2017 Home Care Ontario Annual Symposium Sandy Chan, Audit Director – Health Portfolio May 25, 2017 Presentation Agenda • Background • LHINs (2015) • Recent Value-for-Money Audits • Implementation of Electronic in Health Health Records in Ontario (2016) • Current Value-for-Money Audits & Follow-up Reports n Health • Perspectives on Value-for- Money Audits • 2017 Annual Report VFMs • What’s New in 2017? • CCACs – Financial Operations and Service Delivery (2015) • Questions? • CCACs – Home Care (2015) Office of the Auditor General of Ontario 2 The Primary Role of the Auditor General • To provide information to the Legislature to help it ensure taxpayer funds are prudently spent and government administrators follow sound business practices. • To encourage improvements in the way the government delivers public services (better and more cost-effective service delivery). • To provide assurance that financial accounts are fairly presented (the traditional auditor role). • We conduct our work in accordance with professional standards as per the Chartered Professional Accountants of Canada (CPA Canada) using Canadian Audit & Accountability Foundation (CAAF) methodology for the conduct of Value-for-Money audits. Office of the Auditor General of Ontario 3 Reporting Relationship • As an Officer of the Assembly, the Auditor General is independent from the government. Our key stakeholder is the Legislative Assembly. *Members of the following Associations: Chartered Professional Accountants of Canada (CPA Canada), Canadian Council of Legislative Auditors (CCOLA), and Canadian Audit & Accountability Foundation (CAAF). Office of the Auditor General of Ontario 4 Standing Committee on Public Accounts • The membership of the Committee reflects proportionately the representation of parties in the Legislative Assembly. • Prior to the 2014 provincial election: minority liberal government and the Committee was composed of 3 Liberal MPPs, 3 Conservative MPPs and 3 NDP MPPs. • After the 2014 provincial election: the committee is composed of 5 Liberal MPPs, 3 Conservative MPPs, and 1 NDP MPP. • The committee includes a Chair, Vice-Chair, MPPs, Committee Clerk, and legislative researchers. • The Auditor General is an advisor to the committee. Office of the Auditor General of Ontario 5 Standing Committee on Public Accounts (cont’d) • PAC holds formal hearings on selected contents of our Annual Report at which senior ministry and agency officials are questioned about the matters under review. • After each hearing, PAC usually issues a formal report to the Assembly on the ministry program or entity that was being reviewed. • PAC’s report often reinforces the Auditor General’s recommendations and usually goes even further with additional recommendations. Office of the Auditor General of Ontario 6 Our Staff Office of the Auditor General of Ontario 7 Our Teams 11 Audit Portfolios • Public Accounts • Agency Financial Statements (2 Portfolios) • Education and Training • Health • Health & Energy • Infrastructure and Environment • Social Services & Finance • Justice, Government Services • IT Services • Cross Ministry and Recommendation Follow-up Office of the Auditor General of Ontario 8 Our Work • Value-for-Money audits are conducted annually – mandate extends to ministries, crown agencies, school boards, long-term care homes, hospitals, universities, colleges, etc. • Follow-ups on VFM audits are conducted every two years to determine the status of implementation of recommendations. • Financial statement audits are conducted on the province’s Public Accounts, as well as numerous provincial Crown agencies such as the Liquor Control Board of Ontario (LCBO), TVOntario, and the Ontario Securities Commission. Office of the Auditor General of Ontario 9 Recent Value-for-Money Audits in Health 2013: Health Human Resources Land Ambulance Services Rehabilitation Services at Hospitals 2014: Immunization Palliative Care 2015: CCACs—Home Care LHINs Long-Term Care Home Quality Inspection Program 2016: Electronic Health Records’ Implementation Status Housing and Supportive Services for People with Mental Health Issues Large Community Hospital Operations Physician Billing Specialty Psychiatric Hospital Services Office of the Auditor General of Ontario 10 Current Value-for-Money Audits & Follow-ups in Health 2017 Value-for-Money Audits 2017 Follow-up Reports • Community Health Centres • CCACs – Home Care • Public Health: Chronic • CCACs – Financial Disease Prevention Operations and Service Delivery • Ontario Drug Programs • Local Health Integration • Hospital and Community Labs Networks • Cancer Treatment Services • Long-Term-Care Home Quality Inspection Program Office of the Auditor General of Ontario 11 2017 VFM Audits in Other Areas of the Public Sector • Agriculture • Housing • School Boards • Immigration Services • Infrastructure • Energy Office of the Auditor General of Ontario 12 Community Care Access Centres: Financial Operations and Service Delivery Special Report September 2015 Public Accounts Committee Motion • In March 2014, the Standing Committee on Public Accounts passed a motion to ask the Office of the Auditor General to conduct an audit of CCACs. The key points of the motion were: That the Auditor General conduct an audit of the Community Care Access Centres in the Province of Ontario, including the Ontario Association of Community Care Access Centres. This audit should have a focus on the following issues: • Executive and other compensation of direct and indirect care providers; • Operating and general expenses; • Review of contracts and long-term financial efficacy of existing care protocols; and • Compare efficacy and cost effectiveness of home care visits. Office of the Auditor General of Ontario 14 Background • 14 CCACs determine eligibility for, and co-ordinate access to, home- and community-based services such as nursing, personal support, and therapy for people of all ages. • Total CCAC spending in the year ending March 31, 2014, was almost $2.4 billion, or about 5% of Ontario’s total health-care expenditures. • In 2013/14, CCACs employed a total of 6,630 full-time staff that provide care co-ordination for clients, and staff that work in information technology, and administration. • CCACs generally do not provide care directly, but contract with about 160 service providers (both for-profit & not-for-profit) under 260 contracts to supply the required services. Office of the Auditor General of Ontario 15 Audit Scope • Met key personnel at: • Ministry of Health and Long-Term Care, • Selected Community Care Access Centres, • Local Health Integration Networks, • Ontario Association of Community Care Access Centres, and • nine contracted service providers (represented 69% of total CCAC procurement expenses in 2013/14) • Visited three CCACs that served different regions of province and for 2013/14, represented 30% of total CCAC expenses, and 28% of total clients served. • Surveyed the remaining 11 CCACs. • Met with stakeholders: • the Ontario Nurses’ Association • the Ontario Health Coalition Office of the Auditor General of Ontario 16 Main Findings • CCACs 2013/14 expenses were up 26% since 2009/10, spending a total of $2.4B in the year ending March 2014. • Association spent $40 million in 2013/14, up 6% since 2009/10 – half spent on salaries and wages. • In 2013/14, about 62% of CCAC expenses ($1.5 billion) were for contracted health-service providers. • CCACs’ compensation was 43% higher for CEOs and 21% higher for senior executives than service providers’ compensation for the equivalent positions/levels in 2013 at the nine service-providers we visited. Office of the Auditor General of Ontario 17 Main Findings • Different definitions of direct patient care result in different CCAC percentages: • 92% - CCACs own provincial definition of direct care following Ministry reporting guidelines; • 81% - Excludes overhead and profits of service providers; • 72% - Excludes all activities not involving direct patient interaction; • 61% - Excludes all care co-ordination costs. • In some cases, the same service provider is paid different rates by the same CCAC for the same service. • One provider of personal-support services charged $48.98 per hour in one area and $29.50 per hour in another area within the same region. Office of the Auditor General of Ontario 18 Main Recommendations • Finalize the annual funding each CCAC will receive before the fiscal year begins. • All CCACs should follow a common CEO compensation framework and be required to report any exceptions. • The Ministry should revisit the service delivery model that currently involves 14 CCACs and about 160 service providers. • Study the compensation paid to CCAC direct-nursing and therapist staff and analyze whether this service is best delivered by service provider organizations or direct staff. • Make available to CCACs data on hospital readmission and emergency room visits, and establish performance indicators. • Put harmonized billing rates in place to ensure home-care services are procured in a cost-effective manner. Office of the Auditor General of Ontario 19 Community Care Access Centres: Home Care Program 2015 Annual Report Background • CCAC spending in the year ending March 31, 2015 - $2.5 billion (to provide home-care services to 713,500 clients) versus CCAC spending in 2008/09 - $1.76 billion (to serve about 586,400 clients). This represented a 42% increase in funding from 2008/09. • 6,775 full-time staff that provide care co-ordination for clients, and staff that work in information technology