Long-Term Care Homes Protocol Ministry of Health and Long-Term Care October 9, 2009
Table of Contents Page # Context...................................... 3 Roles and Responsibilities of Individual Ministry Branches........ 6 Bed Programs 1. Interim Beds................................ 7 2. Convalescent Care Program...................... 13 3. Short Stay Beds............................ 19 4. Beds in Abeyance........................... 22 5. Over Beds................................ 27 Bed Licensing and Transfers........................ 31 Appendices Appendix 1 Interim Beds............................. 37 Appendix 1.1 List of Interim Beds per LTC Home per LHIN as of March 31, 2008...........................37 Appendix 1.2 Template: Interim Bed Service Agreement (IBSA)........ 39 Appendix 1.3 Template: IB Addendum.................... 57 Appendix 1.4 Management Contract Template................. 60 Appendix 2 Convalescent Care Program..................... 66 Appendix 2.1 List of Convalescent Care Beds per LTC Home per LHIN as of March 31, 2008........................ 66 Appendix 2.2 Template: Amending Agreement.................. 68 Appendix 3 Short Stay Beds........................... 78 Appendix 3.1 Short Stay Beds per LTC Home per LHIN as of March 31, 2009. 78 Appendix 4 Beds in Abeyance...........................86 Appendix 4.1 List of Beds in Abeyance per LTC Home per LHIN. April 15, 2009.86 Appendix 4.2 Beds in Abeyance Policy, May 1, 2008.............. 89 Appendix A: Beds in Abeyance Application Forms........ 97 Appendix B: Recommendation Form.............. 102 Appendix C: Beds in Abeyance Agreement........... 104 Appendix 5 Bed Licensing and Transfers.................... 107 Appendix 5.1 Nursing Home/Bed Licensing Review Process...........107 Appendix 5.2 Annual Licence Renewal Process................ 110 Final LTCH Protocol July 31 2009 (2) 2 of 114
Context Purpose The purpose of this protocol is to set out basic information about Long-Term Care (LTC) Homes and the different programs, requirements and responsibilities of Local Health Integration Networks (the LHINs ) and the Ministry of Health and Long-Term Care ( the Ministry ). Applicable Legislation, Agreements and Policies The following Ministry legislation regulates the operation of LTC Homes: Nursing Homes Act ( NHA ) Charitable Institutions Act ( CIA ) Homes for the Aged and Rest Homes Act ( HARHA ) Health Facilities Special Orders Act ( HFSOA ) (collectively called the LTC Home legislation ) The Long-Term Care Homes Act, 2007 received Royal Assent on June 4, 2007. When proclaimed into force, this legislation would govern the operation of LTC Homes. This legislation would replace the NHA, CIA and HARHA. In addition, this legislation would amend the HFSOA so that it no longer governs LTC Homes. This protocol will be reviewed and amended once the new legislation is proclaimed into force. LHINs are created and governed under the Local Health System Integration Act, 2006 ( LHSIA ). Pursuant to this legislation, the LHINs have entered into the Ministry-LHIN Accountability Agreement, 2007-2010 ( MLAA ). The LHINS have the power under this legislation to fund and enter into service accountability agreements with LTC operators (who are defined as health service providers ). Currently, the Ministry s service agreements under the NHA, CIA and HARHA with LTC Home operators have been assigned to LHINs. Effective April 1, 2010, LHINs will enter into service accountability agreements with LTC Home operators. Definitions The following terms have the following meanings: Director unless otherwise specified, the Director means the person appointed as the Director under the Nursing Homes Act. The current Director is the Director, Performance Improvement and Compliance Branch, Health System Accountability and Performance Division PICB means Performance Improvement and Compliance Branch Final LTCH Protocol July 31 2009 (2) 3 of 114
Nursing Home- means any premises maintained and operated for persons requiring nursing care or in which such care is provided to two or more unrelated persons, but does not include any premises falling under the jurisdiction of, (a) the Charitable Institutions Act, (b) the Child and Family Services Act, (c) the Homes for the Aged and Rest Homes Act, (d) the Mental Hospitals Act, (e) the Private Hospitals Act, or (f) the Public Hospitals Act; ("maison de soins infirmiers") Beds in Abeyance LTC long-stay beds, previously licensed or approved by the Ministry that are unoccupied and not currently available for occupancy and have been approved by the Director, PICB for temporary withdrawal from the LTC Home funding system but which must be returned to the system within a specified time, or surrendered Convalescent Care Beds LTC short stay (up to 90 days) supportive care beds in LTC Homes for individuals who require time to recover strength, endurance or functioning Interim Beds LTC long-stay beds in LTC Homes that exist for a temporary period of time under the terms of a service agreement for interim beds for individuals who have been discharged from a public hospital Overbeds Additional beds in LTC Homes that are authorized by an increase in licensed or approved capacity for a specified period of time in order to address a short-term need in the community such as: o the admission of a person who requires immediate admission due to a crisis, and o the admission of a person into an interim bed. Short Stay Respite Beds LTC short-stay (up to 60 days) beds in LTC Homes for individuals whose caregiver requires temporary relief from his/her caregiving duties Context There are approximately 600 LTC Homes in the province. LTC Homes are designed for people who require the availability of 24-hour nursing care, daily assistance with activities of daily living or frequent supervision to ensure safety or well-being. LTC Homes offer a higher level of nursing care, personal care and support than that typically offered by either supportive housing or retirement homes. The Ministry sets standards of care and annually inspects all LTC Homes. LTC Homes are owned and operated by various organizations: Nursing Homes are usually operated by private corporations. Municipal Homes for the Aged are operated by municipalities. Municipalities in the southern part of Ontario are required to operate a home for the aged in their area, either on their own or in partnership with a neighbouring municipality. Charitable Homes are operated by non-profit charitable corporations that are usually faith or ethnic based. Final LTCH Protocol July 31 2009 (2) 4 of 114
LTC Homes in the World of LHINs In 2006, the government of Ontario created Local Health Integration Networks (LHINs) and gave them the authority under LHSIA to plan, fund and integrate health service providers, including LTC Homes, subject to certain restrictions. The Ministry, however, retains responsibility for licensing and compliance, inspection and enforcement functions as well as setting legislative, regulatory and policy requirements and standards. Effective April 1, 2007 LHINs were assigned responsibility and authority for the LTC Home Ministry service agreements. Subject to Ministry legislation, regulations, policies and standards, LHINs can amend these agreements with LTC Homes that have been assigned to them to address funding, service and performance expectations. LHINs will enter into service accountability agreements with LTC Home operators effective April 1, 2010. The MLAA is a three year agreement that sets out the roles and responsibilities of the Ministry and LHINs and their respective performance obligations. Schedules 3, 9 and 10 are reviewed and updated annually. Schedule 3 of the agreement outlines specific performance requirements relating to LTC Homes, including Beds in Abeyance, Short Stay Respite Beds, Convalescent Care Beds, Interim Beds, Per Diem Funding, and Construction Cost Funding. This Protocol provides information about these bed programs, as well as the overbed program and bed licensing, including the policies and procedures relating thereto and the roles and responsibilities of LTC Home operators, LHINs and the Ministry in managing these programs. The Elder Care Capital Assistance Program (ELDCAP) was established in 1982 to build long-term care facilities in small Northern Ontario communities. ELDCAP beds are included under the NHA and would continue to operate under the Long-Term Care Homes Act, 2007. Final LTCH Protocol July 31 2009 (2) 5 of 114
Roles and Responsibilities of Individual Ministry Branches Performance Improvement and Compliance Branch (PICB), Health System Accountability and Performance Division PICB is responsible for the licensing and approval of LTC Home operators and the various types of LTC Home beds. The Branch also monitors the performance of LTC Home operators as well as their compliance with Ministry legislation, regulations, policies and standards. The Branch inspects all LTC Homes annually, or more often as required, and takes steps to enforce where necessary. PICB also conducts pre-occupancy reviews relating to licensing transactions and must be informed of any concerns relating to the operation of these homes. LHIN Liaison Branch (LLB), Health System Accountability and Performance Division LLB supports the LHINs in their role as managers of the local health system. The Branch ensures that the LHINs and the Ministry meet their respective obligations set out in LHSIA through the development, negotiation, and management of relationships and accountabilities. LLB will be kept informed of transactions involving LTC beds and support the LHINs and PICB in these matters. Financial Management Branch (FMB), Corporate and Direct Services Division FMB is responsible for the transaction processing of funding/payments to LTC Homes as directed by LHINs and the coordination of in-year and year-end financial reporting from LTC Homes to LHINs. FMB will be kept informed of all LTC bed transactions for funding and reconciliation purposes. Health Data Branch (HDB), Health System Information Management and Investment Division HDB maintains databases of the number of LTC Homes in Ontario, number of different types of LTC Home beds, occupancy levels, and other statistics relevant to policy and operational decisions. HDB will be notified of all LTC bed transactions for health system data management purposes. Health Capital Investment Branch (HCIB), Health System Information Management and Investment Division HCIB provides expertise to manage the decision-making process for the implementation of capital projects for health care facilities/ services and ensures that capital programs are implemented in accordance with legislation and capital strategies, policies and standards. The Technical Specialists for Long Term Care, HCID, review all drawings (architectural, mechanical, and electrical), specifications, operational plans and project summaries for all new beds as well as for all existing homes considering renovations, alterations and/or additions. The review of these documents includes the Beds in Abeyance Program. Final LTCH Protocol July 31 2009 (2) 6 of 114
INTERIM BEDS I. Program Overview 1. Description and Rationale Interim beds are LTC long-stay beds in LTC Homes that exist for a temporary period of time under the terms of a service agreement for interim beds for individuals who have been discharged from a public hospital.. The Interim Beds Program is designed to help alleviate ALC pressures in communities with LTC bed shortages. The purpose of the Interim LTC beds is to ensure that hospital patients who are awaiting transfer to permanent long-term care homes are cared for in a home-like environment that includes programming and services that are specifically designed to meet their needs. As of March 31, 2008, there are 538 interim LTC beds in LTC Homes, hospitals or hospital-managed sites. As outlined in the Call For Applications to Operate Interim Long Term Care Beds dated June, 2005, LTC Homes must provide 100% of interim beds as basic accommodation if this is required to meet the preferences of applicants seeking placement to the site. 2. Models of Interim Beds and Approvals Two models have developed relating to the creation of Interim Beds: The first model is to increase the bed capacity in an existing LTC Home The second model is to licence or approve beds in a new LTC Home The approval processes relating to these two models are different as set out below. 3. Basic Requirements for Interim Bed Program Providers Interim Long-term care beds are LTC beds that are licensed or approved in LTC Homes. Hospitals operating interim beds are approved as operators under the Charitable Institutions Act. Where interim beds are being created by increasing the bed capacity in an existing LTC Home, the LTC Homes must have a satisfactory compliance record: the LTC Homes annual compliance review must show either no unmet standards or only some minor unmet standards and a strategy in place to address the unmet standards. Where interim beds are being created by licensing or approving beds in a new LTC Home, the proposed operator must meet the legislated requirements under the NHA, CIA or HARHA. 4. Funding Funding for Interim Beds is based on occupancy and is provided at the same rate as other LTC beds in the home. Final LTCH Protocol July 31 2009 (2) 7 of 114
The Case Mix Index (CMI) of various LTC Homes differs but all interim LTC beds located in hospitals are funded at a CMI of 100. 5. Accountability a) Legislation: Interim beds are LTC Home beds that are governed under the LTC Home legislation. Hospitals that operate interim beds are approved under the Charitable Institutions Act. b) Type of Agreement between parties: An Interim Bed Addendum to Long-Term Care Home Service Agreement between the LTC Home and the LHIN or, where necessary, an Interim Bed Service Agreement between the LTC Home and the LHIN Management contracts, if required. II. Roles and Responsibilities Ministry and LHIN Responsibilities outlined in the Ministry-LHIN Accountability Agreement (MLAA) Sections 28-29, Schedule 3 of the 2007-2010 MLAA (effective April 1, 2009) outlines the following responsibilities for the Ministry and LHIN in relation to Interim Beds: 28. In paragraphs 28.1 and 29, the term Interim Bed means a long-stay, long-term care bed designated for hospital patients in an existing LTC home that has been approved to exceed its licensed or approved bed capacity or in a new LTC home licensed or approved to provide interim beds. 28.1 The MOHLTC will: (a) (b) (c) Determine the Dedicated Funding Envelope in each fiscal year for the number of Interim Beds funded through that envelope as of March 31, 2008; In consultation with the LHIN, determine annually the operators of those Interim Beds that were funded through the Dedicated Funding Envelope as of March 31, 2008; and Set other conditions of funding related to the Dedicated Funding Envelope for those Interim Beds that were funded through the envelope as of March 31, 2008. 29. The LHIN will: (a) Advise the MOHLTC about the matters referred to in subparagraph 28.1 (b); (b) Use the Dedicated Funding Envelope for Interim Beds, and incorporate any conditions of funding referred to in subparagraph 28.1 (c) into agreements with LTC Home operators; Final LTCH Protocol July 31 2009 (2) 8 of 114
(c) (d) (e) Seek approval under applicable legislation to increase the approved or licensed bed capacity at a LTC home or request that the MOHLTC licence or approve a new LTC home for any additional Interim Beds that are not funded through the Dedicated Funding Envelope; and Determine whether to fund LTC Home operators for additional Interim Beds that are not funded through the Dedicated Funding Envelope, and From the LHIN s allocation, provide all related funding to LTC Home operators for any additional Interim Beds. III. Process 1. Existing Interim Beds As of March 31, 2008, there are 538 Interim Beds in Ontario (See Appendix 1 for list of operators and number of beds per provider per LHIN), which are entirely funded by the Ministry of Health and Long-Term Care. Ministry Roles: As per Section 28.1, Schedule 3 of the MLAA, the Ministry, in consultation with the LHINs, annually determines providers, number of beds, funding allocations and any additional conditions of funding for the 538 existing Interim Beds. The Ministry provides to the LHINs all funding required for the operation of the existing Interim Beds. LHIN Roles: As per Section 29, Schedule 3 of the MLAA, the LHIN will advise the Ministry on decisions regarding the providers, number of beds and funding envelope for the existing Interim Beds located in the LHIN. The LHIN may submit in writing formal recommendations to the Ministry, outlining concerns, community interests, local pressures, and proposed plan of action. The recommendations should be submitted to the Director, PICB, with a copy to the Director, LHIN Liaison Branch. 2. New Interim Beds in Existing LTC Homes As per Section 29, Schedule 3 of the MLAA, as of April 1, 2008 the LHIN can seek approval from the Ministry to add additional Interim Beds to the capacity of a LTC Home. The increase in capacity can only be authorized by the Director, PICB. The LHIN must provide all related funding for any Interim Beds created after April 1, 2008. A) Process for establishing additional Interim Beds in existing LTC Homes after April 1, 2008 Step 1: Operator submits application to LHIN The operator s application to the LHIN should include the following: Operator information, LTC Home/hospital information, current beds information Final LTCH Protocol July 31 2009 (2) 9 of 114
Interim Beds Program Application: - Care delivery: how the operator will meet the requirements of the program, including determining appropriate staff mix and staff levels; - Environment: physical environment, supplies and equipment, information systems; - Readiness to implement the Interim Beds Program: human resources, environmental components, experience; and - Finances: proposed budget. Step 2: Evaluation of application by LHIN LHINs should consider the following during the evaluation process: Identify any opportunities and risks; Develop mitigation strategies, as appropriate; Consult with the community and stakeholders; Take into consideration local pressures on the health care system, such as funding, ALC pressures, human resources limitations, effects of program on other health care sectors; Contact PICB for a determination as to whether all licensing and compliance requirements under applicable legislation are met; Seek advice from experts from various areas such as LTC, hospitals, performance, compliance, community engagement, MOHLTC compliance advisors, etc.; and Request and receive a pre-occupancy review from Area Service Office of PICB for the LTC Home; May request a site visit of the LTC Home or interview with the provider. Step 3: LHIN request Interim Beds approval from Ministry The LHIN submits formal request for approval of additional Interim Beds to the Director, PICB with copy to Director LLB. The information provided by the LHIN should specify the number of Interim Beds, the providers, the period of Interim Beds approval, and source of associated funding. Only the Director, PICB has the authority to authorize the increase in licenced bed capacity. Step 4: Ministry response to LHIN submission PICB reviews the LHIN s request in consultation with LLB and FMB. Service Area Office, PICB, conducts a pre-occupancy and structural review of the premises. The Director, PICB provides an approval letter for the requested Interim Beds to the LHIN with a copy to the Director, LLB; Director, FMB; HDB. The Director, PICB provides an approval letter to the operator, outlining the terms and conditions of the approval, with a copy to the CEO, LHIN; Director, LLB; Director, FMB; HDB In the cases when the LHIN has forwarded a management contract to the Ministry, the Director, PICB provides approval of the Management Contract with a copy to LLB, FMB and HDB. Step 5: Interim Bed Addendum to Long-Term Care Home Service Agreement In the cases when the LHIN adds interim beds or increases the number of Interim Beds in a LTC Home which already has a Service Agreement or an Interim Bed Service Agreement (Appendix 1.2), that has been assigned to the LHIN, the Final LTCH Protocol July 31 2009 (2) 10 of 114
LHIN amends the agreement by entering into an Interim Bed (IB) Addendum to Long-Term Care Home Service Agreement with the operator to reflect the program addition or expansion (IB Addendum template is attached in Appendix 1.3). In the cases when the Service Agreement has not been assigned to the LHIN, the Ministry (Director, PICB) will enter into an Interim Bed Service Agreement) with the operator 1 and then assign the agreement to the LHIN. B) Process for establishing additional Interim Beds at new LTC Homes (retirement home space) after April 1, 2008 1. Issue a licence under the Nursing Homes Act to an existing LONG-TERM CARE HOME operator who operates a retirement home An existing LTC Home operator who also operates a retirement home identifies unused capacity in their retirement home. The LONG-TERM CARE HOME and the retirement home can either be physically co-located or in close proximity of each other. The existing LTC Home operator would apply under the NHA to the Director for a licence to operate interim beds. LHIN must indicate support for the proposal and confirm that all funding associated with the interim beds (including per-diem funding) would be provided from LHIN allocations as per the current MLAA. MOHLTC Compliance staff would inspect the proposed LTC Home site to ensure it meets the requirements of the LONG-TERM CARE HOME legislation and regulations, as well as Interim Beds Program requirements. If all of the statutory requirements under the NHA were met for the issuance of the licence, the Director under the Act would have the authority to issue a licence to the LONG-TERM CARE HOME to operate interim beds. The LTC Home operator would be required to comply with the NHA, the regulations thereunder, the interim bed agreement and the LTC Homes Program Manual. MOHLTC staff would have authority to inspect the interim beds to ensure compliance with all MOHLTC requirements and standards and impose sanctions where appropriate. 2. Approve a public hospital under the Charitable Institutions Act to operate interim beds Hospital identifies unused capacity in a retirement home that can be used to operate interim beds. LHIN must indicate support for the proposal and confirm that all funding associated with the interim beds (including per-diem funding) would be provided from LHIN allocations as per the current MLAA. The Minister would have to approve the hospital as an approved corporation under the CIA and the Director, Health Capital Investment Branch, Health System 1 As per the Local Health System Integration Act, 2006, LHINs cannot enter into service agreements with LTC Home providers until April1, 2010. As an interim measure, the Ministry of Health and Long-Term Care enters into new service agreements with the provider and then assigns the service agreement to the LHIN. Effective April 1, 2010 LHINs can enter into interim bed service agreements with the LONG- TERM CARE HOME provider and notify the Ministry. Final LTCH Protocol July 31 2009 (2) 11 of 114
Information Management and Investment Division would have to approve the site as an approved charitable home for the aged under the CIA. Proposed space in retirement home is inspected by MOHLTC Compliance staff to ensure it meets all requirements under the CIA and Interim Beds Program. The hospital enters into a management contract with the retirement home operator. The Director, PICB would have to approve the management contract. The hospital, as a LTC Home operator, would be required to comply with the CIA, the regulations thereunder, the interim bed agreement and the LTC Homes Program Manual. MOHLTC Compliance staff has authority to inspect the beds to ensure compliance with all MOHLTC requirements and standards and impose sanctions where appropriate. IV. Appendices Appendix 1.1 - List of Interim Beds per LTC Home per LHIN (as of March 31, 2008) Appendix 1.2 Template: Interim Bed Service Agreement Appendix 1.3 Template: Amendment to Interim Bed Service Agreement Final LTCH Protocol July 31 2009 (2) 12 of 114
SHORT STAY BEDS There are 2 types of short-stay programs: the supportive care program (now called the convalescent care program) and the respite program. The convalescent care program is for persons who require time to recover strength, endurance or functioning and the anticipated stay is 90 days. The respite program is for persons whose caregiver requires temporary relief from their caregiving duties. The anticipated length of stay is 60 days. A person can spend a total of 90 days in a short stay bed in a year (combining the amount of days for respite and convalescent care). Final LTCH Protocol July 31 2009 (2) 13 of 114
Convalescent Care Program I. Program Overview 1. Description and Rationale of Program The Convalescent Care Program is a short stay supportive care program, provided by LTC Home Operators to people who need time to recover strength, endurance or functioning. As of March 31, 2008 there are 340 Ministry-funded Convalescent Care beds in the province, which are part of the total LTC Home bed stock. The program expands the range of options for individuals who do not need acute care but cannot yet manage at home; these individuals may be coming directly from hospitals or may be living in the community. The program provides short stay services to people who require a recovery period of up to 90 days. The Convalescent Care Program has a significant rehabilitative component, which includes additional services not provided to residents of other LTC Home beds. Additional funding is provided to the LTC Home operator to provide the rehabilitative component. The primary goals of the Convalescent Care Program are to: 1) provide appropriate, quality care to people who need time to recover strength, endurance, or functioning before returning home; 2) alleviate hospital pressures by providing an environment that meets the care needs of people who do not need acute care; and 3) make the most effective use of resources, primarily long-term care beds. The program is not intended for individuals who are awaiting permanent admission to a LTC Home. 2. Basic Requirements Licensed or approved LTC Home. Satisfactory compliance record: the LTC Home s annual compliance review must show either no unmet standards or only some minor unmet standards and a strategy in place to address the unmet standards. Compliance with the minimum structural requirements as evaluated by the Performance Improvement and Compliance Branch, Ministry of Health and Long- Term Care (MOHLTC or the Ministry ). Rooms for convalescent care residents that are private or semi-private, with a bathroom shared with no more than one other resident. As noted in the program description, Convalescent Care beds should be clustered separately within the facility to maintain the efficiency and effectiveness of the program. Areas to be used by convalescent care residents that are wheelchair accessible, and bathrooms that can accommodate a convalescent care resident in a wheelchair and a staff person at the same time. A proposed budget that does not exceed the funding determined by the Ministry. 3. Funding The resident does not pay any co-payment for Convalescent Care Beds. Therefore, the base daily MOHLTC subsidy for each Convalescent Care Bed in operation prior to March 31, 2008 is $133.75 in 2008/2009 (the same amount as the current long-term care base subsidy plus the co-payment). Final LTCH Protocol July 31 2009 (2) 14 of 114
LTC Homes offering convalescent care are also eligible for an additional $61.59 per bed per resident day in 2008/09 (based on occupancy), bringing the total potential subsidy to $195.34 per bed per resident day in 2008/2009. 4. Accountability: a) Legislative and Regulatory Parameters: The Convalescent Care Program is a short-stay restorative care program under the LTC Home legislation. 2 Convalescent Care Beds exist in LTC Homes. b) Type of Agreement between Parties: A Convalescent Care Beds Amending Agreement between the LTC Home and the LHIN (which amends the Service Agreement). II. Roles and Responsibilities 1. Ministry and LHIN Responsibilities outlined in the Ministry-LHIN Accountability Agreement (MLAA) Sections 22-23, Schedule 3 of the 2007-2010 MLAA (effective April 1, 2009), outlines the following responsibilities for the Ministry and LHIN in relation to Convalescent Care Beds: 22. In paragraphs 22.1 and 23, the term Convalescent Care Beds means those short stay beds that are designated to be occupied by persons who require convalescent care for stays of up to 90 days. It should be noted that Convalescent Care Beds are also available to persons in the community. 22.1 The MOHLTC will: (a) Determine a Dedicated Funding Envelope for Convalescent Care Beds; (b) In consultation with the LHIN, determine the LTC Home operators that will provide Convalescent Care Beds and the number of such beds to be funded by the Dedicated Funding Envelope provided by the MOHLTC; and (c) Set any other conditions related to Convalescent Care Beds; 23. The LHIN will: (a) Advise the MOHLTC on the matters referred to in subparagraph 22.1(b); (b) Use the Dedicated Funding Envelope to fund LTC Home operators to provide Convalescent Care Beds referred to in subparagraph 22.1(b); (c) Determine whether to fund operators for additional Convalescent Care Beds, including the number of such beds, outside the Dedicated Funding Envelope and, if so, provide all related funding for the additional beds 2 The Convalescent Care Program will be governed by the new Long-Term Care Homes Act when the Act is proclaimed. The Long-Term Care Homes Act will replace the Nursing Homes Act, Charitable Institutions Act, and Homes for the Aged and Rest Homes Act Final LTCH Protocol July 31 2009 (2) 15 of 114
(d) from the LHIN s allocation; and Determine the LTC Home operators of additional Convalescent Care Beds referred to in subparagraph (c), subject to a pre-occupancy review by the MOHLTC. III. Process for Convalescent Care Beds Transactions 1. Existing Convalescent Care Beds As of March 31, 2008, there are 340 Convalescent Care Beds in Ontario (See Appendix 2.1 for list of providers and number of beds per provider per LHIN), which are entirely funded by the Ministry of Health and Long-Term Care. Ministry Roles: As per Section 22, Schedule 3 of the MLAA, the Ministry, in consultation with the LHINs, determines providers, number of beds, funding allocations and any additional conditions of funding for the 340 existing Convalescent Care Beds. The Ministry provides to the LHINs all funding required for the operation of the existing Convalescent Care beds, equal to $195.34 per bed per resident day (for 2008/2009). This funding covers the base per diem ($90.60), the amount of the copayment ($43.15), and additional convalescent care per diem ($61.59). LHIN Roles: As per Section 23, Schedule 3 of the MLAA, the LHIN will advise the Ministry on decisions regarding the providers, number of beds and funding envelop for the existing Convalescent Care Beds located in the LHIN. The LHIN may submit in writing formal recommendations to the Ministry, outlining concerns, community interests, local pressures, and proposed plan of action. The recommendations should be submitted to the Director, PICB, with a copy to the Director, LHIN Liaison Branch. 2. New Convalescent Care Beds As per Section 23, Schedule 3 of the MLAA, as of April 1, 2008 the LHIN can decide to convert existing LTC Home beds into Convalescent Care Beds in order to address local pressures. The LHIN must provide any additional funding associated with the new Convalescent Care Beds. Ministry Roles: When the LHIN converts LTC Home beds to Convalescent Care Beds, the Ministry will fund the beds as existing LTC Home beds, for 2008/2009 an average per diem of $90.15. The Ministry (PICB) provides a pre-occupancy review of the beds to be converted, as well as report of the compliance history of the LTC Home provider The Director, PICB provides approval for the requested new Convalescent Care Beds to the operator PICB will continue to provide ongoing compliance reviews of Convalescent Care Beds that have been converted from LTC Home beds. Final LTCH Protocol July 31 2009 (2) 16 of 114
LHIN Roles: When the LHIN converts LTC Home beds to Convalescent Care Beds, the LHIN must ensure that all requirements of the Convalescent Care Program and applicable legislation are met (as outlined under Process below). The LHIN manages all aspects of the new Convalescent Care Beds, including funding, number of beds, providers, evaluation of achievement of program objectives, and LHIN conditions of funding. The LHIN must provide any additional funding associated with the Convalescent Care Beds from the LHIN s own resources. In 2008/2009 the LHIN must provide the following additional funding per resident per day: - Average resident co-payment: $43.15 - Convalescent Care Beds Program Additional Funding: $61.59 Total LHIN funding $104.74 2. a) Process for LHIN approval of converting LTC Beds into Convalescent Care Beds Step 1: Operator submits application to LHIN The operator s application to the LHIN should include the following: Operator information, LTC Home information, current beds information Convalescent Care Program Application: - Care delivery: program description, process for determining needs of convalescent care residents; determining appropriate staff mix and staff levels; needs for diagnostic and laboratory services; - Environment: physical environment, supplies and equipment, information systems; - Readiness to implement Convalescent Care Program: human resources, environmental components, experience; and - Finances: proposed budget. Step 2: Evaluation of application by LHIN LHINs should consider the following during the evaluation process: Identify any opportunities and risks; Develop mitigation strategies, as appropriate; Consult with the community and stakeholders; Take into consideration local pressures on the health care system, such as funding, ALC pressures, human resources limitations, effects of program on other health care sectors; Contact PICB for a determination as to whether all licensing and compliance requirements under applicable legislation are met; Seek advice on clinical services for the proposed Convalescent Care Program from outside experts from various areas such as LTC, hospitals, performance, compliance, community engagement, MOHLTC compliance advisors, etc.; and Request and receive a pre-occupancy review from Area Service Office of PICB for the LTC Home; and May request a site visit of the LTC Home or interview with the provider. Final LTCH Protocol July 31 2009 (2) 17 of 114
Step 3: LHIN notifies the Ministry of changes in the Convalescent Care Program The LHIN must notify the Ministry of any changes to the number and providers of new Convalescent Care Beds 3. The information provided by the LHIN should specify the number of Convalescent Care Beds, the providers, the period of time for which LTC Home beds will be converted into Convalescent Care Beds, and the source of associated funding. The LHIN must confirm in writing that all requirements of the Convalescent Care Program are met. All notifications should be sent to the Director, PICB, with copies to the Director, Health Data Branch and the Director, Financial Management Branch. If LTC Home operator is entering into a management agreement (or the operator or manager is assigning the management contract) a copy of the Management Contract must be submitted to the Director, PICB for approval under Section 11 (1) of the Nursing Home Act. (Approval of these types of contracts is also required for operators of homes for the aged.) LHIN provides a copy of the Home Management Contract for review and approval of the Director, PICB. Step 4: Ministry response to LHIN submission The Ministry (PICB and/or LLB and/or FMB) may provide comments to the LHIN regarding the LTC Home operator, the Convalescent Care Beds program, or as required. The Ministry (PICB) provides a pre-occupancy review of the beds to be converted, The Director, PICB provides approval for the requested Convalescent Care Beds to the operator and the LHIN. In the cases when the LHIN has forwarded the management contract to the Ministry, the Director, PICB provides approval of the Management Contract and comments to the LHIN, with a copy to LLB, FMB and Health Data. Step 5: Convalescent Care Beds Amending Agreement In most cases a long-term care Service Agreement between the Ministry and the LTC Home has been assigned to the LHIN. When the LHIN creates or expands the Convalescent Care Program in a LTC Home which has a Service Agreement that has been assigned to the LHIN, the LHIN amends this agreement with the operator (Convalescent Care Beds Amending Agreement, Appendix 2.2) to reflect the program addition or expansion. In the cases when the long-term care Service Agreement between the Ministry and the LTC Home has not been assigned to the LHIN, the Ministry (Director, PICB) will enter into the Convalescent Care Beds Amending Agreement with the operator 4 and then assign the agreement to the LHIN. 3 LHINs can only make changes to number and providers of Convalescent Care Beds to be created after April 1, 2008. LHIN may advise the Ministry on changes to the number and providers of Convalescent Care Beds existing before April 1, 2008. 4 As per the Local Health System Integration Act, 2006, LHINs cannot enter into service agreements with LTC Home providers until April1, 2010. As an interim measure, the Ministry of Health and Long-Term Care enters into new service agreements with the provider and then assigns the service agreement to the LHIN. Effective April 1, 2010 LHINs can enter into Convalescent Care Beds service agreements with the LONG-TERM CARE HOME provider and notify the Ministry. Final LTCH Protocol July 31 2009 (2) 18 of 114
IV. Appendices (see Appendix 2 Convalescent Care Beds) Appendix 2.1 - List of Convalescent Care Beds per LTC Home per LHIN (as of March 31, 2008) Appendix 2.2 - Convalescent Care Beds Amending Agreement Template Final LTCH Protocol July 31 2009 (2) 19 of 114
SHORT STAY RESPITE CARE BEDS I. Program Overview 1. Description and Rationale The purpose of the short-stay respite program in a long-term care home is to provide temporary care for individuals whose caregivers require temporary relief from their caregiving duties. The maximum length of stay is 60 days. A person can spend a total of 90 days in a short stay bed in a year (combining the amount of days for respite and convalescent care). There are approximately 426 short stay/respite beds currently in the province. Short-Stay beds are part of the regular LTC Home stock of licensed/approved beds. 2. Basic Requirements Short Stay Beds are LTC Home beds and are part of the licensed/approved number of LTC beds in the LTC Home. The minimum occupancy target for the Short-Stay program is set by the Ministry; the current occupancy threshold is 50%. 3. Funding The Ministry funds the per diem cost for short-stay beds, as for other licensed/approved LTC Home beds. The residents are charged a co-payment designed to cover a portion of their accommodation costs. The accommodation fee paid is based on the minimum rate for basic accommodation after a rate reduction is taken, currently $33.75 per day 4. Accountability a) Legislative and Regulatory Parameters: Short-stay beds are LTC Home beds and are governed by the LTC Home legislation. b) Agreements between parties There is no specific Agreement for Short-Stay Beds between the Ministry and the LTC Home operator. II. Roles and Responsibilities Ministry and LHIN Responsibilities outlined in the Ministry-LHIN Accountability Agreement (MLAA) Schedule 3, Sections 20-21 of the 2007-2010 MLAA (effective April 1, 2009) outline the following responsibilities for the Ministry and LHIN in relation to Short Stay Beds (Respite): Final LTCH Protocol July 31 2009 (2) 20 of 114
20. The MOHLTC will determine the minimum threshold for occupancy for short stay beds. 21. The LHIN will: (a) (b) (c) (d) Monitor short stay bed utilization of each LTC Home operator in the local health system and for the local health system; Take action as appropriate to improve the utilization of these beds; Have the ability to set, in its discretion, a threshold for occupancy of short stay beds that is higher than the minimum set by the MOHLTC; and Determine the operators of short-stay beds and the number of such beds. III. Process for assigning LTC Home beds as Short-Stay Respite Beds The LHIN, in consultation with the local CCAC, ALC Steering Committee or equivalent stakeholder group, and LTC Home Operators, identifies need and opportunities for Short Stay Beds through an annual review and approval process. Step 1: Provider submits application to LHIN Operators willing to operate short stay respite beds within their approved/licensed bed complement are required to formally apply each year and complete the Short Stay Application and Survey Form. The operator s application to the LHIN should include the following: Operator information, LTC Home information, current beds information Short-Stay Beds Respite Program Application: - Care delivery: how the operator will meet the requirements of the program, including determining appropriate staff mix and staff levels; - Environment: physical environment, supplies and equipment, information systems; - Readiness to implement Short-Stay Bed Respite Program: human resources, environmental components, experience; and - Finances: proposed budget. Step 2: Evaluation of application by LHIN LHINs should consider the following during the evaluation process: Identify any opportunities and risks; Develop mitigation strategies, as appropriate; Consult with the community and stakeholders; Take into consideration local pressures on the health care system, such as funding, ALC pressures, human resources limitations, effects of program on other health care sectors; Contact PICB for a determination as to whether all licensing and compliance requirements under applicable legislation are met; Final LTCH Protocol July 31 2009 (2) 21 of 114
Consult with the local CCAC and LTC Home operators; Seek advice on clinical services for the proposed Short-Stay Respite Beds from outside experts from various areas such as LTC, hospitals, performance, compliance, community engagement, MOHLTC compliance advisors, etc.; and May request a site visit of the LTC Home or interview with the provider. Step 3: LHIN notifies the Ministry of changes in the Short-Stay Beds Respite Program The LHIN must notify the Ministry of any changes to the number and operators of Short-Stay Respite Beds. The information provided by the LHIN should specify the number of Short-Stay Respite Beds, the providers, the period of time for which LTC Home beds will be assigned as Short-Stay Respite Beds. All notifications should be sent to the Director, PICB, with copies to the local SAO, CCAC; Director, Health Data Branch; Director, LHIN Liaison Branch, and Director, Financial Management Branch. Step 4: Ministry response to LHIN submission The Ministry (PICB and/or LLB and/or FMB) may provide comments to the LHIN regarding the LTC Home operator, the Short-Stay Respite Beds, or as required. IV. Appendices (see Appendix 3 Short Stay Respite Beds) Appendix 3.1 List of Short-Stay Respite Beds per LTC Home per LHIN as of March 31, 2009 Final LTCH Protocol July 31 2009 (2) 22 of 114
Beds in Abeyance I. Program Overview 1. Description and Rationale Beds in Abeyance (BIA) are Long-Term Care (LTC) beds licensed or approved by the Ministry, which are not presently occupied or available for occupancy, which have been approved by the Director, PICB for temporary withdrawal from the LTC Home funding system but are expected to return to the system within a specified period. The term Beds in Abeyance may refer to beds which exist in an operating LTC Home or previously may have been physically removed from the LTC Home either by demolition, change to another use, or by some other means. Beds can be temporarily withdrawn from the system in the following cases: o to facilitate a Ministry-approved change in ownership or transfer of beds; o to allow renovations, repairs, reconstruction, replacement, modifications, or redevelopment of a LTC Home; o when it is in the LHIN s or Ministry s interest to temporarily reduce the supply of available beds in a Service Area at the request of an Operator. o any other circumstances determined by the Director, PICB. Listing of the number of Beds in Abeyance per LTC Home per LHIN is provided in Appendix 4.1. 2. Requirements Beds must be approved to be placed in abeyance by the Director, PICB. Beds in Abeyance are expected to return to the system within a period of no more than 2 years, or surrendered; and If beds are transferred to a new operator after the 2 year period, the new operator must re-open the beds within 3 years. List of Criteria for placing Beds in Abeyance is provided in the Beds in Abeyance Policy (Appendix 4.2, pages 5-7) 3. Funding: LTC Homes receive no funding for beds placed in abeyance 5. The maximum number of Resident Days recorded in the LTC Home Annual Report will also be reduced. The reallocation of funds during the time that beds in abeyance are not operating is addressed in section 19 of the Ministry-LHIN Accountability Agreement. If the beds in abeyance do not return to operation as per the BIA Agreement but are transferred to be operated within another LHIN, the funding moves to the LHIN where the transferred beds are located. 5 Where applicable, an operator may continue to receive funding unaffected by beds being placed in abeyance for Municipal Capital Tax Allowance, Construction Funding Subsidy, Pay Equity, Claim-based funding (e.g. laboratory costs, High Intensity Needs Funding). Final LTCH Protocol July 31 2009 (2) 23 of 114
4. Accountability: a) Legislation: Beds in abeyance are LTC Home beds and are governed under the LTC Home legislation. b) Agreements between parties Beds in Abeyance Agreement between the Ministry and the operator, which has been assigned to the LHIN. II. Roles and Responsibilities Roles and Responsibilities outlined in Ministry-LHIN Accountability Agreement (MLAA) Sections 17-19, Schedule 3 of the 2007-2010 MLAA (effective April 1, 2009), outlines the following responsibilities for the Ministry and LHIN in relation to Beds in Abeyance: 17. In paragraphs 18 and 19, the term Beds in Abeyance means beds that are approved or licensed under applicable legislation and that are approved by the MOHLTC to be out of operation. 18. The MOHLTC will approve Beds in Abeyance applications with LHIN recommendation. 19. The LHIN will: (a) (b) (c) Receive applications from LTC Home operators to put beds into abeyance; Assess the impact of applications for Beds in Abeyance and make recommendations to the MOHLTC; and Monitor the need for the beds that are in abeyance in the local health system and work with the LTC Home operator and the MOHLTC to bring these beds back into operation. 19.1 The LHIN may request approval from MOHLTC to use the amount of funding available as a result of any approved Beds in Abeyance under s. 18 for the creation of new Interim Beds or Convalescent Care Beds. 19.2 The MOHLTC will review the request and may approve the LHIN to use this funding for new Interim Beds or Convalescent Beds. The Ministry will determine the process for the approval and any conditions that may attach to the approval. Final LTCH Protocol July 31 2009 (2) 24 of 114
III. Process 6 1. Process for placing Beds in Abeyance Step 1: Operator submits application to the LHIN The operator completes the Beds in Abeyance Application Form (Appendix A of Appendix 4.2) and submits it to the LHIN. The Beds in Abeyance Application Form should outline detailed information on the operator, the LTC Home, number and type of beds to be placed in abeyance, existing Beds in Abeyance for this LTC Home (if applicable). Where a BIA request is tied to any physical change in structure, the operator will submit to the Technical Specialist, Health Capital Investment Branch, two (2) copies of the architectural drawings, an operational plan, and a project summary. The operator can re-apply to place beds in abeyance after the beds, having previously been placed in abeyance, have been returned to service. Step 2: Evaluation of application by LHIN LHINs should consider the following during the evaluation process: o Identify any opportunities and risks; o Develop mitigation strategies, as appropriate; o Consult with the community and stakeholders; o Take into consideration local pressures on the health care system, such as funding, ALC pressures, human resources limitations, and the impact of placing beds in abeyance on the local LTC Homes system and on other health care sectors; o Contact PICB for a determination as to whether all licensing and compliance requirements under applicable legislation are met; o Ensure that the proposal follows the criteria for placing beds in abeyance as outlined in the Beds in Abeyance Policy; o Discuss with the operator any LHIN-specific terms and conditions. Step 3: LHIN submits application and recommendation for MOHLTC consideration LHIN completes a Beds in Abeyance Recommendation Form (Appendix B of Appendix 4.2). LHIN sends the Beds in Abeyance Application Form and the Recommendation Form to the Beds in Abeyance Coordinator. Step 4: Ministry review and approval The Ministry Beds in Abeyance Coordinator is responsible for receiving and processing the LHIN submission, as well as coordinating all required reviews within the Ministry. Technical Specialist, HSIMID reviews the architectural drawings, the operational plan and a project summary. Upon positive review, the Technical Specialist completes a Beds in Abeyance Recommendation Form (Appendix B of Appendix 4.2) and forwards it to the Beds in Abeyance Coordinator. The Beds in Abeyance Coordinator coordinates review and approval of the Beds in Abeyance Application Form by the Service Area Office Compliance Advisor and the Director, PICB. 6 Additional details on the process are outlined in the Beds in Abeyance Policy (Appendix 2). Final LTCH Protocol July 31 2009 (2) 25 of 114