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The Long-Term Care Act, 1994 (LTCA) assigns specific duties to agencies approved to provide community services. In regulation 33/02 under the Community Care Access Corporations Act, 2001 (CCACA), a Community Care Access Centre (CCAC) is deemed to be an approved agency under the LTCA and is approved to provide the community services set out in this regulation.

Two key CCAC responsibilities are: provision of home care and managing the placement process into long-term care (LTC) homes. The CCAC manages these key activities through case management services, a core service of the CCAC.

Case management in the CCAC is vested in case managers who must assess and review requirements, determine eligibility, and develop and evaluate the plans of service for CCAC services and authorize the expenditures of funds for services in accordance with sections 22 and 23 of the LTCA, and authorize admissions to LTC homes in accordance with subsection 20.1 of the Nursing Homes Act (NHA), section 18 of the Homes for the Aged and Rest Homes Act (HARHA), and subsection 9.6 of the Charitable Institutions Act (CIA). (The admission to LTC care homes is discussed in chapter #11 in this manual.)

6.1.1 CCAC Case Management

The LTCA sets out the case management function of the CCAC for community services:

Plan of service

s. 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges, the agency shall,

(a) assess the person’s requirements;

(b) determine the person’s eligibility for the services that the person requires; and

(c) for each person who is determined to be eligible, develop a plan of service that sets out the amount of each service to be provided to the person.

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.

Co-ordination of services

s. 22(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.

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.

Provision of services

s. 23(1) An approved agency shall ensure that the services outlined in a person’s plan of service are provided to the person within a time that is reasonable in the circumstances.

Waiting list

s. 23(2) If a community service outlined in a person’s plan of service is not immediately available, the approved agency shall place the person on the waiting list for that service and shall advise the person when the service becomes available.

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Case management is a core service provided by the CCAC, and the mechanism through which individuals access a range of services. The interactive involvement and relationship between a case manager and clients must be supportive and assist clients to live independently and make their own health choices. In addition to being a service to individual clients, CCAC case

management also serves a system-level function, promoting service consistency, co-ordination, quality and accountability while maximizing client independence and optimizing resource utilization.

Case management is knowledge-based, and incorporates skills, abilities and experience to successfully carry out the processes of collecting and analyzing information, and developing and managing a plan of service that is mutually agreed to by the client and/or substitute decision-maker (SDM). Communication and client education are key elements in linking the processes with the client, and linking the client with the CCAC and other parts of the health care system.

The CCAC must comply with the LTCA when providing case management and be guided by the following principles:

• respect for the person’s rights, dignity, values and preferences;

• promotion of the highest level of independence possible for the person within the person’s capacity by focusing on the person’s strengths, needs and preferences;

• promotion of quality improvement in all aspects of service management;

• promotion of a collaborative and co-ordinated approach to service delivery; and

• promotion of efficient, effective and equitable use of resources.

Case management is available to persons requesting in-home services, school services, and admission to LTC homes. Case management intensity may vary according to the needs and goals of the individual client. Some clients may benefit from care pathways, while others may require intensive case management.