January 15, 1999

To:Board of Health

From:Dr. Sheela V. Basrur, Medical Officer of Health

Subject:Toronto Task Force for the Frail Non-Receptive Older Adult

Purpose:

This report outlines the planning process taken by the Toronto Task Force for the Frail Non-Receptive Older Adult and identifies recommendations for the Board of Health's consideration.

Source of Funds:

Not applicable.

Recommendations:

It is recommended that:

(1)the Board of Health adopt the recommendations made in the report by the Toronto Task Force for the Frail Non-Receptive Older Adult;

(2)the report be forwarded to the Toronto District Health Council for their consideration;

(3)the Board strongly advocate that the Ministry of Health - Long Term Care Division move quickly to fund the implementation of a service model for frail non-receptive seniors as detailed in the report, accompanied by a strong evaluation component;

(4)Public Health continue to work with community agencies and advocate for improved services for this population; and

(5)Public Health develop a consistent approach to this target population across the City through the re-distribution of existing resources, pending the Ministry of Health's implementation of a service model for this population.

Background:

Historically, the former six Public Health units in Toronto provided varying levels of service to the elderly. The Ministry of Health Mandatory Health Programs and Services Guidelines specify the minimum services that all health units must provide. The most recent Mandatory Guidelines, released in December 1997, do not identify individual services to seniors. Instead, health units are directed to focus on population-based prevention strategies with this target population.

During the same period, the Community Care Access Centres (CCAC's) were being established in each of the six former municipalities. The revised Mandatory Health Program & Services Guidelines, combined with the CCAC mandate to serve seniors, allowed Public Health to transfer services for frail older adults who are willing to receive services to the CCAC's as of January 1, 1998.

However, there is another category of seniors who are frail, in need of service, but reluctant to accept service and therefore do not meet current CCAC eligibility criteria. Public Health currently receives referrals for these individuals, who appear to be largely hidden from society and are often in very poor health and living in precarious conditions. Managing these situations requires intensive cooperation and collaboration between Public Health, CCAC's and other stakeholders. A major issue in the current service delivery system is the lack of a comprehensive, consistent, and co-ordinated city-wide approach to serve this target population.

In March 1998, Public Health seconded a Public Health Nurse to work collaboratively with the CCAC's in forming the Toronto Task Force for the Frail Non-Receptive (FNR) Older Adult. The Task Force's role was to explore options and design a framework to address the needs of this target population. The goal was to develop a consistent community-wide response system for frail older adults who may be reluctant to accept services across the new city of Toronto. The executive summary and full report of the Task Force entitled "Serving Toronto's Frail Non-Receptive Older Adults, October 1998" are attached for further background information.

Discussion:

Since amalgamation, Toronto Public Health has continued to provide the same level of service to frail non-receptive older adults as was previously offered in each of the former municipalities. In 1998, the total number of FNR clients assessed in the city of Toronto was approximately 263. The current level of service among each of the former cities varied from between 8 to 80 clients per year. The reasons for this range were many and reflected the considerable differences among health units in their seniors' populations, resource bases, priorities, and service philosophies. Other factors which have had an influence on service levels have been the stage of development of each local CCAC and their resulting ability to accept referrals, as well as the presence of other agencies in the community who were able and willing to provide the intense, specialized services required by this group.

Referral sources across the City are similar and include emergency service personnel, such as police and firefighters, as well as those well known to the client such as family, friends, neighbours, landlords and other service providers. Many reasons are cited for making a referral. Often the caller expresses a concern for the health, housing or living conditions of the client, as well as frustration in not knowing who to call and being "bounced" around the system. These are some of the issues that the new response system should be designed to address.

In the meantime, Public Health attempts a number of interventions aimed at assessing the situation and connecting clients with the appropriate services where possible. This is very labour intensive, as a level of trust is necessary to have the client accept the services required, or it becomes necessary to seek out family or friends who can have a positive influence on the client's decision making process. Many times some form of advocacy is required to ensure that the client's rights are being respected and that they receive the services they need. Public Health strives for an outcome where the client is able to stay in their home, successfully connected to appropriate services, with continuity of care and some system of monitoring in place. However, this is not always possible. Sometimes when the client is assessed to be mentally incompetent, the Office of the Public Guardian and Trustee must become involved and/or the person may require admission to a long term care facility. None of these steps is easy, as there are gaps in service, waiting lists and cracks in the system that some people fall through.

Over the past year, the Task Force developed a model of service to improve the current system based on a consistent, comprehensive, and a community-wide approach. This model is based on an extensive literature review and is similar to the one currently used by East York.

All Task Force members agreed that there was a need for this response system. They were very committed to providing required services, however, the issue of funding was a major barrier. The CCAC's have stated that they would be unable to implement an intake & referral program for this target group without additional funding. Continued Ministry of Health funding for Client Intervention and Assistance Services is also essential and needs to be enhanced, however even this funding appears to be at risk. In order for the response system to be implemented, the Ministry of Health needs to fund such a model, and agencies receiving this funding need to be involved in implementation.

As Public Health shifts its services away from individual seniors, health service delivery to this target group could be compromised unless the proposed response system is in place. Public Health should review its current response and harmonize its service delivery to this target population and should inform those who make referrals on how to access the CCAC's and other resources. This harmonization of services should occur from within the existing envelope of resources so as not to draw further on City funds for what should be a provincially funded program. At the same time, total withdrawal of Public Health from this area in the absence of provincial funding would put the health and safety of these very vulnerable and isolated seniors even further at risk. It may also not be practical to withdraw given current political expectations for some public health support in this area, if only as a measure of last resort.

Conclusions:

The Board is requested to adopt the recommendations made in the attached reports and to forward the Task Force Report to the Toronto District Health Council for their consideration. It is important that the Ministry of Health-Longterm Care Division move quickly to fund the implementation of the service model outlined and ensure that the service model include a strong evaluation component prior to implementation. In the interim, Public Health would continue to work with community agencies in providing services for this population. Pending the Ministry's implementation of a service model across the new city, Public Health plans to harmonize current levels of service delivery with existing resources and move toward a more consistent approach to this target population.

Contact Name:

Irene Swinson, Toronto Task Force Facilitator for the Frail Non-Receptive Older Adults

Phone: 395-7648

Fax: 395-7691

Dr. Sheela V. Basrur

Medical Officer of Health

Attachments

EXECUTIVE SUMMARY

SERVING TORONTO'S

FRAIL NON-RECEPTIVE

OLDER ADULTS

A Report of the Toronto Task Force

for

Frail Non-Receptive (FNR) Older Adults

October 1998

In the new city of Toronto, it has been identified by Public Health, that a group of seniors, although they may need services, may refuse required services. The frail non-receptive (FNR) older adult may be isolated without identified supports. This individual may be reclusive, have underlying medical problems, mental health problems and/ or substance abuse, poor insight into his/her diminishing capacity, and may be reluctant to accept supportive services. As a frail individual, this person might be at heightened risk of physical harm, be unable to cope with change, and have reduced ability to accomplish activities of daily living. In order to prevent crisis situations for this target group, it is important to understand their requirements, be able to identify them early and then implement successful strategies that would assist them to remain in the community. Providing required services would assist the FNR older adult to remain in the community, promote autonomy and independence, and decrease associated healthcare costs due to inadequate service provision.

This document provides background information on the one year endeavour of the Toronto Task Force for the Frail Non-Receptive Older Adult, to develop the service delivery model for a community response program to address the needs of this target group. In the new Mandatory Guidelines for Public Health (December, 1997), intervention services for individual seniors are no longer included. Due to budgetary constraints for Public Health and the mandate of Community Care Access Centres (CCAC's) to service individual seniors, frail receptive clients were transferred to the CCAC's on January 1, 1998. Public Health collaborated with the CCAC's to assemble this Task Force comprised of a comprehensive, diverse group of consumers, service providers and Ministry staff, to address the needs of the frail older adult who may not be receptive to services.

A brief literature review shows a limited amount of information on the FNR client and on current community response programs. Attributes of a successful model were identified by Task Force members. Existing models were then researched and critically analyzed. A model design was assembled with current service gaps identified. A major underpinning for implementing the program model were Core Values and Principles. Planning assumptions for the model are also identified in the Appendices.

The model design proposes a system for response to frail older adults at risk and consists of two components: (A) Gatekeepers, who are non-traditional sources of referral and usually come into contact with frail older adults through everyday work activities, and (B) the System Response. A single access number is perceived to be essential to accessible service delivery. This System Response includes the: 1) Initial Telephone Call; Receiver of Call and After-Hours Action, 2)Referral to Local Agency, 3) Person(s) Going Out to Client, 4) Engagement, and 5) Action. Three case scenarios are presented as examples of this population, to better explain the profile of the older adult who may not be receptive to the services.

In determining the needs of this target group, estimates of those potentially accessing services could range from 4,800 (population data from those with cognitive impairment/ mental health problems living alone in Toronto) to 9,595 (Senior Link agency door-to-door canvasing) frail older adults who may not be receptive to the services outlined in this report. A major requirement to ensure service delivery to this target group includes current and additional funding for those agencies who currently provide services to these clients. Other requirements include: increasing public awareness through communication and education, translation services, accessibility to geriatricians/psychogeriatricians, and linkages between community agencies and hospitals.

Financial resources are necessary to fund the Intervention and Assistance Services (Seniors) program. Currently 26 community agencies receive funding from the Ministry of Health through its Longterm Care Division to provide intervention and assistance to vulnerable and at-risk seniors and persons with physical disabilities and/ or their caregivers. The additional costing required to enhance services for the frail older adult who may not be receptive to services, could start at $2,406,000 per year. However, as outreach evolves, the Ministry of Health would need to re-evaluate the costing to ensure it is reasonable in meeting ongoing demands for this target population. Details for this costing are found on pages 13 and 14 of the Report.

Additional costing for the Community Care Access Centres to integrate Intake & Referral of this target group would require $200,000 per year, which includes salaries for four full-time equivalent positions and overhead. Details for this costing are found on page 14 and 15 of the Report.

Additional costing for the Gatekeeper Program to raise public awareness and provide educational programs to proactively identify this target population would require $218,000 over 5 years. Details for this costing are found on page 15 of the Report.

RECOMMENDATIONS

1.0That this community-wide FNR Model be received and endorsed by the Medical Officer of Health and subsequently by the Toronto Board of Health.

2.0That the Toronto Board of Health should recommend to the Ministry of Health that:

2.1Assistance and Intervention (Seniors) is a vital service for frail older adults and should be continued as part of the services funded by the Ministry of Health;

2.2Assistance and Intervention (Seniors) services should be enhanced by a minimum of $2,406,000 per year for direct services;

2.3A Gatekeeper Program should be funded for $218,000 (over a period of five years) to undertake the necessary public awareness and education;

2.4Enhance CCAC's funding by $200,000 per year to provide Intake & Referral for the FNR;

2.5Appropriately fund CCAC's and community-based agencies for translator services.

3.0That Community Care Access Centres and Intervention and Assistance Services (Seniors) funded agencies initiate enhanced training & assessment for workers to better recognize and respond to situations of older adults living at-risk.

4.0That the soon-to-be-established Home Care Evaluation & Research Centre at the University of Toronto undertake a study of the frail non-receptive older adult and the impact of receiving early intervention versus no intervention.

5.0That the Ontario Hospital Association, the Ontario Medical Association, Community Care Access Centres and the provincial Regional Geriatric Program make improved discharge planning from hospital a high priority for improvement by the year 2000.

6.0 That the Longterm Care Task Force of the Toronto District Health Council endorse the Toronto FNR Model and act as an advocate on behalf of the population of frail older adults who may not be receptive to services and reside in Toronto.