Management of Long-Term Care Home Waiting Lists by CCACs

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1 Management of Long-Term Care Home Waiting Lists by CCACs 12.1 Overview of Prioritization of Long-Term Care Home Waiting Lists This subsection describes the requirements for prioritizing admissions to long-term care (LTC) homes and maintaining LTC home waiting lists. All legislative references in this chapter, unless stated otherwise, are to the Nursing Homes Act (NHA) and Ontario Regulation 832 under the NHA and will be noted as such. However, similar provisions are contained in the Charitable Institutions Act (CIA) and Homes for the Aged and Rest Homes Act (HARHA) and their regulations Management of Waiting Lists Section 139 of the NHA regulation sets out the requirements for the management of LTC home waiting lists by the Community Care Access Centre (CCAC) as follows: s. 139(1) Each placement co-ordinator shall keep a waiting list for each of the nursing homes for which the placement co-ordinator is designated under subsection 20.1 (3) of the Act. (2) The placement co-ordinator shall place on the waiting list, rank for admission and remove from the list, in accordance with sections 140 to 150, any person described in section 140 other than a person who is to be placed on the waiting list for interim beds under section 153. (3) Each placement co-ordinator shall also keep a refusal list for the purposes of section 141. Pursuant to section 139 the CCAC must: keep an updated waiting list for each LTC home within its geographic area; place a person on the waiting list, rank the person for admission and remove the person from the waiting list in accordance with the regulation; and keep a refusal list. September

2 Placement on Waiting Lists for Admission to a LTC Home Section 140 of the NHA regulation sets out the requirements related to the placement of persons on waiting lists for admission to LTC homes as follows: s. 140(1) The placement co-ordinator designated for a nursing home under subsection 20.1 (3) of the Act shall place a person on the waiting list for the nursing home if, and only if, (a) the person is determined by a placement co-ordinator to be eligible for admission to a nursing home; (b) the person applies in accordance with this Regulation for authorization of his or her admission to the home; (c) the licensee of the home approves the person's admission to the home; and (d) placing the person on the waiting list for the home will not result in the total number of waiting lists for nursing homes, approved charitable homes for the aged under the Charitable Institutions Act and homes under the Homes for the Aged and Rest Homes Act on which the person is placed exceeding three. (2) Clause (1) (d) does not apply to a person who will be placed in category 1A or the shortstay category on the waiting list. Note: As a result of subsection 2 above, the three LTC home waitlist limit does not apply to persons who will be placed in category 1A crisis or the short-stay category on the waiting list. There are no restrictions on the maximum number of waiting lists on which these two groups may be placed. Pursuant to section 140 of the NHA, the CCAC must: add the name of each eligible person to the waiting list of each LTC home to which the person has applied after the LTC home operator has approved the person s admission to the LTC home; and ensure that each eligible person is not placed on more than three LTC home waiting lists at any one time unless the applicant is in category 1A or applying for short-stay Application of Prioritization Criteria The prioritization criteria set out in sections 143 to of the NHA regulation apply to persons who are seeking admission to a LTC home as long-stay residents. Separate prioritization criteria apply to persons seeking admission to short-stay respite or supportive care programs. (See subsection #11.9 in this manual.) The various categories of prioritization for long-stay applicants are: category 1A; category 1A1; category 1B; category 2; category 3; September

3 groups outside of numbered categories; veterans; exchange residents; and LTC home residents who face relocation as a result of redevelopment to: related temporary home; reopened home; or replacement home Classes of Accommodation The ability of the CCAC to make an offer of admission to persons in the above referenced categories is dependant on the class of accommodation that becomes available in the LTC home. Placement co-ordinators must take into account: gender; and type of accommodation (basic, preferred semi-private, preferred private) Overview of Prioritization Categories 1A-3 Note: The CCAC must place a person on the highest possible category of the waiting list. For example, a person who meets the criteria for category 1B but is in crisis must be placed in category 1A of the waiting list. Rank Prioritization Criteria Effective as of October 22, A Crisis Applicants I. Person requires immediate admission as a result of a crisis arising from the person s condition or circumstances. II. Person occupies a bed in a hospital, psychiatric facility or Schedule 1 facility, and within six weeks, there will be no bed for the person as a result of a temporary or permanent closure of some or all of the beds due to an emergency or redevelopment. III. Person occupies a bed in a long-term care home, and within six weeks, there will be no bed for the person as a result of a temporary or permanent closure of all or some of the beds in the home. 1 1A1 Spousal Reunification Reunification of spouses/partners who are determined eligible as a result of their care needs and wish to reside together in the same long-term care home. (This category applies in all of 1 This will only apply in situations where not all residents have been moved out of a long-term care home under category 2. At six weeks prior to closure of the long-term care home, residents may be considered in crisis if they have not been placed in a long-term care home. September

4 Rank Prioritization Criteria Effective as of October 22, 2004 the following situations: where both are still in the community, one is already in a long-term care home or both are in a long-term care home but want to move together to another longterm care home). 1B Ethno-cultural/religious groups Person is of the religion, ethnic origin or linguistic origin primarily served by the long-term care home. 2 I. Person occupies a bed in a public/private hospital, psychiatric hospital or Schedule 1 facility. II. Person is a resident of a long-term care home and will become homeless within 16 weeks as a result of a temporary or permanent closure of all or some of the beds in the long-term care home. III. IV. Person is a resident of a long-term care home and was or will be discharged from the home: - because of the inability of the home to provide a secure environment for the applicant; or - because of an absence for the purpose of receiving medical or psychiatric care or undergoing medical or psychiatric assessment. Person resides in the community and admission to a long-term care home is required within the next three months, because: - should there be any change in the person s condition or circumstances, the person would require immediate admission as a result of a crisis arising from the person s condition or circumstances; or - attending to the person s care needs is jeopardizing the health and well-being of the person s caregiver. V. Reunification of spouses/partners who wish to reside together in the same long-term care home. (This only applies to a spouse/partner determined eligible for the sole purpose of accompanying an eligible spouse/partner into the same home for the purposes of reunification. I.e. Person does not have care needs of their own.) VI. Person resides in a long-term care home and is waiting to move to their preferred longterm care home. 3 Persons who do not meet the requirements for placement in any other category. This includes but is not confined to: People residing in the community and waiting for a long-term care home but admission is not required within the next three months because: - the person s condition is not expected to deteriorate or put the person at risk of physical or emotional harm to self or others; or September

5 Rank Prioritization Criteria Effective as of October 22, the person s caregiver is able to continue to provide the same level of care without risk or harm to the person requiring care or to self. People already residing in a long-term care home who are not waiting for their preferred long-term care facility, but decide they want to move to another long-term care home Change of Category A person s condition can change very quickly. The CCAC must place a person in a different category on the waiting list when the CCAC is aware that there has been a change in the person s condition or circumstances, or a change in the LTC home for which the person is on the waiting list. This requirement is set out in subsection 154(1) of the NHA regulation as follows: s. 154(1) If a placement co-ordinator knows of a change in the condition or circumstances of a person who is on a waiting list kept by the placement co-ordinator or knows of a change in a nursing home for which the person is on the waiting list, and if the person should be placed in a different category on the waiting list under sections 142 to as a result of the change in his or her condition or circumstances or as a result of the change in the home, the placement co-ordinator shall place the person in the different category. For example, a person residing in his or her home in the community who is ranked in category 3 may undergo a significant change in his or her condition such that he or she can not continue to live in the community. This person would then require immediate admission to a LTC home if he or she could not be served in the community. In such a case, the CCAC must consider whether to rank this person in category 1A (crisis) Notification The CCAC must inform the person of his or her position on the waiting list and provide an estimate of waiting time to the best of his or her knowledge Mandatory Reporting of LTC Home Vacancies Subsection 155(5) of the NHA regulation requires LTC home operators to report LTC home vacancies: s. 155(5) A licensee of a nursing home shall inform the placement co-ordinator designated for the home under subsection 20.1 (3) of the Act of available accommodation in the home within 24 hours after the accommodation becomes available. Within 24 hours after a discharge occurs (which includes death, as the regulation now requires a discharge upon death), the LTC home operator is required to inform the CCAC designated for the LTC home that there is accommodation available in the home. September

6 This provision is intended to ensure that a CCAC has current information to facilitate more efficient and timely handling of all placements and improved waitlist management. It does not necessarily mean that a CCAC must immediately admit a new person. The reporting provision relates to the reporting of bed vacancies, not to the timeframe within which a bed must be filled. There may be legitimate reasons why a vacant bed could be considered unavailable for a couple of days following a vacancy (e.g., internal transfers, need to clean and paint, time to allow family to remove the resident s belongings), but the LTC home must still inform the CCAC of the bed vacancy. The CCAC and the LTC home operator must work together to determine when a vacant bed is ready for admission and the CCAC must keep track of the date on which a LTC home advises them of a bed vacancy. Note: The CCAC is not responsible for enforcing this regulatory requirement placed on LTC home operators. This is the role of the Ministry of Health and Long-Term Care (MOHLTC). If a CCAC becomes aware of any LTC home operator that is not complying with this notification requirement, the CCAC must advise the MOHLTC s compliance advisor responsible for the LTC home in question. September

7 12.2 Crisis Admissions Category 1A Section 143 of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 1A of the waiting list for a long-term care (LTC) home: s. 14 (1) A person shall be placed in category 1A on the waiting list for a nursing home if the person requires immediate admission as a result of a crisis arising from the person s condition or circumstances. (2) A person shall be placed in category 1A on the waiting list for a nursing home if, (a) the person occupies a bed in, (i) a hospital under the Public Hospitals Act or a private hospital licensed under the Private Hospitals Act, (ii) a facility that is designated as a psychiatric facility under section 80.2 of the Mental Health Act and is not exempt under that section from the requirement to provide in patient services in paragraph 1 of subsection 4 (1) of Regulation 741 of the Revised Regulations of Ontario, 1990 made under that Act, or (iii) a facility listed in Schedule 1 to Regulation 272 of the Revised Regulations of Ontario, 1990 made under the Developmental Services Act; and (b) there will be no bed for the person in the hospital or facility within six weeks as a result of, (i) a permanent closure of all or some of the beds in the hospital or facility, or (ii) a temporary closure of all or some of the beds in the hospital or facility due to an emergency or redevelopment. (3) A person shall be placed in category 1A on the waiting list for a nursing home if, (a) the person is a long-stay resident of another nursing home, an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act; and (b) there will be no bed for the person in the facility within six weeks as a result of a permanent or temporary closure of all or some of the beds in the facility. Note: The Schedule 1 facilities under the Developmental Services Act (DSA) include: Huronia Regional Centre (Orillia), Rideau Regional Centre (Smith Falls) and Southwestern Regional Centre (Blenheim) Types of Crisis Situations The above referenced provision sets out three types of crisis situations: community-based; hospital and/or LTC home based; and clients requiring relocation due to hospital or LTC home closure within six weeks. As no one situation is more critical than any other, these three types of crisis situations are not ranked in the order in which they are listed above. Ranking among crisis applicants is according to the urgency of each applicant s need for admission. September

8 Community-Based Crisis In the case of community-based clients, a category 1A (crisis) admission to a LTC home occurs when a person, as a result of some accident or event, requires services that cannot be provided in the community and necessitates the person s immediate admission to a LTC home. Persons requiring crisis admission take precedence over other individuals on the waiting list for LTC home admission and must meet the eligibility criteria for admission to a LTC home. To be considered in a crisis situation, the Community Care Access Centre (CCAC) must consider the person s condition or circumstances to be of such severity that it requires the CCAC to make every effort to arrange for his or her admission to a LTC home within the next seven days, or as soon as possible, depending on the availability of an appropriate vacancy. Regardless of the type of crisis situation, only the CCAC is entitled to determine eligibility for and authorize admission to a LTC home. When a person s situation is designated as a crisis, the CCAC must move the person to the top of the waiting list for immediate admission to his or her selected LTC home(s). If the person s selected homes cannot accommodate an immediate admission, the CCAC must advise the person and discuss with the person whether he or she will consent to being admitted into the homes that have vacancies. (A similar issue may arise where a person selects a particular type of accommodation in a LTC home which is not available. The CCAC must advise the person and discuss with the person whether he or she will agree to change the type of accommodation requested in order to facilitate his or her admission into a selected LTC home.) When a person is in the crisis category, the person is expected to accept the first available bed in a home of their choice. 2 However, the person cannot be required to do so. If a person refuses the first available vacancy in a LTC home of his or her choice, the CCAC should, as a matter of policy, consider whether the person still meets the criteria for the crisis category. The CCAC must not place a person in the crisis category to accommodate the person s desire to ensure speedy access to a LTC home of choice. In addition, the CCAC must not categorize a person s situation as a crisis as a strategy to move persons who, for whatever reasons, are resisting movement out of the hospital. Note: The classification of a person in prioritization category 1A does not suspend the consent requirement in LTC home legislation. Even in this situation, the CCAC shall not authorize a person for admission to a selected LTC home unless the person (or if the person is incapable, the person s substitute decision-maker) has applied for admission to the specific home and consented to the admission to the specific home. The only exception occurs where the person is in such a crisis situation, that the person requires an immediate admission to a selected home and it is not reasonably possible to obtain the immediate consent of the person s substitute decision-maker (SDM). In this case, the CCAC may authorize the admission without consent but must take reasonable steps to locate the person s SDM in order to seek his or her consent or refusal of consent to the admission. (See chapter #4 in this manual for information on consent to admission to a LTC home.) 2 Once in a LTC home, the person can remain on the waiting list in category 2 for his or her preferred choice of LTC home. September

9 Crisis admissions of community-based applicants usually arise from the following circumstances: an unexpected change in the person s condition or circumstances that makes existing care arrangements no longer appropriate; or a person being at risk of physical, emotional or financial abuse or harm if he or she remains in the same environment; or others in the environment being at risk of physical, emotional or financial abuse or harm; or caregiver breakdown. The CCAC determines the presence of a crisis situation based on assessments that indicate the person s and/or caregiver s ability to function safely in his or her current environment has been compromised. The CCAC also needs to consider whether the person s health and safety needs can be met immediately by the provision of community-based services, including the capacity of the CCAC to exceed the service maximums for personal support and homemaking services for up to 30 days in exceptional circumstances under subsection 3(3) of Regulation 386/99 of the Long-Term Care Act, 1994 (LTCA). It must be noted that community services cannot be provided without the consent of the person or SDM if the person is incapable of making the decision Hospital or Facility-Based Crisis The majority of applicants deemed to be in a crisis situation by the CCAC will probably reside in the community. However, there may be instances where people could be deemed to be in a crisis situation while residing in a LTC home or hospital. These could be as a result of: condition or circumstances unique to the individual; or systemic pressures. Hospital/LTC Home-Based Crisis: Individual Condition or Circumstances Individual condition or circumstances that could result in a person being declared in a crisis situation while staying in a hospital or LTC home setting include but are not limited to the following: The person has been physically assaulted or injured by another patient or resident. Despite corrective measures taken to ensure that this does not occur again, the person does not feel reassured and remains in a constant state of agitation. The person has been physically abused by a hospital/home employee. Despite corrective action, the person no longer feels safe in the current environment. The person is at risk of jeopardizing the care of other patients because the hospital environment is not able to provide the necessary security to ensure the safety of the person or of others. Of course, the person s care requirements must be able to be met in a LTC home and there may be some persons in this circumstance who require admission to a psychiatric facility. September

10 The CCAC must review the individual circumstances of the case to determine if the person is in crisis arising from the person s condition or circumstances. Presentation at an Emergency Ward The fact that a person on the waiting list for a LTC home appears at a hospital emergency ward does not automatically result in the person being prioritized in category 1A. If the person s condition has changed, the CCAC must of course reassess the person. On the basis of the reassessment, the CCAC may decide to: facilitate community-based services for the person; initiate or increase CCAC in-home services; or change the person s priority category on the LTC waiting list. The CCAC must not reprioritize the person if the conditions or circumstances necessitating admission to an LTC home have not changed. Social Admissions for Emergency Clients A hospital may be the only place that can provide the necessary emergency care/shelter (social admission) to a person experiencing a crisis situation who cannot be safely cared for with community services and where no LTC home vacancy is immediately available. In this situation, the person could be admitted to hospital and continue to be ranked under priority category 1A-crisis for admission to a LTC home. In this situation, the CCAC must conduct a comprehensive assessment of the person s condition and circumstances. After the person s condition has been stabilized, the person may not require admission to an LTC home, particularly if the person s condition is of short-term duration. Note: The CCAC must use this provision judiciously so that applicants do not inappropriately present themselves at emergency wards in order to be placed in the crisis category of the waiting list. Hospital-Based Crisis: Systemic Pressures Hospitals often have patients who respond well to treatment and no longer require acute hospital care. However, the patient is not able to return home. These patients may require care in a complex continuing care hospital, rehabilitation hospital or LTC home. These patients are designated as alternative level of care (ALC). Hospitals have different capabilities to accommodate patients designated as ALCs. When capacity to admit persons to a hospital is severely compromised, one strategy for resolution is to classify that hospital s patients who require care in a LTC home as being in a crisis situation and requiring immediate admission into a LTC home. September

11 There may be circumstances when there is a systemic crisis and it is appropriate to expedite the admission of ALC patients to LTC homes. The CCAC has the authority to change the waiting list category of ALC patients to category 1A. Indicators that there is a systemic crisis that may be resolved by expediting the admission of ALC patients to LTC homes include: normally scheduled elective acute care admissions are cancelled or deferred due to bed occupancy pressures; non-elective acute care patients cannot be admitted to the hospital and are being transferred to other acute care hospitals due to bed occupancy pressures; patients appropriate for admission to one care unit and/or critical care unit cannot be admitted due to bed occupancy pressures in the units; and number of overnight emergency department patients (i.e., admit to no beds ) impedes operations in the emergency department. Since this is a community systems issue, it must be addressed by all service partners in the community. Situations that are not to be considered a systemic crisis include but are not limited to the following: temporary periods of congestion that only last a few days; hospitals closing down beds temporarily in the summer time; and hospitals that retain ALC clients in hospital as long as possible to keep a bed filled until these beds are required and then request the CCAC to place applicants in LTC homes in a compressed time period. Processes involved in designating a systemic crisis include: 1. Discussions between the Ministry of Health and Long-Term Care (MOHLTC) Regional Director, CCAC and hospital regarding the situation and the hospital s ALC patients discharge plans, and where appropriate, discussions between other MOHLTC regional offices. 2. Investigation by MOHLTC staff of the situation to ensure that the hospital s ability to meet the acute care needs of the community is severely compromised as a result of: severe bed blocking in acute care beds; and external forces specific to that community exacerbating the situation. 3. MOHLTC staff ensuring that the hospital s discharge and assessment practices are reviewed and these practices deemed acceptable. September

12 4. Assessment of ALC patients by the CCAC to determine if they are eligible for LTC home placement or if their needs could or should be met through other resources, including rehabilitation or chronic care facilities or community-based services. Notes: CCACs must ensure that the person s needs cannot be met by community-based resources as part of the eligibility determination process for admission to LTC homes. A hospital may recommend that a person be placed in a LTC home; however, the CCAC determines whether the person is eligible for admission. 5. CCACs, in collaboration with the MOHLTC, developing a strategy that will not compromise the safety of community-based residents who are also in crisis and waiting for LTC home admission. Persons placed in the crisis category must be ranked in terms of urgency of their need for admission; consequently an approach that would place all hospital-based clients ahead of community-based applicants would disregard the risk to community-based persons. 6. Determining a specific time period during which this provision will be in effect. This can not be an open-ended arrangement. Notes: A specific timeframe will be established based on the CCAC s estimate of the length of time required to reduce congestion in a specific hospital (e.g., two weeks). Discussions will have to occur between the CCAC, hospital and MOHLTC in this regard. The time period that this provision will be in effect must be clearly defined (e.g., days or weeks), and a date when the situation will be reviewed should be specified. Timeframes must not be specified in an open-ended manner (e.g., during the flu season). 7. The decision to use the systemic crisis provision must be made on a hospital-by-hospital basis as the regulations require that the crisis is due to the person s circumstances (or condition). The determination of a crisis and the subsequent strategy involving admissions to LTC homes, apply to a specific community and at a specific time. Notes: The determination of a crisis situation at a particular hospital and the strategies to deal with the crisis are not automatically transferable to other hospitals in that community. Nor are they transferable to other communities. The classification of hospital inpatients in prioritization category 1A due to a systemic crisis situation does not suspend the consent provisions of LTC home legislation. Even in this situation, the CCAC cannot authorize a person for admission to a selected LTC home unless the person (or if the person is incapable of making the decision, the person s SDM) September

13 has applied to the specific home and consented to the admission to the specific home. The only exception occurs where the person is in such a crisis situation, that the person requires an immediate admission to a selected home and it is not reasonably possible to obtain the immediate consent of the person s SDM. In this case, the CCAC may authorize the admission without consent but is required to take reasonable steps to locate the person s SDM in order to seek his or her consent or refusal of consent to the admission. (See chapter #4 in this manual for additional information on consent to admission to a LTC home.) Furthermore, the regulations require that a CCAC offer an applicant the class of accommodation that the applicant requested. If the applicant has requested a certain class of accommodation, but the first bed available is in a different class, the CCAC may discuss with the applicant the possibility of amending the person s choices and taking the available bed. If the person accepts and the bed is in a LTC home that is not the person s first choice, the person is then be able to wait for a transfer to his or her preferred LTC home in prioritization category 2. If the person accepts a different class of accommodation in the person s first choice home, in that case the person could ask to be placed on the home s transfer list under section 158 of the NHA regulation. Nevertheless, the CCAC cannot compel the hospital applicant to amend his or her choices to take the alternate bed. If the hospital applicant is unwilling to take the alternate bed, the CCAC has no authority to authorize admission. See the comments above concerning consent to admission. LTC Home-Based Crisis: Emergency Situations in LTC Homes Emergency situations requiring crisis admission of residents from one LTC home into another LTC home include: an operator suddenly going out of business; or natural or environmental disasters such as a fire or a gas leak. In disaster situations, an emergency response involving the relevant service partners in the community will be necessary to ensure the safe and speedy relocation of all residents Clients Requiring Relocation Due to Home Closure within Six Weeks A LTC home may need to close temporarily or permanently and partially or totally. Closures may be the result of planned renovations or closures, or emergency situations. With planned closures, either temporary or permanent, it is anticipated that residents will be relocated in a timely manner and that the usual movement of residents and a moratorium on admissions would assist the process. Nevertheless, there may be situations where residents have not been relocated within six weeks of the planned closing. If these persons are not relocated, they will become homeless. To ensure that such persons are appropriately relocated, they are considered to be in a category 1A (crisis) situation and the CCAC must prioritize them as such. September

14 Note: 1A also applies to hospitals, psychiatric facilities and Schedule 1 DSA facilities that are permanently closing beds or are temporarily closing beds due to emergency or redevelopment. (See section 143(2)(b) of the NHA regulation.) September

15 12.3 Prioritization Criteria Category 1A1 Section of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 1A1 of the waiting list for a long-term care (LTC) home: s A person shall be placed in category 1A1 on the waiting list for a nursing home if, (a) the person does not meet the requirements for placement in category 1A; (b) the person s spouse or partner is a long-stay resident of the nursing home or neither the person nor his or her spouse or partner is a long-stay resident of the nursing home but both wish to reside in the nursing home; and (c) the person meets the eligibility criteria set out in subsection 130 (1). According to the above provision, spouses/partners who both wish to reside in the same LTC home and are both eligible as a result of their care needs are to be placed in category 1A1 of an LTC home s waiting list. A spouse/partner who does not require care, but who is determined eligible only for the purpose of accompanying (or joining) his or her eligible spouse will continue to be placed in category 2. Note: There is no change to the requirement to place persons requiring immediate admission as a result of a crisis arising from their condition or circumstances into category 1A of the waiting list. As a result of the wording of clause (b) above, the 1A1 category of prioritization applies in all of the following situations when both spouses/partners have care requirements: when a person is seeking reunification with a spouse/partner who is already in the home to which the person is applying; when the person and the person s spouse/partner are still in the community but both wish to reside in the same LTC home; when both are in different LTC homes, but wish to live together in the same home, be it one of the two where they currently reside or a completely different LTC home; and when both are in the same LTC home, but wish to move together to a different LTC home. Note: In the situation where a spouse/partner who has no care needs of his or her own wishes to accompany a spouse/partner who is eligible for placement based on care needs, the two individuals will be in different categories of prioritization. The person with the care needs will be prioritized in category 1A1, while the spouse/partner who has no care needs will be prioritized in category 2. (See subsection #12.5 in this manual for additional information on prioritization category 2.) A further important and somewhat different feature of the 1A1 category relates to the ranking of applicants within this category. Eligible spouses/partners placed in category 1A1 are ranked in this category according to the time at which their spouses/partners applied for authorization of their admission to the home. September

16 The fact that this date of authorization may predate the determination of eligibility of the spouse/partner who is seeking to be reunified is not relevant as its sole purpose is for ranking within this category. If the applicant s category were to change to another category (e.g., if the applicant became a crisis applicant), the spouse s/partner s date of authorization would no longer apply. In the case where the spouses/partners are prioritized differently because one has care needs and the other does not (i.e., category 1A1 for the spouse with care needs and category 2 for the spouse who has no care needs) their ranking will also differ. The ranking of spouses/partners who are prioritized in category 2 is according to the date of their own application. (See subsection # in this manual for additional information on rules for ranking within categories.) Community Care Access Centres (CCACs) with clients who are spouses/partners seeking admission to the same LTC home must caution applicants that prioritization in category 1A1 will not result in all eligible spouses/partners being reunited immediately or necessarily being able to share the same room once both are admitted to the same LTC home. Some spouses/partners may not even be in the same part of the home. This can result from the lack of availability of accommodation or differing care requirements. For example, one spouse with a severe cognitive impairment could potentially be in a different part of the home than a spouse who does not have a cognitive impairment. In other cases, reunification may not be as fast if the spouses/partners are waiting for specific types of accommodation to become available such as basic, semi-private or private rooms. These are circumstances that go beyond prioritization. It is also important to note that the regulation applies to spouses or partners and the term partners is defined in subsection 1(2) of the NHA regulation as: s. 1(2) Two persons are partners for the purpose of this Regulation if they have lived together for at least one year and have a close personal relationship that is of primary importance in both persons' lives. September

17 12.4 Prioritization Criteria Category 1B Section 144 of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 1B of the waiting list for a long-term care (LTC) home: s. 144 A person shall be placed in category 1B on the waiting list for a nursing home if, (a) the person does not meet the requirements for placement in category 1A or 1A1; (b) the home is primarily engaged in serving the interests of persons of a particular religion, ethnic origin or linguistic origin; and (c) the person is of the religion, ethnic origin or linguistic origin primarily served by the home. A Community Care Access Centre (CCAC) may only place persons of a particular religion, ethnic origin or linguistic origin in category 1B of a LTC home s waiting list if the LTC home is primarily engaged in serving the interests of the particular group. Primarily engaged means that the main intent of the LTC home is to serve persons of a particular religion, ethnic or linguistic origin. This means that if a LTC home dedicates only a portion of its beds to serve the needs of a particular religion, ethnic or linguistic community, it does not pass the regulatory test that it is primarily engaged in serving the needs of a particular community. As such, the CCAC may not place persons from the religion, ethnic or linguistic community in category 1B on the waiting list for this LTC home. There are no provincial guidelines or standardized processes for acknowledging, determining and designating LTC homes that provide services on a religious, ethnic or linguistic basis. The CCAC must determine whether a particular LTC home meets the regulatory test so it can place persons on the waiting list into categories. It is expected that the CCAC would have developed its own processes to determine whether a particular LTC home meets the test. Under LTC home legislation, the CCAC must consider an applicant s preferences relating to admission based on spiritual, ethnic, linguistic, familial and cultural factors. September

18 12.5 Prioritization Criteria Category 2 Section 145 of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 2 of the waiting list for a long-term care (LTC) home: s. 145(1) A person shall be placed in category 2 on the waiting list for a nursing home if, (a) the person does not meet the requirements for placement in category 1A, 1A1 or 1B; and (b) the person occupies a bed in, (i) a hospital under the Public Hospitals Act or a private hospital licensed under the Private Hospitals Act, (ii) a facility that is designated as a psychiatric facility under section 80.2 of the Mental Health Act and is not exempt under that section from the requirement to provide in-patient services in paragraph 1 of subsection 4 (1) of Regulation 741 of the Revised Regulations of Ontario, 1990 made under that Act, or (iii) a facility listed in Schedule 1 to Regulation 272 of the Revised Regulations of Ontario, 1990 made under the Developmental Services Act. (2) A person shall be placed in category 2 on the waiting list for a nursing home if, (a) the person does not meet the requirements for placement in category 1A, 1A1 or 1B; (b) the person is a long-stay resident of another nursing home, an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act; and (c) there will be no bed for the person in the facility within 16 weeks as a result of a permanent or temporary closure of all or some of the beds in the facility. (3) A person shall be placed in category 2 on the waiting list for a nursing home if, (a) the person does not meet the requirements for placement in category 1A, 1A1 or 1B; (b) the person was or is a long-stay resident of another nursing home, an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act; and (c) the person was or will be discharged from the facility, (i) because the facility cannot provide a sufficiently secure environment to ensure the safety of that person or the safety of persons who come into contact with that person, or (ii) because of an absence for the purpose of receiving medical or psychiatric care or undergoing medical or psychiatric assessment. (4) A person shall be placed in category 2 on the waiting list for a nursing home if, (a) the person does not meet the requirements for placement in category 1A, 1A1 or 1B; and (b) the person requires admission within three months because, (i) should there be any change in the person s condition or circumstances, the person would require immediate admission as a result of a crisis arising from the person s condition or circumstances, or (ii) attending to the person s care needs is jeopardizing the health and well-being of the person s caregiver. September

19 (5) A person shall be placed in category 2 on the waiting list for a nursing home if, (a) the person does not meet the requirements for placement in category 1A, 1A1 or 1B; (b) the person s spouse or partner is a long-stay resident of the nursing home or neither the person nor his or her spouse or partner is a long-stay resident of the nursing home but both wish to reside in the nursing home; and (c) the person meets the eligibility criteria set out in section 132. (6) If a person applies for authorization of his or her admission to a nursing home, a home under the Homes for the Aged and Rest Homes Act or an approved charitable home for the aged under the Charitable Institutions Act as a long-stay resident and a placement coordinator, with the consent of the person, authorizes the person s admission to a facility that is not the person s first choice, the person shall, if he or she wishes, be kept on the waiting lists for the person s preferred nursing homes and shall be placed in category 2. The following is a simplified description of the six types of applicants listed in the above provision who fall within this category: 1. A person who is in a hospital, psychiatric facility or a facility listed in Schedule 1 of the regulations under the Developmental Services Act (DSA), and cannot be discharged home because the community-based services are inadequate or inappropriate to meet his or her needs, or because he or she does not have an informal caregiver to provide them with the assistance they require at home. Note: The Schedule 1 facilities under the DSA include: Huronia Regional Centre (Orillia), Rideau Regional Centre (Smith Falls) and Southwestern Regional Centre (Blenheim). 2. A resident of a LTC home who will become homeless within 16 weeks as a result of a temporary or permanent closure of all or some of the beds in the LTC home. Note: Where residents have not been relocated within six weeks of the planned closing, the Community Care Access Centre (CCAC) must categorize them in category 1A (crisis). 3. A resident (or a previous resident) of a LTC home who will be (was) discharged from the LTC home and requires readmission to a LTC home. Two specific types of situations which can result in discharge are identified: a) Resident who requires transfer to another LTC home because the home cannot provide a sufficiently secure environment. Sometimes a resident s condition changes after he or she is admitted to a LTC home. For example, some people with cognitive impairment may reach a stage where they require a secure ward to prevent them from wandering. If the LTC home operator is advised by the health care professionals providing care to the resident that the home cannot provide a sufficiently secure environment to ensure the safety of the resident or the safety of persons who come into contact with the September

20 resident, the LTC home operator may discharge the resident provided that other arrangements are made to provide the accommodation, care and secure environment required by the person. These residents may apply to other LTC homes and the CCAC must place them in category 2. b) Resident who exceeds the permitted length of time to be absent from a LTC home as a result of a medical or psychiatric leave or assessment. LTC homes are required to discharge a resident who exceeds the time limits set out in the regulations for medical/psychiatric leaves of absences. (See section 47.1 of Regulation 832 of the NHA for provisions related to absences for medical and psychiatric leaves.) LTC homes are not required to advise the CCAC when a resident is transferred to a psychiatric facility or hospital. However, the CCAC will be advised of situations involving discharge when the discharged resident or his or her substitute decision-maker contacts the CCAC seeking LTC home admission back to the original LTC home or another LTC home. These individuals may apply to the CCAC for readmission to the home from which they were discharged and the CCAC must place them in category 2. In the majority of cases, persons prefer to go back to the LTC home where they originally resided. Re-admission of these persons is possible if the previous LTC home can provide the type of care the person requires and a vacancy is available. If a vacancy is not immediately available, the person can consent to be admitted to another LTC home until a bed becomes available in his or her preferred LTC home. The CCAC must provide updated and relevant assessment information about the applicant to the LTC home to which the person wishes to return, or to another chosen LTC home if the preferred LTC home is not available. Each LTC home must approve the admission to ensure that the required care can be provided. 4. A community-based applicant whose condition is expected to deteriorate within three months, or attending to the person s care needs is jeopardizing the health and well-being of the caregiver. The Ministry of Health and Long-Term Care (MOHLTC) has developed guidelines that provide a framework for CCACs to differentiate between persons who require admission within three months (category 2) and those who do not. Category 2 applicants are: persons who are totally dependent on others for three or more activities of daily living (e.g., eating, toileting, personal hygiene and locomotion); persons who are verbally or physically abusive, resistant to care, or wander and require 24-hour supervision; September

21 persons who have moderate to severe cognitive impairments and require 24-hour supervision; and persons who have a combination of other issues that may necessitate admission within the next three months include but are not limited to the following: environmental safety issues; medical conditions requiring treatment; recent history of falls or visits to the emergency department; or a change in the capacity of formal/informal caregiving systems to provide the support the person requires. 5. A spouse/partner who has no care needs of his or her own who wishes to accompany or reunite with a spouse/partner who is eligible for placement or is already living in a LTC home. This category of prioritization only applies in the case of a spouse/partner who is determined eligible for admission to a LTC home solely for the purpose of joining or accompanying the other spouse/partner, and not as a result of a personal need for LTC home care. (This contrasts with the prioritization of spouses/partners who are both determined eligible for admission to a LTC home on the basis of their own care needs as these individuals must be prioritized by the CCAC in category 1A1.) The ranking of spouses/partners who are prioritized in category 2 is according to the date of their own application. This also differs from the ranking of spouses/partners prioritized in category 1A1, as these individuals are ranked according to the date of application of their spouse/partner. CCACs must be cautious about counselling a well spouse/partner with regard to the timing of his or her application if the possibility exists that the well spouse/partner could be admitted sooner than the spouse/partner who has care needs. For example, if the well spouse is a male and beds for male applicants have been becoming available more frequently than beds for females, a situation could arise where the well spouse/partner will have to be made a bed offer before the spouse/partner who needs care. In such a situation, acceptance of the offer could leave the spouse/partner who requires care without a caregiver, while a refusal of the offer will result in the person s name being removed from all lists and not being able to re-apply for 24 weeks (unless there has been a deterioration in the person s condition or circumstances in which case the person may apply sooner). Notes: The term spouse is defined in subsection 1(1) of the NHA regulation as: s. 1(2) a person, (a) to whom the person is married, or September

22 (b) with whom the person is living, or was living immediately before one of them was admitted to a nursing home, in a conjugal relationship outside marriage, if the two persons, (i) have cohabited for at least one year, (ii) are together the parents of a child, or (iii) have together entered into a cohabitation agreement under section 53 of the Family Law Act. The term partners is defined in subsection 1(2) of the NHA regulation as: s. 1(2) Two persons are partners for the purpose of this Regulation if they have lived together for at least one year and have a close personal relationship that is of primary importance in both persons' lives. 6. A person who is admitted to a LTC home that is not the person s first choice and he or she wishes to remain on the waiting list for his or her preferred LTC home. Persons who enter a LTC home that is not their preferred choice and choose to wait for a bed to become available in their LTC home preferred choices, remain in category 2 on the waiting list of their preferred home. Such persons shall be ranked in category 2 according to the original date used to rank the person for admission to the preferred LTC home. If a person agrees to be admitted to a LTC home that is not his or her first choice, the CCAC must determine if the person wants to remain on other LTC home waiting lists at the time of admission to the LTC home. If an applicant does not express the wish to remain on the waiting list of his or her preferred choice of LTC home upon admission to the second or third choice home, and decides at a later date that he or she wishes to be on a waiting list for a different LTC home (e.g., because a new LTC home is opened), the resident will be placed in category 3 on the waiting list. The original authorization date will not apply and this will be treated as a new application for transfer from one LTC home to another. September