Introduction

This policy outlines the terms and conditions under which Home and Community Care Support Services (previously the Local Health Integration Networks) fund identified long-term care home licensees for attending nurse practitioner positions under the Attending Nurse Practitioners in Long-Term Care Homes Initiative.

This policy applies only to licensees that have been identified by their Ontario Health regions or Home and Community Care Support Services as selected for implementation of the attending nurse practitioner role in their long-term care home.

The Attending Nurse Practitioners in Long-Term Care Homes Initiative is separate and distinct from the Nurse Practitioner in Long-Term Care Home Project. The Nurse Practitioner in Long-Term Care Home Project is governed by the Direct Funding Agreement between the Ministry of Health and the long-term care home licensees.

Funding for the attending nurse practitioner positions created through the Attending Nurse Practitioners in Long-Term Care Homes Initiative is new funding and is not intended to replace existing nurse practitioner resources in the long-term care home.

Funding approach

Every long-term care home that is eligible for this funding will receive $114,340 in salary and benefits and $8,513 in overhead (see Appendix B for further information) per attending nurse practitioner full-time equivalent (FTE).

Benefits for the attending nurse practitioner FTE are not to exceed 24% of the $114,340 figure. Funding will be prorated in the first year that a long-term care home participates in this initiative.

How funding works

Funding for the attending nurse practitioner FTE will be reconciled and recovered through a separate line in section I of the Long-Term Care Home Annual Report in accordance with the terms and conditions identified in this policy and in the LTCH Reconciliation and Recovery Policy.

The licensee’s actual eligible costs for retaining attending nurse practitioner services for the long-term care home will be reconciled against the licensee’s annual allocation for the calendar year under each category of the initiative in respect of the long-term care home. Any unused funding shall be recovered by the Ministry of Health on behalf of Home and Community Care Support Services.

Costs eligible for funding under the Attending Nurse Practitioners in Long-Term Care Homes Initiative fall into the following three categories:

  • salary
  • benefits
  • total overhead costs necessary for the provision of the attending nurse practitioner services

Attending Nurse Practitioners in Long-Term Care Homes Initiative funding will be reconciled and recovered in accordance with the LTCH Reconciliation and Recovery Policy (PDF) and the additional terms and conditions outlined below. Despite any other ministry long-term care funding policy, the Attending Nurse Practitioners in Long-Term Care Homes Initiative funding reported within section I of the Long-Term Care Home Annual Report is protected and cannot be reallocated toward any other expenditures in the nursing and personal care (NPC), program and support services (PSS), raw food (RF) and other accommodation (OA) envelopes.

Terms and conditions of funding

  1. Licensees will undertake all activities in compliance with all applicable legislation, including:
  2. An eligible licensee will receive $114,340 in salary and benefits and $8,513 in overhead per attending nurse practitioner FTE annually or a prorated amount for any funding provided for less than a year. The following conditions apply to the funding within each of the categories of salary, benefits and overhead:
    • a maximum of 24% of the $114,340 provided for salary and benefits or a prorated amount for any funding provided for less than a year, may be spent on benefits. The amount that is not spent on benefits may be used for salary
    • the $8,513 provided for overhead or a prorated amount for any funding provided for less than a year can only be spent in accordance with Appendix B. Expenditures for overhead must comply with the Travel, Meal and Hospitality Expenses Directive
    • unspent funds in each category of salary and benefits and overhead cannot be used in another category
    • funding in each category will be reconciled in accordance with this policy and the LTCH Reconciliation and Recovery Policy (PDF). Unspent funds in each category will be recovered by the Ministry of Health on behalf of the Home and Community Care Support Services
  3. Attending Nurse Practitioners in Long-Term Care Homes Initiative funding can only be used for:
    • the creation or secondment of an attending nurse practitioner FTE at the long-term care home and any and all partnering long-term care homes that are sharing the position
    • the attending nurse practitioner to carry out the role as described in the attending nurse practitioners in long-term care homes role description and in accordance with the accountabilities described in the attending nurse practitioner in long-term care home role description (see Appendix A)
    • overhead costs that adhere to the eligible overhead expenditures (see Appendix B)
  4. Eligible licensees will use this funding to hire an attending nurse practitioner FTE in accordance with the terms and conditions set out in this policy and any additional terms and conditions identified by Home and Community Care Support Services. Licensees cannot use funds targeted for attending nurse practitioners for any other purpose, including:
    • to “top-up” existing salaries
    • to hire additional health care personnel
    • to support other nursing positions or additional health care personnel

    The licensee is also permitted to use the funding to enter into a secondment arrangement with another health service organization (such as, primary health care organization or Home and Community Care Support Services provider) for the services of an attending nurse practitioner. This secondment arrangement must be supported by an agreement between the parties (such as, licensee, seconding organization and attending nurse practitioner).

  5. Long-term care homes in close proximity to one another may share a full-time attending nurse practitioner to ensure efficient use of the nurse practitioner’s time if it is safe to do so. Long-term care homes will be required to comply with all applicable statutes and regulations governing long-term care homes including Ontario Regulations 146/20 (limiting work to a single long-term care homes) and Ontario Regulations 77/20 (work deployment measures in long-term care homes) and made under Reopening Ontario (A Flexible Response to COVID‑19) Act, 2020. Ontario Health regions, Home and Community Care Support Services and long-term care homes must follow the advice of local public health officials.

    In instances where an attending nurse practitioner FTE is shared, the licensee that is funded for the attending nurse practitioner position is accountable to ensure that any and all partnering long-term care homes that are sharing the attending nurse practitioner FTE employ the attending nurse practitioner such that the attending nurse practitioner is engaged in carrying out the role as described in the attending nurse practitioners in long-term care homes role. Description and in accordance with the accountabilities as described in the attending nurse practitioners in long-term care homes role description (see Appendix A).

  6. Licensees who receive funding for the attending nurse practitioner FTE shall ensure that any and all partnering long-term care homes that are sharing the position or organizations participating in a secondment arrangement, must comply with the terms and conditions of this policy and any other Attending Nurse Practitioners in Long-Term Care Homes Initiative requirements such as participating and contributing to activities of the evaluation of the Attending Nurse Practitioners in Long-Term Care Homes Initiative.
  7. Part-time positions

    Licensees receiving a full FTE

    The hiring of two part-time attending nurse practitioners to fill one FTE is permitted with each attending nurse practitioner providing service equivalent to 0.5 FTE if reasonable efforts have been made to recruit a full-time attending nurse practitioner.

    For licensees sharing an FTE

    Two part-time attending nurse practitioners could be hired (such as one by each of the two licensees) with the positions divided according to the approximate ratio of beds between the two licensees.

    For example:

    • Licensee A has 90 beds and Licensee B has 60 beds
    • The FTE would be divided with Licensee A receiving 0.6 FTE and Licensee B receiving 0.4 FTE
    • Both licensees are to consult with their Home and Community Care Support Services team on dividing the FTE

  8. A licensee may, at its discretion, adjust attending nurse practitioner compensation (over and above the $114,340 in salary and benefits provided under this policy) in order to meet requirements of collective agreements or other existing conditions of employment for attending nurse practitioners.

    Overhead may also be adjusted (over and above the $8,513 provided under this policy) in order to support applicable costs directly associated with implementation of this initiative.

    Nothing in this policy precludes the licensee from using level-of-care funds in the nursing and personal care (NPC) envelope to supplement attending nurse practitioner salary and benefits and in the other accommodation (OA) envelope to supplement overhead (as described in Appendix B), additional hiring costs, start-up costs and indirect costs associated with attending nurse practitioner implementation. All NPC and OA expenditures for this purpose must comply with the Eligible Expenditures for Long-Term Care Homes Policy (PDF).

  9. Home and Community Care Support Services may at their discretion provide additional funding for salary and benefits and for applicable overhead costs associated with the Attending Nurse Practitioners in Long-Term Care Homes Initiative within the terms of this policy, with funding from outside the Attending Nurse Practitioners in Long-Term Care Homes Initiative or from other Home and Community Care Support Services and long-term care home funding allocation. Home and Community Care Support Services may set the terms and conditions of the additional funding. The LTCH Reconciliation and Recovery Policy (PDF) will not apply to  this additional funding.
  10. When hiring the attending nurse practitioners, licensees will ensure that the candidate has the required qualifications and give preference to candidates who have the recommended qualifications set out in Appendix A of this policy.
  11. It is recommended that Home and Community Care Support Services and long-term care home consult with the relevant union (for example, the Ontario Nurses’ Association) regarding the hiring of attending nurse practitioners, to obtain the union’s recommendation about implementation from a labour relations perspective.

Reporting requirements

Program reports

The licensee that is funded for the attending nurse practitioner FTE shall track the position, including across all partnering long-term care homes that are sharing the position or seconding organizations and shall submit the following reports to Home and Community Care Support Services, at the following times.

For each year, beginning in 2016:

Interim project report

  • reporting period of January 1 to June 30 of each year
  • report due July 31 of each year
  • interim project report to include:
    • the total number of attending nurse practitioner FTEs created and implemented

Contact Home and Community Care Support Services for further information.

Project report

  • reporting period of January 1 to December 31 of each year
  • report due January 31 of each following year
  • project report to include:
    • the total number of attending nurse practitioner FTEs created and implemented
    • key achievements and activities related to the attending nurse practitioner role
    • the impact of the attending nurse practitioner role on:
      • continuity of care as the most responsible provider
      • increased access to and quality of health care for long-term care home residents
      • creation and implementation of Quality Improvement Plans
      • research and implementation of best practices
      • increased knowledge capacity of staff and programming in the long-term care home(s) to meet the needs of residents
      • improved care coordination and collaboration across the care continuum among health care providers within the long-term care home(s) and in the region

Contact Home and Community Care Support Services for further information.

Long-term care home annual report requirements

The licensee receiving the funding shall send reports to Home and Community Care Support Services who will send reports to the Ministry of Health per the ministry Home and Community Care Support Services Accountability Agreement.

The licensee receiving the funding shall report the use of Attending Nurse Practitioners in Long-Term Care Homes Initiative funding in a separate line in section I in the licensee’s audited Long-Term Care Home Annual Report in accordance with the form and manner set out in the LTCH Reconciliation and Recovery Policy, other applicable policies and the Long-Term Care Home Annual Report Technical Instructions and Guidelines.

The reporting must indicate the breakdown of expenditures under the program by:

  • salary
  • benefits
  • total overhead

The funding provided under each category is independent of each other and not interchangeable. Any unspent funds in each category shall be recovered as part of the reconciliation.

Licensees are to report on attending nurse practitioners in long-term care homes expenditures in the long-term care home annual report on a calendar year as per the LTCH Reconciliation and Recovery Policy.

In the event that funding is not applied as required by this policy, the licensee shall return to Home and Community Care Support Services, upon request, the excess amounts paid or such amounts may be offset against amounts payable by Home and Community Care Support Services to the licensee as per the LTCH Reconciliation and Recovery Policy.

The licensee that is funded for the attending nurse practitioner FTE shall track the position across any and any and all partnering long-term care homes that are sharing the position or organizations providing a secondment and shall report the applicable expenses in its Long-Term Care Home Annual Report.

Home and Community Care Support Services may require additional reporting and tracking requirements with respect to other elements of the Attending Nurse Practitioners in Long-Term Care Homes Initiative.

Long-term care home staffing survey reporting requirements

The licensee must maintain records of new attending nurse practitioner FTEs created with the Attending Nurse Practitioners in Long-Term Care Homes Initiative funding, provide records upon request to Home and Community Care Support Services and provide information to the Ministry of Long-Term Care regarding the increase of new nurse practitioners through the LTCH Staffing Survey.

The licensee that is funded for the attending nurse practitioner FTE shall track the position across all partnering long-term care homes that are sharing the position or organizations providing a secondment.

Definitions

Attending nurse practitioner full-time equivalent (FTE) – a registered nurse in the extended class who holds the position of attending nurse practitioner (NP) in the long-term care home (LTCH) and who works at least 37.5 hours of nursing service per week. However, where the long-term care home has in place a collective agreement that requires the nurse practitioner to work to maximum hours that are less than 37.5 hours per week the nurse practitioner would still meet this definition providing they worked to the maximum hours permitted under the collective agreement. As per this policy, two part-time attending nurse practitioners may fill a FTE but would be required to work a combined total of at least 37.5 hours per week or as specified in the applicable collective agreement.

Ministry of Long-Term Care (ministry) – the ministry is responsible for the stewardship of the provincial implementation of the Attending Nurse Practitioners in Long-Term Care Homes Initiative: facilitating knowledge transfer, reviewing reports, coordinating project evaluation and communication within the ministry.

Licensee – the holder of a license issued under the Long-Term Care Homes Act, 2007. includes the municipality or municipalities or board of management that maintains a municipal home, joint home or First Nations home.

Interim project report – includes the total number of attending nurse practitioner FTEs created and implemented. The licensee submits the report to Home and Community Care Support Services, who then submits the report to the Ministry of Long-Term Care.

Project report – reports the total number of attending nurse practitioner FTEs created and implemented, key achievements and activities related to the attending nurse practitioner role and the impact of the attending nurse practitioner role on:

  • continuity of care as the most responsible provider
  • increased access to and quality of health care for long-term care home residents
  • creation and implementation of quality improvement plans
  • research and implementation of best practices
  • increased knowledge capacity of staff and programming in the long-term care home to meet the needs of residents
  • improved care coordination and collaboration across the care continuum among health care providers within the long-term care home and in the region

The licensee submits the report to the Home and Community Care Support Services, who then submits the report to the Ministry of Long-Term Care.

 

References to other policy documents and technical instructions and guidelines

For further information, please refer to:

Agreements

Policy

Appendix A: Attending nurse practitioners in long-term care homes role description and position summary

The attending nurse practitioner (NP) reports directly to the Director of Nursing and Personal Care or Administrator and is also accountable to the Medical Director for meeting the long-term care home’s (LTCH) policies, procedures and protocols for medical services.

The attending nurse practitioner is a primary care provider to residents and works within her/his legislative scope of practice as described and outlined by the College of Nurses of Ontario. The attending nurse practitioner:

  • collaborates with the resident and family or caregiver and the health care team in the development, implementation and evaluation of the resident’s plan of care
  • provides leadership and mentorship to long-term care home staff that enhances their knowledge, assessment skills and ability to care for residents in place
  • leads and collaborates in research, education and evidence-based practice initiatives to optimize the resident, long-term care home and health system outcomes

The Long-Term Care Homes Act, 2007 defines staff as follows:

  • “staff”, in relation to a long-term care home, means persons who work at the home:
    • as employees of the licensee
  • pursuant to a contract or agreement with the licensee
  • pursuant to a contract or agreement between the licensee and an employment agency or other third party (“personnel”)

Qualifications

To be qualified as a nurse practitioner, an individual must have:

  • current registration with the College of Nurses of Ontario as a registered nurse in the extended class (primary health care or adult) and entitled to practice
  • post-graduate education and experience in gerontology (an asset)
  • specialty certification in gerontological nursing (an asset)
  • post-graduate certificate and experience in palliative care (an asset)

Accountabilities

The nurse practitioner:

  • maintains confidentiality and acts in an ethical manner, consistent with professional expectations, the written agreement between the nurse practitioner and the long-term care home and the long-term care homes policies and code of conduct
  • is a member of the primary care team and seeks appropriate consultation as required
  • engages in ongoing professional development, maintain clinical competence and currency with legislation affecting her/his practicefootnote 1
  • develops in-depth expertise in care of older persons
  • develops in-depth expertise in leadership
  • holds professional liability protection
  • maintains CPR certification designed for health care professionals and standard first-aid

Roles and responsibilities

70% direct care to residents (“attending NP")footnote 2footnote 3

  • provides comprehensive primary care to residents (including substitute decision-makers as appropriate) as part of the interdisciplinary health care team. Interdisciplinary health care team includes unregulated health care professionals.
  • increases continuity of care through collaboration, consultation and referral as appropriate:
    • collaborates and consults with physicians, director of nursing and personal care, nursing staff, interdisciplinary team members and external:
      • resources regarding resident plan of care
    • assists, supports, guides and provides consultation to director of nursing and personal care, nursing staff and interdisciplinary team members regarding challenging clinical situations
    • makes referrals to specialized consultants, services and other health providers
    • accepts referrals from interdisciplinary team members
  • performs a person-centered health assessment of residents on admission, annually and as needed (including quarterly medication reviews)
  • conducts person-centered comprehensive health histories
  • engages with the resident in regular dialogue about their care plan
  • participates in regular care conferences
  • orders or performs appropriate screening and diagnostic investigations, interpreting results and assuming responsibility for follow-up
  • diagnoses acute and chronic health conditions
  • manages the care of residents by providing pharmacological, complementary or counselling interventions and performs procedures within the nurse practitioner scope of practice
  • advocates for and provides palliative and end-of-life care
  • documents clinical data, assessment findings, diagnoses, plans of care, therapeutic interventions, resident responses and clinical rationale in a timely and accurate manner
  • utilizes communication and counselling skills:
    • engages residents in dialogue to determine what is important to them for health and quality of life
    • provides person-focused health education
  • collaborates with the resident to develop a person-centered plan of care
  • provides outreach and transitional services to long-term care home residents who return to the community
  • liaises with discharge planning services for hospitalized residents to ensure a smooth transition back to the long-term care home. Participates in providing after hours and on-call coverage in accordance with the on-call policy of the long-term care home

30% research, education and leadership

  • participates in creating an organizational environment that supports the safety and quality of resident care and life, collaborative practice and professional growth
  • participates in internal (for example, professional advisory committees, quality committees) and external committees
  • identifies, develops and implements practice innovations in collaboration with the long-term care home’s senior leadership team
  • provides leadership and involves the interdisciplinary team in quality improvement initiatives
  • provides leadership in developing and implementing strategies to optimize the integration of illness and injury prevention, health promotion, health maintenance, rehabilitation and restorative care activities
  • participates with the senior leadership team in program planning to meet the needs of short and long-term residents and of residents of varying age groups
  • teaching and coaching:
    • provides formal and informal teaching and coaching in the management of clinical care to interdisciplinary team members, serving as resource person, educator and role model and contributes to the performance appraisals of registered nursing staff
    • participates in identifying, analyzing and interpreting trends in resident care outcomes and professional nursing practice issues to determine priorities for educational programming
    • contributes to planning, implementing and evaluating learning resources and health education programs for residents, families and substitute decision makers
    • promotes knowledge development of clinical staff by integrating best practices in resident carefootnote 4
  • research:footnote 5
    • engages in evidence-informed practice by critically appraising and applying relevant research and theory in providing health-care services
    • identifies and implements research-based innovations for improving resident care
    • collaborates with members of the interdisciplinary team or community to identify research opportunities and to conduct or support research
    • acts as a change agent through knowledge translation and dissemination of new knowledge that may include formal presentations, publications, informal discussions, the development of best practices, policies and procedures

Appendix B: Eligible expenses for overhead budget

All expenditures must be directly related to the attending nurse practitioner full-time equivalent.

General overhead

IT and IT resources

  • anti-virus software
  • software, software upgrades or repairs
  • hardware rentals or purchase, such as laptop, tablet or desktop, cell phone or personal digital assistant (PDA)

Medical equipment

  • equipment must be otherwise not readily available to the attending nurse practitioner
  • equipment must be purchased in consultation with the attending nurse practitioner
  • equipment must be specific to nurse practitioner scope of practice and for the attending nurse practitioner’s exclusive use
  • does not include medical or nursing supplies

Committee and team meeting expenses (no hospitality)

Communication materials

  • brochures
  • translation services
  • patient education supplies

Library materials and subscriptions

  • library materials and subscriptions according to the needs and in consultation with the attending nurse practitioner

Office supplies

  • computer and copy supplies
  • stationary
  • photocopying and printing
  • postage and courier

Telephone

  • local and long-distance charges for land, cellular or personal digital assistant (PDA)
  • data charges for cellular, tablet or PDA

Travel for clinical services only

Recruitment

  • advertising
  • recruitment
  • recruitment consultation

Professional development