Policy Guideline Relating to the Delivery of Personal Support Services by Community Care Access Centres and Community Support Service Agencies, 2014

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1 Policy Guideline Relating to the Delivery of Personal Support Services by Community Care Access Centres and Community Support Service Agencies, 2014 April, of 14

2 Policy Guideline Relating to the Delivery of Personal Support Services by Community Care Access Centres and Community Support Service Agencies, 2014 Contents 1. Intent and Application of Policy Guideline Definitions Goals Target Population for CSS Agencies Common Standards for all Approved Agencies Eligibility Home and Community Care Access Point(s) Standardized Assessment Practices Waitlist Practices Service Levels Service Maximums Transition/Continuity Provider Performance and Quality Implementation Guiding Principles Agency Approval Performance Metrics and Accountability April, of 14

3 1. Intent and Application of Policy Guideline This Policy Guideline enables selected Community Support Service (CSS) agencies to be approved to provide in-home Personal Support Services (PSS) under the Home Care and Community Services Act, 1994 (HCCSA). This expanded mandate will enhance CSS capacity to provide PSS to clients who are relatively independent and improve the ability of Community Care Access Centres (CCACs) to focus on providing PSS to clients with moderate, complex or post-acute needs. This Policy Guideline does not apply to PSS provided under the Attendant Outreach Services Policy Guidelines and Operational Standards (1996), the Self-Managed Attendant Services in Ontario - Direct Funding Pilot Project - Policy Guidelines (1994) or the Long-Term Care Supportive Housing Policy (1994). In addition, this Policy Guideline does not apply to Approved Agencies who provide PSS to children or Approved Agencies that are not CCACs that provide PSS to persons with Acquired Brain Injuries (ABI). For greater clarity, this Policy Guideline only applies to the PSS provided by Personal Support Workers (PSWs) and not to the broader range of services (e.g. homemaking) provided by PSWs. The Policy Guideline will also ensure that in-home PSS delivery is optimized to support the Ministry of Health and Long-Term Care s (ministry) transformation agenda, Action Plan and Seniors Strategy by: Improving access to safe and effective home and community care; Enabling person-centred care, suited to the needs of clients and caregivers; and Enabling flexibility at the local level to adapt community-based care to the local needs of clients. 2. Definitions Activities of Daily Living (ADL) are things we normally do to care for ourselves such as bathing, dressing, toileting, transfer, locomotion, or hygiene. Approved Agency is an agency that is approved under the Home Care and Community Services Act, 1994 (HCCSA) to provide community services (professional services, personal support services, homemaking services or community support services). In this Policy Guideline, Approved Agency refers specifically to CCACs and CSS agencies. April, of 14

4 Community Support Services (CSS) are the services included in the definition of CSS as set out in the Home Care and Community Services Act, 1994 (HCCSA) and O. Reg. 386/99 under the HCCSA 1. CSS Agency is an agency that has been approved under the HCCSA to provide CSS services. Home and Community Care Coordination Plan is the personalized plan developed or revised through the Home and Community-Based Care Coordination process that details the client s health and social care needs and the full basket of home and community services to meet those needs. See the Policy Guideline for CCAC and CSS Collaborative Home and Community-Based Care Coordination, Home Care and Community Services Act, 1994 (HCCSA) is the legislation under which CCACs and approved agencies provide home care services, including PSS. Ontario Regulation 386/99 (O. Reg. 386/99) under the HCCSA sets out the eligibility criteria and service maximums for the provision of PSS. Instrumental Activities of Daily Living (iadl) are tasks that, in addition to ADLs, one must be able to perform in order to live independently such as grocery shopping, meal preparation, using the telephone, laundry, light housekeeping, bill paying or managing medications. Personal Support Services are services that assist with personal hygiene activities and routine personal Activities of Daily Living (as defined in the HCCSA). Plan of Service is the plan developed or revised by an Approved Agency that sets out the amount of services to be provided to a client (as set out in the HCCSA). Restorative or Enabling Approach is an approach to care coordination, care and service planning, and service delivery that focuses on what the client can do and wants to be able to do, not just on what they are unable to do at present. It offers clients the 1 These services are meals, transportation, caregiver support, adult day programs, home maintenance and repair, friendly visiting, security checks or reassurance, social or recreational, aboriginal support services, client intervention and assistance, emergency response, foot care, home help referral, independence training, palliative care education and consultation, psychogeriatric consulting and public education relating to Alzheimer disease and related dementias, and services for persons with blindness, visual impairment, deafness, congenital hearing loss or acquired hearing loss, all as defined in the HCCSA and O.Reg. 386/99 under the HCCSA. April, of 14

5 opportunity to be actively involved in identifying goals that are important and meaningful to them and to participate alongside their PSW to achieve their goals Goals This Policy Guideline will ensure that older adults with frailty or long-term chronic conditions in need of in-home PSS receive high quality care that is focused on enabling or restoring independence and maintaining optimal level of function for as long as possible. Regardless of the Approved Agency that has been funded to deliver PSS, all clients will receive: Person- and family-centred care: Based on a philosophy of care, treatment and support that empowers clients to be active and knowledgeable partners in the health care process; holistic, collaborative, continuous, culturally sensitive and compassionate care that values client and family experience; considers the whole person - health, social, economic, mental and spiritual as well as their environment and family context. Equitable, accessible care: Ensuring all clients in all geographic regions will have timely, equitable and user-friendly access to PSS based on their assessed level of need and unique individual, family and community circumstances. Consistent home and community practices: Standardized functions and consistent service levels reflecting client population need within and across Approved Agencies. Within these parameters, high flexibility to select and adapt local models to build on community strengths and effectively utilize established, readily available programs and services within a given region. High quality care and better value for money: Service delivery is based on evidence in order to improve quality and outcomes for clients. Service provider and population outcomes are transparent. Payment is based on evidence to reinforce quality and result in efficient use of resources. Quality measures and feedback are embedded to drive continuous quality improvement and accountability for outcomes. Integration: PSS delivery seamlessly supports and compliments arrangements developed through local integration models and structures. Approved Agencies exchange information appropriately with care coordinators, primary care and other approved coordination networks (e.g. Health Links) to ensure home and community care for the client and their family becomes less fragmented as well as better coordinated, monitored and evaluated. 2 NSW Australia (2010) Enabling approach in community care April, of 14

6 It is expected that this will improve client, service provider and system outcomes resulting in: Improved client and caregiver experience; Improved functional outcomes for clients and populations; and Improved system performance and sustainability. See Section 8, Performance Metrics and Accountability. 4. Target Population for CSS Agencies This target population profile only applies to PSS delivered by approved CSS agencies. It is intended to provide decision support in the assignment of clients to the appropriate Approved Agency (CCAC or CSS) for in-home PSS delivery. The profile does not apply to clients requiring PSS delivered by CCACs. The description of the target population does not affect the eligibility criteria for PSS (see Section 5.1, Eligibility ). PSS provided by CSS agencies will be targeted to older adults in the community who, at the time of service initiation: Are eligible for in-home PSS (see Section 5, Eligibility ); Have some degree of functional impairment related to a long-term chronic condition or frailty and need assistance with ADLs in order to restore or maintain their independence 3 (i.e. excludes clients requiring PSS for post-acute/episodic care needs only); May also need assistance with IADLs in order to restore or maintain their independence; May also require or be receiving other CSS; Generally, have predictable care needs and low risk of negative outcomes as a result of their health condition, and are considered capable of independent living with the right supports at the time of initiation of the first PSS visit; Do not require sustained, long-term or intensive home care services delivered by regulated health professionals (i.e. professional services as defined in the HCCSA) on a regular basis (however, it is understood that some clients may require these services from CCACs from time to time as their needs change); 3 CCACs and CSS agencies must use a provincially adopted standardized assessment instrument which includes an assessment of functional needs as a decision support tool to determine whether an applicant requires PSS on a longer-term basis. April, of 14

7 Require significantly less than the maximum amount of PSS hours that may be provided by CSS agencies as set out in Regulation 386/99 under the HCCSA to maintain independence (see Section 5.6 Service Maximums ); Do not require end-of-life or palliative care services; Are not on a waiting list for long-term care home placement; Are not being discharged from a hospital or requiring services in relation to a recent post-acute episode of care; Are not considered at high risk of hospitalizations or multiple care transitions. 5. Common Standards for all Approved Agencies Approved Agencies delivering PSS must comply with the requirements under the HCCSA and O. Reg. 386/99 as well as policy standards Eligibility O. Reg. 386/99 under the HCCSA sets out the eligibility criteria for PSS provided to a client at his/her place of residence as follows: 1. The person must be an insured person under the Health Insurance Act. 2. The place in which the services are to be provided must have the physical features necessary to enable the services to be provided. 3. 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. CCACs and CSS agencies should have policies and programs to ensure that persons who do not meet any eligibility criteria still have access to care, such as through referrals to other agencies/providers. NOTE: Eligible home and community clients are entitled to receive home and community services in accordance with their needs and preferences. For eligible clients, the determination of need for specific services such as PSS and service levels is determined through the Plan of Service Home and Community Care Access Point(s) Clients can be referred to a CCAC and CSS Agency approved to provide PSS through various means, including a health care professional, institution, Health Link or by contacting the CCAC or CSS Agency directly. Referrals for existing home and April, of 14

8 community care clients may also be made through their current service providers (e.g. as their needs start to change). Prior to implementation, the Local Health Integration Networks (LHINs) and sector will have established a transparent and publicly communicated process for collaborative, streamlined intake. While there is no wrong door to go through for initial contact, the organization that is initially contacted by a client should ensure that the need for PSS is determined as part of the coordinated access, intake and assessment process as set out in the Policy Guideline for CCAC and CSS Collaborative Home and Community-Based Care Coordination, Standardized Assessment Practices Service planning and care planning and prioritization are to be informed by evaluating the needs, strengths and preferences of clients through an appropriately comprehensive and provincially adopted standardized functional assessment. Relevant assessment information should be shared where appropriate in order to reduce duplication, enhance the experience of clients and families and minimize staff burden. Approved Agencies are also required under the HCCSA to reassess the client s requirements when appropriate, depending on the client s condition and circumstances, and evaluate the client s Plan of Service and revise it as necessary when the client s requirements change Waitlist Practices The HCCSA requires Approved Agencies to ensure that the services outlined in a client s Plan of Service are provided to the client within a time that is reasonable in the circumstances (e.g. needs based prioritization). If a service outlined in a client s Plan of Service is not immediately available, the approved agency must place the client on the waiting list for that service and advise the client when the service becomes available. In order to ensure equitable access to services, LHINs and Approved Agencies providing PSS must establish regional processes to manage waitlists and waitlist data in accordance with provincially agreed upon standards based on: April, of 14

9 the client s condition; the client s support system; the availability of other community resources; and regionally adopted prioritization criteria Service Levels Recognizing that a range of client characteristics, circumstances and local availability of services factor into service authorization and planning, needs-based standards for receiving PSS should be as transparent and consistent as possible in order to ensure equity in access to care as well as the level of care provided Service Maximums The service maximums set out in O. Reg. 386/99 under the HCCSA apply to CCACs and CSS agencies approved to provide PSS. Subject to the exception set out below, if a client is receiving PSS in his/her home from a CCAC and/or one or more CSS agencies, the person cannot receive more than the following number of hours of PSS: hours, in the first 30 days of service hours, in any subsequent 30-day period. For example, and subject to the exception set out below, if a client is receiving PSS services from more than one CSS agency at the same time or from a CCAC and one or more CSS agencies at the same time, the total number of hours that the client can receive from all of these organizations is 120 hours (in the first 30 days of service) or 90 hours (in any subsequent 30-day period). The exception referred to above is that a CCAC may provide more than the above number of hours of PSS if the CCAC determines that extraordinary circumstances exist that justify the provision of additional services to the following persons: 1. A person who is in the last stages of life (palliative) (no time period); 2. A person who is on a waiting list for admission into a Long-Term Care Home (no time period); or 3. Any other person, but only for no more than 90 days in any 12-month period. Generally, clients receiving PSS through CSS agencies would not require the maximum level of PSS (120 hours in the first 30 days of service or 90 hours in any April, of 14

10 subsequent 30-day period) on a sustained or long-term basis (see section 4, Target Population for CSS Agencies ). Prior to implementation, the ministry, LHINs, CCACs and CSS sector will agree on a province-wide standard mechanism for tracking the total hours of PSS each client receives at any particular time to ensure compliance with the service maximums under O. Reg. 386/ Transition/Continuity An effective population- and needs-based continuum requires strong coordination of care within and across CCAC and CSS sectors for clients receiving multiple home and community care services as well as for clients experiencing changes in care requirements. A standardized, collaborative model of care coordination is required in order to ensure appropriate communication and accountability for care (see Policy Guideline for CCAC and CSS Collaborative Home and Community-Based Care Coordination, 2014). This model must also include standard practices for communicating with primary care and other system care coordination programs (e.g. Health Links). In the event there is a need for a transition between PSS providers, Approved Agencies are required to ensure the client is engaged in advance and there is no gap in service delivery Provider Performance and Quality Performance and quality standards should be outcome-focused. In particular, this means measuring the provider s contribution to enabling or restoring independence and maintaining optimal level of function for target populations for as long as possible. Quality standards for in-home PSS delivery must be consistent across all Approved Agencies providing PSS. Quality standards should be transparent to clients and families. The cost of delivery of in-home PSS must be reflective of evidence-based care in order to achieve high quality care and value for money. The HCCSA requires CCACs and CSS agencies to establish a process for reviewing complaints made to it by a client or their substitute decision-maker and the CCACs and CSS agencies must review all complaints in accordance with section 39 of the April, of 14

11 HCCSA. Section 40 of the HCCSA outlines the right to appeal to the Health Services Appeal and Review Board (HSARB) decisions made by the Approved Agency concerning eligibility, amount of service, exclusion of service from a Plan of Service and termination of service. 6. Implementation Each LHIN will determine how and by what date to implement the delivery of PSS by CSS agencies within the context of their regional priorities, health human resource plans, service delivery plans and models. This approach will allow for the development of processes for sector collaboration as well as specific arrangements in local communities to build on existing strengths and better address client needs. The LHINs and the ministry will establish a province-wide collaborative process with CCACs and CSS agencies to develop service guidelines to aid in resource allocation decision-making. These service guidelines would categorize clients based on their characteristics (as determined using assessment tools) and ensure consistent access to similar services among similar clients. Guidelines would provide parameters for decisions made by Approved Agencies about resource allocation, emphasizing the importance of clinical judgment while providing transparency about service level expectations for clients and families. LHINs and Approved Agencies should work towards province-wide standardized measures for home and community-based personal support functions. As part of implementation planning and roll-out, LHINs must develop a performance framework (see Section 9, Performance Metrics and Accountability ) that includes a consistent way of measuring and monitoring impact in a manner that allows for timely, ongoing modification of the implementation to maximize the impact of this Policy Guideline and ensure changes are delivering value to the overall health care system. This is often referred to as an audit and feedback approach to improving practice Guiding Principles This Policy Guideline should be implemented in a manner that best advances the following principles: Future Oriented Position the community sector for greater capacity to prepare for the future through establishing an effective population- and needs-based continuum of home and community-based care in each region in the Province. April, of 14

12 The focus should be on the client experience A client s existing relationship with an Approved Agency is recognized and respected by other Approved Agencies. In implementing changes to current arrangements, facilitating a positive client and family experience and maintaining respect for existing relationships remains paramount. Service and care planning and delivery place an emphasis on minimizing or managing transitions between direct care providers, Approved Agencies and sectors that impact the client s experience. Respectful collaboration, communication and relationship building Each Approved Agency s services and core competencies are equally recognized, respected and leveraged; all Approved Agencies in the community provide vital services to the client. Informs and builds upon the process for seamless, consistent and client-focused communication across sectors and between providers involved in the client s broader system-wide care plan, as is being established through the development of Health Links. Strong partnership and team approach to streamlined intake, assessment and identification of the appropriate Approved Agency for the delivery of PSS. Collaboration between direct care providers and care coordinators to identify risk to client and family and take appropriate steps to restore or maintain function and independence. Quality, Efficiency and Value Optimize existing assets. Leverage technology and other enablers. Promote adoption of standardized leading practices, while acknowledging appropriate regional differences. Performance measurement, electronic records, current remuneration systems and team-based incentives should be acknowledged and taken into consideration from the early stages of model design and implementation. Appropriate funding /resource allocation based on evidence and population impact. Alignment with ministry and LHIN emerging policies and directions, in particular Health Links. Home and Community-Based Care Coordination will be aligned with regional intake and assessment practices to ensure timely and client-friendly access to the full basket of home and community services. LHINs are encouraged to develop collaborative processes to share facilities, equipment and personnel among Approved Agencies, leveraging existing services to reduce underused capacity and costs. Factors impacting variations should be understood. April, of 14

13 7. Agency Approval Under the HCCSA, approved agency is defined as an agency that is approved under subsection 5 (1) of the HCCSA. The power of the Minister of Health and Long-Term Care under subsection 5 (1) (a) of the HCCSA to approve an agency to provide PSS has been delegated to the Director, LHIN Liaison Branch. In order to approve the agency, the Director must be satisfied that the agency meets the following eligibility criteria: (i) the agency, with financial assistance under the HCCSA or under the Local Health System Integration Act, 2006, will be financially capable of providing the service, and (ii) the agency is or will be operated in compliance with the Bill of Rights set out in section 3 of the HCCSA and with competence, honesty, integrity and concern for the health, safety and well-being of the persons receiving the service. The ministry/lhin Protocol titled Approval of Agencies to Provide Homemaking and Personal Support Services sets out the process for LHINs to seek approval by the Director, LHIN Liaison Branch to approve an agency to provide PSS. 8. Performance Metrics and Accountability Performance Metrics Performance measurement is the ongoing collection of performance data (indicators) to ensure that information required to inform, track and assess the progress of implementation is available. Performance measurement is critical in a continuous quality improvement process as it provides planners and decision-makers with objective quality information to determine if the changes are achieving the goals of this Policy Guideline. Review and analysis of performance data permits the ongoing modification of the implementation to maximize the impact of this Policy Guideline and to ensure changes are delivering value to the overall health care system. While performance measures will need to be finalized once an implementation plan is established, the final framework should be structured to appropriately connect front-line, service provider and team-based care to system outcomes for home and community-based personal support delivery in Ontario. To achieve this, it is recommended that performance metrics take the form of an integrated scorecard approach made up of measures structured as an inter-related cascade of information. April, of 14

14 The final framework of indicators should enable the province, LHINs, CCACs and CSS agencies to monitor and evaluate the quality of care and allow for benchmarking across regions, sectors and service providers. This will in turn support quality improvement and enable target setting to ensure continuous improvement. For example, rolled up to the provincial and LHIN level, results of indicators will provide an aggregated and summarized view of the impact of the implementation of the Policy Guideline. At the service provider level, case-level information can be reviewed in order to help target care processes that might be re-engineered to ensure that high-quality care is provided to clients. Provincial performance metrics should first be established to report on performance domains (policy goals). Team-based, service provider and front-line indicators would then be established within the same domains as part of the implementation planning and continuous quality improvement process. The domains for performance measurement include: o Person- and family-centred o Equitable and accessible o Consistency in practice o High quality care and value for money o Integration of services and transitions of care In order to support performance measurement, the ministry will regularly monitor the total population of clients receiving PSS within and across CSS and CCAC sectors and will work with both sectors to ensure appropriate data sharing agreements and standards are in place to permit cumulative and comparable population analysis prior to implementation of this Policy Guideline. Accountability CCACs and CSS agencies are funded by the LHINs and are held accountable through their multi-sector service accountability agreements (M-SAAs) with the LHINs. These agreements set out financial, operational and performance expectations for Health Service Providers (HSPs). LHINs will be responsible for reflecting any changes to operational expectations, such as enabling select CSS agencies to provide PSS and expectations related to collaboration among the CSS agencies and CCACs to ensure appropriate coordination and integration of care for clients, in their M-SAA with the HSP. These negotiated agreements follow a comprehensive planning process; each HSP must submit a Community Accountability Planning Submission (CAPS). The information contained within an individual CAPS may be reflected in the HSP s M-SAA with the LHIN. Any funding required to implement these changes will come from existing LHIN allocations. LHINs have the opportunity to reallocate funding based on local health system needs and priorities, within parameters set by the ministry. April, of 14

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