Behavioural Supports Ontario: Funding terms and conditions — effective until March 31, 2024

Introduction

This policy outlines the terms and conditions under which Ontario Health (OH) funds identified Long-Term Care Home licensees, primarily for staffing positions, under Behavioural Supports Ontario (BSO). The policy applies only to long-term care home licensees that have been identified by their OH-approved BSO Action Plan (sometimes referred to as a BSO Implementation Plan) as requiring specialized staffing resources to provide a range of behaviour supports in their long-term care homes.

Definitions

BSO action plan — Developed by OH, these documents (also referred to as BSO Implementation Plans) describe the details of regional allocation of ministry BSO funding supports. Using the action plan template provided by the Ministry of Long-Term Care (ministry), OH identifies which health service providers, including long-term care home licensees, receive ministry BSO funding, how much, and for what specific purposes. From time to time, based on local circumstances, updates to these plans may be made. If so OH will describe what will change, when, and how as a result of BSO funding.

The Licensee — The holder of a licence issued under the Fixing Long-Term Care Act, 2021, including the municipality or municipalities or board of management that maintains a municipal home, joint home or First Nations home approved under Part VIII of the Fixing Long-Term Care Act, 2021.

Non-level of care funding — Supplementary funding streams, each with distinct terms and conditions, provided to qualifying licensees and excluding the Level of Care Per Diem funding. Although some supplementary funding may be distributed among the envelopes as set out in the terms and conditions of funding, it does not form part of the Level of Care Per Diems. Non-Level of Care funding may be paid to a licensee by OH through a Service Accountability Agreement or by the ministry through a Direct Funding Agreement. Non-Level of Care Funding initiatives may be amended, terminated or initiated from time to time as the result of changes to policies that provide the specific rules in respect of each form of funding.

Behavioural Supports Ontario Activity Tracker — Data collection form that captures the volume and description of BSO service provision, including, but not limited to, number of accepted BSO referrals, BSO caseloads, transitions supported, etc. Quantitative and qualitative activity tracker data from each long-term care licensee is collected and submitted to regional BSO leads and OH on a quarterly basis where it is reviewed and submitted to the BSO Provincial Coordinating Office (PCO). It is the responsibility of the BSO PCO to review and collate BSO activity tracker data from across the province and submit this data to the ministry on a quarterly basis.

Funding Approach

Identified long-term care home licensees will receive funding for some or all of the following staffing resources based on the OH-approved BSO Action Plan and as described in OH BSO funding letter to the long-term care home licensee:

• Registered Nurses (RN) and Registered Practical Nurses (RPN)
• Personal Support Workers (PSW)
• Other healthcare personnel. These healthcare personnel may include, but are not limited to, occupational therapists, social workers, behavioural therapists, recreation therapists, and physicians^{footnote 1[1]}

A portion of the BSO funding may be used for staff training and purchase of therapeutic equipment and supplies.

How Funding Works

Ontario Health completes a BSO Action Plan that articulates the local approach to serve people who need behaviour supports within a regional geographic area. During the development of the local BSO Action Plan, OH will consult with local healthcare providers across the continuum of care, including a cross-section of long-term care home licensees, to prioritize service enhancements for this population. Long-term care home licensee participation in OH process is vital to the development of an effective BSO Action Plan.

The BSO Action Plan must comply with the terms and conditions required by the ministry and is the basis from which OH directs some or all of the ministry BSO funding for staffing resources and BSO related matters set out in terms and conditions of funding section that are targeted toward behavioural services for the BSO population (as defined in Appendix B) among the identified long-term care home licensees. Once finalized by OH, the OH approved BSO Action Plan shall set the annual funding commitment for BSO resources.

Notwithstanding the ongoing funding allocation, the OH-approved BSO Action Plan may be reviewed and revised from time to time, depending on local circumstances. If the OH-approved BSO Action Plan is revised, OH has the discretion to do any of the following:

• Adjust the funding of any long-term care home licensee identified in the BSO Action Plan.
• Cease the funding of any long-term care home licensee identified in the BSO Action Plan.
• Start the funding of any long-term care home licensee identified in the BSO Action Plan.

Funding only applies to long-term care home licensees that have been identified in the OH-approved BSO Action Plan, as communicated by OH to the licensee via communication letters that stipulate specific funding terms and conditions, including maximum funding amounts and their specific purpose. Long-term care home licensees will use this funding to hire RNs, RPNs, PSWs, and/or other healthcare personnel, and to purchase other BSO-related goods and services, in accordance with the terms and conditions set out in this policy, any additional terms and conditions identified by OH and as identified in the OH-approved BSO Action Plan.

Long-term care home licensees cannot use ministry BSO funds such that the use differs from the OH-approved BSO Action Plan.

Terms and conditions of funding

The ministry Behavioural Supports Ontario funding is defined as ongoing or base funding

Funding for RN, RPN, and PSW staffing resources will be reconciled and, if necessary, recovered through a separate line in the Nursing and Personal Care (NPC) envelope. This includes BSO funding used to hire RNs, RPNs, and PSWs in accordance with the terms and conditions identified by OH in the BSO funding letter to the licensee. In addition, the terms and conditions set out in terms and conditioning and reporting requirements will be considered as part of the reconciliation process for the BSO staffing resources funding.

Funding for other healthcare personnel (such as occupational therapists, behaviour management therapists, social workers), other than RNs, RPNs, and PSWs, will be reconciled and, if necessary, recovered through a separate line in the Program and Support Services (PSS) envelope. The terms and conditions outlined in sections this section and reporting requirements below will be considered as part of the reconciliation process for the BSO staffing resources funding.

Ministry BSO funding will be reconciled and recovered in accordance with the LTCH Reconciliation and Recovery Policy and the additional terms and conditions outlined below.

Behavioural Supports Ontario funding used to hire RNs, RPNs and PSWs is subject to the terms and conditions and the definitions applicable to the NPC envelope as set out in the Eligible Expenditures for Long-Term Care Homes Policy. Behavioural Supports Ontario funding used for other healthcare personnel, other than RNs, RPNs and PSWs is subject to the terms, conditions and definitions applicable to the PSS envelope as set out in the Eligible Expenditures for Long-Term Care Homes Policy.

Long-term care home licensees who receive funding for BSO staffing resources must comply with OH-approved BSO Action Plan, the terms and conditions set out in OH’s BSO funding letter to the licensee, this policy, and other BSO requirements, such as the BSO Framework of Care referred to in Appendix B. Long-term care home licensees will undertake all activities in compliance with all applicable legislation, including the Fixing Long-Term Care Act, 2021 and Ontario Regulation 246/22 under that legislation.

Behavioural Supports Ontario funding can only be used for:

• salaries and benefits of BSO staffing resources, including backfill for BSO staffing resources attending training
• training of long-term care staff who provide supports and services for residents with complex and responsive behaviours associated with dementia or other neurological conditions to ensure all staff have the recommended core competencies as set out in Appendix A
• acquiring eligible therapeutic equipment and supplies that support the delivery of BSO non-pharmacological interventions, which include but are not limited to, equipment and supply items that support the delivery of BSO-related art therapy, doll therapy, music therapy, reminiscence therapy, horticultural therapy, virtual simulation therapy. This can also include, equipment and supplies used to implement BSO-related creative environmental design modifications and applicable BSO-related technological equipment (for example, therapeutic robots), but do not include general recreation supplies for the home 
• except as set out above, the BSO funding cannot be used to support other non-salary costs relating to RNs, RPNs, PSWs, and other healthcare personnel

Despite any other long-term care home funding policy, the BSO funding reported within the NPC and PSS envelopes is protected and cannot be reallocated toward any other expenditures in the NPC, PSS, or Nutritional Supplement envelopes.

Nothing in this policy precludes the long-term care home licensee from using Level of Care funds in the NPC and PSS envelopes to supplement BSO expenditures including for the salary, benefits, and additional hiring costs of BSO staffing resources, as well as start-up and indirect costs associated with BSO. All NPC and PSS expenditures for this purpose must comply with the Eligible Expenditures for Long-Term Care Homes Policy.

Subject to applicable policy and the Ministry-OH Accountability Agreement, OH may provide long-term care home licensees with funding from outside the ministry’s BSO allocation to supplement BSO staffing salaries as well as any additional indirect and start-up costs associated with BSO. Ontario Health may set the terms and conditions of this additional funding. The LTCH Reconciliation and Recovery Policy will not apply to this additional OH funding.

When hiring BSO staff, long-term care home licensees will give preference to persons who have the recommended core competencies set out in Appendix A of this policy. The long-term care home licensee will ensure BSO-related training is provided if newly hired staff do not possess the recommended core competencies. All new staff will receive formalized training to facilitate uptake of BSO care pathways and tools.

If a long-term care home licensee receives new funding for additional BSO staff, the baseline hours of nursing and personal support services, funded provincially through OH, must increase to reflect any additional nursing or personal support services funded through BSO. Long-term care home licensees must also document and maintain baseline nursing or personal support staffing levels that are funded provincially through OH and which are outside BSO funding.

If a long-term care home licensee receives new funding for additional BSO staff, that funding is provided for BSO staffing resources to ensure that each identified long-term care home licensee increases its staffing capacity by the specific number articulated in OH BSO funding letter to the licensee.

Behavioural Supports Ontario staff hired by long-term care home licensees will:

• provide direct care, both in-person and virtual, services (for example conduct assessments, prepare behavioural care plans, deliver therapies to prevent or alleviate responsive behaviours) to the BSO target population within long-term care homes, as identified in Appendix A
• train or advise long-term care home staff in behavioural service delivery and act as mentors and coaches to caregivers within a resident’s circle of care
• use provincial BSO standardized care practices, protocols, tools, and any other approaches within their respective scope of practice
• link to system-wide resources for managing individuals with, or at risk for, responsive behaviours by collaborating with other service providers (for example Nurse-Led Outreach Teams or Baycrest Virtual Behaviour Medicine program) for the development and implementation of a plan of care that addresses an individual’s challenging and complex behaviours and stabilizes them in their care setting
• maintain communication and collaboration among long-term care homes and other health service providers to facilitate partnerships, knowledge transfer, the spread of best practices, and otherwise enhance the behavioural support services available throughout Ontario participate in relevant BSO PCO collaboratives and other working groups

Any funding spent on training will contribute to capacity building that:

• advances long-term care direct care staff competencies to ensure that staff have the recommended core competencies set out in Appendix A
• improves the quality of care provided to the BSO target population in long-term care

Long-term care licensees are encouraged to work with the BSO PCO as well as OH and Home and Community Care Support Services (HCCSS) for idea generation with selecting available education tools which take into consideration staff-specific training needs and readiness that support the translation of new knowledge into practice.

Long-term care licensees must comply with organization specific procurement policies in acquiring any goods or services related to training and development programs and services allowable with this funding.

Any funding spent for the purchase of therapeutic equipment and supplies:

• Is in that BSO services play a significant role in the implementation of non-pharmacological strategies with the goal of preventing or reducing the prevalence of responsive behaviours. These strategies are guided by the principles of several evidence-based programs including P.I.E.C.E.S., GPA, U-FIRST, and DementiAbility.
• Include items that support the delivery of BSO non-pharmacological interventions and therefore can include, but are not limited to, art therapy, doll therapy, music therapy, reminiscence therapy, horticultural therapy, virtual simulation. Other examples are creative environmental design modifications and applicable technological equipment (such as therapeutic robots). This funding flexibility does not include the purchasing of general recreation supplies for the home.

The ministry encourages long-term care home licensees to engage the BSO PCO for further consultation and idea generation regarding the clinical applicability of specific therapeutic resources. long-term care licensees can also seek advice from OH and regional HCCSS.

Long-term care licensees must comply with organization specific procurement policies in acquiring any goods or services related to purchase of equipment and supplies allowable with this funding.

Reporting requirements

Long-term care homes annual report requirements

The long-term care home Annual Report submission referred to in this section is the on the use of funds that must be reported in an audited long-term care home annual report for a defined 12-month period in the form and manner set out in the LTCH Reconciliation and Recovery Policy, other applicable policies, and the LTCH Annual Report Technical Instructions and Guidelines.

Reporting of all BSO staffing expenditures must be made on separate lines of the long-term care home  annual report, by staffing category (specifically, RN and RPN, PSW, and Other Healthcare Personnel). Reporting of equipment and supplies, and training-related expenditures must be made on separate lines of the LTCH Annual Report, under NPC or PSS (specifically Training Activity and Therapeutic Equipment and Supplies). The total funding allocated for training, equipment and supplies will be pro-rated and reconciled based on the related expenditures reported in the NPC and PSS envelopes.

Recovery of unused funds is based on the allocation of funding described in OH BSO funding letter to the licensee. The BSO funding letter will identify the allocation of funding applicable from April 1 to December 31 and from January 1 to March 31.

Although BSO funding is recovered and reconciled through the NPC and PSS funding envelopes, this funding is not part of the Level-of-Care per Diem (specifically, it is Non-Level of Care funding).

In the event that any amount of BSO funding is not applied as required by the Behavioural Supports Ontario Staffing Resources Policy, the licensee shall return to OH, upon request, such amounts may be set off against amounts payable by OH to the licensee, as per the LTCH Reconciliation and Recovery Policy.

Where valid partnership agreements are in place that permit the delivery of nursing, personal support or additional BSO healthcare services to residents in more than one long-term care home, the long-term care home licensee who has hired the particular BSO staff person and received the funding for that staff position shall report the applicable expenses in its long-term care home annual report. All long-term care home licensees are accountable for ensuring that all requirements relating to staffing resources are met.

Should the long-term care home licensee receive additional funding from OH for staffing resources as well as indirect and start-up costs associated with BSO in accordance with above stipulations, the licensee shall report on this funding to OH in accordance with the reporting requirements set by OH. These reporting requirements include, but are not limited to, quarterly reporting requirements for the completion of the BSO Activity Tracker or other prescribed reporting mechanism.

Long-term care home licensees may sign an agreement with OH which may contain additional reporting and tracking requirements with respect to other elements of BSO.

Quarterly Behavioural Supports Ontario activity tracker

The long-term care home licensee must participate in the collection and submission of data for the BSO Activity Tracker. This includes the collection of referrals to BSO, BSO caseloads, supported transitions and all other metrics requested by the ministry, Ontario Health, and the BSO Provincial Coordinating Office. Long-term care home licensees must make mechanisms available to BSO staff to collect and report this data on a quarterly basis through tracking sheets or dedicated computers.

Where valid partnership agreements are in place that permit the delivery of RN, RPN, PSW, and/or Other Healthcare Personnel services to residents in more than one long-term care home, the long-term care home licensee that is funded for the RN, RPN, PSW, and/or Other Healthcare Personnel positions shall track these positions for survey reporting requirements across all partnering long-term care homes who are sharing the RN, RPN and/or PSW position.

References to other policy documents and technical instructions and guidelines

For further information, please refer to:

• Agreements
  • Long-Term Care Homes Service Accountability Agreement
• Policies
  • LTCH Reconciliation and Recovery Policy
  • LTCH Level-of-Care per Diem, Occupancy and Acuity-Adjustment Funding Policy
  • LTCH Cash Flow Policy
  • Eligible Expenditures for Long-Term Care Homes Policy
  • LTCH Annual Report, Technical Instructions and Guidelines^{footnote 2[2]}

Appendix A: Recommended core competencies for working with behaviourally complex population

The following recommended core competencies have been developed by the BSO Provincial Coordinating Office. For further information call 1-855-276-6313 or write to provincialbso@nbrhc.on.ca.

Person and family-centred care

Delivers person and family-centred care, supported by evidence-informed clinical best practices, which recognize both the uniqueness of each person and an awareness of one’s own contribution to that relationship, including personal attitudes, values and actions. This includes:

• contributing to the delivery of the person and family-centred philosophy of care
• acknowledging that the person, the family and care partners all bring expertise and experience to the authentic relationship
• involving the person and family as part of the care team and ensuring that care reflects the person and family’s values, preferences and expressed needs and goals
• ensuring that information and care plans are actively updated and shared with individuals and families using appropriate and accessible methods
• preserving and promoting the abilities, self-esteem and dignity of the person
• considering components of safety, risk and quality of life
• protecting and advocating for the person and family’s rights
• demonstrating compassion, empathy, respect for diversity and cross-cultural awareness
• exhibiting effectiveness as an interprofessional team member through collaboration and cooperation in interacting with the person, their families and other partners in care and ensuring that care is continuous and reliable
• utilizing communication strategies that demonstrate compassion, validate emotions, support dignity, and promote understanding

Knowledge

Within respective scope of practice, demonstrates knowledge of dementia, complex mental health, substance use disorders and neurological conditions and their impact on the person, their family members and other care partners (for example health care professionals, front-line staff). This includes a fundamental understanding of:

• the importance of perspectives of lived experience from the person and their family members
• types of conditions and causes
• cognitive, neurological and behavioural symptoms
• assessment and diagnostic processes
• stages and progression of conditions
• current treatment interventions and approaches
• emerging and best non-pharmacological strategies and practices to promote optimal quality of life
• environmental factors associated with responsive behaviours and personal expressions
• the Fixing Long-Term Care Act, 2021 and other applicable regulations and legislation relevant to the scope of practice

Assessment, care approaches & capacity building

Within respective scope of practice, conducts and/or contributes to a thorough assessment and recommends, implements and evaluates therapeutic interventions and approaches with respect to the expressed behaviours. This includes:

• recognizing that behaviours have meaning and therefore, looking for contributing factors is an essential part of the assessment and care planning process
• assessing the meaning, contributing factors and associated risks of behaviours using an objective, systematic and wholistic process that takes the individual’s personhood into account in addition to the physical, intellectual, emotional and functional capabilities of the person; as well as the environmental and social aspects of their surroundings
• identifying non-pharmacological strategies that are abilities focused and person-centred to prevent and respond to expressed behaviours, including recommendations to mitigate associated risks
• collaborating with the person, their family and interprofessional team members to create, share, implement and model an individualized behavioural care plan
• analyzing and evaluating the ongoing effectiveness of the implemented plan including thorough communication of next steps, suggestions for adherence and thorough follow-up
• providing facilitation, coaching, mentoring and demonstrating team leadership and change management skills
• demonstrating excellent clinical reasoning and critical thinking skills that target prevention of the expressed responsive behaviours by creatively adjusting the social and physical environment; focusing on the person’s abilities and knowing the individual, their life story and aspirations

References

Cabrera, E., Sutcliffe, C., Verbeek, H., Saks, K., Soto-Martin, M., Meyer, G., Leino-Kilpi, H., Karlsson, S., Zabalegui, A., & On behalf of the RightTimePlaceCare Consortium (2015). Non-pharmacological interventions as a best practice strategy in people with dementia living in nursing homes. A systematic review. European Geriatric Medicine, 6(2), 134-150.

Legere, L. E., McNeill, S., Schindel Martin, L., Acorn, M., & An, D. (2018). Nonpharmacological approaches for behavioural and psychological symptoms of dementia in older adults: A systematic review of reviews. Journal of Clinical Nursing, 27(7-8), e1360-e1376.

Registered Nurses’ Association of Ontario (2016). Delirium, dementia, and depression in older adults: assessment and care. Second Edition. Retrieved from: https://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression.

Appendix B: Behavioural Supports Ontario target population and Behavioural Supports Ontario framework of care

Behavioural Supports Ontario target population

The BSO initiative was implemented within the BSO Framework to transform health care system design for older Ontarians with, or at risk of, responsive behaviours and personal expressions associated with dementia, complex mental health, substance use and other neurological conditions. The initiative facilitates seamless, interdisciplinary, intersectoral care for individuals as well as their professional and family^{footnote 3[3]} care partners.

Behavioural Supports Ontario framework of care

Behavioural Supports Ontario’s framework is modeled under three provincial pillars

Pillar 1: System Coordination and Management

Pillar 2: Integrated Service Delivery - Intersectoral and Interdisciplinary

Pillar 3: Knowledgeable Care Team and Capacity Building

Behavioural Supports Ontario principles

BSO is rooted in person, family, and relationship-centred care and is guided by seven value-based principles.

Behaviour is communication - Responsive behaviours and personal expressions can be minimized by understanding the person and adapting the environment or care to better meet the individual’s unmet needs. Behaviours are not meaningless; they are an attempt to express distress, problem-solve or communicate unmet needs.

• Respect
  • All persons are treated with respect and accepted as they are. Respect and trust characterize the relationships between clinicians and the individuals and family care partners, and between providers across systems.
• Diversity
  • Practices value the language, ethnicity, race, religion, gender, beliefs, traditions, and life experiences of the people being served.
• Collaborative care
  • Accessible, comprehensive assessment and intervention require an interdisciplinary approach that includes professionals from different disciplines, as well as the individuals and family care partners, to cooperatively create a joint, single plan of care.
• Safety
  • The creation of a culture of safety and well-being is promoted where older adults and families live and visit and where staff work.
• System coordination & integration
  • Systems are built upon existing resources and initiatives and encourage the development of synergies among existing and new partners to ensure access to a full range of integrated services and flexible supports based on need.
• Accountability & sustainability
  • The accountability of the system, health, and social service providers to funders and to each other is defined and ensured (Ontario Behavioural Support System Project, 2010).

Acknowledgement

For further information please contact the BSO Provincial Coordinating Office or call 1-855-276-6313 or write to provincialbso@nbrhc.on.ca.