judith wahl advocacy centre for the elderly advocacy centre for the elderly 20131

Discharge from Hospitaland Charges in the Health

System Judith Wahl

Advocacy Centre for the Elderly

Advocacy Centre for the Elderly 2013 1

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

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

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)

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

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

ACE Experience


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

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?

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?)


Public Hospitals Act and Health Insurance Act

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)


ALC Co-payment

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


ALC Designation vs. ALC Copayment

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.


Maximum Allowable Rate for ALC Patients UnderHealth Insurance Act

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


Ministry of Health and Long-Term Care Position

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


Hospital Discharge Policies - Problems

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


Long-Term Care Homes Act, 2007

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


Designation of Placement Coordinators

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


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


Applications for Admission

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


Information to be Provided by Placement Coordinator

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


Choice of LTCHs LTCHA s. 44

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


Information Issues

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


Waiting Lists

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


Can Choice List be Shared with Hospital?

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


Issues Regarding Eligibility or Refusal of Admission

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


Home’s Refusals

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


Withholding Approval

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


Hospital Policies requiring people to go into Retirement Homes pending admission to LTC- Not Enforceable

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


Authorized LTCH beds in Retirement homes

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

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


Retirement Home regulation-Two Key Acts

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


Retirement Homes - some Key Points

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

In Summary


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?