Homes for the Aged - 1999 Operating Budget

The Strategic Policies and Priorities Committee recommends the adoption of the Recommendation of the Budget Committee embodied in the following communication (May26,1999) from the City Clerk:

Recommendations:

The Budget Committee on May 25, 1999, recommended to the Strategic Policies and Priorities Committee, and Council, the adoption of the report (May 20, 1999) from the Commissioner of Community and Neighbourhood Services.

Background:

The Budget Committee had before it a report (May 20, 1999) from the Commissioner of Community and Neighbourhood Services providing an analysis of the impact and an exploration of the options that a reinvestment of provincial funding would have on the Homes for the Aged and recommending that:

(1)the 1999 operating budget for the Homes for the Aged be increased by $697,000.00 to enable the Division to access additional provincial funding, which is available to enhance nursing services;

(2)this report be referred to the Community Services Committee for discussion of the policy issues and options outlined herein; and

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

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(Report dated May 20, 1999, addressed to the

Budget Committee from the

Commissioner of Community and Neighbourhood Services)

Purpose:

The purpose of this report is to provide an analysis of the impact and an exploration of the options that a reinvestment of provincial funding would have on the Homes for the Aged.

Funding Sources, Financial Implications and Impact Statement:

The Ministry of Health has confirmed additional funding for long-term care facilities provided that the funding is used to create professional nursing jobs. The Homes for the Aged Division is seeking City Council approval to increase the 1999 operating budget by $697,000.00 (gross). There is a requirement for these new funds to be used specifically for the purpose of enhancing professional nursing services. The funding represents a permanent adjustment to long-term care facility funding from the Ministry of Health and does not result in an increase in municipal net contribution.

Recommendations:

It is recommended that:

(1)the 1999 operating budget of the Homes for the Aged be increased by $697,000.00 to enable the Division to access additional provincial funding, which is available to enhance nursing services;

(2)this report be referred to the Community Services Committee for discussion of the policy issues and options outlined herein; and

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

Council Reference/Background/History:

During the Budget Committee's review of the Homes for the Aged Division's 1999 operating budget,it was requested that the Division report to the Community and Neighbourhood Services Committee and the Budget Committee on the significant loss of provincial funding since 1996. The request was made in light of the federal government's February 16, 1999 announcement that stated that transfers to the provinces and territories were to increase over the next five years by $11.5billion through the Canada Health and Social Transfer (CHST).

In the federal government's announcement, Finance Minister Paul Martin stated that a further $1.4billion will be invested over the next three years to strengthen Canada's health system through research and innovation, health information, improved health services for First Nations, and prevention. The announced increases effectively restore federal transfer payments for health care to levels that were in effect when the present government came to power.

Accordingly, the Budget Committee directed staff to study and report back at a subsequent meeting the impact that a restoration of provincial subsidy would have on the Division if funding were to be restored to the 1996 subsidy level. The report was to include options of expanding the number of available beds, improving the personal care level, as well as other service restructuring restorations.

Comments and/or Discussion and/or Justification:

Long-Term Care Reform:

For many years, the long-term care (LTC) system in Ontario has been under tremendous pressure to reform. In the early 1990s, the provincial government brought together long-term care facility and community programs under one new administrative structure. These programs had previously been the responsibility of separate Ministries, even though the programs served essentially the same client base. In the past, homes for the aged were the responsibility of the Ministry of Community and Social Services and nursing homes were the responsibility of the Ministry of Health. The Ministry of Health is now fully responsible for the funding and administration of all long-term care programs.

During the years that homes for the aged were under the Ministry of Community and Social Services, they were encouraged to design large facilities and dramatically expand and enrich the programs and services provided to their residents. Many municipalities and some charitable boards took advantage of this support and the cost sharing arrangements with the province to enhance their operations, resulting in higher per diems than other sectors of LTC facility care. To achieve some control of these costs, capping on provincial contributions was introduced in 1989 in cases where the extended care per diem exceeded the provincial average.

When the Long-Term Care Statute Law Amendment Act, 1993 (Bill 101), an Act to amend the three long-term care facility Acts, came into effect on July 1, 1993, the Province introduced a red-circling provision. Homes for the Aged were guaranteed to have their current level of care and staffing protected during the transition to a funding system that was to be based on resident care needs. Because of provincial funding constraints, the long-term care system was able to fund only facilities with an extremely modest per diem of $79.61 in 1993. For the Toronto Homes for the Aged, this created a significant shortfall because the Division's operating per diem was $147.58 at that time. This represented approximately $25.0 million in red-circle funding for the Toronto Homes for the Aged.

When the Province determined it would take too many years for the LTC system to be equalized, the Ministry of Health decided to eliminate red-circling by phasing it out over a two to four-year period. The elimination of red-circle funding commenced on June 1, 1996. Of Toronto's 10 Homes for the Aged, five Homes continue to receive a moderate amount of red-circle funding. Red-circle funding accounts for only $1.6 million of the Division's 1999 operating budget revenue. However, the final reduction in red-circle funding has been effectively offset as a result of the recently announced increase in level of care funding.

Toronto Homes for the Aged:

Historically, Toronto's Homes for the Aged have cared for residents who other facilities and service providers find difficult to manage. The average resident in a Toronto Home has three to five chronic diseases, including heart disease, chronic obstructed lung disease, kidney/liver organ failure and other debilitating diseases. Seventy percent of the Homes' residents are cognitively impaired with dementia diseases such as Alzheimer's Disease.

Toronto's Homes for the Aged Division has a recognized history of and commitment to client-centred, interdisciplinary care and quality of life issues. In response to this commitment, the Division historically staffed at a fairly high level, particularly in the nursing, recreation, rehabilitation, and social work areas. Prior to 1993, both the Province and Council supported the enhancement of staffing levels, based on a commitment to providing vulnerable seniors with quality care and quality of life. In more recent years, affordability has become an issue, and the level of care and service has been substantially reduced.

The Homes for the Aged Division has been proactive over the past six years in adjusting to the new provincial funding system. The Division needed to realize significant budget savings during that time in order to respond to the continuing financial pressures of reduced funding. In addition to reduced provincial funding, the Division's municipal contribution has been decreased by $9.7million or 29.6 percent since 1993. Expenditure reductions primarily focused on cost-controls and improved resource utilization. Net savings were realized through program restructuring and staff downsizing.

A comprehensive management plan that restructured the organization, streamlined operations, delayered management, identified numerous operational efficiencies, maximized revenue and formed strong community partnerships was implemented. The plan responded to the need for affordability and spending restraint, but did not abandon the concepts of quality, public service, and public accountability, concepts that the community clearly expects from the municipality.

Management identified numerous innovative and creative approaches to maintaining quality services for our clients during a time in which the Division experienced a significant loss of funding. The ways in which the Homes' services are delivered and resources are allocated have been reviewed and improved. The Division's long term plan contained 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.

New management levels and staffing standards were introduced across the Division and new sources of revenue identified. A client-centred approach to care and service was maintained as efficiencies were implemented in all areas of the Homes' operations. As the Division restructured, the focus on customer service remained. 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.

As part of the Division's strategic planning process, the following options are offered for consideration:

Option 1 - Expanding the Number of Beds:

On April 29, 1998, Ontario's Premier and Minister of Health jointly announced the Province's Multi-year Investment Plan for Long-Term Care. The investment plan involves the commitment of $1.2billion 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. The Province also targeted money for rebuilding and renovating more than 100 older facilities to comply with the new long-term care facility design standards which were released at the beginning of May 1998.

On May 1, 1998, the Ministry of Health released the allocated figures for facility and community reinvestments. For facility-based care, 5,837 new beds (out of the 20,000 provincial figure) have been allocated for the Toronto region over the next six years. This amounts to a $190.9 million reinvestment. A request for proposal process was conducted by the province in mid-1998 for 2,200beds in Toronto (6,700 beds across Ontario). The call was open to both the non-profit and for-profit sectors. Although the City of Toronto did not bid on any new beds, the Toronto Homes for the Aged Division provided consulting services to Doctors' Hospital in the development and presentation of their proposal. The Doctors' Hospital bid was strengthened by the Division's offer to provide consulting services for a multi-year period while Doctors' Hospital developed their own expertise in long-term care. Doctors' Hospital was awarded 200 long-term care beds.

The recently announced second phase of the Ontario government's six-year expansion plan will increase the long-term care system by a further 5,790 beds throughout various regions across the province, including the City of Toronto, where there are 744 beds available. A further 2,893 beds will be offered within Toronto in future phases of the expansion plan. Proposals during this phase must be submitted by 12:00 noon on July 30, 1999.

Level of care funding has been enhanced in recent years. A Home for the Aged with a provincial average case mix index of 100 will receive per diem funding of $95.64. If the City's 1996 funding level were to be restored by means of the City of Toronto pursuing new long-term care beds, the City could consider submitting a bid to acquire 200 new long-term care beds, and thereby open a new Home for the Aged. This option would require the City to make a capital investment of approximately $12.0 million and also to restore a portion of the Division's previously achieved net operating savings in order to sustain quality and service levels consistent with the City's other 10Homes for the Aged.

Option 2 - Improving the Personal Care Level:

Following the Federal Budget, the Ontario Government announced new investments in health nursing services. On March 17, 1999, Long-Term Care Minister Cam Jackson and Health Minister Elizabeth Witmer announced $20.0 million in annual funding to increase the number of frontline nurses available in long-term care facilities.

The additional funding available to long-term care facilities is being provided to enhance support for professional nursing staff and must be used to create professional nursing jobs. This represents a permanent adjustment to long-term care facility funding and will not result in a municipal contribution. For the Toronto Homes, the annualized funding enhancement is approximately $1.0million. However, in order to access these funds the Homes for the Aged Division requires City Council's approval to increase the 1999 operating budget by $697,000.00 for nursing and personal care. The Ministry of Health has implemented stringent reporting requirements to ensure that these new funds are directed solely towards enhancing the nursing and personal care of residents.

Staff are very pleased regarding the newly announced funding for nursing services, as it provides the first opportunity for a significant number of years to marginally enhance the level of nursing care provided to residents, rather than to continue another year of nursing reductions. Senior management have not yet determined the best allocation of the available funding, and will utilize data from the various Homes (including information related to the classification of resident need, feedback from satisfaction surveys, etc.) to make final decisions. However, senior management's initial opinion is that the best value would be realized by utilizing the funding to increase both registered nurse and registered practical nurse hours (up to 10 percent of the available funding can be used for other nursing expenses, such as the nursing supplies required to deliver more complex care). The exact number of registered nurse versus registered practical nurse hours would vary on an individual Home basis, according to the needs assessment of that Home. Initial estimate is that the funding would allow for the increase of approximately 15 nursing FTEs across the 10 Homes.

It is hoped that the recent nursing announcement is the first of a series of reinvestments in long-term care. As long-term care facilities are expected to deal with more and more residents with serious health conditions and complex continuing care requirements, it will be imperative for the Ministry of Health to reinvest health savings into the long-term care system. Other minor increases in base funding are currently being planned by the Ministry of Health. Moving into the year 2000, the opportunity will exist for the Division to begin receiving provincial funding increases rather than reductions in subsidy since the final phase of red-circle funding elimination will have been implemented.

Senior management has been actively involved in on-going discussions with the Ministry of Health to secure additional permanent funding for the Homes' program. As a result, it is anticipated that new monies will be made available to the City within the next year. This will possibly enable the Division to restore some of the previously eroded care levels.

Option 3 - Other Service Restructuring Restorations:

In response to the funding pressures in recent years, the Division has been required to reduce the service level of certain programs that serve to enhance the quality of life of residents. These services, although not all considered mandatory by the Ministry of Health, are considered by the Division to be essential for residents' health and sense of general well-being. The services that fall into this category are typically those funded in the "programs and support services envelope", and include services such as recreation, rehabilitation, complementary care, social work, spiritual and religious care, volunteer services, etc. If funding was restored to the Division, management would target some of the restored funding to expand service in these areas.

For example, the value of rehabilitation services (i.e., rehabilitation workers, occupational therapists, physiotherapists) to residents in the Homes is unquestionable, as it relates to the achievement of the Division's goal of promoting residents' independence, maintaining/improving residents' functional abilities (including behaviours), and preventing/delaying deterioration due to the natural aging process or chronic disease. An increase in rehabilitation service would add value to the Division's overall care and service delivery, particularly as the acuity of residents' care needs continues to increase.

Second, over 137,000 hours of volunteer services were contributed amongst the 10 Homes in 1998. This level of volunteerism far exceeds the average rate of volunteer participation amongst most other providers. The Division believes that additional staff support in the area of volunteer recruitment and coordination would help the homes to realize increased volunteer involvement and volunteer satisfaction, which directly impacts on resident satisfaction. Without question, volunteerism provides residents with an important linkage to the community. In return, community volunteers augment residents' quality of life and contribute substantial dollars through their fundraising initiatives.

Quality of life issues are also addressed by the provision of recreational programs and complementary care services (e.g., massage therapy, music therapy, art therapy, aromatherapy). Both of these services focus on residents as individuals and contribute to their psychosocial and physical wellbeing. In the past academic year, the Division has been able to offer student placement to a number of complementary care students, and these services have been exceptionally well received by residents and their families. Senior management is currently exploring the feasibility of adding complementary care services, on a more regular basis, if increased funding becomes available to cover the costs of same. Likewise, resident and family feedback provides evidence that both of these groups would like to see an expansion of recreation services, particularly in the evening hours and on weekends.

Next, an ever-increasing emphasis for the Division is the critical need to support staff by ensuring that they have access to both on-site and off-site educational offerings, in order to assist them gain and maintain the skills required to competently provide care and service to the Homes' residents and families. Individuals admitted to the Homes are frailer, and have more complex care requirements than several years ago. The Homes are becoming the "new" chronic care facilities, and the Division believes that it should take a proactive role in providing ways and means for staff to upgrade their skills.

Senior management is in the process of confirming a plan, identifying which programs and service areas should be expanded, as a priority, in order to add the most value to residents' lives, if some of the past funding is restored. The cost associated with restoring a portion of the residents' programs and support services would be minimal with substantial returns being measured in the provision of quality care to our residents.

Conclusion:

Over the past six years, the Division has been extremely successful in reducing costs and maintaining quality, in response to the funding reductions imposed. However, senior management has the philosophical belief that seniors residing in long-term care facilities deserve a higher level of care and service, particularly in the nursing and programs and services areas, than is supported through current provincial funding and/or policy. Staff have done a laudable job over the past number of years; however, they have become increasingly more frustrated with their inability to provide the high level of attentive, individualized care that they believe the elderly are entitled to.

For this reason, if there is a potential to achieve further restoration of funding, it would be management's preferred direction to expand the level of care and service provided to the residents currently cared for in the Division's 10 Homes. Prior to the introduction of any resource expansion, it would be management's intention to implement new performance measures, in order to track, manage, and measure efficiencies, effectiveness, and satisfaction.

On the other hand, if City Council made a decision to direct staff to explore the possibility of adding beds to the Homes for the Aged Division's system, immediate action would be required, as the Ministry of Health's current Request for Proposals (RFP) for new long-term care beds closes on July30, 1999 at 12:00 noon. Based on current information, there is reason to believe that there will not be another RFP released until at least 2001.

Contact Name:

Reg Paul, Director, Financial and Administrative Services, Tel: 392-8896; Fax: 392-4180; E-mail: reg_paul@toronto.ca.

The Strategic Policies and Priorities Committee also submits the following communication (May 31, 1999) from Ms. Anne Dubas, President, Local 79, Canadian Union of Public Employees:

This report provides information on potential sources of additional funding for the Homes for the Aged. It notes that there will be a Request for Proposals (RFP) for long-term care beds issued by the provincial government, with a July 30, 1999 deadline (option 1).

A new Home for the Aged in an area of the city which is presently under-served would be a proud asset for Toronto. The downloading of expenses to the City by the Province has had a negative impact o n our infrastructure. By responding to this RFP, we will gain a long-term investment which will enhance the infrastructure - paid for by the Province.

We recognize that it will result in additional operating costs, but the fact is this will probably be the last RFP until at least the year 2001. If we shut the door now by not taking advantage of this opportunity, then will not be serving the elderly on the long waiting lists in the community.

The Homes for Aged Division has the expertise to make a successful application for some of these new long-term care beds. It teamed up with the Doctors' Hospital for the last round of allocations and the hospital was awarded 200 beds.

We believe that the City has a responsibility to plan strategically so that there are enough beds for seniors in the future. We would ask this Committee to recommend that the General Manager of the Homes for the Aged Division respond to this Request for Proposals before the July deadline.

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Ms. Anne Dubas, President, CUPE Local 79, accompanied by Ms. Carmen Smith, Secretary-Treasurer, appeared before the Strategic Policies and Priorities Committee in connection with the foregoing matter.