LTC Outreach Program

Who We Are

• TCE is a developmental service agency in Ottawa

• Funded by the Ministry of Community and Social Services (MCSS) since 1979

• Originally served children with multiple disabilities and special communication needs i.e. deafness, aphasia and autism

What We Do

• Support adults with developmental disabilities- 48 Day Supports - 77 Residential (includes group homes, apartments, townhouses with various levels of support) - 2 in Home share (individual living as part of a family)- 12-17 in LTC Outreach

By the Numbers

• 55% of the individuals supported by TCE are over the age of 50

• Oldest person supported was 80 years old• Oldest person currently supported is 75 years

old• Oldest person with Down Syndrome

supported was 69 years old

History

• TCE is one of 17 transfer payment agencies funded by MCSS to support individuals with developmental disabilities in Ottawa

• In 2005, the Ontario government announced the closure of the 3 remaining provincial facilities for people with developmental disabilities, by March 2009.

Development Stage

• TCE was requested to provide enhanced developmental service support to individuals moving from the provincial facility to Ottawa area LTC homes

• The first individual moved into a LTC home in late 2005

• Over the next four years, 17 spaces were created in LTC (16 individuals from facility and one community)

Partnership

• Majority clustered at 2 LTC homes• Primary partner is the original LTC home in

Kanata • MCSS provided base funding which continues

as an ongoing community resource for support in LTC

• The partnership and program were developed and revised over time and continues to evolve.

MCSS & MOHLTC

• Joint guidelines were developed by MOHLTC & MCSS to support the provincial facility project

• Meetings and discussions were held with all parties including both Ministries to determine how to work together – highly motivated

Current Context

• Referrals are received from different sources- developmental service agencies supporting

individuals ready to transition to LTC- Families supporting family members applying to

CCAC for LTC, already on the list or already in LTC and requiring enhanced support

- Increasingly, enquiries and referrals come from a variety of sources i.e. acute care hospitals, CCAC, specialized services

Referral

• All individuals must be on Developmental Services Ontario (DSO) registry in order to access our Outreach services

• Must have applied and been approved by CCAC for referral to LTC

• Application is reviewed and a determination made by TCE (in consultation with partners) whether ‘enhanced support’ is required

Support

• Not all individuals with developmental disabilities require enhanced support to live successfully in a LTC home

• Individuals with challenges due to communication, complicating conditions or behavior often require extra support

• The type of intervention or resources required is unique to each person

What is Enhanced Support?

• assistance with some activities of daily living• support for integration into community activities• case management and support for appointments• training or mentoring for staff• private room rate coverage if needed• access to specialized resources i.e. multi-

disciplinary clinical team

Statistics

• Program is no longer just ’17 beds’ rather a flexible resource utilized in a variety of ways depending on need

• Originally supported 17 individuals (16 facility and 1 community) in 6 locations

• Since 2005, 9 individuals have passed away• Since 2005, closed 3 sites and opened 4 new• Support 13 individuals in 7 locations• Goal is fewer locations with small clusters

The Team

• 3-4 LTC Outreach staff on team• The workload is divided and shifts depending

on the needs of the individuals• Contact and visits occur daily• Support is provided in accordance with each

person’s individual plan.

Challenges

• Steep learning curve for both partners• Program developed and evolved over time• Government’s guidelines were released which

helped clarify process after our program was well underway

• The models of service, culture, language, procedures and staff roles and responsibilities were different.

Roles & Responsibilities

• There was a significant initial investment of time spent to:– clarify roles & responsibilities – draft job descriptions – Talk with and coach staff about each other i.e. staffing

structure, policies & procedures, different focus and priorities etc

• Lack of clarity could lead to false assumptions and misunderstanding when in fact each were just doing their own jobs

The Plan

• A written plan was developed to address:- how we would work together - how we would communicate formally and informally- how issues would be dealt with as they arose with the goal of resolution as quickly as possible

• It was and is important to check in and ensure things stay on track

Ingredients for Success

• Two willing partners were open to trying something new and developed a trusting relationship over time

• Both understood the value of having a specialized resource

• Ensured we had the right staff in the position(s) with the skill set and motivation to build collaborative partnerships

• Committed to work together through challenges with the goal of maintaining the individual’s placement

Factors to Consider

• As people passed away and the facilities closed, some of the physical beds/spaces were ‘lost’ as other individuals moved into their vacant beds through the CCAC referral process

• Admissions, transfers and referrals occur and resources are stretched and not used as effectively as possible

Future

• Growing need for LTC placements for people with developmental disabilities as ‘baby boomers’ age and people with disabilities live longer

• Feedback from service providers and families indicate a comfort level in referring their loved one to CCAC & LTC if there is an option for placement which provides an ongoing linnk to developmental services

Working Together

• Enhanced support provides a level of comfort to the LTC home in accepting an admission which may have caused hesitation in the past.

• Developing sustainable and affordable models which utilize resources from both systems is the most realistic vision for the future

• Innovative partnerships which combine resources from both sectors will lead to the best quality of life for seniors with often complex needs

Specialized Unit

• By providing appropriate options for individuals transitioning to LTC, new placements and resources for young people will be freed up in developmental services.

• Our joint goal with our LTC partner is a proposal for a designation under the MOHLTC legislation for an 8 bed ‘Specialized Unit’

• If approved by the LHIN, up to 8 beds at this Kanata LTC home would be protected

Designation

• Resources, training, specialized skills and partnerships would not be diluted or lost.

• Essentially, there would be a list maintained by CCAC, meeting a specific criterion for individuals with developmental disabilities requiring enhanced support

• When a vacancy occurred in one of the 8 beds, it would be filled from the designated list.

What You Can Do

• Do not work in isolation. Come together with other like-minded organizations whether developmental service, health care providers, CCAC, LHIN, hospital, etc

• Identify the common issues and needs• Find a ‘friendly’ neighbor. A LTC home or

agency you’ve had casual contact with and set up a time to meet

Find Common Ground

• Share your story• Share others experiences across the province

re cross-sector partnerships• Look for common ground, areas where you

could share resources, (training, lunch and learn, planning meetings, etc)

• Educate each other about your ‘worlds’ • Try a pilot project

Network

• Approach your local planning table with a proposal to ‘pool’ or re-direct some resources and try a small LTC pilot project with a willing partner

• Look for networking opportunities in the MOHLTC world or vice versa

• Don’t give up!