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
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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.
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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.
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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 and administration.
• Met with key personnel and stakeholders.
• Visited 3 CCACs (Central, North East and Champlain) – 2014/15 – 26% of total CCAC expenses, and 25% total clients served.
Office of the Auditor General of Ontario 21 Audit Objective
• To assess whether the Community Care Access Centres, in partnership with the Ministry of Health and Long-Term Care and Local Health Integration Networks:
• Have processes in place to provide care co-ordination to home-care clients in a seamless and equitable manner;
• Monitor service providers in accordance with contractual and other requirements; and
• Measure and report on the quality and effectiveness of home-care services provided.
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Main Findings
Office of the Auditor General of Ontario 23 Assessment of Client and Family Needs Requires Improvement
• Clients not consistently assessed or reassessed on a timely basis:
• At the three CCACs visited, 40% of initial contact assessments were not completed within the required 72 hours, and 65% of initial home assessments were not done within required timelines.
• Of clients reassessed in the complex and chronic populations, 32% of clients were not reassessed within the required timelines.
• Depending on the CCAC, 34% to 39% of clients were not reassessed at all.
Office of the Auditor General of Ontario 24 Untimely Assessment and Reassessment of Clients
Office of the Auditor General of Ontario 25 Access to Personal Support Services Not Equitable & Allocation Dependent on Funding • Access to and extent of personal support services received not equitable.
• Each CCAC visited had different criteria to prioritize which clients would receive services, for example:
• Client with RAI-HC score of 7 would not receive any service from one CCAC but would in the other two;
• High RAI-HC score such as 15 would receive different number of hours depending on CCAC (ranging from 5-10 hours).
• Regulation states that up to 90 hours of personal support services can be provided to clients per month, but actual max. hours typically provided much lower (56-60 hrs) at the 3 CCACs visited.
• CCACs claimed budgetary constraints as a reason.
• Regulation silent on the min. amount of services (e.g. # of baths per week)
Office of the Auditor General of Ontario 26 Minimal Supports Provided to Caregivers
• Care co-ordinators can arrange for a portion of a client’s allocated personal support services to be directed to provide caregivers with respite care, but this time comes out of the client’s overall personal support hours.
• Care co-ordinators can refer clients to other agencies so caregivers can get relief, but these services either have waitlists or are not available at all in some communities.
• At one CCAC, the number of caregiver respite hours decreased 16- fold between 2012/13 and 2014/15, from 18,700 hours to 1,110 hours.
Office of the Auditor General of Ontario 27 Oversight of Services Provided Needs Improvement
• Service providers not assessed for meeting client outcomes
• Corrective actions inconsistently applied when service providers underperformed
• Overall client satisfaction rate not reliable
• Reported complaints about services up since 2010
• Lack of independent verification of additional wages paid to personal support workers through wage subsidy program.
Office of the Auditor General of Ontario 28 Main Recommendations
• Assess and reassess clients within the required timeframes and review reports on overdue assessments and reassessments.
• Assess the types of caregiver supports in other jurisdictions to use in Ontario, and track the amount and type of caregiver support provided.
• Where necessary, revise guidelines for care co-ordinator caseload sizes and follow up with discharged clients within the require time frames.
• Track referrals made to community support service agencies and consider developing centralized wait-list information.
• Develop guidelines for prioritizing clients for services and evaluate ways to provide more service hours closer to regulated maximums.
Office of the Auditor General of Ontario 29 Main Recommendations
• Expedite the process of transferring and diverting low-needs clients needing personal support services from CCACs to community agencies.
• Develop performance indicators and targets to collect data that measure client outcomes, and reassess the use of “missed care”.
• Review and revise the client satisfaction survey methodology to increase accuracy and reliability of survey responses.
• CCACs should conduct routine site visits to monitor quality of care and verify accuracy and completeness of information from service providers.
• Prioritize complaints by level of risk; respond to most urgent first.
• Conduct inspections of service provider records on a random basis to ensure PSW funds are spent for the purposes intended. Office of the Auditor General of Ontario 30 Local Health Integration Networks
2015 Annual Report
Office of the Auditor General of Ontario 31 Audit Objective and Scope
Audit Objective Assessed whether LHINs, in conjunction with the Ministry, have effective systems and procedures in place to facilitate the provision of the right care at the right time in the right place for Ontarians.
Scope Ministry of Health and Long-Term Care Selected LHINs (Central, Hamilton Niagara Haldimand Brant, North East, Toronto Centre) Interviewed representatives from HQO, CCO, and Associations representing all HSP sectors Surveyed all current and former LHIN CEOs and Board Members, all current senior officials at ~1,300 health service providers
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Main Findings – LHINs
Ministry has not clearly defined what would constitute a “fully integrated health system”, or when it is to be achieved by.
Ministry has not developed ways of measuring LHIN effectiveness.
LHIN performance measured against 15 indicators, which are mainly for hospital performance, and little action by Ministry to hold them accountable.
Patients’ access to better integrated care depends on location.
LHINs have not fully defined system capacity in palliative care, home and community care, and rehabilitative services.
Office of the Auditor General of Ontario 33 Electronic Health
Records’ Implementation Status
2016 Annual Report
Background
• Electronic health initiatives are occurring all across the government through eHealth Ontario, the Ministry, and agencies such as Cancer Care Ontario, CCACs, community mental health agencies, and in a big way in hospitals.
• Soon after eHealth Ontario was formed in 2008, in 2009, OAGO conducted a Special Audit of eHealth Ontario which identified as its main issues, the significant number of consultants hired, which exceeded the numbers of permanent full-time staff hired to implement an Electronic Health Record (EHR) Initiative for every Ontarian.
• It also noted that significant work remained to be done to meet the target date of 2015 for completing a fully functional EHR.
• In 2015/16, OAGO decided it was time to review the progress of EHR work by both eHealth Ontario, the Ministry and other health agencies to implementing a fully functional EHR.
Office of the Auditor General of Ontario 35
Audit Objective
• The objective of our audit was to assess whether eHealth Ontario, in conjunction with the Ministry of Health and Long-Term Care, had effective governance, systems and procedures in place to ensure that Electronic Health Records were implemented in accordance with requirements and adopted for use and that status of implementation and adoption is appropriately measure and reported on.
Office of the Auditor General of Ontario 36 Audit Scope
• Ministry of Health and Long-Term Care
• eHealth Ontario
• Lead hospitals in London, Hamilton, and Toronto
• Interviewed management at community and hospital labs, hospital physicians, primary care physicians, Canada Health Infoway, Cancer Care Ontario, Institute for Clinical Evaluative Sciences
• Professional associations – e.g., Ontario Hospital Association, Ontario Medical Association and its subsidiary-OntarioMD, College of Physicians and Surgeons of Ontario, Ontario Pharmacists Association, Ontario College of Pharmacists, Registered Nurses Association of Ontario, College of Nurses of Ontario
• Surveyed physicians on their use of various EHR systems.
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Main Findings
• Lack of provincial strategy and leadership - Cabinet approved an ehealth strategy in 2008 that included the goal of establishing an EHR for every patient in Ontario by 2015; however, strategy documents and Ministry mandate letter did not establish the roles and responsibilities of all the health partners.
• $8 billion of public money provided to implement EHRs – the Ministry through various programs spent more than $4 billion over 14 years, and another $4 billion was through LHINs to various health care organizations.
• By March 2016 eHealth Ontario estimated that it completed about 80% of the EHR initiative, yet there is still no overall budget for EHR.
• EHR systems are not fully functional or contain incomplete information – e.g., the drug system only contains info for Ontarians 65+, on social assistance or paying for high cost drugs; no electronic prescribing available.
• EHR requires buy-in from physicians but data contribution is not mandatory, and standardization of software not there – too many options (14 EMR vendors).
• In response to our survey, only 12% said they used system fully, 35% did not know how to use EHRs, 45% cited technological barriers to use. Office of the Auditor General of Ontario 38
Main Recommendations
Ministry of Health and Long-Term Care should:
• Clarify and document the roles and responsibilities of all parties in the development of relevant projects in the next version of its Electronic Health Record strategy
• Prepare an updated budget of the costs to complete the overall initiative, including estimated costs of all EHR projects to be developed by taxpayer funded health-care organizations – not just eHealth Ontario – along with its revised EHR strategy
• Publicly report, at least annually, on all costs incurred to date and the status of these costs compared to the updated budget and plans
eHealth Ontario should:
• Set timelines for completing all phases and functionalities of all EHR projects
• Monitor that progress is made according to established timelines
• Establish and communicate a consistent definition of active user to be applied across the province;
• Establish growth targets for active usage of each project as more registered users are given authorized access Office of the Auditor General of Ontario 39 Perspectives on Value-for-Money Audits
• Decision-making not always supported by rigorous business cases or collaborative work with other Ministry’s and departments.
• Investment in information technology not always managed effectively.
• Data becoming more available, but more useful for output measurement versus outcome measurement – data reliability still questionable in many cases.
• Waiting lists for services: hospitals, autism programs, vulnerable women turned away from shelters.
Office of the Auditor General of Ontario 40 Perspectives on Value-for-Money Audits
• Seeing variation of services depending where someone lives in Ontario – electricity rates, gas rates, CCAC services, hospital services, rehab, etc.
• Legislation putting more requirements in place, but staffing levels may not be keeping up with expectations.
• More oversight needed where services are delivered by the private sector – would be beneficial to have our reach extend to recipients of public money.
Office of the Auditor General of Ontario 41 What’s New in 2017?
• New Value-for-Money audit topics are underway and will be published in our Annual Report in November or December.
• Follow-up reports are being completed for 2015 VFMs.
• Continuous follow-ups are now being completed for all recommendations dating back to 2012 that have not yet been fully implemented – follow-up will continue until fully implemented.
• New Cross-Ministry and IT teams have been set up to respond to changes in the operation of government and ministries.
• The Auditor General of Ontario has established a panel of Senior Advisors to provide strategic advice and recommendations concerning the Office’s work.
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Thank you! Any questions?
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