Care Facility Admissions Dr Janet Kow Teresa Robitaille

Care Facility Admissions Dr. Janet Kow Teresa Robitaille Nov 4, 2019

Overview: § Review Part 3 of the Health Care (Consent) and Care Facility (Admission) Act Nov 4, 2019 § Definition of a care facility § Definition of capability § Requirements for consent to facility care § Outline the process of incapability assessments 2

Why do we care? § We’ve been waiting almost 20 years! § We have not had a legal framework for admitting incapable adults to care facilities Ø distress amongst care providers Ø inefficiency within the care § Vulnerable adults have not had a process for disputing assessments and/or decisions around facility 3

PRINCIPLES § § § capable adults entitled to live in the manner they wish and accept or refuse support, assistance, or protection as long as they do not harm others adults are presumed to be capable of making their own decisions adults should receive most effective, but least restrictive/intrusive form of support, assistance, or protection when unable to care for themselves 4 4 4

KEY Components § Outlines a framework for consent for facility admission § defines capability to give or refuse consent § sets out assessment process for determining incapability § specifies who will give consent on behalf of an adult who’s been determined to be incapable § requires consent to continued residence if an incapable adult wants to leave 5 5

RIGHTS OF ADULTS § to be presumed capable § to give/refuse/revoke consent to admission (if capable) § to be fully informed about consent decision § to be told the outcome of incapability assessment § to a qualified substitute to make decision if determined incapable § to leave and/or be assessed 6 6

WHAT IS A CARE FACILITY? § facilities for adults licensed under Community Care and Assisted Living Act: long-term care facilities, mental health residences, substance use treatment facilities, rehabilitation units (HFH and GF Strong) & hospices § private and rehabilitation hospitals/facilities, and extended care units licensed under Hospital Act but not assisted living residences, acute care hospitals, Provincial mental health facilities, psychiatric or observation units, or group homes under Community Living Authority Act 7 7 7

Capability § ability to understand the decisions we make § capacity, capability, mental soundness, competence; BC legislation uses capability § Different tests for different kinds of capability Ø for wills, contracts, powers of attorney, representation agreements, consent to health care, consent to care facility admission 8 8

CAPABILITY IS… § presumed: Until the contrary is demonstrated, every adult is presumed to be capable of making decisions about the adult's personal care, health care and financial affairs. AGA, s. 3 § domain specific (kind of decision) § decision specific…so always say: capable or incapable of what? § fluid, not static, changeable “bad” choices do not = incapability 9 9

UNDERSTANDING AND APPRECIATION pillars of decisional capability understanding is the ability to comprehend the information that is provided appreciation is the ability to apply that information to one’s own situation and circumstances 10 10

WHO SEEKS CONSENT under CFA? § “manager” is defined as person who is responsible for the operation of a care facility or for admissions to a care facility or both § “manager” is responsible for seeking consent and ensuring it has been provided prior to admission § “manager” could be a health authority employee or care facility employee 2011 11 11

ELEMENTS OF CONSENT informed: adult must be given information about decision and its implications voluntary: decision is freely made with no pressure or coercion or undue influence §capable: adult must be capable of understanding and appreciating what it means to give or refuse consent §specific: consent applies to a specific care facility 12 12

SEEKING CONSENT § assume capability § provide information § provide opportunity for questions and answers § involve others if appropriate § look for signs of understanding and appreciation § adult consents or refuses consent 13 13

PROVIDING INFORMATION § Adult must receive information about: > care adult will receive in the care facility > services that will be available to adult > circumstances under which adult may leave the care facility § Allow for questions and answers 14

INVOLVE OTHERS “manager” may allow others (adult's spouse, relatives or friends) to help adult understand or to demonstrate an understanding of the matters 15 15

SUBSTITUTE CONSENT FOR AN INCAPABLE ADULT one of the following, in ranked order: 1. court-appointed substitute decision maker (committee of person) 2. substitute appointed by adult (representative) 3. substitute selected by manager seeking consent, chosen from ranked list of relatives and friends 16 16

Hierarchy of SDM § § § § spouse adult child parent brother or sister grandparent grandchild another relative by birth or adoption § § § close friend person immediately related by marriage another person chosen by the Public Guardian and Trustee 17 17

DUTIES OF SUBSTITUTES § consult with adult or adult’s spouse, friend, relative § make decision in adult’s best interests considering: > adult's current wishes and any pre-expressed wishes, values and beliefs, > whether adult could benefit from admission to care facility, and > whether course of action other than admission or less restrictive type of care facility, is available and appropriate 18 18 18

NO ROLE FOR ADVANCE DIRECTIVE advance directive cannot give or refuse consent to facility admission, only to specific health care treatments 19 19

CONSENT TO CONTINUED RESIDENCE § capable residents are free to leave § if incapable resident expresses a desire to leave facility, “manager” must obtain substitute consent to continued residence, unless: > adult admitted in last 30 days or > substitute consent for continued residence obtained in last 90 days 20 20 20

EMERGENCY ADMISSION: Emergency admission without consent: Ø necessary to save adult’s life, protect adult from serious mental/physical harm, or protect others from physical harm (incapability assessment required) OR Ø an adult is being protected under s. 59 of Adult Guardianship Act (no incapability assessment required) When adult admitted without consent, “manager” must seek consent in 72 hours. 21 21 21

WHO ASSESSES FOR INCAPABILITY § medical practitioner or prescribed health care provider § prescribed health care providers: > registered nurses > nurse practitioners > registered psychiatric nurses > occupational therapists > psychologists > social workers 22 22 22

Incapability Assessment Requirements Assessors must: § tell adults why they are being assessed and consequences if found incapable § communicate with the adult in manner appropriate to the adult's skills and abilities. Assessors may: § § include adult's spouse, relatives, or friends to help adult understand assessment process consult others to collect relevant information necessary or advisable for purposes of 23 assessment. 23 23

COMPONENTS OF INCAPABILITY ASSESSMENT § review medical information to ensure no underlying/ potentially reversible health conditions affecting adult’s capability § conduct decision-specific assessment to determine if adult has capability to give or refuse consent § determine if adult is capable or incapable of giving or refusing consent 24 24

ASSESSMENT ACTIVITIES § review medical information § review and consider collateral information § cognitive tests § assessment interview(s) to determine if adult can: o understand information needed to make decision o reason with information o appreciate likely consequences of decision 25 25

Determining Understanding: • What is your understanding of your condition, problem, and needs? • Have you been able to take care of yourself lately as well as you would like? What has happened? What has changed? • Do you have concerns about living in a LTC facility? • Do you understand the information that I have provided about the facility, the services provided and the circumstances under which you will be able to leave if you want? • Do you have any questions? 26 26

Determining ability to reason: • What things are most important to you in deciding whether to move into a facility? • What are you thinking about as you consider your decision? 27 27

Determining Appreciation: • Can you tell me about yourself and your problems/condition/needs and how moving to a facility might or might not help you? • Why do you think that it has been suggested that you move into/don’t move into a facility (eg, impact on family, friends, and dependents). 28 28

Determination of Incapability § § § assessor decides if adult is capable or incapable of giving or refusing consent to facility admission determination of incapability to give/refuse consent to facility admission does not result in permanent label of incapability adult still presumed capable of making all other decisions, including health care decisions 29 29

Assessment Report must include § information identifying the client who was assessed; § the name, professional designation of the assessor, the assessor’s regulatory college and registration number; § confirmation that medical information was reviewed, including the client’s relevant diagnoses and prognoses; § the factors that were considered in making the determination of the client’s capability or incapability; 30 30

Assessment Report must include • the conclusions that were reached on the basis of those factors; and • a summary of information gathered from consulting with, or collecting information from, others (including information relied upon if the client refused or was unable to participate in the assessment). • Ministry of Health Assessment form also available: https: //www 2. gov. bc. ca/assets/gov/health/forms/391 0 fil. pdf 31 31

DOCUMENTATION AND NOTIFICATION § assessor advises adult of outcome of assessment (capable/incapable) § assessor provides copies of assessment report to the manager § offers copies to adult and substitute and provides if requested 32 32

Billing implications for MD • No specific code • Significant increased time spent • Unable to bill for capability assessments? • APP funding certainly applies – direct/indirect patient care • MOH is reviewing billing codes and an update is expected 33 33

ASSESSING WITHOUT THE ADULT § if adult refuses to participate, must be informed that assessment may proceed based on other sources § may assess without adult’s participation if assessor believes they can accurately complete assessment using information from observation and other sources § adults should be encouraged to participate at any stage in assessment process, even if initially refused 34 34

SECOND ASSESSMENT § if an adult is determined to be incapable and disagrees with that determination, a second assessment is conducted § the adult is considered incapable only if the second assessment also results in a determination of incapability § if the initial assessment was not conducted by a medical or nurse practitioner 35 35

COURT ORDERS • Can apply for court order: representatives, committees of person, substitutes, or adults assessed as incapable • Can ask the court to order to: Ø have an adult’s incapability assessed Ø decide who is the substitute Ø confirm, reverse, or vary a substitute’s decision Ø give or refuse consent to facility admission on behalf of an incapable adult 36 36

RESTRAINTS § § § Restraint requirements in the Residential Care Regulation Includes admission to a locked facility Part 3 extends these requirements to Hospital Act facilities 37 37

PRACTICE SUPPORT • Practice Guidelines on Seeking Consent For Care Facility Admission, Ministry of Health, 2019 • Consent to Care Facility Admission in British Columbia: A Course for Managers and Assessors, PHSA Learning. Hub, 2019 • Quick Guide To Care Facility Admission, Ministry of Health, 2019 • Care Facility Admission and the Role of the Public 383838 Guardian and Trustee

Ministry of Health Forms • single facility admission consent form • three preferred care homes admission consent form • Assessment • consent to continued residence 393939