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The CCAC’s responsibility to co-ordinate services is set out in the LTCA:

Co-ordination of services

s. 23(3) If a person is receiving more than one community service provided or arranged by an approved agency, the agency shall assist the person in co-ordinating the services he or she receives, in accordance with the person’s wishes.

Case managers must provide support to the client and the caregiver by: • coordinating services provided by the CCAC; and

• working collaboratively with the client, staff of other approved agencies (e.g., attendant outreach services, community support services, assisted living services in supportive housing), the family physician and contracted service providers to:

• develop integrated plans of service for persons whose needs transcend the service mandates of any one approved agency or service provider; and

• develop area-wide service delivery strategies for persons who are vulnerable, at risk of abuse or being abused, or living at risk in the community, or persons who are at risk of not being served by the existing system (e.g., outreach services specifically designed for persons with mental illnesses or cognitive impairments, the socially isolated and those who may experience cultural and language barriers to service).

Service co-ordination involves co-ordinating all elements of client care, including CCAC services with other services and resources supporting the client. Effective co-ordination includes regular and ongoing communication with clients, family members, physicians, caregivers, and contracted service providers, and discussions with community services and community health care partners relating to provision of service. It may also involve planning for future health care needs and establishing linkages to other services to help ensure continuity of care for the client.

The case manager must:

• co-ordinate all CCAC services identified in the plan of service;

• ensure that individual clients receive services within available resources; and • co-ordinate services from a number of contracted service providers and community

agencies in order to meet the individual client’s needs and respect the client’s preferences for service delivery.

6.2.5 Reassessment

The CCAC’s responsibility to reassess clients’ requirements is set out in the LTCA:

Revision of plan of service

s. 22(2) If a person is receiving a community service provided or arranged by an approved agency, the agency shall,

(a) review the person’s requirements when appropriate, depending on the person’s condition and circumstances; and

(b) evaluate the person’s plan of service and revise it as necessary when the person’s requirements change.

Participation in plan of service

s. 22(4) An approved agency shall provide an opportunity to participate fully in the development, evaluation and revision of a plan of service to,

(a) the person who is the subject of the plan of service;

(b) if the person who is the subject of the plan of service is mentally incapable, the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service; and

(c) the person, if any, designated by the persons referred to in clauses (a) and (b).

Other assessments to be considered

s. 22(5) In assessing a person’s requirements under clause (1) (a) and in reviewing a person’s requirements under clause (2) (a), an approved agency shall take into account all assessments and information that are provided to it relating to the person’s capacity, the person’s

impairment or the person’s requirements for health care or community services.

Person’s preferences to be considered

s. 22(6) In developing, evaluating and revising a person’s plan of service, an approved agency shall take into account the person’s preferences, including preferences based on ethnic, spiritual, linguistic, familial and cultural factors.

Compliance with regulations

s. 22(7) An approved agency shall apply the prescribed criteria, follow the prescribed procedures and comply with the prescribed rules and standards in assessing a person’s

requirements, determining a person’s eligibility and developing, evaluating and revising a plan of service.

There are currently no regulations relating to the reassessment of clients’ requirements. The CCAC must reassess client needs to:

• determine the client’s continuing eligibility and need for CCAC services;

• monitor types and levels of services required, and appropriateness of supplies and equipment used;

September 2006 ₁₃

• adjust goals; and

• as necessary, arrange for new services or the termination of service.

The CCAC must reassess adult long-stay clients using the RAI-HC as follows: • at a minimum of every six months; or

• when there is a significant change in a client’s clinical condition, functional level or living circumstances. This may include the following: new diagnosis, progression of the disease process, functional decline or improvement, return from a stay in hospital, change in caregiver status and/or change in the plan of service.

The CCAC must reassess pediatric long-stay clients, palliative clients and rehabilitation clients as follows:

• at a minimum of every six months; and

• when there is a significant change in a client’s clinical condition, functional level or living circumstances. This may include the following: new diagnosis, progression of the disease process, functional decline or improvement, return from a stay in hospital, change in caregiver status and/or change in the plan of service.

The CCAC must reassess short-stay clients when there is a significant change in a client’s clinical condition, functional level or living circumstances. This may include the following: new diagnosis, progression of the disease process, functional decline or improvement, return from a stay in hospital, change in caregiver status and/or change in the plan of service.