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Long-term care in Nova Scotia

Long-term care in Nova Scotia

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Removing Barriers in Accessing long Term Care

Prepared: December 2010 Final Revision: May 2011

Removing Barriers in Accessing Long Term Care



The Health System in Nova Scotia is.experienclng pressures to ensure that resou rces are used as efficiently as possible. This includes the efficient use of long-term care beds. This report will identify areas where improvements can be made to achieve timely client transitions from hospital or community to long term care. Barriers in accessing the long term care system impacts clients and their families, partners in the placement process and other areas of the health system.
A working group has been formed to review and synthesize issues on barriers in

accessing long-term care beds and to develop recommendations for action to improve efficiencies. The report contains 7 strategic recommendations with its rationals, impacts and risks, Eachstrategic recommendation is supported by a number of actions. A separate initiative is required to develop an action plan, with budget and tirnellnes and to identify the most appropriate lead (E.g. DOH, DHA or provider) for implementation of the accepted recommendation actlons.

2. Key Assu m ptions • • • • • • • Access to the long term care sector involves a number of stakeholders and improving access will require cooperation of all stakeholders. Administrative responsibility for services to long term care clients is shared by the Department of Health, the District Health Authorities and long term care providers. Providing timely access to care will help in achieving system outcomes. Achieving 100% bed occupancy is not a reasonable goal. Improving efficiency in accessing long term care mayor may not minimize the wait for long term care. Adhering to principles of client-centered approaches to care will better support clients and families who are waiting in the community. Recommendations will be implemented across the province by responsible parties including the District Health Authorities, long term care facilities and the Department of Health. Occupancy rates alone are a measure of bed utilization and not efficiency.

3. Context The Department of Health is committed to the ongoing improvement of the health care system through strategic planning. legislation, resource allocation, policy and standards development, leadership, monitoring and evaluation, accountability, and information management. The Department of Health Mandate sets. out the health system strategic priorities in support of provi ncial govern ment priorities and com mltments, relevant legislat ion, the Department's svstem pa rtners, and the overa II hea Ith of


Removing Barriers in Accessing Long Term Care

Nova Scotia ns. Di:strict Health Authorities direction priorities. In 2007f the Dep~rtment, com mitted provi nce, undertook in partnership and to contribute

are accou ntable for governing, planning, ma na g ing, del iveri ng, and ma nito rl ng hea It h 5 ervices ina Iign m ent with Gove rn m ent to the successful achievement of Government goals and

with DHAs, the IWK Health and other system partners direction

for the

hea Ith care professionals,

across the

the process of re defin ing the strategic

healthcara system in Nova Scotia.
Department Generations Mission Working together promote,
S usta

of Health Vision of Nova Scotians Living Well

to empower




and communities


improve, and maintain

the health of Nova Scotians through

a proactive and

ina ble hea lth ca re system.

Goals 1. Timely access and high quality, safer health care for Nova Scotians

In the

P rovi de va Iue for money t h rou gh effective and effici e n t use 0 f P u bl iC
resources Improved health status of Nova Scotians of Health's Statement of Mandate, Continuing Care has and to reduce Timely

2010/11 Department

com mitted to increase the number waiting time for admission

of high quality long term care facilities

in support of the Department

of Health goal described by the DOH, DHA's and

above: "Timely Access and High Quality, Safer Health Core for Novo Scotians." access to long term care beds is an issue that has been identified long term care providers,

Who is Waiting for Long Term care?
Client:s apptying for long term care are assessed using a standardized, validated fratl.or centered strengths assessment tool RAI·HC©, which committed to improving disabled. (http:UwwW.interrai.o.rg) and preferences. was developed in ov.er 30 countries scientifically

by a network of researchers

health care for persons who are elderlv, The RAI-HC© has been designed as a person

assessment system that focuses on quality of life by assessing client needs, RAI-HC© assessments are completed information gathered

by the Care
in their ca re du ring the

Coordinator and support.

with the participation

of the client, family and others involved

Assessment and demographic

assessment process has been analyzed and summarized.


Removing Barriers in Accessing Long Term Care Client Characteristics The clinical and demographic characteristics of 3230 clients added to the wait list in 2009/10 are described in detail in Appendix A. • Of those clients added to the long term care waltlist in 1009/10, 37% were in hospital- 36% were in the community with no publicly funded home care, and 27% of clients were waiting in the commu nfty with publicly funded home care. These clients had similar assessed characteristics regardless of whether they were in the hospital, or community with/without pu blicly fu nded home care. o Client's Cognitive Performance Scale: 0-6 scale with higher scores indicating more significant cognitive impairment. The Cognitive Performance Scale indicates that majority of clients has limited or moderate cognitive impairment. 40% of all clients are cognitively intact, borderline intact, or have mild cognitive impairment (CPS0, I, 2). 16% of all clients have moderately severe to very severe cognitive impairment (CPS4. 5, 6). The levels of impairment are :similar across hospftal, and com mu nity with/without home care settings. See Appendix A o The MAPLe level: 1-S scale used as an indicator of risk for adverse outcomes including caregiver distress. Higher MAPle levels indicate more risk for adverse outcomes. 97% of these clients have MAPLe score of 4, S, or 6. MAPLe levels are similar for clients waiting in hospital, or in the community with/without publicly funded home care services. o CHESS:0-5 scale used as a measure of cllnical instability and a predictor of mortality. CHESS levels are also similar across wait settings. 78.5% of dients have CHESS scores of 0, 1, or 2 indicating a low level of clinical instability. (See Appendix A.) o ADl Self Performance Hierarchy: 0 - 6 scale with higher score indicating greater dependence with ADL performance. 25% of clients in 2009/10 clients are independent with their ADL's. Clients waiting in the hospital tend to have more dependence on others for their AOL performance. This may be related to the model of care in hospital rather than the characteristics of the clients. upon admission. (See Appendix A) Of the 3230 clients that were added to the wait list during 2009/10, 38% live alone and most are female. 37% of clients added to the warthst in 2009/10 had an unpaid caregiver, Of those cI ients wi th unPold caregive rs, 38 % of cares ivers repo rt d tst ress. i The demographic and clinical characteristics of clients waiting for long term care have remained similar over the past three years.

• • •

Clients on the wait list for long term care have clinical characteristics that demonstrate the need for support and care. Of the 2035 clients waiting in the community in 2009/10, only 886 received home care services. Although it is out of scope of this report, better. utilization of pubhclv funded home care services should be promoted-



Removing Barriers in Accessing Long Term Care

How is Demand for long Term Care Changing?
Adding capacity to the tong term care sector has had a number of system impacts. Since 2009, there have been 669 new long term care beds added to the long term care system. Despite the added system capacity, wait lists continue to grow. Although there are a number of contributors to long term care demand, the desirability of new facilities, barriers in accessing home care and other community-based services may result in a preference to have needs met in long term care. Public perception of access issues may also lead to increasing wait lists as some clients may start the process early, before they are prepared to move to long term care, to ensure a bed is available when they need it. Composition of the Wait List The characteristics of the wattlrst for long term care: • The wait llst is organized into three priority groups (See Facility Placement Paliey); Priority 1 (Adult Protection clients), Priority 2 (clients returning 'home', requ iring a different level of care, clients whose family member is in tong term care, and clients requiring peritoneal dialvsisl, and Priority 3 includes all others. Priority 1 clients are placed before Priority 2, followed by Priority 3. Clients are orgamzed in chronological order within their priority in accordance with their care level decision date. The waitlist is comprised of clients waiting for long term care in the community, from hospital. (See Figure 1) Once clients are placed from community or hospital, some chants choose to remain on the waitlist to transfer to a preferred facility. (See Figure 2 and Figure 3) The waft list for long term care, including hospital and community has grown by 38% since 2007. The numbers of hospital clients on the wait list has remained stable over the past several years and is typically between 200·250 clients at any given time. The numbers of hospital clients has remained relatively stable, in part due to the First Available Bed Provision in the DOH Facility Placement Policy; "The xuiding principle of is that the care needs of the applicant shall be addressed first and his Or her

• •

placement preferences shall be pursued second. For an applicant/resident who is subject to the First Available Bed provision, his or her name will he placed on (he wail lists of all LTC facilities that are "suitable" to meet the applicant's care needs ami that are within approximately 100 kilometers driving distance from their "preferred community ofresidence". Because clients in hospital have their name on
multiple facility's wait lists and because they must accept the offer, they have an incre ased pro babiIitv of bei ng pIaced com pared to adient in the comm unity with fewer facitity choices and the ability to defer the placement decision.



Removing Barriers. in Accessing Long Term Care

The numbers of clients waiting to access long term care from the community continue to grow. At April 2007 there were approximately to approximatelv 1284 people waiting for long term care, compared approximately

1740 clients waiting in April 2010. which
the .supply that the

re prese nts a 35,5% increa se. Bed ca p acity ha s increa sed d url ng that sa me pe riod by 13 %. The demand for long term care is outstripping

des pite add ing ca pa city to the secto r,
• The waitlist has grown by 35% since 2007. Statistics Canada has estimated population long term care cannot be completely o describes the relationship term care waitlist po pu Iatio n, • The waltlrst is also comprised factlitv. facilities, term Figure 1 In 2009/10, A transfer of clients waiting to transfer were transfers to another between long term care long 23% of all placements is attributed long term care between explained by demographic

65+ will increase by 12.6% from 2006 to 2011. The increased demand for
changes. Appendix to the long each DHA's relative contribution

(i,e. their demand for long term care). and their relative

to a DHA based upon the DHA of the admitting

care provider. (See Figure 3 for % of transfers over time by OHA)

1600 l~OO

LTC- Average # of Clients/Month Waiting In Hospital and Community






JUL OCT 21107 jeI.







JUL ~_,




JU l




Once clients from the hospital and community about 22% remain on the waitlist the relative proportion 2007. the of transfers requesting

are placed in a long term care facility, to transfer to a different facility. Although. hasn't increased since

(as a % of all placements)

# of clients who request to transfer to a facility of their choice has grown by 58% since 2007, (Figure 2) This is due to the overall increase in the # of placements to
long term care.

Of the 1510 clients placed from the community transfer 2009/10, to their preferred 36.3% requested facility. to transfer

in 2009/10,27.7% facility.

decided to request to

Of the 1363 clients placed from the hospital in to their preferred



Removi ng Barri ers in Acces si ng long Term Care

Figure 2


LTC Transfer List - Average # of Clients /Month .. (_e.q~estin& a Tra "_$.Je'-"'-'-r _
-' -_ ... - ...



200 ------.














2007/0 8
Source: SEA~ape

lOO8/O 901



Figure 3

Transfers: as % of Placements

30% 25% 20%

15% 10%
5% 0%



SOut(l!:: SEAsGpe

Wait Times for Long Term Care In addition to growth in the number of clients waiting for long term care, there has also been an increase in wait times. Many factors contribute to wait times such as increasing demand for long term care services and barriers to access,


Removi ng Barn ers in Acres sing Long Term Col e r

While clients tend to measure wait times based on their full journey, processing times data was collected placement into the facility was documented Compared manualtvbv

wait times data has in the moved

been captured for some steps along the way. In Februarv - June 2008, placement Placement Office staff involved process, The date the bed became vacant, until the date the resident and by DHA. processing and

and analyzed. Re~ults Indicated that the time it takes the lengthiest

to fill a vacant long term care bed varies by long term ca re fadlity, to the rest of the province, DHA 9 was experiencing made af representatives recommendations times. A working committee

from DHA 9, service providers to address the issues.

DOH was struck to develop and implement The median· time for most facilities

to notify the Placement Office was either the same to the facility (for the accepted client) varied to the Placement Office and

day the bed became vacant, or the day after, The median time that the Placement Offices took to send client information from 1- 5 days. The lengthier provider strengths considered accepting notified practice of reviewing and preferences time in DHA 9 was attributed

clients on the list and matching the clients' needs, this practice is it has led to delays, The time it took from the facility

to the available bed vacancy. Although

to be client-centered,

the client until the resident moved in varied from 3 - 6 davs, and DHA 9 had time. The total processing time measured from the day the facility until the placement

the lengthiest

day the client moves in varies from a median of 4 to 12

days, (See Figure 4) Prior to 2005,

most beds were reportedly

filled within

5 days.

Figure 4
Median Walt Time. to Fill Vacant (~ckK dll)'3} LTC Bad

C""! .... I


~ :-~ , _,~.:":'.:·.~:··.:.r·:_?,-.'-:'" ..

.. ; .. ;.:.: .:" ~'_






. .:


•~~:_-.:. : _

Time 1m Facility to ncrtll'j Pllile!;!ment ofvaean~'1 • Time fur PllICltment -.' Time from F9CIII~ to sanG i::llefil infO to F.eility re.cel\fll'lo.;;l elient in«) unul {rtor acee~




clil!nl mOVll!!s in

Weste rn: DHA 1, 2, 3 North@n'1: DHA -4, SOU rre: Placam ant Qffi~e (F eb - June ~OOS[
"MII!:Ila n: reprase nts the m Idway ~(Itnt In a 0 ~ta set.

.5, 6

h stem; 0 HA 7 ,g

C~rltr d I 0 HA 9


I" a sk-l!wed dataset such as this, ~h~ medl~'" tepr-eS@r\lS the typical time,

Removing Barrijers in Accessing

long Term Care

Wait times are also measured by using a data set from Seascape's waitlist module. represent choice, HC©) is completed.

In this case, wait times are measured from the date the client assessment (RAI· until the date the client accepts the bed offer. These dates of the client. The client participates in the the wait from the perspective (See Figure Sand Figu re 6) by district, and by the location of the client

assessment process, and is contacted when a bed becomes vacant in a facility of their

Walt times for long term care vary by facility,

wait. Wait times for clients in hospital are shorter than wait times for clients in the commu nity. The shorter wait times for those in the hospital is related to the First Available Bed provision in the Fociliry Placement voucv, hospital variances as well as open ing new long term care beds. Wait times for clients being placed in long term care in DHA 8 have been the lengthiest in the province waitlist) (See Appendix since 2008. The demand for long term care {31% of the provincial by their population (15% of the provincial population 75+). D) 80 days in 2009/10 to 6S is not explained

The wait for hospital clients has decreased from approximately days in 2010/11 community are

(partial year); wait times for clients in hospital have decreased

in all

DHA's except in OHA 2. Wait times for clients accessing long term care from the

lncreastng, fram 110 davs in 2009/10 to approximately

150 days in

2010/11 (partial year).
Figure 5

Wait Times for Clients in Hospital
(by DHA)
300 2:'0

150 100




DHA 3 DHA4 DHAS DHA6 DHA 7 DHA8 DHA9 • 1008-2009 • 2009-2010 • 2010·2011 •


Source: SEAscape - rneasu red from ~ecepted the bed Dffer .


. ..... . ... of assessment u ~ed in the i nitia I a ppr~d



care le~el (lee iSi<)(> the date the cI ier\t to-


• 2010-2011: Q1 and Q2 on IV


Removing Barriers in Accessing Long Term Care Figure 6

Wa it Times for Clients in the
Comm unity
500 400

(by DHA)


200 100

DHA 1 DHA.2 DHA3 DHA4 DHAS DHA6 DHA 7 DHA8 DHA9 .lOOB·lOO9 .2009-2010
S01.JI'Ce; SEA scape


decision to the d~ t~ t he (Ii~nl

mea51,II"t!d from date of a5Se·~~-.eiit1J5ed in the Inrti.a I ~ ppro~ed ca re I~I

att@pte<J th e bed offer. ~2010 2011: 01 and Q2 only

Wait times are increasing because the demand for long term care continues to outstri p the supply of available beds. Where the supply of available beds is affected by length of stay and adding new system capacity, the demand is affected by a number of complex and inter-related variables including an aging population, increased incidence of chronic disease, limited caregiver availability, pu bhc perception around access issues, public awareness and the availability of affordable, desirable care options (E,g- home care) in the community, and generational differences in attitudes towards care,

How is the System Meeti ng the Dema nd?
Placements to long Term Care As of November 2010, the Department of Health funds 7,623 long term care beds, This includes 61713 nursing home beds in 87 facilities, 820 residential care fac.Hitiesin 37 facilities, and 90 community based options in 31 facilities. The number of placements is limited by the numbers of available long term care beds- The length of time it takes to fill each vacant bed is affected by how efficiently DOH, DHA's and providers work together to manage the placement process, Long term care beds become available primarily due to the death of a res.dent, a request to transfer to another facility or by add ing addltlona I beds to the system.

The numbers of placements fluctuate by fiscal quarter. April - June 1010 experienced the highest numbers of placements since 2007/08. There were a significant number of new beds added to the system during that time, (See Appendix B~


Removing Barriers in Accessing Long Term Care

Figure 7

Placements: from hospita I, commu nity
or Itc facility
1200 1000 800 _. 600

....... _.

n =2720


.- -


no; 2:798 --



o .... gaS 2


n =01719 •

400 -




, ~ '\...p...... \~#~'\~ #~/.#~#\ ...... \~#\~#\tS> .... °_J.fS.,o#\'\t;;}


_ _

_ ..

. ..

_._ .......








& cY OJ ~



&~ ~? cStf ~--,; ,,"

#\Ao.,~~ ..... f;J".;"'\l~\l\"''''

o? \Y~

• From Community
SOU t~: 5 EAK~ pe

• From Hospital

_ Inter·F,)cility Transfer

Partia I ve~ r

Clients in hospital have been p~aced approximately in the community. frequently provision dients In than clients in the community.

2 times more frequently

than clients

2009/10, clients in the hospital were placed 2.6 times more
This is due to a number of factors that Bed to for clients in hospital. such as the First Available

increase the odds of placement

in the Facility Placement Policy, variance decisions which offer placement percentages

in hospital ahead others in the queue. and the practice of offering

long term care

beds to significant in filling new beds, Figure 8

of clients from hospital rather than from the community

% of clients placed each year

(community and hospital)
100.00% 80
R~ti[}: 1 :1.11 Ratlc: 1:l.6 Ratio: 1:1.11


60.00"16, 40.00% 2.0.0&;16 0,0mt. 2007/1'1: 2008/9: • Community

• Ho,>pltilll



R.emoving Barriers in Accessing Long Term Care

PIacem ent Proce sses A care level decision term other care facility 'classifications'. relevant is requ ired in order to determine and if so at which to make the eligibility if the client is eligible for long as and



The process

is known

A Classifications information

Officer reviews RAI-HC© assessment decision.


The date the care level ahead

decision is approved

becomes the client's "waithst each priority.

date". Clients are offered placement
'need' are not prioritized

in order of their warthst date, Clients with the greatest of others with 'less' need within

Once a client has been assessed, has an approved accommodation rate determined and has identified readv to receive a 'bed offer', information provider.

care level decision, financial their facility preferences, s/he is notify the Placement Office wait list to the Office

Long term care providers

when a bed vacancy occu rs, and the Placement Office then selects and sends regarding the ned appropriate The provider client on the facility's reviews the client lnfcrmanon decision-maker and notifies the Placement informs the Placement

of their readi ness to admit the chent. The Placement otfer the 'bed' _The client or su bstitute their decision, and further arrangements arrange for the client's admission. Cornmu nity Variances Most clients are placed following

Office then contacts the client to Office of to

are made with the long term care provider

the process described Approximately

above. However,


arise as

where typical processes are not followed, 'community variances', Community

12% of all placements

were crisis In

(136 clients from Jan - October 2010) clients from the commu nity placed urgently variances are a response to a client/family scenario: the community. See the following


variance scenario:

"Mary lives with her only daughter



can't leave her alone b~cau5e Mary has wondered away from memory is /afling night. daughter's

the bouse. Mary's

and she doesn't always know where she is or whether it is day or occasiorouv, she gets up in the middle of the night and tries to leave her home.

Martha mokes sure that Mary is supervised at alJ times. Although
recognizes that she just

Martha has arranged for some home care to give her a break a couple of times a
week, sbe's recently been diagnosed with cancer. Martha can't do it any longer. Martha is willing to accept any bed in the province.

The chronoiogv

based wattlist

system may contribute

to the numbers of community


va ri ance p Iace m ents in w hich so me die nts/f ami lies identify urge n t need for pi acemen There may be other clients/families contact anyone, with 'urgent' who do not know who to call, or choose not to need who continues to struggle In the community.

Removi ng Barrie rs in Accessing Long Term Care Community variances disrupt the normal flow of placements, and reinforce to clients, the public and partners that access to long term care may not be avallable when needed. Hospital Variances Hospital variances ate a response to systems issues related to overcrowding, or flow issues at a hospital in which hospital administration ask that clients in hospital are considered the priority for placement. Approximately 3% of all placements were (86 (2009/10) and 52 (April, 2010 to Sept 201O) clients from the hospital placed urgently as hosp ita j variances, In addition, a nu mber of hospital variances also occurred when new facilities were opened. 30% - 72% of all placements to new facilities came directly from hospitalHospital and community variances disrupt normal processes and impact fairness and equity in the placement process in that some clients are offered a bed before others who have waited longer in the queue. The duplication of effort and impact to multiple resources (E.g. Care Coordinator, Supervisor, District Management staff, DOH placement, management staff at all levels) leads to delay in the placement process for other clients. The current DOH FacUity Placement Policy respects client choice and preference- Clients in the community can choose one facUity, or may rank their facility choices if they have more than one choice, Facility Placement Policy guiding principle is to meet the care needs first, and preference second. Applicants in hospital are placed on waitlists of all "suitable" facilities within 100 krns of their preferred community of residence. Clients who are in the hospital must accept the first bed that becomes available within 100 krns of their preferred commu nitv, Clients can transfer or request to transfer between facilities of their choice. Commun~ty Deferrals When clients who are waltl ng in the community receive a 'bed offer' but are not ready to accept it, they may choose to defer their decision for as long as 3 months, Placement Office staff must then select and contact the next appropriate client on the list to make the bed offer. This process normally takes no less than 24 hours. creates delays for others waiting, and delays in filling the vacant long term care bedClient choice and system access issues affect: a. the length of time a long term care bed remains vacant b. the utilization of some less desirable facilities c. the numbers of transfers between facilities d. the number of bed offers made by the Placement Offfce



Removing Barriers in Accessing Long Term Care e. wait times when clients choose to wait for placement in a facility with the lengthiest wait list. Striking an acceptable balance between vatu ins a client-centered approach and pro mot ing svstern effi ciency is needed. As per policy, long term care providers have the right to refuse a client for admission if they can demonstrate that they do not have the resources to meet the applicant's care needs.there were 92 refusals from January - October 2010. Information obtained from the 'refusals form' indicates that facilities are refusing to admit applicants for numerous reasons, the majority of which involve their inability to: manage challenging behaviours; provide private rooms for health or behavioural reasons; secure physician coverage; and maintain staffing levels, Currently, Oistrfct Health Authority staff manage refusals. No formal process is in place to track trends in refusals at the facility or provincial level, so although it is reasonable to assume that refusals. result in delays in filling vacant beds, there is no information available on the extent of delay it causes,

Barriers identified by Providers:
All nursing home providers (83) were contacted in August 2010 to better understand their perception regarding bed vacancies and on barriers to getting their beds filled efficiently, Of the 83 providers contacted, 81 providers perceived: • • • variation in the length of bed vacancies around the province, with many homes reporting lengthier bed vacancies than in the past variation in the time it takes to receive client information once a bed vacancy is declared a positive relationship with DOH placement staff and felt that staffing numbers at placement offices were too low to deaJwith the votu me of work versono! Directives Act has created new challenges for facilities and for Care Coordinators that take time to resolve, leading to delays in both transfers of clients between facilities as well as new placements opening of new facilities has diverted attention from regular placements and has increased the volume of inter-facility transfers leading to lengthier bed vacancies facil ity requ irement of ;;I pre-admission assessment and fami'y visit to sign a financial cont ract creates chalIenges families are not fully prepared to make decisions regarding placement in a tlrnely manner changing and complex needs of clients upon admission create chaUenges availability of physicians to participate in the admissions process

• • • • •



Removing Barriers in Accessing long Term Care

Reporting placement facility.

on bed vacancies is operatlonallv

focused, is not coordinated

and is limited. the

Providers notify the Placement

Office shortly after a vacancy occu rs to initiate

process, However, there is no reporting

on the date the client moves into the

Providers also report the sum of vacant bed days (see bed vacancy reporting below) to DOH, However, the data on the duration cu rre nt Iy report ed.


of each bed vacancies is not

Funding long Term Care Providers
Long term care providers term care providers occupied The occupancy to calculate are funded by DOH. Presently, the funding received by long

is based upon a facility's

entire budget regardless of the number of a resident occupies a bed or not. and is ontv used of long term care facilities

bed days. Funding is not linked to whether rate is no longer used in funding a fadlity

per diem in order to bill insurers of fi rst resort. (E.g. Department

Veterans Affairs) Residents pay an accommodation DOH each November accommodation accommodation Long term care providers rate to their long term tare provider, which is set by

I", Residents with lower net income have their fees reduced.
receive, on a bi-weekly basis, their budget less estimated process later adjusts for actual rate.

revenues. A reconciliation

revenues. Prior to January 1, 2005 long term care service providers

were funded based upon occupied bed days, using an occupancy

Bed Vacancy Reporting Scenario: a facility has 100 beds and in a 30 day month hills 3000 available bed davs. (Beds X days;;;: available bed davs). The facility reports 20 vacant bed days for the mo nth - Occupa ney rate 2980 uti Ii zed b ed doilys!3000 avaita bIe bed days = 99,3%.


The occu pancy ra te aic ne does not provide in forrnati on on the length of time at'] individua I bed has been vacant, In this scenario, there could h~\le been 1 bed vacant ror 20 days, 4 beds vacant for 5 days. or other combinations that sum 20,

Presently there is no flnanclat incentive

to fill beds,


Removing Barriers in Accessing long Term Care

Strategic Recommendations and Actions
The Department of Health, District Health Authorities, and long term care providers share the responsibility for the placement process. Eachparticipates in the process to facilitate clients' transitions from the community, hospital, or a long term care facility to another long term care facility. Since 200S a number of initiatives have been undertaken to review the process to access long term care beds in an attempt to better understand and deal with barriers to placement. Many of these initiatives have resulted in recommendations to improve efficiencies in accessing long term care beds. Despite efforts to reduce barriers in the placement of clients to long term care, there have been minimal system impacts.

An internal working group comprised of staff from the Continuing Care Branch has been farmed to review and synthesize previous work on barriers in the placement process completed by service providers, DHA's and DOH and to develop recommendations for action to improve efficiencies. The follow strategic recommendations and actions have been proposed. A separate initiative is required to prioritize recommendations, to develop implementation plans and identify the most appropriate lead (e.g. DOH, DHA or provider) for implementation of the accepted recommendations.


Improve Support and Communication for Clients and Families
Admission to a nursing home for any individual can be very distressing. Clients or their decision maker are asked to make life changing decisions quickly once an offer for a long term care bed is made. While it is true that clients typically wait for a lengthy period, many clients are not fully prepared when the bed offer is made. The full impact of leaving home or hospltal(and not returning home) may not be fully recognized until placement is eminent. Clients may experience an increase in psvcbological and emotional difficulties during this time and would benefit from support that is proactive end appreciative of the client's perspective, Enabling the client/care giver as much as possible through better case managernent, comm un lcatlon and coaching as well asp rovid ing writte n information early on that is suitable for the target population is critical to help them through the experience. Rationale: Better prepared clients and families will be in a stronger position to participate fully throughout the placement process. An improved understanding of 'who to call', of the providers in their community, as well as their role in the placement process will reduce delay- Clients receiving support and early, frequent communic:ation about placement are better prepared to make decisions. If a substitute decision maker is required, that is identified and facilitated.



Removing BarrierS in Accessing Long Term Care


Action:5: responsible for facilitating the client's transition Officer(s), to



a role that is. ultimatelv

long term care. Clients and their families encounter term care providers t ra nsitions, and other professionals

hospital staff if the client is in

hospital- Care coordmetorts), Eligibility Review Officer, Placement as they move through process. The Care Coordinator could be jdentified


the placement

as the key role in facilitating

2. Clarify case management


and provide Care Coordinators

with planning

on how to support the client and family members

about future

when a client is no longer able to live independently.

3. Ensure suitable cornmu nicatlon tools are avella ble to cl ients!families
placement o, related topics including: Personal Directives Act Placement process and

on a variety of

b. Long Te rm Ca re sector and prov iders

e. f.

a client's

role in it is made between facilities.

d. What to expect at the time of admission
What to expect when the offer of placement Tools to educate Power of Attorney Financial Contract signing: facility requirement residents who are transferring

h. 4. 5.

Notify cl tents when they are within the top 10 on the wait list. Encou rage clients/fami facility and meet staff. lies to visit long term care facilities so they may tour the

Impacts and risks: Additional responsibility responsibilities printing resources. Improved for the placement


for the role identified

as having overall

process as wei! as additional

case management

are needed to better support clients and families. The development, of communications tools will require human and financial

and distribution

support and communication

will reduce

detav in placement, and better meet

the need S 0 f cI ients and thei r fa mil ies.


Removing Barriers in Acce~sing Long Term Care


Improve Policy and Process
of Health is committed to providing fair, consistent and

The Nova Scotia Department appropriate mandate. placement Placement placement placement process.

to Long Term Care facitities. that fall within the Department's focus. in the

The Facility Placement Policy also emphasizes a dient centered

processes are complex, inter-dependent process, requiring mutual understanding and data sharing practices. Facility Placement

and involve multiple of roles, and efficient

partners. in the

communication Rationale:

A re-developed

Policy which is articulated of redundant

with goals,

standards and expected outcomes. allows for measurement improvements. duplication

and performance processes and areas of

The identification

and elimination

will improve


Recommended Actions:
1. Rede:Sign long term care policy to better support the current a. b. c. environment. of


goals which allow for measurement goals are met.

and a better understanding gu idel lnes and

Redefine .and develop policy objectives, standards that support the objective. Measure and ensure compliance opportunities

with accompanying

with existing polky which will reduce to screen clients on the to the and preferences

for the Placement Office and providers

wait list and match the clients' needs, strengths avai lable bed vacancy. d. Modify the organization wait list from chronology identified Instrument jurisdictions incorporated e. and management

of the waitlist

to respond first to

clients with the greatest need for long term care; change the long term care only, to chronology scientifically plus need and risk measures as The Resident Assessment comprehensive by the RAI&HC© assessment system. is a standardized,


assessment tool used in NOva Scotia and other Canadian and international used to provide information into decrsion-making. ~E.g. tt of initial choices, delays deferrals) but which may be creating on the client's strengths, should be more fully weaknesses and preferences, and this information

Review policies that support client preference, transfers or requests to transfer, in the placement

and Care Coordinators Education who know the client best, on RAI-He


Revi ew ca re leve Ide C IS ion - rna ki n {l processes. One co nsiste nt p rovl ncl aI process shou Id be adopted, development of mechanisms shou Id make the care level decisions.


to outputs,


to ensure quality assessments, the


Removing Barrie rs in Accessing Long Term Care development of criteria and procedures to flag complex clients. as well as an altsrnatjve mechanism for care level decision-making for complex clients are recommended. 2. Re-evaluilte and re-design current processes. Long term care providers, DHA's and DOH have processes that intersect and are inter-dependent. Eachgroup should analyze .and improve processes that have the greatest impact on the client experience. Process areas that don't contribute to effective and efficient care of the client need to be eliminated. The identification of duplication of processes, areas of unnecessary wait, and miscommunication will reduce opportunity for delay. An improvement plan that takes into account the degree of difficulty to implement process improvement initiatives and the level of impact it wou Id have on core indicators is recommended. 3. Create policy with a better defined or more restricted rationale for variances to minimize these requests. 4. Improve and coordinate admissions processes to enable more efficient admissions, as we II asp Ianned adm iss-ions0 n wee kends, a. Create innovative, flexible approaches to admissions which could include a district "admissions team" with representation from DOH, DHA, physicians and facilities that could work to facilitate admissions when needed. The admissions team could support both weekday and weekend admisslcns. b. Work. toward admitting clients on weekends, particu larly planned admissions, where the financial and care level approval are completed.


Review the need for the Medical Status Report. The Medical Status. Report can be up to 3 months old when admission takas place, and as.such may/may not reflect the client's status at the time of admjssjon. AdditionaHy, clients without .;J family physician experience challenges in finding a physician to complete the report on their behalf. This creates additional burden for families moving through the placement process. The information in the Medical Status Report may add little vaJ ue to resident care consumes physici anand other resou rce ti me.

6. Create policy with better defined rationale for facility refusals. 7. Create refusals committees in each DHA, with reporting requirements. With clear reporting requirements, the abUity to identify trends that may indicate system gaps, identify specific facilities that have proportionately more refusals than others8. tdentify areas where duplication of effort exist, and manual processes C;;Inbe automated. a- Data flow between Care Coordinators and Placement Office, Eligibility Review and facilities need to be streamlined, and then automated. 18


Removl ng Barri ers in Accessing Long Term Care b. System enhancements to SEAscapesuch as improving the long term care template, create new operational reports to better support data flow between DHA discharge Planners, tRU, (('S, the Placement Office and service provl de rs. c. Automating transfer of client information between the Placement Office and service prov iders, d. Automate generating fetters: letters for care level decision, respite letters, deferral letters and associated revisions to letter when cancellations and changes occur, Manual processes involve time consuming and costly practices such as file retention, filing, faxing, photocopying, etc. 9. Review manual processes such as managing respite bookings with plans for automated processes. 10. Obtain automated accessto Canada Revenue information for specified staff at the Etigibility Review Unit. 11. Better use and broader access to information to those involved in the placement process, a. Supervisors of Care Coordlnatlon staff currently have access to wait list information. Supervisors could provide guidance to Care Coordinators regarding appropriatelv timing of the RAI·HC© assessment prior to a bed offer being made. Care Coordinators could also be provided with direct access to the waittlst lnforrnatlon to enable them to better manage their caseloads. b. Provide reports to long term care providers on clients who wish to transfer so they can prepare for their transition, c. Provide long term care providers with a limited number of names of clients waiting for their facHity. Providing this information may expedite processes, but will require close management to ensure that clients are offered admission to long term care following policy. Impacts and Risks: The above recommendations will allow for more efficient placement of clients in homes by removing some of the current limitations. However, precise coordination between Care Coordinators, the Placement Office and multiple facilities will be required particularly when clients have multiple facility choices-


Improve Transition Planning
Improve clients' transition between hospital and community to long term care, as well as transfers between long term care facilities. There are a number of system improvements to better support this transition.


Removi ng Barriers in Accessl ng Long Term Care

Rationale~ placement


planning identifies

issues early that can lead to delay in the exploring community-based options placements,

process, Good transition

planning may result in better and faster transitions helps to avoid unnecessary

for clients requiring prior to consldenng by supporting Reco mmended

long term care. Thoroughly long term care placement

chents at home. Act ions:


For clients in the community: aensure RAI·HC© assessments, accompanying information the client's list of facility choices, and other and current to mitigate the practice that conduct their own in person may create delay and uses scarce human the identification of a is complete effort,

of some long term care providers assessment which duplicates resources inefficiently.

b. ensure appropriate

consents are in place including if required is up


as weH as Enduring Power of Attornev,

or Power of Attorney.

c. ensure income tax information fi na nci a I proce sses
2. for clients in hospital:
a. establish transition their stay protocols

to date to facilitate the required

for patients at risk for long term care early in to long term care

b. screen patients for risk factors that may delav transition
c. d.

begin discharge planning shortly after admission to hospital, explore

opportu nities to support clients in the community identify clients with complex clinical presentations incfudtng challenging behavior, special dietary or equipment needs and have plans in place prior to
transition to long term care issues are dealt with prior to planned discharge and that and hasn't lapsed for choices and other effort, of a coverage is in place for new medications, ensure medication pharrnacare


exi stj ng med i cane ns f.er'lsure providers g.

RAI-HC© assessments, the client's list offacility
information ls complete and current.


Some long term care

conduct their own in person assessment which duplicates consents are in place including the identification

may create delay and uses scarce human resources inefficiently. ensure appropriate substitute h.


if required as well as Enduring Power of Attorney,
is up to date to facilitate the required

or Power of Attorney ensure income tax information fi nan cia I processes standardize tools and practices between hospitals and long term care (E.gPatient.s. are charged a lower per diem rate for Ale beds in OHA 9 as


R.e movi ng Barri e rs in Acce sslng Long Te rm Care


to the per diem rate in nursing home. This can contribute

to delay

for clients who prefer to remain in the lower priced ALe bed.)


For clients transferring


long term care facilities: are timely, comprehensive of care plans at the receiving must adopt and of a

~_ ensure information facility b. c.

such as discharge summaries

and sta ndardized to assist in the development develop a standardized ensure appropriate substitute d. e. or Power of Attorney ensure any special dietary requirements in advance ensure re-assessments {E.g. Residential creating appropriate a situation of clients transferring financial contract

that all providers

in co rpo rate f nto prov ider se rvice agreem e 11 ts consents are in place including the identification .if required decision-maker as well as Enduring Power of Attorney, and equipment needs are arranged ~evel of care or to an

from a different

Care Facility} are available to avoid delaying a transfer, in which a client requires immediate transfer

level of care due to safety and risk concerns. transitions options contribute to a less stressful experience for

Impacts and Risks: Smoother exploring placement. cornrnunitv-based Good transltlon

the client and family. For clients in the community

as well as in the hospital, thoroughly means shorter hospital to facilitate stays,

may delay or avoid the need for long term care

planning for those in hospital with other care providers

m itigati ng so me of the deb iIltat ing im pa cts of Ions hosp ita I stays on the f ra iI e Ide rly client. Establishing from hospital transitioning partnerships patient transitions Delays in better supports clients and minimizes d uoucaucn of effort.

patients can lead to longer wait times, and bed vacancies and dissatisfied

clients and families.


Create a Measurement Plan that Monitors Improvement and Promotes Accounta b iIity
All partners in the placement efficiency goals and provide performance accountabilities process shou Id collect and monitor information that is actionable. consistently common indicators of

in accessing long term care. The indicators that are clearly articulated,

should be linked to articulated Targets and and enforced communicated

mea nth at im proveme nts in perfo rrn aoce can be p roa ctive Iy identif ed and acted upon. Rationale: of indicators performance Creating performance supports monitoring initiatives expectations, activities, that can be measured by a common of targeted set

and enables the development


quality improvement

in specific areas where they are needed. Measuring success. Basejine data will allow for a

also provides a tool to demonstrate


Removing Barriers in Accessing Long Term Care common understanding of current system performance regarding efficiency and will set the stage for performance targets,

Recommended Actions:

Monitor the quality (E.g. accuracy/timeliness) of information that supports transition to long term care,

2. Identify 'what' data is reported [i.e. reporting requi rements) and 'how' [i.e, processes that organize the flow of data) between the providers, DHA's and DOH. a. Develop standard definitions of the data to be reported b. Clarify the roles and responsibilities for those involved in data collection and analysis, 3, Develop clearly articulated performance measures with benchmarks and targets. 4, Adopt the following lndlcatorls] of efficiency: a, The number of calendar days each bed is vacant, measured from the day afte r the bed beco mes vacant unti I the day the bed is nUed, (E,g. reside nt vacates the bed on Saturday and a new resident is admitted on Wednesday. The number of days the bed is vacant == 4) b. Wait times to placement as measured by the n of days from the date of assessment used in the initial care level decision to the date the placement offer was accepted. 5. Develop and communicate response time standards for each partner in the placement process in order to manage and monitor the placement process. Although it is currently expected that beds in long term care facilities remain vacant no more than 5 business davs, DOH, OHA's and providers shou Id be held accountable for meeting standards for their portion of the process. a. Adopt the following performance expectations: i. RAI·HC© assessments are completed within 3 months of placement. Assessments must reflect the client's current status. ii. long term care facilities send the Notice of Vacancy form to the Placement Office in their area no later than lOam of the next normal working day following the day of death or discharge (see Ccntjnuing Care Information Release #22.05, January 19. 2005 for more information); iii. The Placement Office sends the client information for the 1st offer to the facility within 24 hours of receiving the Notice of Vacancy. iv. Long term care facilltles advise the Placement Office of their acceptance or refusal of a client within three hours of receiving lt from the Placement Office; and agree to an admission date and



Removing Barriers in Accessing Long Term Care



is within


hours maker

of the facility



a p pi icatio n.

v, Clients/substitute


are encouraged to make the

decision to accept, reject, or defer the bed offer within The client moves into the facility within

24 hours.

24 hours.

Impacts and Risks: Measuring and reporting on efficiency alone may shift the focus to
efficiency, additional to the detriment of important areas of performance such as Quality, safety, and etc. Providers may not have the capacity

to adopt new reporting requirements

resources may be required to su pport timely and accurate reporting.


Create Fina ncia I Performa nee Incentives
Funding models that encourage integrated, Rationale: efficient, providers to work together in delivering coordinated, comprehensive

and high quality care is desirable.
will encourage better use

A financial incentive to admit residents efficiently

of long term care beds. With the current funding approach, the funding based upon actual bed occupancv which creates a disincentive RKommended 1.

is not adjusted

to fill beds efficiently.

for occupied bed days.

Fund providers

2. Explore incentives and penalties for providers that do not achieve performance
standards [i.e. speclfic occupancy levels and response time standards) below a specific target. Impact an d RIsks: SeW ng ta rgets tha t can not be met by pro vl ders rna y p Iace fi nan cia I pressures on facilities impacting on the quality of care received by residents. Penalties

cou Id include a reduction to a facility's Oi ract Care Envelope if the provider achieves


Review roles, responsibilities the placement process

and staffing levels for those in

The pi acerne nt process req uires ·approp ria te staffi ng level s, as we II as knowl edge abIe staff to ensure client-centered, Rationa~e: consistent and efficient placement practices.

Staff at all levels have evolving responsibilities care sector is restructuring,

as the health care system to grow with new


changes. The continuing

and continues

R.emoving Barriers in Accessing long Term Care

and expanding including

programs that generate


demands on scarce resources



of Classification Officers, Care and

I. Review, redefine and clarify roles and responsibilities
Coordinators duplication 2. and Placement of effort. Coordinators

to avoid miscommunication

Research appropriate In light

work volu rnes for Care Coordinators,

and Placement Officers.

of this


Review staffing levels of Care Coordinators

b. Review staffing levels at the Placement Office 3. Provide information and support to Care Coordinators secto r, an d placeme nt proc es ses,
regarding the long term care

4. Provide Placement Office staff on-going education and support to improve effi cie n c i es.
5. Provide irforrnatlon placement processroles, responsibilities of continuing and levels may have budget staff are required to care services with the District and areas of accountability to long term care providers and District Hea Ith Authorities understanding of the on

the RAI·HC©, and the placement

process to improve

lssues and risks: A review of staffing and other implications Health Authorities achieve desired efficiencies.

if roles change signiftcantlv, The integration

and additional

will likely change roles, responsibilities

that wi II need to be addressed.


Manage for Success
Since 2005, a number of initiatives (See Appendix C) have been undertaken to understand have resulted to review in

the process to access long term care beds in an attempt barriers to long term care placement.

and deal with

Many of these initiatives

re com mend atlons to improve efflci encie sin acce ssing long term care bed s, Des pite efforts to reduce barriers in the placement minimal system impacts. Rationale: authority. Leading system change effectively will require commitment, focus, and to act move forward. of clients to long term care, there have been

Leaders from DOH, DHA's and service providers

who are accountable


on these recommendations

are needed to ensure the recommendations

Removing Barriers in Accessing Long Term Care

Recommended Actions: 1, Formally engage system leaders who can become champions and can buJld broad based suppo rt fo r the chi!nge in policv, pro cess and practice req uired to create change. 2. Identify leaders at all levels (E.g. providers. DOH and OHA) 3. Develop a coordinated approach to moving forward on the accepted recommendations where recommendations are prioritized. and progress is tracked and regularly reported to decislon-makers. 4. Develop a change management strategy, Impacts and risks: Even with strong, effective leadership, removing barriers so that vacant long term care beds are filled efficiently m~y not achieve signiflcant system impacts. The integration of continuing care services with the District Health Authorities will likely change roles, responsibilities and areas of accountability that witl need to be addressed.

Next Steps
DHW has shared the recommendations with the Vp's of Community, the Continuing Care Council at HANS, and (CANS executive. Two additional reports: "Long Term Care Placement Process Review" completed by HANS, and "Continuing Care Long Term Care Placement" completed by Cape Breton Health Authority were also reviewed and 14 priority recommendations were identified, DHW has extended an invitation for sector representation on an advisory committee to provide feedback on the overall project developments and working groups to develop requirements and processes to implement the 14 priorities. The work is expected to be completed by November 1, 2011.


Removing Barriers in Accessing Long Term Care

Appendix A:

All data sourced from 5EA~cape. Please go to http://


for details

RAl© outputs. Clients added to the long term care waitlist in 2009/10:
Hospital Femal~ Male Community (No He) Female 774 Male Community {He) Female 626 Ma~e

Wait Setting

# of Clients

767 83

428 79

375 80





Clients Living Alone:

Clients with Caregivers Reporting

'4~· . ,~~ ':.,. .





0.... COO '"'C)




.(:Q.'ruTl....--t'i (HCt

Cognitive Pe.~(;)_r..".1.e.a.l1ce ScaJe: ".....
IO~ I... '" • .

ADL Self· Performance


'Oin. .



• ~'.I • CDI',rllUI"II'''' (No

-1 •....
1<1 • (~ni1.,~1'10


-1.1• ~till • COI"9I"J.Jf'III...~Nc. H(~ • (,~~ ...Ito( I

Sourc~- S'[l\s(<lPt:, RAI-HC a~ses~ment output Cogn n~ Periotma nC-I!Scale: Source: Morr'5 J N, Ffles J t, Meht Dr ~l al, MDS C.o8n.i~ill-e Perf(lrm~n(e scale, JOufM I of
GetQntol{]g)' 1994; 49 [3): M 174-182.

Sou rce: S EAsCil pe • RAI-H,


ou tput

ADl PeMefm:a nC'E!H ie rarch~: sou rce: Morfl'> Gemnrolllg)':

m. FfieS J E.

MOft IS SA. Scali n8 ADt5 with in rbe MOS. Journa I of Me-i;llCal soen ces 199-9. Vol. S4A. No. 11,


MAPLe Levels:



..,,' .

~" '" .
,.",I~.J'I. .


. .




.l"tosMill •


I tN,o tiCl


" ....
J~~ .

l~"'" .

~ ..


I r





I• .-[~lIw(1«:1


• C.:.tnm...r.h.lIH()


SEAscape. RAI-He


ssessment output

Sou rce: SEMc~pe, RAI· He a ssassrnant nutput

Removing Barriers in Accessing Long Term Care

Appendix B
Since 2009, 669 new long term care beds have been added to the system- The table below illustrates the number of business days it took to fill the new beds. The process.of placing clients into the new beds put additional demands on staff (E,g- Care Coordinators, Placement Office staff and facility staff) involved in the placement process. When new facilities opened, approximately 60% of beds were filled with clients from the community, and 40% were fHled with clients in hospital. Existing facilities have reported that filling the new beds diverted attention and resources from placements to existing facilities, which created delay. Aside from the additional work created in filling the new beds when the facilities opened, additional numbers of beds in the system will create opportunities for higher volumes of placements on an on-going basis that will place demands on staff involved in the placement process.
New Sed:. F~cility


# of new

# of business
days to full occupancy

Date opened


BridBew.ater Kenlville Greenwich Annapcus Royal Bible Hill



25 16

Moily 19 2010 _._. -Nov 18 2009 Mar 312010 F@b 12D10 April 15 2010 May 272009


Sh:annex Shannsx Shannex Sh:annex Shannsx


Brookfield Amher~t Sydney Sprit'lghill Co le H oil rbeur Lower S.a .. ilie ck Bedford West

60 36 36 36 36

9 9 9 9

o« 27 2009

Rosecrest Northwood

20 50 50 156

Mar 1 2010 Sept 30 ,,009 ! Jan 292010

13 -31 (lock

i June


I June 22010
. April 142010

; 2009

issues) 5S


Removing Barriers in Accessing long Term Care

Appendix C:
• Long Term Care Waitlist Information and Placement Working Group {February 2006~ whose mandate was to recommend policies and procedures for the efficient and effective sharing of provincial LTCwaiting list information to LTC facilities. Report with recommendations presented May 2006. In February 2008, a working group with representation from the Department of Health and long term care sector in District 9 met to discuss long term care placement issues in District 9. Recommendations were developed. Care level decision making process evaluation 2007. (final report had a number of re com me nd ations aro u nd the pia ce ment p recess, incl uding sh ifti ng ca re leve I decision mak.ing to Care Coordinators, and adopting a needs based waitlist management system) On 2S-Mar-09, working group formed to review barriers to placements and consider ways to improve current processes.


Removing Barriers in Accessing Long Term Care

Appendix 0


200&'10 cIIMtB


c:1..... wailing

", .. nust cM .... owr

% rill provine'"


prwlo ... 1ft

populdon 7S+

LTC beds

",or ...




8~ 8~ 10-"

3 4




2~ 22"
2~ -1K


8 9








!!5" 1K 331ft 1~



5'" 5"
1!!5% 38... 100%.



2'"' 1~

31 ...



This table [llustrates:

The distribution of long term care beds. by DHA, and the percentage of the population 75+ in each DHA. The distribution of long term care beds was made based upon a methodology that included demographic information and indicators of frailty and need. The proportion of beds to population 75+ is closely aligned. However, the demand for long term care placement, particularly tn DHA 8 where a higher proportion of their population 75+ are seeking long term care placement. For example, although 465 clients in DHA 8 comprise 31% of the waitllst, thev have 15% of the provincial population over the age of 75. The demand for long term care placement in DHA 8 related to their population 75+ is higher than the rest of the province.



of Health and Wellness Care Branch


9.02·424· 7233


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