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Licensed residential care facilities have three essential features that set them apart from other supportive living environments, such as assisted living. Each is an important consideration when applying and interpreting the law in this area.
:a) A person cannot be admitted to a subsidized residential care facility or extended care facility without having specific care needs. The person must have a level of care need that cannot be appropriately met in the community. ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|1]])Today, that means the person requires what is referred to in the British Columbia health system as “complex care”.
:b) All licensed residential care facilities (including private pay hospitals and extended care facilities) have a responsibility for monitoring on-going care needs, identifying significant changes and meeting the current and changing care needs of the residents.
To be eligible for residential care, the person must:
* Have a health care need that requires 24-hour nursing and personal care ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|2]])
* Be a citizen of Canada or have permanent resident status *
* Be 19 years of age or older
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Some health authorities state in their public information that the individual must also exhaust all other home care community options. ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|3]])Nothing in the Ministry of Health eligibility criteria requires this. The primary issue for most residential care admissions is that the person meets the high threshold of needing 24 hour care. For subsidized residential care, the person must also meet the financial eligibility requirements for the public subsidy.
The most common reason for people to need residential care these days is a blend of physical health and cognitive factors for the prospective resident, as well as environmental factors such as risky living circumstances and caregiver burnout. The prospective residential care facility applicant is often a person with multiple and complicated chronic health conditions, with or without dementia that has progressed to the moderate to advanced stages.
* their conditions are clinically complex (meaning they have multiple disabilities or complex medical conditions that require professional nursing care, monitoring or specialized skilled care);
* they are moderately to severely cognitively impaired; or
* they have severe behavioural problems on a continuous basis.([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|4]])
To determine the prospective resident’s health care needs in the community the Ministry of Health uses a standardized tool called the Resident Assessment Instrument (or RAI). That assessment tool helps to identify needs and degree of urgency for placement. A specific version of the standardized assessment tool Resident Assessment Instrument Minimum Data Set (RAI MDS 2.0) is used in residential care facilities for the assessment and care planning.
For any type of health authority decision made about prospective or current residents, an exception is always possible. It may be rare, but it is possible.
:''“Health authorities may authorize exceptions to policy in client specific circumstances, based on assessed need. Health authorities must maintain a record of waivers and any exceptions to provincial policy and report these, with the relevant background information such as rationale and timeframe for the exception, to the ministry.”''([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|5]])
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==Moving to Residential Care==
[[File:Old lady.jpg | left | frame | link=| <span style="font-size:60%;">Copyright www.shutterstock.com</span>]]
A prospective resident (or applicant) may come from a variety of places while waiting to move to a residential care facility. This includes living at home, in an assisted living residence, in a hospital, an alternate level of care (transition care facility) ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|6]]), in a non-subsidized residential care bed, or in a subsidized residential care bed that is not in their preferred facility or community.([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|7]])
Placement in residential care is based on a system of “priority access”. According to Ministry of Health policy, clients on the waiting list are prioritized based on the urgency of their care needs. That priority is established by the assessment process administered by health authorities and is commonly referred to as the “first available bed” or “first appropriate bed” process. (The Ministry of Health now prefers the term “first appropriate bed.”)([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|8]]) In recent years, the health authorities in British Columbia have given priority for residential care placement to people transferring from hospital over those at home or in another facility.([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|9]]) The health authorities, not the private care facility operators, manage the waitlists for all funded beds in the residential care facilities.
{| class="wikitable"
===Transfers===
People who are not able to move directly into their preferred facility can put their names on a waiting list to be transferred to their facility of choice. The health authorities maintain transfer waiting lists in addition to the lists of people waiting for initial placement. ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|10]])In practice, transfers from other residential care facilities are becoming far less common, in part because of the complex care needs. Today the average length of residence for people from the time of their admittance to the care facility to the end of life is only six to eighteen months. Families find that the waiting time to transfer commonly exceeds that, ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|11]])and one health authority states it does not permit transfers within the first two months.([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|12]])
==Costs==
===Cost of a (subsidized) residential care facility===
The cost of publicly funded residential care services is shared between the Ministry of Health and the person receiving services. The Continuing Care Fees Regulation sets out the fees payable for subsidized residential care, identifying a maximum and minimum rate. This is referred to as a “client rate”.([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|13]])
The Ministry of Health and the health authorities pay for the cost of care in publicly funded residential care services. The resident pays the “accommodation costs” in what is sometimes referred by the Ministry as a “co-payment”.
Accommodation in some older residential care facilities may consist of 3 or more beds to a room. Most new residential care facilities have semi-private rooms (2 beds in a room), or a private room has a single bed in a room. Multi bed rooms are considered “basic accommodation,” with private rooms commanding a higher rate.
The Resident Bill of Rights for Residential Care Facilities, private hospitals, and extended care units in hospitals identify a responsibility on the Operator to “advise persons who are being admitted of all fees, charges, and policies”, and “provide an avenue to file concerns or complaints.” ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|14]]) This requirement is reinforced by s. 48 (1) (a) of the Residential Care Regulations.([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|15]])
People in subsidized residential care will pay up to 80 per cent of their after-tax income to cover the cost of housing and hospitality services including meals, routine laundry and housekeeping (“the accommodation costs”), subject to a minimum and maximum monthly rate. The actual amount paid must leave the individual with at least $325 (effective February 1, 2012) remaining from their income each month. For many British Columbia residents, this remaining amount often may be all that is available to cover all their “optional costs” (for examples, telephone, own wheelchair, “preferred” incontinence or grooming supplies, recreational activities). There is considerable variation among Operators in what is included in the accommodation cost, and what can be charged extra, and how much can be charged. ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|16]])
The resident “co-payment” ranges from $958.90 per month to $3,059.00 per month. The minimum rate is adjusted annually based on changes to the Old Age Security/Guaranteed Income Supplement rate as of July 1 of the previous year. The maximum client rate is adjusted annually based on changes to the Consumer Price Index.
===Applying for subsidized residential care.===
The cost of subsidized residential care is typically borne by and paid by the individual resident. It is based on income not assets. To apply for subsidized residential care, residents first must consent to disclosure of the income tax information they provided to Revenue Canada. This consent to disclose is required annually. If there is a spouse, the spouse must consent as well. If either person does not consent or cannot consent, the resident will be assessed at the highest residential rate. ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|17]])
This default position can cause considerable hardship for the individual and a spouse, partner, or family. According to the Home and Community Care policy, a spouse or other person can only give consent to provide the income tax and other financial information for the purposes of determining financial eligibility if they can show they have legal authority to do so (that is through a power of attorney, section 7 Representation Agreement, or as a Committee of the Estate).([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|18]]) Documentation of that legal authority is required. After calculations, the health authority informs the Operator of the appropriate client rate and is not permitted to share any income information. ([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|19]])
===Hardship Waiver (“Temporary Rate Reductions”)===
As previously noted, the statutory authority for client rates is covered by the Continuing Care Fees Regulation. The person may have low income, or may have higher income but his or her spouse is still living at home. If paying the full client rate would cause serious financial hardship, the resident or his or her substitute may apply for a temporary reduction of the rate.
This is referred to as a “hardship waiver” in the regulations. The Ministry of Health and health authorities use the term “temporary rate reductions”. These waivers or reductions are also available for other costs such as wheelchair fees. Residents and families may not be unaware these waivers exist, how to apply, or the need to re-apply annually. For others, the fact these are referred are called hardship waivers is itself embarrassing and stigmatizing,([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|20]]) especially given the fact that many older people and their families do not want to be thought of as “charity cases”.
===Cost of private pay (unsubsidized) residential care facility===
In a private hospital or any unsubsidized care bed in a private pay facility, residential care services are accessed by the individual directly from the Operator.([[Chapter Three Legal Issues in Residential Care {{PAGENAME}}#References|21]]) The facility staff conducts an assessment to decide whether or not the facility can provide the services that are being requested. In private pay facilities, the services and accommodation received are part of a private business arrangement between the Operator and the person in care and are defined through the contract.
All aspects of service provision are agreed to by the individual and the Operator in the contract. Government does not provide any financial assistance to individuals or Operators for the service.([[{{PAGENAME}}#References|22]]) ==References==#There are no specific admission criteria for private hospitals or the private pay beds in residential care facilities, other than the ability to pay. However, most of the people using the resource will have similar care needs to those in a subsidized residential care facility or extended care facility. As the Ombudsperson report The Best of Care (2012) notes all three types of facilities now provide complex care. [page 210]. This report will be referred to as the “Ombuds, Best of Care” throughout this manual.#This is determined by the health care tool, the Resident Assessment Instrument (RAI).#See for example, Interior Health, which states that the person must also “Have tried all of the avenues available for receiving care at home.” Online: http://www.interiorhealth.ca/YourCare/HousingHealth/ResidentialCare/Pages/Eligibility.aspx (Last accessed May 1, 2014).#British Columbia. Health Services. Health and Safety. Long-Term Residential Care. Online: http://www2.gov.bc.ca/gov/topic.page?id=4FEC0F570BC04692810548267D09577E (Last accessed May 1, 2014).#Ministry of Health Home and Community Care Policy Manual, Chapter Three Legal Issues 1, Overview.#Alternate Level of Care refers to the transition period between acute (hospital) and post-acute ( non hospital) settings. People in this transition period are referred to as alternate level of care (ALC) patients. Even though they no longer require the intensity or specialized medical care provided by acute hospitals, they are not able to be discharged to the community ( to a residential care facility or “back home”) because the available resources are unable to meet their needs. They may be delayed from being discharged to a post-acute Provider, typically because of lack of appropriate, available space. See: Canadian Institutes for Health Information. November 2012. Seniors and alternate level of care: building on our knowledge. Online: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf (Last accessed May 1, 2014).#Adapted from Best of Care. [pg.34].#Ombuds, Best of Care. [pg. 225].#Ombuds, Best of Care. [pg. 34]. Also for a good discussion of surrounding the law and ethics of discharge from hospitals to nursing homes and other settings in the Ontario context, see J. E. Meadus & J. A. Wahl. Transfer from hospital to long-term care: reframing the ethical debate from the patient’s perspective. (Toronto: Advocacy Centre for the Elderly, 2008), 4 Online: http://www.acelaw.ca/appimages/file/ACE%20-%20Ethical%20Issues%20&%20First%20Available%20Bed%20Policies%20-%202008.pdf (Last accessed May 1, 2014).#Ombuds, Best of Care. [pg. 34].#Ombuds, Best of Care. [pg. 33].#See for example, Vancouver Island Health Authority Residential Care References|22Guide, pg. 6[ “VIHA”].#Home and Community Care. Online: http://www2.gov.bc.ca/gov/theme.page?id=A8F32056E4192102A51A3F0FF373223C#Resident Bill of Rights. Online: http://www2.gov.bc.ca/assets/gov/topic/D3E0B9FAB55484D135A5C5201D799D96/pdf/adultcare_bill_of_rights.pdf (Last accessed May 1, 2014).#Residential Care Regulations. B.C. Reg. 96/2009, as amended. Online. http://www.bclaws.ca/Recon/document/ID/freeside/96_2009#section48 #The Ministry of Health is currently reviewing “Chargeable extras”.#HCC Policy Manual. Chapter: 7 Client Rates Number: 7.B.1 Section: B Income-Based Client Rates. Subsection: 1 Assessment of Client Rates. (Effective: January 1, 2013) (“HCC, c. 7”)#HCC, c. 7.#HCC, c. 7. #Farrell, J. (July 15, 2013). Why wheelchair fees are not fair and what they say about the state of seniors care in BC. Centre for Policy Alternatives. Online: https://www.policyalternatives.ca/publications/commentary/why-wheelchair-fees-are-not-fair-and-what-they-say-about-state-seniors-care#sthash.y4TGTDck.dpuf (Last accessed May 1, 2014).#Ministry of Health. Who pays. Publicly subsidized or private pay services. Online : http://www2.gov.bc.ca/gov/topic.page?id=D2A2D928853B489DBC280E9F451187F1&title=Publicly%20Subsidized (Last accessed May 1, 2014).%20or%20Private%20Pay%20Services [“Who pays”](Last accessed May 1, 2014). Fraser Health for example notes under “How do I access private pay facilities? that “an assessment by Fraser Health staff is not needed for admission to a private pay residence.” Online: http://www.fraserhealth.ca/your_care/residential_care/options_for_residential_care/ ( Last accessed May 1, 2014) .#Ibid. Who pays.
{{REVIEWED | reviewer = BC Centre for Elder Advocacy and Support, June 2014}}
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