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Case Study: Nursing Home Without Walls, New Brunswick

Background: Aging-in-place model and setting

Nursing Home Without Walls (NHWW) was created by Suzanne Dupuis-Blanchard, PhD, the Université de Moncton’s Health Research Chair in Population Aging, director of the Centre for Aging Research and full professor in the School of Nursing. Beginning as a pilot program in 2019, NHWW launched in four nursing homes located in Port Elgin, Lamèque, Paquetville and Inkerman, rural communities in New Brunswick.

The NHWW program aims to empower communities to improve access to health and social services for older adults living in their own homes, as well as their caregivers. The program has since expanded through the Provincial Health Plan. Most recently, 14 additional nursing homes in the province have joined the program, supported through a partnership with Healthcare Excellence Canada and the NHWW innovator at Université de Moncton’s Research Centre on Aging.

The program is designed to enhance quality of life for older adults living at home and their caregivers by offering supportive initiatives developed in collaboration with local communities and organizations. The NHWW nursing homes act as hubs to enable aging in place. They leverage community networks and apply trusted knowledge of dignified aging and skilled expertise in addressing health and social care needs of older adults. The NHWW nursing homes also provide physical space, infrastructure and administrative oversight to support NHWW programming and operations.

NHWW strengthens access to services, information and resources for aging in place. The program combats social isolation through health initiatives for older adults and their caregivers, while also improving awareness and access to relevant services. This is achieved through robust collaboration with local community organizations, community members, and health and social service providers. Examples of possible NHWW initiatives include:

• check-in calls and in-person social visits with older adults
• intergenerational activities that connect young people with older adults
• help with navigating relevant programs, resources and services
• transportation to medical appointments and other social outings via the nursing home’s minibus
• access to nursing home bathing facilities and other specialized equipment

The genesis of the NHWW program began with Suzanne Dupuis-Blanchard’s impassioned desire to improve the lives of older adults in the community. Leveraging her background as a community health nurse and her expertise as a scholar in population aging, Dupuis-Blanchard adopted a facilitative coaching approach to initiate, implement, spread and scale the NHWW program. This effort was supported by partnerships with the New Brunswick provincial government and Healthcare Excellence Canada.

Development and expansion of the NHWW program was influenced by Dupuis-Blanchard’s deep understanding of how to care for older adults in their community – applied knowledge she had gained from working as a community health nurse. Alongside this, Dupuis-Blanchard’s experience as a population-aging scholar equipped her with an appreciation for evidence-based best practices for aging in place and relevant system-level policies. She engaged key interest holders, including the Nursing Home Association of New Brunswick, the Association francophone des aînés du Nouveau-Brunswick (Francophone seniors organization) and the New Brunswick Senior Citizens Federation discuss a pivotal question: Do nursing homes have a role to play in aging in place? The answer – a resounding “YES” – emerged from these dialogues and sparked a cascade of community engagement. Before Dupuis-Blanchard could conceptualize what this program might look like, a local nursing home reached out to her with the same goal in mind. 

In the community and of the community, the nursing home would become the hub for community engagement for older adults at home. Dupuis-Blanchard’s small seed idea grew into a tree made up of far-reaching community-engaged branches.

Engagement approach with community

Making connections

Community engagement began with Dupuis-Blanchard and the NHWW nursing homes leveraging informal networks to connect with the communities they intended to serve. These efforts were rooted in building relationships, starting with past colleagues, non-profit organizations and word-of-mouth connections. These informal relationships formed the foundation for deeper community involvement and collaboration.

Moving from consultation to co-creation

Applying the principle of co-creation, rather than consultation, fostered a grassroots motivation and encouraged diverse partners and organizations in the community to engage with NHWW as it developed. This approach broadened participation among those involved in or interested in the care of older adults.

NHWW prioritized diverse voices via a kick-off consultation: an inclusive and accessible invitation that drew all actors involved in care of older adults (including the older adults), as well as those intrigued by the concept of aging in place. The local nursing home led the effort to advertise an open invitation to the event. The home advertised in spaces that older people and their networks frequent, such as grocery stores, pharmacies and other local gathering places. Encouragement to attend was further spread through word of mouth, as well as through flyers in church bulletins, on Facebook and amongst local organizations.

At the event, roundtable discussions were characterized by openness and idea-sharing, recognizing and respecting that communities know themselves best and that nursing homes hold specific expertise that make them invaluable. Interest holders – from local organizations to associations and non-profits – blended with older people, their families and their grandchildren. Three questions made up the discussion:

1. What services or supports do we need to stay at home?
2. How do we think a nursing home can help address your answers to Question 1?
3. Who in the community could join alongside the nursing home to help us stay at home?

These questions were discussed in small groups. Later, the groups were welcome to share amongst the entire room. These discussions took place over a couple hours and combined rapid priority setting with a needs assessment. Highlights of the discussions included the following:

• The group discussed the needs of older adults as well as community asset mapping. This dialogue enabled engagement through trust-building and knowledge-sharing.
• NHWW was able to position itself as a complement rather than a competitor to the services available to older adults through the communities’ local organizations, non-profits and health professionals.
• Groups were able to learn about and identify untapped resources within their locality. Engagement was prioritized here via the in-person nature and physical presence of those in the room, enabling people to better develop relationships face-to-face.
• Voices from different perspectives were able to hear directly from one another, and the inclusive space made all parties feel comfortable speaking their lived experience.
• Throughout the event, iterative relationships were made that would facilitate sustained engagement as the program was implemented.

This kick-off consultation was action-oriented and established bi-directional communication, laying the foundation for co-creation and instilling a sense of ownership within the community. Using these co-creation methods, a report quickly followed the launch. The rapidness with which the report was disseminated deepened trust among community members and with the program.

The documentation of the meeting discussion, along with action-oriented steps toward developing further connections, was vital to echoing and amplifying the voices that spoke up during the kick-off. The report provided the main takeaways of the discussion and gave the community a commitment to action. Timely and transparent communication, tied to active momentum, was a major enabler for trust and connection, keeping NHWW moving forward while also keeping the community engaged.

Flexibility and adaptability

The flexible and adaptable approach that NHWW took to engaging with the community was a grassroots-motivated strategy rooted in a commitment to co-creation. By recognizing community assets and placing the locus of control in the hands of the community, the program maintained momentum, flexibility and dynamism. NHWW facilitated action at every stage, ensuring that no idea or resource was overlooked or left untapped.

Timely and transparent communication was a cornerstone of NHWW’s engagement with diverse partners involved in care of older adults, including participants from the kick-off consultation and newly engaged partners. The diversity in the interest holders ranged from nonprofit organizations and volunteers to grandchildren, reflecting a broad spectrum of perspectives. Regular updates on funding, new partnerships and program developments were crucial during the program’s initiation and implementation. This ongoing communication by NHWW empowered communities to identify resources and actively engage in real-time decision-making. The commitment to communication built trust within the community and contributed to the program's sustainability and momentum.

Engagement fostered relationships between local communities, enabling them to understand their capacity to contribute through shared information and connections. Rather than prescribe engagement opportunities, NHWW guided groups to lean on their inherent local relationships, creating a full circle of connection. Relational networks were identified and strengthened, mapping existing community assets and empowering those who needed support.

Tactics included encouraging sites to set their own meetings and agendas, organizing community events such as setting up information tables at grocery stores to spread the word, and presenting at seniors clubs and municipal council meetings. These efforts served a dual purpose: enabling local nursing homes, in collaboration with community members and organizations, to take ownership over the program while simultaneously promoting it to other communities. This reciprocal and collaborative approach strengthened local relationships, fostered learning about community needs and expanded the capacity for aging in place programs.

Support through coaching

To support sustainability, NHWW adopted a backseat approach, guiding communities from the sidelines after program implementation. This practice empowered co-creators to maintain pride and ownership over the program. Tactics included “coaching pods”, where experienced NHWW staff met monthly and provided on-call support to nursing homes implementing the program. The coaching pod calls were designed to answer questions, facilitate connections and uphold NHWW’s principle of an open, hands-off approach that places responsibility in the hands of the community.

This engaged coaching approach emphasized maintaining momentum by equipping nursing homes with the tools needed for success and allowing them to adapt the tools in their own way. For example, a particular nursing home might undertake a unique activity and, at times, some tools and guidance could be tailored from community to community. Nursing homes were able to operate within NHWW in their own ways, according to their own contexts. NHWW’s foundation of genuine empathy, compassion and authentic desire to do well for older adults in the community transitioned ultimately into nursing homes acting as community hubs, while remaining aligned with NHWW principles.

NHWW grassroots beginnings were aptly paired with vast knowledge of system-level connections that allowed the program to sustain momentum through funding. Policy, infrastructure and system-level knowledge, stemming from Dupuis-Blanchard’s intimate knowledge of research funding, was key to growing the program as well as spreading awareness of timely population needs.

Conclusion

Leaders attribute the program's effectiveness to empathy, encapsulated by the principle of “caring people caring for people”. NHWW's engagement success stems most notably from an unwavering commitment to co-creation and its ability to transform nursing homes into hubs for the care of older adults in the community. By engaging with the community, local nursing homes expanded their reach, providing health and social care services and navigation supports directly in older adults’ homes.

NHWW’s strategy leveraged existing community assets, including relational networks, respected leaders, and spaces where people could gather and share. By tapping into these structures, nursing homes initiated, implemented and sustained the goals of aging in place, thereby delaying or avoiding a move to a nursing home, in partnership with the community. The program's potential lay not in what it could do for the community, but what it could empower the community to create. NHWW's community engagement exemplifies the transformative power of empathy and commitment to co-creation and empowerment.

From the outset, NHWW prioritized creating and sharing over seeking pre-determined answers or enforcing rigid plans. Co-creation requires acknowledging the uniqueness of each community and the diverse interest holders involved in caring for older adults. NHWW embraced a blank slate approach, understanding that communities know their needs best, and enabling adaptable and diverse collaborations.

NHWW success is deeply rooted in its foundation of trust and mutual respect. Its open-handedness – adapting to community needs rather than requiring communities to conform – created fertile ground for sustainable engagement. NHWW creates an environment where communities feel safe to connect, share and actively participate. Most importantly, it cultivates bidirectional value, where nursing homes act as hubs that expand beyond staff and residents to include family, volunteers and potential future residents or older adults at home. By embracing the diversity of individuals within each community, NHWW became of the community, not just for it.

The key takeaway from NHWW’s engagement model is that creating shared value and ownership fosters broadly-based, community-centered programming. NHWW shows that potential is not something that must be crafted; it already exists if we listen, not just to hear, but to truly understand.