Table 10.2: Most Relevant International Residential Care Systems – Canada Mandated Care Auditing of Funding Country Payment level determination Care Classification levels Review of needs funding tool Claims Canada Internal – Facility Assessor Post-entry interRAI – case RUGs-ADL 44 Groupings Facility Assessors Data checks and mix results in audit visits are The Ministry of Health and local health care (Varies Case Mix Design Facility assessors RUGs used to undertaken to assess authority manage waiting lists and determine who across complete the interRAI Yearly adjustments determine the accuracy of the is admitted to a facility. Clients on wait list must provinces) quarterly on each based on historical funding group. RUGs MDS. take first offer (could be 50km away) or go to the resident to determine Example average yearly Casemix bottom of the list. When a place becomes available Algorithms vary care needs. Facility case based on index. at a facility nearer their home/family, a further across provinces. managers need to Ontario. The funding groupings ADLs are the biggest move can be approved. There are significant issues account for claims for each quarter are driver of funding. regarding the waiting times. The median waiting and accuracy. then averaged time is around 4 months, while those in hospital Therapy minutes based annually, to determine Penalties apply for needing placement wait around 3 months. on care provided, not the Casemix average inaccurate claiming Getting timely access to residential care has outcomes. or index (CMI). The patterns. become a system issue which is being addressed by funding is then related Therapy question under a new ‘home first’ program. to the variations in review due to inability to resident care needs RUGs groupings result from the case mix audit and lack of linkage and by implication classification system. The groups are determined by to outcomes. resources, via these the coding of specific interRAI MDS items related to updated groupings. the intensity of assistance the resident received with ADLs plus selected treatments, health conditions, diagnoses, behaviour and cognitive status. While the Aged Care Provider determines their overall funding post-entry via regular individual resident RUGs ADL determinations, the provider is not paid on a resident by resident basis. Payment is based on an annualised Casemix average (case mix index – CMI).
Table 10.2: Most Relevant International Residential Care Systems – Canada Country Payment level determination Mandated Care funding tool Care Classification levels Review of needs Auditing of Funding Claims Canada (Varies across provinces) Example based on Ontario. Internal – Facility Assessor Post-entry The Ministry of Health and local health care authority manage waiting lists and determine who is admitted to a facility. Clients on wait list must take first offer (could be 50km away) or go to the bottom of the list. When a place becomes available at a facility nearer their home/family, a further move can be approved. There are significant issues regarding the waiting times. The median waiting time is around 4 months, while those in hospital needing placement wait around 3 months. Getting timely access to residential care has become a system issue which is being addressed by a new ‘home first’ program. RUGs groupings result from the case mix classification system. The groups are determined by the coding of specific interRAI MDS items related to the intensity of assistance the resident received with ADLs plus selected treatments, health conditions, diagnoses, behaviour and cognitive status. While the Aged Care Provider determines their overall funding post-entry via regular individual resident RUGs ADL determinations, the provider is not paid on a resident by resident basis. Payment is based on an annualised Casemix average (case mix index – CMI). interRAI – case mix results in RUGs used to determine funding group. Algorithms vary across provinces. RUGs-ADL 44 Groupings Case Mix Design Yearly adjustments based on historical average yearly Casemix index. ADLs are the biggest driver of funding. Therapy minutes based on care provided, not outcomes. Therapy question under review due to inability to audit and lack of linkage to outcomes. Facility Assessors Facility assessors complete the interRAI quarterly on each resident to determine care needs. The funding groupings for each quarter are then averaged annually, to determine the Casemix average or index (CMI). The funding is then related to the variations in resident care needs and by implication resources, via these updated groupings. Data checks and audit visits are undertaken to assess the accuracy of the RUGs MDS. Facility case managers need to account for claims and accuracy. Penalties apply for inaccurate claiming patterns.
acfi_review_report_part_2_main_report.docx