Discharge from Hospital and Charges in the Health System

1. Discharge from Hospitaland Charges in the Health System Judith Wahl Advocacy Centre for the Elderly Advocacy Centre for the Elderly 2013

2. Advocacy Centre for the Elderly Community Legal Clinic in Ontario In operation since 1984 Half of legal practice is Health Issues Advocacy Cross Provincial Experience

3. Key Issues Eligibility Higher level of care needs to be eligible for publicly funded and regulated care services What was eligible, no longer eligible or shifts within funding year Access Geographic Access across Province Waiting Lists without real alternatives

4. Key Issues Problem of “Good Law, Bad Practice” Access – rights to get publicly funded/ regulated health services The hospital discharge issues Pressure to take first available bed vs. rights of choice When you can apply for LTC and where you need to wait for admission ( Wait at Home/ Home First) Fees charging practices (charges for palliative care, psychiatric care, ALC when not yet ALC)

5. Key Issues The embedding of private pay care in the Retirement Home system A parallel LTC system to publicly regulated/ funded LTC instead of a continuum May offer and provide same care levels and types as LTC but not covered by health dollars Not subject to same care oversight The “Private” regulatory structure Set up in legislation but private structure Operational costs of regulatory body directly from users via licensees

6. ACE Experience • Increase in requirements for Eligibility by area or at times of year • Charges that not comply with OHIP- while in hospital and to motivate to accept discharge options • Hospital policies control process not the legislation • Pressure to take first available Bed anywhere despite effect on patient Advocacy Centre for the Elderly 2013

7. ACE Experience • Pressure to take accommodation in Retirement Homes (Rental Accommodation with Private Pay Care which may be at levels equivalent to LTC which health services are publicly funded) • Lack of LTC beds/ homecare • Dissonance in transitions

8. Hospital Discharge Scenario • Senior in Hospital for acute care episode • Care progressing and discharge now possible soon • Ontario – Hospital has discharge staff however Community Care Access Centre (CCAC) (publicly regulated and funded coordinating/case management agency) responsible for access and eligibility to publicly funded home care and Long Term Care and info on other community resources (care and other services) and other forms of accommodation ( info on Retirement homes, supportive care, respite care etc) • Seniors Rights within that process?

9. Public Hospitals Act and Health Insurance Act • When Acute care, Palliative Care, Psychiatric Care – no individual charge for care (public health coverage) • Physician can discharge patient • If discharged, patient expected to leave within 24 hours • However, if patient needs care, although not acute, cannot be “abandoned” • If needs long term care and cannot return home with supports, then can remain at hospital pending transfer (Alternative Level of Care) • When ALC, can be charged up to amount permitted under Health Insurance legislation which is $55.00 and change. That rate is also subject to a rate reduction under the Health Insurance Act • If person is not ALC ( so person trying to stay like an over holding guest when not need LTC or hospital care) and discharged, hospital may charge a much higher per diem of THEIR choice (person then not under OHIP) if person refuses to leave hospital (the issue is then WHEN is a person ALC?) Advocacy Centre for the Elderly 2013

10. ALC Co-payment • Attending physician must designate patient as requiring chronic care and being more or less permanently resident in a hospital or other institution • Only applies to patients who are presently in certain types of public hospitals as set out in the regulations • Cannot charge a patient who received services under the Mental Health Act- i.e. at any time was a mental health patient – even if are now ALC (s. 46 of the Health Insurance Act) Advocacy Centre for the Elderly 2013

11. ALC Designation vs. ALC Copayment • As of July 1, 2009, all acute and post-acute hospitals were required to use a standardized Provincial ALC Definition • Designation as ALC does not mean person can be charged • Can only be charged copayment if meet requirements of s. 10 in Reg. 552 to the Health Insurance Act • If returning home cannot charge ALC rate Advocacy Centre for the Elderly 2013

12. Maximum Allowable Rate for ALC Patients UnderHealth Insurance Act • Maximum amount can be charged pursuant to regulations under Health Insurance Act is $55.04. • Rate reductions are available – for both low income as well as spouses still in community. Advocacy Centre for the Elderly 2013

13. Ministry of Health and Long-Term Care Position • Minister of Health & Long-Term Care Deb Matthews has stated that persons in hospital have choice of LTCHs • Cannot charge anything other than Health Insurance Act when person is waiting for one of the beds on their list • Memorandum from Ruth Hawkins, ADM of Health dated February 2011 confirms this • Memorandum of Catherine Brown, ADM of Health dated January 2013 confirms rights of patients to apply to long-term care and wait in hospital Advocacy Centre for the Elderly 2013

14. Hospital Discharge Policies - Problems • Hospitals may attempt to control admission process even though CCAC responsible for admission • Hospital cannot have discharge policies that are contrary to the law • For example: • Choice - Cannot require certain number of choices or number of choices from “short lists” • Choice - Cannot require patients to accept “available beds” • Choice - Cannot prohibit patients from making applications to any LTCH of choice even if waiting list is lengthy Process – When you can apply to LTC - Cannot prevent patients from applying to LTCHs from hospital • Processs – Where you wait - Cannot require persons to go home or to a retirement home to “wait” • Charges - Cannot be threatened with “discharge” and charges of a “daily rate” which often run from $500 - $1500 per day Advocacy Centre for the Elderly 2013

15. Long-Term Care Homes Act, 2007 • Authority of CCAC vs. Hospital for Discharge • Provides that the CCAC (Placement Coordinator) is responsible for applications to LTC homes NOT the hospital personnel • CCAC must determine eligibility for LTC home admission • CCAC must assist person to apply to LTC homes • Authority for CHOICE • Confirms requirement for CHOICE of homes is that of the person • Can choose maximum of 5 homes (except for crisis) • Person cannot be required to go to LTC home unless he or she consents • Consent must be INFORMED and voluntary and not based on misrepresentation Advocacy Centre for the Elderly 2013

16. Designation of Placement Coordinators • LTCHA s. 40 & 41 and Reg. 79/10 s. 153 designate CCAC employees as placement coordinators • Most of the process unless otherwise set out in the legislation must be performed by CCAC • This is reason why Hospital Discharge staff cannot control process and why hospitals cannot create policies and practice that override rights of patient in discharge process Advocacy Centre for the Elderly 2013

17. Applications for Admission • People cannot be told that can only apply for LTC after being discharged from hospital when out of hospital • CAN encourage people to return home with home care if person’s care needs could be managed at home with sufficient home care • Can talk with people about alternatives to long term care placement – but it they are eligible for long-term care cannot REQUIRE them to go to an alternative Advocacy Centre for the Elderly 2013

18. Applications for Admission • While retirement homes may be considered – they are not the equivalent of LTCHs and cannot be used as such (see Nineteenth Annual Report of the Geriatric and Long-term Care Review Committee to the Chief Coroner for the Province of Ontario – September 2009, page 35) • Cannot set arbitrary “rules” about where and when applications can be made that takes away right of choice of when to apply • People have right to apply (no pre screening of eligibility) and have right of review before a Tribunal if found not eligible Advocacy Centre for the Elderly 2013

19. Information to be Provided by Placement Coordinator • Information about alternative services • Responsibility to pay and maximum amounts that may be charged • Rate reductions that are available and application requirements • Approximate length of waiting lists • Vacancies • How to obtain information, including compliance reports, from the Ministry of Health and Long-Term Care Advocacy Centre for the Elderly 2013

20. Choice of LTCHs LTCHA s. 44 • Where the person/SDM wishes the CCAC shall assist the applicant in selecting homes • Shall consider the applicant’s preferences relating to admission, based on ethnic, religious, spiritual, linguistic, familial and cultural factors • Application can only be made with the consent of the applicant – therefore homes that have not been applied to cannot be “offered” • Applicants may choose any home in the province of Ontario and the CCAC shall work with the CCAC in that area regarding the application Advocacy Centre for the Elderly 2013

21. Information Issues • Some CCACs/Hospitals advise clients to apply for preferred accommodation (private rooms – at higher rate – not available for rate reductions) as it has shorter wait lists – and then can transfer after 1 year. UNTRUE. • Applications for transfer can be made on the DAY OF ADMISSION to the long-term care home; HOWEVER, actual transfer may take years due to alternate waiting list regulation • Homes CANNOT “income test” or request income information and CANNOT refuse based on issues of income Advocacy Centre for the Elderly 2013

22. Waiting Lists • Applicant can only apply for a maximum of 5 LTCHs (except for crisis) • Can apply to interim short stay, which are not included in the 5 maximum • May, but is not required, to add homes if they are on crisis waiting list • Can only be put on waiting list if there is valid consent unless it is crisis under HCCA Advocacy Centre for the Elderly 2013

23. Can Choice List be Shared with Hospital? • As with other types of consent – consent to release personal health information must be voluntary, knowledgeable, relate to the information, and not obtained through deception or coercion (PHIPA s. 18) • Can choice of home be released without specific consent to CCAC to do so? • PHIPA allows information to be released if it for the provision of health care • Arguably the choice of facilities is not • Additionally – person/SDM can prohibit this information being released to the hospital Advocacy Centre for the Elderly 2013

24. Issues Regarding Eligibility or Refusal of Admission • If person found to be ineligible for LTC by CCAC – if feel incorrect – can apply to HSARB for review • Home must accept eligible applicant unless meets one of 2 criteria: • Home lacks the physical facilities necessary to meet applicant’s care needs • Staff of home lack the nursing expertise necessary to meet the applicant’s care requirements Advocacy Centre for the Elderly 2013

25. Home’s Refusals • Home has five business days to provide notification that approval is being withheld unless requires more information – once that information is received – again has 5 business days • If withholding approval – must provide written notice Advocacy Centre for the Elderly 2013

26. Withholding Approval • Must notify Applicant, Director and CCAC in writing that approval is withheld • Notice must include the following: • Ground(s) for withholding approval • Detailed explanation of supporting facts as they relate both to home and applicants condition and requirements for care • Explanation of how the supporting facts justify the decision to withhold approval • Contact information for the Director Advocacy Centre for the Elderly 2013

27. Hospital Policies requiring people to go into Retirement Homes pending admission to LTC- Not Enforceable • Retirement homes are TENANCIES – rental accommodation where a landlord may also offer care services of different types • Retirement homes are NOT “private” long term care homes and are not health care facilities • If a person needs and is eligible for LTC, nothing requires that person to go to a retirement home pending admission or instead of admission into a LTC home Advocacy Centre for the Elderly 2013

28. Authorized LTCH beds in Retirement homes • Persons eligible for LTC admission cannot be “required” to go into a retirement home pending transfer – a person may CHOOSE to do that if willing to private pay for health care and if they believe that retirement homes will meet care needs. These are not “Authorized” beds • IF a retirement homes is AUTHORIZED by the MOHLTC to offer LTC beds as a transition home, then those retirement homes will be considered the same as LTC beds Advocacy Centre for the Elderly 2013

29. Authorized beds in Retirement Homes • The retirement home beds must have specific authorization by MOHLTC, those beds then come under inspection and oversight by MOHLTC and are treated as if beds in a LTC Home under LTCH Act, and consent would be necessary from person before admission as is required to admission in ANY other LTC home bed • Authorization of beds for use in this manner must be obtained from MOHLTC BEFORE any such beds used in this manner – Charges in authorized beds are the same as in any LTCH bed and health care is funded and is not private pay

30. Retirement Home regulation-Two Key Acts • Retirement Home accommodation in Ontario has been regulated (since 1995) and will continue to be regulated as “care homes” under the Residential Tenancies Act • Retirement Homes Act ALSO regulates those retirement homes that are occupied by 6 or more people (65 plus) but are STILL tenancies Advocacy Centre for the Elderly 2013

31. Retirement Homes - some Key Points • Retirement homes may to provide ANY level of care, including the same care that is provided in long term care homes • Retirement Home tenants (called “residents” in the RHA) will private pay for their care • Care services in retirement homes are NOT covered by the provincial health insurance even if the care level is the same as in long term care homes • In LONG TERM CARE HOMES, residents pay only for room and board as the provincial government pays the LTC homes for the health care that is provided Advocacy Centre for the Elderly 2013

32. In Summary • BASIC INFORMATION - getting info on basic right • People DON’T KNOW their rights in the health system and • Who can they trust to get the RIGHT and legally correct info? • SYSTEM PRESSURES - Pressures to be discharged/ transferred / moved somewhere else • ELIGIBILITY -Changing Eligibility and the challenge of regulating eligibility Advocacy Centre for the Elderly 2013

33. In Summary • CHARGES – What are we required to pay for and what don’t we pay for? • Charges for ALC • Charges for Health Insured Care ( so when is a person designated as Palliative care? ) • How Charges are calculated – lack of transparency and oversight • Charges in Retirement Homes for SAME care as provided in LTC homes – Two Tier and who is raising this as an issue?