Introduction
Borden Ladner Gervais LLP (BLG) recently represented a CCAC in a noteworthy appeal before the Health Services Appeal and Review Board (HSARB). The issue before the Appeal was whether the Appellant was eligible to more personal support (PSW) hours than the CCAC had assessed and whether her need for such services was of greater priority than assessed. The Appeal Board concluded that the Appellant was not entitled to additional care nor greater priority, thereby affirming the CCAC's decision.
The decision is important because it upheld a decision to reduce wait list services due to resource constraints and a need to re-allocate services to those clients in greatest need. HSARB held that a uniform and consistent criteria was applied by the CCAC to determine eligibility for services. This was in keeping with the objectives and requirements of The Home Care and Community Services Act 1994 (HCCSA).
Background to the Appeal
The Appellant, an elderly woman, had previously received CCAC PSW care for several years at the time of the appeal, although the level of services provided to her had fluctuated over time. In the fall of 2009, she travelled abroad for an extended visit. Prior to her departure, she was receiving 14 PSW hours per week.
On her return to Canada, following reassessment, she was placed on a wait list for services. This determination was based on the results of the Resident Assessment Instrument (RAI) assessment and a new policy which allocated PSW service to clients based on their RAI score. The decision to place the Appellant on a wait list was in keeping with the CCAC's newly introduced "Wait list Management Guidelines".
The family was dissatisfied and requested a second assessment where the same determination was reached. Ultimately, the case was referred to the Case Review Committee as part of the internal complaint and appeals process at the CCAC which reviewed the matter and recommended that the Appellant be provided with 2 hours of PSW per week, plus occupational therapy and suggested that the Appellant should consider a short term admission to a convalescent care facility which would encompass a further assessment of her abilities.
Issues for the Appeal
The issue for HSARB was whether the Appellant was entitled to more PSW hours than assigned by the CCAC. The family argued that the Appellant should be provided with the same level of PSW services she had received prior to leaving Ontario. Her condition had not changed from the time of her departure to the time for the RAI assessment. Thus, they argued her PSW hours should not change.
The main concern raised by the family was that the Appellant's son, as principal care provider, was unable to provide certain types of care, such as bathing and toileting.
The CCAC confirmed that the Appellant had been assessed for eligibility for services using a standardized tool (RAI). The RAI score was applied to an established set of guidelines determined by the CCAC which indicated which services could be offered to clients with RAI scores in designated ranges. These service guidelines were partly brought about due to recent Ministry of Health and Long Term Care policy changes requiring CCAC's to focus their services on complex high need clients awaiting placement in a long term care facility. In addition, to direct the CCAC's finite resources services were also focused on those clients with the most complex needs.
The Decision
Notwithstanding that the Appeal Board recognized the concerns raised by the family about the adequacy of two hours of PSW care per week and the fact that the Appellant's personal care needs continued to be at a "high" level, the Appeal Board was satisfied that the CCAC had reviewed the appellant's requirements and had developed a plan of service which satisfied all of the criteria set out in the HCCSA.1 It upheld the CCAC's decision to offer PSW services to only "very high need" clients as determined by the RAI score. The Board accepted this approach was required to deal with budget constraints and that it allocated service in accordance with the HCCSA. For example, the Appellant's needs had been thoroughly evaluated and "every effort" was made to take into account the Appellant's preferences. Further the evidence before the board confirmed that the Appellant would be assessed on an ongoing basis and, should her requirements change, her service hours would change accordingly.
Conclusion
The decision in this case confirms that HSARB will support a reduction in services, due in part to budgetary restrictions and other considerations, even where an applicant's care needs are "high", where the eligibility criteria applied by the CCAC is uniform and consistent.
It is helpful to note that in a subsequent decision of HSARB raising similar issues, the Board has confirmed this position by stating "it is reasonable and consistent with the intent and purposes of the HCCSA to adopt and apply tools and guidelines that promote equitable access to community services through the application of consistent eligibility criteria and uniform rules and procedures, and that promote the effective and efficient management of human, financial and other recourses involved in the delivery of community services".2
Provided consistent criteria are applied and the requirements of the HCCSA are met (by providing a comprehensive review of an applicant's requirements to determine eligibility for services, and by formulating a plan of service in the appropriate manner) a reduction of services can be justified even where the decision to reduce care is in part based on human, financial and other resources involved in the delivery of community services. It is important to note that the re-assessment in this case was brought about due to the client's discharge and subsequent re-admission to the CCAC. This case does not address a situation where a client has consistently remained on service but the client's care plan is modified due to the introduction of new service guidelines.
These recent cases demonstrate that HSARB recognizes CCAC resources are limited and that measures to re-allocate service to those with the greatest need is appropriate, provided the assessment criteria are objective and applied equally to all.
Footnotes
1. Subsections 22(1)(a) and (b) of the HCCSA direct the CCAC to assess an applicants requirements and determine the applicants eligibility for services that the applicant requires. Subsection 22 (1) (c) and subsections 22 (4)-(7) set out the requirements for a plan of service.
2. Per paragraph 31.
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