June 4, 1998

 To:Community and Neighbourhood Services Committee

 From:Commissioner, Community and Neighbourhood Services Department

 Subject:Ontario Minister=s Announcement on Long-Term Care Reinvestment

 Purpose:

 The purpose of this report is to provide Toronto Council with an overview of the Ontario Minister=s announcement on long-term care reinvestment and the implications for the City of Toronto.

 Funding Sources, Financial Implications and Impact Statement:

 There are no immediate financial implications stemming from this report.

 Recommendations:

 It is recommended that:

 (1)the Commissioner of Community and Neighbourhood Services undertake a review of the program and policy implications of expanded provincial funding for long-term care services for the City and report back the findings to Toronto Council;

 (2)the Commissioner of Community and Neighbourhood Services with the General Manager of the Homes for the Aged arrange a meeting with senior staff of the Ministry of Health to discuss the issues and concerns:

 (i)raised within the report regarding the lack of a city-wide placement coordination system for facility referrals, and

 (ii)regarding current and prospective gaps in community-based service provision that are arising out of the Community Care Access Centre structure and funding process;

 (3)this report be forwarded to the Seniors= Task Force (formerly known as the Task Force on Developing a Strategy for Issues Concerning the Elderly) for consideration in the development of a seniors= strategy; and,

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

 Council Reference/Background/History:

 On April 29, 1998, Ontario=s Minister of Health announced that the Province will invest $1.2 billion annually to expand and improve long-term care services across Ontario. This infusion of redirected monies from hospital services adds 20,000 new beds into homes for the aged and nursing homes. Twenty thousand beds are said to be the equivalent of adding 175 new facilities into the long-term care system. The Province is also targeting money for rebuilding and renovating more than 100 older facilities to be able to comply with soon-to-be-released new design standards for long-term care facilities.

 The provincial government has earmarked $602 million for operating funds to open new homes for the aged and nursing homes and, overall, to enhance services in long-term care facilities. The remaining $551 million of the $1.2 billion will go towards expanding and enhancing community long-term care services such as in-home nursing, therapy, homemaking, meals on wheels, supportive housing and services for the physically disabled.

 Approximately $96 million a year over a multi-year period will go towards construction costs to build new and rebuild older facilities. Thirteen thousand existing beds are expected to be upgraded. In total, $2.5 billion in capital costs will be spent.

 The Province estimates that 70,000 new jobs will be created as a result of this reinvestment: 27,500 in health care provision (7900 in nursing positions, 19,600 positions for health care aides, homemakers and other front-line care workers) and 42,500 in construction. This provincial long-term care reinvestment plan is expected to take eight years to complete.

 Comments and/or Discussion and/or Justification:

 Facility-based Reinvestment:

 On May 1, 1998, the Ministry of Health released the allocated figures for facility and community reinvestments. For facility-based care, 5837 new beds (out of the 20,000 provincial figure) have been allocated for the Toronto region over the next eight years. This amounts to a $190.9 million reinvestment. An initial call for requests for proposals for 2200 beds for Toronto (6700 beds across Ontario) has been released with a deadline of July 31, 1998 for submissions. This call is open to both the non-profit and for-profit sectors. After construction of these initial new beds and renovations for the 13,000 existing beds have begun, a second call for proposals will be released for the remaining 13,300 new beds across the province. For Toronto this means a further 3637 new beds.

  Currently, Toronto has approximately 11,850 home for the aged and nursing home beds in the long-term care system. Based on 1996 census population data, Toronto has 91.2 beds per 1000 population of those 75 years or older. With 5837 new beds being introduced into the Toronto long-term care system, this results in 17,637 beds, 136.3 beds per 1000 population 75 years or older. These figures are approximate and use 1996 census population data. Realizing that these new beds are scheduled for completion in 2006, figures will need to be revised using new 2001 census population data.

 The City=s current number of long-term care beds approximates 5 per cent. of the total provincial allocation. This has enabled the City to maintain a presence at the provincial planning table which ensures the City=s ability to influence financial decisions, policy development and service planning for the City=s long-term care system. This is especially crucial as the Homes for the Aged Division continues its traditional role in caring for those more difficult to tend. Historically, Homes for the Aged has cared for residents that other facilities and service providers find difficult to manage. The average resident in a Home has three to five chronic diseases including heart disease, chronic obstructed lung disease, kidney/liver organ failure and other debilitating diseases. Seventy per cent. of the Homes= residents are cognitively impaired with dementia diseases such as Alzheimer Disease.

With a growing number of seniors within the Greater Toronto Area (G.T.A.) concentrating in the City of Toronto, it is crucial that the City maintains its ability to shape services for its senior population. According to 1996 census data, 63 per cent. of all seniors in the G.T.A. reside in the City=s boundaries. The City will need to review current municipal levels of facility-based care with updated senior demographics to ensure appropriate allocations for long-term care services into the twenty-first century.

 New Design Standards For Homes For The Aged and Nursing Homes:

 On April 29, 1998, the Minister of Health announced that new design standards will be introduced into the design of new long-term care facilities and implemented within existing facilities. Some key areas of importance, such as minimum bedroom size and mandatory call systems for emergencies, are prescribed in the design standards. With regard to space requirements, the design standards require that a gross amount of space be provided for each resident. In addition, precautions for safety and accessibility will be enhanced ensuring security systems to protect people with dementias such as Alzheimer Disease, and accessible building layouts and designs to ensure people with physical disabilities maintain their independence. These enhancements are said to provide more opportunities for personal privacy and increased safety and accessibility for residents and their families. The operator will be allowed to determine how the remaining space is allocated across the facility for such uses as recreational space or lounge areas, provided that minimum space requirements are met for the bedroom and dining room areas. All long-term care facilities will have to comply with these new standards.

It is expected that detailed information on the new design standards and capital funding provisions will be made in the next few weeks. The Ministry of Health has conducted an internal review of all long-term care facilities and has made a preliminary categorization of them into several groups: those that are at or above the new provincial standards, those that almost meet design standards, those that will require substantial assistance to meet the standards and those that will be required to be torn down and rebuilt. The process for identifying and approving the upgrading of the 13,000 beds is expected to occur after the initial 6,700 beds are approved. The Homes for the Aged may be notified as early as the summer of 1998 of any possible upgrading required to its facilities. Once more detailed information becomes available, staff will report back on the implications for the City.

 Facility Capital Funding:

 The Ministry of Health has introduced a comprehensive capital funding policy which will apply to all long-term care facilities. The policy includes an incentive-based capital funding per diem for replacing or upgrading capital to meet the new design objectives. The Province has decided that funding will no longer be provided to homes for the aged by way of up-front capital grants. The concept of a single pool of funds that provides funding on the basis of a specific per diem allowance will be implemented. These funds will be paid through the accommodation envelope of each Home's operating budget.

 The proposed model is estimated to provide just enough dollars to meet the payments on a 20-year mortgage for half the costs of the building. The difference is that payments will be spread over 20 years rather than up front. In financial terms, this model is much the same for building a new facility as implementing the traditional matching grants formula across the whole long-term care sector. This standardized system of capital funding is based on the Ministry of Health=s move towards equitable funding and treatment of all long-term care facilities, including municipal and non-profit homes for the aged, and nursing homes.

 Facility Operating Funding:

 The Province will provide an increase of 1.7 per cent. in operating subsidy in both the nursing and personal care, and program and support services funding envelopes, retroactive to April 1, 1998. The true benefit of this moderate funding increase will not be fully realized this year by the Toronto Homes for the Aged due to red-circling provisions which are still being applied to half of the Toronto Homes. These Homes will continue receiving funding at a level which is still marginally higher than the recently adjusted level of care funding amounts. It should also be noted that the Division continues to receive transition funding which was announced by the former Minister of Health on March 28, 1996. The stated purpose of this three year transition fund was to provide temporary assistance to any long-term care facility that had higher than average salary and benefit costs. While this fund will be discontinued on May 31, 1999, Divisional staff are still involved in discussions with the Ministry of Health to establish a permanent mechanism which will recognize legitimate price differentials on an ongoing basis.

 The Homes for the Aged Division has been proactive over the past several years to adjust to the new provincial funding system. Management has identified numerous innovative and creative approaches to maintaining quality services for our clients during a time that we have experienced a severe loss of funding. The ways in which the Homes' services are delivered and resources are allocated have been reviewed and improved. The Division continues to plan strategically and improve operationally in order to maintain effectiveness in a more diverse, competitive, and changing long-term care environment. The Division also continues to pursue within the community working partners with whom strategic alliances can be forged.

 Within the Division's long term plan was the expectation that level of care facility funding would be adjusted to more accurately reflect the true cost of providing care and services to seniors. This announced funding increase will result in a higher than budgeted provincial subsidy for the Homes for the Aged program in 1998, thereby requiring less of a municipal contribution. However, this surplus is temporary and will be offset in 1999 as a result of the expected loss of provincial transition funding identified above and as the Province continues to phase out the red-circle subsidy to the City. The Division plans to maintain current expenditure levels and produce unbudgeted net savings during 1998, in anticipation of reduced 1999 provincial funding and maintained municipal contributions at the forecasted 1999 requirement.

 It is noteworthy that with this recent announcement the Ministry of Health has now introduced a mechanism that will enable them to annually adjust the level of funding provided to facilities in the nursing and personal care envelope. Prior to this announcement funding levels to individual facilities were adjusted each year based on the home's change in its residents' average care requirements relative to the overall change province-wide. This relative averaging exercise was done in deference to the fact the total funding available for facilities was not increased, despite the evidence provided by historically trended data that the acuity of residents was increasing province-wide by one to two per cent. each year.

 Community Health Services Reinvestments:

 Allocated figures for community long-term care services were also released by the Ministry of Health on May 2, 1998. Out of the $551 million announced for community reinvestment throughout the Province, $125.5 million will be allocated for Toronto. Seventy-five per cent. of these dollars will go to Community Care Access Centres (C.C.A.C.s). Six C.C.A.C.s operate in the City of Toronto and are mandated to coordinate access to homemaking, nursing, therapy and other services to people at home, and provide long-term care facility placement and appropriate information to consumers and their families about the services and support available to them.

 The other twenty-five per cent. will go to volunteer-based community services such as meals on wheels, day programs, friendly visiting and other such community supports. The split essentially amounts to approximately $11.8 million per year over the next eight years for C.C.A.C.s, and $3.9 million per year for volunteer-based community long-term care programs, for a total of $15.7 million annually.

   Community Care Access Centres:

 The Province has suggested that the money earmarked for C.C.A.C.s will be directed to frontline care in the form of home care, nursing, homemaking and therapy services to people=s homes. The Province should also reconsider the level of resources allocated for technological and human resource supports at the six access centres and their ability to carry out the placement coordination function in a coordinated, consistent and informed manner across the City. To date, no coordinated region-wide information database has been developed to assist with this coordination. As a result, service information provided to applicants at any one geographic site may not have the up-to-date information on long-term care facilities and their range of specialized services in other geographic areas. This has access implications for both consumers and their families as well as financial implications for the City=s Homes as beds that could be offered to prospective applicants remain vacant for longer periods.

 In addition, the Homes for the Aged has witnessed inconsistency in the interpretation of eligibility for long-term care services with the establishment of six autonomous access centres across the City. Coupled with inadequate resources to complete more complex-level assessments required for facility referrals and reduced levels of interpreter services, access to long-term care services is becoming compromised. There is reason to believe that access to services will continue to be impacted with the implementation of the managed competition process for allocation of home care dollars over the next two years.

 Effective April 1, 1999, the funding currently provided by the Ministry of Health to agencies for home help/homemaking services through the paid employee model, will be transferred to the C.C.A.C.s. Over this coming year, requests for proposals will be submitted to the respective geographic C.C.A.C. for consideration in the allocation of funding to home care service providers for that geographic area. Any organization that is unsuccessful in obtaining a purchase of service agreement, will continue to receive 70 per cent. of their 1997/98 funding for eligible clients until April 1, 2001, through the C.C.A.C. After this two year period, the organization will have to compete for any further funding.

 Some movement can already be seen in the community as service providers, including some of the volunteer-based organizations, realign their service provision levels in preparation for opting out of the managed competition process. With some agencies no longer providing these services, there will be decreased service options for consumers and increased pressure on the Homes for the Aged=s Homemakers and Nurses Services Program (H.N.S.P.) to locate alternative forms of service provision. As this is the beginning of the managed competition process, further decreases in service options are expected and will ultimately result in gaps in services.

 The H.N.S.P. is currently experiencing higher levels of referrals, especially from the community, as the provincially-mandated C.C.A.C.s move towards a more medical approach to service provision and funding. It is anticipated that with this approach and with the implementation of a managed competition process that pits the non-profit with the for-profit sector, there may be a fundamental shift in long-term care service provision within the City=s community services system. This may have service and funding implications for the H.N.S.P. and the Community and Neighbourhood Services grants program in its provision of grants for seniors= programs.

 Community-based Seniors Supports:

 Much of the details related to community reinvestments in the volunteer-based service sector are still unknown. It is not clear what the effective date by which dollars will flow to community services will be nor the process for the distribution of dollars. It is evident, however, that an infusion of dollars will be reallocated to community organizations for home support programs.

Within the amalgamated City of Toronto, total municipal funding for all community-based seniors= programs amounted to over $3.4 million to 93 organizations across Toronto in 1997. The bulk of this money was administered by the regional Municipality of Metropolitan Toronto through the Community Services grants program. Approximately $3.1 million in grants funding ($1.2 million for elderly persons= centres and almost $1.9 million in home support) was provided to 83 community organizations across the City of Toronto.

 During the course of this year, a review of municipal grants programs and policies will be undertaken. For the Community Services grants programs, the review will provide opportunities for reallocating existing resources to meet emerging needs. Given the reinvestment in long-term care community services, the review may look at ways the City can more strategically fund seniors= services. It is within this context that long-term care community reinvestments will be reviewed and referred for discussion to the Municipal Grants Review Committee.

 Planning Initiatives with Implications for Seniors:

 A number of planning and research initiatives looking at issues impacting on seniors are currently underway. Most recently, at its April 16, 1998 meeting, Toronto Council had before it Community and Neighbourhood Services Committee Report No. 3, Clause No. 7, Report of the Dementia Task Force. In reviewing the work of the Task Force on the increasing rate of dementia in the Greater Toronto Area, Council adopted the Task Force=s recommendations including that Council advocate for enhanced provincial funding and resources to provide appropriate levels of community services and facility-based care. In addition, Council recommended that the Commissioner of Community and Neighbourhood Services submit a report back to the Community and Neighbourhood Services Committee on an advocacy strategy to compel the Provincial government to address the issues raised by the Task Force and on the future role of the City in providing long-term care services.

 Other research initiatives include a Community and Neighbourhood Services commissioned report on the issues arising from changes within the long-term care system and its impact on the Department, and the establishment of a Public Health staff work group to review its continuing role in preventative outreach to the frail elderly and isolated seniors. Public Health staff have recognized that the needs of more vulnerable, isolated seniors, often those with mental health concerns that would not willingly seek help from the C.C.A.C.s, will need to be addressed in a more preventative manner.

 These initiatives indicate the range of issues affecting seniors that impact on the City, its program areas and its senior residents. In an amalgamated City of Toronto, and particularly within the human services portfolio of the Community and Neighbourhood Services, there are opportunities to strengthen linkages between program areas to ensure that integrated responses to consumer and community concerns are developed.

 Conclusion:

 Currently there are 68 long-term care facilities within the City of Toronto, with approximately 11,850 beds. Applying the formula used by the Province in estimating the possible number of new facilities for Ontario, the introduction of 5837 new beds for the City is the equivalent of building approximately 50 new homes. With a current waiting list of a little over 5000 individuals for placement into long-term care facilities, these new beds have the capability of making a significant impact on waiting periods for long-term care consumers.

 The current provincial allocation for community long-term care services in Toronto is $168.8 million for C.C.A.C.s and $92.7 million for community support which includes funding for home support, supportive housing for the elderly, palliative care, the Homemakers and Nurses Program, and attendant care for people with disabilities. These figures are approximate and amount to a total of $261.5 million. The new dollars of $125.5 million will raise the total to approximately $387 million by the year 2006. This represents a 40 per cent. increase in community long-term care expenditures. These are significant long-term care investments that will be made over the next eight years.

 The Canadian Union of Public Employees, Local 79, has approached the City, via the Mayor=s office, to consider opportunities for redeveloping hospital sites scheduled for closure into possible municipal long-term care facilities. The Department believes that decisions related to the conversion of current hospital sites into long-term care facilities are best resolved by the facilities= Boards. Senior management of Homes for the Aged have been approached by the Ontario Association of Nursing Homes and Seniors= Services (O.A.N.H.S.S.) to provide its management expertise to those non-profit organizations seeking to submit proposals in the first round of long-term bed allocations. The Division is prepared to strengthen its partnerships with other community-based facilities and provide its management expertise, with limited implications for the City.

The Community and Neighbourhood Services Department anticipates provincial notification to upgrade one or two of its homes to meet recently-announced facility design standards. In its consideration for retrofitting those identified facilities, the Department will report back to City Council with site-specific service requirements/enhancements and financial implications for the City. In response to changes to the long-term care system and issues identified within recent planning and research initiatives outlined above, the Department will undertake a review of the program and policy implications of expanded provincial funding for long-term care services for the City, and report back the findings to Toronto Council.

Contact Name:

Sandra Pitters (phone 392-8907, fax 392-4180)

Lydia Fitchko (phone 392-5397, fax 392-8492)

Commissioner, Community and Neighbourhood Services Department