Design of PC’s new Ontario Autism Program falls short of needs-based recommendations from Advisory Panel

Premier Doug Ford and Minister of Children, Community and Social Services Todd Smith

New details have emerged on how the new Ontario Autism Program will be structured and it has many in the autism community alarmed. Social media attention to a call for applications for the Ontario Autism Program Independent Intake Organization have left many to speculate that the program is returning to it’s problematic benchmarking days. Here’s my attempt to breakdown what we know and don’t know about the design of the new OAP’s Core Services.

Care Coordinators and a way to evaluate needs is not a new development

1. The Ontario Autism Advisory Panel Report recommended Care Coordinators and a process to forecast needs:

A standardized clinically-informed process developed by discipline-specific clinicians and researchers with expertise in the field of autism should be used to forecast each child’s support needs to the ministry, to enable other children to be moved off of the waiting list. This process should be developed by clinical and research experts and implemented by a Care Coordinator.

The key word in this recommendation is forecast. The panel further explained:

Once the family receives their discipline-specific clinical assessment(s), it is recommended that the clinicians report their proposed service plans back to the Care Coordinator, who would then be responsible for updating/refining the forecasted service plan and funding needs to the Ministry.

I’ll come back to this element later when contrasting against the Ministry’s design.

2. At Minister Todd Smith’s December 17, 2019 press conference he announced that core services would not be available by April 2020. His excuse was the design gaps in the panel’s report regarding service and duration caps, transition in service, and the role of the Care Coordinators. He also made reference that it would take time to get the “Needs based tool that the Care Coordinators will be using”.

3. The Ministry’s Implementation Working Group mandate included service caps and the creation of “needs levels”. I wrote about this back in December 2019 (see thought #4), noting:

It’s very interesting that bureaucrats have slipped in “no fewer than 5 levels of need”. This cannot be found in the Ontario Autism Program Advisory Panel Report. Couple that with core services being capped based upon service and/or duration and we’re prime for a system of benchmarks

It was at this point that the Ministry injected program design that differed from that of the Ontario Autism Advisory Panel Report.

What’s revealed in the Independent Intake Organization Call for Applications Guidelines document

1. The Independent Intake Organization (IIO) is structurally different from the previous iterations of the autism programs in Ontario. Some on social media are suggesting the intakes will be done by the ministry itself, this is incorrect. The IIO will be an arms-length organization, but yes they’re contracted by the Ministry.
2. The ministry is awarding a contract to an organization to enable a system of 5 Regional Service Networks (RSNs) to coordinate service delivery.
3. Organizations have until February 26, 2021 to submit their applications. The winning organization “will assume responsibility for key program functions of the new needs-based OAP beginning in Spring 2021.” Other program features will be phased by 2023–24.
   Does this mean that kids eligible for entry into Core Services will have their funding allocation by Spring 2021 (Spring starts March 20)? Unlikely. It’s going to take time to set up the system, let alone process the needs of each child. I hope they’ll focus on the waitlist kids first, after all by March 20 it will 2.5 years since Lisa MacLeod froze the waitlist! The mandate states that a minimum of 8,000 kids are to move off the waitlist. Legacy program kids that have active behaviour plans should be processed afterwards so as not to delay waitlist kids getting therapy.
4. The IIO is restricted from delivering services, hence the “independent” in the IIO. This is the significant difference from the old Autism Intervention Program (AIP) where the Direct Service Providers themselves determined level of need based on benchmarks. It was the Goldilocks system where a child’s progression had to be “just right” to stay in the program. Many children were denied service or discharged from service prematurely by hitting the benchmarks too quickly or not progressing fast enough.
5. The IIO’s RSNs will employ Care Coordinators who will determine the level of need of each child via a “standardized clinically-informed process”. This term has been criticized on social media, but note that this the exact phrase used in the Ontario Autism Advisory Panel Report. This is also “the tool” that Minister Smith refers to. The document provides zero details on what this tool will look like.
6. The Ministry calls out this distinction between a Care Coordinator and a clinician: “The determination of needs process is separate and distinct from the clinician-based assessment that would be completed by a clinician as a first step of core clinical service provision.” Huh? I think what this is saying is the “determination of needs process” = your annual spending level, and once you have your money allotted you can provision core clinical services where a clinician will put together an assessment and treatment plan. If this is correct, this is what has many livid. “Needs Based Therapy” is to be determined by the qualified clinician, whereas under this scenario the clinician has to work within the funding allotment the Care Coordinator determined. I’m pretty sure this is what is planned, hence why the concept of a “Dispute Resolution Process” is also introduced in this document. Contrast this with the panel’s recommendation for the Care Coordinator’s to use the tool for forecasting followed by a forecast realignment based on the clinicians assessment, and you can see that the Ministry is taking great liberties in implementing the panel’s recommendations. This is a needs determination switcheroo, taking away the prescription of treatment from qualified clinicians in favour of Care Coordinators that will place you into one of Todd Smith’s 5 levels of need which is likely a spend bracket.
7. The IIO will distribute funding either directly to families or to service providers. This is a family choice. You’ll also have to reconcile invoices with the IIO. A web portal is being developed that will allow you to submit invoices online.
8. Needs will be assessed at least yearly. This could be a painful experience for those that dispute the Care Coordinators needs determination. Just what parents of children of autism need, more stress!
9. The Ministry will set waitlist management performance expectations with the IIO. The performance expectations are not defined in the document. This could be harmless, or has the potential to be a waitlist churn mechanism, as in the Ministry could set expectations to move out a certain percentage of kids each year to take in new ones. If so, let’s all agree to rename the Care Coordinators to Churn Coordinators!
10. It’s estimated that Care Coordinators will need one day of training to learn the standardized tool. Much has been made of this on social media as 1 day of training seems rather light for a role that will dictate the funding level your child will receive in the new OAP.
11. Care Coordinators will have a maximum caseload of 80 families. We don’t know how many children will be in Core Services at once. If there’s 15,000, then at least 188 Care Coordinators will be required.
12. Some new statistics were revealed. The age distribution of children and youth registered for the OAP is 8%-11% 0–3 years of age, 24%-29% 4–6 years of age, and 59% to 68% 7–17 years of age.

Cause for significant concern that the new OAP won’t be needs-based

The autism community rightfully should be very concerned with the design of the new OAP. There are many important details that are still unknown, which will continue to cause much speculation. Will the OAP become a nightmare benchmark-based program that promotes waitlist churn, and causes already fragile families more distress as they have to fight for their child through a dispute resolution process? We simply don’t know enough details to say.

One things for sure, the Ministry is creating an expensive administrative function that will unfortunately eat into the OAP budget, reducing the amount of dollars targeted towards therapy. That is a shame. The legacy OAP program could have been tweaked to add checks and balances to clinician’s therapy programs which would have kept things needs-based with caps. That’s how things are done in healthcare. You trust the clinicians, but also set some boundaries. Ah yes, perhaps that’s the biggest problem at the end of the day. An OAP administered by a social services ministry is never going to get a healthcare program right.

One last thought, by the time the PCs get this program up and fully running, we’ll be in another election cycle with the next election due by June 2022. Depending on who wins the next election, we could be looking at yet another revamp of the program in the near future.