Monday 1 February 1993

Long Term Care Statute Law Amendment Act, 1993, Bill 101

Subcommittee report

Ministry of Health; Ministry of Community and Social Services

Hon Frances Lankin, Minister of Health

Geoffrey Quirt, acting executive director, long term care division, Ministry of Health and Ministry of Community and Social Services

Gail Czukar, counsel, Ministry of Health

Ian Matthews, counsel, Ministry of Community and Social Services

Patrick Laverty, director, policy branch, long term care division, Ministry of Health and Ministry of Community and Social Services


*Chair / Président: Beer, Charles (York North/-Nord L)

Vice-Chair / Vice-Président: Daigeler, Hans (Nepean L)

Drainville, Dennis (Victoria-Haliburton ND)

*Fawcett, Joan M. (Northumberland L)

Martin, Tony (Sault Ste Marie ND)

Mathyssen, Irene (Middlesex ND)

*O'Neill, Yvonne (Ottawa-Rideau L)

Owens, Stephen (Scarborough Centre ND)

White, Drummond (Durham Centre ND)

Wilson, Gary (Kingston and The Islands/Kingston et Les Îles ND)

*Wilson, Jim (Simcoe West/-Ouest PC)

Witmer, Elizabeth (Waterloo North/-Nord PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Carter, Jenny (Peterborough ND) for Mrs Mathyssen

Hope, Randy R. (Chatham-Kent ND) for Mr Drainville

Jamison, Norm (Norfolk ND) for Mr Gary Wilson

Marland, Margaret (Mississauga South/-Sud PC) for Mrs Witmer

O'Connor, Larry (Durham-York ND) for Mr Owens

Sullivan, Barbara (Halton Centre L) for Mr Daigeler

Sutherland, Kimble (Oxford ND) for Mr White

Wessenger, Paul (Simcoe Centre ND) for Mr Martin

Clerk / Greffier: Arnott, Douglas

Staff / Personnel: Drummond, Alison, research officer, Legislative Research Service

The committee met at 1402 in committee room 1.


Consideration of Bill 101, An Act to amend certain Acts concerning Long Term Care / Loi modifiant certaines lois en ce qui concerne les soins de longue durée.

The Chair (Mr Charles Beer): I would like to call this meeting of the social development committee to order. We are gathered, dear friends, this afternoon to hear from the minister and from officials from the ministry with respect to Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: Before we turn to the minister, I just want to report to all members of the committee that the subcommittee met on two occasions, and we need to have the approval of that report.

Mrs Joan M. Fawcett (Northumberland): I move the adoption of that report.

The Chair: Ms Fawcett has moved the adoption of the subcommittee report, which you should all have in front of you and which sets out the schedule of meetings between now and the completion of the committee's work. That being moved, all in favour? Approved.

I would just note that at the completion of hearings this afternoon, if the subcommittee members could stay behind briefly, there are a couple of matters I'd like to raise with you.


The Chair: That being said, I'd like to welcome the Minister of Health, the Honourable Frances Lankin, to our hearing. Minister, we thank you for coming today and beginning these hearings with a presentation. I believe there are a number of members of the ministry who are also here. We welcome them, and if you would like to proceed with your opening remarks.

Hon Frances Lankin (Minister of Health): I will take the opportunity a little bit later in my remarks to both thank and introduce the various officials who are here from both the Ministry of Community and Social Services and the Ministry of Health. But joining me at the table right now are Gail Czukar, who is the legal counsel person assigned as lead legal counsel with respect to this bill, and Geoff Quirt, who is the acting executive director of the long-term care policy. Mr Chairman, you will certainly know Geoff from your past responsibilities in this area.

I intend to stay pretty close to the written text that has been circulated to you, which my staff think I can't do actually. It's unusual for me, but I intend to do that so that we can read into the record what we see as the prime reasons for the bill, what we hope to accomplish with the bill, and some areas where we expect that we will be hearing from people as they come forward before your committee and hopefully hear from you in your recommendations with respect to those areas as well.

As I indicated in the Legislature during the second reading debate on Bill 101, I'm certainly pleased to have this bill referred to the social development committee for review and I look forward to hearing the opinions of the members and the presenters as the public hearings proceed. It's certainly useful to have this opportunity to participate with the committee in examining these important amendments, and I look forward to the members' constructive suggestions for achieving our objectives in long-term care.

I'd like to begin by briefly outlining the purpose and scope of the bill and the consensus achieved on essential issues during the course of extensive consultations. If I might, I'd just comment that the consultations that took place were very broad across the province. There were thousands of people who individually presented their own views and who, on behalf of organizations and families of clients and care givers, came forward and took part. So we actually heard a tremendous amount during that period of time which is very helpful to us in terms of developing our overall approach to the redirection of long-term care.

The purpose of this bill -- and I want to stress that this is only a part of the whole picture. I know that is an issue of concern for members of the Legislature wanting to see how it will fit within the whole picture, but I think that the five major policy goals that are set out in terms of the provisions of the amendments to the various bills are things that we can agree with up front, irrespective of what the overall redirection looks like.

Our first goal is to achieve equitable and needs-based funding for long-term care facilities. Currently, the funding arrangements differ for nursing homes and charitable and municipal homes for the aged, and there has been a great deal of work done on behalf of parts of the community out there with respect to this issue over the years and the need to bring about equity. Amendments to the current facility legislation will replace the existing arrangements with a consistent approach to funding which is based, in part, on the nursing and personal care needs of residents.

These changes will result in improved accountability in relation to both financial management and service quality and provision. Strengthened accountability to residents, to their families or representatives and to workers, as well as to government, is the second goal that we've set out for ourselves in this bill.

The amendments also will result in a consistent facility resident payment policy, which is our third policy goal. Residents will be asked to contribute to their accommodation costs only. The province will continue to pay for nursing and personal care. Residents' ability to pay will be based on their income; assets will not be included. No one will be refused care because they lack income.

Bill 101 will also enable us to meet our fourth goal of establishing a single point of access to facility services. Placement coordinators will assist in streamlining and simplifying access to long-term care facilities.

Finally, our fifth goal is to be able to make payments directly to adults with disabilities so that they can purchase and self-manage their own support services. This goal addresses the essential importance to consumers of maximizing dignity and independence, which was stressed as an overarching need and preference of both seniors and adults with physical disabilities during the consultation process.

Bill 101 will amend the Ministry of Community and Social Services Act to create authority for the minister to make direct payments and enable us to meet that goal.

Bill 101 is an amending statute and it is the beginning of a reform process that will result in major restructuring of long-term care and support services for elderly persons, adults with physical disabilities and people who need health services at home. The amendments will enable the implementation of very specific strategies that will correct several long-standing deficiencies in services for elderly persons requiring residential care and the range of independent living options for adults with physical disabilities.

Again, I should stress for everyone that we see this as the very beginning. This is an amendment to a series of existing acts that deal with residential services in the whole long-term care field, and this is only part of the overall policy response to the redirection of long-term care that the government will be bringing forward.


For example, the bill does not address new models for local community planning and the integration of health and social long-term care and support services. That's apart from the purpose we have here. We do expect that there will be further legislation that will be brought forward in a second phase of legislative action around long-term care redirection.

You will recall that I indicated in my statements to the Legislature in November and December that a report on the highly successful public consultation and the resulting policy decisions would be ready for release in January. Mr Chairman, given your extended involvement with the long-term project, I know you will appreciate the amount the time, energy and detailed work involved in a reform of this type.

As the Ontario Community Services Association said in its brief on redirection, "We have a once-in-a-lifetime opportunity to get it right," and we certainly intend to live up to that mandate.

Although we're very close to finalizing the policy development process, we are now targeting the end of March for the release of our public document. In the meantime, work continues on a number of fronts, most importantly with the district health councils, which will be key players in implementing policy decisions and doing the planning work on the local level.

I've already asked the councils to assume the lead role for long-term care planning in their communities. They will be restructuring their long-term care planning capacities to bring in the full spectrum of stakeholders, including representatives of municipalities, social service planning and delivery sectors and consumers. DHC long-term care subcommittees will undertake the developmental work required to create local, comprehensive multiservice agencies that, when fully implemented, will integrate case management and service delivery functions to provide consumers with a single point of access to a full range of long-term care services.

Planning is also under way now for a conference soon after the release of the policy paper and implementation guidelines. The conference will provide an opportunity for key stakeholders in the redirection to roll up their sleeves and work together to develop the next steps of the redirection process.

Bill 101 reflects the outcome of the consultation with service providers and consumers, who, along with the members of the Legislative Assembly, have been called upon during the past decade to consider and comment on proposed strategies for reforming the nursing homes and homes for the aged programs, particularly in the areas of funding, resident payments, access to services and assuring quality of care and financial accountability.

From the perspective of the consumer, advocates and the general public, the consensus has always been that it is the obligation of government to ensure that the residents of these homes are treated equitably, that the highest quality of care is provided and that financial accountability for public funds is achieved. Consensus has now been reached among service providers, residents, their families and representatives and the government on the need to adopt a consistent approach to funding homes and resident payment policies. This was the message to us during last year's public consultation, in which 75,000 people participated in some 3,000 local meetings across the province.

Since the introduction of the first attendant care program in Ontario nearly 20 years ago, increasing numbers of adults with physical disabilities have demonstrated their ability to live independently when the appropriate supports are available. For some time now, many consumers have been stressing their desire to have more control over the services they use and indicating their willingness to take responsibility for their own service arrangements.

Over a number of years, individuals and consumer groups have submitted proposals to the government, and consensus has been achieved on the benefits to the individual and the government of the direct funding model of service. The arguments are sound. We have heard them, and we are now acting on them by creating a new authority for the direct funding service model through an amendment to the Ministry of Community and Social Services Act.

At this time I would like to review in further detail what Bill 101 will change in current facility services and how those changes will be made. Later this afternoon our legal staff will provide you with a technical explanation of how these and other changes are achieved within each statute.

First of all, amendments to the Nursing Homes Act, the Charitable Institutions Act and the Homes for the Aged and Rest Homes Act will change to provide provincial funding arrangements, resident payment schemes, access to facility care, and requirements for accountability to consumers and government.

Turning first to funding, the three distinct funding methods currently in effect for nursing homes and the two types of homes for the aged will be replaced by a uniform funding scheme for all homes. In the present system, one home caring for an elderly person with high levels of personal care and monitoring may receive less provincial funding than another home caring for a person with exactly the same level of need. It's certainly not fair to either the residents or the operators.

Bill 101 will change that by establishing a common approach to funding all three types of homes which will achieve consistency in the amounts of provincial funding available to each home for the provision of care and services to residents. The existing extended care per-diem scheme, the cost-sharing arrangements between the province and charitable and municipal homes for the aged and the extended and residential care levels will be eliminated and replaced by a new funding scheme and resident classification procedure.

The new levels-of-care funding methodology bases funding levels in part on the actual nursing and personal care needs of residents, as determined through an annual classification survey of all residents of homes. The classification, as I'm sure you are all aware, is based on the Alberta classification tool, which has, however, been adapted and modified for use in Ontario. Each year, the results of these surveys will provide a basis for calculating the portion of the total provincial funding available that is to be provided to each facility to meet the mix of resident nursing and personal care needs. Separate amounts will be allocated to all facilities to assist with the cost of programs and accommodation for residents. With the introduction of the levels-of-care classification scheme, for the first time in Ontario we will have a method of documenting the changing needs of the residents of nursing homes and homes for the aged. And that's the first step in creating a more responsive, needs-focused system of facility care.

Bill 101 will change the current schemes for charging residents, which vary significantly depending upon whether a person occupies a residential or extended care bed. In some cases now, residents are charged not only for their accommodation but also for essential care. Two elderly persons with identical needs may be charged at two different rates depending on the type of home or bed they occupy. In addition, both income and assets are assessed at present in determining the ability of the resident in a residential care bed to pay, whereas every extended care resident would pay the same standard rate. Some residents may have to deplete their assets; for example, sell a home. Others may have their assets attached by the home for the aged to cover the cost of their care and maintenance.

The amendments will enable us to achieve our objective of establishing for all homes a uniform scheme for resident payments and to eliminate the current lack of equity in how and for what items residents are charged. Residents will be expected to contribute to their accommodation costs only, that is, for room and board. No charges will be permitted for provincially funded nursing and personal care and services. The current means test of ability to pay will be replaced by a simple, straightforward test of income. Residents who indicate that they cannot afford to pay the full accommodation fee may request a reduction in the rate.

For most residents, the income test applied will be based on whether the person receives the federal guaranteed income supplement and the amount received. The amount of the GIS received would be established by having the person provide a cheque stub or letter from the federal Department of Health and Welfare. The greater the income supplement, the greater the reduction in the fee. Where residents are not able to pay the full cost of accommodation, the province will provide funds to the home to cover the balance of the resident's payment for his or her accommodation. An alternative form of income test will be used for a small number of persons such as immigrants with limited means who would not be eligible for the guaranteed income supplement or other forms of assistance, since they do not meet residency requirements. As I stated earlier, no one will be denied care because they are unable to pay.

I would like to note that all residents will continue to retain a personal needs or comfort allowance for discretionary spending. This allowance is currently $112 per month and will not be affected by the amendments.

Bill 101 will result in a significant change to the way in which a consumer obtains access to care in a nursing home or home for the aged. After many years of listening to the pleas of elderly persons and their spouses and other family members for some mechanism that would help them locate appropriate residential care in a timely fashion, Bill 101 is responding.

The amendments will establish a province-wide system for coordinating and managing access to facility services that will enable us to achieve two fundamental objectives. We want to ensure that those in the greatest need have a priority of access, and, second, that all community-based service options are explored prior to facility placement.

Accordingly, the amendments assign these responsibilities to a placement coordinator, designated by the minister, and enable the establishment of a uniform system of local placement coordination that will make these objectives a reality across Ontario.

Finally, Bill 101 will change substantially the accountability relationship that the home has with the residents and their families or representatives, and with government. The amendments will introduce for the first time in Ontario a consistent framework for accountability in all three types of homes and enable us to achieve our objective of enhanced accountability to facility residents and the taxpayers of Ontario.


The key components of this framework, which were outlined in some detail during the second reading debates, consist of new requirements that all homes enter into a service agreement with the province which will set out the care, programs, accommodation, services and goods to be provided to residents and the amounts of provincial funding.

The service agreement will require that homes comply with the standards set out in a new program manual that is being developed in collaboration with advocates, consumer groups and service providers. We anticipate that further refinements will be made to the manual after stakeholders have had experience using it.

We'll develop a plan of care for each resident admitted to the home. The resident and his or her family or representative must be involved in the development of the plan, and the amendments also contain a specific obligation for the home to provide the care that is outlined in the plan.

We'll also provide for the development and implementation of a quality assurance plan. Our intent is to ensure that the home involves staff and residents in the development of the plan.

Homes will also be required to meet enhanced standards for care and services, meet enhanced financial reporting and reconciliation requirements and comply with specific obligations to share information with residents, their families and representatives and staff of the home as well as government.

I would like to take a moment, Mr Chairman, to expand a bit on the requirements to share information with residents, as I believe that unless we make it possible for residents, their families and their representatives to understand and assess what a home should be doing or is doing on their behalf, with their contribution and that of the taxpayer, we will have done little to reduce their vulnerability or to empower them in their dealings with the home.

To ensure that essential information is provided, homes will be required to give every resident a written notice outlining the accommodation, care, services, programs and goods the home is required to provide under the act and service agreement and the resident's right to request access to and an explanation of his or her plan of care.

The written notice must also identify procedures for a resident to make complaints regarding the maintenance and operation of the home, the conduct of the staff of the home, the treatment or care received by the resident, and any additional matters that would be set out in the regulations.

The amendments also require that the homes post within the home a copy of the service agreement between the home and the province, copies of certain financial statements and other documents, and information as required by the regulations.

Finally, in order to ensure that these requirements are met, the amendments will establish a uniform system in all homes for monitoring, assessing and achieving compliance with the act, the regulations and the service agreements. It will enhance powers of inspection and will improve the range of sanctions for non-compliance that are available to the government.

I'll just comment at this point that members might know there's a very different approach in terms of monitoring and ensuring compliance currently in homes for the aged and nursing homes, and powers of inspection differ greatly. This will bring about some enhancement and uniformity across the system. The approach to monitoring will continue to be based on a consultative, collaborative relationship between government and the service provider.

In closing, Mr Chairman, I'm certainly willing to respond to any issues and questions that are raised during the course of this process. I wanted to comment that during the second reading debate I listened carefully to a number of the concerns that were expressed by members. Comments were made about the fact that we're proposing to describe the rules governing day-to-day operation programs in regulations, in the facility sector in particular, rather than in the acts themselves.

I want to say that I understand this concern and I'm sensitive to it and want to work with the committee in terms of its recommendations around this. I think there are some areas in which it is prudent to allow the system to work under the new regulations and the provisions and to have the flexibility to adapt as we go along, and there are other areas where we will want to make sure that the concrete consensus that has developed is enshrined in legislation right from the beginning.

I think, for example, with respect to some of the funding mechanisms under levels-of-care funding that as we experience this and work with the homes in this kind of major change, it is most prudent to have the actual formulas set out in regulations so that there is the possibility of responding to needs in the sector, as we have done in the past. I would point to the kind of bridge funding mechanisms that we've put in place in the past year to try and assist the sector during very difficult financial times, particularly in this case the nursing homes and charitable homes for the aged sector.

We were able to do that through regulation changes. If those mechanisms were enshrined in legislation, it would take an act of the Legislature, and we know the length of time that would be involved in that. I think in some areas we need to be sensitive to the need for that flexibility, while ensuring that as much is put in concrete legislative language as possible so that our main concerns as legislators are dealt with.

One of the other areas that I know was raised, a particular comment by members during second reading debate with respect to this concern about what is in legislation versus regulations, was the issue around eligibility criteria for admission to both the facilities and to any kind of direct funding project for adults with disabilities. In this case, I would say again this is something we want to continue to work with in a consultative way, and I think we're most able to do that if we are dealing with regulations.

Particularly, let me talk about the direct funding. This is an area where we have taken the step of saying that we are going to do this, but we want to work to develop it in conjunction with constituents from that community, persons with disabilities who have been living with attendant care, who can best describe to us what their needs are and how the program needs to be designed. They have expressed very directly their desire to be involved in the design and in the testing and in the monitoring and evaluation of any programs such as this. If we were at this time to attempt to establish the eligibility criteria and write them into legislation in the fullest of descriptive ways, we might find ourselves bound in a way that doesn't give enough flexibility for us to monitor and evaluate and to change.

However, having said that, I will certainly be prepared to give full consideration to any suggestions that emerge over the next few weeks in this area in terms of the sensitivities of legislators with respect to that balance between legislation and regulation, and of course in terms of other areas that come forward from those who have been presenting to the committee.

I'd like to take an opportunity to introduce the staff from the ministries who will be involved in this project or this bill as it goes forward and who will be participating in the hearings as you receive the technical briefing and hear from members of the public.

I've introduced Gail Czukar. She's from the Ministry of Health, legal services branch, and as I said, is the lead counsel for this project. Ian Matthews, who's sitting in the front row, is counsel from the legal services branch of the Ministry of Community and Social Services. Geoff Quirt, beside me, is acting executive director to the long-term care division, and Patrick Laverty, in the front row, is director of the long-term care policy branch. Just behind Patrick is Louise Hurst, policy coordinator for legislation development. In terms of my staff, Peter Block is my legislative assistant who will be working with you, and Lin Grist is a policy assistant, long-term care, from my office.

I want to thank all of these people, and others who've participated in the policy and legislation development process, for their hard work and persistence in helping me to bring forward this legislation.

I share the conviction of the Ontario Community Services Association about the need to seize this once-in-a-lifetime opportunity to get it right. What we need to do is get it right for consumers, many of whom have told us that they feel as if they've been waiting a lifetime to see the goals of more equitable funding, greater accountability, consistent residents payments, improved service access and independence and dignity become a reality. I hope that Bill 101 is our opportunity to do just that.

Mr Chair, I'd be pleased to both listen to and answer any questions that I can that may come from other members, and I would take the opportunity also to rely on ministry staff who are here to assist me with answering any questions.

The Chair: Thank you very much, Minister. I understand as well that at some point you will have to leave for another meeting, so my thought was that we would first move to the two critics and let them express their thoughts, ideas, questions, whatever, and then take questions from other members of the committee.

Just in terms of having a sense of time, what time do you feel you would be able to stay here for, another hour?

Hon Ms Lankin: About 45 minutes, if that meets the time. If that puts too much pressure on the two critics, then I will extend my time here and just be even later for the other meeting.

The Chair: If it's agreeable with the critics, perhaps we'll start with providing 15 minutes to each of the critics and then we'll move to questions from members of the committee. Okay? Ms Sullivan.


Mrs Barbara Sullivan (Halton Centre): We are pleased today to start what will clearly be a well-attended group of public hearings with respect to this piece of legislation. I think one of the reasons the committee meetings over the next few weeks will be well attended is that there is considerable confusion and some concern about where in fact the government is going in terms of its long-term care plans, and whether in fact those ultimate policy decisions and implementation decisions will meet what are seen to be real needs in the community.

This bill, having come forward, speaks really to one or two small components of long-term care reform. I want to speak specifically about Bill 101, the level-of-care funding issues, but as well about how difficult it is as a legislator -- I think people on all sides of the House will find this to be the case -- dealing with this particular bill in a vacuum, without the combined sense of what other portions of long-term care policy will be implemented and placed on the table, when they will be implemented and how they will be implemented, and what that will mean in terms of delivery of care, either in the home or in a facility, over the longer period, and how demographic change and other change is taken into account, whether it's a structural change in the health care industry itself or changes in delivery of services in the community.

How those issues have been taken into account very much impact on our assessment, frankly, of the viability and usefulness of this bill.

My party, in the past, has clearly subscribed to the concept of the need for level-of-care funding as part of the continuum of service in facility-based care. We concur that the right services should be given at the right place by the right person -- I think the coalition of seniors coined that phrase -- and that studies in the past have shown that the acuity of patients in a nursing home or in a community or municipal home for the aged or a charitable home for the aged is not much different. I think statistically there is some difference of about 17%, but it's not substantially different in terms of care needs.

What we see, however, in this bill is a number of components associated with equalizing service or ensuring equitable service delivery between those two types of facilities being proceeded with without the other information and data or apparent government support for other services in the long-term care field.

When we looked at this bill in the beginning, believing that this was going to be the only long-term care legislation on the plate -- although I understand that some of your officials, although not you, have said that is not the case, that we will be having another long-term care bill latterly, although not in this session -- we had to look at it and say, "What's being left out?" other than the one or two very short, curt statements of intent with respect to palliative care, which were welcome but not explored in any way.

The chronic care role study, a singularly important component of long-term care health service delivery has been left out. The role study is not available; therefore the issue is being left out of the discussion. The issue of rehabilitation, the institutions and the cooperation between community-based rehabilitation services and those services which are contracted for delivery within facilities has been left out.

We have, in this bill, discussion of the placement coordinator. There is no sense of where that placement coordinator will fit in terms of, by example, the discharge planner in the hospital and other community services that are in place, depending on the community in Ontario in terms of finding appropriate places for people who require care.

We see in my community, by example, that we have placement coordination services. We are one of four in the province which has an independent board of directors. We don't know if that is what you are contemplating as the direction for the placement coordinators, or are you looking at something completely different and new and that the kind of placement services offered in my area will be thrown away and a new base come forward?

We've seen no indication, by example, of where you're going in respite care. We know there is going to be increased dependence on care for seniors or others who require long-term care from their own informal care givers. We don't see any indication of how the integration of the facility-based services with respite care in the home or in the community will proceed. We see no direction or discussion at all of the requirements for dental care services, although we know it is anticipated that will be included as part of a service agreement, no discussion of to what level, of what concern of the current residents will be met, and similarly with lavatory and pharmacy services. Assistive devices fit into the same strain.

We see no other -- I think this is a key issue that has not been adequately addressed in any way to this point -- indication of how community-based services will be enhanced, and I think that's a clear lack. We want to be very certain that some of the studies that have taken place in America which show community-based services frequently being an add-on rather than an alternative to facility services -- they have in fact increased health care costs.

If community-based services are going to be very much a part of the long-term care strategy, then we should already have had, first of all, a policy indication from you as to where we're going in that area, and secondly, an indication in terms of dollars that the enhancements are going to come forward.

Home care in virtually every community in Ontario has gone through a period of shrinkage in the ability to provide services, and if there's going to be a heavier dependence on community-based care, home care and other care which is delivered through service agencies in the community, then we'd better see first of all the policy statements and the money that goes with them to ensure they're in place.

We see, as we're looking at this particular bill, a lot of problems in that so much of it will be prescribed through the regulations. We see that those regulations will prescribe everything from how a person can be admitted to what can be charged to what the grounds for refusal are. We see no basis of appeal in any of those circumstances. The criteria, the process for the determination of eligibility, all of that is done through regulation.

We don't see, because it's not before us, the kinds of standards that are going to be required from nursing homes and from homes for the aged, how the accountability is going to be enhanced or perhaps detracted from.

I suggest to you, by example, that most homes for the aged have independent boards of directors. Where will they fit, given a new service arrangement that is now going to be prescribed by regulation and around which there is going to be very little freedom for discussion? It's going to be a reg. They're going to have to comply. What happens if there is a conflict between the accountability methods required by the new regulation and the accountability required by the existing board of directors?

We see that your bill emphasizes a quality assurance program in these institutions and I'm asking you, frankly, if the legislation in fact is talking about the right quality programs. I'm wondering if you don't mean a CQI program rather than a quality assurance program. They're very different things. It seems to me that if we want an emphasis on improving quality, then we've used the wrong words in the bill, and I think that should be addressed directly as we go through this process.


The service agreement is also problematic, once again not being a public document at this point. My understanding is that there are some drafts circulating, but they certainly have not been made public outside the industry. It appears that there's no appeal or no other method for public interjection into the approach and drafting of those service agreements. One doesn't know, by example, if there will be independent service agreements with each facility that are substantially different from another facility or what will be the common threads between them.

We don't know what upper end there is, by example, on the requirements of a facility to provide service. Through the service agreement, will the ministry be able to require a facility to provide health care and medical service delivery above and well beyond that which is required now and that which is now offered in either the acute or chronic care setting? Those kinds of issues will all be included in the regs, but we have no opportunity to look at them and discuss them in a more complete way.

I'm sure that people in the industry themselves, as well as consumers, will be asking those very kinds of questions: What levels of service will you expect? How will they be changed? Where will you be requiring homes to usurp what has been traditionally seen as the responsibility of an acute or chronic care facility?

I am disturbed that chronic care, although clearly a long-term care facility, whether it's delivered in a hospital that is exclusively a chronic care hospital or whether it's delivered in association with an acute care hospital, is in no way addressed by this bill and appears not to be addressed through other areas so far that we've heard you speak of with respect to the long-term care strategy.

We understand that the current thinking in the health care industry is that this government has made a mess of its planning at the Perly Hospital in Ottawa, and that this is the generally accepted understanding of what has occurred there. We will have representatives from the Perly speaking with us. The sense, among certainly the chronic care industry experts, is that the government's approach to chronic care is without much understanding of what in fact chronic care institutions and facilities deliver and why they need to deliver those particular services.

In my view and the view of my party you cannot talk about long-term care without discussing the chronic care issues, where there are enormous acuity needs, and we just don't see that addressed here, nor have we seen that addressed in any other approaches to your policy.

I've been very interested recently in hearing from people from all parts of Ontario who are very unsure about what your intentions are with respect to the placement coordinators, who they will be, whether they will be individuals, whether they will be groups and agencies, how they will be selected, what qualifications or training will be required of them, what their mandate will be and how it will be delivered, whether it will be delivered on a geographic basis or whether the mandate will proceed beyond geographic boundaries, what community will be served and what their link will be with other long-term care facilities, including home care, respite care, the community-based, agency-delivered care.

Integration with the central community service agency is also very problematical and not well understood. Frankly, I have yet to find anyone who can answer those questions in any detail in order to translate them to the community.

There is enormous concern about what your intent is in putting the continuum in place, where the district health council, given its current mandate, which is a very limited one -- it's legal mandate, I should say, which is a limited one -- will in fact direct the policies associated with the placement coordinators and the multiservice agencies.

Will the coordinators be located simply in each facility? Will their responsibilities be broader, integrating with the single-access agency? Where does the DHC all fit? When will that system be up and running? If you have level-of-care funding, presumably with a legislative mandate, by late spring, when will you be able to then in fact ensure that what has become legislation is implementable? We will have none of the answers to those questions.

We know in the past that there has been difficulty in terms of the funding of inspectors for the nursing home sector, and we see additional requirements by regulation in this bill for inspection of not only the nursing homes but the chronic care facilities, which had a different mechanism in place in the past.

We have seen no commitment to incremental funding within the ministry for a revised inspectorate and revised numbers of inspectors. If one were to combine the totals of institutions we would be looking at that would require inspections, I think we'd be looking at in the nature of some 500 individual places. Where will those inspectors come from and how frequently do you expect that they will be monitoring the standards and quality within those institutions and facilities?

The Chair: Mrs Sullivan, if I could ask you just to --

Mrs Sullivan: Just to sum up?

The Chair: -- sum up.

Mrs Sullivan: Clearly, there are a number of other areas that I think will come before this committee which are highly pragmatic issues associated with this legislation. The issues that surround this bill are not issues of great philosophical debate. These are highly pragmatic questions that are coming from seniors, from people in the Legislature and from people in the community. Because this bill is presented in such isolation from the policy surround, which itself becomes a pragmatic surround, the questions are very much on the table. We certainly hope that during the course of these hearings and even this afternoon we may have some response to those.

Mr Jim Wilson (Simcoe West): With the committee's indulgence, and the minister's, since many of my concerns are identical to those expressed by Mrs Sullivan -- very ably, I may add -- perhaps I could just take a very few brief moments to put those on the record and then have the minister respond to them all at once.

I'll talk also, Minister, about some of the things that are missing at this stage in the intended funding formula. Currently there's no requirement that funding be proportionate with the level of funding required to provide services outlined in service agreements. As has been said, Bill 101 requires service agreements between each home and the government and between the home and residents, and residents will also be provided with the overall service agreements between the homes and the government. The service agreement will make it clear what services are to be provided to the resident by the operator of the facility. Nursing home operators fear that without a formula that requires the government to provide a proportionate level of funding, they could find themselves in breach of agreements and facing lawsuits.

The government at this stage has not provided what the industry calls the case mix index. I'll just put that on the record to note.

The funding allocations discussed in your government's long-term care redirection paper that was released in October 1991 are vague at best. Again, the document does not provide figures on current spending. It also fails to break down the $647 million total it says will be spent on long-term care by 1996-97.


This legislation sheds no light on how these arrangements are to work. The government has promised a little over $200 million of the $647 million to nursing homes and homes for the aged, and the government believes that they will be able to generate $150 million of this $200 million through increased copayments for user fees which are attached to accommodation costs.

At the same time, Minister, you've been making a big deal out of the fact that residents will not have to pay for nursing and personal care services in homes for the aged or nursing homes under the proposed scheme. I believe that the reality is that for most residents, they're now not required to pay for these services under the current funding system because we have extended care programs.

A number of groups have expressed to me scepticism over the government's ability to raise this $150 million through the proposed accommodation copayment increase of $11 a day. The Ontario Association of Non-Profit Homes and Services for Seniors calculates a net gain of only $64 million using the government's own data. This is $86 million short of what the government expects to generate.

Bill 101 requires each home to develop quality assurance programs. Quality assurance is a management approach and studies have argued that quality assurance does not improve the quality of care for a patient in a hospital, for example. Instead, many hospitals now use the total quality management approach which has been proven to improve patient care, and the Ontario Nursing Home Association believes that the quality assurance approach is outdated and conflicts with other management processes used in hospitals and nursing homes.

The legislation has proposed the creation of placement coordinators who will determine eligibility for placement in a facility. The legislation does not indicate who will conduct pre-admission assessments on potential residents, a necessary step in the placement process in both the nursing home and homes for the aged sector, and the Ontario Medical Association has expressed that point. The legislation is unclear about what happens to existing placement services, that is, whether the services will function together or whether the placement coordinators replace the current services.

There's a very loose definition of eligibility, which I hope to take up with your technical advisers later this afternoon. The consumer's ability to appeal the decisions of a placement coordinator seems quite limited. A consumer may appeal a decision under Bill 101 only on the ground of eligibility. The Ontario Nursing Home Association is also concerned about the degree to which the facility's administrator will be allowed to make determinations about the care of particular residents or refuse applicants if warranted. Presently, administrators decide whether or not their facility can care for an individual, where that resident should be situated, with whom he or she could share a room etc. The proposed bill would remove an administrator's ability to refuse an applicant.

Most importantly in this area of concern from the Ontario Nursing Home Association and homes for the aged and charitable homes are the sanctions that are envisioned under Bill 101. The sanctions can be applied for being in breach of a home service agreement, freezing admissions by directing placement coordinators to assign applicants elsewhere, reducing or withholding payments or suspending or revoking approval to operate. The legislation does not provide operators with an appeal process, should they feel sanctions have been improperly applied. Financial sanctions could impact significantly on other residents of the facility.

In regard to the private sector operators, something that wasn't addressed in your remarks, Minister, the nursing home association concedes that these institutions will likely be immediately in breach of service agreements due to their funding shortages. This problem must be addressed immediately or operators will find themselves in a potentially liable situation, and I'd like to get into that in more detail.

We're also concerned, the Ontario PC Party, that the legislation presents tremendous potential for action against private sector operators of nursing homes. Changes to the Nursing Homes Act will allow the government to provide capital funding for non-profit nursing homes, albeit this is consistent, Minister, with what you've said in the past and your government's preference for the not-for-profit sector.

There are several components within the field of long-term care services that have not been included in Bill 101; for example, rehabilitation, regulation of retirement homes, support for primary care givers, human resource management and training. Bill 101 allows for the hiring of inspectors to monitor the facilities' operations, and again the Ontario Nursing Home Association expressed some concern to me about its role -- power, staffing etc -- and is requesting a more in-depth explanation of the function of these inspectors.

Finally, and again to be brief, I would simply point out -- and this is a series of notes, Mr Chairman -- as Ms Sullivan did, that chronic care is not addressed at all and the role of chronic care hospitals remains unclear.

Minister, I want to read a couple of paragraphs from a letter from a registered nurse who resides in Simcoe county and works in Simcoe county at a home for the aged. Her concern is, and I quote:

"However, it is the disadvantages that I find alarming. First, will an elderly person and their family be able to choose the facility that they wish to be connected with? There is a human rights factor in there.

"Secondly, a good portion of the facilities will now have to admit patients that the facility is not physically equipped to handle. The government has not made any proposals that I am aware of as to how this is to be done.

"Thirdly, up until now patients with intravenous lines, catheters, oxygen tanks etc could not be admitted to nursing homes and especially not to homes for the aged. All of a sudden, as of April 1, 1993, these patients can be admitted to long-term care facilities. Has anyone given any thought to the staff of these facilities? All of the nursing staff in all of these facilities right across Ontario now must be updated in current procedures. I am not in any way denigrating either the staff or their abilities in the nursing homes or homes for the aged, but technology, especially today, is moving quickly, and a good many of us have not kept up except for that which applied to our field."

She goes on to say that the response from her county has been that she will have to upgrade herself on her own time and that indeed is a very serious concern of this particular registered nurse.

I believe Mrs Marland has a couple of concerns she wants to raise, Mr Chairman.

The Chair: Yes. I thought I might have two others who wanted to raise questions, Ms Marland and Ms O'Neill. Perhaps we could do that and then ask the minister to respond.

Mrs Margaret Marland (Mississauga South): Minister, I think when we're looking at those areas of accommodation that are addressed in Bill 101, we also have to recognize that some of these nursing homes do provide services for psychiatric patients as well.

I want to ask you very directly and up front whether your ministry is going to cut $45 million from the psychiatric hospitals' funding, because that is a rampant rumour right now that the Friends of Schizophrenia patients' organization in this province is very, very disturbed about. It is directly related to Bill 101, because if $45 million is cut out of the psychiatric hospital funding, there are people resident in those facilities today who are going to have to go somewhere else, and my concern is where that somewhere else will be. I want to give you the opportunity to say whether that's a rumour or not.

Another direct question: Is it really the intention of your government to get the private sector out of the long-term care business, the same as is the direction of your government with day care and housing? If that's the case, then I think the people in Ontario, in fairness, need to know that now, because I can't personally see where Bill 101 addresses some of the areas of concern that were raised during the public meetings on long-term care.

I personally attended a number of those meetings and I think the most poignant one was chaired in the Mississauga Hospital, the residents' council meeting there, by Kathie Harvie, a quadriplegic and a very active, capable, bright young woman who's been a resident of that hospital for some 14 years now. She's in her mid-40s.

The residents on that council at Mississauga Hospital were expressing the concern that there simply is not a solution for the philosophy of "Everybody can get out of an institution," and when we look at long-term care and we look at people with varying disabilities and to varying degrees, I think we have to know that the direction of your government is to provide more care and not less care, in terms of the people who really need a facility and don't have the option of coming home, as it were.

Coming home is an ideal goal for everybody, but it's not attainable for everybody unless your government wants to make the same mistake that our government made when we tried to close a lot of the psychiatric beds and put everybody out on the streets and we didn't have the home-based community support programs in place. People are very frightened right now because they really don't know what is in the future. As I say, in general they look at your day care and your housing policies and they think what you want is government-run everything, and it's not affordable for the taxpayers in the long run. I would appreciate it if you could address those two areas for me.


Mrs Yvonne O'Neill (Ottawa-Rideau): As you can see from our critic's response, we have discussed this issue at great length within our caucus. I have looked with a great deal of interest at the district health councils' role in all of this, and the first thing that comes to me in my critic role is, the district health councils across this province to this point have never really been involved in social services. They've certainly been involved in health issues, but not in social services, and this seems to be almost a given here, that the district health council will have that other component to it now. I might like to give you the opportunity to comment on that.

I'd also like you to say a little more about the direction you've given the district health councils, because in the original statements of December you were suggesting that this be accelerated. As I understand it, that hasn't happened as quickly as was anticipated at that time.

My other concern deals with the municipalities, which again I feel today have not been mentioned at all. The municipalities are very key players at this time in long-term care. There has certainly been much actual funding that's been raised at the municipal level and directed to the integrated homemaker, home care and the actual homes for the aged. But the role of municipalities, certainly even in talking to municipal officials in several parts of the province to this point, is very foggy for them at the moment. I'd like to ask you to comment on that, because each time we come to the subject, there doesn't seem to be much attention paid to the partnership that I think will have to continue.

The third area that I would like just to present as we begin is, there are several spots where deinstitutionalization has not been as quick as many had projected. Of course, when we began that policy thrust, we did know that in some areas it would take 15 to 20 years, and we're in about year six or seven of that process. But there are many developmentally delayed individuals in institutions who somehow feel that the facility they're in is in great jeopardy. They have but two options: nursing homes that they don't think they fit into or group homes or their own home in their own community. So they feel very, very threatened, and they feel particularly threatened because, again, they're not mentioned in this legislation.

So I just bring those three things to mind: municipalities, institutions that are in the process of consolidating and the role of the DHCs.

The Chair: Mrs Fawcett, you had one point.

Mrs Fawcett: One very quick one, thank you very much. There has been a lot of anxiety expressed to me by homes for the aged and other similar facilities around the funding formula and when that will take effect. I know that they assumed it would take effect January 1, 1993, and then it was put off until March, and now I understand that it could be September. Right now, when budgets are of prime concern, and attempting to formulate budgets, it really is an anxious moment for a lot of them to know exactly when this funding formula will take effect and then whether it will be retroactive. So could you shed some light on that, please.

The Chair: Minister, there are a number of questions and issues there, if you would care to respond.

Hon Ms Lankin: I think what I would like to do is deal very quickly with the specific questions that have been raised by Mrs Marland, Mrs O'Neill and Mrs Fawcett, and then speak more generally to the comments that have been raised by the two critics. Perhaps then that would lead naturally into other questions, if there are any, or into the technical presentation by the ministry. I'm going to go backwards in terms of the way the questions were posed.

Mrs Fawcett, with respect to the question of when levels-of-care funding would be implemented, we are still at this point in time anticipating spring, following passage of Bill 101. We will be giving notice to residents of nursing homes about the resident payment proposals so that they will know what is intended, but we will be stressing that of course it's subject to the discussions that go on through the committee hearings and final passage of the bill and what provisions are passed. But we're going to try to let people know what our intent is and what we're thinking about as we go through this process over the next couple of months.

On the question of retroactivity with respect to levels of care, I think that we are looking at what the current needs are across the sector in the three sectors, three types of homes. We have in the past addressed problems through various mechanisms of bridge funding. If that becomes a necessity, I think we would approach it that way, as opposed to retroactive application of the levels-of-care funding formula. But that is an item still under discussion within the ministry and with the industry.

Mrs O'Neill, with respect to the developmentally handicapped and the fact that they are not part of the client group that is contemplated for long-term care redirection, that in fact is true. That is the case. I think that, for historical reasons, when the governments of various types started looking at the nonsystem that we had for care for our seniors, the movement for reforming long-term care started with a focus there. It did expand over a period of time to realize that adults with physical disabilities, many of whom shared residential care in certain facilities and access to other kinds of programs like home care and others, were also an appropriate client group for consideration as we looked at reform of long-term care. The focus on those two client groups has in fact been the focus of long-term care reform discussion in governments for many years and continues at this point in time, although I think, as we went through the consultation, it's fair to say that we heard very, very clearly from the community, families and care givers for persons who are developmentally handicapped that this was a community and a constituency which also required a systems approach to a delivery of care and a continuum of care being provided, and that we needed to turn our attention to that.

The Minister of Community and Social Services has said on a number of occasions that she recognizes that and is prepared to start those discussions with that community, and that we may see at some point in time the convergence of policy development and care delivery. I think it's important to note that the money that has been budgeted at this point in time is money that has been budgeted for the original client groups for enhancement of services to seniors and persons with disabilities, and that we need, as we look to enhancing programs and services for persons who are developmentally handicapped, to look at the budgetary requirements there as well. I think it would be inappropriate to see that they would be folded in under the budget projections that currently exist, because we would not do service to any of the client groups in that situation.


With respect to the DHC role, clearly, we're now starting to bridge and to talk about overall long-term care reform as opposed to the specific bills that are in front of us, and I understand the desire and the need for people to understand the connections. The role that we see for the long-term care subcommittees of district health councils, reformulated in terms of who's there around the table, is to be involved in the planning for the implementation of long-term care reform in their local communities. They know the people, they know the players. They can work with the various stakeholders to plan the timing and the direction of the reform and the implementation.

You commented that they'd never been involved in social services, and actually, in terms of the technical mandate that has been given to the district health councils, that's true. In terms of on-the-ground reality, in most cases that's not true. In most cases, they themselves have run right up against the need for integration on the ground of health and social services as they try to do planning around the delivery of care to people. With respect to long-term care, in fact that has been most obvious to the district health councils in the long-term care subcommittees. I think if you look at the composition of many of those committees, you will find that they overlap with councils for aging and social planning councils and others already there. There's been that tacit understanding. I think what we're doing is making it explicit and asking for a composition that very clearly reflects that kind of partnership of health and social services in the delivery of services to the whole person in the client groups with respect to long-term care.

Since the December announcement we have established a task force that involves ministry officials and a couple of executive directors from district health councils and from the Ontario association to talk about the scope of planning that we're requiring and what resources might be required by the DHCs and how we would fund that. We are bringing together representatives, delegates, from all the district health councils in about another month or so to have a full briefing on implementation and to get the process started.

I guess I should also respond to you on the issue around municipalities. It is clearly our stated intent that municipalities would be represented on the planning bodies, these long-term care subcommittees of district health councils, and that they are partners with respect to the planning of the larger implementation of long-term care reform.

You talked about funding partnerships. Essentially, in the programs that are currently out there in the community, like home care or integrated homemaking, there isn't a requirement for municipal funding. There is, as you know, a requirement for funding with respect to homes for the aged, and we don't see any additional burden being given to the municipalities through any of the reforms that we're suggesting with respect to Bill 101.

Ms Marland, I think you addressed three main issues. Let me first of all speak to the issue of not everyone being appropriate for delivery of services in their homes, in their community, outside of some kind of a residential facility. I think we are very sensitive to that. What we are attempting to do is understand that there really is a continuum of care that is required, and while we have pieces of it in Ontario now, we don't have good linkages and we don't have the sense of the continuum, that people can enter and exit various points of the system at appropriate times to get the care they require at that point in time.

I think we understand that there will always be some people who will require the support of residential facilities and an adequate supply of services delivered in that venue. From all the work that has been done over the years preceding our government, I think we believe that there is room for many more people to be taken care of through community-delivered services in their homes than have been in the past. I think that's the point we want to make through the enhancement of those services, that we may be able to provide appropriate services that will help some individuals maintain home living arrangements where they might not have been able to in the past.

There may also be some people who are currently either in chronic care beds or in nursing homes or homes-for-the-aged beds who may be able to be taken care of in a different kind of setting: for example, a chronic care patient who might actually be able to be taken care of in a residential facility or someone who is in a residence who may be able to be taken care of in a supportive housing arrangement.

We hope that by building up some of the other pieces around the long-term care facility sector, the three types of homes that are in existence now, which is the focus of the legislation in front of this committee, that we will in fact develop the continuum which will allow us over time to be able to make the appropriate assessment with individuals and their families of their needs and help them along that continuum where those services are best found.

It is not an attempt to force people to their home or their community as the preferable or the only way of delivering care. It is to find what is preferable and appropriate for the individual and their circumstances, medically, physically and socially. I think that all of those things need to be considered.

With respect to the issue of the private sector and what is the future of the private sector, I think I have been very clear in terms of a preference for not-for-profit delivery of services. As we look at health care changing and as we see more and more being done outside of the historical program of medicare, which is based on principles in the Canada Health Act and which also has public administration as one of those principles, I think there is a consistency to seeing that as a preference for a model of delivery throughout the range of our delivery of services.

I've been also very clear with the nursing home association that I don't intend to do anything to destabilize the existing system and to create a crisis in which we end up with all sorts of homes that are unable to continue to operate and residents who are then faced with changes in circumstance or location. I think that managed approach to change is always important. In this case I think that we can look at growth in the future being in the not-for-profit sector and policies which allow and support that to happen but which don't destabilize and disadvantage the existing private sector involvement that is there.

You also asked specifically about the $45-million expenditure reduction target for psychiatric hospitals. As you may know, this is pre-budget time and this is a time in government where all ministries are going through the development of their expenditure projections, their estimates, to be submitted to treasury board and for budget preparation. The Ministry of Health is certainly going through that process. We are looking at targets for expenditure reduction across a number of parts of the ministry's budget, as well as looking at internal reallocation goals.

With respect to psychiatric hospitals, in general I can tell you that there are no final decisions with respect to estimates. It goes through a process of approvals which is not completed yet. With respect to psychiatric hospitals, I have held meetings with some administrators and with representatives of some of the local unions from psych hospitals and have indicated that we are looking over a number of years at a target of reductions which I don't think will approximate $45 million, but we started with that as a target. That certainly wouldn't be in one year.

We have stressed both planning that is consistent with the Graham report and the strategic planning which has been going on in the psychiatric hospitals, planning that is consistent with workers following their clients into the communities, if that's where they go, planning that is consistent with cuts being taken in those areas of inefficiencies and administration and within the psychiatric hospital system as opposed to affecting front-line delivery of service and attempting to keep those principles in place as we look at, can we do a better job with the resources or can we do as much with fewer resources as well.

That's a larger-picture challenge to the government as we deal with the fiscal context we're in, but I think that --

Mrs Marland: Essentially, you haven't made a decision yet.

Hon Ms Lankin: No, and I think your comments with respect to ensuring that it's done in a planned way, so that patients aren't dumped into the community without supports, is a very, very appropriate warning to be made.

I can tell you a couple of the things that we are looking at. For example, in London and St Thomas we have talked about the fact that we have two psychiatric hospitals with a decreased number of inpatients and more work being done on an outpatient basis. Two physical plants, is there a possibility of amalgamation of administration? They're 14 miles or kilometres from each other. There's the possibility for doing things better.

Those are the sorts of things that we're looking at in this point in time, but there is not a decision that has been taken and any decision that would be taken would not involve taking $45 million out of the system in one year, which would lead to the kind of cautions that you have raised.


In general, let me say that I appreciate tremendously the comments that have been made by both critics. I think the questions you ask in fact are pragmatic, to pick up on the terminology that Ms Sullivan used, and I agree that we are all interested in putting together, in an overall sense, a system that works for Ontario. I look forward to your continued advice with respect to that.

I do want to say that there is in my mind a very clear distinction in the task that is asked of this committee with respect to reviewing Bill 101 and the amendments to the existing pieces of legislation that govern the three types of homes for residential care that exist in Ontario and the broader long-term care reform in those initiatives.

This reform of the system will not happen overnight. It will not happen even with one framework document that sets out our thinking about the linkages of the system. There are many pieces that will continue to be worked on and to be developed and to be implemented. I think we've tried to give some sense of the direction and the vision that we have, but the pieces that are before us here today, quite frankly, are ones that would be important even if there wasn't going to be overall systemic reform in the area of long-term care: bringing out equity in the funding formulas, bringing about accountability to residents and their families, bringing about consistency in terms of resident copayment policies. These things, I think, are all laudable goals in and of themselves and can stand outside of the more comprehensive reform that we have envisioned for long-term care.

Many of the questions that you have asked with respect to the bill and the amendments that are proposed, I think, are ones that can be answered as we go through the technical briefing. I will also ask for the transcript of your remarks today and be able to provide you with some more specifics with respect to the things you've raised, because I think that with respect to the bills, they are important.

For example, we will be providing you with copies of the draft standards manual. We are consulting. This is something we are working on. What you get will be something that is in development with the communities at this point in time, but your comments too would be helpful. There you will see such things as reference to the policies around the number of beds that will be maintained for respite care. We do see the connection. Some of the other comments that you've made about the role of chronic care facilities and what will happen in the future are critically important questions for us in the system. Again, they don't, I think, directly need to be answered before we can deal with the amendments before us.

We do expect the chronic care role study to be available in February and I do think it is a very important piece. There are certainly linkages, and I take the points made about the shifting of some patients to a residential setting by changing some of the rules of what services they're allowed to provide; specifically, for example, the use of oxygen and catheters and some of those things that we think can be done in a facility as opposed to having to be done only in a hospital if we provide the changes in the legislation.

Training for staff will be an essential, and that's a subsidizable cost under the funding formula, as well as the kind of money that we've put into training for palliative care, which will be available to staff in the residential facilities as well.

I do think that there are answers to most of the questions with respect to the amendments in Bill 101. I think there's room for debate and discussion, and I'd be certainly pleased to continue that through the course of the hearings and to work with you to improve the bills where necessary to ensure that we're getting the best we can.

But I urge people again to understand that this is only -- and I understand that this is only -- one part of a very large system, that system reform will take much longer than this one piece of legislation will take before the committee and the House and that we will continue to work and to roll out pieces of the reform over the next period of time.

The Chair: Thank you, Minister. Mrs Sullivan and Mr Wilson, I will just give you an opportunity for one short final comment, because I know the minister has to leave.

Mrs Sullivan: I have two quick questions that can only be placed to the minister. First, will there be other long-term care legislation coming forward, and when are we likely to see that? Second, if there is other long-term care legislation coming forward, why this bill now when in fact much of what's included in this bill could be done through the regular contractual negotiations with the sectors involved?

Hon Ms Lankin: It is my anticipation that we will have further long-term care legislation. I actually made that comment in my opening remarks. I cannot give you timing at this point in time. The fall, next spring would be a very rough estimate, and I will have to ask not to be held to that, because I think at this point in time it is premature for me to actually know when we will be bringing it forward.

I see that focusing on some of the broader issues around the planning, the community organization of delivery of services in a different part of the system than the bill that is before us here today. I think there is reason to bring this forward to the legislative process instead of just through contractual negotiations, because it is a direct change in terms of how we're funding our homes, bringing together the equity and the funding policies with respect to three types of homes.

I think it is a change in terms of some of the service accountability issues that we will be demanding of service providers. Some of the issues around placement coordination are a departure from the past in some parts of the province, although not in others, and I think they are worthy of having the more concrete and focused advice of consumers and care givers and people from the community and legislators than perhaps we've been able to have during the broader consultation on long-term care reform.

I also think that the promise of an equitable funding formula has been out there for a long time, and moving to levels-of-care funding has been a goal for some considerable period of time under the previous government and under this government, and I think while we are developing what I think is a much more substantial and large-picture reform for the system of long-term care than existed in government before, it is important to move ahead, however, on some of these outstanding commitments to try and address inequities that can be addressed as standalone pieces.

Mr Jim Wilson: Thank you, Minister, for your comments this afternoon and for your time.

Just going back to your comments regarding levels-of-care funding, it strikes me that there's a limited pool of money available to the nursing home and the two types of homes for the aged sector. I guess there's been a great deal of concern expressed out there that if you're going to sort of deinstitutionalize the hospital side of the health care setting and place residents who may require, as you mentioned and as I mentioned earlier, catheters, oxygen and intravenous lines, high levels of care, into the nursing home sector, what if the demand out there exceeds the pool of money that your government has set aside for the implementation of this bill?

Is there any flexibility from the government on that? Because that's a tremendous concern out there with care givers that while it all sounds good and well, this levels-of-care funding, if you're offloading greater responsibility to the nursing home sector, you may find that there simply isn't enough money to provide adequate care and, to use the terminology of the bill, quality assurance to patients and consumers.

Secondly, may I indicate to you my strong displeasure with the number of regulations that will be required to actually implement and put meat on the bones of the structure that's presented in Bill 101. I'd like your commitment, where possible, that if as a committee we can come up with consensus to actually eliminate in parts the need for regulation and actually put clauses in the act which would spell out exactly what eligibility is, for example, and exactly what responsibilities placement coordinators will have and put more meat on the bones in a number of other areas, we be allowed to do that and that your ministry be directed from here on in to cooperate, where possible, in putting as much in print as possible, because I think it's difficult for the public and care givers to have faith in this legislation, given that so much is left up to regulations and the cabinet.


Hon Ms Lankin: With respect to the first issue you raise, in terms of the pool of money that's available and what flexibility there is, of course every ministry goes through estimates and budget-setting every year and has to look at the various pressures that are on the system.

I think that what will be important as we look at the period of implementation that follows the passage of Bill 101, in whatever form it finally ends up, is to understand that one of the first things that will happen is the implementation of the formula for levels-of-care funding, and that will happen before patients who are at the very highest end of level of care are moved in to where there's experience with those patients in the system. I think we will have some time to experience the funding formula and to get some sense of it before we would have gone through the staff training and been able to look at that kind of shift of patient care or admitting new patients who require that care.

I expect, by and large, that what will happen in many cases is that residents who might have had to move out because of requiring some small additional amount of care that could only have been provided by a hospital would in fact become some of the first people to experience that.

Just to address your second issue, with respect to what's in the regulation and what's in the legislation, this is one of the reasons we need some flexibility over the next year or two to work with the stakeholders in this sector, in order to ensure that we can change what needs to be changed as we go along to address the real situation. To move to this kind of levels-of-care funding is very new in Ontario, and we will be developing and are working on in consultation the formula that attaches with it, but we need to have some experience and to see if we've got it right or if there are some changes that are required. So that's an area I think it would be helpful for the community to look at: Is it possible for us to leave that in regulations and do you understand why, and would the public understand why that portion would be in regulation?

In general, the comment you made is one which I can be very supportive of. Where it is possible to move commitments into the legislation, I agree. I will, for example, tell you that while the drafting was going on with the bill, some of the accountability measures, like the posting of financial documents, were at first seen as provisions that would say that such things as prescribed by regulation would be posted. I actually, in looking at it, said, "Why can't we move some of that into the legislation?"

We were concerned about how we would describe it. We thought we could make the legislation more explicit. I'm certainly willing to receive and would appreciate your advice with respect to other areas where that may be done. But again, I caution that as we experience something very new in the system, it is helpful to have the flexibility to be able to deal with real problems and not be tied into a legislative framework or set of criteria which may not be workable and which would have to go through a very lengthy process to amend, as opposed to having some experience for a year or two and then enshrining those in legislation.

All of you around this table have collectively experienced legislation and the need for changes where it becomes outdated, and the impossibility of getting it on the legislative agenda. That's a concern of mine, but I think the higher concern is to ensure that, where possible, we have clear legislative prescription for what we're about to undertake in terms of reform. So I'm with you on that point, and we'll try to work with the committee in appropriate areas to achieve that.

The Chair: Thank you very much, Minister. We recognize that you have to go on to another meeting, so we thank you for this time this afternoon. Perhaps the other officials would like to come forward to the table or however you'd like to organize that, Mr Quirt. I understand there are some things you would like to go through. Perhaps we could do that and then get into questions, but maybe you should set out how you would like to proceed.

Mr Geoffrey Quirt: I will ask Gail Czukar and Ian Matthews to give you a brief overview of the actual contents of the bill at this time.

The Chair: Fine. For Hansard, as we begin the technical briefing, I wonder if I could ask each of the ministry representatives to reintroduce yourselves and give your titles. That will make it easier as we comb through Hansard later to find out all the interesting comments that are made; we'll know exactly who was making them.

Ms Gail Czukar: My name is Gail Czukar. I'm counsel with the Ministry of Health legal services branch.

Mr Ian Matthews: I'm Ian Matthews. I'm counsel with legal services, Ministry of Community and Social Services.

Ms Czukar: What we propose to do is go through in a fairly general way the provisions of the bill, not actually section by section, because it's confusing to read an amending bill that way, but to describe some of the components you've talked about a fair amount here and in the second reading debates in a little more detail. I'm not sure how you want to handle it, Mr Chairman, whether you want to wait until we've finished our presentation and then have questions, or have questions as we go along.

The Chair: If the committee is agreeable, I suggest you make your presentation and then we have questions. Is that agreeable? Seeing no raucous disapproval, we will proceed in that way. Mrs Marland would never provide raucous disapproval.

Mrs Marland: I would hope not.

Mr Jim Wilson: Tremendous humour today, Mr Chair. See all the NDP here?

Ms Czukar: As the minister outlined, there are basically five major goals being achieved by this bill. I propose to outline three of those, and then have Mr Matthews outline the other two and speak to the amendment to the Ministry of Community and Social Services Act. I don't propose here to outline specifically the proposals to the Health Insurance Act, the Ministry of Health Act or the Municipality of Metropolitan Toronto Act except to state very briefly what the purpose of those is, because they're truly consequential amendments.

I'm going to deal with levels-of-care funding, the service agreements and the resident payment provisions, and Ian will deal with the provisions regarding access; that is, eligibility and admission and accountability. The way we've done this for many groups so far is to outline those provisions in all of the statutes, because the amendments to the Charitable Institutions Act, Homes for the Aged and Rest Homes Act and Nursing Homes Act are almost identical. There are a few differences, which I'll outline at the end; that's how I'd propose to deal with it. With the provisions I speak about, I don't propose to refer to the section numbers for each of them, because it's fairly confusing, but we can get into those details in the questions, if you wish, for a technical explanation. There aren't very many differences.

The levels-of-care funding scheme really has a number of components. The first one is the description of the operating subsidy itself. As many people have pointed out, basically what the legislation says is that the payments are to be made in accordance with the regulations and they're to be made to the facility for assistance with the cost of providing accommodation, care, services, programs and goods. That phrase you'll see throughout the bill, because those are the proposed components of the funding formula.

The cost of accommodation, which includes room and board, will be largely the resident payment. The cost of nursing care and personal services will be, of course, the major portion of the budget which deals with the levels-of-care classification scheme. Funding for services and programs in the facility would be a separate item, and "goods" is added because there's currently a requirement on operators of homes to provide certain kinds of goods in connection with the per diem they currently receive under the Health Insurance Act. So that phrase is meant to encompass all of those components of the funding formula and to allow for those to be described in detail in the regulations.

The exact funding that will be provided to each facility will be spelled out in the service agreement. It's clear in the legislation that the requirement of the service agreement is a condition of operation for charitable homes for the aged and nursing homes. It's not a requirement as a condition of operation for municipal homes, because they're required by legislation to operate a home so we couldn't make that conditional on signing a service agreement, but we have made their receiving funding conditional on being a party to a service agreement.


The provisions for service agreements may be spelled out in the regulations or they may be a matter of agreement between the parties. The intention at this point would be to spell out a standard form agreement that will pertain to all the homes. What will be unique to each home would be the specific schedules -- the funding schedule, the staffing schedule and the program description -- so that it's clear what money the facility is receiving, what staff they're going to hire and what programs they're going to provide in return for that. The service agreement is a tool of financial accountability of the home to the province.

It will also require the home to comply with the program manual, and the service agreement must be posted in the facility by way of giving information and accountability to residents and their families. That's also a requirement in the bill. One exception to that, of course, will be any part of the service agreement which reveals personal information within the meaning of the Freedom of Information and Protection of Privacy Act. We wouldn't require facilities to post anything that would breach that legislation, so there'll be an exception for personal information.

Let me say one thing more about the levels-of-care funding scheme. There is also the provision for additional funding to be made, only in very limited circumstances. Those limited circumstances are to be spelled out in regulation so that it's clear that the operating funding that's being provided under the general provision is the funding that is expected to cover all the costs of the care, services, programs, goods and accommodation to be provided, and that additional amounts for funding are only provided in very limited circumstances.

The resident payment aspect has been treated, again, the same way in all three of the statutes. There is no longer a section which states that residents are obliged to pay the home X amount. The obligation for the resident payment is between the home and the resident. The province is not involved in enforcing that obligation, so it's not an appropriate matter for legislation. Therefore, the legislation places a limit on the amount a home can charge to residents -- and it disallows excessive charges and imposes penalties for excessive charges -- including the charge for basic accommodation, as well as others, but it's the basic accommodation amount that will be the resident payment, which is currently called the copayment. It's no longer a copayment because we no longer have a per diem funding scheme, but that's how the resident contribution is handled.

The scheme for resident assistance or the income test that will be related to the amount a resident will be obliged to pay if he or she is in receipt of GIS or, in that small minority of cases where he doesn't receive GIS but has other limited means, will be a very simple scheme, also to be included in the regulations. As there's no general scheme in the statute for the resident payment, it's obviously not an appropriate place to put it.

That's the very general description of the funding system and the resident payment scheme. I might just cover, under the resident payment scheme, some of the other specifics around excessive charges. An operator is prohibited from charging more than the regulations would allow for basic accommodation, preferred accommodation -- there will still be private and semiprivate and possibly other classes of preferred accommodation; rates will be set in regulation -- care, services, programs or goods other than those that might be included in the service agreement, and others that the resident can agree to purchase independently.

The intention in these sections -- and we believe we've accomplished it in the wording -- is that residents will know what it is they're going to get and what they can be charged for over and above what the province is paying the operator directly for. In other words, there are things like cable TV or magazine subscriptions or other kinds of things, trips out or whatever, that are not covered by provincial funding that the operator can charge residents directly for. The operator must inform the resident in writing what those are and what the charges will be or they can't charge more than that. If they do, the minister has the right to recover the money and pay it back to the resident under the legislation.

That's the general outline of the funding scheme. I think if you have specific questions about other things later I can answer some of those, or I think Mr Quirt is prepared to answer some of those from a funding point of view. Mr Matthews is going to address the issues of access and accountability.

Mr Matthews: In terms of access to facility services, if we look first to the role of the placement coordinator, in the first instance, the minister for each respective act will designate one or more persons, classes of persons or entities as placement coordinators. These designations may change over time. If one placement coordinator is no longer willing or able to assume the role or is not functioning in an appropriate manner, it is possible for that designation to change. Along with the designation, the placement coordinator will have authority to authorize admissions to a particular home, and a home can only accept persons who have been authorized for admission by the placement coordinator who is responsible for that home.

Looking at some of the conditions of admission, no person will be admitted to a home unless he has been found eligible by a designated placement coordinator and the placement coordinator who is responsible for admissions to a given home has authorized that admission.

Admissions will be required where an eligible person has been authorized for admission unless the home has grounds for a refusal -- those grounds will be set out in the regulations -- and the director will have the power to order a suspension of admissions if an operator continually refuses admissions in violation of the regulations.

As far as determination of eligibility is concerned, the designated placement coordinator is required to determine a person's eligibility for facility services in accordance with eligibility criteria which will be set out in the regulations.

There is an appeal from eligibility decisions. A person who has been found ineligible by a placement coordinator must be informed that he has a right to appeal the decision to the Health Services Appeal Board, and that is the board that currently hears extended care certificate eligibility appeals. The appeal board must hold a hearing if a person who is denied eligibility gives notice that he requests a hearing. In terms of the powers of the board on the appeal, it can either confirm the decision of ineligibility or it can find that the person is eligible. If the board upholds the decision of ineligibility, the person may appeal further to Divisional Court.

Placement coordinators also authorize admission to a particular facility, and the designated placement coordinator for a specific home must decide whether that person should be authorized to be admitted to the home.

The director, under the act, is authorized to freeze admissions to a home in the event that the home is in contravention of the act, the regulations or the service agreement. The two chief uses of this power contemplated at the present time are in the event of structural non-compliance of homes or where there is a continual pattern of refusal by an operator to admit eligible and authorized persons as residents. The designated placement coordinator is also required to comply with the director's instructions to cease authorizing admissions.

Placement coordinators are also provided with an immunity against liability for damages, provided that they act in good faith in carrying out their duties under the act.


Moving next to accountability, I'd like to touch on the plan of care, the quantity assurance plan, and deal with some of the provisions concerning information sharing and the inspection powers.

Looking first at the plan of care, the home is required to develop a plan of care for meeting the residents' needs and also to revise the plan as the residents' needs change. Homes are required to assess the needs of each resident on an ongoing basis, and they are also required to provide the care that is outlined in that plan.

In terms of the quality assurance plan, homes are required to ensure that a quality assurance plan is developed and implemented for the home. The plan must set out a system for monitoring the quality of accommodation, care, services, programs and goods that are provided to residents.

With respect to information sharing, the amendments will create a statutory requirement that homes make available to residents, their families, the staff of the home and the public, and as well post within the home, certain information concerning the finances, staffing and operation of the home.

Homes are required to give to each resident a notice which describes the accommodation, care, services, program and goods that the home is required to provide under the act and the service agreement between the province and the home, as well as outline the resident's right to request access to and an explanation of his or her plan of care.

They are also required to provide the resident with procedures for making complaints regarding the maintenance or operation of the home, the conduct of the staff, the treatment or care that is received by the resident and any additional matters that would be set out in regulations. As well, if a resident requests access to his or her plan of care, the home is required to provide access to that plan of care and an explanation of the information that is contained in it.

Homes will also be required by the statute to post in the home three items, three general areas: Firstly, a copy of the service agreement between the home and the province; secondly, copies of certain financial statements; and thirdly, any other documents or information that are required by the regulations.

In terms of inspection powers, new powers of inspection, which are based on those currently in the Nursing Homes Act, are introduced for charitable homes for the aged and municipal homes for the aged. The minister for each act will have the power to appoint inspectors.

Currently in the Ministry of Community and Social Services system inspectors are referred to as "provincial supervisors," for nursing homes they are referred to as "compliance advisers" and "enforcement officers." All of the appointed inspectors will have cross-appointments and will be able to move interchangeably between municipal, charitable homes for the aged and nursing homes.

Highlights of the inspection powers include clarifying the definition of "record" so that it encompasses electronic or photographic records; also requiring inspectors to produce identification when requested to do so.

In terms of the actual inspection powers, inspectors will be able to enter a home or a place where records or items pertaining to the home are kept. An inspector may demand that a record or item be produced, whether it is in the home or whether it is kept on other premises. Inquiries may be made of staff, residents, volunteers and others, subject to the right of that person to have a representative present.

The home's own computer system may be used by the inspector to produce records. Samples, records and other items may be removed from the premises of the home or other place where samples, records or other items pertaining to the home may be kept and tests may be made upon those items. As well, inspectors can call upon experts if they require expert assistance during the course of their inspection.

The inspector is required to make a written demand that certain things be produced, and inspectors must also return items that have been taken. They must return those items in a reasonable period of time. In circumstances where an inspector has removed certain items, the inspector has to make the item available to the home so that it too can test, review and examine that item. This ensures there is equitable treatment for the operator where evidence is being prepared. Copies of documents will have the same value in evidence as originals.

Persons who have custody of records or other things that an inspector is entitled to demand must assist the inspector in obtaining the item in readable form, and must also provide assistance to help the inspector interpret the record.

Offences have also been created so that it is an offence to "hinder, obstruct or interfere with" an inspector. For a first offence, a fine of not more than $5,000 is prescribed, and for second and subsequent offences the maximum fine is $10,000. Inspectors are also protected from personal liability. The crown may be sued for alleged negligence of an inspector even though the inspector cannot personally be sued, so the crown will have liability.

Directors also have authority to suspend or revoke approvals where a home is in contravention of the service agreement, the act or the regulations, or where a home has not operated for six months and is taking no reasonable steps to resume operations. Those powers apply specifically to charitable homes for the aged.

The last item I'd like to deal with today is the amendment to the Ministry of Community and Social Services Act.

There is due authority created for the minister to make payments directly to disabled persons who are 16 years of age or older to enable them to purchase their own services and to self-manage those services. The minister also has authority to make payments directly to other persons on behalf of a disabled person to enable the person to obtain the goods and services that he or she requires to live independently. Regulations will be developed which will set out the rules, policies, procedures and accountability requirements for those payments.

Subject to whatever questions you may have, that is the end of my formal comments.

The Chair: Thank you very much for running through the different acts, and we'll turn to questions. I have Ms Sullivan.

Mrs Sullivan: I have several questions with respect to the presentation that has just been made. I think you'll know where I'm coming from as a result of previous comments. I will put the questions all together so that you'll have an opportunity to prepare for them.

First of all, on the levels-of-care funding, I'm interested that the operating subsidy for each facility is going to be spelled out in the service agreement. What that means is that there will be an individual home-by-home service agreement. The question I'm asking is, who will do that, how will that be negotiated, and over what period of time is it anticipated that those service agreements will be put into place?

If there are approximately 500 facilities for which individual service agreements have to be written, it will clearly take some time. Additionally, those service agreements must include -- and in fact by their very nature reflect -- the residents who are in the care of that particular institution. So that has to be factored in not only to determine the care which is going to be provided but the level of funding which is going to be provided.

The basic question is, who's going to negotiate these service agreements, how are the individual portions of these service agreements to be analysed, how long is it anticipated it will take to develop the service agreements, and what right of appeal is there once the service agreements have been written? Presumably the ministry has the last say.

On the resident payment scheme, we know the obligation to pay is that of the resident, and the obligation of the ministry in terms of the resident portion is negligible, including, I assume, in representing to the resident the necessity for payment. What is the home's position if the resident refuses to pay? That is one question.


The second is, could you suggest to us what services precisely you see the government placing maximums on in terms of what can be charged? Is there, by example, going to be a maximum charge for foot care, if that's a part of a service agreement over and above the general level, or are we talking about hairdressing? I would like to see some very specific information here.

On access, the authority to authorize admissions by the placement coordinator: If the facility has refused to accept a person on the basis that it cannot provide the appropriate services for the level of care required by that person, why should the facility be penalized for refusing to accept the admission of a person?

Other areas of accountability: With respect to the inspection, what is the incremental funding going to be to introduce the new inspection system? Why haven't homes for the aged and nursing homes been integrated under one minister instead of having two ministers responsible for delivery of these services? That's one question.

The Chair: With many parts. It seems to me there were a number there. Perhaps the best thing would be to allow you to respond to Ms Sullivan, and then I'll move on to Mr Wilson and Ms O'Neill, who also have indicated they have questions. But I think there were a number of things there that may get lost if we don't --

Mr Quirt: I'm Geoff Quirt, acting executive director of the long-term care division. Ms Sullivan, you're quite correct that there would be an individual home-by-home service agreement developed for each long-term care facility. That agreement would be a contract signed between the facility and the province of Ontario. There are about 511 facilities that would enter into such an agreement.

The agreement would be general, in the sense that it would set out expectations that the facility would comply with the legislation, comply with the regulations, comply with the operations manual now under development in consultation with the industry, but it would be specific to the facility with respect to three schedules that would be attached to the legal agreement. One schedule would detail the funding commitment from the province. That funding commitment would vary in accordance with the size of the facility and also vary with respect to the funding of nursing and personal care in regard to the actual care requirements of the residents in that facility. On an annual basis, those care requirements would be measured in a peer classification exercise organized by the province, and nurses from long-term care facilities in their particular area would measure the actual care requirements of residents in other long-term care facilities in teams in various locations around the province.

The first schedule would detail the province's funding obligation. It would provide so much for accommodation, provide so much for quality-of-life programs, like physiotherapy, occupational therapy, social work, recreation and so on, and also provide for a specific amount of funding for nursing and personal care in relation to the actual care requirements of those residents.

The service agreement would be negotiated with the facility, so it would be done jointly by facility staff, by the boards of corporations or municipalities that would operate the facilities and by provincial officials. Those provincial officials would be program supervisors located in the 14 offices of our long-term care division across the province and also by the compliance advisers, who now monitor compliance with provincial expectations in nursing homes. So it would be a combined effort of compliance advisers and program supervisors who were already on staff.

Currently, those provincial staff establish budgets for the 181 homes for the aged in the province, and we also maintain an enhancement contract with the 335 nursing homes, so there is already a degree of contractual negotiation with each facility. We hope that would be a more streamlined process and a more equitable process using a new service agreement that's consistent for all long-term care facilities.

Mr Jim Wilson: Perhaps as we go along we could interject and ask questions. For instance, we're doing service agreements right now. I have a specific question on what was just covered by the ministry.

The Chair: All right.

Mr Randy R. Hope (Chatham-Kent): If you were to keep the questions specific, it would probably help in this process.

The Chair: I think that's what he means.

Mr Jim Wilson: It's preferable. For me to go back over service agreements again, Geoff will have to repeat everything.

The Chair: Did you wish to --

Mr Jim Wilson: Yes. I'm probably cutting him off, but it's just on service agreements. Before we get into what Bill 101 is going to require from homes, I'm worried about those nursing homes now, for example, that may not be up to standard. I understand there's quite a backlog. I guess it goes to Mrs O'Neill's question previously: Is there going to be funding to bring nursing homes up to scratch in terms of the fire code or a number of other areas that were brought to our attention? So before we get into exactly what the future looks like, I'm sort of wondering about the past.

Mr Quirt: Okay, if I might take a minute, it's not directly related to the service agreements, because --

Mr Jim Wilson: I think it is, because the homes feel that at the beginning they'll be in breach of a service agreement or won't be able to come up to snuff, and they're worried about what Ms Marland said about a preference for not-for-profit versus profit. In the profit sector, a number of those homes are in danger of never getting out of the starting blocks with this legislation.

Mr Quirt: I'll try to address that with a bit of history first. Of the 335 nursing homes in the province, approximately 140 of them do not meet the structural requirements as laid out in the current Nursing Homes Act, one of the acts that's subject to revision by Bill 101. The structural requirements in that act have applied to any nursing home built since 1972 and have applied when any nursing home has been renovated since 1972. But in 1972 there were some 170 facilities, if memory serves me correctly, that were licensed as nursing homes and grandparented; in other words, given an exemption from the requirements of the Nursing Homes Act with respect to structural compliance.

The Minister of Health, in 1988, indicated that those nursing homes were to become structurally compliant with the Nursing Homes Act by June 1993. Some nursing homes have done so; other nursing homes have not. As I mentioned earlier, there are currently about 140 facilities that have yet to become structurally compliant, some of which would require a total renovation to do so, others of which would require some minor renovations.

The government is aware that many nursing homes have not been in a position to make the investment necessary to become structurally compliant because of the difficult economic circumstances facing the nursing home sector. It's also aware that capital funding is available in a very limited supply but available to long-term care facilities that are funded under the Homes for the Aged and Rest Homes Act or Charitable Institutions Act at the level of 50%. In keeping with our efforts to rationalize the funding arrangements for long-term care facilities, the capital funding program for long-term care facilities is being reconsidered now, under review, but no policy decisions have been taken in that regard at this time.

So the direct answer to your question is that we intend to implement service agreements with all nursing homes, all homes for the aged, and we do not expect that there would be any provision in that service agreement that would immediately put a nursing home in violation of that agreement. We note that in the homes for the aged program there are some facilities that are very old and very outdated and there are others that are very new, having gone through recent renovation projects.

It's our expectation that the service agreement will speak to the quality of programs and services delivered in those facilities, irrespective of the actual date at which the facility was built or when it was last renovated. Our intention is certainly not to obligate a facility to sign a service agreement that can't be upheld or can't be delivered strictly on the basis of the architecture of the building.


If I might go back to Ms Sullivan's question with respect to right of appeal, currently there is no right of appeal per se available to municipalities or to charitable corporations that operate homes for the aged with respect to the enhancement contract they may sign or with respect to the amount of provincial funding for which they're eligible. Obviously, those facilities can exercise their right to appeal to government or to the Ombudsman if the government decision is viewed as unfair from their perspective. With respect to the nursing home program, there are unlimited numbers of examples of where a nursing home may ask the Nursing Homes Review Board to rule on a particular government decision or policy decision taken by the director under the Nursing Homes Act.

At this juncture we do not propose a separate appeal process for the sponsors to appeal the nature of the service agreement. We hope that it will be negotiated in the best interests of the residents of each facility. That's certainly been our intention and the way we have been able to manage the implementation of the enhancement contracts with nursing homes. If an appeal was necessary, it would be an appeal through provincial officials to the minister and an appeal through other channels, as necessary, but not a prescribed appeal mechanism for individual facilities in this round of legislative reform.

Mrs Sullivan: May I just have a supplementary? If a home has, say, a number of patients who die, and they're being replaced by new residents with greater acuity, what would happen then in terms of an appeal with respect to the funding requirements for nursing and personal care?

Mr Quirt: Under the current system of funding, a nursing home would get approximately $78 a day, regardless of whether the residents that nursing home was caring for required one hour, two hours, three hours or four hours of care.

Mrs Sullivan: But that would change.

Mr Quirt: That will change, and on an annual basis, we will re-establish the funding commitment from the province to the nursing home on the basis of the actual care requirements of the facility residents. So, for example, if this fall we were to do our second annual classification of residents and a particular nursing home's population had changed dramatically or the care requirements increased, the commitment from the government for funding of nursing and personal care would be adjusted upward in recognition of that.

The question has been asked by some: "Why don't you do the classification on a more frequent basis? Why don't you do it every three months or every six months?" Experience in other jurisdictions has shown us that we don't see a rapid fluctuation up and down in the care requirements of a facility population. We see a gradual increase over time.

Secondly, the classification exercise has one single purpose: to determine how much funding to provide in a budget approval. Because we fund facilities on an annual basis, we have to make a commitment that allows committees of management or charitable boards or private companies to plan their expenditures for a reasonable period of time. Our commitment applies to the year. Therefore, our funding level for the facility would apply for the year as well and would be adjusted accordingly if care requirements were to change for the second budget period or the next year or the year after.

The Chair: Mr Wilson, do you have a question?

Mr Jim Wilson: I think this still pertains to service agreements, but I'm not quite sure. In the original presentation of the ministry, additional funding in circumstances to be spelled out in regulation was mentioned. Could you elaborate on that? What circumstances would qualify a home for additional funding?

Mr Quirt: I think the reference was to exceptional funding.

Mr Jim Wilson: Yes, I suppose.

Mr Quirt: Under exceptional or extraordinary circumstances, for example, if a facility was in an area hit by a natural disaster, if there was a flood or a fire in a particular facility, or if in the unlikely probability that there was a serious infection or a serious problem within the facility where there were extraordinary costs associated with a major incident in the operation of the facility during the year, the provision would give the minister the right to provide funding that would be specific to that particular problem and in all likelihood would be provided in such a way that it would defray the actual costs associated with extra staff that would be required because of an evacuation or a problem that was encountered beyond the control of anyone.

Mr Jim Wilson: So it's truly exceptional circumstances.

Ms Czukar: Can I just clarify something connected to that?

Mr Jim Wilson: Yes.

Ms Czukar: It is truly exceptional, and it's outside the service agreement. That wouldn't be covered. It's an exceptional grant and the minister can impose conditions and so on, but that's why it's in a separate subsection. It's not part of the service agreement.

Mr Jim Wilson: I'm sorry. In the original briefing my notes run together, so I wasn't sure.

Briefly on the service agreements, there are a number of sanctions in there against homes if they breach service agreements. There was some concern expressed by the industry itself -- now, I don't know how this would ever happen because service agreements are renewed annually -- that if homes were found in breach -- you know, it wasn't their fault -- -of a service agreement through a complaint from a resident or something, what mechanism is there to ensure that there's cooperation between the ministry, the inspectors and the owners of the home, for instance, before any sanctions would be taken?

Mr Quirt: That's a very good question, Mr Wilson. The approach currently employed with the homes-for-the-aged program and to an increasing degree with the nursing home program is an approach used by ministry staff to be more consultative and collaborative than they have in the past.

Several years ago, the inspection service of the Ministry of Health with respect to nursing homes was criticized by a consultant's report for its black and white approach to monitoring compliance with standards in the nursing home program. At that point in time a new approach was initiated called the compliance management approach, an approach that involves our compliance advisers in the identification of not only the problem, but in recommending how that problem might be solved, involving them in the solution. Their job is to provide advice and support to the facilities in the recognition that the vast majority of facilities are interested in doing a good job on their own and may need some advice and support to do that.

With respect to an individual complaint, the example that you mentioned, we're obligated to investigate any individual complaint, whether anonymous or otherwise, in the nursing home program. In the investigation of that complaint, the problem identified would be discussed with the administration of the facility, with the staff involved, if necessary with the family and the complainant, if he or she wishes to be involved in those discussions. Unless there was a chronic problem or a series of serious complaints that would lead us to believe that the public interest wasn't being protected in that facility, I wouldn't see the normal complaint investigation process impacting severely on the signing of a new service agreement.

If we were of the opinion that the residents were at risk in the facility, obviously we'd have the sanctions available to us with respect to signing the service agreement and the other sanctions in the act to allow us to protect the public interest in that facility.

Mr Jim Wilson: Is the compliance management approach, though, part of this legislation, or is it just that it's been an established policy of the ministry?

Mr Quirt: It is not specifically referenced in the legislation. That may be more of a question of how legislation is drafted and the terminology that's necessary in drafting legislation. But certainly, in our development of the manual and in our discussions with provider associations, representatives of workers and representatives of consumers, we've made it clear that we want to continue that collaborative approach to problem-solving in the facility.

As a matter of fact, we've had two joint committees established with representatives, as I've mentioned, from provider associations, from worker organizations and from consumer groups developing the manual, actually writing the sections of it and commenting on it, and also developing the funding formula, answering questions or discussing questions on how the provincial funding available might be distributed among the three budget categories. We've made it clear in those discussions that our intention is to continue to be collaborative rather than rigid in our measurement of compliance.

I might add in that respect that our approach to monitoring compliance in facilities will change with a view to focusing on, I believe, 17 key outcome measurement areas; in other words, looking at 17 or 18 key indicators of client satisfaction or indicators as to whether the facility's doing a good job and delivering good service. If the facility were to show up as meeting client expectations in those areas, the investigation, or the annual review, if you like, would be much shorter than if problem areas were identified by looking at those key indicators of client satisfaction.

Only when we need to be more intrusive because of a particular problem being identified would we be more intrusive, with a view to finding out what the root cause of that problem was and suggesting how it might be corrected.


The Chair: Was there still a question or two left from Ms Sullivan's earlier remarks?

Mr Quirt: Yes, I think there are two. I'll try to deal with them as quickly as I can.

Ms Sullivan asked about the obligation of a resident to pay and questioned the necessity for payment and questioned what services precisely homes would be able to charge extra for and what would be the role of government in that respect.

The obligation of facilities and placement coordinators, first of all, is to determine fairly how much a resident is able to pay for the basic accommodation.

Mrs Sullivan: Who determines that, the placement coordinator or the home?

Mr Quirt: The act currently allows placement coordinators to do that. I believe it also accords the facility administrators that right to make a determination as well. I think there are three or four people who the minister may designate as placement coordinators who --

Mrs Sullivan: They determine financial eligibility for assistance.

Mr Quirt: That's correct, and as has been mentioned briefly, the income test for the cost of basic accommodation boils down to one question. The question is asked of the resident, "Are you in receipt of the guaranteed income supplement?" If the resident says, "No, I'm not," then we'll know that resident can afford to pay the basic accommodation rate and still have enough income left over, $112 a month, to cover the cost of some personal necessities.

If the resident says, "Yes, I do receive the guaranteed income supplement," then he will be entitled to a rate reduction, and whether one lives in a facility that used to be called a home for the aged or used to be called a nursing home, or whether it's in Kenora or in Kingston, people will be eligible for a rate reduction based on the amount of the guaranteed income supplement they receive. It's our proposal that this rate be detailed in regulation, given that it will change as the guaranteed income supplement amount from the federal government changes.

The facility will receive a guarantee of the $38, or whatever the copayment rate is at the point of implementation. As I mentioned, it's tied directly to the guaranteed income supplement level. The facility would receive a guarantee of that level of funding. If residents are unable to pay the $38, the province makes up the difference between what the resident is able to pay and that $38. So we'll prescribe what that amount is for basic accommodation in all long-term care facilities.

In addition to that, the province will prescribe the rate that might be charged extra, to those residents willing to pay for it, for preferred accommodation, namely, a private room or a semiprivate room. We currently do that now. We set a maximum that can be charged for semi-private or private accommodation, a maximum premium that can be charged for the nursing home program, and we set a maximum premium for homes for the aged for preferred accommodation in general. In other words, we set two figures for the nursing homes and one figure for the homes for the aged.

It's our intention to specify in regulation the premium that can be charged for preferred accommodation, so that residents would not be subject to a charge that was greater in one facility than in another. So there will be a uniform approach to the charges residents would pay for preferred accommodation as well.

While it is not our intention to specify precisely what a resident might pay for hairdressing or for cable TV or for drycleaning in regulation, we're asking for the act to give us permission to require a facility to make it clear in writing to the resident what he or she might be requested to pay or be expected to pay if he or she were to purchase cable TV or hairdressing from the nursing home operator.

We're also asking in the act for permission to get involved and compensate residents who are unfairly charged or charged an amount greater than is called for in that agreement between the resident and the facility.

Mrs Sullivan: If the care needs of the person changed and it was the determination of people who were assessing the resident that this patient needed private duty nursing care or particular attention and that is not covered in the service agreement or the contract with respect to that particular resident, will the government contemplate allowing a private duty nurse to provide services to a patient at an extra fee?

Mr Quirt: We do not prohibit that under the current legislation. In other words, a consumer has the right to purchase that extra service if he or she wishes. Under the new bill, we are not precluding that possibility. In other words, we're not telling residents they no longer have the right to purchase an extra service if they so choose.

What we are achieving under the bill is the right to monitor the appropriateness of the charge if they happen to purchase that service from the nursing home operator or the home-for-the-aged operator themselves. The bill does not allow us to tell a resident, "You shall not buy from the VON office down the road extra private duty nursing for your mother or for yourself," and the bill does not allow us to specify what the VONs would charge if they were to come in to provide that extra service. It does allow us to monitor those charges if the client, the consumer, chooses to purchase that service from the individual facility operator.

I might add that while that does happen on a very limited basis, there are very few clients in long-term care facilities who purchase additional private duty nursing in their facility. The purchase of private duty nursing is more likely to happen when a client is living in his or her own home.

We expect that by matching the provincial funding for nursing and personal care to the actual care requirements of the resident population in each facility, facilities are going to be better equipped to meet, in general terms, the nursing and personal care requirements of the residents.

We, as a government, would be very interested in those situations where a facility were to suggest that private duty nursing was required. Our obligation would be to ensure that resident was receiving all the services he or she should be entitled to from the provincial funding provided.

Mr Jim Wilson: On that, so that I'm clear on what you've just said, take hairdressing which is a personal care requirement: Are you setting a range that you think is appropriate for hairdressing?

Mr Quirt: No, Mr Wilson. Our intention would be as follows: If the resident were to make an arrangement with the local hairdresser --

Mr Jim Wilson: But assuming it's purchased through the home.

Mr Quirt: Assuming it's purchased through the home, yes. First of all, we're obliging the facility to explain clearly and in writing to the resident what he or she may be charged extra for with respect to having his or her hair done. Secondly, we're asking for the right to intervene if those charges are excessive or unreasonable. If they were charged $200 to have their hair cut, in a ridiculous example --

Mrs Sullivan: Well, if you have a perm --

Mr Jim Wilson: It depends if you're in a home on Fifth Avenue.

Mr Quirt: If we were to become aware or a complaint was lodged, we would have the right to deem that was an excessive charge and would have the right to take action to have money returned to the resident.

Mr Jim Wilson: This is the type of thing our constituents latch on to. They understand hairdressing and they understand whether it's $25 or $35 a shot. You're going to put a ceiling on that? I don't understand how you do that. In the service agreement, it will specify that for the following year, this home can't charge you any more than $35 because that's it has agreed to if you purchase hairdressing through it.

Mr Quirt: I'm going to ask Gail to answer that specific question.


Mr Jim Wilson: I'm sorry, but that's the type of thing we get letters on.

Mr Quirt: But we wouldn't expect the policy on hairdressing to be outlined in the service agreement per se, if we're still on that topic.

Mr Jim Wilson: Then how do you make a determination whether the home is charging excessively for a particular service?

Mr Quirt: If we had a complaint from a family or resident, it would be the most logical way in which we would become involved in the discussion between the client and his or her hairdresser as to whether the fee was appropriate or not.

Mr Jim Wilson: Isn't that kind of Big Brother at its worst, though?

Ms Czukar: Let me just clarify what the legislation allows on this business of excessive charges. There's the charge for basic accommodation, which will be spelled out in the legislation, and charges for preferred accommodation, and the facility can't charge above that.

We could also prescribe by regulation certain services, I suppose, or programs, and a maximum amount that could be charged. That is currently allowed under the statutes as they are now and it is not done; my understanding is it's never been done. So we haven't prescribed by regulation any other services or goods that a facility is allowed to charge for and a maximum amount. It's not currently done. We could do it still under this. It's not a change.

We could also include in the service agreement items or services that the facility would be allowed to charge for over and above the basic accommodation, the resident payment rate, and prescribe a maximum amount in the service agreement that it would be allowed to charge for that. One example that occurs to me is that if a home is offering the quality-of-life programming, that component, certain kinds of opportunities for trips to go here or there, the facility could be allowed to charge the resident for a certain portion of those. In addition to the funding they get, we could spell out in the service agreement a maximum amount they would be allowed to charge to the resident.

The final category is that which has to be spelled out in the contract between the home and the resident. That's where things like hairdressing, cable TV and those kinds of things would be included. The home is not allowed to charge anything at all for anything they haven't told the resident about, and they're not allowed to charge over the amount they've put in their contract with the resident.

On things like hairdressing and those kinds of things, it's really a question of the bill allowing the resident -- I don't think this is a change. It's not a change under the Nursing Homes Act, and I think it probably wasn't addressed directly in the other two statutes, so it's not a change from the current procedure with nursing homes that they have to inform the resident of what they're going to charge for and how much it's going to be and that they can't charge over that. These provisions are in the Nursing Homes Act now. So it's really a question of the resident monitoring that himself or herself. I don't think it's the intention of this bill to introduce hairdressing maximums into legislation or regulation.

Mr Jim Wilson: Just on this point, because I've had complaints. My own grandmother, for instance, wasn't told in advance that you had to pay for hairdressing and a couple of other things. It comes out of her comfort allowance, I guess, for as long as that lasts: $112. Is there any sort of proactive new thing in this bill that says you have to -- in the service agreement it's spelled out, so that's the proactive part, I imagine.

Mr Quirt: That's correct. In the service agreement with the province, on an exceptional basis, there may be a requirement where the service agreement would stipulate a maximum. But the more important aspect is that the home would be obliged in its admission agreement or in its agreement with the resident, directly between the resident and the operator, to say, "Look, you have to pay extra for hairdressing, and our rate is X."

Mr Jim Wilson: But it's been pointed out that that's the current case, and that's not a change. I'm just pointing out that it seems to fall between the cracks.

Mr Quirt: No, it is a new provision with respect to how homes for the aged would operate.

Mr Jim Wilson: Okay.

Ms Czukar: The Nursing Homes Act currently provides that the licensee can't demand or accept or cause or permit anybody to demand or accept payment for services exceeding the amount provided for under written agreements for those services between the licensee and the individual residents. So it's a current requirement in the Nursing Homes Act.

Mr Jim Wilson: Just to clear the record, my grandmother is in a home for the aged, so that's why it would be a new provision for her.

Ms Czukar: Okay, there you go.

Mrs Sullivan: I think there is an issue associated with health care services, foot care by example, which may not be a part of the ongoing personal care plan, which may be charged for additionally. If that is not included in the original service agreement and is needed, then how is the ministry going to determine at a point in time X number of dollars, and only X number of dollars, should be apportioned to that if the service agreement, as you say, isn't going to be renegotiated other than once a year?

Mr Quirt: First of all, if there's a necessary nursing and personal care service a resident requires, the facility would be obligated to meet that need. There are some areas where there might be some question as to whether the provision of the service would be a necessary aspect of the nursing and personal care a person requires, for example, foot care for an individual who's unable to do it on their own, and that may be the case for a large percentage of the residents in facilities. It would be our view that basic foot care would be a requirement of the health care staff, the RNs, RNAs and health care aides in a long-term care facility, to provide.

There are some extra health services that aren't provided on a health insurance basis now in Ontario. Sometimes clinics are operated in facilities where a person is either not covered under the Ontario Health Insurance Act or only partially covered to provide a service to residents, and in those cases, if it's not a requirement from a health care point of view that the resident receive it, the resident does pay a premium sometimes or a portion of the cost.

It has been our practice with the nursing home program, and it will continue to be our practice, to deal with those particular services on an individual basis and to list in the program manual, or to talk about in the program manual, how a determination might be made about whether that service is a requirement the resident has and should be met with the funding provided by the province, and those other services that we feel aren't necessities and where an extra charge might be appropriate. The list where an extra charge might be appropriate would include things like cable television, dry-cleaning or a trip to the theatre or something like that.

We don't want to see the basic requirements a resident would have on that list of things where extra charges might be appropriate, and while it's easy to develop a list in that regard -- and we have had those discussions on an ongoing basis with the nursing home association in particular -- there's often a grey area or a particular item that comes up that would require us to sit down and talk about it and determine what would be fair.

We have asked the cooperation of both provincial associations to work with us, not only in the development of the draft 1 of the manual and the draft 2 that's coming out shortly, but to work with us on an ongoing basis with a joint committee that would involve the Ontario Association of Non-Profit Homes and Services for Seniors, the Ontario Nursing Home Association, representatives from groups like the Ontario Association of Residents Councils, Concerned Friends of Ontario Citizens in Care Facilities and others, to form a regular committee that would meet on a regular basis and deal with problems associated with that program manual or grey areas that emerge from time to time. Then, rather than the province simply drafting a new policy and mailing it out, those new policies would be subject to debate and consideration at that committee level. Ideally, consensus would be reached on them and a page in the manual might be changed accordingly.

The minister made reference earlier to her hope that whatever goes in the act is material about which considerable consensus has been reached. We know this is a dynamic program and we hope to retain the flexibility to alter provincial policy as it makes sense to do so.

We've certainly established a much more collaborative relationship with provider associations than we've had in the past in the development of the funding formula and the new manual, and we hope that process will continue.

The fine-tuning, the things that might be considered a requirement from a health care point of view, or things that might be considered an extra that a charge might be appropriate for -- no doubt those issues will come up and be dealt with in that manner.

If I might try to deal with the two remaining questions that Mrs Sullivan raised --


The Chair: Just before you do -- please, do that -- Ms O'Neill, I know, still has a question, and I rather suspect Mr Wilson has a question lurking somewhere as well.

Mr Quirt: I'll be as brief as I can. A question was raised about access. It's our proposal in the bill that long-term care facilities would have the right, under certain circumstances stipulated in the regulation, to refuse admission of a resident to a long-term care facility. In practical terms, we don't see that right of refusal having to be exercised very often.

We hope that the placement function would involve residents, for the first time, all across the province, having a full explanation of the facility options available to them, allowing residents to express their preference for the facility to which they wish to be admitted, and a process that would involve a fair selection of who on the list who have interest in going into that particular facility requires that service the most and would get in first.

Mrs Sullivan: That's the exact opposite to the way we read the act and the way that everybody in the community whom I've talked to reads it. So you may need some drafting changes, because it's exactly the opposite.

Mr Quirt: We'd be pleased to take recommendations and directions from the committee on how our intention might be more accurately reflected in the bill. Clearly, that's the purpose of this process. I reiterate that our intention is to provide clients with information and choice about the facility to which they wish to be admitted and to ensure that those eligible clients who have expressed a preference for a particular facility are considered fairly in terms of the needs that they present.

In that process, we expect that there would be dialogue between a resident, the placement coordinator, the facility in question; that the resident may have had a tour to perhaps a couple of facilities, or the family might have had a tour, so that they understand what option is the one they wish to choose and the facility for which they'd like to apply. Through that process, we hope that it would be an unusual circumstance where a facility would be at odds with the province or the placement coordinator and would exercise its right to refuse a resident under the provisions specified in regulation.

Mr Jim Wilson: Could I just stop there on placement coordinators? I'm trying to flesh out exactly what or who these people are. Would they replace current discharge planners, for instance?

Mr Quirt: No, they would not replace current discharge planners in hospitals. Discharge planners in hospitals currently are involved in planning the discharge of people in hospital, most of whom don't go to a long-term care facility, most of whom go home with the support of the existing home care program and so on.

Certainly discharge planners and placement coordinators in our placement coordination service program in, I believe, 22 locations in Ontario work collaboratively in that regard. Certainly when we introduced the placement coordination services in those areas we didn't do away with all the discharge planners. There was an expectation that they would work collaboratively. That seems to have been the case. The discharge planners in hospitals work with a broader range of clients than those clients for whom a placement in a nursing home or home for the aged would be appropriate.

Mr Jim Wilson: But it seems to me that, yes, they deal with all patient discharged from hospitals, but their major workload is finding, in Simcoe county, for instance, a place in a nursing home. That's usually when we get the calls. The current system, as I understand it, having been through it a few times with my family, is basically that you get your grandmother or whoever on a few different lists in the county, whether it be a nursing home or a home for the aged or a charitable home for the aged, and the discharge planner does his or her best to emphasize the need with the administrator of the home that "Mrs Wilson desperately needs in, regardless of the 237 people who are supposedly on your list."

You also work with the physician assigned to that home to put a little influence into the system and hope you get your grandmother or somebody else's grandmother into the home. So how does a placement coordinator coordinate all this? Who is this person who will usurp this current system?

Mr Quirt: Okay. I will try to explain that as quickly as I can. Currently, in about half the province, where placement coordination services don't exist, discharge planners in hospitals, who have a primary obligation to manage the flow of patients through the hospital system, can help and do help someone who's in a hospital bed to get discharged appropriately to a nursing home or home for the aged. But if you happen to live in that community where there isn't a placement coordination service and you happen to not be sitting in a hospital bed, then you're left to your devices to find out where there's a vacancy or what the difference is between a rest home and a retirement home and a home for the aged and a nursing home, and you're left to your own devices or often your physician on his own or his staff are involved in trying to deal with an emergency placement situation. Discharge planners fill that role only for people who happen to be in the hospital. Their obligation is to the people in the hospital. Where there's a placement coordination service that exists currently, placement coordinators are responsible to help people make decisions about the facility to which they'd like to go, whether they happen to live in a hospital or, which is more often the case, when they happen to live at home or somewhere else or perhaps have only been in the hospital for a couple of days.

Our intention is to expand that placement coordination function across the province, first of all -- step number one. We intend to expand it in a similar fashion to the way we fund placement coordination services currently. In other words, we have an agency designated, as was mentioned, I believe, by Mrs Sullivan earlier. There are four placement coordination services that are their own agency on their own. Often it's the home care program that, in addition to coordinating services for people in their own home, has the responsibility of coordinating access to facilities. Sometimes it's a hospital that does it. It depends on what part of the province you happen to be in.

So our first step is to establish new placement coordination services, probably with existing agencies across the province, so that regardless of where you live, there's somebody there who can assist you in knowing what options are available and fulfil the obligations of Bill 101. Those obligations are twofold. In other words, the placement coordinators have to determine your eligibility for being in a long-term care facility. Part of that determination is to make sure that you and your family have been made aware of and have considered the community service alternatives that may be possible for you in your community.

Secondly, there's an obligation, in determining eligibility, to determine how you might rank in terms of the urgency of your admission with respect to other clients, in a fair way. That's the first obligation of the placement coordinator: to figure out who's eligible, make sure that's an informed choice that the family's making about moving to a long-term care facility and to determine the relative priority for access or how one's particular circumstances might compare against someone else's.

The second obligation is to be the gatekeeper, to a certain degree, or to manage access to the facilities in your own area. For example, if you were the placement coordinator who served Villa Colombo home for the aged here in Toronto, you would have a list of all those people around the province who have expressed an interest in going to Villa Colombo, probably residents with that particular ethnic background or an interest in being in a facility that offered that culturally appropriate environment.

So you'd have a list of all those people who were deemed eligible and have an understanding of their relative priority, and your responsibility would be to make sure that the names of those people most in need who have wanted to get into Villa Colombo were forwarded to the facility, and it wouldn't matter whether someone happened to live in Kingston or Sault Ste Marie if, through the placement coordination function, those people would find out about that culturally specific home and have an opportunity to be fairly considered for it.


In the longer term -- and I know this was a question raised in Mrs Sullivan's and others' questions earlier -- it's our intention to create comprehensive multiservice agencies -- I know this is outside the scope of Bill 101 -- where the functions of service coordination, in other words, the functions now fulfilled by the home care program -- it doesn't deliver service; it assesses the need for it and makes arrangements for it and pays for it -- and the functions of placement coordination would be brought together with the functions of service delivery, so that we'd achieve a situation where one agency could meet all the needs of someone, when she presented herself, for not only direct service delivery but access to facilities as well.

So I hope that explains the access issue. The only other question that was outstanding was incremental funding for the inspection system. I mentioned earlier that the monitoring of compliance with long-term care facilities will be a combined effort of our existing compliance advisers, who are in the residential services branch of the long-term care division, and the program supervisors, who work from the 14 offices around the province. So those two groups of staff resources will share responsibility for the establishment of the service contract and for monitoring compliance with provincial expectations in the facilities.

Bill 101 provides for compliance advisers, who used to only be able to go into nursing homes, to go into homes for the aged, and for program supervisors, who had a mandate only to visit homes for the aged, to go into nursing homes. So that staffing force, we hope, combined with a new approach to monitoring facility compliance, which looks at quality-of-service indicators as opposed to going the whole gamut with each facility, will allow us to discharge that responsibility with the staff available now. If that doesn't prove to be the case, obviously the estimates process affords us an opportunity to revisit that question on an annual basis.

The Chair: Mr Wilson, do you have a --

Mr Jim Wilson: I'll yield the floor to one of your colleagues, Mr Chair.

Mrs O'Neill: I have two questions. The first one is a follow-up to what you just said about Villa Colombo. I wanted you to be very clear, and this is a question, certainly, we're asked often. Are you suggesting that anyone in the province could have access to any facility in the province on preference?

Mr Quirt: Yes, in a nutshell, I'm suggesting that. That currently is the case with any of our charitable homes for the aged that operate and provide a particular spiritual or a particular ethnic or cultural environment. Technically, because it's provincially funded, anyone could rightly expect to be considered for admission to that facility. In practical terms, it's people who want to live in that type of cultural environment, who speak that language or who wish to live in that particular spiritual environment who say they're interested. They would be the people who express a preference, like they do now, and their needs for admission to that facility would be prioritized.

Mrs O'Neill: So you're going to be continuing, basically, that policy. Okay.

My next one goes back to the disabled, because I find every time we talk about the disabled it takes about one twentieth of the time that we're using on the other situations. One of you suggested that the grants would be on conditions, and very little said about that. I wonder if you can say a little more about that and who is involved in setting these grants, schedules and the conditions attached to them, where we are with the discussions. I think there's a very vulnerable group of people out there who are quite concerned about this going on at Queen's Park. So could we say a little bit about that?

Mr Quirt: Certainly. We are now meeting with representatives of consumer groups of persons with physical disabilities to look at the piloting of direct funding approaches. I believe we've met a couple of times with them and I'm going to turn this over to my colleague Patrick Laverty in a second, to give you precise information about who's been involved in meeting with us and so on, how many times we've met.

You asked about some of the parameters and how it might work. Currently we fund what we call attendant care services for physically disabled people in two ways. We fund supportive housing programs called support service living units, where we provide a group of staff that's specific to a particular apartment building to meet the attendant care needs of the disabled consumers who live there.

The second way in which we deliver those services is to fund a social service agency to deliver the same kind of services but on a visitation basis, where people drive in cars and visit people at prescribed times, and we call that program the attendant care outreach program. It's our intention to be able to provide money to the individual consumer to allow him to purchase the services of a attendant through this provision.

Some of the parameters or guidelines that are being discussed at this point, although no final policy decisions have been taken, might be a guideline, for example, that would say: "Well, look, if you were to be served through the regular home care program, this is the kind of service level you'd be entitled to," or, "If you were served from the existing attendant care outreach program, this is how much service you'd get. So rather than giving you three times as much money as it costs to do that, we'll give you the same amount of money that would have been spent on the provision of your services for you to manage on your own."

So those are some of the guidelines that are under consideration and discussion with the disabled community, and I'll ask Patrick Laverty, director of policy in the long-term care division, to speak specifically to who's involved in those discussions currently.

Mr Patrick Laverty: To date we've had four meetings with representatives of persons with physical disabilities. They represent the Attendant Care Action Coalition and independent living centres. Their participation has been endorsed by the broader group of individuals within the Consumer Coalition on Long-Term Care Reform, which includes a number of other organizations representing consumers with physical disabilities.

We're at the point in our proceedings where we've had an exchange of views. We've provided them with an outline of our thinking, and at this point in time we have not gotten to the point of pinning down any of the particulars with regard to that formula in terms of how it will work. We hope to be able to do that over the next several meetings with them.

Mrs O'Neill: Is there any major discussion going on regarding the care that's attached to the supportive housing? It's very hard because what's being said is very sketchy, and I can understand we're at the preliminary stages, but are the residences where the care is attached to the residency going to be changed? I have two of those in my riding. You suggested that people would purchase service. To be honest with you, I get complaints from time to time from those residences about some of the care. How much would this apply to that kind of a situation?

Mr Quirt: There's certainly no intention to diminish the level of support to supportive housing programs in the province as a result of exploring direct funding possibilities. It may well be, it's possible, that an individual who now lives in a support service living unit may decide that he would like to manage his own care and take advantage of an opportunity that might be provided through this pilot. But, as I believe Minister Lankin said earlier, the long-term care consultation document and the consultation process certainly reinforced the need for an investment in new supportive housing spaces in the province.

The consultation results clearly indicate that a portion of that $441-million community service investment will be directed to new supportive housing options for younger adults with physical disabilities as well as seniors. So you can expect to see an expansion in that program.

Mrs O'Neill: I think that will be well received.

Mrs Marland: Just a procedural question through you to the clerk, Mr Chairman: When would we have available today's Hansard, today being Monday, just approximately?

The Chair: Tomorrow noon.

Mrs Marland: Excellent, thank you. Could I just further these questions about the attendant care programs. Do you feel that you're currently meeting the needs of people with disabilities in this province in terms of attendant care?

Mr Quirt: Currently, we have long waiting lists for attendant care programs, whether they are offered on a site-specific basis through support service living units, supportive housing, or whether they're provided on an outreach basis. Through our consultation process, the minister has proposed that supportive housing become a key element of the redirection strategy, and that profile and emphasis on supportive housing was certainly substantiated through the results of the consultation. It was viewed, I think it's fair to say, as one of the most popular strategies proposed in the consultation document.

So the short answer is, no, we don't think we're meeting the needs now and we hope to make a significant investment in new supportive housing options that will help meet the needs of not only consumers with physical disabilities but frail elderly people as well.


Mrs Marland: Mr Quirt, I appreciate your direct and honest answer because I'm very concerned about the fact that we're not meeting the needs, anywhere near, for people with disabilities, and I am very much aware of the long waiting lists. My concern with Bill 101 is that I think it elevates the hopes of the people who need these services. I wouldn't want them to be misled into thinking that there's going to be an instant solution for them to meet their needs.

With long waiting lists, I think it's great if there's going to be a formula and a very practical way for people to manage their own attendant care through a direct funding mechanism to the client and letting the client hire his own people. Those options have great possibilities in terms of the individual person who is disabled having someone who is compatible, for goodness' sake, and having the same person rather than two or three people a week, let alone a couple of people a day, which can sometimes be the situation in the worst scenarios.

I think having someone who individually understands the individual needs of that client is terribly important. But I have a concern about going around the province flag-waving and raising everybody's hopes, and really on the ground nothing changing with the troops. We still have long waiting lists. Where's the money going to come from? I don't see Mr Laughren running around waving his money bags for everybody to reach up and grab.

Mr Hope: I saw him just the other day.

Mrs Marland: I met him in the hall today. I thought he looked kind of depressed, to tell you the truth.

But this $441 million you mentioned for community services, where is that money coming from? Also, could you comment on something that has been raised in this whole area? If this program gets off the ground where it's possible that you would consider spouses staying home to look after their spouses in need instead of having outside help hired as attendant care providers, how would you look at that closely enough to know that the level of care in terms of "professional care" was what you would want it to be for those clients?

The Chair: Just before you answer that, Mr Quirt, could I indicate that this will be the last question, and would members stay because we have just a couple of procedural things to deal with prior to closing our hearings this afternoon.

Mr Quirt: Ms Marland, if I might answer your question in a little different order than you posed the question, the $441 million that you referenced is part of the long-term care redirection investment commitment. That still stands. Mr Wilson earlier asked --

Mrs Marland: It's new money, you're saying.

Mr Quirt: If I might, I'll explain precisely how that $441 million fits into the overall redirection budget. The government remains committed to a $647-million investment in long-term care programs and services. The lion's share of that $647-million investment will go to the establishment and improvement of community-based services, including supportive housing, community support services and in-home services like the services provided by VON and Red Cross homemakers.

Now, $441 million of the $647 million, roughly two thirds, is an investment in new provincial funding on an annualized basis for community-based services. The balance of the $647 million -- in other words, $206 million, because $441 million and $206 million adds up to $647 million -- is more specifically the focus of Bill 101. In other words, that's the amount by which the budgets of nursing homes and homes for the aged in the province will be increased on an annual basis. The budgets of nursing homes and homes for the aged will go up by $206 million on an annual basis. That $206 million, however, is comprised of two components.

Mr Jim Wilson: This is the catch, man.

Mr Hope: I have been listening.

Mr Quirt: There are two components. One component is $56 million in new provincial funding. The other $150 million is the new revenue generated by one consistent, income-based copayment for the user fee for the 58,000 people who live in those long-term care facilities. Obviously, those 58,000 people benefit directly from not only the $150-million increased fee they pay as a whole, but also from the $56-million provincial contribution.

It's an investment of $441 million in community services and an investment of $206 million in facility services, for a total of $647 million. In total, the subsidy provided by the government is $497 million in new provincial funding, $150 million in new revenue raised by consumers in nursing homes and homes for the aged.

Mrs Marland: I don't want to prolong this but in fairness --

Mr Quirt: What we could do is provide the committee with a list of how all those figures break down.

Mrs Marland: I would like that, but I think it's important to say, so everybody understands, that this $150 million is coming from the clients. It's a user fee. It's not money being provided by --

Mr Quirt: It's in addition --

Mr Hope: What about the other half of the equation, Margaret?

Mrs Marland: It isn't money provided by the government.

Mr Quirt: That's correct.

Mrs Marland: I just want him to finish the other question that I raised. You won't be back tomorrow, will you?

Mr Quirt: Either I or Patrick Laverty will be at all your committee hearings. Patrick is as well or better equipped to answer whatever question you might have.

Mrs Marland: We start the deputations tomorrow. That's why I need the answers today.

Mr Quirt: You're quite right. Of the $647-million investment, roughly $500 million is new funding from the province and roughly $150 million comes from increased client contributions in facilities. I would point out that those facility residents now pay about half a billion a year as it is, about $550 million. That figure is subject to confirmation if the committee's interested; that's off the top of my head. So it is an increase but they do make a serious contribution currently.

Minister Lankin spoke earlier of the context within which Bill 101 is presented. Clearly, the commitment to change the Ministry of Community and Social Services Act to allow us to explore direct funding for disabled consumers is in no way the only way in which the redirection will benefit people with disabilities.

Part of that $441-million annual increase will go to attendant care, outreach-like services, and it will go to increasing the number of support service living unit programs in the province. The bulk of the improvement in services for consumers with physical disabilities does not come from the fact that we have the right. We're asking for the right to pilot direct funding. That's an important initiative asked for by consumers with physical disabilities but obviously there's another context for a commitment of a substantial amount of community service money to expand their service system as well.

Mrs Marland: And the question about paying spouses and their qualifications?

Mr Quirt: Yes. At this point in time we are prepared to and interested in exploring all the implications of that with appropriate consumer groups and provider groups, but we have not taken a policy position that would say yes, we're going to pay someone's spouse to stay home and look after them. Patrick, you may have a more definitive position on this. There has been no commitment by the government to pay family members to deliver the services they provide.

It's important to note, as we did in the consultation, that the lion's share, about 90% of the long-term care that gets delivered in Ontario, isn't delivered by publicly funded formal programs; it's delivered by spouses, family members and friends, and it's certainly the case when it comes to health and social services other than those directed simply at adults with physical disabilities or seniors. Obviously that's the case in children's services as well and the implications of a family care giver compensation policy we're quite prepared to discuss with the relevant parties, but no policy decision has been taken.

Mr Laverty: Geoff is correct. The question of compensation of a family care giver was raised in the redirection consultation paper. At this time, the minister has not made any announcement with regard to government direction in that regard, so at this point she has not yet responded as to how she wishes to go on that matter.

The Chair: I just wanted to clarify that you were going to provide a breakdown of those amounts of money. Thank you, because that would be useful for the committee.

A final, final, short, pithy comment.

Mrs Sullivan: I just wondered if when the ministry officials are doing that breakdown they could also do an analysis for us of the analysis done by the non-profit homes, which would suggest that the copayments are not going to bring in $150 million annually, but something closer to $64 million. I suspect the ministry has done an analysis of those figures and I think that would be useful because we will be hearing from that group.

I also wonder if the ministry could provide us with additional detail on the placement coordinators, on their function -- on what is envisioned as the role, function, responsibility of the placement coordinator, whether they'll be working geographically, how they will be tied to institutions and so on. What you said today was news to us. Our reading of the bill does not show that and we would like to have more information.

Mr Quirt: If I could comment briefly, Mr Chairman, that I don't want to speak for OANHSS but I understand their estimate now is somewhere around $120 million as opposed to $60 million. We have met with them to show them how we arrived at that calculation and we're more than happy to continue to discuss with them how that estimate should be arrived at.

The Chair: One of the things I would note is that the parliamentary assistant is on the committee and will be with us as we go along. I'm sure there will be other questions where either he or someone in the ministry will be able to provide us with full information.

Mr Wilson, did you have a point of information?

Mr Jim Wilson: A request for information. I wonder if I could request, since we didn't have time in the more extensive question-and-answer session this afternoon to go into detail on the powers of inspectors, a briefing for the committee concerning the current powers of inspectors so named in the various acts or with the various names they have and functions in the acts we are amending and, second, perhaps what new powers with respect to inspections and access to records.

Mr Quirt: I will ask the staff to compare the current and future powers.

Mr Jim Wilson: I'd appreciate that.

The Chair: Mr Quirt, to you and through you to your colleagues, thank you very much for your presentation this afternoon and response to questions. You indicated that there would be officials from the ministry with us as we go on with our hearings and, as I noted, the parliamentary assistant is here, because I think in other committees of this sort it's been useful at times to either request more information or simply to get an explanation, and we appreciate that. Thank you.

If I could ask the committee just before we break -- one thing, this Hansard from this afternoon, it might be early afternoon, so if I could just ask for some understanding.

The other thing is to remind committee members that tomorrow is going to be a long day because we have sittings morning, afternoon and evening.

Interjection: Get lots of rest.

The Chair: Yes, as the member says, get lots of rest.

That being the case, I would like to ask the subcommittee to stay behind briefly. The committee stands adjourned until 10 o'clock tomorrow morning in committee room 1.

The committee adjourned at 1714.