Nursing homes are the last of the big institutions where hundreds of strangers are expected to live in harmony. We no longer put children in orphanages, or people with mental illness in psychiatric asylums. We don’t consign people with intellectual disabilities to vast residential centres. Bit by bit we’ve dismantled these impersonal fortresses which often deserved their reputation for abuse and neglect. The alternatives, especially for psychiatric patients, have not always worked. But the philosophy has survived – that small, home-like settings with live-in carers are preferable if people can’t live in their own homes or with their families.
For the old, it’s another story. Once home care is no longer possible, the only alternative is a big institution. Rather than dismantling them, we’re building aged care facilities bigger than ever. Few people actually like them but we seem to be stuck with the model. And even if the more modern places have dispensed with long corridors and four-bed wards, they’re at best like an upmarket hotel or at worst a soulless warehouse of no-return.
Tamar Krebs was working in one of the country’s best aged care facilities, the Montefiore in Randwick, Sydney, when she started to question the whole model of institutional care. “Can we deliver true person-centred care in an institutional environment?” she wondered. And “Were adult children choosing institutions for their parents because that’s what they wanted or because there was nothing better out there?”
Since that time of questioning, Tamar has opened two group homes for people with dementia despite just about everyone telling her it couldn’t be done. Both homes are in the upmarket Sydney suburb of St Ives. In the first which opened a year ago, six women live, and in the second, which was purpose-built and opened in May, there are seven residents with room for three more.
“If children with severe disabilities can live in a group home in the community why do we warehouse older people?” she said. “People flourish when they live in their own home, with purpose and meaning in their life and where their individuality is celebrated.”
In the group homes, people can help with the cooking and laundry if they want. They can work in the garden. Their outings are to the local shops or to their favourite hairdresser. They can get up in the morning when they want. The houses don’t look like a traditional nursing home and they don’t operate like one. The staff: resident ratio is 1:3 in the day (with one worker overnight) compared to 1:7 or 1:10 in a typical nursing home. The staff are called “home-makers” not carers, and they multi-task. A registered nurse is on-call. “This woman here who makes pancakes would be in a lock-up dementia unit,” Tamar tells me.
It’s hard not to be impressed with this 36-year-old American/Australian who’s done so much in her nine years here. Apart from having twins and two more children, she’s added to her nursing qualifications with a master in health services management from the University of Technology Sydney. She’s managed nursing homes for under-privileged people in Israel, and managed the high and low care dementia units at Montefiore, an experience she describes as “a master class in aged care.”
In the absence of state or federal government funding she’s achieved her goal of providing a new model of aged care. Despite all the talk in the aged care sector about innovation and choice, she’s succeeded in the face of scepticism and discouragement. In Scandinavia, the Netherlands, and Japan, and in the US where the Green House movement is shrinking some aged care facilities to a homely size, the group home model is no longer revolutionary.
But despite my admiration, I had lots of reservations which I put to her. For a start, her homes are not covered by the federal government’s aged care accreditation system. For all its limitations, accreditation provides clear standards to be met and protections for residents and managers. It also provides for unannounced visits by inspectors. The group homes are also outside the government’s aged care complaints system.
Also it’s for good reason Australia has moved to bigger aged care facilities over 20 years: Mum and Dad-run 30-bed facilities, once quite common, could not meet the higher care and building standards that governments demanded in return for funding. (Tamar calls these “mini institutions not group homes”).
Finally, the group home choice is one for people of considerable means with a house to cash in. Sydney’s well-heeled eastern suburbs are earmarked for the next home. Residents each have their fees structured in a different way, depending on the level of care required, and the size of their up-front (refundable) payment.
Glenn Rees, chief executive of Alzheimer’s Australia, who visited one of the homes, said: “I could imagine living there.” He was impressed with Tamar’s dementia care philosophy. “But the problem with the group home idea has always been financial viability,” he said. Tamar, who’s got two major backers for her company Group Homes Australia, says one home breaks even and the other makes a profit; and if the model can work in high-price Sydney it will be easier elsewhere.
More choice and innovation in aged care can only be good. Our current model of institutional care is hardly gold standard. But the need for family members to be vigilant outside the system is even greater. “I want to be the one setting the standard for this kind of care,” Tamar said, “to keep the cowboys out.”
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