Assisted Living Tenancy Task Force Review...Assisted Living stakeholders through a BC Continuing...

AssistedLivingTenancyTaskForceReviewAReportofFindingsandRecommendations July2017ChairedbyTomCrump

AssistedLivingTenancyTaskForceReview |Page2

ASSISTEDLIVINGTENANCYTASKFORCEREVIEW

AREPORTOFFINDINGSANDRECOMMENDATIONSFORTHEBCCAREPROVIDERSASSOCIATIONBOARD

SubmittedbytheHowegroup:

WynonaGiannasi&JenniferHystadJuly2017


TABLEOFCONTENTSEXECUTIVESUMMARY 4

ACKNOWLEDGEMENTS 7

INTRODUCTION 8

Impetusforreview 8

Scope 8

Aboutthisreport 9

BACKGROUND 10

Assistedliving 10

AssistedLivingRegistrar 10

AssistedLivingTenancy 10

AssistedLivingServiceAgreements 11

ChanginglandscapeofAssistedLiving 11

CommunityCareandAssistedLivingAmendmentAct(Bill16) 11

METHODOLOGY 12

FINDINGS 13

I.NoticeofAssistedLivingAgreementTerminationoftheTerracesonSeventh 13

II.Bill16 16

III.RiskofEvictions 24

SUMMARYOFRECOMMENDATIONS 26

NoticeofTermination 26

UnderstandingthechangingAssistedLivingsectorwithinBC 26

EnsuringsustainabilityoftheAssistedLivingsectorwithinBC 27

FundingAssistedLiving 27

AssistedLivingagreements 28

EvictionduetoNon-paymentofFees 28

APPENDICES 29

AppendixA:AssistedLivingTenancyTaskForceTermsofReference

AppendixB:TerracesonSeventhandVancouverCoastalHealthCommunications

AppendixC:TerracesonSeventhLetter


EXECUTIVESUMMARYInMarch 2017 anAssisting Living operator terminated its Assisting LivingAgreementwithVancouverCoastalHealth.NegativemediaattentionsparkedconcernwithinthesectorandthequestionaroseastowhetherearlyAgreementterminationsandmovementtowardprivatepayassistedlivingwouldbecomeanemergingtrend.Primaryfactorsinplayatthistimewereincreasingrealestatevaluesaswellasthechanging landscapedue to the impending regulatory changes from theCommunityCareandAssistedLivingAmendmentAct(Bill16).BCCareProvidersAssociationwasalsoconcernedabouttheextenttowhichevictionsdue tonon-payment impactsproviders in thesector. Toaddress these issues,BCCPAformedanAssistedLivingTaskForce.TheTaskForce,chairedbyTomCrumpandsupportedbytheHowegroupwascomprisedofAssistedLivingoperatorswithtwohealthauthorityrepresentativesactinginanadvisorycapacity.TheTaskForcewasmandated to: (1) review the circumstances that led to Pacific Reach Seniors Housing Management(PRSHM)providingVancouverCoastalHealthwithasix-monthterminationnoticeandassesswhetherthiswasanisolatedissueoronethatisexpectedtooccurmorefrequentlywithinthesector;(2)engagethesector to determine the impact of Bill 16 regulatory changes on Assisted Living operators; and, (3)determinethemagnitudeandimplicationsofclientnon-paymentintheAssistedLivingsector.Amixedmethodsapproachofkeyinformantinterviews,asector-widesurveyofAssistedLivingoperators,andadocumentreviewwasusedtosupportthereview.TerracesonSeventhTheTaskForceconcludesthatthe issuessurroundingtheterminationof theAgreementarerooted inincreasinghousingcostsandpoorcommunication.WhilePRSHMwaswithintheirrightstoterminatetheAgreement, the process bywhich the termination occurred and the communication to residents andfamilieswas lacking.TheTaskForcealso concludes that the languageandexecutionof clauses in theAssistedLivingAgreement(theagreementbetweentheoperatorandthehealthauthority)waslacking.AsaresultofthiseventVancouverCoastalHealthhasamendeditsAgreementswithitsoperatorstoatwelve-monthnoticeofterminationwithallAssistedLivingoperators.TheTaskForceconcludesthattheTerracesonSeventhwasanisolatedeventandtheresultofabreakdowninprocessandcommunication.The Task Force does foresee an increase in Assisted Living operators exiting from publically fundedservicesinthefutureunlessfundingmeetsbothmarketvalues(BCHousing)andlevelofcareprovision(healthauthorities).1.1 The Task Force recommends that the Assisted Living Service Agreements between the health

authorityandoperatorbeamendedtoinclude:(a)languagestatingthataminimum12-monthnoticeperiodberequiredtoterminatetheAgreementandthatthehandlingofthereductionofsuitesbediscussed and determined collaboratively by the health authority and the provider, and (b) astandardizedcommunicationplanandtransitionplanbeinplacepriortoanoticeofterminationtoclearlystatepractices/documentstominimizehardship/emotionalimpacttoseniorsandfamilies.

1.2 TheTaskForcerecommendsthatthetenancyagreementbetweenoperatorsandclientsbeamendedtoincludelanguagetoclientsstatingthatitisrare,butnoticecouldbeprovidedtovacatetheunit,ifthehealthauthorityandtheAssistedLivingproviderdonotmaintaintheirAgreement.Itshouldalsobestatedthata12-monthnoticeperiodwouldbeprovidedandthattheoperatorandhealthauthoritywouldworktogethertoensureclients’needsaremet.


CommunityCareandAssistedLivingAmendmentAct(Bill16)TheTaskForceconcludesthatthereisalackofunderstandinginthescopeandramificationsofBill16frombothoperatorsandhealthauthorities.Operatorsareconcernedaboutthepotentialforallservicestoberequired,thelackofdefinitionofterms,changestostaffingcompositionandincreasesinoperatingcosts. Operators and health authorities need further clarification on Bill 16, including roles andresponsibilitiesandtimelinesforimplementation.AstheregulationsarenotyetenactedtheTaskForcerecognizestherecouldbedelayswithachanginggovernment.The Task Force concludes that there is currently a low rating from operators with respect to theirconfidencethathealthauthoritieswilladequatelyfundrequiredincreasesincareservicesresultingfromBill16.Conversationswithhealthauthoritiesthroughoutthisreviewhasemphasizedthewillingnessofhealth authorities to support operators and engage in consultation on how this will happen as theyprovidecareservicesforseniors(i.e.adjustfundingasneeded).TheTaskForceconcludesthatthereisaneedforhealthauthoritiesandoperatorstoworkwithBCHousingasakeyfundingpartnerinthisprocesstoensureproviders are adequately compensated forhousing costs and thatmethods for funding aretransparent.TheTaskForceconcludesthereneedstobeachangetoAgreementlanguage,betweenthehealthauthorityandtheoperatorandtheoperatorandtheclienttobetterprotectclientsintheeventaterminationisnecessary.2.1 TheTaskForcerecommendsBCCPAandtheMinistryofHealthworktogethertoengagethehealth

authoritiesandtheAssistedLivingRegistrararoundthepotentialimplicationsofBill16includingtheimplementationofregulations.(NotethattheMinistryofHealthhasstartedaconsultationprocessalready).

2.2 TheTaskForcerecommendsBCCPAfacilitaterobustdiscussionsbetweenAssistedLivingoperatorsandhealth authorities around capacity toprovide safe, appropriate andaccessibleoptions forBCseniors.Thisincludesconductingaformalreviewtodetermineoperators’intentionandcapacitytoprovidepublicallyfundedAssistedLiving,specificallytoclientswithgreaterneeds.ItisadvisedthatarepresentativefromtheMinistryofHealthbeincludedinthisprocess.

2.3 The Task Force recommends BCCPA, in partnership with the Ministry of Health, bring togetherAssistedLivingstakeholdersthroughaBCContinuingCareCollaborativetoensureaccess,growthandsustainabilityofassistedlivinginBC.

2.4 TheTask Force recommendsBCCPA, alongwith theMinistry ofHealth and thehealth authoritiesleverageinitiativesalreadyunderway,andconductaprovince-widereviewofanticipatedsupplyanddemandforAssistedLiving(overthenext5-10years)toalignwiththeseniorscarehumanresourcestrategy.

2.5 TheTaskForcerecommendsareviewtounderstandbothcurrentandfuturerolesandresponsibilitiesof BC Housing, health authorities and operators to enhance clarity, consistency of services,transparencyandaccountability.

2.6 TheTaskForce recommendsa formal reviewof theAssisted Living fundingapproach toallow forconsistency within the sector, decreased administrative burden and flexibility to support thecontinuumofcareforseniors.

2.7 TheTaskForcerecommendstheMinistryofHealthtoexploretheintroductionofacarecreditmodelforAssistedLivingusingbestpracticesfromCommunityLivingBC,allowingforclientstodirecttheirowncareandselectprovidersoftheirchoice.

2.8 TheTaskForcerecommendshealthauthoritiesandBCHousing, togetherwithBCCPA, alongwithother related industry associations review Assisted Living Tenancy Agreements (the agreementbetweentheassistedlivingproviderandtheclient)todevelopcommonelementsoftheagreementstostandardizeacrossoperatorsacrosstheprovince.


Evictionsduetonon-paymentTheTaskForceconcludesthatthe issueofevictionsduetonon-payment isnotbroadly impactingthesector.TheTaskForcealsoconcludesthatprocessesexisttosupportclientsandoperatorsthroughthePublicGuardianandTrusteeandthehealthauthorities.Keyrolesarethatof:(a)thehealthauthorityinsupportingoperatorswhenthereisadiscrepancyinfeescollectedfromclientsand(b)thePublicGuardianandTrusteeenhancing itscommunicationregardingexistingprocessestosupportclients, familiesandoperators.3.1 Recognizingaformalprocessalreadyexists,theTaskForcerecommendsjointcommunicationfrom

thePublicGuardianandTrusteeandhealthauthoritiestodetailtheprocessesandsupportsthatexistforclients,familiesandoperators.ThisincludestheprovisionofanannualreconciliationofAssistedLivingfeesfromhealthauthoritiestosupportoperators.


ACKNOWLEDGEMENTSTheAssistedLivingTenancyTaskForceandtheHowegroupacknowledgewithgratitudethecontributionsoftheAssistedLivingOperatorswhoparticipatedinoursurveyaswellassectorassociationsandhealthauthoritieswhoparticipatedinourinterviews.WethanktheMinistryofHealthandtheBCSeniorsLivingAssociationforhelpingusdisseminateouronlinesurvey.We thank the Seniors Advocate for an open discussion on the changing needs of seniors and therepresentativesfromtheAssistedLivingProjectCommitteeforsharingtheirexperienceinthesector.Wethanktheresidents,staffand leadersoftheTerracesonSeventhwhowillinglyparticipated inourinterviewsandprovidedinsightstohelpshapetherecommendationsinthisreport.TheTaskForceexpressesgratitudetotheBCCareProvidersAssociationfordevelopingtheTaskForceandfundingthisreviewtosupporttheimprovementofseniorscare.TheTaskForceisexpresslygratefultoVancouverCoastalHealthandFraserHealthforprovingtimelyandthoughtfuladvicethroughoutthisreviewandthecraftingoftherecommendations.


INTRODUCTIONImpetusforreviewInMarch2017anAssistingLivingoperatorterminateditsAssistingLivingAgreement(Agreement)withVancouverCoastalHealth.NegativemediaattentionsparkedconcernwithinthesectorandthequestionaroseastowhetherearlyAgreementterminationsandmovementtowardprivatepayassistedlivingwouldbecomeanemergingtrend.PrimaryfactorsinplayatthistimewereincreasingrealestatevaluesaswellasthechanginglandscapeduetotheimpendingregulatorychangesfromtheCommunityCareandAssistedLivingAmendmentAct(Bill16).BCCareProvidersAssociationwasalsoconcernedabouttheextenttowhichevictionsduetonon-paymentimpactsprovidersinthesector.Toaddresstheseissues,BCCPAformedanAssistedLivingTaskForce.

The Task Force, chaired by Tom Crump and supported by theHowegroup,wascomprisedofAssistedLivingoperators,oneofwhomistheChairofBCCPA’sMembershipCommitteeandtheotherthechairof theQualityAssuranceCommittee,alongwith twohealthauthorityrepresentativesactinginanadvisorycapacity.BCCPAprovidedtheTaskForcewithdirectionaspertheTermsofReference.TheTaskForcehasactedindependentlyfromBCCPAandtheBoardthroughoutthisreview.ScopeTheTaskForcewasmandatedto:

1. Review the circumstances that led to Pacific Reach SeniorsHousing Management (PRSHM) providing Vancouver CoastalHealthwithasix-monthterminationnoticeandassesswhetherthisisanisolatedincidentorthestartofanemergingtrendinthe industry which would lead to a reduction in access topubliclyfundedAssistedLiving.

• Develop recommendations regardinghowseniors canbeprovidedwithbetterprotection to reduce the risktheywillberequiredtosuddenlyvacatetheirpremisesduetoacontracttermination.

• Develop recommendations regarding how serviceagreementsbetweenahealthauthorityandanAssistedLivingprovidercanbestrengthenedtomeettheneedsofboththeseniorsandoperators.

2. Engage the Assisted Living sector to determine the potentialimpactofBill16regulatorychangesonAssistedLivingoperators.

• Develop recommendations toensure seniorshaveadequateaccess topublicly fundedAssistedLivingintheircommunity.

ImpetusforBill16Bill16amendmentstotheCommunityCareandAssistedLivingActweretheresultofconcernsbroughtforwardbyinterestgroupssuchasSeniorsAdvocate,BCSLAandBCCPA.TheActwasover12yearsoldandAssistedLivingresidentsandtheirserviceneedshavechangednoticeablysincetheintroductionofAssistedLivinginBC.AdditionallyitwasfeltthatseniorswerebeingmovedoutofAssistedLiving(andintoresidentialcare)beforeitwasnecessary.Awide-rangingindustryadvisorygrouphasbeenpartoftheformulationofRegulationstotheAct.IntentionofBill16AkeyintentionoftheamendmentsinBill16isthatthechoiceofthenumberofandspecificservicesofferedisthatoftheoperator.TheintentoftheincreasedserviceselectioninBill16istoallowtheoperatortomatchcapabilitiesoftheorganizationwithitsbusinessplan.


• Develop recommendations aimed at strengthening any proposed regulatory changesincludedintheCommunityCareandAssistedLivingAmendmentAct.

3. Determinethemagnitudeandimplicationsofclientnon-paymentintheAssistedLivingsector.• Develop recommendations to provide better protection to seniors who face possible

evictionduetofinancialabusefromtheirfamilyand/orfriends.• Develop recommendations to support Assisted Living operatorswith the collection of

clientfeestoreducetheriskofunnecessaryeviction.• DeterminewhetherthereisastrongerroletoplayfortheOfficeofthePublicGuardian

andTrusteeasitpertainstothecollectionofunpaidfeesandevictions.PleaserefertotheTermsofReferencefortheTaskForceinAppendixA.ForthepurposeofthisreportAssistedLivingreferstoregisteredAssistedLivingresidenceswithinBC,whichcurrentlyprovidenomorethantwoprescribedservicesundertheCommunityCareandAssistedLivingAct.

AboutthisreportThisreporthasbeendevelopedfortheBCCPABoardtoreviewandpresenttotheBCMinistryofHealth.This report provides a summary of the current state of Assisted Living in BC, details the approachundertakentoconductthereview,documentskeyfindingsfromstakeholderconsultationandpresentsconclusionsandrecommendationsforendorsementbytheBCCPABoard.Recommendationshavebeendevelopedby theTaskForcewithin thescopeof the termsof the referencewithadvisory input fromVancouverCoastalandFraserHealth.


BACKGROUNDAssistedlivingAssistedLivinghousingcombinesapartment-styleprivateunitresidenceswiththeprovisionofhospitalityandpersonalcareservices.AssistedLivingisintendedforseniorswhoareabletodirecttheirowncare.Asof2015,therewereapproximately7,600AssistedLivingunits inBC.Ofthese,approximately4,400weresubsidizedand3,200wereprivatepay1.ThisreviewonlyincludesregisteredprivateAssistedLiving.ItshouldbenotedthatthisreviewonlyaddressesRegisteredAssistedLiving.Theothermodel,termednon-registeredprivateassistedliving,iswherecareserviceisprovidedbyathirdpartyhireddirectlybytheresident.Thereareapproximately15,000privatepayassistedlivingunitsinBC.AssistedLivingisregulatedbytheCommunityCareandAssistedLivingAct(CCALA),requiringoperatorstoregistertheirresidences.HealthauthoritiesadministersubsidizedAssistedLivingservices,overseenbytheMinistryofHealth.Inadditiontohousing,AssistedLivingoperatorsmustprovidehospitalityservices(meals,housekeepingandlaundryservices),socialandrecreationalopportunities,anda24-houremergencyresponsesystem.Operatorsmustalsoprovideonebutnomorethantwoofthefollowing‘prescribed’services:assistancewithdailylivingactivitiessuchaseating,mobility,dressingorpersonalhygiene;medicationmanagement;therapeuticdiets;financialmanagement;intensiverehabilitationtherapy;andbehaviouralmanagement.Every Assisted Living operator within the province has chosen to provide the same two ‘prescribed’services:assistancewithdailylivingandassistancewithmedications.TheMinistryofHealthdistinguishesbetweenservicesprovidedatthe‘prescribedlevel’andthe‘supportlevel’,asalessintensivelevel.Operatorscanofferanynumberofabove-listedprescribedservicesatthe‘supportlevel’.RegisteredAssistedLivingresidencesreceivepartialfundingfromIndependentLivingBC.Thisprogramprovides housing with support services to seniors and people with disabilities intended to provide a‘middleoption’betweenhomecareandresidentialcare.IndependentLivingBCisapartnershipbetweenBCHousing,provincialhealthauthorities,theCanadianMortgageandHousingCorporation(CMHC)andnon-profitandprivate-markethousingproviders.AdmissionstofundedAssistedLivingresidencesaretheresponsibilityofthehealthauthority.AssistedLivingRegistrarTheOfficeoftheAssistedLivingRegistrar(OALR)wasestablishedundertheCommunityCareandAssistedLivingAct(CCALA)in2003withthemandate‘toprotectthehealthandsafetyofassistedlivingresidents’.The OALR falls within the Ministry Health and is funded jointly through the Ministry and throughregistrations from operators. The OALR registers Assisted Living residences, develops policies andproceduresandrespondstoconcernsandcomplaintsregardingthehealthandsafetyofresidents.AssistedLivingTenancyAssistedLivingresidentsrenttheunitstheyliveinandthereforeareconsideredtenantsoftheoperatorsoftheirresidences.TheResidentialTenancyAct(RTA)outlinestherightsandresponsibilitiesoftenantsand landlords, however Assisted Living residents are not covered by the RTA or other comparable

1Seniors’HousinginBC,OfficeoftheSeniorsAdvocate(2015)


legislation.AnagreementbetweenAssistedLivingprovidersandtheirtenantsarereferredtoasAssistedLivingTenancyAgreements.TheseagreementsareuniquetoeachAssistedLivingprovider.ImportanttothefocusofthisreviewisthefactthatundertheRTA,landlordscanevicttenantsforreasonslaidoutintheAct(i.e.totakeoverthesuiteforpersonaluse,torenovate,etc.).EvenifAssistedLivingclientswereincludedintheRTA,thiswouldnotprecludethemfrombeingevicted.InclusionintheRTAdoesnotprovideaguaranteeoftenancy.AssistedLivingServiceAgreementsAgreementsexistbetweenhealthauthoritiesandoperators toprovidea framework foracooperativeworking relationship. Agreements help to identify specific responsibilities for the delivery of AssistedLivingservices,suchasclientneeds,hospitalityandcareservices,staffing,privacy,standards,fundingandreporting.

ChanginglandscapeofAssistedLivingInformation from the Seniors Advocate 2 describe the type of seniors living in subsidized registeredAssistedLivinginBC.Atthetimeofthereportin2012,sixtypercentofresidentswereovertheageof85,almosthalfhadadiagnosisofAlzheimer’sorotherdementiaand20%adiagnosisofpsychiatricormooddisorder condition. Nearly all (90%) needed minor assistance to complete personal care and 10%moderatetosignificantassistancewithpersonalcare.Sixty-threepercenthadacombinationofcomplexconditions indicating high or very high need to facility level care. Key to this review, considering theimplicationsofBill16,isunderstandingthatthetypeofseniorslivinginAssistedLivinghaschangedovertime. Anecdotally, both FraserHealth andVancouver Coastal Health have admitted clients at greaterlevelsofacuity,andinaddition,clientshavetendedtostaylongerwithhigherlevelsofacuity.EvidenceindicatesthattheAssistedLivingsectoriscaringformorecomplexseniorsthanadecadeago.

CommunityCareandAssistedLivingAmendmentAct(Bill16)ActingonrecommendationsfromtheSeniorsAdvocateandotherkeystakeholders,theGovernmentofBritishColumbiaintroducedlegislationinMarch2016thatwouldallowAssistedLivingresidentstoremainintheirownhomelonger.Bill16hasreceiveditsfirstreading,theMinistryofHealthhasundertakenacomprehensiveengagementofAssistedLivingstakeholdersand,atthetimeofthisreport,regulationshavenotbeenreleased.Bill 16 proposes to remove the two-service limit, increase regulatory oversight for Assisted Livingresidences,allowtheAssistedLivingRegistrartoinspectaresidenceatanytimetodetermineifhealthandsafetyofresidentsareatrisk,andimproveAssistedLivingserviceoptions.

2Seniors’HousinginBC,OfficeoftheSeniorsAdvocate(May2015)


METHODOLOGYAmixedmethodsapproachwasusedtosupportthereview,includinginterviewswithkeystakeholders,aprovince-widesurveyofAssistedLivingoperators,andadocumentreview.InterviewswereconductedbytheTaskForceChairandtheHowegroupin-personwherepossiblewithleadersfromtheMinistryofHealth,healthauthorities,andoperators;AssistedLivingclients;theSeniorsAdvocate; and representatives from the Assisted Living Project Committee (supporting the BC LawInstitutereviewofAssistedLiving).ThroughsupportfromtheMinistryofHealthandtheBCSeniorsLivingAssociation,theonlinesurveywassent to leaders of over 200Assisted Livingoperators inBC. TheMinistry ofHealth’s recent surveyofAssistedLiving(April2017)wasreviewedtoavoidduplicationinquestions.ThiswasparticularlyimportantashalfoftherespondentstotheTaskForce’ssurveyhadalreadycompletedtheMinistry’ssurvey.JustunderonethirdofAssistedLivingoperatorsrespondedtothesurvey(N=63).Halfoftherespondingoperators represented private companies (52%) and half not-for-profit organizations (48%). Overall,operators reporthavingapproximatelya50/50mixofprivateversuspublically fundedAssisted Livingunits.Therewasabalancedrepresentationacross theprovincewithonethirdof respondentscomingfromVancouverCoastalandFraser regions;a further third fromVancouver Island,andtheremainderfromtheInterior(19%)andtheNorth(8%).Themajority(60%)representurbancentres,35%representruralareasand5%representremoteareasoftheprovince.NearlytwothirdsofAssistedLivingoperatorsarepartofalargermulti-siteorganization.Inundertakingthisreview,wereviewedthefollowingfoundationalandinfluentialdocumentsoutliningissues,influencesandrecommendationsinseniorscareBC:

• ReportonAssistedLivinginBC-areportpreparedfortheBCLawInstituteandtheCanadianCentre for Elder Law by the members of the Assisted Living Project Committee (2013):Recommendationswithinthisreportweredevelopedtoimproveandreinforcethelegislativeframework for Assisted Living in BC. The reportwas issued as the final publication in theAssistedLivingproject,a jointprojectoftheBCLawInstituteandtheCanadianCentreforElderLaw.

• RealizingthefullpotentialoftheNewCommunityCareandAssistedLivingAmendmentAct(Bill16),BCSeniorsLivingAssociation(Draft)(2016):Apositionpaperpresentinganoverviewof theproposedchanges inBill16, suggestions regarding theMinistry’sprocess forsectorconsultationandaseriesofrecommendations.

• Seniors’HousinginBC,OfficeoftheSeniorsAdvocate(2015):Areporthighlightingsystemicissues facing seniors in independent living, assisted living and residential care. The reportbringsforthhousingprioritiesandrecommendationstoimprovinghousingforBCseniors.

• TheBestofCare:GettingitrightforseniorsinBritishColumbia(Part2),BCOmbudsperson(2012):Areviewofissuesfacingseniorsinhomeandcommunitycarefromtheperspectiveofadministrativefairness,adequacyofinformation,programaccessibility,standardsofcareandmonitoringandenforcementofstandards.

• Seniors Care for a Change, BC Care Providers Association (2014). This report wascommissionedbyBCCPAtoprovidetheBCGovernmentwithspecificrecommendationstoreduce the administrative burden of regulatory and reporting overlap for publicly fundedbeds/unitswithinthecontinuingcaresector,andtoredirectresourcestofrontlinecare.


FINDINGSFindingsarepresentedinthreeseparatesectionsalongwithTaskForceconclusionswithreferencetothemandatesetoutintheTermsofReference:

I. NoticeofAssistedLivingAgreementterminationoftheTerracesonSeventhII. ImpactofBill16anditsensuingregulationswithinthesectorIII. Magnitudeofnon-paymentofAssistedLivingfees

I.NoticeofAssistedLivingAgreementTerminationoftheTerracesonSeventhIn2016VancouverCoastalHealthintroducedasiteoperationalreviewofallAssistedLivingoperators.Thesamereviewtoolwasusedandresultscomparedtothehealthauthoritystaffing/fundingmodel.Based on this review, Vancouver Coastal Health directed PRSHM to enhance overnight staffing. Theincreased cost associated with this staffing enhancement, combined with recent capital and serviceupgradeswasfelttobetoogreatfortheTerraces.PRSHMthendecidedtoterminatetheAssistedLivingAgreementwithsixmonths’noticetoresidents.VancouverCoastalHealthrequestedtojointlydevelopandcommunicateatransitionplanandtoextendtheterminationplantoayeartoeasethetransitiontoclientswhileVancouverCoastalHealthfoundnewaccommodationandsupportsforclients.Followingthisdecision,PRSHMandVancouverCoastalHealthworkedtogethertocommunicatethenewsto20tenantsandtheir familieswhostoodtobe impactedbythedecision.Tenantsandtheir familiesreceived written and verbal communication explaining how they would be relocated. Two residentmeetingswereheld jointlywithPRSHMandVancouverCoastalHealthtoalleviateresidentandfamilyconcerns.PRSHMdidnotissueevictionnoticesaswasreportedinthemedia.Throughnegotiationsbetweenthetwoorganizations,theremainingsubsidizedclients(nowat18)willremainattheTerracesonSeventhuntiltheAssistedLivingAgreementendsintwoyears’time.Subsidizedclientslostthroughattritionwillbereplacedwithprivatepayresidents.Thefutureoftheclientsremainingat the end of this existing Assisted Living Agreement is unknown and currently under discussion.VancouverCoastalHealthreportstheywouldnothavedonethisdifferentlyasthis isaprocessthat isusedbyallsites.AsaresultofthiseventVancouverCoastalHealthhasamendeditsAgreementswithitsoperatorstoatwelve-monthnoticeofterminationwithallAssistedLivingoperators.MembersoftheTaskForcemetwithresidentsoftheTerraces.OnewomaninsubsidizedAssistedLivinghaslivedattheTerracesonSeventhforalmosttwoyears.SherecallsbeinggivenaletterstatingPRSHM’sdecisiontoterminatetheAssistedLivingAgreementwithVancouverCoastalandattendingaresidentsmeetingtoprovidefurtherdetails.Shereportedunderstandingtheletterandfeelingstunnedandupset.“IunderstoodwhenImovedinitwouldbemyownchoicetoleavehere.Itneveroccurredtomethatthismovewasnotpermanent.Ifthiskindofthingcanhappenitshouldbemadecleartoresidentswhentheymovein.IhaveParkinson’s.Thishasaffectedmeandsetmebackabouttwoyears.”WhenaskedwhethershefeelsconfidentinthelivingarrangementnowthatPRSHMhasdecidedtofulfilltheremainderofthetermoftheAssistedLivingAgreement,shestatedthatshewasnotlookingelsewhere,butshedidnotappearentirelyconfidentinherlivingenvironment.OnemaninprivatepayAssistedLiving,whoisnotpersonallyaffectedbythesituation,recalledbeingalittlesurprisedbythenews.‘It’snotnicetoseepeopleoflimitedmeansworrying’.HeemphasizedthefactthattherewerenobadfeelingstowardthemanagementoftheTerracesonSeventhandwaspleasedhowquicklythingsturnedaroundwhenthedecisionwasmadetoseetheremainderoftheAssistedLivingAgreementthrough.“Iamjusthappythatitallworkedoutforthosewhowereaffected.”


Twoadditionalresidentswereinterviewedinownershipindependentliving.OnesitsontheResidentandFamilyCouncilandindicateslearningaboutwhathappenedthroughthemedia.“Eventhoughthisdoesn’taffectmeatall,Ithinkweshouldhavelearnedaboutthiswithinour[TerracesonSeventh]community.”AnotherwomanwhohaslivedattheTerracesfor12yearsstatedquitefactuallythatthedecisionwasthattobemadebytheownersandthattheorganizationwaswellwithinitsrights.ShefeltstronglythattheresidentsweregoingtobehelpedbyVancouverCoastaltorelocateandthatthetransitionwouldbemade as smoothly as possible.What she did feel was that the ‘tact’ in the communication to thoseaffectedbythedecisioncouldhavebeenimproved.“It’sabigdecisiontomovefromyourhometocomesomewherelikethis.Iwouldhavelikedmoretransparencyandtohaveheardaboutthenewspersonally,ratherthanthroughrumours.”TheSeniors’AdvocatewasinterviewedregardingthesystemicinfluencesontheeventsattheTerraces.ShefelttheeventsattheTerracesonSeventhhighlightedaverypublicissuethatdoesoccuronindividualbasisandbroughttolightthequestionabouttenureoptionsifstratified:aseniorinanapartmentorathome,receivinghomecarecannotbe‘evicted’asaresultofincreasingcareneeds.Howeverinretirementliving and Assisted Living, both subsidized or private pay, there is a common issue: what are thecircumstances under which the operator can say a seniors has to move out? A discussion ensuedregardingcontracts.InAssistedLivingthereexiststwoseparatecontracts:therentalagreementiswiththe operator and the client and a separate agreement exists between the health authority and theoperator.Additionally,theSeniorsAdvocatefeelstheissueofsubsidizedunitsconvertingtoprivatepayisgoingtobecomeincreasinglysubstantialwithrisingrealestatevalues,whichareaffordingseniorstheabilitytomove into Assisted Living whilemaintaining their savings. Operatorsmay find they can leverage theprivate paymarketwhichmay be able to recover costs associatedwith capital and service upgradesdemandedbythemarket.PleaserefertoAppendixBforacopyofthecommunicationsenttoresidentsandfamiliesfromVancouverCoastalHealthandPRSHM.

PleaserefertoAppendixCforaletterfromtheCEOofPRSHM.


ConclusionsTheTaskForcewasaskedtoreviewthecircumstancesthatledtoPRSHMprovidingVancouverCoastalHealthwithasix-monthterminationandtoassesswhetherthisisanisolatedincidentorthestartofanemergingtrendintheindustrywhichwouldleadtoareductioninaccesstopubliclyfundedAssistedLiving.TheTaskForceconcludesthatthespecificinstanceoftheTerracesonSeventhwasanisolatedeventandtheissuessurroundingtheterminationoftheAgreementarerootedinincreasinghousingcostsandpoorcommunication.WhilePRSHMwaswithintheirrightstoterminatetheAgreement,theprocessbywhichtheterminationoccurredandthecommunicationtoresidentsandfamilieswaslacking.TheTaskForcealso concludes that the language and execution of clauses in the Assisted Living Agreement (theagreementbetweentheoperatorandthehealthauthority)waslacking.OverthecourseofthisreviewanotherAssistedLivingprovider,thistimewithintheFraserHealthregion,providednoticetoterminatetheirAgreement.Inlightofthis,andtheanticipatedchangesresultingfromincreasingreal-estatevalues(incertainareasoftheprovince),shiftingdemographicsofseniorsrequiringAssisted Living services along the continuum of care, funding not matching inflation (primarily forhousing),andtheanticipationofadditionalservicesresultingfromBill16,theTaskForceexpectstoseemoreoperatorsleavingpublicallyfundedAssistedLivinginthefuture.Recommendations1.1 The Task Force recommends that the Assisted Living Service Agreements between the health

authorityandoperatorbeamendedtoinclude:a. Languagestatingthat:

i. Aminimum12-monthnoticeperiodberequiredtoterminatetheAgreementii. The handling of the reduction of suites be discussed and determined

collaborativelybythehealthauthorityandtheproviderb. A standardized communication plan and transition plan in place prior to a notice of

termination to clearly state practices/documents to ensure hardship and emotionalimpacttoseniorsandtheirfamiliesisminimized.



II.Bill16UnderstandingofthescopeandramificationsofBill16Nearly two third of operators state they are confident with their understanding of the scope andramificationsofBill16,meaningthatonethirdarenotconfident(figure1).Figure1.ConfidenceintheunderstandingofthescopeandramificationsofBill16

BenefitsofBill16:totenants/clientsWhen asked about the greatest benefits of Bill 16 to tenants and clients (Figure 2), the top twoconsiderationswerethe:

1. Increasednumberofservicesavailablefortenantsandclientstosupporttheirwell-being2. Factthatspousesareabletolivetogetherlonger

NotfarbehindwastheincreasedlengthofstayinAssistedLiving,morechoicefortenants/clientstoageinplaceandanincreasedsenseofindependence.Figure2.Greatestbenefitstotenants/clientsfromBill16

BenefitsofBill16:tooperatorsSurveyrespondentsreportedthegreatestbenefitsofBill16tooperatorsareincreasedlengthofstayandtheability tooffermorecare.Thebenefitsassociatedwith increased lengthof stay include increasedrevenueopportunity,longertermplanning(bothforcareandoperations),andalessturnover.Benefitsofprovidingmorecareincludedincreasedflexibilityofservices,abilitytoprovideawiderrangeofservicestherebyallowingclientstoageinplaceinAssistedLiving.

Wewillhavetheabilitytoprovidemorehelpwhichwillmaintainresidents’independencelonger,keepingthemoutofresidentialcareorfromlivingatriskofabuseoutsideofacommunity.

YES,63.5% NO,36.5%

0% 50% 100%

60% 58%53%

47% 45%

25%

INCREASED NUMBEROF SERVICES FORTENANTS/CLIENTS

SPOUSES ARE ABLETO LIVE TOGETHER

LONGER

INCREASED LENGTHOF STAY IN ASSISTED

LIVING

MORE CHOICE FORTENANTS/CLIENTS TO

AGE IN PLACE

INCREASED SENSE OFINDEPENDENCE

EMOTIONAL WELL-BEING


Wewillbeabletoprovidemorecareandclientswon’thavetomovetoresidentialcare.Movingwhenaresidentisfrailisnotgoodfortheirhealth.

–AssistedLivingOperatorsChallengesofBill16:totenants/clientsSurveyrespondentsfeltthegreatestchallengespresentedbyBill16totenants/clientsincludethemixofwell-seniorswith those requiringmore care, staffing levels andno specific considerationof dementiacare/mentalhealth intheBill.Withrespecttoclientmix,respondentswereconcernedaboutAssistedLiving ‘looking like’ extended care, integrationof a rangeof high/low client needs and the emotionalimpactonrelativelyindependentclientslivingaroundclientswithhighneeds.Concernsaroundstaffingincludetheneedfor24/7professionalstaffandhavingthecorrectstaffingcomposition.A fewsurveyrespondentsalsoindicatedBill16maypresentchallengeswithrespecttobuildingsandequipmentnotmeetingmorecomplexcareneeds.

ItmayfeelmorelikeanextendedcarefacilitythanAssistedLiving.

<Itwillbechallengingtostaffbecause>…therewon’tbenotenoughcareaidesavailable.

DementiacareisnotaddressedbyBill16.–AssistedLivingOperators

ChallengesofBill16:tooperatorsWhen asked about the most significant challenges of Bill 16 from the perspective of operators, thegreatestchallengeisthepotentialforhealthauthoritiestorequireallservicesidentifiedinBill16tobeprovided(figure3).Thelackofdefinitionofterms(i.e.‘intheopinionof’theRegistrar),changestostaffingcomposition(i.e.increasedLPN/RNand24-hourcoverage)andincreasesinoperatingcostswerealsotopconcerns. Of least importance was the potential for changes to the physical living environment (i.e.changestoinfrastructure,safetygates,cameras,etc.).Beingmandatedtoincreaseservicewouldbeprohibitiveasaprivate,non-fundedproviderforlow-incomeseniors,

wecouldnotabsorbthecostofextrastaffingorequipment.–AssistedLivingOperators


Figure3.SignificantchallengestooperatorsfromBill16

ImpactofBill16onthesupplyanddemandofAssistedLivingAs a result of the provision of increased serviceswithin Bill 16, among other factors, including agingdemographicsandincreasingrealestatevaluesresultinginseniorshavingmoreequitytoinvestincareservices(incertainareasoftheprovince),themajorityofoperatorsareanticipatinganincreaseinthedemandforAssistedLiving(figure4).Thisanticipationisalsosharedamonghealthauthorityleadersandotherkeystakeholderswithinthesector.Figure4.IncreaseddemandforAssistedLivinganticipated

When asked about Assisted Living operators’ future intent to provide subsidized Assisted Living asregulations from Bill 16 come into effect, 40% reported intending to maintain their current level ofoperations,31%saiditwoulddependonexpectationsanddiscussionswiththehealthauthority,18%saidtheywould likely expand, and 8% said theywouldmove away frompublically fundedAssisted Living(figure5).Figure5.IntentionsforfutureprovisionofAssistedLiving

79%67%

61% 59%

28%

POTENTIAL FOR HEALTHAUTHORITIES TO REQUIREALL SERVICES IDENTIFIED

IN BILL 16TO BESUPPLIED

LACK OF DEFINITION OFTERMS

CHANGES TO STAFFINGCOMPOSITION

INCREASES IN OPERATINGCOSTS

CHANGES TO THEPHYSICAL LIVINGENVIRONMENT

INCREASE,62% DECREASE,6%STAY THE SAME,19% OTHER/DON'T KNOW

13%

MAINTAIN CURRENT OPERATIONS,40% UNKNOWN,31% EXPAND,18% MOVE AWAY 8%


ImpactofrealestateequityvaluedondemandforAssistedLivingNearlytwothirdsofoperatorsfeelthattheincreasingrealestateequityvalueswillplaceahigherdemandonassistedliving(figure6).Ofthosereplyingyes,themajoritywerefromVancouverIsland,followedbymetro-Vancouverand thegreaterVancouverarea.Asone respondentpointedout, “this isa complexquestionbutgenerallyifpeoplearefinanciallysecure-throughwhatevermeans-theyareabletoaccessprivatecareservices”.Figure 6. Increased demand anticipated for assisted living due to real estate equity in specific regions of theprovince.

HealthauthoritiesandoperatorsworkingtogethertoimplementBill16AssistedLivingoperatorsprovideanaveragerating(scaleof1to5)ofhowwellhealthauthoritiesandAssisted Living operators areworking together to deliver publically fundedAssisted Living.OperatorsreportfairlylowconfidencethathealthauthoritieswilladequatelyfundincreasesincareservicesduetoBill16(figure7).Figure 7. Effectiveness and confidence in operators and health authorities collaborating to support publicallyfundedAssistedLiving

WhenaskedwhatoperatorsandhealthauthoritiescoulddotoimprovethewayinwhichpublicallyfundedAssistedLivingisprovidedoperatorsoverwhelminglyreportedbettercommunicationandcollaborationbetween operators and health authorities. Specifically, respondents would like health authorities todiscuss(andlisten)tothechallengesfacingoperators,increaserespectforoneanother’sposition,sharebestpracticesandincreasesharingofclientinformation.Additionally,respondentsindicatedadequatefundingandstaffinglevelswereessentialtoimprovingAssistedLivinginBC.

Bettercommunicationbetweenoperatorsandthehealthauthoritiessothatallareworkinginthebestinterestofaclient/resident.Untilwehaveseamlessserviceswearenevergoingtogettoanimproved

serviceforanyclients.

Sitesneedtoberespectedintheirchoicewhennottohouse/moveinormoveoutwithout[healthauthority]pressureandfundingincreasesandprofessionalresourcesneedtobeavailablenotjustLPN.Registrarshouldbeveryclearthatsitesmakethedecisiononwhotheyhouseand

whatservicestheychoosetoprovidewithin[healthauthority].

YES,61%N/AIN MY

COMMUNITY,23% NO,16%

1.7

2.8

1 2 3 4 5

CONFIDENCE THAT HEALTH AUTHORITIES WILL ADEQUATELY FUNDREQUIRED INCREASES IN CARE SERVICES

EFFECTIVENESS OF OPERATORS AND HEALTH AUTHORITIES INWORKING TOGETHER TO DELIVER PUBLICALLY FUNDED ASSISTED

LIVING


Sharebestpractices.Havemorepersonalaccessavailableinsteadofalwaysbeingreferredtoabook.

Increasefunding,resources,education,staffingofcasemanagers,mentalhealthresources,social

workers,equipment,pharmacists,dietitians.–AssistedLivingOperators

Aswith any legislative change, there is no funding allocated for the changes associatedwith Bill 16.InterviewswithhealthauthoritiesrevealedfarreachingdifferencesinhowBill16maybeimplementedacrosstheprovince.Onehealthauthorityhasconductedanin-depthreviewandconsultationprocessandanother is in the process of conducting a review, expecting it may take 18-24 months to complete.TimelinesforimplementingregulationsassetoutinBill16rangefromimmediatelytoupwardsoftwoyears.Onehealthauthorityintendstousebusinessprocessestodetermineservicesprovidedbyoperatorswhereothers intend tobemoreconsultativeandcollaborative innature.Regardlessof the individualhealth authority ‘style’ they all acknowledge a change in funding will be necessary. A change ingovernmentmayalsoimpacttheimplementationoftheActandRegulations.

Bill16willhelpushavetherightconversationsandworkcollaboratively.–HealthAuthorityDirector

ResidentialtenancyCurrently,Assisted Living tenants/clients arenot covered in theResidential TenancyAct.Overhalf ofoperatorsdonotsupporttheinclusionoftenants/clientsintheAct(figure8).ReasonsincludeAssistedLiving servicesandcarearenot included inRTA, theRTAdoesnot considerdeterioratingmental andphysical conditions of residents and the need inAssisted Living tomove clientswhen their conditionchanges.

WedealwithsituationsthatdonotfallinthescopeofexpertiseoftheTenancybureaucracy.Wearedealingwithseniorswhoseneedcanchangequicklyandmustbeaddressedonadifferent

timelinethanthatoftheTenancyAct.–AssistedLivingOperator

Figure8.AgreementwithinclusionofAssistedLivingtenants/clientsintheResidentialTenancyAct

FairminimumnoticeforAgreementterminationWhen asked what the fair minimum notice should be for health authorities or operators to removethemselvesfromanAssistedLivingAgreement(safetyviolationsnotwithstanding),surveyrespondentspreferred no termination by the health authority, yet felt that 12 months’ notice was adequate foroperators(figure9).

YES,22% NO,52% DON'T KNOW,26%


Figure 9.Minimum notice from health authorities and operators to terminate agreements (safety violationsnotwithstanding)

FutureofAssistedLivingBasedonthepopulationdemographics(bothintermsofnumbers,andexpectations)itisanticipatedthatresidentialandcommunitycarewillcontinuetogrow.TheSeniorsAdvocatefeelsthatthereisasignificantopportunity in thenext15-20yearsasboomerswillbemore inclined topay for services.TheSeniorsAdvocate has confidence in the privatemarket, but recognizes a role for the government to provideAssisted Living for thosewho cannot afford private pay and in ruralmarketswhere numbers do notsupportprivatepay.“Assistedlivingservesanicheinseniorscare.Wedon’twantAssistedLivingmorphingintocarefacilities.”

32%

23%

19%

12% 12%

2%

18%

30%

22%

18%

12%

NO ABILITY TOREMOVE THEMSELVES

12MONTHS 24+MONTHS 6MONTHS 18MONTHS NO NOTICE

HEALTH AUTHORITIES OPERATORS


ConclusionsTheTaskForcewasaskedtoconsultwithAssistedLivingprovidersinBCtounderstandconcernsregardingBill16regulatorychangesandtodeterminewhether:pendingBill16regulatorychangeswillnegativelyimpactthesustainabilityofoperators’abilitytoprovideAssistedLivingservices;providersaremoreorlesslikelytocontinuetheirAssistedLivingoperationsaftertheBill16regulationscomeintoeffect;andtheintroductionofBill16willimpactindependentlivingoperations.TheTaskForceconcludesthatthereisalackofunderstandinginthescopeandramificationsofBill16frombothoperatorsandhealthauthorities.Operatorsareconcernedaboutthepotentialforallservicestoberequired,thelackofdefinitionofterms,changestostaffingcompositionandincreasesinoperatingcosts. Operators and health authorities need further clarification on Bill 16, including roles andresponsibilitiesandtimelinesforimplementation.The Task Force concludes that there is currently a low rating from operators with respect to theirconfidencethathealthauthoritieswilladequatelyfundrequiredincreasesincareservicesresultingfromBill16.Conversationswithhealthauthoritiesthroughoutthisreviewhasemphasizedthewillingnessofhealth authorities to support operators and engage in consultation on how this will happen as theyprovidecareservicesforseniors(i.e.adjustfundingasneeded).TheTaskForceconcludesthatthereisaneedforhealthauthoritiesandoperatorstoworkwithBCHousingasakeyfundingpartnerinthisprocesstoensureprovidersareadequatelycompensatedforhousingcostsandthatmethodsforfundingaretransparent.The Task Force concludes there needs to be a change to Agreement language, between the healthauthority and the operator and the operator and the client to better protect clients in the event aterminationisnecessary.RecommendationsUnderstandingthechangingAssistedLivingsectorwithinBCMorethanonethird(36%)ofoperatorsstatetheydonothavesufficientconfidenceinunderstandingthescopeandramificationsofBill16.Operatorsreportedthefollowingconcerns:thepotentialforallservicestoberequired,thelackofdefinitionofterms,changestostaffingcompositionthatmayberequiredandincreases in operating costs. Operators and health authorities need further clarification on Bill 16,includingrolesandresponsibilitiesandtimelinesforimplementation.

2.1 TheTaskForcerecommendsthatBCCPAandtheMinistryofHealthworktogethertoengagethehealthauthoritiesandtheAssistedLivingRegistrararoundthepotential implicationsofBill16including the implementation of regulations. (Note that theMinistry of Health has started aconsultationprocessalready).

2.2 The Task Force recommends BCCPA facilitate robust discussions between Assisted Living

operators and health authorities around capacity to provide safe, appropriate and accessibleoptionsforBCseniors.Thisincludesconductingaformalreviewtodetermineoperators’intentionandcapacitytoprovidepublicallyfundedAssistedLiving,specificallytoclientswithgreaterneeds.ItisadvisedthatarepresentativefromtheMinistryofHealthbeincludedinthisprocess.

EnsuringsustainabilityoftheAssistedLivingsectorwithinBC


Demandtosupportseniorscareneedsintheircommunitiesisincreasingduetotheagingdemographics,theprovisionof additional servicesunderBill 16, and, in certainareasof theprovince increasing realestatevalueresultinginseniorshavingmoreequitytoinvestincareservices.Thismayresultinashiftwithin the continuumof care, placing an increasingdemand forAssisted Living andother communityserviceswhichwillhaveanimpactonsustainabilityinthesectorandonhealthhumanresources.

2.3 TheTaskForcerecommendsBCCPA, inpartnershipwiththeMinistryofHealth,bringtogetherAssistedLivingstakeholdersthroughaBCContinuingCareCollaborativetoensureaccess,growthandsustainabilityofassistedlivinginBC.

2.4 TheTaskForcerecommendsBCCPA,alongwiththeMinistryofHealthandthehealthauthoritiesleverageinitiativesalreadyunderway,andconductaprovince-widereviewofanticipatedsupplyanddemandforAssistedLiving(overthenext5-10years)toalignwiththeseniorscarehumanresourcestrategy.

FundingAssistedLivingCurrentlythereexistsatripartitemodelbetweenBCHousing,healthauthoritiesandoperatorstoprovidehousing and care services. The current model is coming under increased tension as a result of theeconomic market (including rising real estate values), demographics and client needs(composition/acuity).

2.5 The Task Force recommends a review to understand both current and future roles andresponsibilitiesofBCHousing,healthauthoritiesandoperatorstoenhanceclarity,consistencyofservices,transparencyandaccountability.

CurrentlythereisalackofaconsistentapproachtoandmethodoffundinginAssistedLiving.Thereareinconsistenciesamonghealthauthorities,betweenhealthauthoritiesandoperatorsandBCHousingandoperators.

2.6 TheTaskForcerecommendsaformalreviewoftheAssistedLivingfundingapproachtoallowforconsistency within the sector, decreased administrative burden and flexibility to support thecontinuumofcareforseniors.

2.7 TheTaskForcerecommendstheMinistryofHealthtoexploretheintroductionofacarecreditmodel3forAssistedLivingusingbestpracticesfromCommunityLivingBC,allowingforclientstodirecttheirowncareandselectprovidersoftheirchoice.

AssistedLivingagreementsAssistedLivingdoesnotfallundertheResidentialTenancyAct(RTA)whichgovernsmostrentalsoflivingaccommodation inBC. This leavesAssisted Living facilitiesoutside the scopeofRTA inmanyareasofuncertainty such as applicable legislative requirements, security deposits, right of entry to providerequiredservices,rentcontrolandcontrolofservicechargesandnoticeoftermination.

2.8 TheTaskForcerecommendsthehealthauthoritiesandBCHousing,togetherwithBCCPA,along

with other related industry associations review Assisted Living Tenancy Agreements (theagreementbetweentheassistedlivingproviderandtheclient)todevelopcommonelementsoftheagreementstostandardizeacrossoperatorsacrosstheprovince.

3ExploringOptionsforImprovingBC’sContinuingCareSector,Part1,BCCPA(2016)


III.RiskofEvictionsForthevastmajorityofoperatorsnon-paymentofAssistedLivingfeesisnotanissue.Lessthan10%reportfrequentissues(figure10).Figure10.Frequencyofissuesrelatedtonon-paymentofAssistedLivingfees

These findingswere validated through interviewswith operators and health authorities. For the fewoperatorswhodoreportissues,thegeneralconsensusisthatinstancesofnon-paymentissimplythecostofdoingbusiness(figure11).Figure11.Frequencyofissuesrelatedtonon-paymentofAssistedLivingfees

ThemajorityofoperatorsfeelthereisagreaterroleforthePublicGuardianandTrusteeinthecollectionofunpaidfeesandevictionshowevertherewasnotagreementinwhatcapacity(figure12).Figure12.SupportforanincreasedroleofthePublicGuardianandTrusteeinthecollectionofunpaidfeesandevictions

57%

33%

8%2%

NEVER RARELY (1-4ISSUES PERYEAR)

OFTEN (5-9ISSUES PERYEAR)

FREQUENTLY (10OR MOREISSUES A YEAR)

81%

16%

3%

NO,IT RARELY HAPPENS NO,WE CONSIDER THIS A COSTOF DOING BUSINESS

YES,IT IS TIME CONSUMINGAND/OR IMPACTS OUR REVENUE

Yes,70% No,30%IWOULD LIKE TO SEE A GREATER ROLE FOR THE PUBLICGUARDIAN AND TRUSTEE


RespondentsalsofeltthattheneedforsupportmayincreaseasAssistedLivingclientshaveincreasingphysicalandmentalhealthneeds.

Morepeoplearemovinginwithmentalhealthissueswhichcouldusesupportinthisarea.Clientswithdementiacausethemostdifficultiesinregardstofinanceswhenthereisnofamilyadvocate.

ConclusionsTheTaskForcewasasked todetermine themagnitudeand implicationsof clientnon-payment in theAssistedLivingsector.TheTaskForceconcludesthatthe issueofevictionsduetonon-payment isnotbroadly impactingthesector.TheTaskForcealsoconcludesthatprocessesexisttosupportclientsandoperatorsthroughthePublicGuardianandTrusteeandthehealthauthorities.Keyrolesarethatof:(a)thehealthauthorityinsupportingoperatorswhenthereisadiscrepancyinfeescollectedfromclientsand(b)thePublicGuardianandTrusteeenhancing itscommunicationregardingexistingprocessestosupportclients, familiesandoperators.RecommendationsWhileitappearsthatevictionduetonon-paymentoffeesisnotasignificantissueamongAssistedLivingoperators,thereiscurrentlyalackofawarenessregardingwhatprocessesexisttoevictclientsintherareinstancesthisisrequired.

3.1 Recognizinga formalprocessalreadyexists, theTaskForce recommends joint communication

fromthePublicGuardianandTrusteeandhealthauthoritiestodetailtheprocessesandsupportsthatexistforclients,familiesandoperators.ThisincludestheprovisionofanannualreconciliationofAssistedLivingfeesfromhealthauthoritiestosupportoperators.


SUMMARYOFRECOMMENDATIONSRecommendationshavebeendevelopedbytheTaskForcewithinthescopeofthetermsofthereferencewithadvisoryinputfromVancouverCoastalandFraserHealth.ThefollowingrecommendationsareputforwardtotheBCCPABoardforreviewandconsideration.NoticeofTerminationCurrentlythereareinconsistenciesintheAssistedLivingServiceAgreements(theagreementbetweenthehealthauthorityandtheoperator)aswellasalackofclearcommunicationprocessesregardingnoticeoftermination.1.1 The Task Force recommends that the Assisted Living Service Agreements between the health

authorityandoperatorbeamendedtoinclude:a. Languagestatingthat:

i. Aminimum12-monthnoticeperiodberequiredtoterminatetheAgreementii. The handling of the reduction of suites be discussed and determined

collaborativelybythehealthauthorityandtheproviderb. A standardized communication plan and transition plan in place prior to Notice of

Termination to clearly state practices/documents to ensure hardship and emotionalimpacttoseniorsandtheirfamiliesisminimized.


Aprovince-wideframeworkforHomeandCommunityCarehasbeeninexistencesince2002.Thereisafeelingamong thesector thatAssistedLiving shouldbeoperatingunderaparallelpolicy for changingneeds in Assisted Living. There are some parallels to the Managing Changing Needs (‘365 clause’)subsectionof theResidentialCareServices chapterof theHomeandCommunityCarePolicyManual.Understandingthedisruptiontobothoperatorsandseniors,theintentofthepolicywastomakesureoperatorsandthehealthauthoritiescouldmanagethechangingneedsofseniors.UnderstandingthechangingAssistedLivingsectorwithinBCMorethanonethird(36%)ofoperatorsstatetheydonothavesufficientconfidenceinunderstandingthescopeandramificationsofBill16.Operatorsreportedthefollowingconcerns:thepotentialforallservicestoberequired,thelackofdefinitionofterms,changestostaffingcompositionthatmayberequiredandincreases in operating costs. Operators and health authorities need further clarification on Bill 16,includingrolesandresponsibilitiesandtimelinesforimplementation.2.1 TheTask Force recommends thatBCCPAand theMinistryofHealthwork together toengage the

health authorities and the Assisted Living Registrar around the potential implications of Bill 16including the implementation of regulations. (Note that the Ministry of Health has started aconsultationprocessalready).


2.2 TheTaskForcerecommendsBCCPAfacilitaterobustdiscussionsbetweenAssistedLivingoperatorsandhealth authorities around capacity toprovide safe, appropriate andaccessibleoptions forBCseniors.Thisincludesconductingaformalreviewtodetermineoperators’intentionandcapacitytoprovidepublicallyfundedAssistedLiving,specificallytoclientswithgreaterneeds.ItisadvisedthatarepresentativefromtheMinistryofHealthbeincludedinthisprocess.

EnsuringsustainabilityoftheAssistedLivingsectorwithinBCDemandtosupportseniorscareneedsintheircommunitiesisincreasingduetotheagingdemographics,theprovisionof additional servicesunderBill 16, and, in certainareasof theprovince increasing realestatevalueresultinginseniorshavingmoreequitytoinvestincareservices.Thismayresultinashiftwithin the continuumof care, placing an increasingdemand forAssisted Living andother communityserviceswhichwillhaveanimpactonsustainabilityinthesectorandonhealthhumanresources.

2.3 The Task Force recommends BCCPA, in partnership with the Ministry of Health, bring together

AssistedLivingstakeholdersthroughaBCContinuingCareCollaborativetoensureaccess,growthandsustainabilityofassistedlivinginBC.

2.4 TheTask Force recommendsBCCPA, alongwith theMinistry ofHealth and thehealth authoritiesleverageinitiativesalreadyunderway,andconductaprovince-widereviewofanticipatedsupplyanddemandforAssistedLiving(overthenext5-10years)toalignwiththeseniorscarehumanresourcestrategy.

FundingAssistedLivingCurrentlythereexistsatripartitemodelbetweenBCHousing,healthauthoritiesandoperatorstoprovidehousing and care services. The current model is coming under increased tension as a result of theeconomic market (including rising real estate values), demographics and client needs(composition/acuity).2.5 TheTaskForcerecommendsareviewtounderstandbothcurrentandfuturerolesandresponsibilities

of BC Housing, health authorities and operators to enhance clarity, consistency of services,transparencyandaccountability.

CurrentlythereisalackofaconsistentapproachtoandmethodoffundinginAssistedLiving.Thereareinconsistencies amonghealth authorities, betweenhealth authorities andoperators, andbetweenBCHousingandoperators.

2.6 TheTaskForce recommendsa formal reviewof theAssisted Living fundingapproach toallow for

consistency within the sector, decreased administrative burden and flexibility to support thecontinuumofcareforseniors.

2.7 TheTaskForcerecommendstheMinistryofHealthexploretheintroductionofacarecreditmodelforAssistedLivingusingbestpracticesfromCommunityLivingBC,allowingforclientstodirecttheirowncareandselectprovidersoftheirchoice.


AssistedLivingagreementsAssistedLivingdoesnotfallundertheResidentialTenancyAct(RTA)whichgovernsmostrentalsoflivingaccommodation inBC. This leavesAssisted Living facilitiesoutside the scopeofRTA inmanyareasofuncertainty such as applicable legislative requirements, security deposits, right of entry to providerequiredservices,rentcontrolandcontrolofservicechargesandnoticeoftermination.

2.8 TheTaskForcerecommendsthehealthauthoritiesandBCHousing,togetherwithBCCPA,alongwith

other related industry associations review Assisted Living Tenancy Agreements (the agreementbetweentheassistedlivingproviderandtheclient)todevelopcommonelementsoftheagreementstostandardizeacrossoperatorsacrosstheprovince.

EvictionduetoNon-paymentofFeesWhileitappearsthatevictionduetonon-paymentoffeesisnotasignificantissueamongAssistedLivingoperators,thereiscurrentlyalackofawarenessregardingwhatprocessesexisttoevictclientsintherareinstancesthisisrequired.

3.1 Recognizingaformalprocessalreadyexists,theTaskForcerecommendsjointcommunicationfrom

thePublicGuardianandTrusteeandhealthauthoritiestodetailtheprocessesandsupportsthatexistforclients,familiesandoperators.ThisincludestheprovisionofanannualreconciliationofAssistedLivingfeesfromhealthauthoritiestosupportoperators.


APPENDICESAppendixA:AssistedLivingTenancyTaskForceTermsofReferenceCOMPOSITION

• TheTaskForceiscomprisedofthreemembersincludingthefollowing:o TomCrump,Chairo RonPike,ChairofMembershipCommitteeo AnnMarieLeijen,ChairofQualityAssuranceCommittee

• ArepresentativefromboththeVancouverCoastalHealthAuthorityandtheFraserHealthAuthoritytoactinanadvisorycapacity.

SCOPEOFWORKTerracesonSeventh

• ReviewthecircumstancesthatledtoRetirementConceptsprovidingVancouverCoastalHealthwithasix-monthtermination.

o Thisincludesseekingawrittenand/orverbalsubmissionfrombothparties.• ReviewrecommendationsandfindingsinLawSociety-AssistedLivinginBC(Final)Report,and

TheConsultationPaperonAssistedLivinginBC.• Providerecommendationsregardinghowseniorscanbeprovidedwithbetterprotectionto

reducetherisktheywillberequiredtosuddenlyvacatetheirpremisesduetoacontracttermination.

• Developrecommendationsregardinghowserviceagreementsbetweenahealthauthorityandanassistedlivingprovidercanbestrengthenedtobetterbalancetheneedsofboththeseniorsandoperators.

• Assesswhetherthisisanisolatedincidentorthestartofanemergingtrendintheindustrywhichwouldleadtoareductioninaccesstopubliclyfundedassistedliving.

Bill16–CommunityandAssistedLivingActRegulatoryChanges

• ConsultwithallassistedlivingprovidersinBCtodetermine:o ArethereconcernsregardingBill16regulatorychanges?o WillpendingBill16regulatorychangesnegativelyimpactthesustainabilityoftheir

abilitytoprovideassistedlivingservices?o AreprovidersmoreorlesslikelytocontinuetheirassistedlivingoperationsaftertheBill

16regulationscomeintoeffect?o WilltheintroductionofBill16impacttheirindependentlivingoperations?Ifso,whatis

theanticipatedimpact?• Developrecommendationstoensureseniorshaveadequateaccesstopubliclyfundedassisted

livingintheircommunity.• Developrecommendationsaimedatstrengtheninganyproposedregulatorychangesincludedin

theCommunityCareandAssistedLivingAmendmentAct.


IncreasedRiskofEvictions–Non-PaymentofClientUserFees• Determinethemagnitudeoftheissueofclientnon-paymentoffeesisinassistedlivingsettings.• Assesswhatmechanisms/regulationsareinplacetoprotectseniorsfromfinancialabusewhich

mayresultinpossibleevictionduetonon-paymentofclientfees.• Developrecommendationstoprovidebetterprotectiontoseniorswhofacepossibleeviction

duetofinancialabusefromtheirfamilyand/orfriends.• Developrecommendationstosupportassistedlivingoperatorswiththecollectionofclientfees

toreducetheriskofunnecessaryeviction.• DeterminewhetherthereisastrongerroletoplayfortheOfficeofthePublicGuardianand

Trusteeasitpertainstothecollectionofunpaidfeesandevictions.TIMELINE

• ProvideasetofrecommendationstotheBCCPABoardofDirectorsbynolaterthanJune15,2017.

• TheBCCPAwillforwardtheTaskForcerecommendationstotheMinistryofHealthbynolaterthanJuly2017.

RESOURCES

• Amaximumof$25,000allocatedfromthe2017/18OperatingBudgettosupporttheworkoftheTaskForce

• Wherefeasible,theBCCPAtoassisttheTaskForcewithbasicsecretariatandadministrativesupport.

OTHER

• Uponsubmissionofitsreportandrecommendations,theTaskForcewilladvisetheBoardofDirectorsifitrequiresadditionaltimeandresourcestofulfillitsmandate.


AppendixB:TerracesonSeventhandVancouverCoastalHealthCommunications


AppendixC:TerracesonSeventhLetter

1160-1090WestGeorgiaStreet,Vancouver,BC,V6E3V7

Thank you for the opportunity to respond to the Task Force with regards to the situation at Terraces on Seventh.

First of all we want to state we did not evict any of the funded residents living with us, nor is Terraces on Seventh part of the Retirement Concepts portfolio - it is an independent board. All decisions for Terraces on Seventh are made by Pacific Reach Seniors Housing Management (PRSHM) and the owners of Terraces on Seventh. We exercised our legal right to terminate the contract with Vancouver Coastal Health (VCH). We were in the process of a confidential discussion of a transition and communication plan to ensure a smooth transition plan of the clients. The plan was yet to be determined in full.

We value our relationship with VCH, as well as our other Health Authorities and work hard to maintain them.

The decision to terminate a long standing contract was not an easy one, and came after a review of several contributing factors, as discussed:

• Contractrequirementsforincreasesinstaffing• Changestoleaseagreements• Hospitalityserviceprovision• Increaselevelofcareservicesdeliveredatthecommunity.

We appreciate the opportunity to respond in writing and hope our contributions can add value to the Task Force Mandate.

Azim Jamal

PRSENIORSHOUSINGMANAGEMENTLIMITEDPARTNERSHIP

PRSENIORSHOUSINGMANAGEMENTLIMITEDPARTNERSHIP

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