Implementation of a Waiting List for the

City of Toronto's Homemakers and Nurses

Services Program

The Community and Neighbourhood Services Committee recommends the adoption of the recommendation of the Advisory Committee on Homes for the Aged embodied in the following communication (May 28, 1999) from the City Clerk:

Recommendation:

The Advisory Committee on Homes for the Aged on May 28, 1999, directed that its support of the recommendations contained in the attached report (May 18, 1999) from the Commissioner of Community and Neighbourhood Services respecting the implementation of a waiting list for the City of Toronto's Homemakers and Nurses Services Program be conveyed to the Community Services Committee.

(Report dated May 18, 1999, addressed to the

Advisory Committee on Homes for the Aged from the

General Manager, Homes for the Aged)

Purpose:

To update City Council regarding the impact felt by vulnerable individuals in the community as a result of the restrictions in community-based long term care, i.e., service available through the Community Care Access Centres (CCACs) and the effect of these restrictions on the City-operated Homemakers and Nurses Services Program.

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 1999 approved gross budget is $4.28 million, of which the City of Toronto pays approximately $1.2 million. There is no impact on either the gross or net budget as a result of this report at the current time.

However, staff are still negotiating with the Ministry of Health in an attempt to secure enhanced funding, for an interim period of time, to deal with some of the transitional issues (e.g., gaps in service) that are emerging. If transitional funding is secured, it will be requested as 100 percent Ministry of Health funding, and, therefore, there will be no resultant impact on the net budget.

Recommendations:

It is recommended that:

(1)City of Toronto Council direct the Commissioner of Community and Neighbourhood Services to write to the Ministry of Health and the Executive Directors of the various CCACs to express concern about the growing gaps and inequities in both access to and level/scope of service provided to citizens of the City of Toronto, served by the various CCACs;

(2)the Homes for the Aged Division continue to monitor the waiting lists for the Homemakers and Nurses Services Program, and notify the Ministry of Health regarding specific cases in which individuals are left at risk as a result of the CCACs not providing the requisite services;

(3)if 100 percent transitional funding to the City is approved by the Ministry of Health to assist with reducing the gaps in service on an interim basis, the service provided by the Homemakers and Nurses Services Program be immediately expanded to the full capacity (taking into account both the financial resources approved and the time frame for the enhanced funding) of the transitional funding; and

(4)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 annual service agreements with the City.

Approximately 52 percent of all HMNS clients are elderly; the remaining clients are under the age of 65, but who are suffering from stable chronic illness, physical or psychiatric disabilities, and families in crisis, who require respite support for a period of time, in order to prevent family breakup. Geographically, approximately 44 percent of HMNS clients live within the boundaries of the previous City of Toronto, 39 percent within the previous City of North York, 9 percent within the previous City of Scarborough, 5 percent within the previous City of Etobicoke, 2percent within the previous Borough of East York, and 1 percent within the previous City of York.

Clients of the HMNS are expected to have reasonably stable health status and no resultant personal care requirements. Individuals who do not meet this profile are entitled to receive, and should receive, their service from the Ministry of Health programs funded and case managed directly by the CCACs. Unfortunately, although the Ministry of Health policy clearly indicates that CCACs are to provide homemaking services to their clients, CCACs have had numerous financial pressures and have implemented their own priority ranking system in an effort to control expenses. This priority ranking system has resulted in those with the more acute and/or higher risk needs being served first. Only if budget remains are individuals with lower level needs provided with service from the CCACs. As a result of these constraints and this management direction, CCACs appear to be discharging individuals at the lower end of the service spectrum from their caseload, in an attempt to manage their budgets. The impact of this direction is that elderly citizens with light service needs are being discharged from CCAC service or being provided with marginal levels of service, which are not sufficient enough to assist in maintaining independent functioning. These individuals are then being faced with the need to live within the service limits imposed by the CCAC (with negative impact on the quality of their lives), or to purchase services privately on a fee-for-service basis, or (if they qualify financially and functionally) to attempt to access service through HMNS.

At the City Council meeting of November 25, 26, and 27, 1998, through adoption of Clause No. 5 of Report No.11 of the Community and Neighbourhood Services Committee, City Council raised concern about the increasing demand on the City of Toronto's HMNS as a result of the limitations in the CCAC system, directed staff to meet with representatives of the Ministry of Health regarding the disturbing trends in an attempt to find resolution, and to continue to revise and streamline the HMNS eligibility criteria and scope of service, with a view to implementing a waiting list protocol if such was required to continue to operate HMNS within budget.

All of these strategies have been addressed, albeit with limited success. The pressure on HMNS has not eased. In April 1999, the HMNS initiated a waiting list for the first time ever in the history of the program.

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 CCAC Program. 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. Applications to HMNS must demonstrate financial need, as determined by legislation, and must be assessed to have a functional need associated with one of 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 co-ordinate access to long term care facilities and to provide a full range of community-based long term care services to eligible clients. Ministry of Health policy clearly states that CCAC clients are eligible to receive professional services of all types, personal care (e.g., bathing and hygiene), and a full range of homemaking services. However, CCACs do assign priority for admission to the range of services, based on the applicant's degree of health risk.

As a result of their own financial pressures, CCACs appear to be declining service to and/or restricting service to individuals who, although eligible for their services, demonstrate a lower degree of health risk. For example, the elderly without personal care requirements are being denied service. In another recent example, a woman with significant health issues as a result of multiple sclerosis (but whose husband was willing to complete her required personal care tasks) was declined service from the CCAC, until the HMNS staff and her husband advocated strongly on her behalf. Another disturbing trend is that individuals who have been in receipt of CCAC service for a number of years are being discharged; many are frail seniors, whose health and functional status have not changed significantly to warrant a transfer to an alternative level of care. Also disturbing was a recent case in which a client was discharged from CCAC service to HMNS; on investigation, the discharge and referral had been made because the client was a "complainer" who was using "too much" case management time from the CCAC, who is already strapped trying to provide care to clients with high risk health needs. The impact of CCACs denying service is that they are increasing their referrals to HMNS.

A number of the clients being referred to HMNS are beyond the scope of the service provided by HMNS and/or do not meet the financial eligibility criteria for the HMNS program. Although HMNS has "stretched" its eligibility criteria in order to provide a safety net to Toronto citizens, it is not the role of the City to provide clients who are eligible to receive CCAC services with service under its HMNS. If HMNS proceeded in this direction, it would simply become another CCAC and then be unable to serve the low income citizens that it is intended to protect.

Table 1 details trends in HMNS service delivery over the period of 1994 to 1998.

In the first and second quarters of 1999, the number of referrals and intakes to HMNS have continued to rise. HMNS staff have historically managed the budget by monitoring the number of new intakes, number of discharges, and number of authorized hours per week. No more than approximately 3,600 hours per week are authorized for approved clients, in order to administer the program within the approved annual budget. To date in 1999, there have been six weeks in which the authorized hours have exceeded this level, and this has resulted in staff initiating a waiting list protocol.

However, it is alarming that a growing number of individuals are "falling through the cracks" and being left without the requisite service. In the long term, this type of strategy will have a negative effect on the health status of frail citizens and will likely add to the overall health system costs, as they will require institutional care at an earlier stage, probably with heavier care needs. This type of strategy is also of concern in that it may result in a two-tier system, in which only people who can afford the full cost of their own in-home services will be able to maintain their independence.

In the short term, staff are anxious to find an interim solution to protect those individuals who are not able to access the requisite services. Staff have developed an action plan with two main themes; first, attempting to secure additional Ministry of Health funding to manage through the current "bottleneck" of referrals; and second, attempting to manage the waiting list for HMNS and administer the HMNS without incurring an over-expenditure.

(a)Additional Funding:

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

Funding was provided to the individual 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 individual CCACs to meet the needs of their "service areas". 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 of this equity funding approach, some of the CCACs within the City of Toronto were "redcircled", and will not receive new funding until their current level of funding matches their new entitlement. This has resulted in significant pressure amongst the CCACs in the City of Toronto.

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. Ministry of Health staff estimate that CCACs within the City of Toronto will receive approximately 30percent of all new funding up to the year 2006.

However, until the annual budgets of the individual CCACs increase accordingly, there will continue to be pressure on the HMNS, particularly within the boundaries of the previous Cities of Toronto and North York.

The Ministry of Health has expressed some willingness to look at the feasibility of flowing increased funding through HMNS, on a temporary basis, in order to assist in managing the transition. To date, there have been no firm commitments, but staff will continue to pursue this option, on behalf of the City's population. If funding is secured, staff propose to immediately increase the number of clients served by HMNS, particularly those who are eligible for CCAC service but who have been denied service based on CCAC-imposed volume restrictions. Although it is acknowledged that this is a "stop-gap" approach, staff recommend it as an interim strategy, with very tight controls and a firm end date, in order to alleviate negative community impact.

(b)Waiting List:

The HMNS has now implemented a waiting list protocol, as approved by City Council in November 1998. This is the first time in the history of the program that a waiting list has been implemented. The waiting list protocol has been introduced in a way that minimizes the negative impact on clients. Priority admission is given to clients with no alternative family and/or community support; these clients are being admitted within approximately five days of the referral. Clients who are currently receiving service from an alternative service provider (e.g., CCAC) are ranked at a lower priority and in general are waiting approximately 10 to 12 business days for admission to HMNS. The manager of HMNS is monitoring the waiting list and case workers are advising her of the applicant's status during the waiting period. The manager has regular conversations with CCAC staff, in an attempt to deliver the best service plan possible between the resources of the two programs. In most cases, the CCAC staff are working very collaboratively with HMNS staff, and their co-operation is appreciated, particularly in light of the fact that it is becoming increasingly more difficult to serve the population eligible for CCAC-funded service within their restricted budget allocations. However, conflict between the two programs has increased, and the staff and manager of HMNS spend considerable time advocating for citizens and managing conflict. For example, complaints from applicants and clients about service provision have risen by approximately 40 percent over the previous year. Most complaints relate to the denial of service, discharge from service, or the limited level of service provided by the CCAC. It is unfortunate that the changes in long term care have resulted in so much of staff time being directed at conflict resolution instead of service delivery.

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 does not appear to be working effectively to ensure that individuals receive the care and service that they are legitimately entitled to, as envisioned in 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 meet regularly with CCAC staff, in an effort to work collaboratively, it is apparent that the funding pressures within the system are larger than can be jointly managed solely by the staff of the programs. Increased Ministry of Health funding, either on a transitional or permanent basis, is needed in order to prevent further deterioration of community-based long term care.

Conclusions:

There is evidence that the community-based long term care system is not working effectively, as a result of the significant funding pressures being faced by the CCACs within the City of Toronto. As a result, clients who are technically eligible for CCAC service under government policy are either being denied service or are being referred to either fee-for-service agencies or HMNS. From a public policy perspective, this is worrisome. It provides the wedge in the door for a two-tier system, where the elderly with modest financial resources might be forced to either directly purchase service from their limited assets or go without service. It also provides a worry that the City-operated HMNS might be forced to become a "quasi-CCAC", since there is no other safety net within the City to provide service to low income seniors.

HMNS has historically provided service to clients not served by other programs and has a history of collaborating with other providers to provide a continuum of care. Although staff are continuing to work with community partners through this transition period as long term care reform is further unfolding, it is clear that the system is strapped, and the past good will between service providers is eroding, as individual agencies focus on balancing their budgets at all costs.

The current demand on service is creating a strain on the available resources. It is anticipated that, unless alternative solutions are identified, this strain could well continue to exist until the provincial equity funding formula is fully implemented.

In the interim, staff of HMNS will undertake to manage its waiting list with a balanced approach, considering issues such as risk, quality of life, compassion, and financial control. In addition, staff will continue to work with Ministry of Health staff in an attempt to identify alternative funding from the Province, which might be used in the transition. If transition funding is not secured, HMNS staff will need to resort to stricter eligibility and priority criteria, referring applicants and clients back to their respective CCACs, and advising them that HMNS is unable to approve them for the City-funded service as they qualify for services from the CCACs, as determined by Ministry of Health policy and funded by the Ministry of Health's long term care program.

Contact Name:

Margo McNamara,

Co-ordinator, Homemakers and Nurses Services Program

Tel: 392-8543/Fax: 392-8457

E-mail: margo_mcnamara@toronto.ca