Executive Summary

On March 11, 2020, the World Health Organization (WHO) declared the novel coronavirus disease (COVID-19) to be a global pandemic and it soon became apparent that community residential care settings, and nursing homes or long-term care (LTC) facilities in particular, were the epicentre for infection and death. Pre-pandemic systemic and structural deficiencies (such as a precarious front-line workforce fuelled by decades of deregulation, privatization, contracting out of support services, inadequate staffing levels, antiquated hospital-like institutions, reduced care services, and lack of effective oversight), created an overstretched system unable to respond to the pandemic. The systematic reduction of staff providing medical coverage, regulated nursing staff, physical and recreational therapists, and social workers left inadequately trained care aides struggling on their own with little support to meet the complex needs of residents. In these circumstances, in many facilities, an institutional model of care with a focus on basic physical and personal care, and on task completion, has resulted. Psychosocial, mental health, and emotional needs, as well as factors that promote well-being and quality of life, have been largely ignored as staff struggle to provide even basic physical care compassionately, and as residents languish.

Mental health problems are common in LTC, with the majority (76%) of residents diagnosed with a mental disorder (40%) or Alzheimer’s Disease and Related Dementia (36%). As well, delirium affects 40% of residents in LTC facilities, up to 20% of residents live with an anxiety disorder, and between 6.5% and 58.4% of residents experience clinically significant symptoms of anxiety. Two to three per cent of residents in LTC live with schizophrenia. Dementia has a median prevalence of 58% in LTC facilities, and 78% of individuals with dementia are affected by behavioural and psychological symptoms of dementia (BPSD). Approximately 19% of residents have severe to very severe aggressive behaviours. Access to ongoing training for facility staff about recognizing and managing mental illness and BPSD is limited, as is access to mental health consultants, particularly in rural and remote areas. Given these circumstances and an overstretched front line, pharmacological interventions may be implemented rather than psychosocial ones, sometimes inappropriately.

The aim of this report is to develop a comprehensive guidance with recommendations to support the mental health and well-being of people living in community residential care settings, and that could provide a framework for a new standard.

The methodology included (1) a review of peer-reviewed scientific literature, and grey literature, about strategies/interventions, practices, programs, training, and policies that support the mental health and well-being of people living in community residential care settings, (2) key informant interviews, and (3) an online survey of people with lived experience in community residential care settings. A summary of the results was compiled into a research report (Part A), organized around a mental health promotion framework. The key points from the research literature were then used to develop a guidance document (Part B).

A mental health promotion framework focuses on the mutuality of residents, family caregivers, and staff within the residential care environment, and applies to those without mental illness as well as those at risk of or living with mental illness. A mental health promotion framework is in line with the World Health Organization’s Global Strategy and Action Plan on Aging and Health. Key actions include orienting health systems around intrinsic capacity and functional ability, developing and ensuring access to quality older person-centred and integrated clinical care, and ensuring a sustainable and appropriately trained, deployed, and managed health workforce.

The physical and social environments, often interacting, are potent influences on the daily life of residents and their capacities and functioning. Evidence and expert opinion are provided about how facilities can be designed, modified, and adapted to support residents’ mental health, well-being, and quality of life. Likewise, there is evidence presented that a social environment underpinned by a relational person-centred care model has positive effects on residents’ mental health, well-being, and quality of life, and on the staff’s morale, satisfaction, and retention. There are many effective approaches to reducing social isolation, strengthening residents’ capacities, and addressing mental health problems that can be implemented in community residential care settings. Relationships between residents, their families, and staff are important to the residents’ well-being and can be supported and enhanced.

The link between residents’ quality of care and quality of life with a supportive work environment and staff well-being has been made explicit by the effects of the pandemic. More front-line/direct-care staff, empowered and with better working conditions, changes to how care is organized, supportive person-centred leadership, and an increase in allied health care professionals are all required to enable facilities to create environments and conditions that support the mental health and well-being of all residents, families, and care providers. Additionally, given the diversity and complexity of the resident population in LTC facilities and the prominence of mental health issues/illness, access to specialized dementia and mental health training, consultation, and management of challenging behaviours is imperative to both increasing the capacity of facility staff to provide competent mental health care and to ensure the well-being of residents.

COVID-19, by exposing the flaws in how community residential care is provided, has also given us a map and an opportunity to implement the changes that will make LTC and other residential care settings places where residents thrive and where staff look forward to going to work. Policies and practices to facilitate a positive residential care environment for residents, families, and staff are outlined while recognizing that the government has a responsibility for funding facilities and for building and adequately supporting a workforce, sufficient in number, and with the diverse skills and knowledge required to meet the holistic and complex needs of our most vulnerable citizens.