Algorithm Helps Change Ontario Policy on Assisted Living

Algorithm Helps Change Ontario Policy on Assisted Living

For four years, the “only thing” Dr. Norma Jutan thought about was assisted living for high-risk seniors. Well, perhaps there were other thoughts, but for this CIHI senior analyst, most of that time was spent entrenched in a PhD dissertation.

This is a story of what Jutan developed and how it changed government policy in Ontario.

Assisted Living

In 2008, Ontario started focusing on the assisted-living (a.k.a. supportive-housing) sector of the health care system. There was great potential there for a care setting that meets the needs of people who can no longer remain at home but are not yet in need of nursing home placement.

Assisted living (AL) is, essentially, an apartment with on-site services and health care professionals. For her PhD, Jutan discovered that one in five seniors moves from AL to a nursing home within a year of admission. The other four remain in AL, managing just fine, which shows that people can stay in the community and keep their independence within this care environment.

There was but one problem: which individuals were best suited for AL? Jutan’s research, based out of the University of Waterloo, has helped clinicians identify ideal candidates.


As the first step, the Ontario Ministry of Health and Long-Term Care mandated an interRAI (Resident Assessment Instrument) assessment for AL—similar to those already in place at the home and nursing care levels. These instruments are used around the world to assess people who live in many health care settings. They are also used by CIHI as part of its Home Care and Continuing Care reporting systems. interRAI assessments are the result of collaboration between clinicians and researchers in more than 30 countries, including Canadian Dr. John Hirdes—Jutan’s PhD supervisor.

Jutan’s core success was the DASH: Decision Algorithm for Supportive Housing. Data from the interRAI assessments feeds into the DASH, which then enables home and continuing care clinicians to determine which seniors are most appropriate for AL, home care or nursing care.

Jutan interviewed clinicians in home care, AL and nursing homes to find out which factors were most important when deciding about placement in an AL setting. Their answers, such as cognitive status, challenging behaviors and presence of a caregiver, guided the DASH’s creation. After four years of complex analyses, Jutan created a decision tree whose criteria laid the path to each possible care setting.

And there it was: the evidence needed to place the right client in the right care setting at the right time.

Ministry of Health Comes Calling

Meanwhile, the Ontario Ministry of Health and Long-Term Care had listed the factors it thought were important in making such decisions. Since Jutan was writing a PhD dissertation on the subject, the ministry asked her to collaborate as it updated its Assisted Living Services for High Risk Seniors Policy.

Jutan shared the DASH with the ministry to inform its policy change. As such, the DASH now defines the characteristics of high-risk seniors in Ontario’s AL policy, which was officially mandated last September. According to a ministry memo, the DASH has provided greater clarity for health service providers in assessing whether AL is the right service for each individual.

The DASH can now be used alongside other outcomes of the interRAI assessments to help Canadian health care providers determine the most appropriate care setting for seniors.

In university, dissertations typically lead to academic papers or presentations at conferences. Jutan’s was used to change policy. As such, it will help change the lives of aging Canadians.