October 16, 1998

To:Community and Neighbourhood Services Committee

From:City Clerk

Subject:Increasing Demand on the City of Toronto's

Homemakers and Nurses Services Program

Recommendation:

The Advisory Committee on Homes for the Aged on October 16, 1998, recommended to the Community and Neighbourhood Services Committee the adoption of the attached report (September24, 1998) from the General Manager, Homes for the Aged, respecting the impact on the Homemakers and Nurses Services Program resulting from changes to the community-based long-term care system, subject to amending Recommendations Nos. (1), (2) and (3) by adding the words "and Ministry of Long Term Care" after the words "Ministry of Health", so that the recommendations now read as follows:

(1)City Council direct the Commissioner of Community and Neighbourhood Services to meet with representatives of the Ministry of Health and Ministry of Long Term Care in order to express the municipality's growing concern regarding lack of equity in both access and level/scope of service available to citizens living in areas of the City of Toronto served by different Community Care Access Centres (CCACs);

(2)the Ministry of Health and Ministry of Long Term Care be requested to convene a meeting between the Executive Directors of the six CCACs within the City of Toronto to develop a plan to address the variances in service access, scope, and level being felt by Toronto citizens; and that this plan include the development of a communication network amongst the six CCACs;

(3)the Ministry of Health and Ministry of Long Term Care introduce an accountability system for the monitoring of CCACs to ensure service equity, a customer service approach in day-to-day operations, and compliance with Ministry expectations;

(4)City Council approve, in principle, the continued revision and streamlining of the Homemakers and Nurses Services Program (HMNS) eligibility criteria and scope of service, with the objective of ensuring that the available resources are directed to those most in need of service; and that HMNS implement a waiting list protocol, if such is required in order to continue to operate within approved budget; and

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

The Advisory Committee on Homes for the Aged reports, for the information of the Community and Neighbourhood Services Committee, having requested the General Manager, Homes for the Aged, to work with other providers of Homemakers and Nurses Services who are trying to achieve changes within the system.

City Clerk

R. Dyers/tl

Item No. 2

Sent to:Community and Neighbourhood Services Committee

General Manager, Homes for the Aged

(Communication dated September 24, 1998, addressed to the

Advisory Committee on Homes for the Aged from the

General Manager, Homes for the Aged)

Purpose:

To update City of Toronto Council regarding the changes in community-based long term care, their impact on the municipality's Homemakers and Nurses Services Program (HMNS), and the evidence of increasing gaps and differences in service levels provided to Toronto citizens as a result of the creation of six independent Community Care Access Centres (CCACs).

Funding Sources/Financial Implications/and Impact Statement:

The municipality's Homemakers and Nurses Services Program is cost-shared by the Ministry of Health and the City of Toronto on a 80:20 basis, as outlined in the Homemakers and Nurses Services Act. The 1998 approved gross budget is $4.28 million, of which the City of Toronto pays $1.5 million. There is no impact on either the gross or net budget as a result of this report.

However, this report identifies growing pressure on the HMNS to provide service to an increasing number of clients, due to the fact that the CCACs are rejecting clients for service, based on their own financial constraints. The negative outcome from this is threefold. First, individuals at risk in the community are being declined service to which they are entitled as outlined in the Ministry of Health policy directions for community-based long term care. Second, a large number of the referrals to HMNS from the CCACs are for individuals who should not be served by the HMNS program; this is placing an unfair onus on the municipal staff, to try to secure some type of service on behalf of citizens who are potentially at risk. Last, since the HMNS budget has not been increased, it may be necessary to initiate a waiting list protocol for the program for the first time in the history of HMNS, which will create a delay in service to vulnerable individuals.

Recommendations:

It is recommended that:

(1)City Council direct the Commissioner of Community and Neighbourhood Services to meet with representatives of the Ministry of Health in order to express the municipality's growing concern regarding lack of equity in both access and level/scope of service available to citizens living in areas of the City of Toronto served by different Community Care Access Centres (CCACs);

(2)the Ministry of Health be requested to convene a meeting between the Executive Directors of the six CCACs within the City of Toronto to develop a plan to address the variances in service access, scope, and level being felt by Toronto citizens; and that this plan include the development of a communication network amongst the six CCACs;

(3)the Ministry of Health introduce an accountability system for the monitoring of CCACs to ensure service equity, a customer service approach in day-to-day operations, and compliance with Ministry expectations;

(4)City Council approve, in principle, the continued revision and streamlining of the Homemakers and Nurses Services Program (HMNS) eligibility criteria and scope of service, with the objective of ensuring that the available resources are directed to those most in need of service; and that HMNS implement a waiting list protocol, if such is required in order to continue to operate within approved budget; and

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

Council Reference/Background/History:

Under the authority of the Homemakers and Nurses Services Act, the Homes for the Aged Division operates a municipal Homemakers and Nurses Services Program (HMNS), purchasing homemaking services such as meal planning and preparation, shopping, personal laundry service, and household cleaning, on behalf of elderly and disabled adult clients and families in crisis, who demonstrate both financial and functional need. The program provides in-home assistance, in order to support clients in remaining in their own homes; the goal of the program is to prevent premature institutionalization and family breakup. HMNS operates on a brokerage model. HMNS staff perform a case management function; direct service is provided by 14 contracted agencies (both for-profit and not-for-profit), who sign an annual service agreement with the City.

Approximately 53 percent of all HMNS clients are elderly; the remaining clients are individuals under the age of 65 who are suffering from stable chronic illness, disabilities, or psychiatric illness, and families in crisis, who require respite support for a period of time, in order to prevent family breakup.

Historically, HMNS worked in close cooperation with the Home Care Program of Metropolitan Toronto, and the two programs consulted frequently, to ensure that clients did not "fall through the cracks" of varying eligibility determination of the two programs.

In January 1996, the Minister of Health announced changes to Ontario's long term care system, which substantially changed community-based long term care. The Province's 74 existing Home Care programs and existing Placement Coordination Services were amalgamated into 43 new agencies called Community Care Access Centres (CCACs). Governed by non-profit Boards, the CCACs are mandated by the Ministry of Health to process and authorize applications for admission to all Ontario's nursing homes and homes for the aged, and arrange for the provision of community-based long term care services, on behalf of eligible clients. CCACs operate on a managed competition model, purchasing services from contracted agencies who have been awarded the contracts on the basis of best quality-best price.

Throughout Ontario, the creation of CCACs reduced the overall number of agencies responsible for the provision of home care. However, such was not the case in the City of Toronto. Rather, the Ministry of Health's direction to establish CCACs preceded the creation of the new City of Toronto; therefore, the CCACs were established on the six pre-existing municipal boundaries. There are currently six independent CCACs within the City of Toronto.

This policy direction was accompanied by a financial commitment from the Ministry of Health to increase community-based long term care funding by $551 million over the period of eight years, realizing a financial commitment of $1.75 billion by the year 2005/2006.

Funding was provided to the new CCACs on the basis of an equity funding formula developed by the Ministry of Health. Simply stated, the Ministry determined the amount of money currently available, and redistributed it to the "38 service areas" created by the development of the CCAC model. The City of Toronto is one "service area". The City of Toronto's allocation is then further broken down into funding for the six CCACs.

The equity funding formula is based on the determination of population and needs assessment (including factors related to age and sex distribution). As a result, some of the CCACs within the City of Toronto were "red-circled", and some received new base funding, in the initial year of operation. Ministry of Health representatives clearly communicated to the CCACs that they were expected to work within the approved budgets, and that continuing deficit budgets (as was often in evidence in the pre-1996 practice) would no longer be tolerated.

In terms of future planning, the Ministry of Health confirmed that the equity funding formula would continue to direct new dollars to CCACs each year up to the year 2006. The formula assumes an annual 2 percent increase in the range and type of service provided, and is structured to respond to population growth and changes in hospital discharge trends. Ministry staff estimate that CCACs within the City of Toronto will receive approximately 30 percent of all new funding up to the year 2006.

Although the 1996 announcement created CCACs as a replacement for the pre-existing Home Care programs, the announcement did not rescind the Homemakers and Nurses Services Act. Rather, the Ministry of Health encouraged continued involvement by municipalities in the discretionary municipal HMNS program, in order to continue to offer a social safety net to vulnerable individuals, who are deemed ineligible for CCAC service, but who, without some type of in-home support might suffer premature institutionalization and/or family breakup.

The City of Toronto's HMNS program has remained intact, with continued provincial funding and commitment, and staff have been active in reviewing and tightening eligibility criteria, to ensure that support is available to those vulnerable individuals at risk in the community. Staff have met regularly with the Executive Directors of the various CCACs, in order to establish a coordinated system for citizens of the City of Toronto.

Comments:

Individuals eligible to receive service from the HMNS program have historically presented with a different profile than those clients served by the previous Home Care program and the current CCACs. The municipal HMNS is developed specifically for low-income individuals who require some type of in-home support to remain independent, but who do not qualify for the Ministry of Health's long term care program. Applicants to HMNS must demonstrate financial need, as determined by legislation, and must be assessed to have a functional need associated with one or more household tasks related to activities of daily living. HMNS does not provide direct personal care, professional nursing, and/or professional therapy service, and therefore clients admitted to the program must be medically stable.

By contrast, the CCACs are agencies created by the Ministry of Health to coordinate access to long term care facilities and to provide a full range of community-based long term care services to eligible clients. The long term care services available to community clients include professional services of all types, personal care (e.g., bathing and hygiene), and homemaking. CCACs assign priority for admission to the range of service, based on the applicant's degree of health risk. Eligibility to receive assistance with homemaking is based on the prerequisite of the client's need for personal care.

As a result of their own financial pressures, particularly within CCACs which are redcircled, CCAC referrals to HMNS have increased dramatically. For example, prior to 1997, HMNS averaged 115 referrals from CCACs per month. Throughout 1997, this figure rose to an average of 129 referrals per month. From January to June 1998, there were an average of 139 referrals per month from the CCACs to HMNS. In July 1998, HMNS received 186 referrals. Of these 186 referrals, 44 percent originated from the CCAC serving the previous City of North York, and 30 percent originated from the CCAC serving the previous City of Toronto. These two CCACs are experiencing particular financial difficulties.

In addition to the marked increase in referrals, there is a disturbing trend developing, with respect to the type of client being referred. A number of referrals have been for individuals who have been in receipt of CCAC service for a number of years; many were frail elderly, whose health and functional status have not changed significantly to warrant a transfer to an alternate level of service.

A number of the clients referred were beyond the scope of service provided by HMNS, and/or did not meet the financial eligibility criteria for the program. Historically, the rejection rate for HMNS (i.e., the percentage of applicants deemed to be ineligible for service) has been approximately 35 percent; year-to-date in 1998, the rejection rate is 51 percent. It is worthy of note that 72 percent of all applicants to HMNS deemed to be ineligible for service have been referred from the CCACs.

The total units of service provided by HMNS is also rising significantly in 1998, to the degree that, unless steps are taken to manage the total number of individuals served and the total volume of service provided, HMNS will accept a growing risk of being over-expended within the next several years. Table 1 details trends in HMNS service delivery over the period of 1994 to July 1998.

In order to remain within the approved 1998 budget, HMNS staff are in the process of developing a "priority ranking" system and waiting list protocol. For example, based on the average number of hours of service per client (2.16 hours per client per week), the intake rate, and the average attrition rate, the program can reasonably admit an average of approximately 94 clients per month over the course of a year. Using this as a guide, staff may need to more strictly apply eligibility criteria, delay implementation of service for approved clients, and develop a waiting list, admitting on a priority ranking system. That is, the waiting list will need to make priority provision for those individuals who are in receipt of no alternative community-based service, and who may be at risk if homemaking services are not provided in a timely fashion.

Although it is acknowledged that these steps will effectively manage the HMNS budget, they do not address the larger policy issue; that is, the current community-based long term care system is not working effectively to ensure that individuals receive the care and service that they are legitimately entitled to, as envisioned by long term care reform and identified in provincial policy. There are gaps in the system and Toronto citizens are being left without service. Although HMNS staff regularly meet with CCAC staff, in an effort to work collaboratively, it may be appropriate to ask the representatives of the Ministry of Health to coordinate a meeting amongst the Executive Directors of the various CCACs in an attempt to develop a plan to improve service delivery, with respect to equity of access and scope/level of service and case management and coordination.

Conclusions:

HMNS has historically provided service to clients not served by other programs and has collaborated with the other providers to provide a continuum of care. Staff are continuing to work with community partners through this transition period as long term care reform is further unfolding, in an attempt to find solutions to the apparent increasing community need for service.

The current demand for service is creating a strain on the available resources. It is anticipated that, unless alternative solutions are identified, this strain will continue to exist until the provincial equity funding formula is fully implemented. Therefore, further review and immediate action are urgently required, in order to ensure that citizens of Toronto are not left at risk.

Contact Name:

Margo McNamara,

Coordinator - Homemakers and Nurses Services Program

Tel: 392-8543/Fax: 392-8457