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05 - March 26, 2019 County Council Agenda Package y n y e t o t c i i i y l l s t n e a i e s a r l t u a n l a i t e p i g p C c i r s i m x o D p o E H C S March, 2019Elgin Residential Hospice Planning Committee Residential Hospice Planning in Elgin County - ), long Dennings the committee to help join Committee has been championing the vision for a Hospice for over a decadeCommittee consists of representatives from east, west, and central ElginCommittee includes MPP Jeff Yurek, SW LHIN, health service provider agencies (e.g. Serenity, VON, HOPE), funeral services (term care, West Elgin Community Health Centre, Mennonite representation, physicians, farming community, and local community representatives advocating for the needs of patients and their families. advance the planning, bringing experience, resources, and expertise in building Hospices (London and Sarnia). Committee is focused on collaboration, ensuring the diverse needs of those living in Elgin County are represented in the planning. Elgin HospicePlanning Committee Welcome Home life for - of - Hospice provides expert care, comfort, support, dignity and qualitypeople who are dying. Care not only relieves pain and other physical symptoms, but also addresses the psychological, social, spiritual and cultural needs of each person and their family. Hospice care is provided by a dedicated team of registered nurses, registered practical nurses, personal support workers, spiritual care providers, social workers, physicians and volunteers. Residential hospices provide expert palliative care 24 hours a day, 7 days a week. Services and care (in the residence and the community) are offered at no cost to those who use them. What is a Residential Hospice? No cost to those we serve(Community Support ) the provincial than ) etc.) * population (those over 65 years Leamington increasing by 3.5% each year - larger aging Surrounding communities with Residential Hospices (Chatham, London, Woodstock, Stratford, Approximately 800 deaths per year in Elgin annually *Elgin has a average *Aging demographicGeography and transportation barriers in rural communities *No palliative beds at St. Thomas Elgin General Hospital *Costs of Hospice versus Acute Care (funding is shifted to the community) IN THE NEED ELGIN COUNTY Sourced from the SW LHIN* - cover: building costs (hydro, not Approximately 50% is funded by the Ministry of Health and LongTerm Care (MOHLTC)MOHLTC funding covers (nursing, PSW costs)What does MOHLTC funding heat etc.), food costs, linen, administrative staff, spiritual care, housekeeping services, counseling, etc.Annual operating shortfall will require the generous support of the community. Funding Model of Hospices Palliative Care in Ontario Costs Attorney General 2015 2018) No Funding - this time. (May funding for new Responded to letter residential Hospice at stating there is no new MOHLTC (2018) reviewed and Endorsement plan and issued a South West LHIN requesting funding letter to the MOHLTC Leadership and Board endorsed the business Support) Study (2018) Community Volunteer Lead Agency, Case for ( Fundraising Feasibility Strong signals suggest a Leadership, Experienced successful in Elgin County capital campaign would be 10 - Barnes (2017) in Elgin final report Lough and develop a Business Plan business plan. The to assess the needs recommended 8 Consulting was hired beds centrally located Update on Elgin Hospice Planning Update on Elgin Residential Hospice Planning Provincial Budget - to be released 11 2019 Waiting for Capital and MOHLTC to be confirmed Operating Funding from the April Invited Elgin to Yurek - Funding (December 2018) apply for Hospice Capital MOHLTC Media Announcement with Jeff 2018) October - (May Malahide, Central Elgin) Provincial Election Pause Received municipal support (Bayham, City of St. Thomas, County of Elgin, Township of Elgin) 30 parking spaces) - Advocacy (Thank you)Identification of possible sites Identify influential Community Leaders AWARENESS (once funding is confirmed)SUPPORT future fundraising initiatives (and campaign) (approx. 14,000 square feet, centrally located, in a beautiful serene environment (gardens or green space), somewhat visible to the community, with 20(looking for influential leaders within the community to sit as a member of the Board of Directors and Capital Campaign Cabinet representing various industries and geographies across How can the County of Elgin Council help... 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Uif!gbtuftu!hspxjoh! bsf!po!bwfsbhf!%54:!qfs! wvmofsbcmf!qpqvmbujpo! boe!efbui/!Gbnjmz-!gsjfoet! ebz!jo!dpousbtu!up!%2-211! jo!Fmhjo!jt!bhjoh!! boe!puifs!mpwfe!poft!bsf! gps!b!iptqjubm!cfe tjohmf!tfojpst tvqqpsut!gbnjmz!boe! gsjfoet!jo!bekvtujoh!up!mjgf! xjuipvu!uifjs!mpwfe!pof/ FMHJO!SFTJEFOUJBM!IPTQJDF!QMBOOJOH!DPNNJUUFF & Alcohol Strategy Elgin Community Drug Identified Need gencies willing to lead the strategy gories) ousing Mental healthDrugsH Elgin Situation Table identified a need in 2016 (top risk cateNo a 1.2.3. Pillar Workgroups currently meeting Present meeting Committee First Steering 2018 September Timeline brainstormingMission/VisionInterest to participate 2018 August discussions Situation Table June 2018 Steering Committee Chair: Jackie Harris (Central Community Health Centre)Troy Carlson (OPP)Jody Berkelmans (Social Services)Linda Sibley (ADSTV)Pauline Meunier (EMS)Nancy Lawrence (SWPH)Andy Kroeker (WECHC)Deanna Guernsey (SOAHAC)Michele Murray Smith (St. Leonard’s) Mission & Vision and healthy community in Elgin without the VisionMission A safenegative impacts of drugs and alcohol. Create, implement and evaluate a comprehensive drug and alcohol strategy that meets the needs of our community based on the pillars of prevention, treatment, harm reduction and justice. Guiding Principles judgemental - SustainableInclusiveCollaborativeRelevantEvidence InformedNon Community Terms of Reference and Alcohol Strategy. de guidance and oversight to the development, Mandate of Steering Committee: Proviimplementation and evaluation of the Elgin Drug Pillar Workgroups Reduction (Jody/Pauline) Prevention (Nancy/Andy)HarmTreatment (Jackie/ADSTV/Deanna)Justice (Troy/ Michele) 20 - 13 alcohol addictions the community about the risks of drugs and addict” without duplicating work done elsewhere ducate E with broad, holistic approaches that support the “person” and not treat the “ to substance use and Prevention Pillar Objectives (Draft) risk (Draft) ies and friends of individuals at Continue to distribute naloxone kits to all service agencies and/or famil comprehensive model of care (wrap around services) Harm Reduction Pillar Objectives overdose experience care prescribe and manage Suboxone within 24 hours following unintentional support model where a person with lived - strategies to address transportation barriers for people training for community physicians to ol use/misuse by providing timely access Decrease preventable deaths, injuries and illness related to drug and alcoh Provide Develop patients on Methadone/ visits an individual accessing services Treatment Pillar Objectives (Draft) crisis the right resources and care related ensure treatment an addiction people who use drugs and law enforcement on the Good transition from EMDC/detention and hospital to the maritan Act and duty to report legislation for the welfare of children Educate Sa Provide education and training to judges and police officers about Collaborate with first responders to substance use, harm reduction and community are mobilized to respond to Justice Pillar Objectives (Draft) to the Steering ific data to inform the spec - Present Pillars collecting ElginprocessRecommendations from all PillarsCommitteeBuy in from all levels of government, community agencies/businesses & the communityDedicated staff person to implement/oversee the strategy TBA April 2019 Start the Conversation Event Brian Lima, Director of Engineering Services Development Charges Council Information Session Background Development Charges Act Overview Services that Could be Considered DC Process Overview DC Rates in Other Communities Council Considerations Consideration of Next Steps Discussion The County does not currently levy DCs DCs are implemented through by-law(s) which have a maximum life of five years DCs are governed by Provincial statute: the Development Charges Act, 1997 Both upper and lower tier municipalities can levy DCs (and school boards) Background Hemson Consulting Ltd. August 29, 2014 retained by Council to prepare Development Charge Background Study May 12, 2015 - Development Charge Background Study presented, Council then chose not to proceed with required public consultation and supporting by-law Background growth pays for growth Fees imposed on development to finance development-related capital costs As a municipality grows, new infrastructure and facilities are required to maintain service levels (e.g. ambulance facilities, roads, etc.) financial burden of servicing development is not borne by existing taxpayers or jeopardizes sustainability of capital program What are Development Charges? Fund a share of the capital cost of expanding Statutory and non-statutory reductions on DCs Fund operating costs and long-term repair and municipal infrastructure to service the needs arising from new development replacement of municipal infrastructure Development Charges Property Taxes Development Charges Context -service basis by Act also permits the collection of DCs at the time of subdivision approval for engineering services DCs are most commonly collected at the time of building permit issuance County DCs are collected at the municipality level DC reserves/accounts must be established on a service- Development Charge Context Cultural or entertainment facilities, including museums, theatres and art galleries Tourism facilities, including convention centres The acquisition of land for parks Hospitals as defined in the Public Hospitals Act Landfill sites and services Waste incineration Headquarters for the general administration of municipalities and local boards DC Act Service Exclusions Maximum years years StatutoryPlanning Period 1010 years10 years10 years10 years1010 yearsBuild out Maximum DC StatutoryCost Recovery 90%90%90%90%90%90%90%100% Service County of Elgin Possible DC Services for Consideration Note: Services shared with the City of St. Thomas are eligible Service General Government (Studies)LibraryLand AmbulanceLong Term CareProvincial OffencesOntario WorksRoads and Related Costs to acquire and improve land (including leasehold interest in land) Building and structure costs Rolling stock with a useful life of 7 years or more Furniture and equipment, excluding computer equipment Development-related studies Interest and financing costs DC Act Eligible Costs 2 $51.4M$4,291$2,723$2,193$8.41 / m (fully serviced) (fully serviced) Singles & Semi Detached Rows & Other Multiples Apartments Ten-Year Gross Capital Forecast Cost Calculated Residential Rate Calculated Non-Residential Rate 2015 Development Charge Study Findings $300,000 $150,000 $150,000 $250,000 $400,000 $250,000 $2,500,000 Estimated Cost Road Improvement Anticipated installation of turning lane improvements Installation of northbound left-turn lanes with 50 metres of storage length from Sunset RoadInstallation of a westbound left-turn lane with 25 metres of storage length from Talbot LineImplementation of signal optimization and retiming to achieve acceptable level of service operations, and installation of a new southbound shared through/right-turn laneInstallation of traffic signals Installation of a northbound left-turn lanes from Colborne and Warren streets with 25 and 40 metres of storage length respectivelyRealignment of East Road and the installation of the intersection 125 metres to the north, and a northbound left-turn lane with 25 metres of storage length from East Road Road turn lanes with 50 metres Location Intersection of Furnival (CR 103) and Hoskins Line Intersection of Sunset Road (CR 4) and Talbotville Gore Road (south) Installation of northbound left-of storage length from Sunset RoadIntersection of Talbot Line (CR 3) and Sunset Road (CR 4) Intersection of Wellington Road (CR 25) and McBainLineIntersection of Colborne Street (CR 4) and Warren StreetIntersection of East Road (CR 23) and Sunset Road (CR 4) Anticipated Unfunded Capital Projects - Roads Municipality West Elgin Southwold Central Elgin $100,000 $150,000 $150,000 $500,000 $500,000 $150,000 $150,000 $150,000 $5,850,000 Estimated Cost TOTAL -turn tapered lane Improvement Road Installation of a northbound left-turn lane with 15 metres of storage length from East RoadImplementation of signal optimization and retiming to achieve acceptable level of service operations, and extension of the existing eastbound left-turn lane with an additional up to 70 metres of storage length from Southdale LineInstallation of a northbound left-turn lane with 25 metres of storage length from Sunset RoadAnticipated installation of traffic signals and turning lane improvementsAnticipated installation of traffic signals and turning lane improvementsPotential installation of turning lane improvementsPotential installation of turning lane improvementsInstallation of southbound left-turn and slip around lane, and northbound right Southdale Line Location Intersection of East Road (CR 23) and Hill Street Intersection of Sunset Road (CR 4) and Intersection of Sunset Road and Glenwood Avenue Intersection of Sunset Road and Sparta Line Intersection of Centennial Road and Elm LineIntersection of Ron McNeil Line and Omemee Street Intersection of Whittaker Road and Nelson Street 11766 Imperial Road Anticipated Unfunded Capital Projects - Roads Municipality Central Elgin Malahide 201650,0691.0% 201149,5560.6% 200649,2412.1% 200148,2501.0% Census Population 199647,752 Population Source: Statistics Canada Too Levy DCs Growth Must Be Occurring Elgin County YearCensusGrowth % School Boards Municipal buildings Minor residential expansions (e.g. basement apartments) Industrial expansions up to 50% DC Act Land-use Exemptions DC Study Process Public Meeting must also be heldLost revenue cannot be made up through higher DCs on other uses Background Study showing all calculations must be made available 60 days prior to by-law passage Council can adopt DCs at Background Study rates or any level under that amount Council may also utilize DC discounts and exemptions Key Council Considerations ) 2020 Unit -$9,955.03 DCs Charges Per Single Detached NoNo DCsDC Background Study Underway$640.05$8,480.41$4,461No DCs (however considering in$11,133 Dunwich DCs of Member Municipalities Municipality West ElginDutton/SouthwoldCentral ElginAylmerMalahideBayhamCity of St. Thomas $4,291 2015 Elgin County $9,449$7,120$5,232$4,145$2,873$1,842 No DCsNo DCsNo DCsNo DCsNo DCs $8,144.10 Charges Per Single United Detached County County County County County Municipality SimcoePeterboroughGreyWellingtonDufferin CountyOxford CountyNorfolkLambton CountyMiddlesexHuron CountyPerth CountyEssex DCs in Other Counties (w/o water or wastewater) Prepare growth forecast Compile historic inventories Prepare 10-year DC capital plan Council direction on whether to proceed with DC study If study proceeds, next steps would be: Consideration of Next Steps 1 2 3 4 5 6 10 11 12 13 .ǒźƌķźƓŭ tĻƩƒźƷƭ 17 Elgin CountyElgin County 2015 Development Charges Study2015 Development Charges Study Council Information SessionCouncil Information SessionCouncil Information SessionCouncil Information Session Tuesday May 12 2015TuesdayTuesdayTuesday May 12 2015,, May 12 May 12,, 2015 2015 Today We Will Discuss Background Development Charges Overview Development Forecast Draft Capital Programs Draft Calculated RatesDraft Calculated Rates Council Consierations Nt StNext Steps Њ Background The County does not currently levy DCsThe County does not currently levy DCs DCs are implemented through by-law(s) which have a maximum life of five yearswhich have a maximum life of five years DCs governed by Provincial statute: the Devel Ch 99lopment ChargesAct,1997 Ayylmer, Malahide, Central Elggin, & St. Thomas (separated) all levy DCs Ћ What Are Development Charges? Fees imposed on development to finance development-related capital costs As a municipality grows, new infrastructure As a municipality grows, new infrastructure and facilities are required to maintain service levels (e.g. ambulance facilities, roads etc)roads, etc.) Principle is “growth pays for growth” so that fiil bd f ii dlt i financial burdenofservicing development is not borne by existing taxpayers Ќ Development Charge Context Development Charges Fd h f th itl t f di iil Fundashareof thecapitalcostofexpandingmunicipal infrastructure to service the needs arising from new development Direct Developer Contributions Fund costs that would normally be required as part of a subdivision agreement(i.e. internal roads, sidewalks, streetlights, intersections, park elements) Property Taxes Statutory and non-statutory reductions on DCs Fund operating costs and long-term repair and replacement of municipal infrastructurereplacement of municipal infrastructure Ѝ Development Charge Collection DCs are most commonlyy collected at the time of building permit issuance Act also ppermits the collection of DCs at the time of subdivision approval for engineered services Upper tier DCs are collected at the lower tier level DC reserves/accounts must be established on a service-by-service basis Ў Overview of the DCA Service exclusions: Cultural and entertainment facilities, including museums, theatres and art galleries Tourism facilities including convention centres Parkland acquisition HitlHospitals Headquarters for general administration of municipalities and local boardsmunicipalities and local boards Waste management Џ Overview of the DCA Eligible capital costs: Costs to acquire and improve land (including leasehold interest in land) Building and structure costs Rolling stock with a useful life of 7 years or more Furniture and equipment, excluding computer equipment Development-related studies Interest and financingg costs А County of Elgin Proposed DC Rate StructureProposed DC Rate Structure StatutoryStatutory ServiceMaximumMaximum 11 DC Cost RecoveryPlanning Period General Government (studies)90%10 years Libraryy Services90%10yyears LandAmbulance90%10 years Long Term Care90%10 years Provincial Offences90%10 Years Roadsand Related 100%Build out Note: 1)Both general and engineered services are based on a 10-year planning period from 2015-2024 Б Preliminary Development Forecast Forecast of population, households, employment and bildi h b ltd t 2031d buildingspace has beencompleted to 2031 TenTen-year and to 2031 forecast informed by:year and to 2031 forecast informed by: Census data Official Plan targets Employment Land Strategy, September 2012 В Preliminary Development Forecast All Services Planning Horizon (2015Planning Horizon (2015-2024)2024) AtGrowthAt 20142015-20242024 Dwelling Units18,2001,30019,500 Census Population50,0001,70051,700 1 Place of Work Employment11,70040012,100 New Non-res Building 52,800 Space (sq.m) 1 Excludes work at home ЊЉ Service Levels Maximum allowable charge for general services based on average service level provided in preceding ten years (2005 – 2014)2014) Calculated by multiplying ten-year historical service level by the forecast growth in the ten-year planning period Establishes a development charges ceiling for “soft” services ЊЊ Capital Programs Capital costs have been adjusted in accord ith DC liltidancewith DC legislation: Capital grants & subsidies Replacement/benefit to existing shares 10% legislated discount for “general services” Available DC reserve funds Post-period benefit shares (post-2024) Capital programs are largely based on 2015 capital budget ЊЋ General Government Total Capital Grants/Non-DC EligibleDC RecoveryFuture DC’s ProgramSubsidies(BTE, 10% etc.)(2015-2024)(Post-2024) $725,000$101,750$323,550$299,700$0 Development-related studies: Development Charges (2) Official Plan Review (1 partial 1 full)Official Plan Review (1 partial, 1 full) Agricultural Study Various Strategy Studies (Accommodation, Investment, FDI, Residential Attraction) Community Improvement Plan Duuo dusa a Sudy ttonIndustrialPark Study ЊЌ Library Services Total Capital Grants/Non-DC EligibleDC RecoveryFuture DC’s ProggramSubsidies((BTE,,) 10% etc.)((2015-2024))((Post-2024)) $3,396,700$0$2,973,600$197,900$225,200 New Projjects: Material acquisition (book purchases) New AlymerBranch (ten-year lease costs) New Shedden Branch (tenNew Shedden Branch (ten-year lease costs)year lease costs) ЊЍ Land Ambulance Total Capital Grants/Non-DC EligibleDC Recovery Future DC’s ProgramSubsidies*(BTE, 10% etc.)(2015-2024)(Post-2024) $140,000$60,600$7,950$71,450$0 New Projects:New Projects: Additional Ambulance Vehicle Equipment to outfit 10 additional paramedics * Grants and subsidies include the City of St. Thomas share of new capital projectsprojects ЊЎ Long Term Care Non-DC Total Capital Grants/DC RecoveryFuture DC’s Eligible(BTE, ProgramSubsidies(2015-2024)(Post-2024) 10% etc)10% etc.) $29,000,000$7,250,000$21,434,600$315,400$0 New Projjects Terrace lodge new building construction* * Total DC eligible cost only includes area relating to proposed Great Room ЊЏ Provincial Offences Non-DC Total Capital Grants/DC RecoveryFuture DC’s Eligible(BTE, ProgramProgramSubsidiesSubsidies*(2015(2015-2024)2024)(Post(Post-2024)2024) 10% t)0%etc.) $7,867,000$2,247,700$1,899,300$26,350$3,693,650 New Projects: Accessibility/ Space Needs (Museum/ POA) (2016) Accessibility/ Space Needs (Museum/ POA) (2017) *Total amount of grants and subsidies reflects share of museum space that has been removed from the DC calculation ЊА Roads & Related Total Capital Grants/Non-DCDCRecovery Future DC’s ProgramSubsidiesEligible(BTE)(2015-2024)(Post-2024) $10,275,000$2,125,000$4,598,100$3,551,900$0 New Projects: Centennial Line Urbanization Road 5 FDR/DST Various bicycle lanes Improvements to Miller Road (engineering and road works) Various infrastructure works (East Street and Imperial Road)Various infrastructure works (East Street and Imperial Road) Dexter Line Relocation Transportation Master Plan and Highway 3 By-pass Study New Drains (County share) ЊБ County-wide Services TenTen-Year Capital Program SummaryYear Capital Program Summary Total Gross Cost ($millions) $ 51.40 Less: Grants & Subsidies*$ 11.78 L Bfit t Eiti Sh Less: Benefit to Existing Share$ 3070$ 30.70 Less: 10% Discount$ 0.54 Less: Available Reserve Funds$ 0.00 Less: PostLess: Post-2024 Benefit2024 Benefit$ 392$ 3.92 DC Eligible Share$ 4.46 *Grants and subsidies includes contributions from other municipalities, the province and ineligible DC costs ЊВ Calculated Fully Serviced Residential DC RateResidential DC Rate Library Services, 4.0% Land Singles & Semi- General Abl Ambulance,12%1.2% Gt Government, Detached 5.4% $4,291 Long Term Care, 7.2% Provincial RowsRows& O& Otherther Offences, 0.5% Multiples $2,723 Apartments $2,193 Roads And Related, 81.5% General Services = 18% Engineered Services = 82% ЋЉ Calculated Fully Serviced NonNon-Residential DC RateResidential DC Rate GeneralLand Government,Ambulance, 68%6.8%1.5% 15% Provincial Offences, 0.7% Non-Residential Charge per Charge per Square Metre $8.41 Roads And Related , 91.0% General Services = 9% Engineered Services = 91% ЋЊ Rate Comparison: Single Detached UnitsSingle Detached Units London $28,123 Brantford $21,453 $21,453 Oxofrd -Ingersoll $17,971 Oxford -Tillsonburg $16,328 Norfolk $13,022 Strathroy-Caradoc $12,205 Elgin County Calc. -Central Elgin $11,850 Haldimand $11,039 Elgin County Calc. -Malahide $10,664 Upper/ Single Tier St. Thomas (SA1) Current St Thomas (SA1) Current $9089 $9,089 Local Area-Specific Elgin County Calc. -Aylmer $8,199 Elgin County -Calculated $4,291 ChthChatham-Kt (Wt & Kent (Water & $3,578 Wastewater) $-$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 ЋЋ Rate Comparison: Single Detached UnitsSingle Detached Units Simcoe $6,283$6,283 Peterborough $5,250$5,250 Grey $5,203$5,203 Elgin County -Calculated $4,291$4,291 Wllit Wellington $280$2,805$280$2,805 Upper Tier Oxford County $2,652$2,652 Dufferin $2,647$2,647 Middlesex County $0 $0$1,000$2,000$3,000$4,000$5,000$6,000$7,000 ЋЌ Rate Comparison: NonNon-Residential (Commercial)Residential (Commercial) London $73.34 OxofrdOxofrd-IngersollIngersoll $6800 $68.00 Chatham-Kent (Water & Wastewater) $67.98 Oxford -Tillsonburg $63.77 St. Thomas (SA1) Current $60.86 Strathroy-Caradoc $57.98 Norfolk $57.74 Elgin County Calc. -Central Elgin $55.56 Elgin County Calc. -Malahide $42.96 Upper/ Single Tier Local Brantford $38.00 Area-Specific Haldimand $30.47 $0.00 $20.00 $40.00 $60.00 $80.00 ЋЍ Rate Comparison: NonNon-Residential (Commercial)Residential (Commercial) Simcoe $31.28 Wellington $19.16 Peterborough $11.95 Oxford County $10.64 Elgin County -Calculated $8.41 Upper Tier Dufferin $6.24 Middlesex County $0.00 GreyGrey $0.00$0.00 $0.00 $5.00 $10.00 $15.00 $20.00 $25.00 $30.00 $35.00 ЋЎ Key Council Considerations Council not being asked to pass DCs at this point If Council wishes to further consider DCs, a backggyypground study and statutorypublic meeting are required Council can adopt DCs at calculated rates or any Council can adopt DCs at calculated rates or any level under that amount Absence of DCs would result in approximately $400,000+ per year in tax supported funding for identifiedggrowth-related infrastructure ЋЏ DC By-law Exemptions Statutory Exemptions: School BoardsSchool Boards Municipal buildings Minor residential expansions Industrial expansions up to 50% Pibl NPossible Non-Sttt EtiStatutory Exemptions: Industrial? Farms?Farms? Places of Worship? BIA/CIP Areas? ЋА Next Steps Council direction on whether to proceed with public consultation Prepare Background Study & Draft DC By-law Advertise for Public Meeting Hold Public Meeting Council consideration of ratesCouncil consideration of rates ЋБ Table1:Overview of Library Usage *Note: branch visits count the amount of foot traffic within the individual library branches. These measurements are not tracked within the total use section as the library does not yet have five years of data for this metric for all branches. Branch visits will be further discussed in the section titled Branch Visits. o o o o Table 2:Overview of Total Circulation Table 3: Branch circulation of physical items borrowedper year Table 4:Overview of Holds Placed Table 5:Branch visits per year o o Table 6:Number of programs, tours and attendance per year Table 7:Overall Internet Logins Table 8:Overview of library membersper year Planning Act Planning Act Environmental Impact Study (EIS), 10117 Talbotville Gore Road Township of Southwold, Leonard + Associates in Landscape Architecture, August 2018 Holding Zone is defined by a geographic boundary, within an attendance area (usually with high concentrations of new or imminent development), for which the Trustees have approved that students residing in it are to attend a specified school based on available capacity, until such time as long-term accommodation and related revised attendance areas can be established. Land Titles Act Registry Act Land Titles Act Land Titles Act. Registry Act Registry Act Certification of Titles Act Ontario Water Resources Act Environmental Protection Act Oil, Gas and Salt Resources Act Planning Act Occupational Health and Safety Act Act Approval Authority Certificate This final plan of subdivision is approved by the County of Elgin under Section 51 (58) of the Planning Act, R.S.O. 1990, on this___day of _____________20___. __________________ Manager of Planning Planning Act Planning Act rate visit 3.8% ƚƓ reach target źƌƌğ tĻƩŅƚƩƒğƓĭĻ 33% 67% Not AdmittedAdmitted ƩĻƭźķĻƓƷƭ Reaching the Target by 1 to .ƚĬźĻƩ 9 Reduce the number of visits to the ED ЊВ ķğƷğΜ ED Visits Ώ 390150 ЊБ Ʒƚ vЋ ЋЉЊБ Ώ 340130 tĻƩŅƚƩƒğƓĭĻ ЋЉ ŭƚğƌ Ʒƚ źƒƦğĭƷ ĭƚƓƭĻƩǝğĬƌĻ ķğǤƭ ǞźƷŷźƓ ŷƚƭƦźƷğƌƭ ǞźƷŷźƓ ƷŷĻ {‘ \[ILb wĻŭź Ώ 9ƌŭźƓ tĻƩŅƚƩƒğƓĭĻ ƷĻƩƒ ĭğƩĻ ŷƚƒĻƭ Λ\[/IΜ ƦĻƩ ЊЉЉ \[/I Ώ 290110 {ƚǒƷŷ ‘ĻƭƷ ΛĬğƭĻķ ƚƓ vЌ ЋЉЊА 90 240 70 190 ƩĻƭźķĻƓƷƭ ƚŅ ƌƚƓŭ ŷĻ ƓǒƒĬĻƩ ƚŅ ǝźƭźƷƭ Ʒƚ ƷŷĻ ĻƒĻƩŭĻƓĭǤ ķĻƦğƩƷƒĻƓƷ Λ95Μ ƒğķĻ Volume of VisitsVolume of Visits ĬǤ 50 140 9030 ĻƩƒ /ğƩĻ IƚƒĻƭ ğƩĻ ğ ƉĻǤ ƦğƩƷƓĻƩ źƓ ƚǒƩ C—ЋЉЊВ Ώ \[ƚƓŭ 4010 -10-10 8.0%3.0%8.0%3.0% -2.0%-2.0% 48.0%43.0%38.0%33.0%28.0%23.0%18.0%13.0%33.0%28.0%23.0%18.0%13.0% ED Visit Rate (per 100 LTCH residents)ED Visit Rate (per 100 LTCH residents) rate visit 7.1% ƚƓ reach target 56% Manor Performance 44% Not AdmittedAdmitted ƩĻƭźķĻƓƷƭ Reaching the Target by 3 to Elgin 27 Reduce the number of visits to the ED ЊВ ķğƷğΜ ED Visits Ώ 390150 ЊБ Ʒƚ vЋ ЋЉЊБ Ώ 340130 tĻƩŅƚƩƒğƓĭĻ ЋЉ ŭƚğƌ Ʒƚ źƒƦğĭƷ ĭƚƓƭĻƩǝğĬƌĻ ķğǤƭ ǞźƷŷźƓ ŷƚƭƦźƷğƌƭ ǞźƷŷźƓ ƷŷĻ {‘ \[ILb wĻŭź Ώ 9ƌŭźƓ tĻƩŅƚƩƒğƓĭĻ ƷĻƩƒ ĭğƩĻ ŷƚƒĻƭ Λ\[/IΜ ƦĻƩ ЊЉЉ \[/I Ώ 290110 {ƚǒƷŷ ‘ĻƭƷ ΛĬğƭĻķ ƚƓ vЌ ЋЉЊА 90 240 70 190 ƩĻƭźķĻƓƷƭ ƚŅ ƌƚƓŭ ŷĻ ƓǒƒĬĻƩ ƚŅ ǝźƭźƷƭ Ʒƚ ƷŷĻ ĻƒĻƩŭĻƓĭǤ ķĻƦğƩƷƒĻƓƷ Λ95Μ ƒğķĻ Volume of VisitsVolume of Visits ĬǤ 50 140 9030 ĻƩƒ /ğƩĻ IƚƒĻƭ ğƩĻ ğ ƉĻǤ ƦğƩƷƓĻƩ źƓ ƚǒƩ C—ЋЉЊВ Ώ \[ƚƓŭ 4010 -10-10 8.0%3.0%8.0%3.0% -2.0%-2.0% 48.0%43.0%38.0%33.0%28.0%23.0%18.0%13.0%33.0%28.0%23.0%18.0%13.0% ED Visit Rate (per 100 LTCH residents)ED Visit Rate (per 100 LTCH residents) rate visit 8.7% ƚƓ Performance reach target 57% 43% Not AdmittedAdmitted ƩĻƭźķĻƓƷƭ Reaching the Target by 4 to Terrace Lodge 37 Reduce the number of visits to the ED ЊВ ķğƷğΜ ED Visits Ώ 390150 ЊБ Ʒƚ vЋ ЋЉЊБ Ώ 340130 tĻƩŅƚƩƒğƓĭĻ ЋЉ ŭƚğƌ Ʒƚ źƒƦğĭƷ ĭƚƓƭĻƩǝğĬƌĻ ķğǤƭ ǞźƷŷźƓ ŷƚƭƦźƷğƌƭ ǞźƷŷźƓ ƷŷĻ {‘ \[ILb wĻŭź Ώ 9ƌŭźƓ tĻƩŅƚƩƒğƓĭĻ ƷĻƩƒ ĭğƩĻ ŷƚƒĻƭ Λ\[/IΜ ƦĻƩ ЊЉЉ \[/I Ώ 290110 {ƚǒƷŷ ‘ĻƭƷ ΛĬğƭĻķ ƚƓ vЌ ЋЉЊА 90 240 70 190 ƩĻƭźķĻƓƷƭ ƚŅ ƌƚƓŭ ŷĻ ƓǒƒĬĻƩ ƚŅ ǝźƭźƷƭ Ʒƚ ƷŷĻ ĻƒĻƩŭĻƓĭǤ ķĻƦğƩƷƒĻƓƷ Λ95Μ ƒğķĻ Volume of VisitsVolume of Visits ĬǤ 50 140 9030 ĻƩƒ /ğƩĻ IƚƒĻƭ ğƩĻ ğ ƉĻǤ ƦğƩƷƓĻƩ źƓ ƚǒƩ C—ЋЉЊВ Ώ \[ƚƓŭ 4010 -10-10 8.0%3.0%8.0%3.0% -2.0%-2.0% 48.0%43.0%38.0%33.0%28.0%23.0%18.0%13.0%33.0%28.0%23.0%18.0%13.0% ED Visit Rate (per 100 LTCH residents)ED Visit Rate (per 100 LTCH residents) DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 1 of 13 SCOPE This policy applies to addressing resident inquiries or requests for Medical Assistance in Dying (MAID) (see definition) in a long-term care home (the “Home”). This policy does not apply to situations other than MAID and is separate and distinct from withholding or withdrawing treatment, palliative care (see definition) and palliative sedation. POLICYSTATEMENT The County of Elgin Long-Term Care Homes recognizes the provision of MAID to a resident who meets the eligibility criteria (see definition) as a legal option within a publicly funded organization participating in MAID. The County of ElginLong-Term Care Homes acknowledges the right of individual healthcare practitioners to conscientiously object (see definition) to participating in the provision of MAID in accordance with any requirements outlined in law, professional regulatory standards, and the Home’s requirements. DEFINITIONSAND ASSOCIATED COMMENTARY Canadian Medical Protective Association (CMPA): A mutual defenceorganization for physicians who practice in Canada. Its mission is to protect a member’s integrity by providing services, including legal defence, indemnification, risk management, educational programs and general advice. Capacity: A person is capable of making a particular decision if the individual is both (1) able to understand the information that is relevant to making that decision \[the cognitive element\] and (2) able to appreciate the reasonably foreseeable consequences of that decision or lack of decision \[the ability to exercise reasonable insight and judgment\]. In this regard, it is stated that in the context of MAID, the resident must be able to understand and appreciate the certainty of death upon self-administering or having the physician administer the fatal dose of medication (hereinafter referred to as “CPSO MAID Policy”). DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 2 of 13 Conscientious Objection: When an individual healthcare practitioner (medical practitioner, nurse practitioner, pharmacist or other individual supporting a resident who wishes to have MAID), due to matters of personal conscience, elects not to participate in MAID. The level of comfort and support an individual practitioner may or may not be willing to provide will likely vary in scope. For example, individual healthcare practitioners may be comfortable supporting a range of activities, such as having an exploratory discussion with the resident or providing a second medical opinion, but not be willing to prescribe or administer, while other individual healthcare practitioners may wish to limit their involvement in MAID to the full extent permitted by their professional regulatory colleges or the Home with which they are affiliated (including as employees). Consent: To provide informed consent to MAID, the following four requirements must be met: individual consenting must be capable (see definition of capacity – Definitions and Associated Commentary); the decision must be informed (i.e., risks, benefits, side effects, alternatives, and consequences of not having treatment provided); made voluntarily (i.e., not obtained through misrepresentation or fraud); and be treatment specific (i.e., information provided relates to treatment being proposed). Note:Neither substitute-decision-maker consent nor advance consent for MAID is legally permittedor recognized. \[The Health Care Consent Act was not amended to include MAID as a “treatment” under that Act for which an appeal of an incapacity finding could be made to the Consent and Capacity Board.\] Eligibility Criteria For purposes of this Policy, the eligibility criteria includes the following elements: Ontario Health Insurance Plan (OHIP) Eligible: Satisfies all OHIP eligibility requirements (but for the 90-day waiting period). Adult: Resident, as required by the Criminal Code, is 18 years or older. Note: the requirement that residents be at least 18 years or older departs from Ontario’s Health Care Consent Act, which does not specify an age of consent. DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 3 of 13 Capable: (See definition for capacity – Definitions and Associated Commentary) Resident must be capable to make decisions with respect to their health. Grievous and irremediable medical condition (including an illness, disease or disability) that meets all of the following requirements: o a serious and incurable illness, disease or disability; and o in an advanced state of irreversible decline in capability; and o that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and o their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining. Voluntary: Resident has made an individual request for MAID that was not attributable to external pressure. Informed consent (to MAID): Resident provides informed consent to receive MAID after having been informed of the options available to relieve their suffering, including palliative care. ETHICAL PRINCIPLES: For the purposes of this policy, ethical principles include the eight high-level ethical principles developed by the Joint Centre for Bioethics MAID Task Force members to help guide decision- making around implementing MAID, specifically: Accountability: Mechanisms exist to ensure that decision makers are responsible for their actions; all have an obligation to account for, and be able to explain, one’s actions. Collaboration: Partnering with relevant stakeholders in a respectful and accountable manner such that each individual and entity understands their associated role and accountabilities. DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 4 of 13 Dignity: The state or quality of being worthy of honour and respect of both humans and society. It belongs to every human by virtue of being human and to society as a product of the interactions between and among individuals, collectives and societies. Equity: It suggests that like cases are treated similarly and dissimilar cases treated in a manner that reflects the dissimilarities; and is characterized by the ‘absence of avoidable or remediable differences among groups of people regardless of social, economic, demographic or geographic definition’ (WHO). Respect: Recognition of the individual’s right to make individual choices according to their values and beliefs (within shared legal parameters). The collective endeavours of individuals may also deserve respect, though perhaps of a different degree than the level of respect afforded to individuals. Transparency: The quality of acting in a way that ensures that the processes by which decisions are made are open to scrutiny, and the associated rationales are publicly accessible. Fidelity: (Interpersonal-level) An enduring commitment to support residents and families to help people get through all facets surrounding MAID requests from inquiry to post-provision. (Organizational-level). An ongoing commitment to support health care Professionals that support MAID provision and those that conscientiously object. Compassion: A deep, affective response to individual suffering and an appropriate response to relieve suffering. Independent (Eligibility Assessment):an objective assessment provided by a medical or nurse practitioner who is not in any of the following relationships with the other medical or nurse practitioner assessing the resident making the request: Beneficiary relationship: (Do not know or believe that they are) a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person’s death, other than standard compensation for their services relating to the request; or Professional relationship: a mentor to them or responsible for supervising their work; or Personal relationship: connected in any way that would affect objectivity. Medical Assistance in Dying (MAID): Per Bill C-14, the administering by a medical or nurse practitioner of a substance to a resident, at their request, that causes their death; or the prescribing or providing by a medical or nurse practitioner of a substance to a resident, at their request, so that they may self-administer the substance and, in doing so, cause their own death. DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 5 of 13 The intent for the treatment to result in the resident’s death is unique in MAID. This intent to result in the resident’s death distinguishes it from other options such as palliative care, palliative sedation, withholding or withdrawing treatment, or refusing treatment because death is not intended but may incidentally occur due to the resident’s underlying condition. Most Responsible Physician/Nurse or Medical Practitioner (MRP): Themedical or nurse practitioner who is considered the resident’s attending health practitioner (in most cases in long- term care, this will be the attending physician) is accountable for the medical management of that resident and thus plays a key role throughout the decision-making process and provision of care. The MRP may or may not be the medical or nurse practitioner that facilitates MAID for an eligible resident but may be an initial point of contact to receive an inquiry or request for MAID. Resident: Refers to any individual that has been admitted to and living in a long-term care home. Internal Resource Group (IRG): An interprofessional group comprised of individuals internal to the Home that is responsible for the administrative oversight of MAID provision. Note: It is important that any prospective review is distinct and separate from retrospective oversight of MAID cases, to ensure independence. Long-term care homes will determine whether they wish to have such an internal committee, or what other oversight of MAID will be required, e.g. through another existing committee of the Home. Oversight activities may include the following: leading development of clinical and administrative processes to implement MAID, supporting staff to meet their professional obligations when a resident makes an inquiry or request for MAID, reviewing documentation of a resident’s MAID eligibility assessment, or retrospective review of documentation for quality improvement purposes. \[A MAID-IRG Terms of Reference document is available on the Joint Centre for Bioethics website\] Palliative Care: Aims to provide comfort and dignity for the resident living with the illness, as well as the best quality of life for the resident and family. An important objective of palliative care is relief of pain and other symptoms. Palliative care meets not only physical needs, but also psychological, social, cultural, emotional and spiritual needs of each resident and family. Palliative care may be themain focus of care when a cure for the illness is no longer possible. (Definition adapted from the Canadian Hospice Palliative Care Association, 2016). DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 6 of 13 Palliative Sedation Therapy: The continuous use of sedation until the resident’s death. It is an intervention to relieve suffering that is intolerable and refractory to the usual treatments for symptom management of the imminently dying (Adapted from Sunnybrook’s Palliative Care Unit Palliative Sedation Clinical Practice Guideline, 2015). POLICY The policy’s overarching premises are the following: The Home acknowledges an ethical obligation to respond to a resident’s inquiry or request for MAID whenever it may occur within the resident’s healthcare journey. When a resident makes an inquiry or request for MAID, assistance in dying is only one among several possible options that may be explored with the resident. The Home acknowledges the right of individual healthcare practitioners to conscientiously object to the provision of MAID in accordance with any requirements outlined in law and their professional regulatory standards. The Home recognizes that healthcare practitioners’ conscientious objection may vary in degree and points of time. For example, a healthcare practitioner may feel comfortable counselling a resident or assessing eligibility but object to prescribing or administering medication. TheMost Responsible Physician/Practitioner (MRP) remains responsible, but given the interprofessional reality of current healthcare practice, the support of other healthcare practitioners is essential. The ethical principles of accountability, collaboration, dignity, equity, respect, transparency, fidelity, and compassion inform deliberations for inquiries/requests for MAID. Residents who are deemed ineligible for MAID will continue to receive appropriate and high quality care that meets their needs. The Home is committed to providing ongoing education and support to both healthcare practitioners that support MAID provision as well as those that conscientiously object. DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 7 of 13 ON SITE MAID SERVICES The following represents a recommended procedure for staff receiving a request for MAID services/information: The County of Elgin Homes staff shall not provide nor allow external providers to provide/administer MAID on site. County of Elgin Homes staff will link individuals to MAID resources. PROCEDURE 1.Process for notifying appropriate persons to initiate an exploratory discussion in response to a resident inquiry or request for MAID. Discussion of MAID is initiated when a resident makes an inquiry or request for MAID to any member of their interprofessional healthcare team. The County of Elgin Homes staff/attending physicians shall provide information, resources and referrals; and shall allow assessors to come on site to conduct assessments. a. Identify appropriate persons to facilitate exploratory discussion. For example, if the request is made to someone other than the Most Responsible Physician/Practitioner (MRP), the healthcare practitioner receiving the inquiry or request should communicate to the resident that their MRP will be notified to have a follow-up discussion with the resident. If the MRP is not the individual having the follow-up discussion, the MRP should be informed that the resident has made an inquiry or request. MAID Internal Resource Group (MAID-IRG) may be contacted (or, an existing internal committee may assume any MAID-IRG functions). If the identified person (e.g. MRP) conscientiously objects to having an exploratory discussion with the resident (of available options, potentially including MAID), the MRP must refer the resident to an appropriate physician or agency (in accordance with CPSO MAID policy, 2016). The MOHLTC initially established a clinician referral support line; however, its functions are now subsumed under the provincial care coordination service to help Ontario clinicians to arrange for assessment referrals and consultation for residents requesting MAID. b.Preliminary considerations/issues: i. Explore a resident’s motivation for inquiring/requesting MAID. ii. Have all other alternatives for care (that are acceptable to the resident) been explored? DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 8 of 13 iii. Has the resident been informed of alternatives for care and the likely associated outcomes? iv. How urgent is the resident’s condition? For example, is the resident’s death or loss of capacity imminent? v. Have the perspectives of all appropriate individuals (with the resident’s consent) been involved? vi. If appropriate, make a referral to palliative care or other specialists to explore options for symptom management. vii. Has input from ethics, legal, and/or spiritual care been considered? 2.Respond to a resident inquiry or request for MAID.The MRPcommunicates with the resident to clarify if the discussion with the resident constitutes an inquiry for additional information or a request for MAID. If the discussion is merely a request for information, not all steps outlined in 2(a) below may be required. The County of Elgin Homes staff shall allow external assessors to come on site to conduct assessments. If the discussion reveals that the resident is making a request for MAID, theexternalmedical or nurse practitionerperforming the assessmentshould explore the following areas with the resident: a. Assess the resident to see if the eligibility criteria aremet. i. Confirm resident’s age and residency status, i.e. 18 years or older and eligibility for the Ontario Health Insurance Program. ii. Confirm resident’s capacity. iii. Does the resident have a grievous and irremediable medical condition (including an illness, disease or disability; see definition under eligibility criteria)? Confirm that all of the following grievous and irremediable medical condition requirements aremet: condition is serious and incurable; and resident is in an advanced state of irreversible decline in capability; and condition or state of decline causes enduring physical or psychological suffering that is intolerable and cannot be relieved under conditions acceptable to the resident; and natural death has become reasonably foreseeable, taking into account all medical circumstances. If not, other options should be explored. iv. Is the resident experiencing intolerable suffering (see definition under eligibility criteria)? If not, other options should be explored. DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 9 of 13 v. Has the resident’s request for MAID been made freely, without coercion or undue influence from family members, healthcare providers or others? (See definition of consent - Definitions and Associated Commentary). If not, other options should be explored. b. Confirm that the resident request meets legislated documentation requirements, e.g. written request and independent witnesses, etc. c. Determine and communicate to the resident if the medical or nurse practitioner assesses that the individual is eligible or ineligible for MAID. i. If resident is deemed eligible, the external medical or nurse practitioner will inform them of the MAID process involved, particularly of their ability to decline MAID at any point. Inform resident that they have a grievous and irremediable condition. Have the resident sign and date the written request after being informed that the resident has a grievous and irremediable condition. ii. If resident is deemed ineligible, the external medical or nurse practitioner will inform themof alternative options and the option to consult another medical or nurse practitioner to reassess eligibility. The medical or nurse practitioner should reasonably assist in identifying another medical or nurse practitioner to do the assessment. 3.Clarify resident eligibility determination – completed by external medical or nurse practitioner a. If the resident meets the eligibility criteria (outlined in 2a above), the externalmedical or nurse practitionerrefers to an independent medical or nurse practitioner not previously involved in the resident’s care for a second assessment of the resident’s eligibility. If it is unclear if the medical practitioner meets the independence requirement, medical practitioners should consult the Canadian Medical Protective Association. b. An independent external medical or nurse practitioner assesses the resident’s eligibility (criteria outlined in 2a above). DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 10 of 13 c. If the resident is deemed eligible, explore available options for offsite medical or nurse practitioner administration. d. Explore the resident’s preference and options for the setting for MAID, (e.g. hospital, hospice, familymember’s home, etc.). County of Elgin staff shall not provide nor allow external providers to administer MAID on site; shall allow assessors to come on site to conduct assessments; and, shall assist with transfers/transportation to external provider/resident location of choice. e. If the resident does not meet the eligibility criteria, the MRP or delegate provides the resident with an explanation regarding their ineligibility. i. Resident is informed that they may consult another externalmedical or nurse practitioner for an eligibility assessment. The MRP/medical or nurse practitioner should reasonably assist in identifying another MRP/medical or nurse practitioner to performthe assessment. ii. MRP repeats discussion of alternatives for care. 4.Plan for off siteMAID provision to an eligible person- completed by externalprovider (Medical or nurse practitioner). a. Key planning considerations: i. Confirming that the 10 clear days reflection period is fulfilled (unless resident’s imminent death or loss of capacity can be confirmed by two independent medical or nurse practitioners). Note: The term “clear days” is defined as the number of days, from one day to another, excluding both the first and last day. Therefore, the MAID reflection period would begin on the day after the resident request is made and would end the day after the 10th day (CPSO MAID Policy, 2016). ii. Identify an appropriate resident-centred location where MAID will be provided, (e.g. hospital, hospice, family member’s home, etc.). Note: If resident wishes to be an organ or tissue donor, this may affect the setting in which MAID can be provided in order to facilitate organ or tissue retrieval. iii. External medical or nurse practitioner discloses to resident that the Office of the Chief Coroner will investigate all MAID-related deaths. The extent of the coroner’s investigation cannot be determined in advance and may or may not include an autopsy (CPSO MAID Policy, 2016). iv. Confirm details of resident’s holistic end-of-life care plan, (e.g., who will be present, and any additional comforts that may be incorporated such as music, reading, pet visitation, etc.). DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 11 of 13 5.Provision of offsite (hospital, hospice, family member’s home, etc.) MAID a. Before proceeding, the external medical or nurse practitioner willconfirm the following: i. Resident is capable and wishes to proceed with MAID. ii. Required MAID and clinical documentation has been completed. In particular, ensure resident capacity and consent has been documented in accordance with the rules established with the enactment of Bill C-14 and the Home’s requirements. 6.PostMAID provision: Ongoing support, monitoring, and follow-up. a. Complete documentation (transfer of resident to location of choice arranged by resident and external provider) and any necessary reporting requirements – the medical practitioner reports the MAID details to the Coroner. b. Debrief with interprofessional team as well as the family regarding the MAID process and any opportunities for improving the process. c. Identify resources that healthcare practitioners may access to obtain additional support. Case Study –Mrs. Jones Mrs. Jones is an 82-year-old woman who by all accounts has been independent her whole life. She arrived at your home almost two years ago. She has been diagnosed with a disease that she has clearly said is causing her great suffering and that “she cannot take it anymore.” Her attending physician at the home has supported this clinically, confirming with her specialists that Mrs. Jones is suffering from a condition that has few treatment options left that she will agree to pursue. She says she is ready to die. Since Mrs. Jones is telling anyone who will listen that she knows that assisted suicide is now legal and that she wants it, this is upsetting some staff members. A few have gone into her room together to convince her that life is worth living, at all costs. Two of her adult children are very upset by her position; the third adult child says he doesn’t like it, but it’s her choice and she should be supported. Eventually Mrs. Jones instructs you to stop talking to her children about what she is asking for. The nurse manager on that floor reports that there is a real buzz among staff members, and the issue seems to be dividing teams. What would you do? What should you do? DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 12 of 13 Tips for staff approached by a resident raising the issue of MAID Listen well and try to respond thoughtfully. Think of the resident raising this as an invitation to a conversation they are asking to have. Acknowledge that MAID is legal in Canada, but that there may be a broader discussion required about their current situation and what is driving their desire to receive MAID, e.g., pain, fear. Ask whether the resident has raised this with anyone, such as his/her attending physician, staff of the home or family members. In this case, there may be some limitations if Mrs. Jones insists that you not communicate with her children; but a thoughtful discussion should occur with her, to establish what concerns she has in sharing information with family members. It may be a moment of frustration with her, rather than an absolute instruction. It is still important to have a nuanced discussion. Offer to bring the resident more information, and make sure that happens. Turn to the appropriate person in the home, e.g. a supervisor who will be familiar with the policy adopted by the home to deal with MAID Clinical team and senior leadership (and/or internal working group) Develop the means to explore the resident’s wishes regarding end-of-life care. What information does this resident need to make informed choices? Is the request for information about MAID (or a formal request to have it) grounded in pain and suffering? Have options for these been explored? Compassion and non-judgment must remain the focus. Be prepared to manage any discord between the resident and/or staff and family members, and keep the focus on thoughtful, productive discussions. Attend to staff needs as you would in any new or stressful situation, as these conversations may not be easy ones. DRAFTNEW HOMES ANDSENIORS SERVICES POLICY & PROCEDURE NUMBER: DEPARTMENT:AdministrationSUBJECT: Medical Assistance in Dying (MAID) APPROVAL DATE: March 2019 REVISION DATE: Page 13 of 13 References: AdvantAge Ontario Advancing Senior Care Toolkit: Medical Assistance in Dying: What You Need to Know Now, Updated Edition, November 2017 County of Elgin Nursing Policy: Palliative Performance Scale: PPS County of Elgin Nursing Policy: Palliative and End-of-Life Care County of Elgin Nursing Policy: Pain Management CPSO Policy Statement #4-16 Medical Assistance in Dying CPSO Fact Sheet: Ensuring Access to Care - Effective Referral College of Nurses of Ontario: Guidance on Nurses' Roles in Medical Assistance in Dying, May 2017 Changes since Approval the 7Floor, Frost Building South7étage,Édifice Frost Sud 7 Queen's Park Crescent7Queen's Park Crescent Toronto ON M7A 1Y7 Toronto ON M7A 1Y7 Telephone: 416-325-0400Téléphone: 416-325-0400 Facsimile: 416-325-0374 Télécopieur: 416-325-0374 Municipal Act, 2001 Municipal Act, 2001 Municipal Act, 2001 Municipal Act, 2001 Municipal Act, 2001 Planning Act GENERAL FINANCIAL SERVICES COMMUNITY & CULTURAL SERVICES COMMUNITY & CULTURAL SERVICES - COMMUNITY & CULTURAL SERVICES ENGINEERING SERVICES LONG-TERM CARE HOMES HUMAN RESOURCES LAND DIVISION PLANNING APPLICATION FEES TOURISM FEES PROVINCIAL OFFENCES SERVICE FEE GENERAL FINANCIAL SERVICES COMMUNITY & CULTURAL SERVICES – SERVICE 2 FEE COMMUNITY & CULTURAL SERVICES - SERVICE 3 FEE COMMUNITY & CULTURAL SERVICES – ENGINEERING SERVICES SERVICE 4 FEE LONG-TERM CARE HOMES SERVICE 5 FEE HUMAN RESOURCES LAND DIVISION SERVICE 6 FEE PLANNING APPLICATION FEES TOURISM FEES PROVINCIAL OFFENCES SERVICE 7 FEE