Senior's Plan of Care in Ontario Retirement Homes - Explained

So, you’ve decided to move into a Retirement Home in 2021. One of the first things you should expect is an assessment of your health and well-being. This assessment outcomes will then be used to develop your Care Plan. 

In this two-minute read, learn about: 

• special requirements when dementia care is delivered,

• Care Plan approval and reassessment; and

• the use of External Care Providers in the development of a Care Plan.

Assessing your care needs

There are a number of types of assessments undertaken, both immediately after you move-in and then another within a prescribed timeframe. These assessments are re-performed semi-annually thereafter.

How are your immediate care needs determined in a Retirement Home?

An initial assessment of your immediate care needs is conducted no later than two days after you move in the Home.

This initial assessment addresses these areas:

• Continence
• Presence of infectious diseases
• Risk of falling
• Known allergies
• Dietary needs including known food restrictions
• Cognitive ability
• Risk of harm to self and to others
• Risk of wandering
• Needs related to drugs and other substances 

The Retirement Home Operator is exempt from the requirement to conduct an initial assessment if:

The Retirement Home Operator, a staff member in the Home or a member of a College, as defined in the Regulated Health Professions Act, 1991, conducts:

• an initial assessment of the resident not more than 30 days before you move into the Home, or
• a full assessment of the resident not more than 30 days before the resident moves into the Home, or
• the Retirement Home Operator or a staff member in the Home conducts a full assessment of the resident not later than two days after the resident moves into the Home. 

When is a full assessment of your care needs performed in a Retirement Home?

A full assessment of your needs and preferences is conducted no later than 14 days after you move into the Home. 

The full assessment addresses these areas:

• Physical and mental health
• Functional capacity
• Cognitive ability
• Behavioural issues
• Need for care services
• Need for assistance with the activities of daily living
• The matters listed for the initial assessment
• Any other matter(s) relevant to developing your plan of care 

If a Retirement Home Operator or a staff member of the Home has reason to believe that your care needs may include dementia care, skin and wound care, or the use of a personal assistance services device, the Retirement Home Operator ensures that the full assessment is:

• conducted by a member of a College, as defined in the Regulated Health Professions Act, 1991; and
• if the resident’s care needs include dementia care, carried out using a clinically appropriate assessment instrument that is specifically designed for the assessment of dementia and related conditions. 

What’s included in a Retirement Home Plan of Care?

Your Plan includes the following:

• the care services that are part of a package of care services that you’re entitled to receive under your agreement with the Retirement Home Operator, whether or not you receive the services;
• the planned care services for the resident that the Retirement Home Operator will provide, including,

the details of the services,

the goals that the services are intended to achieve, and

clear directions to the Retirement Home staff who provide your direct care.

• if you consented to the inclusion of the information in the Plan, the planned care services that you’ll receive from External Care Providers (not Retirement Home Operator) including,

the details of the services, and

the goals that the services are intended to achieve.

• your consent to the Retirement Home Operator to collect information from external care providers, to use such information and to disclose the contents of the Plan to external care providers and others.

Retirement Home Operator ensures the Plan is based on your assessment and your needs and preferences:  

• any information that is necessary to allow the Retirement Home staff to understand your needs and preferences, including cultural, spiritual and religious preferences and customary routines,
• the names and contact information of your substitute decision-makers, if any,
• the names of the persons who participated in the development of the Care Plan; and
• whether you and your substitute decision-makers, if any, participated in the development of the Care Plan; and
• the Care Plan was approved appropriately by a person with the requisite expertise in assessing the suitability of care services set out in the Plan.

What happens if you need dementia care, skin and wound care or use a personal assistance services?

If your assessment indicates that your care needs include dementia care, skin and wound care or the use of a personal assistance services device, your Care Plan receives additional attention and coordination to ensure services are effectively delivered:

• In order to deliver and coordinate your care services, Retirement Home Operator is required to convene an interdisciplinary care conference as part of the development of your Care Plan; and
• your Plan should take into account the results of this care conference. 

Can you participate in the interdisciplinary care conference where your Care Plan is developed?

The Retirement Home Operator ensures that you, your substitute decision-maker, if any, and any other person designated by you or your substitute decision-maker like an External Service Provider are given an opportunity to participate in the interdisciplinary care conference.

Who approves your Care Plan if it involves dementia care, skin and wound care or use of personal assistance services?

If your assessment indicates that your care needs include dementia care, skin and wound care or the use of a personal assistance services device, your Care Plan is mandated to be approved by a member of the College of Physicians and Surgeons of Ontario or the College of Nurses of Ontario. 

Who approves your Care Plan?

Retirement Home Operator ensures that you, your substitute decision-maker, if any, and any other persons designated by you or your substitute decision-maker are given an opportunity to participate in the development, implementation and reviews of the Plan. 

Retirement Home Operator makes sure the Plan is approved, including any revisions to it, and that a copy is provided as follows:

• You or your substitute decision-maker if any.
• A person with the requisite expertise in assessing the suitability of care services set out in the Plan. 
• This means the Plan is approved by: a member of the College of Physicians and Surgeons of Ontario or the College of Nurses of Ontario; or
• a person acting under the supervision of a member of these people (Note: only if your Care Plan does not include dementia care, skin and wound care or use of personal assistance services)

When is your Care Plan Reassessed?

Its critical your Plan of Care is reviewed and updated regularly. But how often? And when should other housing options (like Long-Term Care Homes) should be discussed with you.

How often is the plan of care reassessed?

The Retirement Home Operator ensures that you're reassessed, and your Care Plan reviewed and revised at least every six months and at any other time if, in your opinion or the opinion of the Retirement Home Operator,

• a goal in the Plan is met;
• your care needs change or the care services set out in the Plan are no longer necessary; or
•  the care services set out in the Plan have not been effective. 

How do you learn about your alternative senior housing options?

Pro Tip: It’s important for you and your advisors to understand available options for your continued care, if it’s not within the existing Retirement Home. You may be eligible to move into a LTC home. Many Retirement Home residents are also on waitlists for LTC homes.

If an assessment indicates that you meet one or more of criteria, the Retirement Home Operator will,

• provide the resident or the resident’s substitute decision-maker with information about other alternatives to living in the Home and information about admission to a long-term care home; and
• if the resident or the resident’s substitute decision-maker so requests, contact the Local Health Integration Network (LHIN) placement coordinator for the purpose of providing you and your advisors with information about alternatives to living in the Retirement Home.

The Retirement Home Operator will provide you with information about alternatives to living in the Home if:

• your assessment indicates that you may be eligible for admission to a Long-Term Care home; or
• your care needs cannot be met at the Retirement Home. 

When Can You Use of External Care Provider to Assist with Your Assessment and Care Plan Development?

Did you know you can involve External Care Providers to assist with your assessment and Plan of Care? Once you’ve decided to move into a Retirement Home, you can advise the Retirement Home Operator that you want to have your assessment done by a third party. 

The Retirement Home Operator will facilitate your access to the External Care Provider. 

Pro Tip: You have the right to apply for publicly funded care services and assessments. And the right to be informed about and to apply for care services and assessments from an external care provider. These are two of the Resident’s Bill of Rights. Watch the video that covers this topic.

The Retirement Home Operator will ensure that there are protocols to promote the collaboration between the Retirement Home staff, External Care Providers and others involved in the different aspects of your care. Specifically:

• assessments are integrated and are consistent with and complement each other; and
• in the development and implementation of the Care Plan, different aspects of care are integrated and are consistent with and complement each other. 

Can a Retirement Home Resident use the services provided by External Care Provider?

If you request information about the services of an External Care Provider, the Retirement Home Operator will provide you with this information.

And if an assessment indicates you need care services that the Home is not able to provide, the Retirement Home Operator will provide you with information and that will enable you to obtain those services from an External Care Provider.