The LTCA sets out the case management function of the CCAC for community services:

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1 6.1 Introduction to Case Management The Long-Term Care Act, 1994 (LTCA) assigns specific duties to agencies approved to provide community services. In regulation 33/02 under the Community Care Access Corporations Act, 2001 (CCACA), a Community Care Access Centre (CCAC) is deemed to be an approved agency under the LTCA and is approved to provide the community services set out in this regulation. Two key CCAC responsibilities are: provision of home care and managing the placement process into long-term care (LTC) homes. The CCAC manages these key activities through case management services, a core service of the CCAC. Case management in the CCAC is vested in case managers who must assess and review requirements, determine eligibility, and develop and evaluate the plans of service for CCAC services and authorize the expenditures of funds for services in accordance with sections 22 and 23 of the LTCA, and authorize admissions to LTC homes in accordance with subsection 20.1 of the Nursing Homes Act (NHA), section 18 of the Homes for the Aged and Rest Homes Act (HARHA), and subsection 9.6 of the Charitable Institutions Act (CIA). (The admission to LTC care homes is discussed in chapter #11 in this manual.) The LTCA sets out the case management function of the CCAC for community services: Plan of service s. 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges, the agency shall, (a) assess the person s requirements; (b) determine the person s eligibility for the services that the person requires; and (c) for each person who is determined to be eligible, develop a plan of service that sets out the amount of each service to be provided to the person. Revision of plan of service s. 22(2) If a person is receiving a community service provided or arranged by an approved agency, the agency shall, January

2 (a) review the person s requirements when appropriate, depending on the person s condition and circumstances; and (b) evaluate the person s plan of service and revise it as necessary when the person s requirements change. Co-ordination of services s. 22(3) If a person is receiving more than one community service provided or arranged by an approved agency, the agency shall assist the person in co-ordinating the services he or she receives, in accordance with the person s wishes. Participation in plan of service s. 22(4) An approved agency shall provide an opportunity to participate fully in the development, evaluation and revision of a plan of service to, (a) the person who is the subject of the plan of service; (b) if the person who is the subject of the plan of service is mentally incapable, the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service; and (c) the person, if any, designated by the persons referred to in clauses (a) and (b). Other assessments to be considered s. 22(5) In assessing a person s requirements under clause (1) (a) and in reviewing a person s requirements under clause (2) (a), an approved agency shall take into account all assessments and information that are provided to it relating to the person s capacity, the person s impairment or the person s requirements for health care or community services. Person s preferences to be considered s. 22(6) In developing, evaluating and revising a person s plan of service, an approved agency shall take into account the person s preferences, including preferences based on ethnic, spiritual, linguistic, familial and cultural factors. Compliance with regulations s. 22(7) An approved agency shall apply the prescribed criteria, follow the prescribed procedures and comply with the prescribed rules and standards in assessing a person s requirements, determining a person s eligibility and developing, evaluating and revising a plan of service. Provision of services s. 23(1) An approved agency shall ensure that the services outlined in a person s plan of service are provided to the person within a time that is reasonable in the circumstances. Waiting list s. 23(2) If a community service outlined in a person s plan of service is not immediately available, the approved agency shall place the person on the waiting list for that service and shall advise the person when the service becomes available. January

3 Case management is a core service provided by the CCAC, and the mechanism through which individuals access a range of services. The interactive involvement and relationship between a case manager and clients must be supportive and assist clients to live independently and make their own health choices. In addition to being a service to individual clients, CCAC case management also serves a system-level function, promoting service consistency, co-ordination, quality and accountability while maximizing client independence and optimizing resource utilization. Case management is knowledge-based, and incorporates skills, abilities and experience to successfully carry out the processes of collecting and analyzing information, and developing and managing a plan of service that is mutually agreed to by the client and/or substitute decision-maker (SDM). Communication and client education are key elements in linking the processes with the client, and linking the client with the CCAC and other parts of the health care system. The CCAC must comply with the LTCA when providing case management and be guided by the following principles: respect for the person s rights, dignity, values and preferences; promotion of the highest level of independence possible for the person within the person s capacity by focusing on the person s strengths, needs and preferences; promotion of quality improvement in all aspects of service management; promotion of a collaborative and co-ordinated approach to service delivery; and promotion of efficient, effective and equitable use of resources. Case management is available to persons requesting in-home services, school services, and admission to LTC homes. Case management intensity may vary according to the needs and goals of the individual client. Some clients may benefit from care pathways, while others may require intensive case management. January

4 6.2 Responsibilities of Case Managers Case managers must co-ordinate service delivery provided by the Community Care Access Centre (CCAC), their contracted service providers and informal caregivers, and link clients to appropriate volunteer and community resources. Case managers must collaborate with clients and service providers to determine the nature, intensity and duration of services required to address the client s needs and ensure the most effective use of resources. A case manager must authorize each CCAC service provided to a client. The case manager must have the knowledge and skills to work with clients and local community resources to provide efficient and effective services to clients. Community services can supplement those provided through the CCAC to complement and strengthen the individual's plan of service. Case managers must ensure that their practices use quality improvement, risk management and best practice principles that strengthen service delivery. As a primary objective the CCAC case manager must ensure that the right services are provided to the right clients at the right time. The primary objective is achieved by: assessing client needs (see subsection #6.2.1 in this manual); determining eligibility for services (see subsection #6.2.2 in this manual); developing plans of service for eligible clients in collaboration with client/caregivers (see subsection #6.2.3 in this manual); co-ordinating services to help clients meet the goals of optimal health and independence (see subsection #6.2.4 in this manual); conducting regular reassessments of clients (see subsection #6.2.5 in this manual); adjusting CCAC services when client requirements change (see subsection #6.2.6 in this manual); discharging clients as soon as the services are no longer required, the client is no longer eligible for services, the client withdraws consent to receive services or the client is no longer available (see subsection #6.2.7 in this manual); and supporting clients through the health and social support systems. Case managers must assess needs, determine eligibility based on eligibility criteria, and develop, authorize, monitor and evaluate plans of service. These plans of service may include professional services, personal support services, homemaking services, and school services as well as supplies, equipment or other goods within their legislated authority. Case managers must provide other supports to the client and the caregiver by: counselling clients and families that are adapting to change or are in crisis and having difficulty coping, making decisions and problem solving; assisting persons to develop the knowledge, skills and ability to make choices that enhance their health and well being; January

5 developing appropriate strategies for clients who may be resistant to services and who live at risk in the community; assisting and supporting family caregivers or substitute decision-makers (SDMs) that must act on behalf of family members who are no longer capable; and monitoring clients who are at risk, including clients with medical conditions that have the potential to deteriorate at any time; clients who may have an urgent requirement for 24-hour, seven-day supervision; clients who may need crisis placement; clients with cognitive disabilities and an inadequate support system; caregivers at risk of burn out; and clients who may be subject to abuse, neglect or self-neglect. Under the Long-Term Care Act, 1994 (LTCA), case managers are responsible for the following functions: Function Reference in this Manual assessment #6.2.1 eligibility determination #6.2.2 service planning (plan of service development and resource allocation) #6.2.3 service co-ordination #6.2.4 reassessment #6.2.5 monitoring and revision of plan of service #6.2.6 service termination (discharge) #6.2.7 (See case managers functions with respect to long-term care (LTC) home admissions in chapter #11 in this manual.) Assessment The assessment process is set out in the LTCA: Plan of service s. 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges, the agency shall, (a) assess the person s requirements; Other assessments to be considered s. 22(5) In assessing a person s requirements under clause (1)(a) and in reviewing a person s requirements under clause (2) (a), an approved agency shall take into account all assessments and information that are provided to it relating to the person s capacity, the person s impairment or the person s requirements for health care or community services. January

6 Compliance with regulations s. 22(7) An approved agency shall apply the prescribed criteria, follow the prescribed procedures and comply with the prescribed rules and standards in assessing a person s requirements, determining a person s eligibility and developing, evaluating and revising a plan of service. There are currently no regulations relating to the assessment of a person s requirements. Assessment is a dynamic and collaborative process that actively involves the client and others. The CCAC case manager must collect and analyze relevant information in order to understand and identify an individual s requirements for care. This process serves as the foundation for consistent service planning across the CCAC. The CCAC case manager must ensure that the client s values, functional and cognitive capacity, strengths, impairments, abilities, preferences, non-financial resources, supports, and needs are identified and documented consistently and accurately in a timely manner and that client needs are well understood. Service providers and external community resources provide valuable information that contribute to the CCAC case management function. Client assessment is the foundation for many other functions. Assessment must be completed before the CCAC can determine eligibility for CCAC services or referral to other services. It is also important for goal setting, service planning, service authorization and client outcome evaluation. In addition to standardized client assessment data, the CCAC requires significant additional client information. These items are collected by other methods and may include other types of information or assessments such as physician orders, the Health Report form for LTC homes, consent and capacity evaluations, and identification of a SDM. (For information on health assessment, see chapter #11 in this manual. For information on consent and capacity evaluation and SDM, see chapter #4 in this manual.) The CCAC may have agreements to provide assessment on behalf of community service agencies such as adult day services (see subsection #3.9 in this manual), or programs funded by the Ministry of Children and Youth Services (MCYS). The RAI-HC Assessment Instrument The Resident Assessment Instrument-Home Care (RAI-HC) has been adopted as the comprehensive standardized instrument for evaluating the needs, strengths and preferences of adult long-stay individuals in the community, including individuals requesting admission to LTC homes. The RAI-HC has been implemented in all CCACs. The longer-term objective is to implement a standardized assessment process, which will include all CCAC client populations. Standard assessment instruments for intake and shortstay, palliative and other specialized client groups are under development. January

7 Policies and guidelines have been drafted to assist the CCAC in the introduction of the RAI- HC. The policies and guidelines described below will be reviewed, and if necessary, modified based on past experience. Policies for Assessment of the Adult Long-Stay Client in the Community All RAI-HC 1 assessments must be administered by CCAC case managers who are regulated health or social work professionals and have been trained (two-day education program) to administer the tool. This includes, but is not limited to, a registered nurse, physiotherapist, occupational therapist, speech-language pathologist, social worker, dietitian and psychologist. These professionals are required to be members in good standing of their regulatory body. The CCAC case manager must: Use the RAI-HC assessment tool and related assessment process to assess and reassess all CCAC adult long-stay clients for both CCAC services and LTC home placement. An adult long-stay client is defined as an adult who requires more than 60 uninterrupted days of service through a CCAC, or a client who requires admission to a LTC home, including crisis situations. Conduct all RAI-HC assessments in face-to-face interviews with the client. Complete all sections of the RAI-HC assessment tool. Complete the RAI-HC assessment within 14 calendar days following the date that the client is identified as long-stay, according to the priority for assessment parameters. This refers to the time frame that is allowed for the initiation of the face-to-face assessment. Complete the RAI-HC at the time of the initial visit. In exceptional circumstances only, when the RAI-HC assessment cannot be completed on a single visit, the CCAC case manager must complete the assessment within three days of the initial visit. If on the second visit the case manager determines that the client s condition has changed significantly, the CCAC case manager must complete a new RAI-HC. Maintain proficiency in administering the RAI-HC by completing an average of eight to 10 assessments/reassessments per month. If this level of activity is not maintained, the CCAC must develop and implement protocols to ensure that assessors who have not been using the tool for a significant period of time are proficient. Policies for Assessment of the Adult Long-Stay Client in the Hospital The CCAC case manager must conduct the RAI-HC assessment at home according to the priority for assessment parameters or within 14 days following hospital discharge according to the professional judgement of the case manager. 1 See RAI-HC guidelines provided to CCACs by the MOHLTC Priority Project. January

8 Note: A long-stay client may be discharged home from hospital with a short-term plan of service following initial triage in the hospital setting. The CCAC case manager must conduct the Minimum Data Set for Home Care (MDS-HC) (hospital version) in the hospital setting for a client who is ineligible for home care services and unable to return to the community and is therefore applying for admission to a LTC home Eligibility Determination Eligibility determination requirements are set out in the LTCA: Plan of service s. 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges, the agency shall, (a) assess the person s requirements; (b) determine the person s eligibility for the services that the person requires; and (c) for each person who is determined to be eligible, develop a plan of service that sets out the amount of each service to be provided to the person. Compliance with regulations s. 22(7) An approved agency shall apply the prescribed criteria, follow the prescribed procedures and comply with the prescribed rules and standards in assessing a person s requirements, determining a person s eligibility and developing, evaluating and revising a plan of service. There are regulations under the LTCA relating to eligibility for homemaking, personal support and school services and regulations under the Health Insurance Act (HIA) relating to eligibility for professional services (see chapter #3 in this manual). The CCAC case manager must determine and document a client s eligibility for CCAC services and/or for admission to a LTC home based on the regulated eligibility criteria (see chapter #3 in this manual). The CCAC has no authority to provide services to clients who do not meet these eligibility criteria. The CCAC case manager must ensure that services are provided to eligible persons in keeping with their assessed needs and the resources available, and in accordance with the Bill of Rights (see subsection #2.2.1 in this manual). The case manager must also consider the respite care needs of the client s caregiver. The CCAC case manager must also refer persons to the appropriate health, social service or community resources that can address their needs. These persons would include, for example, persons determined ineligible for CCAC services, persons whose CCAC services have terminated and persons who do not consent to CCAC services. The case manager s judgement will determine the duration of the provision of case management service to the individual (e.g., January

9 families requiring ongoing assistance with end of life care to a loved one who does not have Ontario Health Insurance Plan (OHIP) coverage, may receive case management services) Service Planning The requirements relating to the development of a plan of service are set out in the LTCA: Plan of service s. 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges, the agency shall, (a) assess the person s requirements; (b) determine the person s eligibility for the services that the person requires; and (c) for each person who is determined to be eligible, develop a plan of service that sets out the amount of each service to be provided to the person. Participation in plan of service s. 22(4) An approved agency shall provide an opportunity to participate fully in the development, evaluation and revision of a plan of service to, (a) the person who is the subject of the plan of service; (b) if the person who is the subject of the plan of service is mentally incapable, the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service; and (c) the person, if any, designated by the persons referred to in clauses (a) and (b). Person s preferences to be considered s. 22(6) In developing, evaluating and revising a person s plan of service, an approved agency shall take into account the person s preferences, including preferences based on ethnic, spiritual, linguistic, familial and cultural factors. Compliance with regulations s. 22(7) An approved agency shall apply the prescribed criteria, follow the prescribed procedures and comply with the prescribed rules and standards in assessing a person s requirements, determining a person s eligibility and developing, evaluating and revising a plan of service. There are currently no regulations relating to the development, evaluation and revising of a plan of service. Service planning involves the following processes: determine and authorize the services to be provided to eligible clients based on assessed requirements; determine the frequency and duration of the services; set out in the plan of service, the services to be provided to the client; determine whether the services are immediately available; January

10 discuss the proposed plan of service with the client, including the need, if any, to be placed on any waiting list; if any of the CCAC services are not immediately available, place the client on a waiting list for these services based on priority of need 2 as determined according to local policy; provide or ensure the provision of services in the plan of service that are available; monitor the waiting list and provide or ensure the provision of services in the plan of service once they become available; and co-ordinate these services. The CCAC case manager must develop and authorize a plan of service for each person who is determined eligible for CCAC services. The plan of service must set out the amount of each service to be provided to the person by the CCAC. Some elements of the plan of service may be short-term and others long-term. The plan of service should also refer to the community services to which the client has been referred by the CCAC as well as other supports and services, including family support or self-paid or privately insured services. The CCAC case manager must work closely with clients and others on the care team and take into account the person s preferences, including preferences based on ethnic, spiritual, linguistic, familial and cultural factors when developing the plan of service. Provision of Services The LTCA states: Provision of services s. 23(1) An approved agency shall ensure that the services outlined in a person s plan of service are provided to the person within a time that is reasonable in the circumstances. Waiting list s. 23(2) If a community service outlined in a person s plan of service is not immediately available, the approved agency shall place the person on the waiting list for that service and shall advise the person when the service becomes available. Under section 23(1) of the LTCA, the CCAC must provide the services set out in the client s plan of services within a time that is reasonable in the circumstances. These circumstances could include, for example, the financial circumstances of the CCAC as well as availability of contracted service providers. If services set out in the client s plan of service are not immediately available, the CCAC must place the person on a waiting list. With respect to the financial circumstances of the CCAC, the CCAC must optimize the use of CCAC services by using a resource allocation methodology. Case managers who carry a caseload must have a service envelope. This envelope must be made up of service units based on the allocation by the CCAC of approved service units (i.e., for personal support and homemaking and shift nursing, one unit is one hour; for nursing and therapy services, one unit 2 Priority of need must be re-established and kept current. January

11 is one visit). Case managers who have a service envelope must be accountable for their service envelope and receive timely, regular reports about the availability of CCAC resources. In addition to each case manager s envelope, the CCAC must also develop a type of team envelope for exceptional circumstances Service Co-ordination The CCAC s responsibility to co-ordinate services is set out in the LTCA: Co-ordination of services s. 23(3) If a person is receiving more than one community service provided or arranged by an approved agency, the agency shall assist the person in co-ordinating the services he or she receives, in accordance with the person s wishes. Case managers must provide support to the client and the caregiver by: coordinating services provided by the CCAC; and working collaboratively with the client, staff of other approved agencies (e.g., attendant outreach services, community support services, assisted living services in supportive housing), the family physician and contracted service providers to: develop integrated plans of service for persons whose needs transcend the service mandates of any one approved agency or service provider; and develop area-wide service delivery strategies for persons who are vulnerable, at risk of abuse or being abused, or living at risk in the community, or persons who are at risk of not being served by the existing system (e.g., outreach services specifically designed for persons with mental illnesses or cognitive impairments, the socially isolated and those who may experience cultural and language barriers to service). Service co-ordination involves co-ordinating all elements of client care, including CCAC services with other services and resources supporting the client. Effective co-ordination includes regular and ongoing communication with clients, family members, physicians, caregivers, and contracted service providers, and discussions with community services and community health care partners relating to provision of service. It may also involve planning for future health care needs and establishing linkages to other services to help ensure continuity of care for the client. The case manager must: co-ordinate all CCAC services identified in the plan of service; ensure that individual clients receive services within available resources; and co-ordinate services from a number of contracted service providers and community agencies in order to meet the individual client s needs and respect the client s preferences for service delivery. January

12 6.2.5 Reassessment The CCAC s responsibility to reassess clients requirements is set out in the LTCA: Revision of plan of service s. 22(2) If a person is receiving a community service provided or arranged by an approved agency, the agency shall, (a) review the person s requirements when appropriate, depending on the person s condition and circumstances; and (b) evaluate the person s plan of service and revise it as necessary when the person s requirements change. Participation in plan of service s. 22(4) An approved agency shall provide an opportunity to participate fully in the development, evaluation and revision of a plan of service to, (a) the person who is the subject of the plan of service; (b) if the person who is the subject of the plan of service is mentally incapable, the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service; and (c) the person, if any, designated by the persons referred to in clauses (a) and (b). Other assessments to be considered s. 22(5) In assessing a person s requirements under clause (1) (a) and in reviewing a person s requirements under clause (2) (a), an approved agency shall take into account all assessments and information that are provided to it relating to the person s capacity, the person s impairment or the person s requirements for health care or community services. Person s preferences to be considered s. 22(6) In developing, evaluating and revising a person s plan of service, an approved agency shall take into account the person s preferences, including preferences based on ethnic, spiritual, linguistic, familial and cultural factors. Compliance with regulations s. 22(7) An approved agency shall apply the prescribed criteria, follow the prescribed procedures and comply with the prescribed rules and standards in assessing a person s requirements, determining a person s eligibility and developing, evaluating and revising a plan of service. There are currently no regulations relating to the reassessment of clients requirements. The CCAC must reassess client needs to: determine the client s continuing eligibility and need for CCAC services; monitor types and levels of services required, and appropriateness of supplies and equipment used; adjust service levels if client requirements change; January

13 adjust goals; and as necessary, arrange for new services or the termination of service. The CCAC must reassess adult long-stay clients using the RAI-HC as follows: at a minimum of every six months; or when there is a significant change in a client s clinical condition, functional level or living circumstances. This may include the following: new diagnosis, progression of the disease process, functional decline or improvement, return from a stay in hospital, change in caregiver status and/or change in the plan of service. The CCAC must reassess pediatric long-stay clients, palliative clients and rehabilitation clients as follows: at a minimum of every six months; and when there is a significant change in a client s clinical condition, functional level or living circumstances. This may include the following: new diagnosis, progression of the disease process, functional decline or improvement, return from a stay in hospital, change in caregiver status and/or change in the plan of service. The CCAC must reassess short-stay clients when there is a significant change in a client s clinical condition, functional level or living circumstances. This may include the following: new diagnosis, progression of the disease process, functional decline or improvement, return from a stay in hospital, change in caregiver status and/or change in the plan of service Monitoring and Revision of Plan of Service The CCAC s responsibility to revise the plan of service is set out in the LTCA: Revision of plan of service s. 22(2) If a person is receiving a community service provided or arranged by an approved agency, the agency shall, (a) review the person s requirements when appropriate, depending on the person s condition and circumstances; and (c) evaluate the person s plan of service and revise it as necessary when the person s requirements change. Participation in plan of service s. 22(4) An approved agency shall provide an opportunity to participate fully in the development, evaluation and revision of a plan of service to, (a) the person who is the subject of the plan of service; (b) if the person who is the subject of the plan of service is mentally incapable, the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service; and (c) the person, if any, designated by the persons referred to in clauses (a) and (b). January

14 Person s preferences to be considered s. 22(6) In developing, evaluating and revising a person s plan of service, an approved agency shall take into account the person s preferences, including preferences based on ethnic, spiritual, linguistic, familial and cultural factors. Compliance with regulations s. 22(7) An approved agency shall apply the prescribed criteria, follow the prescribed procedures and comply with the prescribed rules and standards in assessing a person s requirements, determining a person s eligibility and developing, evaluating and revising a plan of service. There are currently no regulations relating to the evaluation and revision of a plan of service. However, the plan of service can only be changed if the client s requirement s change. Service monitoring, like service planning, is a dynamic process. Depending on the person s condition or circumstances, the client and/or caregiver, the case manager, and contracted service providers and physicians as appropriate must: interactively and regularly review the client s requirements; evaluate the plan of service in consideration of the changing needs of the client; and measure client outcomes against previously agreed upon goals and commitments. The case manager must monitor and revise the plan of service as necessary when the client s requirements change. The CCAC does not have the authority to revise a client s plan of service unless the client s requirements change. To monitor service allocation for each client, the case manager must solicit and review information including the following: contracted service provider reports; client and/or caregiver and physician input; client and/or caregiver, contracted service provider and case manager conferences, and telephone calls; and case manager reassessment of client needs Service Termination The CCAC case manager must begin service termination planning when the client is admitted and continue the process throughout the time services are being provided. Service termination planning may focus on terminating all services or on terminating a single service among the range of services the client is receiving. January

15 The case manager must: work with the client to plan for service termination when planning goals, developing a plan of service to meet these goals, and monitoring the client s progress towards the goals; collaborate with the client, caregivers and contracted service providers throughout the client s service to identify and link the client with ongoing supports that may be required by the client when the CCAC services are no longer required or appropriate to meet the client s service needs; and determine when to discharge a client. The CCAC must terminate services when the client no longer requires services, the client is no longer eligible for services, the client withdraws his or her consent, or the client is no longer available to receive services. For example: The client has reached the service and treatment care goals and no longer requires service. The client and/or caregiver have been trained to provide the necessary care and can carry out the care without further supervision and support. Other available resources outside the home setting may meet the client s care requirements. The client s needs cannot be met in the home setting. January

16 6.3 Case Management Staff Qualifications Position Requirements for the Case Manager CCAC clients often have health conditions that require multi-dimensional assessments to be provided by a health or social work professional whose scope of practice includes comprehensive assessments. A case manager must be qualified to undertake the core functions of: assessment; eligibility determination; service planning (plan of service development and resource allocation); service co-ordination; reassessment; monitoring and revision of plan of service; and service termination (discharge). The minimum qualification for persons that undertake these core functions in a CCAC is that the person be a registered health or social work professional. This includes, but is not limited to, a registered nurse, physiotherapist, occupational therapist, speech-language pathologist, social worker, dietitian and psychologist. These professionals are required to be members in good standing of their regulatory body. Case managers should be trained as capacity evaluators to assess a person s capacity to consent to admission to a long-term care (LTC) home. Not all health and social work professionals may act as evaluators of capacity to consent to admission to a LTC home. For example, dietitians are not evaluators of capacity for this purpose. January

17 6.4 Supports to the Case Management Function The Community Care Access Centre (CCAC) must ensure that an efficient and cost effective staffing model is in place to support the case management functions. Staff who do not have professional qualifications to carry out core case management functions may support the case management process by performing administrative tasks; however, these staff will still require decision-making skills and a sound understanding of the case manager role. Examples of activities that may be undertaken by other staff include, but are not limited to: directing calls received to the appropriate case manager or contracted service provider; obtaining basic information on intake to assist case managers to determine eligibility and facilitate access to program and community resources; ordering prescribed services, equipment and supplies approved by the case manager; scheduling services; cancelling drug benefit authorizations; notifying contracted service providers of changes to plans of service; handling communications of a non-urgent, non-case management nature; documenting receipt of reports; flagging reports requiring review by the case manager; assisting to maintain the client s record; undertaking follow-up calls to identified persons at the request of the case manager; and researching community options on request. The above are examples of tasks that the CCAC may reasonably delegate to other staff and should not be considered responsibilities that must be undertaken by staff with professional qualifications. The delegation of these tasks will enable case managers to concentrate on activities that require their professional expertise. January

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