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7 LONG TERM CARE SERVICES Patient Name: HCN: What is it? Special Behaviour Support Unit (SBSU) Letter of Understanding and Choice Agreement: The Special Behavioral Support Unit (SBSU) is a TREATMENT TRANSITIONAL Unit for patients who have a primary diagnosis of dementia with significant behaviors. The SBSU is not intended to be a resource for emergency treatment or intervention. What Can You Expect? Length of stay is dependent on progression in the program and in consultation with the SBSU care team Ongoing discussion i.e. discharge plan to ensure the most appropriate option is determined Linking with your MH LHIN Placement Coordinator to assist in your transition to a LTCH setting or home in the community Discharge from the unit Your family member will be discharged from this unit should any of the following apply: a) Your family member develops a complex medical problem that the unit cannot manage b) Your family member exhibits extreme behaviors that cannot be managed safely within the SBS unit. c) The care team determines that your family member requires hospital inpatient medical and/or mental health services Special Behaviour Support Unit (SBSU) ACCOMMODATION RATES Basic ($1,848.73/Month) Private ($2,640.78/Month) LTCH residents who do not have sufficient income to pay the full co-payment rate (i.e., have income less than the maximum basic accommodation charge and the comfort allowance) may be eligible to have their co-payment amount reduced. This is known as rate reduction and is available only to residents in basic accommodation. Agreement I have read the above for the SBSU and understand and agree to the above: Signature of SDM/POA Print Name: Date: Information subject to change without notice PS-108-SBSU Letter of Understanding and Choice Agreement June 2018

8 Special Behaviour Support Unit Application Checklist Patient Name: HCN: Clients that have significant behavioural disturbances Primary diagnosis of a progressive dementia Clients that have been assessed by a Psycho Geriatric Outreach Program and are still exhibiting some significant behaviours Clients that are ambulatory or a light 1 person assist to transfer. If clients, who are more than 1 person transfer, are in wheelchairs to manage their dementia rather than a physical challenge, they may also be considered for the unit. Due to the nature of the unit, SBSU does not consider anyone who requires very heavy medical care, has a primary diagnosis of a psychiatric illness, and/or requires tube feeds. Health Assessment Form MOHLTC (Completed by Doctor, RN or NP) Inter-RAI HC Full (AOC eligible) - (Completed by CC) Capacity Evaluation for LTCH Placement (Completed by CC) Behavioural Assessment (Completed by CC, information gathered from all collateral sources) Application for Determination of Eligibility for LTCH Admission Form (Consent) (Capable patient: signed and dated; Incapable patient: signed and dated by POA/SDM) Choice Form (Incapable Patient: Signed and dated by POA/SDM.; Ranking and Accommodation of choices checked off) Letter of Understanding (Incapable patient: signed and dated by POA/SDM) Determination of Eligibility for Admission to a LTCH (Completed by CC) Wait List Prioritization Form (Completed by CC) Notes and other Reports (BSO, PRC, RRN, Outreach team, ADS) Medication List and Treatment Administration Record Inter LHIN Communication Form (External LTCH choices) Notice of Assessment (If applicable) POA Personal Care (If applicable) POA Property (If applicable) Smoking and Alcohol Assessment (If applicable) Physician name/address/phone CHRIS contact address/phone for all SDM/POA Etobicoke Office Mississauga Office Milton Office Tel: The West Mall, Suite North Sheridan Way, Suite Holly Ave., Unit 203 No area code required Etobicoke, ON M9C 5J5 Mississauga, ON L5K 2P8 Milton, ON L9T 0K4 PS-108-CVC/Restore-Checklist Revised June 26, 2018