and one of those wide wraparound porches where I can sit and read or just watch the world go by. Kids play road hockey in the street, young couples laugh together and ambitious working types march off to their posts in the morning. There is an adjacent park where I stroll — maybe with my walker — and shops nearby where I browse and chat at my own pace.

Perhaps most important, my imagined home is a “congregate” setting. Its shared with my wife and other couples and singles with similar interests and activities. We eat our dinners together and social engagement is always just a living room or a porch away. We rely on each other’s assistance where possible, but also on regular nursing and housekeeping visits as our needs (increasingly) demand. I have the freedom to come and go — as long as I’m able — and wake up, eat and bathe at times that suit me.

There are logistics to all of this, of which I am well aware. Someone needs to own the home, which requires “capital”. There are also “operations” for which someone must take responsibility — groceries to buy, floors to clean, appliances to repair and, of course, those nursing visits to arrange.

But the biggest challenge to my retirement vision is not the logistics. Its actually the law. My home may exist in Norway, but it won’t clear legal hurdles where I live. In Canada, seniors residential care is under provincial jurisdiction and, in Ontario, the governing regulations state that no person shall operate residential premises “in which nursing care is provided to two or more unrelated persons” without obtaining a long-term care (LTC) homes licence. An exemption exists for retirement homes, which have their own licensing requirements (but no public funding).

With the LTC license comes the full weight of regulation and reporting to Ontario’s Ministry of Health and Long-term Care. There are rules for hallway widths, bedrail heights, window openings and backup generators. Three different levels of illumination apply to stairways, corridors and resident rooms. My century home idea is looking like a non-starter.

And from a care point of view, everything from tooth brushing to toenail cutting is contained in provincial regulation, all to be in accordance with a plan of care designed for each resident, and all governed by the LTC home’s policies and procedures manual. The Long-term Care Homes Act also requires that a registered nurse be on duty in the home 24/7, which could easily cost my housemates and me several hundred thousand dollars a year.

Despite good intentions around stringent regulation, research suggests that the resident experience may not be any better for it. Few scholars are as knowledgeable on the subject of LTC homes as Dr. Pat Armstrong of York University, or as compassionate about the welfare of their residents. In a recent study, she compares seniors residential care in Norway, Sweden, Germany, U.K., U.S., and Canada and notes the tendency to impose detailed regulation at the facility level, often as a response to publicly reported scandals in the LTC home setting.

Her study finds that, particularly in North America, the balance is increasingly tilting toward tighter regulation, reporting, inspection and enforcement. She notes instances in Ontario where regulations have become overly complex, difficult to implement, and of questionable value in improving outcomes.

Armstrong points to the unintended consequences of rules aimed at avoiding risk. Where policies are adopted in response to accidents or complaints, the reaction can be to limit unnecessarily the freedom of residents. She cites the examples of puréed food to avoid choking, bibs to protect clothes, and diapers to limit the number of accidents that occur when caregivers are too busy to take residents to the toilet. The greater risk may be that risk avoidance itself takes priority over autonomy of the resident.

When oversight becomes too strict, distrust also arises between those enforcing the rules and those operating the homes. Where my research has included interviews of LTC homeowners, I have been surprised by responses describing micromanaged, punishing, and suffocating inspection practises. Feedback from care workers also points to paperwork taking precedence over better care.

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