North East Local Health Integration Network

Transcription

1 North East Local Health Integration Network Meet Eva Cardinal, 87, a St-Charles resident lives independently at home in her own apartment. Older adults like Eva are the reasons why the North East LHIN works to enhance health care capacity in communities so that Northerners can live at home for as long as possible. Photo submitted by Sylvianne Cardinal Pitre North East LHIN All About Northerners photo contest. As much independence as you want, with as much care as you need.

2 Table of Contents THE NEED FOR CHANGE... 4 A Provincial Perspective...4 Caring for Our Aging Population and Addressing Alternate Level of Care...4 Commission on the Reform of Ontario s Public Services...4 Ontario s Action Plan for Health Care...5 Strong Action for Ontario...6 Senior Care Strategy; Living Longer, Living Well...6 POLICY... 7 History of Assisted Living/Supportive Housing...7 Supportive Housing Target Populations North East...7 Program Description Assisted Living/Supportive Housing...7 History of Supportive Housing in the North East...9 Current State...9 Common elements of Supportive Housing/Assisted Living...9 FUTURE STATE North East Models for Assisted Living/Supportive Housing North East Models for Individuals with Acquired Brain Injury North East Models for Individuals with Physical Disabilities FUNDING - Current State COSTING MODELS AGING AT HOME FUNDING NORTH EAST LHIN APPROACH Key Performance Indicators First Nations HOUSING AND HEALTH World Health Organization Definition of Health THE NEED Housing Study Lean Approach Timelines NE LHIN 2011 and 2012 Community Engagements APPENDICES Appendix A: Current approved and funded Assisted Living hubs Page 2

3 Appendix B: North East LHIN Assisted Living Eligibility for Services Frequently Asked Questions Appendix C: Assisted Living for High Risk Seniors Distribution Areas Appendix D: NE CCAC Personal Support Worker Service Clustering Appendix E: Action Plan Appendix F: NE CCAC Assisted Living Expanded Role Project Page 3

4 THE NEED FOR CHANGE A Provincial Perspective Several reports have been published over the past two years outlining the need for change including Dr. David Walker s reports, as well as the recently released, Living Longer, Living Well, by Dr. Samir Sinha, Provincial Seniors Strategy Lead. All of these reports point to the fiscal and demographic challenges faced by Ontario and the need to provide better care for our seniors. In addition, the provincial government s Ontario Action Plan for Health Care spoke to the need to begin shifting more resources to community providers focused on helping older adults live independently in their homes. This action was supported by changes at a policy level to supportive housing, as outlined in the Assisted Living Services for High Risk Seniors Policy of Caring for Our Aging Population and Addressing Alternate Level of Care (The Walker Report ), 2009 Dr. David Walker visited the North East LHIN consulting with senior staff and other health care leaders as part of his research in compiling this report. The North East has implemented many of his recommendations including creating a regional Emergency Department (ED)/Alternate Level of Care (ALC) Leadership Committee tied to specific urban communities across the region. An essential component in the continuum of care, Dr. Walker explained that appropriately resourced assisted living venues could serve as an alternative to the premature placement of individuals into the long term care (LTC). Coupled with restorative and rehabilitation supports, assisted living in many cases would provide the necessary supports to allow seniors to live independently in a community setting. However, Dr. Walker advised that more resources are needed to support both the addition of assisted living spaces and to increase the coordination and access to those venues. Having established connections to primary care is also a key component to supporting older adults and enabling them to remain in a community setting. In addition, Dr. Walker recommended investigating other models of assisted living such as group homes for seniors. This aligns with similar recommendations contained in the NE LHIN Seniors Residential/Housing Options Report, Commission on the Reform of Ontario s Public Services (The Drummond Report ) Contained within the Drummond Report are succinct examples detailing the importance of shifting in our focus from institutional to community health care. We know that many individuals occupying acute care beds would be better served in more appropriate settings. We also know that population growth of seniors 75-years and older will impact our health care system. Long-term care (LTC) will not be able to keep pace nor is it always the most appropriate place for many seniors. There is a need to look at other options. The Drummond Report references models of care in places such as in Denmark, where its government stopped adding new LTC beds and instead put health care funding into a broad spectrum of community residential options. Page 4

5 Disparities in funding in the LTC, community care and home care sectors were highlighted in the report, as well as the need for increased integration. Drummond also recommended the testing of the service models. Related recommendations included: Fiscal Issues Recommendation 5-7: Support a gradual shift to mechanisms that ensure a continuum of care and care that is community-based. Funding for community-based care may need to grow at a higher rate in the short to medium term in order to build capacity to take pressure off acute care facilities; on the other hand, with a shift away from a hospital focus, hospital budgets could grow less rapidly than the average. Recommendation 5-9: Do not apply the same degree of fiscal restraint to all parts of health care. Some areas including community care and mental health will need to grow more rapidly than the average. Community Care, Home Care and Long-Term Care Recommendation 5-74: Increase the focus on home care, supported by required resources, particularly at the community level. Recommendation 5-75: Match seniors to the services that they need from the earliest available care provider, reduce alternate level of care days, and improve co-ordination of care through the use of referral management tools for long-term care, home care and community services. Recommendation 5-76: Implement the recommendations contained in Caring for Our Aging Population and Addressing Alternate Level of Care, a report prepared by Dr. David Walker and released in August More specifically, the government should move quickly to implement his proposals that [the] continuum of community care must be supported through additional and sustained resources to integrate, co-ordinate and enhance traditional sectors and assisted living arrangements while bridging gaps through new models of care that serve populations whose care needs exceed what is currently available. Recommendation 5-5: To improve the co-ordination of patient care, all health services in a region must be integrated. This includes primary care physicians, acute care hospitals, long-term care, CCACs, home care, public health, walk-in clinics, Family Health Teams (which for the purposes of this chapter includes Family Health Organizations [FHOs], groups and networks), community health centres and Nurse Practitioner-Led Clinics (NPLCs). Ontario s Action Plan for Health Care In January 2012, the Ministry of Health and Long-Term Care (MOHLTC) released Ontario s Action Plan for Health Care. The Plan calls for better patient care through better value for health care dollars. Page 5

6 A cornerstone of the plan is the idea of providing The right care, at the right time, in the right place. Putting more care and support for seniors at home in the community will provide both appropriate care and alleviate the upward substitution of more expensive options like long-term care and hospital. As we continue to be challenged by the number of ALC patients in hospital, mainly the frail elderly awaiting placement elsewhere, our focus has to be on caring for people at home or in the community in more appropriate venues. The entire health care system benefits from the focus on community care as our hospital beds will be used more appropriately and be available for urgent care. Strong Action for Ontario Ontario s Action Plan for Health Care (January 2011), and the provincial budgets of both 2012 and 2013 are strong indications of health care transformation and actions that will help to achieve the government s goal to make Ontario the healthiest place in North America to grow up and grow old. The 2012 provincial Budget committed to increasing investments in home care and community services by an average of four per cent per year. The 2013 Budget proposed an additional one per cent per year for a total increase of over $700 million by compared to Ontario s Action Plan for Seniors, which includes Dr. Samir Sinha s report -- Living Longer, Living Well --draws on new and existing government programs to ensure seniors and their caregivers have access to the services they need, when and where they need it. This includes better access to health care, quality resources, and improved safety and security for seniors. Senior Care Strategy; Living Longer, Living Well The demographic and fiscal imperative as described in the document, Living Longer, Living Well Highlights and Recommendations, leads Dr. Sinha to encourage communities to plan for additional assisted living/supportive housing. Through inter-ministerial cooperation and partnerships, alternatives to premature institutionalization need to be developed across the province. These alternative living arrangements would support older adults to remain in their own homes for as long as possible. A further recommendation by Dr. Sinah is for the Ministry of Health and Long Term Care to lead a capacity planning process to meet the needs of older adults in the most appropriate care venue. The North East LHIN s Integrated Health Service Plan (IHSP), More than 4,000 Northerners contributed to the creation of the North East LHIN s strategic plan, which maps out its priorities over the next three years, beginning in April of Built by Northerners, for Northerners, the plan calls for four regional health care priorities, including to: increase primary care coordination; enhance care coordination and transitions to improve the patient experience; make mental health and substance abuse treatment services more accessible; and target the needs of culturally diverse populations. While enhanced care for our growing seniors population is a focus that weaves its way through each of the LHIN s priorities, it is the plan s second priority Enhance Care Coordination and Transitions that focuses on ways to support seniors to continue to live independently in community. Over the past Page 6

7 several years, the NE LHIN, in partnership with community stakeholders, has made significant investments to build community capacity by adding more assisted living spaces. This new IHSP calls for further expansion of affordable seniors assisted living services, under the priority s goal to enhance targeted service capacity where required. Outcomes of this goal s achievement will be measured through the metrics of more clients served in their homes by NE CCAC and community support services and the reduction in ALC days. POLICY History of Assisted Living/Supportive Housing The Government of Ontario began to fund supportive housing projects for people with disabilities in 1976, beginning with four pilot projects. These projects were referred to as Support Service Living Units (SSLUs). The first supportive housing program to support the elderly was launched in 1980 in partnership with a housing provider and The Ministry of Community and Social Services (MCSS). By 1989, the Elderly Services Branch of MCSS released Living in the Community: New Directions in Residential Services for Frail Elderly People. To expand upon the original policy statement, the provincial government commissioned a paper that identified the need to change the focus of supportive housing by delinking the providers of housing from the providers of service. This separation was recommended to reinforce tenant rights without impacting access to services. The government of Ontario has since released two policy documents for assisted living, the 1994 Long- Term Care Supportive Housing Policy and, more recently, the 2011 Assisted Living Services for High Risk Seniors Policy. Although the terminology has been updated essentially the terms Supportive Housing and Assisted Living are interchangeable and have the same meaning. A challenge we face is that assisted living is generally a broad term however for the purposes of funding it refers to very specific initiatives. Supportive Housing Target Populations North East Adults with Acquired Brain Injury (ABI) Seniors with Cognitive Impairment Persons with Disabilities Program Description Assisted Living/Supportive Housing Supportive housing is a program that is funded through each of the 14 Local Health Integration Networks (LHINs) across Ontario. Providers of supportive housing and assisted living are non-profit organizations that meet the legislative requirements of the Home Care and Community Services Act (1994). Services provided through the current supportive housing and assisted living programs are outlined in the Long-Term Care Supportive Housing Policy and the Assisted Living Services for High Risk Seniors Policy. Page 7

8 Services provided include: Homemaking Services Housecleaning Laundry Ironing, mending Shopping Banking, paying bills Meal planning and preparation Caring for children Assistance to carry out the above activities or training someone to provide the services outlined above Personal Support Services Personal hygiene activities Routine personal activities of living Assisting or training a person to carry out the above Security Checks and Reassurance Visits to the client to assure health and/or safety, these visits shall be available to clients 24/7 both scheduled and unscheduled. Frequency of visits is dependent on individual client care plans. Care Coordination A comprehensive care plan will be developed by the assisted living provider that is client-centred and involves all of the care partners. The coordination of the care will be done by assisted living providers that specify all of the services provided to the client. Principles of Assisted Living/Supportive Housing Individualization Services will support people with varying degrees of needs and creating appropriate care plans that reflect their individuality. Service plans are developed in a manner that put emphasis on the needs of the client. Flexibility Services offer maximum choice to the client to maximize preferences. Community Integration Services are provided in housing locations that promote opportunities for social interaction with others. Independence Self-determination is promoted and clients are able to influence provider decisions about housing and support services. Stability Continuity in housing and support services are paramount to successful living. Page 8

9 Safety Service delivery incorporates client choices without compromising client safety. The service is delivered in order to promote and maintain safety while preserving the clients right to the dignity of risk. Self Help Services are designed to augment social interaction with friends and family, not replace it. History of Supportive Housing in the North East Funding for assisted living/supportive housing in the North East began in 1977, to repatriate adults with disabilities to their community from institutions such as Smith Falls, Hospitals for Crippled Children and other institutional settings. The genesis of supportive housing in the North East was segregated housing and support services. Over the past two decades, supportive housing programs evolved and expanded to serve other populations such as seniors and adults with acquired brain injury. Current State Within the NE LHIN boundaries, there are 17 health service providers that offer supportive housing and assisted living to seniors, persons with disabilities and individuals with acquired brain injury. Services are provided in both rural and urban communities. Common elements of Supportive Housing/Assisted Living Services are delivered by non-profit organizations in an apartment complex or homes that are in close proximity to the provider Landlord/tenant relationship exists Units that are specifically designated for supportive housing are clustered in a specific building Campus model provides a cost-effective model of supporting individuals by offering communal services such dining, laundry as well as additional supports on a fee for service basis. Tenants/clients are responsible for all living expenses (i.e. rent, food, social activities) Page 9

10 FUTURE STATE Future State for Assisted Living 24 hr support and nursing care on site Frequent personal support with visits within a 24 hr period and unscheduled care needs Scheduled care Frequency of Services Emerging / Future State Home with Support Assisted Living Services CCAC Unlimited Support Long-Term Care Home (LTCH) Low Medium High Very High Urgency and Intensity of Services Home with Support Scheduled Care: Home visits Prompt with IADLs Professional Services Social Support Medication Support Episodic Acute Care Assisted Living Services with High Risk Seniors Scheduled and Unscheduled Care: Just-in-time support for urgent personal care Essential Homemaking Social Support IADL Provision Medical Prompting Relationship with professional services for chronic conditions CCAC Unlimited Support (May 2008) Persons on LTCH waitlist receive CCAC personal support and homemaking services at a level that exceed the standard service maximums Long-Term Care Home (LTCH) July 2010 Nursing Care 24/7 supervision Hands-on support with IADLs Medication Management North East Models for Assisted Living/Supportive Housing Campus Model With this model, the provider serves a group of people in a more controlled, quasi-supervised setting where there is access to personal care, homemaking, and for a fee, services such as communal dining, laundry, transportation and recreation. Services are provided primarily to seniors over the age of 65 years. Campus models of care are located in the Sault Ste. Marie, Elliot Lake, Sudbury, Sturgeon Falls and North Bay. Each of the campus models have unique attributes, whether cultural or with respect to target population. A comprehensive list of providers is detailed in Appendix A. Dedicated Segregated Supportive Housing Units Individuals with disabilities are supported in three communities where the housing and services are provided exclusively to those who need both. The services and housing are not separated. This can be a cost efficient way of delivering services to individuals with high needs, but presents the challenge of Page 10

11 promoting community integration. This model is available in Sudbury at ICAN Independence Centre and Network, in Parry Sound at The Friends, and in Timmins at Access Better Living. These models were created to support the de-institutionalization of adults with disabilities in the late 1970s and early 1980s. Clients include those with spinal cord injuries, acquired brain injury, cerebral palsy, spina bifida and stroke. Specialized Supportive Housing for Older Adults with Cognitive Impairments A specialized 12-unit assisted living complex that provides highly specialized care to older adults who have cognitive impairments and require around the clock personal support and nursing in order to live independently is available at Huron Lodge, in Elliot Lake. It is the only such service of its kind in the North East. Mobile Assisted Living for High Risk Seniors With mobile assisted living, services are delivered to older adults with higher care needs, living within a specific geography and services are delivered by a specific provider. Generally, it is in an area where a high density of seniors reside and where a provider can meet the standards set out by the NE LHIN to be a designated assisted living hub. In the North East, assisted living services for high risk seniors has been funded since 2011 in eleven different communities. In larger urban areas, health service providers have been organized to serve a particular geographic area and establish an assisted living hub from which the services can be provided. Service provider maps have been created for Sault Ste. Marie, North Bay/District of Nipissing and the City of Greater Sudbury. Specific Standards for the North East Mobile Assisted Living: 1. There is a population density of at least 10 eligible high risk seniors within a 15 minute response time. It may be a small community of private dwellings or a cluster of apartment buildings within a particular neighborhood. In a rural community it could be a particular town or group of towns in close proximity. 2. It is recommended that all geographic service areas/hubs have a physical space for employees of the assisted living providers. Optimally, space is provided in a building/neighbourhood where assisted living is provided. 3. Proximity and or connection to other community support services need to be established in order to support seniors to remain in their homes. I.e. falls prevention/exercise program, foot clinics, social opportunities. 4. Access to pharmacies and grocery stores is an important factor as is attachment to a primary care provider, including nurse practitioners. 5. The provider response time should be within a 15 minute to contact the senior and 30 minutes to respond to essential service requests. Page 11

12 Target population: high risk seniors Characteristics of a high risk senior: Approved agencies use a common assessment tool to determine whether an applicant for assisted living services meets the characteristics of a high risk senior, as described in the three scenarios in Table 1. While the standardized assessment tool will provide an objective assessment of need and assist in the determination of eligibility, the results of the assessment shall include the wishes and preferences of the client or his/her substitute decision-maker, if any, and incorporate the expert opinion of the person conducting the assessment. Characteristics of a high risk senior are described in the policy using three different scenarios. Characteristics of a High Risk Senior Scenario 1: Presence of a live-in informal caregiver who is available to provide sufficient support, provide direction to staff, and manage inappropriate behaviours and potential hazards in the home Caregiver lives with client Impairment/Intensity Range Possible RAI item options (Item O2) AND Difficulty with some or all of the following issues: High or Very High Need Dressing, toileting, transfer, locomotion, hygiene Verbally or physically abusive, wandering, socially inappropriate, resisting care Difficulty with memory, and/or in decision making, and/or in making self understood Falling Difficulty managing medications Difficulty with meal preparation Pressure/stasis ulcers Difficulty swallowing Functioning safely in current environment MAPLE Score high/very high (4 or 5) OR Page 12

13 Scenario 2: Informal caregiver (if any) is unable to provide sufficient support Cognitively intact or borderline intact Caregiver lives with client Possible RAI item options (Item O2) AND No or limited difficulty with the following: Short term memory Cognitive skills for daily decisions making Making self understood Eating Cognitive Performance Scale (0 or 1) AND Great difficulty in performing instrumental activities of daily living independently Scenario 3: Informal caregiver (if any) is unable to provide sufficient support Ability to: Prepare meals Do ordinary housework Use the phone use IADL Capacity Scale (5 or 6) OR Caregiver lives with client Possible RAI item options (Item O2) AND Mild to Severe Cognitive Impairment Mild to moderate difficulty with the following: Short term memory Cognitive skills for daily decisions making Making self understood Eating Cognitive Performance Scale ( 2+) AND Manageable bladder incontinence No more than occasional bladder incontinence as defined by the RAI instrument i.e. High Risk if frequently or completely bladder incontinence Hospital to Home Transitional Units Page 13

14 The transition to home model of service is designed for high risk seniors in the North East who still require some medical care and would benefit from a safe place to recover, with the goal of returning home to a community setting. Specifically, the target group includes individuals who require 24 hour support with activities of daily living during their convalescence. The length of stay for these units can be up to 90 days. Access to these units is through hospitals in some communities, or the Community Care Access Centre (NE CCAC) in others. Clients eligible for this service would be transferred to the apartment setting from hospital. This model is designed to provide transitional care for medically/physically fragile individuals who are transitioning to a home environment. North East Models for Individuals with Acquired Brain Injury Group Homes ABI Congregate Care Description Wade Hampton House The ABI Congregate Care setting is located in the North East end of City of Greater Sudbury. Through funding from various federal and provincial funders, the home opened in August The group setting features a 24-hour accessible site geared to adults who have experienced a moderate to severe brain injury. This residential setting addresses high levels of care and provides an alternative to inappropriate placement in LTC homes or hospitals. The current setting supports 10 individuals who benefit from ongoing ABI rehabilitation. The setting supports eight individuals in a congregate setting along with two one-bedroom units to assist individuals who have a greater potential to transition to a less supervised setting. The congregate setting has an exercise room, hydrotherapy room, and cognitive therapy stations. Services are provided through an individualized plan that includes ABI rehabilitation and personal care supports. Individuals residing in the home are supported through NE LHIN funding or third party funding available as a result of Motor Vehicle Accident Benefits or the Workplace Safety and Insurance Board Serious Injury Program. New Sudbury Congregate Care Setting A smaller setting located in New Sudbury supports up to five individuals who have access to Individualized ABI funding from the Ministry of Health and Long-Term Care and third party funding as a result of Motor Vehicle Accident Benefits. Staffing is provided 24/7 with a focus on individualized ABI rehabilitation and personal support services. The home is owned by a private landlord with rent, household and occupancy costs divided appropriately between the residents. North East Models for Individuals with Physical Disabilities The United Nations Convention on the Rights of Persons with Disabilities, Article 19 b), states that [persons] with disabilities have access to a range of in-home, residential and other community support services, including personal assistance necessary to support living and inclusion in the community, and to prevent isolation or segregation from the community. The Convention was ratified on April 3, 2008 and became legally binding on May 3, The Canadian House of Commons has unanimously endorsed Canada s ratification of the Convention. Page 14

15 Services for persons with disabilities are delivered through different models of assisted living/supportive housing. The different models for persons with disabilities include a mobile service similar to the model developed for high risk seniors, dedicated units within a segregated apartment building and also units within an integrated apartment building. Services are delivered to adults with physical disabilities who are able to direct their own care and manage all aspects of their lives. The independent living philosophy is the cornerstone of service delivery for this population. The "independent living model" considers a person with a disability in a holistic manner and takes into account his or her lived experience. The account of the person s lived experience includes the barriers faced to living with a disability and the supports necessary to living fully integrated into society with a secure income, housing and non-medical daily supports. FUNDING - Current State The NE LHIN funds 17 providers to deliver supportive housing/assisted living to seniors, high risk seniors, adults with disabilities, and adults with ABI. Currently, we have more than $13 million invested in assisted living for all population groups. ALSSH Funding by HUB, Base Funding James and Hudson Bay Coasts $160,000, 1% Nipissing- Temiskaming, $3,940,423, 23% Algoma, $4,990,285, 29% Manitoulin-Parry Sound-Sudbury, $6,742,558, 39% Cochrane, $1,357,921, 8% Recent community investments have been made in assisted living which will move and increase the capacity of Community Support Services providers to meet the service demands. Page 15

16 2011/ 2012 Community # of Clients Funding North Bay 16 $350,000 Sudbury 16 $350,000 Manitoulin Island 10 $160,000 Kapuskasing 8 $128,000 Kirkland Lake 15 $132,000 Total: 65 $1,120, /2013 Community #of Clients Funding North Bay 16 $320,000 West Nipissing 10 $200,000 Sudbury 80 $1,350,000 Sault Ste. Marie 17 new (15 existing) $390,000 Algoma 15 $300,000 Timmins and Hearst 16 $320,000 James and Hudson Bay Coasts 8 $160,000 Total 162 $3,040,000 COSTING MODELS The cost of delivering assisted living varies considerably due to the range of clients and the level of service required. Under the 1994 Supportive Housing Policy, funding was limited to supporting seniors with some light housekeeping and minimal personal care. However, through Aging at Home funding, the NE LHIN improved the capacity of health service providers (HSP) to support seniors with more complex needs in an assisted living environment. The recommended cost per client is $15,000 in the campus model and $20,000 in the mobile model. The cost per client is a guideline and must take other factors into consideration. For example, a provider may or may not have the infrastructure to support an expansion of assisted living, and in order to meet the client needs and reporting requirements, the health service provider may require additional administrative support. Alternatively, the health service provider may have the resources to acquire additional capacity with the addition of direct service dollars only. AGING AT HOME FUNDING Funding through the Aging at Home initiative August 2007 was leveraged to increase the capacity of assisted living providers to provide services to more clients and to augment services to existing ones. The additional funding supported those clients identified to be at-risk of not being able to remain in the Page 16

17 community. A total of $3,154,905 was invested from year one to three. Any Aging at Home funding allocation after the release of the Assisted Living policy, January 2011, was allocated to support high risk-seniors. NORTH EAST LHIN APPROACH As we strive to provide the right care, at the right time, in the right place, the NE LHIN has taken a proactive approach to positioning our health care system for transformation. As noted earlier, at the provincial level, the Ministry of Health and Long-Term Care released a new Assisted Living Services for High Risk Seniors Policy that positions all Community Support Services (CSS) as integral parts of the health care system. Coinciding with the release of that policy was the decision to implement the CCAC Expanded Role for Assisted Living/Supportive Housing, Adult Day Programs, and Complex Continuing Care (CCC) and Rehabilitation (Rehab). The expanded role positions the NE CCAC as the central point for intake, assessment and waitlist management. The North East took a two-pronged approach to the intersecting initiatives. Initially, the policy was introduced to all 17 assisted living providers at the same time the expectation regarding the NE CCAC expanded role was communicated to all sectors. To implement the policy, a Regional Assisted Living Steering Committee was created that was comprised of assisted living providers, social housing partners, hospital and mental health sectors. The purpose of the regional steering committee was to provide input and strategic direction to the rollout of the 2011 Ministry of Health and Long-Term Care Assisted Living Services for High Risk Seniors Policy, and the development and implementation of a Regional North East Assisted Living Model. The Regional Assisted Living Steering Committee has completed the following initiatives: Clarification and finalization of the eligibility criteria, including the publication of the Frequently Asked Questions document (See Appendix B) Development and publication of key performance indicators for assisted living that include measurements for the NE CCAC and assisted living providers Creation of standards for the geographical service areas Sharing of communication tools such as brochures and PowerPoint presentations Knowledge exchange of different models of service On the NE LHIN collaboration space, an assisted living vacancy portal was created for the purposes of planning and reporting as it relates to alternate level of care. This planning tool gives the CSS Sector, the NE LHIN, the NE CCAC and hospitals an at-a-glance update on where assisted living vacancies are occurring across the region. Key Performance Indicators As part of the Assisted Living for High Risk Seniors policy implementation, the Regional Assisted Living Steering Committee brought together assisted living providers, NE CCAC leadership and NE LHIN planning and decision support to develop the North East LHIN key performance indicators for assisted living. Page 17

18 The development of the key performance indicators was led by the NE LHIN using a modified Delphi method. This method provided the health service providers the opportunity to formulate the indicators as a group. Health service providers were provided with training on the key performance indicators and how to report on those to the NE LHIN. The first year will see the collection of data beginning in Q3 of 2012/2013; second year will be the development of performance standards as appropriate for each indicator. Phase two of the performance indicator development is to create a common client satisfaction survey for all assisted living health service providers to implement. Indicator Indicator Description Accountability 1 Frequency of CCAC PSW Service provision NE CCAC 2 Sum of CCAC PSW Hours of Service NE CCAC 3 Characteristics of a high risk senior are met NE CCAC 4 Number of ALC Clients NE CCAC 5 Number of LTC waiting clients NE CCAC 6 Number of resident days Assisted Living Provider 7 Number of hours Assisted Living Provider 8 Number of ER visits Assisted Living Provider 9 Number of hospital admissions Assisted Living Provider 10 Assessments (Assisted Living provider) Assisted Living Provider 11 Assessments (CCAC) NE CCAC 12 Client length of stay Assisted Living Provider 13 Reasons for discharge Assisted Living Provider 14 Client falls Assisted Living Provider 15 Client satisfaction (not yet completed) Assisted Living Provider Page 18

19 Step 1 Step 2 Step 3 Step 4 Appointment of Sub - committee Agreement that Assisted Living Indicators shall focus on 4 areas: 1) Assisted living serves high risk seniors (eligibility) 2) Service outputs 3) Service impact 4) Quality/Safety Informed by characteristics that are: - accepted/meaningful - simple, logical, repeatable - feasible, meaningful - timely - drive action Presentation of list of 27 indicators compiled from several sources and initial discussion Survey of members to score proposed indicators Review of survey scores indicated high level of support for all indicators Multiple hours of discussion with members to finalize list of indicators Development of Technical Specifications for Assisted Living Indicators Reporting Template for HSPs Assisted Living Indicators recommended to Steering Committee LOCAL PLANNING The Regional Assisted Living Steering Committee has worked alongside local planning tables in four communities: City of Greater Sudbury The Sudbury-Manitoulin Supportive Housing Network, on a time limited basis, was repurposed to assist with the immediate issue of confirming gaps in services and organizing the assisted living providers to serve the entire community. The committee was renamed the Sudbury Assisted Living Steering Committee and membership was broadened to include representation from the housing sector, the NE CCAC, and the hospital. The Sudbury Assisted Living Steering Committee provided guidance and support as the NE LHIN and the NE CCAC worked with the Sudbury municipal planning department to create maps that show the population density of seniors, the density of NE CCAC Personal Supports, and the location of social housing and long-term care homes. The mapping exercises allowed the NE LHIN to organize the health service providers into distinct areas of the community, with an agreement reached by the providers through consensus. The provider maps give the NE LHIN a guide into the number of assisted living hubs required in the Sudbury area and the provider assigned to each hub. In the city of Greater Sudbury, a total of 10 hubs were identified, with three of those areas funded between the fall of 2011 and spring In the fall of 2012, 40 assisted living spots were allocated to affordable housing units at Finlandia Village. Sault Ste. Marie Page 19

20 As a subcommittee of the Sault Ste. Marie Alternate Level of Care Solutions Group, the Community Supports Advisory Committee was consulted to develop a local approach for assisted living planning for Sault Ste. Marie. It was agreed that a multi-sector planning committee was required in order to effectively plan for assisted living in Sault Ste. Marie. The Sault Ste. Marie Assisted Living Steering Committee was created in February of 2011, with members from assisted living providers, the NE CCAC, the Sault Area Hospital, the Garden River First Nation, District Social Services Administration Board (DSSAB), a non-profit housing provider, and the Older Adult Centre. The committee went through a similar mapping exercise to Sudbury, with the technical portion of the exercise being completed by geographic information system staff of the Sault Ste. Marie Innovation. The assisted living health service providers in Sault Ste. Marie were organized according to existing locations and density of services provided. Planning for assisted living in Sault Ste. Marie highlighted the need to create better public awareness of assisted living. The NE LHIN publicized assisted living through the dedicated Seniors Column in the Sault Star and broadcast featured spots on cable television. (See Appendix C) District of Nipissing In the fall of 2011, a work group was created in the District of Nipissing to formalize recommendations for assisted living. The group, consisting of housing providers, the NE CCAC, assisted living providers, and the hospitals, focused on organizing providers and service areas. A different approach was taken for the City of North Bay, as the two main providers of assisted living decided to take an integrated approach and will act as one hub for the entire city of North Bay. Additional work in the District of Nipissing is underway to organize a provider for West (Sturgeon Falls) and East (Mattawa) Nipissing. The planning work revealed that Au Chateau, the main provider in that community, primarily serves seniors who are residents of their apartment complex. The Assisted Living Services for High Risk Seniors Policy promotes the creation of assisted living service hubs that will serve an entire neighbourhood. The District of Nipissing Assisted Living Steering Committee is collecting data on the amount of service going into Sturgeon Falls by all providers and will be making recommendations for improvements to access and a simplified service delivery model for that community in fiscal The next step for the District of Nipissing will be to identify an appropriate assisted living provider for Mattawa. It is recommended that the current Assisted Living Steering committee for the District of Nipissing be transitioned to a Community Support Services Network for the area. This network would be supported by the Community Support Services System Navigator with a direct line of accountability to the NE LHIN Hub Officer. Timmins A recommended planning approach for Timmins is to work with Network 13 to establish a small working group to make recommendations for long-term assisted living investments and connect those to the measurement of improving alternate level of care in the community. The recommendation coming from the Network 13 meeting of June 28, 2012 was to bring the key stakeholders together and consult Page 20

21 on the need for assisted living. In September 2012, a meeting of the Cochrane Assisted Living providers was convened to review the need for assisted living for seniors in Timmins and surrounding communities. Through consultation with providers, NE CCAC and the DSSAB the following recommendations were made: Canadian Red Cross would have one hub for Timmins that would serve the entire community. There would be the possibility to expand Assisted Living for seniors with a separate hub in South Porcupine. Access Better Living will be the designated assisted living provider supporting persons with disabilities. Currently there are individuals with disabilities on the Outreach Attendant Care waiting list that require high levels of service. As Outreach Attendant Care is a CSS program the needs of that target population need to be taken into consideration when doing the planning for the community. Planning for specific populations and providers must be done in conjunction with the Cochrane realignment report. There is opportunity to expand partnerships with the Cochrane DSSAB. There are 700 units in Timmins for seniors. There are 10 buildings that could house assisted living and our Community Support Services. It was agreed that demographics on the tenants in those buildings would be helpful information to assist in our decision making and priority setting. There is a need to provide personal support workers to Cree speaking elders in Timmins. While some decisions have been made in Timmins related designated assisted living hubs, further activity is required for full implementation of the policy. Rural Communities Informal planning has taken place for the rural communities of Blind River, Thessalon, Elliot Lake, Kapuskasing and Sturgeon Falls. Since the announcement of the assisted living for high-risk seniors policy, funding has been allocated to the following rural communities: Kapuskasing Kirkland Lake Manitoulin Island Elliot Lake Sturgeon Falls Hearst Moosonee Moose Cree Further planning is required for rural communities that have a high density of seniors that meet the eligibility requirements under this policy. NE CCAC Personal Support Worker Service Density A key planning tool for assisted living has been to examine NE CCAC personal support worker service density. This demonstrates where the high users of NE CCAC services are concentrated and has been used as one measure of where assisted living hubs could be viable. (See Appendix D) Page 21

22 First Nations There is interest within the First Nations health service providers to provide assisted living for high-risk seniors or other target populations. Interest in expanding assisted living services to First Nations has been expressed generally through the Local Aboriginal Health Committee and by the following specific communities: Garden River First Nation Moose Cree First Nation Serpent River First Nation Batchewana First Nation In response to the identified needs and gaps in services by some of the First Nations communities, a working group was struck to review the current service levels with the current funding for Community Support Services. It was recommended that the next step would be engagements within the First Nations communities to review gaps, identify priorities, and look for opportunities to leverage existing resources from current funding and housing supports to offer assisted living. Informal dialogue has taken place with Ontario Aboriginal Housing Services in an effort to align assisted living resources with any new housing developments in the region. Developing the capacity for First Nations to provide assisted living services for high risk seniors in their communities will reduce caregiver burden and increase quality of life for elders by offering the opportunity for elders to age in place. HOUSING AND HEALTH World Health Organization Definition of Health Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. The NE LHIN has developed local and regional alliances with the housing sectors as the release of the new Assisted Living Services for High Risk Seniors Policy provided the impetus to solidify partnerships. Further, dedicated LHIN resources for the planning of assisted living has provided the opportunity to increase connections to the housing sector in local communities and through regional planning entities. There is an acknowledgement across all sectors that housing and health are intertwined, however making the right connections when a person is in need can sometimes be nearly impossible. In order to have successful community-based models of care, both the housing and health issues related to aging in place must be addressed simultaneously. This shift has begun with the enactment of the new Housing Services Act (2011). This legislation requires that all service managers develop long range strategic plans that include supportive housing. Page 22

23 The 10-year strategic Housing and Homelessness Plan must reflect the evolving demographics of communities and address the needs for specific target populations, including seniors. In the North East, the first DSSAB to develop its strategy is the Algoma District Social Services Administration Board. It is anticipated that the other DSSABs and the municipal service manager will link with the NE LHIN when they begin to develop the Housing and Homelessness Plans as required by legislation. It will be essential to contribute to and inform the Housing and Homelessness Plans to reflect health issues related to housing. Taken from the Aging in Place-Joint Center for Housing Studies of Harvard University: THE NEED Housing Study With the announcement of the Aging at Home strategy, the NE LHIN commissioned a comprehensive study of the options for older adults to receive support along the continuum of care. The study focused on both the current and future needs of older adults in three different settings: long-term care, retirement homes and assisted living/supportive housing. The study interfaced with the work of the Balance of Care Research Group being conducted by the University of Toronto. Recommendations contained in the study have formed foundational directions for the NE LHIN and their health service providers. The Seniors Residential/Housing Options Capacity Assessment and Projections Report provided a snapshot of the current inventory of residential options, the population projections and the gaps based on the data. Analysis of the data has been completed and the NE LHIN has been able to clearly articulate the gaps in assisted living/supportive housing if we are truly to divert the premature placement of older adults into long-term care homes. The final report was released to the NE LHIN and health service providers in March Summary of Recommendations Improve coordination and collaboration between organizations providing housing and support services Page 23

24 Increase emphasis on health promotion and disease prevention Improve access to hospice care In partnership with housing providers, formalize planning for seniors supportive housing with identified funding commitments including the exploration of a rent subsidy program for seniors Provide a mechanism to advocate for increased capital and support service funding Identify creative options for supportive housing, such as conversion of surplus schools Promote the Cluster Care Model (Mobile Assisted Living) Pilot the Abbyfield Model, which is a small group home setting where a small number of seniors can live together in a single family dwelling with shared common spaces Designate long term care homes to provide more specialized care Develop a First Nations Supportive Housing Plan Promote the use of funding from all government levels for renovation and repair programs (i.e. the Residential Rehabilitation Assistance Program and Home Adaptations for Seniors Independence) Increase funding for the training of personal support workers Promote the use of volunteers in supportive housing Improve linkages with other venues of care, such as retirement homes Develop a comprehensive communications strategy targeted at seniors Gap analysis based on the Seniors Residential/Housing Options Capacity Assessment and Projections Report Recent community investments have been made in Assisted Living which will increase the capacity of Community Support Services providers to meet the service demands. Although focused on assisted living/supportive housing other initiatives aligned with the release of the 2009 Seniors Residential Options study dovetail and provide synergies to reinforce the recommendations made in the report. A significant initiative is the Home First Program. This program forms the basis of a province-wide initiative that incites a paradigm shift about where and when LTC and other long term care plans are developed for older adults. The shift is from making decisions while in hospital to making those life altering decisions at home. Since the release of the Seniors Residential/Housing Options Report, the NE LHIN has invested funding through Aging at Home and Home First, as well as by providing enhancements to existing assisted living services and the creation of new Assisted Living spaces. Lean Approach Using quality improvement techniques from the lean methodology, assisted living value stream mapping exercise was undertaken which focused on the patient experience going from hospital to assisted living. The current state exercise highlighted the need for improved understanding of assisted living, improved work place equipment, including technology, and improved communication. The future state map eliminated many steps and reduced the wait time and task time from 151 hours in wait times and 13.5 hours in task times in the current state to 71 hours of wait time and 9.8 hours in task time. This represents a significant improvement in process that will result in a better client experience. Page 24

25 In order to realize our future state for assisted living from hospital to home, a six month action plan has been developed, and the Regional Assisted Living Working group with the NE LHIN assisted living lead will provide oversight of this plan. Other lean tools have been used as we venture through the expanded role. To address the problems of matching the NE CCAC referrals to assisted living capacity the NE CCAC, assisted living providers and the NE LHIN worked on a cause and effect diagram (a.k.a. fishbone) that outlines some of the reasons and potential solutions. To address the problems with sustainable solutions, a follow up to the initial work and action plan was created. (See Appendix E) Timelines As we move to full implementation of the expanded role, the NE CCAC has mapped out the timelines for all geographies and target groups. The timeline created has been ambitious on the part of the NE CCAC and the health service providers but will mean improved access for clients across the region. The Expanded Role for all North East LHIN funded Assisted Living Services was implemented as agreed upon by March 31 st, (See Appendix F) COMMUNICATION STRATEGY NE LHIN 2011 and 2012 Community Engagements In the spring of 2011, the NE LHIN held several community consultations across the North East. In total, 25 different communities were visited with over 700 individuals participating. Throughout the community engagement sessions, there were resounding themes one of which was the need for more assisted living/supportive housing. The need for additional assisted living/supportive housing capacity was specifically mentioned in Kapuskasing, Timmins, Cochrane, SSM, Hornepayne, Wawa, Manitoulin Island, Mattawa and Kirkland Lake. Following those community engagement sessions, funding has been allocated for assisted living services for high-risk seniors in the communities of Kapuskasing, SSM, Manitoulin Island, North Bay and Kirkland Lake. This need was reinforced during the NE LHIN s 2012 community engagements and consultations with more than 4,000 Northerners as part of its work to develop an Integrated Health Service Plan, which maps out its priorities for the years 2013 to Through the regional and local planning efforts, the goal is to align our health care system so that individuals can access supports along the entire continuum of care. This will mean the appropriate resource allocation so that individuals can access the right service at the right time by the right provider. Communications Plan A comprehensive community engagement and communications plan is essential to reach a variety of audiences. Those target audiences include, but are not limited to: The general public Older adults Page 25

26 Persons with disabilities Persons with acquired brain injuries (ABI) Families and caregivers NE CCAC staff The CSS Sector The hospital sector Seniors clubs Self-help organizations Common communication tools have been created for assisted living. The NE LHIN has created a seniors assisted living video, a web page and a key messages on assisted living. Our health service providers have created a generic brochure and power point documents. Several presentations have been delivered to a variety of audiences on assisted living, the policy and service flexibility. Future communications will focus on how clients access services and will be led by the NE CCAC. SUMMARY Over the past three years the NE LHIN has put emphasis and focus on increasing the capacity of assisted living providers to support older adults to remain in the community for as long as possible. The release of the policy, Assisted Living for High Risk Seniors 2011, provided the framework necessary to begin to organize providers in the Community Support Services sector to provide mobile assisted living services. The policy has enabled providers to take a flexible approach by placing the focus on the care plan and not the building. Opportunities to partner with housing projects have permitted increased capacity in Iroquois Falls, Sudbury, Walden and Thessalon. The expanded role of the CCAC has been a key success factor as access to services has been standardized and equity of service enhanced. Additional work is required for all sectors within the health care system to gain a better understanding of assisted living and how the supports provided can positively impact the challenges faced i.e. alternate level of care. Full implementation of the common assessment project has led to a common language across health care sectors and a greater ability to objectively determine client needs. Further, the common assessment tool project will lead to the Integrated Assessment Record (IAR) which will lead to better coordination, improved care plans, and data for health care planning. Above all, the multi sectoral approach to planning and implementation is a significant enabler to success. The input and wisdom from assisted living providers, housing partners, hospital and CCAC has made this system change possible. Next Steps: 1. Implement a process for approving geographic service area for Assisted Living Services for High Risk Seniors 2. Develop standardized policies for assisted living providers (intake, referrals, vacancy) Page 26

27 3. Initiate First Nations Assisted Living work plan 4. Evaluate the impact of Assisted Living 5. Explore different models of care for the elderly (i.e. group homes) 6. Initiate focused regional planning for other target populations i.e. Physical Disabilities, ABI, HIV/AIDs 7. Actively participate in the development of the Housing and Homelessness Strategy for all DSSABs and the single municipal Housing Services throughout the North East 8. Create approved Geographic Service Areas for each planning hub 9. Develop and implement a comprehensive communications strategy with multiple target audiences 10. Explore and capitalize on opportunities for housing development 11. Using the National Health Service U.K. (NHS) survey to conduct a sustainability assessment for Assisted Living in the North East. Page 27

28 APPENDICES Appendix A: Current approved and funded Assisted Living hubs Algoma Sault Ste Marie Elliot Lake Blind River Canadian Red Cross - Downtown Huron Lodge Blind River Health Centre Town of Blind River Canadian Red Cross East March of Dimes Central March of Dimes West Ontario Finnish Rest home Campus Sudbury/Manitoulin/Parry Sound Sudbury Manitoulin Parry Sound ICAN Downtown/Flour Mill/West End VON - Little Current/Mindemoya Red Cross New Sudbury Red Cross Azilda/Chelmsford VON South End VON Walden VON Espanola Finlandia Aide Aux Senior Sudbury East Finlandia Village - Sudbury Ukrainian s Seniors Centre Downtown The Friends Parry Sound District of Nipissing/Temiskaming Au Chateau Sturgeon Falls Cassellholme and PHARA City of North Bay Temiskaming Home Support Services Kirkland Lake, New Liskeard District of Cochrane Canadian Red Cross - Timmins Canadian Red Cross Iroquois Falls Canadian Red Cross Kapuskasing Canadian Red Cross - Hearst James Bay and Hudson Bay Coast Canadian Red Cross - Moosonee Moose Cree First Nations Moose Cree First Nations Page 28

29 Appendix B: North East LHIN Assisted Living Eligibility for Services Frequently Asked Questions 1) Who is eligible to receive assisted living services funded under the North East LHIN? The following groups are eligible to receive assisted living services in the region: a. Anyone already in receipt of said services as of January 1 st, 2011 b. Anyone with Physical Disabilities or Acquired Brain injury who meets the criteria of the Assisted Living Services in Supportive Housing Policy, c. Anyone who meets the criteria of the Assisted Living for High Risk Seniors Policy, 2011 as endorsed by the North East LHIN. 2) How soon after a referral must the eligibility process occur? The eligibility determination process must begin within 24 hours of referral as per the Assisted Living for High Risk Seniors policy, and must be completed within 14 business days as per CCAC admissions practices. 3) How are the criteria in Section 6 of the Assisted Living for High Risk Seniors Policy, 2011 interpreted by the North East LHIN and/or the Ministry of Health and Long Term Care? An approved agency shall not provide assisted living services to a person unless the person meets all of the following eligibility criteria: 1. The person shall be an insured person under the Health Insurance Act; This is self-explanatory in that a person must be eligible to receive Ministry of Health and Long Term Care funded services. 2. The person shall require personal support and homemaking services on a 24-hour basis and have care requirements that cannot be met solely on a scheduled visitation basis. The person shall require services to be delivered in a frequent, urgent, and intense manner described as follows: Frequent meaning that the individual has needs where intermittent visits through the day may be necessary; Urgent meaning that the individual has concerns that warrant a prompt response that cannot wait to be scheduled; Intense meaning that the individual s condition or predicament demands direct personal attention from staff to address needs; Frequent is interpreted as meaning a minimum of 1 face to face visit every day, 7 days a week; Urgent speaks to requiring in-person care within 15 minutes of calling for aid, 24 hours a day; and Intense speaks to the need for care to be direct. 3. Unless there are circumstances deemed relevant through the clinical judgement of a health professional, the person shall meet the characteristics in Table 6.1 Page 29

30 These characteristic speak to the attributes of clients who tend to reside in Supportive Housing or Assisted Living venues as per the Decision Support Algorithm for Supportive Housing (DASH). Clients RAI information will meet one of the three scenarios as measured by a recent administration of an InterRAI tool (CHA, HC, MDS, etc), unless the clinical judgement of an allied health professional conflicts with this determination. 4. The person shall not be on a waiting list for a LTCH; This criteria is *not* to be considered while the policy is being implemented, rather it speaks to a desired end state several years in the future. As such, persons who are on Long Term Care Home Waiting Lists may be considered for assisted living services until such time that the North East LHIN and/or the Ministry of Health and Long Term Care communicate such to those determining eligibility. 5. The person shall reside in a LHIN approved designated geographic service area but shall not reside in a care home within the meaning of the Residential Tenancies Act, 2006 within that area 1 ; 6. The person shall be able to remain safely at home between visits; 7. The person shall not require immediate or 24-hour availability of nursing care or other professional services; This criteria speaks only to professional services as offered through the NECCAC, not Mental Health Care nurses, hospital outreach services, etc. 8. The person s home shall have the physical features necessary to enable the services to be provided; and 9. The risk that a service provider who provides the services to the person will suffer serious physical harm while providing the services must not be significant or, if it is significant, the service provider must be able to take reasonable steps to reduce the risk so that it is no longer significant. Both the NECCAC and the Assisted Living Service providers are responsible to assess these criteria at intake. Providers will monitor ongoing level of risk as care is delivered. 3 This criterion does not apply to persons residing in supportive housing buildings that are designated as care homes within the meaning of the Residential Tenancies Act, 2006, for example, Legion Village Inc. Branch 133 (Coburg) and Alpha House (Windsor). Page 30

31 Appendix C: Assisted Living for High Risk Seniors Distribution Areas Appendix D: NE CCAC Personal Support Worker Service Clustering Page 31

32 Page 32

33 Appendix E: Action Plan People Processes Resources Not enough assisted living funding Staff not wanting to change working conditions Home first funding? transitions Knowing who s in charge No active evaluation No buy-in Including caregiver Reluctance of person to change providers Training HPG Finding people that Met criteria Implementation plan Changed or not clearly communicated Implementation/interpretation of policy Timing and turnaround Process not communicated Misunderstanding of 180 hours Lack of flexibility (transitions) Needs increase Lack of knowledge exchange with other LHINs No physical promotional piece Lack of documentaion of process by early adopter Lack of HR Respite needs recruitment Filling available spots in assisted living is proving to be a challenge Lack of relationship building Relationship Management SAAs Characteristics of Population ill-defined Lack of clear communication Promotion to help client to change provider Leadership Policy Promotion Page 33

34 Appendix F: NE CCAC Assisted Living Expanded Role Project Page 34