55 John Street

Station 1113, 11th Floor

Toronto, ON M5V 3C6

Tel: (416) 392-8906

Fax (416) 392-4180

Community and

Neighbourhood Services

Homes for the Aged Division

January 28, 1998

To: Community and Neighbourhood Services Committee

From: Acting Executive Commissioner, Community and Neighbourhood Services

Subject: Restructuring and Continuation of the Supportive Housing Program, within the Homes for the Aged Division

Purpose:

To seek authority for the Homes for the Aged Division to maintain its supportive housing program, through renewing annual agreements with identified supportive housing sites to provide a full range of personal support and homemaking services for frail and/or cognitively impaired seniors; and

To seek authority from the City of Toronto to implement a three-year transition process to restructure the Supportive Housing Program, as outlined in the body of this report in order to comply with recently confirmed provincial policy. Implementation of the three-year transition process will be contingent upon Ministry of Health endorsement.

Funding Sources, Financial Implications and Impact Statement:

There is no net impact as a result of the recommendations in this report. The personal support services provided under provincial supportive housing policy are now funded one hundred (100) percent by the Ministry of Health.

However, discontinuation of the current client co-payment system will mean that a maximum of 276 clients will receive service under the program (in comparison to a previous maximum of over 300 clients).

If the Ministry of Health is able to provide enhanced funding as requested in the transition plan, the number of clients will not reduce as outlined above.

There is a positive impact on the majority of individual clients enrolled in the supportive housing program, in that removal of the client co-payment requirement will provide additional disposable income, for use related to personal needs.

Recommendations:

It is recommended that:

(1) the Homes for the Aged Division be authorized to implement the three-year transition plan for restructuring the supportive housing program, as outlined in this report, contingent upon Ministry of Health approval;

(2) subject to the approval of the Ministry of Health as outlined in Recommendation No. (1), the per diem rates paid to supportive housing operators be revised effective April 1, 1998, or as soon as is practicable thereafter;

(3) the Homes for the Aged Division be authorized to renew the current agreements for the provision of supportive housing services with the supportive housing site operators and community service agencies outlined in the body of this report;

(4) the Homes for the Aged Division be authorized to enter into an agreement with The Meadowcroft Group, as the new owner of Livingston Lodge, for the purpose of continuing supportive housing services at that site;

(5) the agreements with the supportive housing operators be in form and content acceptable to the City Solicitor; and

(6) the appropriate City officials be authorized and directed to take the necessary action to give effect thereto.

Council Reference/Background/History:

Prior to 1993, the Homes for the Aged Division operated a satellite home program under the authority of the Homes for the Aged and Rest Homes Act, whereby the Division entered into contractual agreements with a number of for-profit and non-profit residential care facilities to provide light, residential care in a facility or group-home setting, to eligible seniors who did not require the full services of a home for the aged. The program was decentralized so that each satellite home was linked to one of the municipal Homes for the Aged, or "parent home". This provided a framework for admissions, monitoring of care and services provided to residents in the satellite home, and discharge planning when the scope of the satellite home program no longer met residents' needs.

Payment to the operators of the satellite home was made on a negotiated per diem rate for a specified number of residents in each site, to provide accommodation, nursing services, meals, housekeeping and personal care such as bathing and dressing. The per diem was constituted from three funding sources, i.e., provincial subsidy, resident co-payment, and municipal subsidy. The total per diem was considerably less than the per diem of nursing homes or homes for the aged.

Subsequent to the July 1993 proclamation of Bill 101, "The Long Term Care Statute Law Amendment Act", the Ministry of Health discontinued the Satellite Home Program and replaced it with a community-based program entitled Supportive Housing, as an integral part of the long-term care reform process. Any municipality who delivered a satellite home program prior to 1993 was given the option to restructure its existing program into the new supportive housing program, as a prerequisite to the receipt of continued provincial funding under the supportive housing program.

The Ministry of Health defined long-term care supportive housing as "providing personal support (e.g., assistance with the activities of daily living such as bathing, dressing, toileting) and essential homemaking services in community residential settings, for frail and/or cognitively impaired elderly persons where their service requirements justify the need for the availability of 24-hour on-site assistance".

Most of the satellite homes contracted with the Municipality of Metropolitan Toronto at the time accepted this program change. Metropolitan Toronto Council, by adoption of Clause No. 9 of Report No. 5 of the Executive Committee, approved an extension of the 1993 contracts. In consideration of the significant impacts of Bill 101 on the satellite home program, the Ministry's Long-Term Care Division verbally approved an initial three-year transition plan during which time Metro would undertake a reconfiguration of the satellite home program to comply with the values, principles and policies of the Province's supportive housing program.

During the transition between 1993 and 1996, Metro staff worked closely with the site operators, clients and their families to implement major program changes, based on the Ministry of Health's initial vision and principles for restructuring. These changes included eliminating the municipal subsidy component, separating accommodation costs from service packages for clients, creating a landlord and tenant relationship between the site operators and the clients, providing funding that more closely reflected the level of services being provided to the clients, and eliminating the continuum of care arrangements between the sites and the parent home for the aged.

By 1997, the Ministry of Health had refined and finetuned its vision of supportive housing, and released a document entitled "Planning, Funding, and Accountability", setting out service requirements. The Ministry also communicated a requirement for funded supportive organizations to file a written three-year transition plan, outlining how they intended to further restructure to comply with the provincial requirements, as set out in the abovementioned document.

At its meeting on June 19, 1996, through the adoption of Clause No. 6 of Report No. 8 of the Human Services Committee, Metropolitan Toronto Council authorized the Homes for the Aged Division to restructure the municipality's supportive housing program, to comply with provincial legislation, policy, and implementation guidelines.

With respect to the size and scope of the current supportive housing program, the Homes for the Aged Division directly employs 6.0 FTE in case management and administrative functions. In terms of service delivery, the Division currently contracts with a number of retirement and/or group home sites and one community support service agency. With respect to retirement and/or group homes, the Homes for the Aged Division has had long-standing contracts with:

(1) Beach Arms Lodge, 505 Kingston Road, Toronto

(2) Cedarbrook Lodge, 520 Markham Road, Scarborough

(3) Greenview Lodge, 880 Lawrence Avenue East, Don Mills

(4) Harold and Grace Baker Centre, 1 Northwestern Avenue, Toronto

(5) Livingston Lodge, 65 Livingston Road, Scarborough

(6) Magdalena's Rest Home, 379 Lake Promenade, Etobicoke

(7) New Horizons Tower, 1140 Bloor Street West, Toronto

The community agency contracted in the supportive housing program is St. Elizabeth Health Care, which provides supportive housing services to clients residing at Willowdale Manor, a building which is owned and operated by the Metropolitan Toronto Housing Company Limited.

On May 8, 1996, Livingston Lodge, 65 Livingston Road, Scarborough, a privately owned retirement setting, which has held a contract with the Municipality of Metropolitan Toronto since December 1, 1989, was purchased by The Meadowcroft Group, and the new owner requested a continuation of the contract for the supportive housing program for the site. On October 23, 1996, Metropolitan Toronto Council, by adoption of Clause No. 5 of Report No. 13 of the Human Services Committee, approved the continuation of the agreement of supportive housing services at this site, subject to the outcome of a formal evaluation, to occur after six months of the change of ownership. The evaluation was to be conducted jointly by representatives of the Ministry of Health, the Municipality of Metropolitan Toronto, The Meadowcroft Group, and clients and their families, and has been completed as required. The Report of Findings resulting from this evaluation identified several opportunities for improvement in both care and service provision and in compliance with the requirements of the contract with the municipality. The Meadowcroft Group has responded very positively to the recommendations in the report and have now implemented appropriate systems and procedures to address the issues identified. In early January 1998, Supportive Housing Program staff completed another on-site review of the Meadowcroft Group's responses and are satisfied with their commitment to deliver the services required by contract and by supportive housing policy.

The total gross budget for the supportive housing program is $2,671,830.00, which is one hundred (100) percent funded by the Ministry of Health.

The supportive housing program is one of the programs delivered by the Homes for the Aged Division, in its mandate to provide a continuum of care and services to eligible adults, in both facility and community settings. Appendix I outlines the Division's various programs.

Comments:

Since 1993, the Homes for the Aged Division has made payments to the contracted supportive housing operators on the basis of a per diem rate, for the "full service package" of professional nursing services, meals, housekeeping, and personal care services. Clients of the program have been assessed for eligibility on the basis of both functional and financial assessments, and have paid a co-payment for the aforementioned services, at a level as determined by their personal income and assets. In addition to the co-payment for services, clients have paid rent for their units, as set by the individual site, and have signed tenancy agreements with the sites.

The per diem rate paid to each site has not been increased since 1994, and has ranged from $12.11/day (all inclusive, for all services) to $26.37/day (all inclusive, for all services). In all cases, operators have asked for an enhanced payment system; to date, no increases have been authorized. Revenue directly received by the sites from clients, as a result of their tenancy agreements, is separate and apart from the aforementioned per diem rates.

In the Ministry of Health's "Planning, Funding, and Accountability" manual (Section 4), clarification was provided that provincial supportive housing funding will be limited to funding the following services:

(1) personal care services,

(2) food planning and food preparation, and

(3) home help services (e.g., housekeeping and laundry).

As a result, professional nursing services, historically funded to the contracted operators through the old all-inclusive per diem rate, will need to be accessed, in the future, through the recently established Community Care Access Centres (CCAC). CCACs were established by the Ministry of Health to organize, administer, and fund purchased community long-term care services, including nursing visits. There are six (6) CCACs in the City of Toronto.

Also as a result of the funding changes, all costs associated with independent living, such as food costs and personal hygiene products will be the responsibility of individual clients.

This shift in provincial vision and policy provided the impetus and opportunity for the Homes for the Aged Division to work collaboratively with the contracted supportive housing operators to restructure the current program, and to develop the requisite three-year transition plan. Consensus has been reached on the proposed changes and timeframes, and all the contracted operators have provided written endorsement of the plan, which has been communicated to the Ministry of Health.

The main elements of the restructuring plan are as follows:

(1) elimination of the requirement for client co-payment for services;

(2) establishment of a standard client fee, to cover the costs related to raw food, at the rate of $133.33/month; this rate will be reviewed by the parties at the latest, by the end of the three-year transition period;

(3) establishment of a standard per diem, for the payment of personal care, home help, and food preparation services, at the rate of $22.01/client/day;

(4) establishment of regular administrative reporting, in order to comply with the Ministry of Health requirement for reporting on "units of service" provided to supportive housing clients;

(5) elimination of the direct provision of professional nursing services; professional nursing services will be accessed by the sites (on their clients' behalf) from the CCACs.

The restructuring plan will result in all contracted sites receiving at least a minor increase in revenue for service provision, when considering combined the revenue received from the Ministry of Health and clients' payment for food. In addition, some sites have indicated that they will be attempting to secure funding from the CCACs, for the provision of professional services. Last, some sites plan to further increase revenue by increasing rental costs, by the percentage allowable under current legislation.

Although significant planning has gone into the development of the transition plan, there are a number of risks to the plan's success and/or ultimate approval.

First, the elimination of the co-payment for service provision will markedly decrease the total number of clients served at any one time from over 300 to 276. Although the Homes for the Aged Division has requested enhanced provincial funding to maintain the current service level (i.e., 300), there is no guarantee that this will be approved.

Next, there are a small number of current clients who will be unable to afford the client fee for raw food, in addition to their rental payment. The transition plan makes provision to subsidize these costs, with Ministry of Health approval, for up to three years. However, as a result of directing provincial funding at food costs for an interim period, the total number of clients served will further reduce marginally over the same period of time.

Next, it is possible that the Ministry of Health will reject the proposed continuation of a per diem payment system. Accurate implementation of the full provincial policy would require payment strictly on a "unit of service" system, i.e., assessing a specific number of hours/minutes of service per client per day, and paying only for the actual service delivered, as would happen in a visiting homemaker program. Because the Homes for the Aged Division contracts with a variety of for-profit and not-for-profit retirement and/or group homes, it is impossible for them to organize their staff response around a community visitation model. The Homes for the Aged Division understands the infrastructure costs realized by the contracted operators, and supports their request for continued per diem funding.

However, if the Ministry of Health insists on the strict implementation of a "unit of service" approach, it is possible that some contracted sites will withdraw from the program, as this decision would impact negatively on the sustainability of their businesses. If the sites withdraw from the program, it will create risk to current clients, who may not be able to access an appropriate, affordable alternative. In the event that this happens, the Division would collaborate with the sites and the Ministry of Health, to develop an exit strategy that minimized risk to the degree possible.

Next, it is acknowledged that the rents at some sites will discourage low income applicants and negatively impact on accessibility to affordable housing. The Homes for the Aged Division will continue to work with the contracted sites over the period of the transition to find a long-term solution that ensures a range of affordable options to individuals requiring supportive housing.

Last, it is acknowledged that the profile of clients in the Homes for the Aged Division's supportive housing program is different from many other supportive housing programs; clients tend to be frailer and/or have more cognitive impairment. The Division will continue to have a strong involvement in case management and quality monitoring, in order to ensure public accountability, quality of service, and the maintenance of long-standing and valuable strategic alliances with community partners.

Conclusions:

Approval of this report will permit the Homes for the Aged Division to renew contractual agreements with the eight existing supportive housing providers and enter into contractual agreement with the Meadowcroft Group, to continue the provision of supportive housing services at Livingston Lodge. As noted above, all supportive housing sites are committed to continuing their partnership with the Supportive Housing Program and are supportive of the transition plan being proposed. Pending approval of the transition plan by the Ministry of Health, the program changes outlined in the transition plan will be implemented and will result in improved conformity with Ministry of Health direction and policy requirements. If the plan is not approved by the Ministry of Health, staff will report back to the Community and Neighbourhood Services Committee, outlining issues and options.

The supportive housing program will continue to operate on the basis of one hundred (100) percent provincial funding for the actual supportive housing services.

The municipality will continue its role in advocacy, case management, and monitoring of the care and service provided by the contractors, to ensure that frail and/or cognitively impaired seniors in the city have access to high quality services in a variety of residential settings. These settings, on their own, would not be eligible to directly receive Ministry of Health supportive housing funding.

Contact Name:

Sandra Pitters, General Manager, Homes for the Aged Division

Tel: 392-8907; Fax: 392-4180; E-mail: Sandra_Pitters@metrodesk.metrotor.on.ca

General Manager, Homes for the Aged Division

Acting Executive Commissioner, Community and Neighbourhood Services

Appendix I

$ 10 Homes for the Aged (2,641 residents)

$ Supportive Housing (approximately 300 clients)

$ Homemakers and Nurses Services (approximately 25,000 clients/year)

$ 5 Adult Day Centres (approximately 300 clients/year)

$ Specialty Medical and Dental services provided through community partnerships

$ 2,929 staff, full and part-time (1,927 FTE)

$ 1,585 volunteers (126,000 volunteer hours/year)

$ involvement of 69 service clubs

$ alliances with multiple community organizations