Wednesday 3 February 1993

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

Victorian Order of Nurses, Durham Region Branch

Gloria Tuck, president

Rick Howarth, board member

Sheila David, executive director

Victorian Order of Nurses (Ontario); VON, Guelph-Wellington-Dufferin Branch

Jan Lord, executive director, VON, Guelph-Wellington-Dufferin

Gale Murray, provincial director, VON Ontario

Ontario Association of Registered Nursing AssistantsS763

Verna Steffler, executive director

Sheila Arsenault, president

Oshawa Deaf Centre

Betty McPhee, executive director

Multicultural Alliance for Seniors and Aging

Dr Fred A. Sunahara, chairman

Sam Ruth, Baycrest Centre

Dr Dimitrios Oreopoulos

Tabor Manor Senior Citizens' Home

Peter Warkentin, vice-chairman

Rudy Seimens, administrator

Unionville Home Society

Marie Hogan, board member

Margaret Hill, administrator, Union Villa Home for the Aged

Lloyd Dennis, board member

Belmont House

Mary-Jane Large, executive director


*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 Iles 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

Jackson, Cameron (Burlington South/-Sud PC) for Mrs Witmer

Jamison, Norm (Norfolk ND) for Mr Gary Wilson

Marland, Margaret (Mississauga South/-Sud PC) for Mr Jim Wilson

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

Sullivan, Barbara (Halton Centre L) for Mrs O'Neill

Wessenger, Paul (Simcoe Centre ND) for Mr Martin

Also taking part / Autres participants et participantes:

Arnott, Ted (Wellington PC)

Matthews, Ian, counsel, Ministry of Community and Social Services

Quirt, Geoffrey, acting executive director, joint long term care division,

Ministry of Health and Ministry of Community and Social Services

Clerk / Greffier: Arnott, Douglas

Staff / Personnel: Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 1007 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 now call this session of the standing committee on social development to order. We are gathered again to consider Bill 101, An Act to amend certain Acts concerning Long Term Care. I guess this will be the first morning under the new Minister of Health as announced prior to the meeting beginning.


The Chair: We have two deputations this morning, both from the Victorian Order of Nurses. We're going to begin with the VON from Durham region and then go on to the VON from Guelph, Wellington and Dufferin. We have representatives from Durham at the table. I want to welcome you to the committee. If you would introduce yourselves for Hansard, then please go ahead.

Ms Gloria Tuck: Good morning. It is a pleasure to be here today to make this presentation to the standing committee.

I am Gloria Tuck, president, board of directors, Victorian Order of Nurses, Durham region branch. Accompanying me today is Rick Howarth, Durham branch board member and constituent assembly representative for VON (Ontario), and Sheila David, the executive director.

The Durham branch of the Victorian Order of Nurses applauds the government for its movement towards amending certain acts concerning long-term care in Ontario. Bill 101 represents the first piece of reform legislation in long-term care.

The Victorian Order of Nurses of Canada is a national, not-for-profit, charitable, community-based organization that has been in existence for 95 years. In Durham region a branch in Whitby was started in 1914 and staffed by one nurse. Today the central office of the Victorian Order of Nurses, Durham branch, is located at 292 King Street West, in the city of Oshawa. There is a branch suboffice in Port Perry. There are 65 nursing staff, registered nurses and registered nursing assistants representing a diversity of experience and educational backgrounds.

The voluntary board of directors of Victorian Order of Nurses, Durham branch, represents a cross-section of the region and brings a variety of skills, expertise and community sensibility to the governing of the branch. The board holds fiscal responsibility and strategic planning roles. Regular opportunities are provided for the board and staff to participate in decision-making, consultation and planning.

Programs currently offered by the Victorian Order of Nurses, Durham branch, include visiting nursing, mental health nursing, foot care, enterostomal therapy, early obstetrical discharge, volunteer services and third-party consulting.

The Victorian Order of Nurses is committed to the philosophy that, "All Canadians have the right to comprehensive, coordinated and compassionate health care and that, whenever possible, care should be provided in the familiar surroundings of home."

To meet the challenge of the future, Victorian Order of Nurses, Durham branch, is developing new concepts for services delivery to accommodate the changing health care and wellness needs of the residents of Durham region.

The Victorian Order of Nurses, Durham branch, continues to expand its knowledge and scope of services through research, education and program development. It is from this base of information that we speak to the proposed legislation, Bill 101. The areas of concern that we will outline include system fragmentation, health care providers, quality versus inspection control, funding and community agencies.

Our primary concern with this proposed legislation is that it does not appear to fit with the reform agenda for health care as outlined by the Minister of Health in Goals and Strategic Priorities. Rick.

Mr Rick Howarth: Thank you, Gloria.

System fragmentation: This legislation stands alone and does not envision a fully integrated system of reform. Rather it fragments the long-term care system into sectors dealing with the nursing homes and homes for the aged, while completely ignoring the institutions and community agencies.

Fragmentation of the system must cease, and the integration of all facets of long-term care must be considered prior to the passing of any legislation. That is to say that this proposed legislation must not be dealt with in isolation. Provision has not been made for the development of a seamless system of care for the consumer. Such a system would allow the consumer to move from sector to sector, that is, community to institution to community again, with ease and comfort.

The consumer does not have the opportunity to access an integrated system of care to meet their short- or long-term needs in an innovative way, but rather to become entangled in a complicated system. Surely there must be an easier way for the citizens of this province to access the services they require.

The use of a comprehensive, multiservice coordinating body to ensure the appropriate allocation of services to the consumer is essential to the successful implementation of a long-term care system of service delivery in Ontario. Therefore, recommendation 1 is that the legislation be reworked to include the entirety of the long-term care sector in its proposed changes so that all segments of long-term care are integrated.

Health care providers: The unique abilities of the registered nurse and registered nursing assistant in the delivery of care to the elderly population should be recognized and considered with the development of the new system. Education for the evolving role of health care providers, to meet the changing and growing needs of those in nursing homes and homes for the aged, will be required to ensure that needs are met.

The proposed changes do not appear to have any regard for nursing assessment based on outcome orientation. Use of the traditional medical model should be refocused to a wellness/prevention orientation, which includes participation by all health care professionals and consumers. The notion of consumer satisfaction has been omitted. It would appear that the intent of the legislation moves away from the proposed health and wellness model outlined in the Goals and Strategic Priorities of the Ministry of Health.

Nurses are clearly the providers of choice in a health and wellness model of care delivery congruent with the Ministry of Health direction. Therefore, recommendation 2 is the refocusing of the proposed legislation to be congruent with the health and wellness model, with a view to returning consumers to their optimum health.

Recommendation 3 is to provide education to meet the changing needs of the consumer using existing professional personnel, that is, registered nurses and registered nursing assistants.

Quality versus inspection control: History has demonstrated that control through inspection does not achieve the desired outcome but in fact increases deviant behaviour due to fear and uncertainty. Notions of inspection develop antagonistic relationships and do not foster partnerships. This system is being set up for inspection and punishment, that is, built-in enforcement to regulation versus continuous quality improvement and customer satisfaction. The proposed system is not incentive-based, but rather punitive with no use of total quality management or continuous quality improvement concepts.

Recommendation 4, therefore, is that prior to instituting an inspection control model, the use of quality improvement concepts must be addressed to ensure the highest standard of care for the consumer and highest satisfaction for all within the system. Gloria.

Ms Tuck: Funding: The level of payment based on consumer acuity is not an incentive for wellness but an incentive to increase illness. If this funding concept is instituted for the nursing homes and homes for the aged, then should we expect system-wide implementation? Are we paying for higher levels of care, for example, acuity, without regard for prevention and return to wellness?

Who will monitor the consumer needs versus the need of the home to increase revenues? Is there any assurance that consumer need will be the primary focus? Is there assurance that the incentive for wellness will be a priority for funding purposes?

Recommendation 5, therefore, is that funding formulas should be developed that will focus on consumer need and care provision, rather than solely on acuity.

Community agencies: Community needs have been overlooked in the development of the proposed legislation in terms of the individual needs of the consumers. Consideration should be given to geographic, demographic and cultural needs of the individual communities. The role of the agencies and homes to educate and inform the consumer regarding choices and options available to them in their individual communities should be incorporated into the regulations.

The Victorian Order of Nurses plays a pivotal role in delivery of service to the community. Integration of community services with the nursing homes and homes for the aged sector is critical to ensure the highest level of care provision for the consumer. Why should a consumer of the Victorian Order of Nurses be denied specialized service because he or she is admitted to a nursing home or home for the aged?

For example, in our branch we provide foot care and enterostomal therapy services to some consumers within Durham region. If one of these consumers is admitted to a nursing home or home for the aged, this service provision is at best interrupted and at worst discontinued. This results from the lack of a viable, integrated payment procedure as well as from the system fragmentation referred to earlier in this presentation. The proposed legislation continues to ignore this problem.

Recommendation 6, therefore, is that the proposed legislation must include a linkage of community agencies with the long-term care sector to ensure continuous service provision to consumers.

We would like to thank you for the opportunity to come before you today and we will be pleased to take your questions. The final page summarizes the six recommendations.

The Chair: Thank you very much for your presentation and also for the specifics of your recommendations. We'll begin the questioning with Mrs Sullivan.

Mrs Barbara Sullivan (Halton Centre): Thank you very much. I appreciate this brief. I must say I always find that when I receive material or hear from the VON, it's always a very thoughtful presentation and I think this is a useful one for everybody on the committee.

You are not the first group or organization to talk about the concern about the isolation of this particular piece of legislation from the long-term care strategy and policy, which is yet to be seen in full, and I like the words you use, the seamless system, to describe the continuum of care and the integration of a full long-term care philosophy.

I'm interested in your focus on the funding for levels of acuity in the nursing homes and homes for the aged. I assume that what you're doing there is providing a warning that it ought not to be an appropriate funding system for other elements in the long-term care system, that you're not objecting to levels of acuity in terms of funding for nursing homes and homes for the aged. Is that correct?

Ms Sheila David: The level-of-acuity payment system is at best increasing -- the homes look at resources and revenues. But for us in the community, if in fact the nursing homes are going to have levels-of-care payment, then perhaps we can be looking at that as well, because clearly we have different levels of acuity that we're taking care of. So if it's going to happen in the nursing homes, then one would always ask the question.

Mrs Sullivan: Have you proposed other funding methods to the ministry with respect to services that would lead to, say, a wellness program that is provided by the VON, as an alternative to an emphasis on the acuity levels, if you like?

Ms David: That would probably come from a VON (Ontario) perspective. We deal only in our own region.


Mrs Sullivan: Okay. The other question I wanted to put to you -- and I certainly see concern in my own community with respect to this -- moves away from this bill, but you have included reference to service integration, which I think is going to be ultimately extremely important. Latterly, we have heard talk about the multiservice agency or the confluence of various agencies.

One of the things that's a matter of concern in my own area is the loss of historical identity of various organizations. The VON, the Red Cross, the Helping Hands organization, the home care organizations that have been providing services for many years have unique identities, independent volunteer boards usually, and very high community identification and trust. How are people in Durham feeling about the thought that maybe the VON won't be an identifiable body and will become anonymous in another organization?

Mr Howarth: I can't speak for every person in the region of Durham, but I can certainly speak for myself, having been involved with the Victorian Order of Nurses for several years. It is of grave concern to me that we don't lose our identity. I am sure that if you spoke to anyone involved with VON, they would agree 100% with that, and I would assume, therefore, that our clients and the families of our clients and consumers in the area would also be upset with that kind of situation occurring.

Mrs Sullivan: Have you had discussion at the local level about where the fit for VON would be in a multiservice agency?

Ms David: I think I can say for Durham region that we're having meetings with the district health council, not only VON but the other service agencies as well, and that we're not unlike any other region in the province in terms of trying to work that through. But I think there's clearly some innovation and creativity that can take place, and certainly the VON in Durham region has been there for 79 years and plans to stay.

Mrs Joan M. Fawcett (Northumberland): Just briefly, do you find that there really is a difference in the delivery of service in rural Ontario as opposed to the urban centres? Is there an increased cost to you because of increased transportation, those kinds of things? Do you feel the service is as good in rural Ontario right now?

Ms Tuck: Certainly the costs are there because of the travel. Durham region, in particular, is very large and there's a lot of travel connected. I think the service is very good, though.

Mrs Fawcett: But does it cut into what you can do, because the money has to be allocated to transportation? That's really what I meant.

Ms David: Just purely from an operations point of view, the cost of driving from our Port Perry base up to Beaverton adds significantly to the cost of that particular suboffice. It would not be that we would deny service, but certainly it's difficult to maintain all of the services that are required in the region when it is such a vast region, and we certainly are limited by the funding that we receive.

Mrs Margaret Marland (Mississauga South): I really would like to compliment you on this brief. Probably I'm going out on a limb, but I really think it's the most constructive brief we've received so far on Bill 101, because I think you've been very direct in your comments and your recommendations are very clear.

As someone who has been associated with the VON in Peel for the last 30 years on and off, I'm very familiar with VON, and I must say when you started out saying that you applauded the government, that surprised me. Frankly, that statement surprised me.

I think you're applauding the government for its movement, but then when you get into its movements, you're not so happy about its movements. So I think I'd like you to enlarge a little on some of the things you're saying. I'd like to give you that opportunity to enlarge a little. Cam?

Mr Cameron Jackson (Burlington South): It was a good joke, Margaret.

Mrs Marland: I know it was. I realized it was as soon as I said it, especially to the nursing profession.

Mr Jackson: It wasn't quite the four-letter word we were thinking of.

The Chair: Order, please.

Mrs Marland: Fortunately, I don't think in those terms.

I think the most important thing is that you've pointed out the conflict with another ministry, and unfortunately -- this is my comment, not yours -- we have seen a number of instances with this particular government where it seems like one ministry goes off on a tangent in conflict with another ministry and they don't seem to get together. I don't know what happens at the cabinet table, but maybe after today we might have less or we might have more of that kind of conflict. But I think it's important that you've made that point. In the long term, obviously sickness prevention is the thing that's going to get the health budget under control in this province and make health care affordable for everybody.

That brings me back to the fact that you're saying the proposed changes do not appear to have any regard for nursing assessment, which I think is one of the most important statements you make here. I think that's a pretty scary thought, because long-term care is dependent on medical assessment, and nursing assessment obviously is part of that. So I wondered whether you'd like to elaborate a little more on that area.

Ms David: Our concern with the nursing assessment aspect is dealing with the issue of care plans and how in fact the care plans will be carried out, that there is not always a follow-through of what is written on a nursing care plan or written on a plan of care and what actually takes place, and that in fact there is not within the bill an incentive to increase the assessment skill or the level of assessment or the opportunities for assessment. That may come in regulation. We still have the opportunity through regulation to see some of that, but there is a concern that we're not going to see the adequate assessment that needs to be made. And if in fact the inspector group are the ones who are going to be carrying out the rules and regulations, if you will, then one would have to ask the question about the inspectors and who these inspectors would be and how they would be able to carry out their role.

Mrs Marland: I think that's a very important point: Who are the inspectors going to be? When we went into the rent control legislation we went through the same thing: Who are the people who are going to be making the decisions and are they qualified to make those decisions? When we're dealing with the health of individuals, it's such a specialized area that I think that's a very important consideration.

Our frustration, of course, is that, as with all legislation, it's always backed up somewhere in the back room with the regulations and we never get a chance to see the regulations or debate them. It's a tremendous frustration for those of us who are in opposition.

Mr Jackson: You make several points about the fact of the continuum of care and about all aspects of community-based health care and that they're not really integrated here. I think for people who are familiar with the field, we know that there are three aspects to long-term care reform, and this is just one of them. We're very much going on faith or we're accepting that the new frontier will be a model that we can work with in the other two elements of long-term care, which we're yet to see: how we deal with staffing and funding elements. All that is unclear to us.

But I want to revisit your point about getting a full sense of what's going on in long-term care in the community. I understand that VON in some jurisdictions is providing the home sharing program or is part of the pilot. Are you involved with home share at all in your jurisdiction? Is there a pilot such as home share working in Durham?

Ms David: Not that I'm aware of.

Mr Jackson: It's suggested that in fact they might. I guess one of my concerns is that if we're not looking at a medical model here and then we're not looking at accommodation and other aspects of it for how people live in the community, just how focused is this in terms of care delivery and ability to maintain one's life outside an institutional setting?

I'll reserve that line of questioning for when I know one organization that is involved with it is before us, and I know it's coming before us because the whole funding of that project is in jeopardy, but it ties in with the sharing of some of the interventions having supervision in the home, so that your periodic interventions have follow-up and reporting. It's an outstanding program and we can't get it off the pilot stage and into a full-blown program.


Ms David: Just to add some light to that, when the next VON presentation takes place you may want to bring that question back, because they may be able to share some information with you that we don't have in Durham region.

Mr Jackson: We don't even know exactly what your DHC is doing and neither does the DHC in my jurisdiction whom I talked to last night, but do you have a sense of what the DHCs are actually looking at in terms of review of -- help me with the wording here, because I can't even get the proper words out properly. The ministry has sort of asked them to look at a model; they don't want to call it a model, but it's a recommended approach. Are you involved in that discussion, and how intimately involved are you in that discussion? Because at this point, as legislators we want to get a sense of just how firmly you're plugged in and if you're progressing in that. That would be helpful because that's where you're actually involved in the long-term care process as opposed to coming before us here.

Ms David: The branch itself is represented around the DHC task force table. We also have representatives whose names have come forward for appointment to the district health council. In our area, the district health council is restructuring and is undergoing considerable change to meet not only the ministry needs but also our community needs. I'm feeling very positively about our district health council and the direction it's taking. In fact, next month at our board meeting for the branch they're coming to present how they feel they will be integrated into the system and how we can help them and they can help us.

Mr Jackson: That sounds very much like a top-down process. As I understand it, the minister asked the DHCs to begin now in a proactive way with developing a model for how the delivery system might work. Those words sound proactive to me. What I just heard from you was a process of the DHC coming and informing you. Are we that slow off the mark that they're now just coming to you to say, "Here's what we think we might do and we'd like your input"? I thought there was a formal committee struck to begin discussions.

Ms David: No. She hasn't funded them yet.

Mr Jackson: I understand she hasn't funded them yet, but that doesn't prevent DHCs from pulling together. In our jurisdiction -- Barbara and I come from Halton region -- they have one committee already in place, which is dealing with long-term care, chronic care needs, and it seems to be the appropriate framework for them to begin their discussions.

Ms David: I think I can say that -- when I was talking about the restructuring within Durham region -- the original committee structure has been disbanded in order to regroup committees, and one of those committees will be the long-term care/community care committee, and certainly we have been asked, as have some of the other providers, ie, Red Cross and some of those groups, to come to that table. I don't think it's a particularly top-down direction in our region. In fact, to have the chair and the executive director of district health council come to one of our board meetings so that we can talk to them about the types of things that we do in VON is, I think, a very positive step. I see it as being very much a partnership and certainly a lot of collaboration.

Mr Jackson: Mr Chairman, could we ask the PA what time lines his ministry is giving DHCs in order to do this review?

The Chair: Could you please just repeat that again?

Mr Jackson: My question to Mr Wessenger was, what is the time line which your ministry is suggesting is appropriate for completing this discussion stage? I wasn't here when the minister may have responded to that question. Is this open-ended consultation, or do we have a fixed time -- within a year, two years?

Mr Paul Wessenger (Simcoe Centre): I'm not aware of the actual time frame. I know it's proposed that the policy statement would come forward at the end of March now. Originally, it was supposed to be the end of January. Then, of course, with the new minister, I think that could change the time frames.

Mr Jackson: Okay. Thank you, Mr Chairman.

Mr Drummond White (Durham Centre): With respect to your last question, Mr Jackson, the local district health council has had a long-term care committee for some time. It was disbanded through restructuring. They have a new executive director. I think they're doing a very admirable job, as the presenters reflected, but they are in a state of some transition which has to do with their own internal workings as opposed to the ministry dictates.

I want to thank you for coming out and for doing an excellent presentation. It really was very enlightening and I think made us think. The issues you bring up -- fragmentation of services and some of the concerns about a focus on wellness as opposed to the traditional medical model -- are dead on.

As you know, this is only a part of the whole long-term care strategy, but do we have the cart before the horse when we deal with an issue that is the most susceptible to the traditional medical care language first? Do we then frame everything else in the same way as opposed to dealing with the coordination of services, the seamless web that you've talked about and of which your agency is an integral part? I also know that your agency has no fear of losing its identity in Durham region or anywhere else in the province. Whether you're involved with placement coordination services or any other forum, you know who you are and you're going to keep on doing it.

Although we're talking here primarily of the long-term care facilities -- again, more residential facilities -- you spoke with recommendation 6, which is a very appropriate one for this legislation, and you've put us to rights here. Granting that we've got the cart before the horse and we're dealing with the wrong thing first, let's talk about item 6. Let's talk about how you could be more involved with an elderly person, with a disabled person, even while he's in an institution. Talk about that seamless web, how you would see that happening in Durham with Extendicare, with Sunnycrest, with Hillsdale or Fairview Lodge.

Mr Larry O'Connor (Durham-York): Lakeview Manor.

Mr White: Lakeview Manor. Do you have any other facilities in your riding, Larry?

Mr O'Connor: I've got lots of nurses.

Ms David: I think the example we gave in the brief was specialized service. When we have a client who may be admitted to a nursing home, even for a short stay, our services cannot be continued because the payment schedule doesn't allow for that. What we're looking at is someone who may be admitted to a nursing home for something other than the service we provide, but we would like to be able to continue to provide our specialized service to that individual, but we can't because of the way in which the homes are structured.

In fact, we had an incident just the other day, a client who had a colostomy. We were doing some work with him to try and get some healing around the skin area that had broken down. The person was admitted to a nursing home, and when the enterostomal therapist tried to get into the nursing home to see this person, the therapist was told that there could be no service because it couldn't be paid for. If we wanted to do it we could come in and do it, but it couldn't be paid for because of the system that was in place in the nursing home.

This happened to be a long-term client of ours, a man, so we went in anyway and did the work, but the follow-up of that was that the providers within the nursing home didn't have the expertise to carry on the care either. So we were left with a client now in a nursing home who wasn't going to be receiving that particular specialized service.

The other program we are very active in is foot care. Certainly, if we could provide foot care to the residents of the nursing homes and homes for the aged, we might not have as many long-term problems with their feet as we do now. But we don't have that ability unless we enter into separate contracts, and the homes are indicating that they are really quite under the gun in terms of dollars and cents in funding so that they can't do that. It, in turn, becomes the client or consumer's responsibility to pay for that service when he is in a nursing home or home for the aged.

We also have the opportunity to teach some of the providers within the nursing homes to do the type of care that we do by being consultants to that care. That's something we're certainly looking at in Durham region, being able to teach the providers how to do foot care so that they can carry on that type of care. That's also something that's down the road, and who pays for that?


Mr O'Connor: Could I put a supplementary in there, Mr Chair?

The Chair: Okay. We're getting a little close to the time of Ms Carter; if it's a very brief, pointed supplementary.

Mr O'Connor: Okay. The supplementary, if I might, would be, we're talking about a plan of care. How would you perhaps see the role? I believe the Victorian Order of Nurses usually does develop a plan of care for its clients. How could you perhaps see some of that plan of care then being continued with a client who may move into a different type of facility, perhaps a long-term care facility or something?

Ms David: That's the issue, moving the person and his records and everything else --

Mr O'Connor: Their plan of care with them.

Ms David: -- through the system and moving them right back, so that we're seeing this kind of activity as opposed to stopping, starting, starting again.

Mr O'Connor: Do you see a direct role then with yourselves as, say, placement coordinator or that continued type of care?

Ms David: Even with the actual home it would be advisable to have that kind of collaboration and partnership so that we're moving back and forth. Certainly, in our area we're also dealing with some of the area hospitals in trying to have some of our staff work with their staff so that there is a smooth transition for people, as opposed to getting lost in the system.

The Chair: The Chair notes how skillfully two questions were woven in there. Ms Carter.

Ms Jenny Carter (Peterborough): Maybe I can hang on to the same line of thought. I might say I am familiar with the work of my local VON organization. I was once on the United Way panel that was kind of looking at them and so on, and I certainly feel that it's an extremely valuable organization.

I don't see any reason why you would lose your identity under the new arrangement. I would have thought that the opposite would be the case, that you would be required more and more and would be able to fulfil your role more than you do now.

I agree with most of the things you say, but my puzzlement is that they sound exactly to me like the kinds of things I've been hearing as a member of the government caucus who has been taking an interest in these issues and I think knows exactly what we're trying to do with this legislation.

Obviously, Bill 101 doesn't cover it all, but when we talk, for example, about wellness and consumer satisfaction being the goal, I think that's exactly what we're trying to achieve. I would hope that when a person is assessed, we won't just be looking at the treatment he needs for whatever is wrong with him, but that we will be looking at rehabilitation and whatever can be done to help him to become more well and maybe to be in a nursing home setting and then move back into the community. That's one reason we're not asking people to dissolve their assets to pay, because we want them to have a home to go back to. That has been very definitely thought of.

I think this kind of interaction between the community sector and the institutional sector that you are saying is desirable is exactly what we are hoping to achieve here. I'm just wondering if there's anything very specific in the bill that makes you feel that we are not going in that direction or that there's anything that would militate against that.

Ms David: I think, first of all, there is provision in the bill for short stay, but there isn't a clear understanding of what short stay may be and I don't think it provides for the loop to come back into the community. That's the first thing.

When we say that we don't want people to dissolve their assets, it may not matter; they may get locked into a system. I guess that's the concern, that once you enter a system, is there an opportunity for you to leave that system? When you build a system that's based on acuity, you're not building in the out, you're building in the in and staying.

Ms Carter: Yes, but I don't think there's an assumption that the person is going to go necessarily from one level of acuity to a higher level. I think the hope is that sometimes their very specific problems can be pinpointed and they can either need a lower level of care or be able to return.

Again, when you're talking about going in and doing services for people who are in an institution, you're talking about the present situation, surely, and I would have thought that the changes would mean there would be more outside agencies providing services within institutions than is at present the case. It is my understanding that was the intention.

Ms Tuck: I would hope so too, but that was not recognized in the wording.

Ms Carter: I see, but certainly that's what I had understood.

Ms David: We also know where hope gets us.

The Chair: I want to thank you for your presentation. I think what's been particularly useful for the committee, being the first -- I know we have a number of representations --

[Failure of sound system]

The Chair: -- practical level of how this system will work and raising some questions around that. So thank you very much for being here this morning.


The Chair: We call then our next deputation, also the Victorian Order of Nurses, but this time from the esteemed communities of Guelph, Wellington and Dufferin. We also welcome the honourable member from that area.

Mr White: You didn't make reference to the esteemed communities of Whitby and Oshawa.

The Chair: The brief is being circulated. We want to welcome you to the committee. Please have some water. If you would be good enough just to identify yourselves for Hansard, then please go ahead when you're ready.

Ms Jan Lord: I am Jan Lord, the executive director of the Guelph-Wellington-Dufferin branch of the Victorian Order of Nurses.

Ms Gale Murray: Good morning, I'm Gale Murray. I'm the provincial director for VON in Ontario. Thank you for the opportunity, Mr Chairman, and committee members, to present this morning on Bill 101.

Before we proceed with our presentation, I'd like to clarify that I'm going to be giving some introductory remarks with regard to the overall position of VON in Ontario. These are draft remarks because we haven't had a chance to do our full consultation within our organization.

What I've distributed to you is our overall position summary on long-term care, which has been vetted through our branches as well as our provincial board and has been presented to the Minister of Health in November.

The Chair: Could I just note -- I think you may be aware of this -- following this discussion there still is a period of time, if you wish to present anything in written form, and the committee would be happy to have it.

Ms Murray: Thank you, Mr Beer. In fact, we do intend to submit to you specific comments on Bill 101 in written form before the end of your hearings.

I'll be speaking on our broad direction, our initial comments on Bill 101, and Jan will be speaking about the Guelph-Wellington-Dufferin experience. You've had the opportunity just previously to hear the perspective of our VON Durham branch.

I would also note that Rick Howarth, who presented to you on behalf of VON Durham, is also the chairperson of our external relations committee provincially, so we're bridging local and provincial this morning.

The Chair: A seamless web.

Ms Murray: A seamless web, right.

In terms of our response, we'd like to start out with what we are trying to understand is the vision of Bill 101. In our position summary, you'll see in our initial statement that our vision is a long-term care system that is consumer oriented, that allows the consumer a choice of needed services in his preferred location and with his preferred service deliverer within, we know, limited resources available for the province. So we really like the thrust of the philosophical statements by government and also by the other parties to say we really have to turn the system around from being one that's provider-driven to one that's truly consumer-driven.

Part of our problem in reviewing Bill 101 is that we aren't seeing the policy framework, so it's very difficult -- and from your earlier questions to VON Durham -- it's hard for us, in a way, to evaluate totally if Bill 101 is taking us in the right direction. I am making some assumptions here and perhaps we can have some further clarification.

We see Bill 101 as an incremental improvement in terms of the vision of a consumer-driven system, and specifically we're pleased to see direct funding through grants to the physically challenged because ultimately that gives the person the power to say yes or no, to measure quality and to walk if they do not feel they're getting the appropriate quality and cost-effective services.


We see that as a very, very important innovation that should be looked at, not just in terms of the physically challenged but perhaps in broader application, and we draw your attention to some of the literature, particularly in England, about the cost-effectiveness of this kind of approach.

Secondly, we like to see this movement of omnibus legislation pulling together different pieces in terms of the Charitable Institutions Act, the Nursing Homes Act and the Homes for the Aged and Rest Homes Act. However, we still have three acts and, additionally, we don't speak to the chronic care beds. As Durham has mentioned, and I think you'll find all of the branches saying, we really are talking still a fragmented approach that's risky in terms of moving on one piece without us seeing the whole picture. But it is an improvement to at least have some consistency in terms of this system of long-term care facilities.

We also see that the movement to ensure consumer information is important, and that's an improvement, meaning that the consumer knows well what the services and programs are that the facility is going to be offering. I think you might also want to expand that to community-based services -- I mean, what is good for the facility surely is good for all of the health and social service system -- and specifically the requirement that the plan of care be shared with the clients. So we move away from what has been a somewhat if not overbearing paternalism within our health care system, that the professional knows better than perhaps the consumer knows.

We also note that the appeal process regarding eligibility for services is an important improvement, so that if the proposed placement coordinator doesn't approve eligibility, there is a mechanism for appeal. So the client has more redress.

If we are going to go incremental, and our overall recommendation is not to, but if you decide that is the way you're going to go, we also would urge you to look at the chronic care beds, because when you look at the overall dollars in the system and you look at the allocations, they're a very significant component of the long-term care facility network and you're only dealing with part of it. I would think that if you're going to make these changes, you would want to look at that component as well.

Later on, in my other remarks, you'll see we have a much broader concept of an envelope of funding that would allow the consumers to have more choice in the sense of where they would receive services. We're still, it seems, in your legislation, making a distinction: We have certain kinds of care in the community and we have certain kinds of care in facilities. Why are we not moving to a concept of consumer-need-based service, where they choose their location? We can give you examples of our branch experience in Hamilton where we've looked after quadriplegics in the community for years.

But we have not got that kind of flexibility yet, in what we've seen in the legislation here, to allow the consumer -- in some cases the facility may be the best place for the care to be delivered, in consultation with the family, the consumer and the professionals, but in other cases we might very well be able to sustain people at home because there's a commitment by that person to wish to take more self-care or there's neighbourhood support. Let's move to a more generalized envelope of funding for the individual and not still think in chimneys of institutional and community. We want a long-term care system.

We additionally note that even within some of the incremental changes -- within the Nursing Homes Act there's a reference to the residents' council being notified of what the services and programs of the facility are. There's no other reference in the homes for the aged or the charitable homes legislation requiring the same thing. I think it reflects the fact that in those pieces of legislation you probably don't reference residents' councils. So if you're going to do incremental change, we would recommend that you incorporate the residents' council, at least in all three pieces of legislation.

As we said, in terms of our vision of long-term care, we see it as a comprehensive system that isn't fragmented by category-of-care location but rather is based on the premise that people receive needed care and that they will receive the care in their preferred location, assuming it's within the resources available.

Specifically, in turning to Bill 101, we have some concern about the expansion of the role of the placement coordinators whereby they seem to have the power to decide what facility the person could access. Surely this should be attempting at least to meet the consumer's choice of facility wherever possible.

In terms of the funding and the cost, we're concerned that if the government moves ahead with Bill 101 now, you are still sending the message that you are preoccupied with institutional care, unfortunately, because we have not seen anything that tells us the shape of the future in terms of health promotion, wellness and community-based in-home services. We're seeing a lot of activity by this committee, but the focus is within Bill 101. We feel that given the fact that we already have such an allocation of resources towards institutional care in the sense of chronic and extended care beds, we really should be very cautious about proceeding with legislative change. You may be further entrenching the bias towards institutional care, not intending to do so, but because of the train of development we're maybe going to put some things into place before we see the whole picture, and we might not want this once we have the bigger picture to look at.

Secondly, I would like to comment on the fiscal accountability model in the legislation. It's essentially what I'd call a control on resource utilization as opposed to implementing resource outcome. Specifically, you're looking at controlling the number, type and funding of beds rather than setting a mechanism of cost benefit into place to look at whether facility-type care is the most effective care for particular kinds of client groups or to even cost across the system. We would ask that, as part of the move ahead in long-term care redirection, we develop management information systems such that we can compare service delivery costs, whether it's facility or community or in-home, a medical or a nursing model. Without that kind of integrated information system there's no way to do that kind of cost-benefit analysis that ultimately is in both the taxpayers' and the consumers' interests.

As VON Durham noted in their presentation, we seem to be moving into more of a regulatory control model. I don't know whether that's the model of the future that we want to put into place in the health system. Regulatory control is very expensive. It also tends to result in gross application of regulation and doesn't allow for the kind of flexibility we want. We might be better to look at a quality management model where we're looking for accountability by people having to report on the use of their resources and their outcome, and where we also look at perhaps third-party accreditation as opposed to the government specifically legislating and controlling.

We may also need a blend. It may be not totally one or the other, but certainly we would ask that you give consideration to a model that is not just regulatory but that has quality management. Within the legislation now you're talking about quality management or quality assurance, but it doesn't have the concept of quality management that we were working towards in VON, which is the idea that we are trying to continuously improve care and be more cost-effective. There are the two components of the quality management model. The problem in regulatory may be that you may be wishing to increase the quality, but are we going to add on more costs because we don't have enough flexibility to restructure and reorganize how we deliver, how we staff and where services are available?

In terms of the major components of the long-term care system, we've alluded in our reference paper to planning, allocation, coordinating, MIS and human resources. Right now we're moving ahead with the planning for Bill 101, but again, we haven't brought out the larger policy framework and we haven't linked this with our local DHC planning process. So I feel that we're moving away from the government's stated direction of wanting to develop the health care system from a strategic policy framework and that there is a real risk here to go with legislation before you have those other pieces in place.


In terms of the allocation of resources, and here I'm making an assumption, it appears from the legislation that we're going to continue centralized funding of extended care beds and we're not even, in that, going to deal with the chronic care beds as at least the same mini-envelope. As you'll know from our paper, we are strongly recommending the concept of devolution. Given the fact that we're talking within the health care system of a $17-billion expenditure, we really need to rethink how we deliver and fund services and to move towards the concept of a long-term care funding envelope that would include the facility components, the in-home components and the community-based components.

But with the envelope being administered at a closer level, ie, a district level or a municipality level, it will allow for us to be much more flexible in how we structure the services and meet the needs. I think we'll find that communities will have different priorities when we look at the size of Ontario, that there will be possibilities for the mix and match of services. Some of your earlier discussion is very different from community to community. So moving in this direction, and particularly focusing on the long-term care component of the health system, is an ideal opportunity. You've probably been reading the southwestern planning commission, which was broader and talked about the whole of the envelope. That may be unmanageable at this time, but we have an opportunity to at least look at long-term care components.

We're noting also that you're talking about the level-of-care funding. In our position summary on redirection we said we should be very flexible about our ideas on funding. Again, and I think VON Durham alluded to some of the VON concerns, when you move into a level-of-care funding are you in effect creating some fiscal incentives to heavy care; meaning, where is the incentive for rehabilitation and discharge? If we're going to fund, certainly we want to use the fiscal lever to achieve the kind of outcomes that we want in the system, so I think we would want to do something more than just straightforward level-of-care funding. We also have to look at level-of-care funding in the historical context in other parts of the country and look at its impact.

We may wish to consider some kind of blended funding of capitation plus level-of-care funding so that we're building in incentives for, again, as I was saying, flexible service delivery and not because level-of-care funding is this and this is how we therefore end up delivering the services. If we allow the ultimate flexibility of an envelope for the consumer, then we may find that in fact we end up spending less money.

I'd like to cite you an example of research we did in Hamilton with regard to in-home respite and education and counselling of families. We found that if the families received the education and support, they required fewer units of in-home respite because they were better able to cope with the situation. Whereas if we had just put the in-home respite in, in a way that's sort of the bandage and not drawing back to understand what are the underlying dynamics.

So whenever we start to think about funding, I think let's be flexible and not too rigid in terms of our approach to that kind of question. Right now the government is looking at issues like comprehensive multiservice agencies which VON is very interested in, and Jan will be talking about some of what we're trying to do in Guelph right now to be more integrated. They're also looking at different kinds of funding models in other parts of the system, so I'd ask you to give real thought to how we end up funding, because it is such a powerful incentive.

We also would like to comment on placement coordination because we've run a number of these programs now within the province. We're very pleased to see the expansion across the province. That is necessary because for many consumers it's extremely difficult to access facilities at the moment. You mentioned how many there are in Durham. If you're in Metro Toronto, it's difficult. So this is an improvement.

We also would like to bring in the consumer. Again, here in the legislation speaking to the coordinator's role, make sure that we also empower the consumer to have some rights to choice in that. We also would see placement coordination logically situated with the devolved board because information referral and placement would seem to be some logical functions that should be at a general level in the system as opposed to in every agency in the system.

In terms of the flexibility, if you put it in with the devolved agency, then it allows the person to be referred to the community as well as the facility. Again, we aren't biasing the system towards facility care as opposed to community care.

That summarizes our initial thinking to date. Within VON we have 33 branches in Ontario and we have a consultation process. We'll be sending out our initial review, which has gone through some committee work, and then we hope to have our final comments back to you in terms of the end of the month for a written brief to the committee.

I think Jan is going to speak now from the perspective of VON, Guelph.

The Chair: Please go ahead.

Ms Lord: I'll just tell you a little bit about our branch. We're a branch that serves the city of Guelph, all of Wellington county and all of Dufferin county, so it's a mix of urban and rural. In reviewing Bill 101, in consultation with VON Ontario, I share the concerns. What I wanted to make you aware of is that within our branch we are trying to respond to the direction of the minister in terms of integrated and coordinated service delivery.

Our branch is a multiservice branch, because we provide more than just visiting nursing. There are two branches in the province of Ontario that provide homemaking services as well as visiting nursing, and Guelph-Wellington-Dufferin is one of those branches, with approximately 275 homemakers on our staff who provide home support services, including a lot of personal care to clients we serve.

We believe very strongly that having the right provider provide care is a better use of resources and probably meets the needs of the consumer better. Again, the focus, I believe, in community-based service is not necessarily following a strong medical model but looking at a blended model that looks at the support services required to maintain people in their community. We also provide foot care clinics across both counties and we have friendly visiting for the frail elderly, both in the urban area and the rural area of Wellington county.

We sit on a variety of committees across both counties looking at integrating services. One of them is in the north Wellington area. Under the direction of the north Wellington advisory group, we are looking at a multiservice facility in which there would be six to seven agencies that would share physical space in a single building. But it would be more than just the sharing of space; it would be beginning integration of programs.

Some of the programs that would be in there would be the health unit, VON, the Guelph counselling service, the north Wellington advisory group, the rural women agency, again looking at common intake, common information sharing, beginning to look at the development of possibly single records for the transfer of information.

The other area that we're looking at in terms of integrating and coordinating care is within our branch itself, to try and get away from the chimney way of delivering service. Right now, we deliver homemaking and visiting nursing and the volunteer visiting, and we might be involved with one client with all those services, but they tend to operate relatively independently.

What we're going to be and currently are planning on is developing two pilot projects in our branch where we integrate the services within our own branch, so that from the consumers' perspective it's a single service that meets their needs, whether it's for professional visiting nursing service, home support or homemaking service.

Part of our planning will be to develop collaborative relationships with other providers of service in the community, particularly our local home care program, which right now, because of the home care legislation, really does the resource management for clients receiving care under the home care program. We have a very positive and good relationship with our home care program, so we're very optimistic about being able to develop these collaborative relationships.


We're also collaborating with several other agencies in developing an in-home respite program, again building on the experience Hamilton had with its in-home respite, which is a model that focuses on the care giver, so it's a respite program for the care giver as opposed to what we would ordinarily call the patient or the client.

Again, we're submitting a joint proposal with the Guelph services for the physically disabled, which provides in-home attendant care service, and our branch, the Alzheimer Society of Guelph District and Wellington, the placement coordination service, and with the support of certainly the home care program, although it's there as a resource.

Our concern in terms not so much of the legislation but of the whole focus of long-term care is that we don't have a clear sense of what the policy direction will be related to this comprehensive multiservice agency, so we're not sure how VON will fit into this but feel very strongly that VON, first of all, supports comprehensive multiservice delivery of care, both in the community and across the community in institutions. But it's very difficult to plan and understand how that is going to work without the policy direction from the government.

The Chair: Thanks very much. You've given us a lot of food for questions. As I mentioned, the member for Wellington has joined us. I would like to ask the committee, as a courtesy, if he could ask a question, but I need the approval of the committee.

Mr O'Connor: By all means, Mr Chair.

The Chair: Thank you. Mr Arnott, welcome to the committee. Please go ahead.

Mr Ted Arnott (Wellington): Thank you, Mr Chairman, and thank you both for coming in today. You've given this committee a great deal of information and your local perspective, Ms Lord, of what wonderful work we're doing in Wellington county. We certainly appreciate that.

I guess we get back to the Orser report when we see some of the origins in terms of health care recommendations devolving power from Queen's Park to regional centres. I've listened to what you've said on that and I think there's a good deal of merit in terms of that approach, but there are also, I think by definition, going to be problems with that approach. I guess if we as a society determine that decentralization of service is the best way to go in health care, a responsibility the government has, we have to address the problems that may be forthcoming.

I think the Ministry of Community and Social Services has to a large extent done exactly what you're saying. There are two things that probably come up, though. One is the resistance by the civil service in Queen's Park to devolving its power to local offices. That seems to be a natural inclination. But second, there is a loss of political accountability, I think, when powers devolve to local regional offices.

The third thing is that when you draw boundaries and you have different services on either side of the boundary, you're going to have people who are living close to the boundary who wonder why, if they lived one concession road over, they would have a service. With Community and Social Services we have that problem. I'd just like to ask you to comment on those issues.

Ms Lord: I'd certainly agree with you, and we were encouraged to see the expansion of the integrated homemaker program, because currently neither Wellington nor Dufferin county has integrated homemaking, but Waterloo does. On one side of the highway people are in the Waterloo area and on the other side of the highway they're in the Wellington area and some people can get it and some can't.

I think it's the whole idea of how you define community and, although we talk a lot about the community, we each have a different perspective of what that community is. Again, I think it would take a great deal of consumer input and local input to determine what were going to be the boundaries of community that would meet particular needs in that community.

Mr Arnott: They're very difficult to draw, though.

Ms Lord: Yes.

Ms Murray: I'd also note that when we're proposing the devolved authority for the long-term care envelope, that does not preclude provincial responsibilities as well. I think it's very important. The province has to ultimately decide how much money it can afford to spend, ie, what is going to be the boundary of resources. The province will also have to ensure some definition of what are core programs, meaning what will every community in Ontario have? That's a prerequisite. Thirdly, standards in terms both of the quality of service and cost-effectiveness. We don't see it as unilateral, that we just hand all the problems down. We see it as a balanced approach of understanding what can be most effective provincially, what can be most effective.

The issue of political accountability that you raise: I think the Premier's Council noted earlier on two basic ways to go. One could be with the municipal model; the other could be with special-purpose body. In any case, the concept of some kind of local control, as Jan alluded to, in the sense of an electoral process such as they're now looking at in Quebec, would probably help to offset some of those. Certainly, the move to at least core programming across the province would help the equity question.

Mr Arnott: I have just one other question. British Columbia is going through this process right now. Do you think it would be prudent for us in Ontario to watch what they're doing very closely and maybe wait a bit to see what their experience is going to be and see what we can learn from them?

Ms Murray: I think it would be prudent for us to look at the experience of all of the provinces: Quebec, Saskatchewan, BC, New Brunswick, everybody is looking at restructuring. We should also look at the international experience, but on the other hand, I think we also have to move ahead. There may be ways of at least maybe trying some piloting of approaches, getting some more sense of what is going to be most effective for us.

The Chair: I don't know whether that means we should travel.

Ms Murray: As a committee?

Mr Jackson: Do you want to put that in the form of a motion, Mr Chair?

The Chair: No. I'm not going to touch that.

Mr Wessenger: Thank you very much for your presentation. First of all, you mentioned how you did not think a regulatory approach works. I'd just like to throw out to you what we heard from a consumer yesterday when we asked about her perspective concerning how the system worked. She indicated that she felt that rampant through the system there were problems with the way the institutional system worked with respect to difficulties.

Although one can say, when you approach this problem, shall we say the good-cop, bad-cop routine, you first of all try to work with the institution to get it to improve its position, don't you think that at some stage you have to have some enforcement mechanism, some way of ensuring that institutions do comply? I think it's fair to say there appears to be some criticism of the present system, which is basically sort of the soft glove approach.

Ms Murray: I think we have accountabilities. The province has to ensure that things it's funding -- services, whether they're institutional, community or medical or what else -- are giving the consumer quality and cost-effectiveness. But we have different models of how we do that. If we look at the professional colleges in the new legislation, we're talking about peer monitoring. If we look at the hospitals, we're talking about accreditation processes and, yes, ultimately the minister can put a trustee in to run a hospital.

I'm wondering if you're looking at the Nursing Homes Act as your model for the long-term care facilities, as opposed to expanding and looking at how we regulate and encourage quality and cost-effectiveness in other parts of our system. I'll put the question back to you: If you've had experience with nursing homes and the Nursing Homes Act, do you feel that the act accomplished the required outcome? It's the most regulatory in nature of all of the acts that we have before us.

Mr Wessenger: It's fair to say that there are problems in that situation.

Ms Murray: Exactly.

Mr Wessenger: Obviously, it's not working as well as it ought to be. There may be many factors involved in that, aside from the legislative scheme. I think sometimes looking purely at legislative schemes is not necessarily the cause of the problems. There may be other aspects.

Ms Murray: Can you regulate caring?

Mr Wessenger: No, I think that's fair to say.


Ms Murray: That's the heart to me. I'm not arguing against regulation. I'm saying we're going to have to have some of it, but we can't expect regulation to achieve what we really want, which is a long-term care system that cares. How can we? How can we support the caring components? That's what we were balancing out here, and that's why I'm saying, when we address the issue, if we think that regulation alone is going to create this kind of heart and soul of the system that we want, it won't. So what can we do to create the heart and soul?

I think empowering the consumer to have more choice is the quality issue. It's not just sort of philosophical. If they have choice, their experience of whether they're getting care in a facility -- by the way, I have worked in nursing homes too, so I've got direct experience. The issue of consumer choice is so important.

The person who gets put in a facility feels disempowered. The issue of having control over one's life is so important; you know, not having a paternalistic system. There are many other issues, and I'm just drawing to your attention that overemphasis on regulation may not get what you want. Look at our experience to date, and then let's try and come up with some other alternatives that are going to create the structure.

Fiscal incentives, as I referenced, incentives for people to get well, to focus the system on wellness rehabilitation -- I think Ms Carter referenced that earlier -- are very important. It directs us where we want to go, as opposed to paying for levels of care. What's the message on levels of care? Higher care, more money.

How do we offset that with, yes, we have to fund adequately, but where are the incentives to rehabilitate? How do we structure where we locate services? We referenced earlier that VON is doing a lot of infusion therapy. We're quite prepared to go into facilities now and do that because we have enough base to have the credential aspect of quality, and you're not going to have enough client case load and it's going to be very costly to maybe do it in the facility, so we need to be, again, flexible in how we fund.

How would we fund VON to go into facilities to do infusion therapy? Similarly, how would we take the experienced team from a geriatric assessment and use it in the home? That's why we can't do one piece of the system alone. We have to look at it holistically.

Mrs Marland: I think the ministry should hire Gale. That's extremely well said.

Mr Randy R. Hope (Chatham-Kent): As we go through this process we listen to sides of stories and comments that people have, and yesterday there were some comments made on which I need some type of clarification from you. I was reading your document as you were talking, which talks about this support for non-profit services, in human services I guess. Is that support still there?

Ms Murray: Do you mean does VON support preference for not-for-profit delivery? Yes, we do. We have a position paper that we will share with the committee on that subject.

Mr Hope: The other question I have is, I was reading your paper and it talks about providing services for the consumer. Yesterday I heard comments saying: "The non-profits are very selective in what they take. They won't take the two-hour case load." I want the opportunity to help me to understand.

I need a balance of the stories here, because a presentation yesterday said, "The reason commercial agencies have increased their share of public funds in home care in recent years is because their flexibility, responsiveness and effectiveness efficiently enable them to meet the service demand not-for-profit agencies could not." I would like you to comment on that, please.

Ms Lord: I'd like to address that. In terms of being flexible and providing service for more than selected clients in Guelph-Wellington-Dufferin, we provide, I would think, 100% of the visiting nursing to the home care program. We service clients who require two-, three-, four-hour visits. We make visits at 4 o'clock in the morning, I know, to one client. We have three visiting nurses who work on a permanent evening and night basis, so we truly have 24-hour-a-day coverage, and that is true in our homemaking program as well. We provide quite a lot of evening homemaking service and weekend homemaking service.

In the rural areas, we provide visiting nursing and visiting homemaking, and it is my understanding that the for-profit visiting homemaking services certainly provide service in the Guelph-Wellington-Dufferin area. We get most of the rural homemaking, again because it's more expensive than providing homemaking in an urban centre, generally speaking.

But our sort of philosophy is that we're there to provide a service and that we'll do it whether it's two hours, one hour or half an hour. Certainly in our homemaking we have clients to whom we provide one hour of service in the morning and one hour of service in the afternoon. From my own particular branch's perspective, one of the things we are is flexible and comprehensive.

Mr Hope: Are you financially accountable too, by the way? Because I've heard the comment saying you wait for the blank cheque to pick up the deficits for the non-profit agencies.

Ms Lord: We feel extremely fiscally accountable both to our own board, and to VON (Ontario) and the VON (Ontario) board, which negotiates provincially with the Ministry of Health for our home care fee-for-service and visiting nursing. Our whole objective for the last two years has been to operate in a deficit-free situation. Our branch has been deficit-free.

Mr Hope: My final one would be, are you working on --

The Chair: A short and final one?

Mr Hope: Yes, it's short and final. As you notice, all my questions have been short.

You are a provincial organization. I'm curious, are you working on a province-wide standard that can apply to all home care providers? Are you working with other groups to develop a home care, and who are you working with?

Ms Murray: Perhaps I might respond to that. VON initiated a request to the ministry about a year and a half ago that we in fact put together a providers' group at the provincial level to develop, in this situation, visiting nursing standards and also guidelines for contracts across the province so that we have what we said earlier, that provincial standard. We're also interested in pursuing accreditation in community agencies. We've had discussions with ministry staff about moving in that direction in order to ensure quality.

Mr Hope: Could you tell me who is in that group?

Ms Murray: The group is chaired by Greta Spalding-Martin, the director of in-home services. The VON is at the group. St Elizabeth Vising Nurses is at the group. The consultants from the home care in-home services branch are at the group as well.

Mrs Sullivan: Before I start, I understand that our next intervenor is not going to be appearing. I wonder, if there are additional questions, if we could take extra time and perhaps go around the table once again, if necessary.

The Chair: You may have noticed that we have taken extra time.

Mrs Sullivan: Even more?

The Chair: The Chair has tried to be open to the committee.

Mrs Sullivan: I know. You've been very flexible and open, as usual, Mr Chair.

Mr Jackson: And fair.

Mrs Sullivan: And fair.

I think this has been an interesting presentation. One of the things that it underlines and that you have underlined, it seems to me, is the frustration that we have as legislators when we have a piece of implementation legislation without having the full surround of the legislation and the fit within a policy or strategy. This has been certainly a frustration of ours. We have put that on the table.

We were very concerned that the policy document is not available to us at this time and will not be available for some months, we understand, and we're dealing in fact with a piece of legislation that is putting into place something where there may not be a fit over the longer term.

I think one of the poignant points that comes from your presentation is in dividing the roles of legislative responsibility. Even seeing where this legislation fits, we have to know what the provincial standards are, the guidelines, the policy directions, the goals. The province is going to have to define the funding availabilities, and in fact a prioritization of the enhancement of services over time and how it will integrate one with another. Because we don't see that surround, I think we face the same frustration that you face.

We have seen from all of our presenters so far, I think, evidence that you have given of frustration of working within the existing system where, because of rules that are put in place, largely because of a funding requirement, integration is blocked, so that, by example, the home care agency can't refer someone into a respite care or adult day care for a portion of the time where there may be a more cost-effective approach.


I think those are the kinds of things that we are having difficulty with in dealing with this piece of legislation now. That's not to say that we don't support the concept of this piece of legislation. Frankly, in our party we don't think there's much difference in the nursing and personal care needs of residents in a nursing home or in a home for the aged, which is a fundamental part of this legislation.

I wanted to just walk through some of the points that you have made. I think we have heard from other presenters as well, and it is a concept that is very much one that we are more interested in looking at and you have raised as something that's valid and useful, about the direct funding of individuals other than the disabled. I was very disappointed that the Minister of Community and Social Services said in the original debate on this bill that they couldn't even proceed with the pilot on direct funding for the disabled because she needed a legislative sanction.

In my view, that's not correct. I think that indeed there has been direct funding in the past, and it just seemed a bizarre statement to me. However, I think those kinds of pilots could extend into areas other than the physically challenged, and seniors certainly are one area where the personal choice then becomes the priority. I was interested that you as well are concerned and in fact a proponent of direct funding for other than the disabled.

The omnibus legislation that you've mentioned and the fact that we're still dealing with three acts and the chronic care is not in, we are concerned about. We feel that the role study should have been available to us, and chronic care facilities should be considered as part of a long-term care, facility-based delivery. In fact we have other concerns in that there are still two ministers involved. The tugs between the two ministers on the direct funding issue, by example, are still, it seems to us, problematic.

Mr Jackson: Two new ministers.

Mrs Sullivan: And now two new ministers. That's right.

Mr Jackson: They can arm-wrestle each other in cabinet. It's going to be fun.

Mrs Sullivan: That's right. I think that once again, were that strategy document available, we might well see what kind of a structure is going to drive the vision ultimately, and we don't have that.

The fiscal accountability that you talked about moves, I think, quite well into the quality assurance, quality improvement area. We have given the government the benefit of the doubt that it used the wrong term in drafting the legislation. I think we have a commitment from the parliamentary assistant that the government is going to look at whether the words are going to be changed and perhaps bring in an amendment.

Whether or not that amendment will in fact change the entire enforcement approach as well -- and I'd like comments on this -- and whether other amendments will be required in that area becomes, I think, the next problematic, because it seems to me that they are integrated concepts. If you have continuous quality improvement methodologies in place -- or quality management, which is, I suppose, the more generic term which could go into the bill -- then what relationship does that have in terms of the enforcement models versus outcomes measurement?

So that all members around the table will be able to understand that debate, I'd like to hear more of your comments on that. I think it's a very important aspect in dealing with this particular bill and what will happen over the long term in the LTC stratagem.

Ms Murray: I'm filling in gaps here. It doesn't speak, in the legislation I'm reading, vis-à-vis the levels-of-care funding. I'm assuming this is prerequired in order to put in the levels-of-care funding. So you're funding people on some kind of patient classification system and you're allocating units of resources for that. What's the link between the units of resources and the expected outcomes? Unless you start to build in a data system to be able to look at how many resources you're putting in to get what outcome, you're going to be in a quality assurance mode. You're not going to move that loop over to be the quality management, because the quality management essential difference -- and it's why we have to go -- is that it's not cost-plus.

I'll give a bit of my own personal background. I was involved with the quality assurance coordinators' group and I did develop some initial concepts about long-term care quality assurance systems. You set standards and then you kept trying to meet the standards, improve the standards, but you never looked at it in terms of how many resources it took to improve the standard or what the cost-benefit was. We have to move to that second stage now and look at what are the outcomes we want. We continuously improve, but we have to continuously improve with more cost-effectiveness.

There's a tension, in my mind, between the more you regulate and specify how and where and what is done, and those concepts of flexibility to continuously improve and be more cost-effective. Because you have to free up, in this case, the facilities we're talking about, plus their clients, their residents' councils, their families, to rethink how they do services all the time. But legislation specifies how you will do the service. It says, "You will have the care plan, you will review at this time, you will involve this person and that person." How do we balance what we really need to regulate -- and maybe physical fire safety is an example of what you must regulate on -- against the care process?

We may need to be a lot more flexible and be cautious about regulating that care process, because you're building in that people don't have the flexibility to change. If they can't change, how can they continuously improve in a cost-effective manner? That's the other part we always have to bring together. That's what we're exploring in VON.

Going back to some of the questions I assume the for-profits were raising about the flexibility of the not-for-profit agency, I would say to you -- and we're on the record and if you read our position paper carefully -- that having choice in the system is very important. Whether it happens to be a for-profit and not-for-profit choice to me is not the question. It's the choice that forces people to have to compete on excellence.

I wouldn't often use a US model because I don't think it's the most appropriate, for sure, for Canada, but there are some things in it that are interesting in terms of their HMOs, health maintenance organizations, reporting. They have to publish their quality indicators. That might be something we might want to think about: So I get to rate VON versus other agency versus the facility.

And I want us not to just think facility here; we've got to think the whole system. That's the risk: If you put stuff in for the facility, again you're predisposing how the system's going to look in the future, and that's why my point about placement coordination. If you leave it with just the officer who is the placement coordinator, you've again robbed the consumer of being empowered. You also force excellence into the system when there isn't only one choice. Choice becomes important, I think, for continuous improvement and cost-effectiveness.

That's why, in our position, we're very interested in the CMSA, comprehensive multiservice organization, but we don't think it should be one CMSA. If you do that, then the consumer is locked into only one agency providing the comprehensive service. It might be good to have some choice, but we can't have tens of thousands of these either, because that doesn't become effective. But what's the balance here? Allowing for consumer choice, then building in more emphasis on quality management, and yes, regulating where we really have to regulate.


Mrs Sullivan: Following up on that, the Ministry of Health has provided specific funding for MIS improvement in the hospital sector. It seems to me that it would be a useful approach in long-term care as well. Mind you, it may well be in the strategic document; we don't know. In your discussions with ministry officials, have you put a recommendation forward with respect to MIS funding over the entire spectrum of long-term care services? How do you see specific funding being used, given the kind of fragmentation we have now?

Ms Murray: Yes, we have made a recommendation. In that summary paper to the Minister of Health, we strongly recommended that we build on the initiative of the unique identifier number, which now allows us for the first time to track the use of the system by individual. And we shouldn't just be looking at the long-term care MIS; it should be the health MIS, so that we can begin to evaluate some of our outcomes. A lot of money has gone into the hospital system. Virtually nothing has gone into developing the community side.

I would strongly recommend, before we spend any more money, that we do an integrated, health-system-wide approach, because then we can start to do that analysis of cost-benefit. Until we do that, we're still thinking, "We have the hospitals over here, and we'll have the long-term care facilities over here and we'll have physicians over there and VON someplace else." How can we know that a nursing model is not the more effective model in terms of health outcome if we can never measure this type of practice model against, say, a medical model, against a different kind of model?

Within VON we've done a lot of systems development for better management, because without information, you can't be fiscally accountable. But we can't do that as an individual organization. This really requires government leadership, because the capital cost to do such a thing is beyond the ability of any one organization. Besides, we don't want it fragmented; we want it universal.

Mrs Sullivan: Do we have time?

The Chair: I know there is further interest. I was going to allow one more question from each caucus because that has been requested, so you may have your one last question.

Mr Hope: Mr Chairman, mine is not a question; it's for clarification from ministry officials.

The Chair: Okay, I'm going to allow each caucus to seek clarification and/or ask a question. So Mrs Sullivan, if you have a last question?

Mrs Sullivan: My last question goes into a different area which relates to accreditation, but I also wondered if the parliamentary assistant of Health could provide us with information about consideration of MIS enhancement, with respect specifically to long-term care. Additionally, because the issue has come up and I think we have a promise from him of an amendment, if additional documentation with respect to quality management introduction in the legislation could come forward at some point, I think that would be useful. But my question --

The Chair: So noted, parliamentary assistant?

Mr Wessenger: So noted.

The Chair: I want everyone to note that the parliamentary assistant is noting everything.

Mrs Sullivan: Good. The issue of the unregulated worker, in terms of the long-term care spectrum, has been raised, and certainly we know that with the RHPA there are scopes of practice and so on. But in long-term care actual delivery there are a lot of people who are providing services -- not the least of which are families -- perhaps without training and without a standard or measurement in terms of what ought to be the basics for the provision of services. There is a difference in basic things that have actually no relationship in terms of delivery but, by example, the bonding of the individual.

I wonder if you have prepared documentation or recommendations with respect to the unregulated worker and how you see that becoming part of an accreditation process, if at all. Accreditation, of course, moves into another area, but it seems to me that you have to talk about personnel in the context of an accreditation argument.

Mr Hope: I thought you said one question.

Mrs Sullivan: It is.

The Chair: It is one question with a surround.

Ms Murray: I think the core of the question, though, is with regard to the paraprofessional worker -- ie, homemaker, health care aide -- because they are not professional and do not report to a college under the health professions legislation.

I don't think we want to have all care in the community and in facilities to be professionally based. However, I think one of the things we can do to ensure the quality issue is to have curriculum that's standardized across the province through the community colleges with regard to homemakers and health care aides, so we know that when people go through the training program in Thunder Bay or Windsor or Toronto, they're getting at least the core units that are necessary.

I also think the thrust, whether they call it homemaker or health care aide, is that we move to the more generic worker concept, but I would also like to distinguish between what I'll call the generic personal care worker and the home support worker. I think these are two different kinds of services.

The home support worker might be going in to assist with some light housekeeping; it may be the snow-shovelling; it might be errands. They are not doing personal care, in contrast to the health care aide or the homemaker 2 or 3 within our current system, who is laying on hands and doing personal care.

I think we want to make sure that the person who is laying on hands has at least the core program and that we do that through our community college; therefore agencies, if they're using these workers, would hire people. In order to facilitate retraining, which I know the government's interested in, grants to assist people to train, which has been in place and could be enhanced, would assist to make sure that we have appropriate numbers available.

If we're going to be cost-effective, I think we have to use the paraprofessional worker wherever we can. Within VON, I draw to your attention that approximately 20% to 25% of our workforce is RNA. If you'd talked to me two and a half years ago, we would have been talking less than 1%. We have restructured our workforce because we believe, with the changes in the standards of the practice of the College of Nurses, that the RNA is a very appropriate care giver for certain clients, and we expect to see some further expansion of that.

We wish to introduce the health care aide, homemaker 3, whatever we're calling that. Right now there are structural barriers. We believe that if we got funded for the care of the client in whole and we could then put together the team that's appropriate -- be that RN or physiotherapist, other therapist, a health care aide -- we could be more cost-effective. So we would look forward to funding changing as well and how we deliver services to allow that to occur.

Mrs Marland: I was very impressed with a lot of what you had to say this morning, until you said you had a preference for the not-for-profit sector. I understand, of course, as you come from that sector yourself, but then you went on to talk about the importance of choice.

Frankly, in a region where the Red Cross and the VON rate came in at $15-something an hour and the private sector came in at $13-something an hour and we could have saved $650,000 if we had taken the lower rate instead of paying what then became the government rate, I have a lot of concern.

I agree with you that there should be a choice. There's any number of reasons that there should be a choice for the person who needs the service, not the least of which is that it's still a free, democratic society, and whether or not we use the services as clients or patients, we're paying for them as taxpayers.

I'd like you to explain to the committee how you support a choice and yet your preference is for the not-for-profit sector, and how you explain that for the patient who makes the choice, not-for-profit isn't necessarily less expensive and, we would hope, that through licensing and supervision and everything else, the service is going to be the same.


Ms Murray: I think I said to you that our key issue is pluralism and choice, and that you can structure pluralism and choice in a number of ways. You can do it on for-profit or not-for-profit, but you can also do it with the consumer having a choice of taking services in facility or community or having it from agency A or agency B. I think how we structure choice can differ.

Specifically, let's deal with the not-for-profit and the for-profit question. What VON has said is that all things being equal, why would you not prefer the not-for-profit system? Because the surplus or the profit is being reinvested in the service and specifically, in some cases, in the local community. That's what you're getting. So if all things are equal, why would you not prefer the not-for-profit?

You're also getting added social value in the sense of the community involvement in the design of the service delivery, the governance role of local people being involved on boards, such as Guelph or the 32 other boards we have around the province.

But I think the for-profits have offered the not-for-profits a challenge in Ontario. We've had to compete with them on price. By the way, you must be talking about the homemaker program. I want to say that we have competed successfully overall with the for-profits over the last two years: We've maintained our market share of visiting nursing. They have presented us with a challenge to which we have had to rise.

That's why I believe we need to keep some choice in the system, but there can be different ways to how you structure the choice. Philosophically, the NDP has said it wants to go with the not-for-profit system; that's ultimately their choice as government. But if they are going to go that way, don't go to a monolithic or monopolistic system: Learn from the experience of other sectors, be that education, be that public utilities, be that private sector. There's something for us to learn about how to make the best system. We have not explicitly come out and said, "Don't have for-profit." We have said, "Do have choice."

Mrs Marland: Well, that's some relief.

Ms Murray: I will make sure the committee gets a copy of our position paper on this question, because I think that may help clarify. But we're saying that if all things are equal, why would you not want to have that social reinvestment and why would you not want to have that added social value of the volunteer component?

The Chair: With the last question, thought, perusal, musing or clarification: Mr Hope.

Mr Hope: Clarification: I'd ask the legal people from the Ministry of Community and Social Services if they wouldn't mind taking the appropriate place, because Mrs Sullivan had made comments about the individualization of payment. I would like to get clarification on the record for us as members to really understand what's being said about that.

The Chair: I ask you to again identify yourself for Hansard.

Mr Ian Matthews: Ian Matthews, legal counsel, Ministry of Community and Social Services.

A question arose regarding the necessity of the amendment to the Ministry of Community and Social Services Act. As section 12 of the ministry act is written right now, without the amendment, it merely permits individualized funding whereby the ministry will flow funds to a transfer payment agency to arrange for the provision of services to a disabled person.

Those services can be individualized or customized to the individual's need, but the money is not paid directly to the disabled person. The proposed amendment to the ministry act enables the minister to pay funds directly to the disabled persons to enable them to purchase their own services.

The Chair: Given the nature of this, I think just for clarification we can give Mrs Sullivan a supplementary.

Mrs Sullivan: I'm interested in that, because what was promised was a pilot project, and it seems to me that one doesn't want legislative change before introducing a pilot project. I give you in comparison, by example, the pilot project with respect to the full computerization of health cards which is now under way in the Kenora-Rainy River area. There was no need for a legislative change there for that pilot project to proceed.

I shouldn't be arguing with a person from the ministry; it should be you I'm taking on.

Mr Hope: Well, come on.

Mrs Sullivan: What I'm suggesting to you is that for a pilot, surely the government could have taken action through an order in council to ensure that the pilot could proceed rather than saying that even for the pilot to move ahead, we have to have legislative change. It seems to me that the pilot is to prove whether or not there is validity to the project so that legislative change would occur in one way or, if the pilot has failed, in a different way.

Mr Hope: Mr Chair, what does that have to do with this? This is turning into a comment more than it is a clarification of the act.

The Chair: I'm going to let Ms Sullivan finish her point, and then, if there is anything you wish to say to that, okay. But it sounds to me as though we're going to understand what has happened or not happened and that we'll just have to leave that as a difference of opinion and/or approach. If you could just bring your comments --

Mrs Sullivan: For clarification, Mr Chairman, in the debate in the House I specifically asked on this bill --

Mr Hope: But you made a comment today about the individualization --

Mrs Sullivan: Precisely.

The Chair: Mr Hope, order, please.

Mr Hope: I wanted to make sure it was for clarification.

Mrs Sullivan: Precisely, Mr Hope. In the debate in the House I specifically asked why the pilot had not proceeded. The Minister of Community and Social Services responded that there was required to be a legislative change. We have now had from the ministry an opinion with respect to the existing act about a change which would be necessary if an entire program were to be implemented. My view still remains that the pilot could have proceeded through ministerial and cabinet action on the basis of an order in council. That is how other pilots proceed.

The Chair: Is there any comment you would wish to make?

Mr Matthews: The only comment I would make is that it was our opinion that we needed legislative change to authorize funding for the pilot.

The Chair: I think we've heard those views, and we'll leave that on the record.

I want to thank you very much. As I noted before, the Chair has used his discretion in seeing the clock. By way of explanation, clearly we were given some extra time because the next deputation didn't appear. Also, as it happened, we had with both of you a local Victorian Order of Nurses as well as the provincial order. I think that was very useful for the committee to perhaps expand on some of the issues and the points. We want to thank you both very much for your time this morning.

With that, the committee will stand adjourned until 2 o'clock this afternoon.

The committee recessed at 1159.


The committee resumed at 1408.

The Chair: Good afternoon, ladies and gentlemen. I call the standing committee on social development to order. We are again reviewing Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: Our first deputation this afternoon is representatives from the Ontario Association of Registered Nursing Assistants. We're delighted to have you with us. If you'd be good enough to introduce yourselves for Hansard.

Mrs Verna Steffler: Sure. I'm Verna Steffler, the executive director of the Ontario Association of Registered Nursing Assistants.

Mrs Sheila Arsenault: I'm Sheila Arsenault, president of the Ontario Association of Registered Nursing Assistants.

The Chair: Just before you begin, we were joking earlier, and I know Mr Hope was here, and a few others. We're seeing a lot of familiar faces from the Health Disciplines Act legislation, so good to see you again.

Mrs Steffler: Thank you. There are so many things that are going on in health, small wonder you're seeing us frequently.

The Chair: We even have a new minister.

Mrs Steffler: Yes, I heard that today. Anyway, we are here to present today in regard to Bill 101, An Act to amend certain Acts concerning Long Term Care. About one third of the 25,000 RNAs working in our health care system today are employed by nursing homes, homes for the aged and charitable homes, so you can see why this legislation is of particular interest to the members of our profession.

In every part of the province, RNAs are the front-line workers responsible for providing basic nursing care to elderly and disabled persons living in these facilities. Our members are deeply committed to ensuring that these residents receive high-quality care and service and that provincial legislation governing these facilities supports that objective.

Our presentation today will focus on four areas: what we like about the proposed legislation, what we object to in the legislation, what has confused us about this legislation and what we would like to see eliminated or amended in this legislation.

What OARNA likes most about this legislation is the fact that it attempts to establish an equal basis for dealing with nursing homes, charitable homes and homes for the aged, which until now have been governed under different rules. Given the similarity in patient populations living in these facilities, legislation aimed at a more unified approach makes good sense and will promote equity in the system.

OARNA was also pleased by the bill's effort to address the need for increased accountability, particularly with respect to requirements for establishing service agreements, individual care plans, financial reporting and a process for reconciling the funding provided by government with proof of actual expenditures by each facility. Inadequacies in this area are overdue for reform, and Bill 101 provides an explicit step forward in clarifying the rights and responsibilities of institutional providers of long-term care service.

The fact that the province will now have the right to withhold some or all of the funding from facilities that are in breach of their service agreements establishes a clear line of authority between the funder and the service-providing agency. Although we have some reservations about the implications of these provisions, to be addressed later on in this presentation, we applaud their intent and the government's obvious desire to create a more responsible and responsive system of long-term institutional care.

In particular we applaud the bill's requirement for facilities to post service agreements and to share with each resident an explanation of his or her individualized care plan. These provisions should create a more open environment for negotiation between residents, their families and the facility's administration. By making the terms of the institution's responsibility explicit, many misunderstandings can be avoided.

Given our professional interests, we were particularly pleased to find that regulations requiring in-service training now provide for governing such training. This issue is of major importance to RNAs wishing to enhance their skills.

By establishing, through regulation, an in-house responsibility for governing training, educational deficiencies could be addressed directly by the institution. By designing and delivering purpose-specific, in-service training, facilities could encourage RNAs to perform to their full potential, while at the same time permitting more cost-effective service provision.

OARNA also supports provisions in the legislation permitting regulations governing the allocation and distribution of beds for specific purposes, classes of need, type of accommodation or level of care. One of the recurring themes throughout government's consultation on long-term care reform was the urgent need for care giver support, in particular the need for more access to respite care. While the majority of presenters seemed to have preferred in-home respite care, the availability of facility-based respite care also has a place in our system.

At the same time, by allowing regulations to prescribe the provision of preferred accommodation in each facility, the province will have a mechanism which, over time, could be used to increase the availability of single-person rooms within long-term care institutions.

As you know, the majority of rooms in homes provide shared accommodation, usually for two people. Residents have little choice in the matter of whom their room-mate is to be, and those who would prefer to have a single room are frequently accommodated only with difficulty and virtually always at additional expense.

If you think about it for a moment, it's as if I asked you to look at the person sitting next to you and consider whether you'd want to share a room with him or her for the next several years.

Mrs Marland: Do you want the answer on the record?

The Chair: I will now poll the members.

Mr Jackson: It's kind of like having a debate at home.

Mrs Steffler: This is a quality-of-life issue.

Mrs Marland: I'll take the Chairman.

Mr Jackson: You can have him.

The Chair: I feel compelled to cry, "Order!"

Mrs Marland: I'm sorry.

Mrs Steffler: This is a quality-of-life issue, brought to our attention many times by consumers and those who advocate on their behalf for a more responsive system.

I'd like now to turn to OARNA's major points of disagreement with Bill 101. As you are no doubt aware, this legislation is only part of a much broader attempt to reform Ontario's long-term care system, which includes in-home health care and home support services, day care, rehabilitation, chronic care and palliative care as well as facility-based services. Long-term care reform also must address the need for better linkages between the long-term care system and the primary-care and acute-care sectors.

Now, after years of effort, we finally seem to be on the brink of major systemic reforms aimed at ensuring that consumers can easily move from one care setting to another according to their needs and their preferences. What's needed to accomplish this includes improved planning at the local level, enhanced funding for the community care sector so that individuals who wish to do so can safely remain in their own accommodations, new incentives to encourage the creation of multiservice agencies to reduce fragmentation in the delivery system, and better coordination along the full continuum of care.

The government says its major policy directions in long-term care will be announced later this month. That being said, it seems obvious to wonder whether the proposed legislation before us is compatible with the reform framework to be announced later this month.

As just one example, consider the references in Bill 101 to the roles and responsibilities of the placement coordinator. Currently, placement coordination services are not available in every part of the province. Where they're not available, a physician's order is required to admit a patient to a long-term care facility. But Bill 101 would establish the placement coordinator in each area as the sole authority for determining eligibility for a home, and the sole person able to authorize a particular placement. In addition, under the proposed legislation the placement coordinator would remain immune from legal action in the exercise of these sweeping powers. Is this in fact the government's intention? OARNA respectfully suggests that this is not the case.

The committee should be aware that there were strong objections by many involved in the consultation to the concept of service coordination agencies, as originally proposed by the former Liberal government in Strategies for Change and also put forward in the NDP's Redirection paper.

These SCAs, which were supposed to combine the offices of home care and placement coordination, were seen as too bureaucratic and too distant from the consumer to work well. Concerns were raised about the need to be sensitive to an individual's ethnic, linguistic and religious affiliations. People objected to the idea that a paper review was sufficient to make good decisions about facility placement. Consumers and providers argued that responsibility for placement in facilities needed to be a shared function with opportunities for consumer choice and provider input and advice. We see little opportunity for consumer choice reflected in this proposed legislation.

It is our understanding that the government's new policy framework will not identify placement coordination as the responsibility of a placement coordinator, but rather as a responsibility or function of community care agencies. That being said, we believe that sections in Bill 101 referring to the powers of the placement coordinator may need to be revised to reflect government's overall reform plans.

Bill 101 permits a regulation to come into effect retroactively. OARNA finds this difficult to justify and objects to this provision as being unfair and unduly arbitrary. Regulations should come into effect when they are filed.

Under the proposed legislation, individuals who wish to dispute a determination about their eligibility for or placement in a facility can make an appeal to the Health Services Appeal Board, provided they apply within 30 days of the decision or apply for an extension of this time limit. Should they disagree in law or in fact with the findings of the appeal board, they can lay the matter before the Divisional Court for resolution.

OARNA is also concerned that people will have to wait a long time to have their appeals heard if their only recourse is a centralized provincial body. Given the fragile status of most long-term care applicants, time may be in short supply. We would therefore like to suggest the creation of an appeals process a bit closer to home. An arm's-length appeals board could be established in each district serviced by a district health council. That way, hearings could be held in a more timely fashion in locations more convenient to consumers and providers alike.

We were surprised to find that, for the purposes of Bill 101, a quorum of the appeals board is one person. This is not an acceptable definition of a quorum, and we urge that the legislation be amended to require at least two people from the appeals board be required for a quorum.

One of the greatest disappointments in the proposed legislation is its approach to the issue of quality. Committee members should be aware that serious concerns about the quality of care provided within some long-term care institutions are widespread and have been well documented by advocacy organizations as well as by the government itself.

For example, according to a review of compliance reports for 263 nursing homes conducted by Concerned Friends of Ontario Citizens in Care Facilities, 146 had serious violations. Pre-arranged inspection visits, made to ensure standards are being met, do not appear to have resulted in meaningful improvements. The 1990 Provincial Auditor's report concluded that procedures to monitor quality of care in homes for the aged were also inadequate and required improvement. They had reported exactly the same finding four years earlier.


Bill 101 certainly does strengthen procedures for inspection, and it also provides government with the power to reduce or even withhold funding from facilities that fail to fulfil their service agreements. The problem is that this approach, relying on inspection and financial penalties as the major mechanisms to improve quality, doesn't work.

Experts in quality from industry, and more recently from health care, have made this very clear. Inspection processes invariably create a climate of fear and blame and actually promote dissembling, data tampering and other similar efforts to escape punishment. I've enclosed a copy of Dr Don Berwick's article from the New England Journal of Medicine on this subject as additional information on this important topic.

Current thinking about quality suggests that our present health and social services system relies too much on sticks and too little on carrots. The result is a system filled with resentment and fear of retribution. There is strong motivation to hide problems and deficiencies. Key problems remain unresolved.

More modern management techniques aimed at improving quality use a completely different approach. So-called total quality management and continuous quality improvement recognize that a system built on inspection -- what is, in effect, a hunt for bad apples -- is counterproductive. Instead, these newer approaches focus on consumer satisfaction and a team approach to problem-solving. They assume that quality is a shared responsibility and that its improvement lies in designing better systems and processes for delivering care rather than laying blame and punishing individuals.

What would be more productive, from our point of view, is a system geared to rewarding facilities that have found ways to serve their customers better. These rewards would be tied to funding or other incentives such as increased opportunities for continuing education.

Bill 101 would also require facilities to develop a quality assurance plan, but here too the definition of the plan as a system of monitoring quality is totally inadequate. Monitoring quality is only one element necessary for its improvement. To actually improve quality, an action plan must be developed and implemented when monitoring shows there is a problem. The bill should therefore be amended to reflect the need for a more comprehensive quality assurance plan, including a requirement to establish monitoring based on sound measurement techniques and a requirement to take action on those deficiencies in quality identified by the monitoring process.

In addition, OARNA believes that monitoring resident and family member satisfaction is a key element which should be included as a requirement in any quality assurance plan. We are also convinced that information about the quality of care provided in each facility should be publicly available.

Now I want to address a number of elements in Bill 101 that have confused us and left us uncertain about the government's intention with respect to long-term care reform. Many long-term care facilities have responded to the need for more formal mechanisms to obtain resident input by creating permanent residents' councils. These councils serve to bring to the attention of management a variety of issues and concerns from the perspective of consumers.

Reference is made in the section of the bill dealing with the nursing homes to existence of residents' councils and their right to receive copies of the service agreement and to be informed about the rights of residents with respect to receiving copies and an explanation of their individual care plans. However, residents' councils are not required by this legislation, nor is there any reference to them in sections of the bill dealing with charitable homes or homes for the aged. Is this intentional or is it just an oversight?

People seeking admission to a long-term care facility apply under this bill through a placement coordinator. The bill permits regulations to be developed which would establish the frequency with which applications could be made. Presumably this implies that if an individual has been found ineligible for placement in a home, that person must wait for a certain period before applying again for admission.

The problem with setting arbitrary time limits for reapplying for admission is that an individual's health status and other circumstances, such as the death or incapacity of a family care giver, could occur at any time. Setting a time limit on the right to reapply for admission does not appear to recognize this.

Bill 101 makes no reference whatsoever to the involvement of physicians and other health professions caring for residents. We're uncertain about what implications should be drawn from this omission.

Bill 101 has a series of clauses dealing with the issue of charges to residents -- prohibiting, for example, charges for accommodation or care and services that are higher than the amounts stipulated in the regulations.

This has confused us. The government has given assurances that residents will never have to pay any user fees for the health and personal care services provided within institutions. However, the proposed bill appears to leave the door open for this to change. New regulations could be filed establishing fees for such services. We are wondering why the bill is not more explicit in forbidding user fees for any health or personal care service received in a nursing home.

You'll see, on page 8, all the recommendations that have come out of what I've just said. That's basically our response, Mr Beer.

The Chair: Good. Thank you very much. We have a number of questions. I would just note, with members of the committee, that we have a full afternoon, so the largess I had this morning will not be quite as large. We'll begin with Mr Hope.

Mr Hope: I was interested in your presentation today and I'm just curious about a little bit of clarification when you're talking about providing service agreements. I take it you're in support of service agreements being in place.

Ms Steffler: Yes, so that people know what it is they're getting in that institution.

Mr Hope: Why I ask that just for clarification is that earlier in the presentation, as you know, we were getting a number of different presentations before this committee and there were some from the Ontario Nursing Homes Association. They're quite opposed to the service agreements being in place as regards the function, maintenance and equity around the service aspect. I'm wondering, why would there be different viewpoints between the nursing profession and the administrative profession?

Mr Jackson: Mr Chairman, in fairness, Mr Hope may not have caught this correctly, but that is not what they said. They said that they and this committee had not been privy to a sample of it, but I was here for the presentation and they did not say they objected to it. It would be helpful if the assistant research director clarified that or someone else.

The Chair: We would have had it in the Hansard, certainly.

Mr Steffler: I would personally hope they would support it, because I think people have not known what they were entitled to before entering an institution and then suddenly finding, "This costs me money and that costs me money." People should know upfront, so they should have an agreement that says what's going to be provided.

Mr Hope: The other question that was brought up -- you're talking, reflecting the profession you represent. You also, in your brief, presented some issues dealing with the client.

In here, in a presentation that was made earlier to us, it says that the inspectors should not have access to personal records when they're doing a review of the quality assurance programs. Should that information, with the quality plan that's put forward, with the information that's available in a home, be available to an inspector? I just want your viewpoint.

Mrs Steffler: If you're talking about a resident's personal chart that says what type of care he's getting and so on, I would say yes, they should, because how do you do a final analysis of the quality of care if you don't use all avenues to assess that?

Mr Hope: I was interested in what you were bringing out when you said that we should, maybe instead of using a stick, use a carrot. Then I'm wondering, how do we get to the bottom of all the information if the information is not all there to obtain?

Mr Steffler: I think also they're talking about a better quality of care system where you're addressing and trying to improve things. That is what I guess I was trying to get across because we've used the stick approach where we go in and do an assessment and then there are all these recommendations and people must abide by them and so on. We're looking at it from the wrong direction. We should be trying to promote the institution to provide better quality care and then become an example to everyone else instead of the bad stick.

Mr Hope: I noticed you focused on --

The Chair: I'm sorry. I'm afraid we are a little tight this afternoon, so I'm going to have to move on.

Mrs Sullivan: Thank you. Because we are tight, I'm going to concentrate on your comments with respect to the placement coordinator. As you know, this government and the previous government have been attempting to find a balance between the concept of a one-stop shopping operation or the go-direct, which has caused some concern for people who are seeking appropriate care.

We were surprised, frankly, with this legislation to see the extent of the power of the placement coordinator which Bill 101 provides. Indeed, it appears that the placement coordinator would have additional responsibility that would override patient choice or resident choice. We have asked for a clarification of that. We've been assured that this is not the intent, but this is what the legislation says, so we've asked for a clarification of that.


In your paper you speak about the appeal process and you indicate that individuals who wish to dispute a determination about their eligibility for or placement in a facility have the right to make that appeal. In fact, that's not what the legislation says. It says that they can appeal their eligibility, but they can't appeal the place they are put in, which is why we have asked for that clarification. This brings us back to the original point you make: How do you deal with an implementation bill when you don't have the strategy yet and the original goal paper there to deal with?

The other aspect I'd like you to address on the placement coordinator is that under Bill 101 the placement coordinator appears to be attached to the facility. What we can't figure out is, if you're going to a community role in terms of developing a full long-term care implementation, how that can be done if you're also attempting to bring into play some of the ethnic, cultural or religious requirements where a facility may be outside of that geographic area which is covered. Can you comment on that and suggest how you see the role of the placement coordinator? Is one facility, by example, going to have perhaps 100 placement coordinators attached to it?

Mrs Steffler: Actually, we see it better. The district health councils have regions and you have coordinators within them, but I don't see them being connected with any one institution.

Mrs Sullivan: That's what the bill says.

Mrs Steffler: As long as they're connected with an institution, they're going to make sure that institution has always got its beds occupied. It has to be external to be an independent body, but our biggest problem is that one person as a coordinator has that control. That might not be so difficult in some areas, but I live two lives. I live in the city during the week and in a small community on the weekend, and I can tell you that in a small community where everyone knows everyone, if you had a conflict of personalities, I might have a problem getting into a home because my placement coordinator doesn't happen to like me. That's one of the major problems we see with one individual having that kind of power that says, "Yes, you can go into a home," and, "No, you can't go into a home." It needs to be made up of more than one person.

Mrs Sullivan: I didn't mean to imply, by the way, that the placement coordinator would be in the employ of the facility, but under the act the coordinator would be responsible for placements to that facility. The concern was that if we were looking at, say, a regional funding envelope, ultimately, or a regional delivery of long-term care and, by example, a home that deals with, say, a Chinese community, is located outside of that geographic region, how is the placement coordinator then going to function on a community basis which is geographic and also on a community basis which is ethnocultural?

Mrs Steffler: That's the big problem you have with any kind of laws you set down, that there are always the people who are caught in the grey zone who should be, if you're talking about an ethnic group, preferenced in what home they want to go to. If it's their local home, one that's, say, Chinese, then those options have to be looked at. You have to look at people as people, not as "You're in this area and you can't go anywhere else."

Mr Jackson: I'd like to build on that, because in the last four or five years, literally the only nursing home licences that were extended were to ethnocultural-based, non-profit, charitable organizations. We do have a fair number of them and they're tied in to the accumulated wealth and caring of that particular ethnocultural community. So that begs some larger questions that you're not getting into but that I wish we had more time to explore, because what is "equity" and what is "equitable access" and what is "fair and reasonable"? However, thank you, both Mrs Sullivan and you, for getting into the subject.

I want to pursue the item you identified on page 7. I agree with many of your concerns as expressed in the brief. I've referred to long-term care as three shoes that have to drop, and we've only seen one hit the floor; we're still waiting for the other two. I believe you concur with that. There's a lot we're accepting on faith here.

I didn't catch this business of the oversight of the residents' council, and thank you for bringing it to our attention. I sat on the committee last time we opened up the Nursing Homes Act. It was a minority government and I remember it extremely well. I remember the lobbying that David Cooke, the then Health critic -- he fought long and hard for this. So in the presence of our deputants, I would personally like to ask the PA if he'd undertake to get a definitive statement as to whether it was an oversight or whether it's the intention to involve the residents' councils with this information, and that is a mechanism which we see working hand-in-glove with the legislation.

Mr Wessenger: Certainly that'll be noted. I think the ministry's staff may take note of that.

Mr Jackson: I'm sort of used to something a little more proactive than simply noting it. Would you undertake to get back to us with an answer?

Mr Wessenger: I'll certainly request an answer.

Mr Jackson: But you're not making any promises. Okay. Just so we understand each other.

Maybe you didn't dwell as much as perhaps I thought you might in terms of a service model versus a medical model in terms of assessment and placement, and certainly with your nursing background and the kinds of services you provide, you're probably more concerned about that aspect of it -- unless I missed that or it was the first part of your brief as I was walking in, a bit late; I apologize.

Mrs Steffler: I don't think there's a great deal in here other than -- we were talking about the educational aspect of it.

Mr Jackson: But in terms of linking your skills with the client's needs, we've received some concerns about there not being a more comfortable link between client need and the services provided, that more and more of that care could be done by persons with less professional standing, if I can put it in those terms. Did you get a sense of that in reading this, or have you talked to some allied professional groups about this subject, and do you want to take a moment just to share that with us?

Mrs Steffler: Yes, I think I got that idea out of it all right. I have a bit of a concern about having people who are not properly prepared to provide care, because the residents in these institutions are not the residents who were there 10 or 15 years ago. They are now the more handicapped. With keeping people at home, I see that people in institutions are going to require total patient care. They're not going to be capable of doing an awful lot for themselves.

Therefore, you're looking at a higher level of need of the client than you have now or had 10 years ago, and I believe it is important that we have people who know how to deal with the client, with the appropriate preparation to do so, and have a centred attention in the elderly and their problems.

The Chair: Thank you very much, Mrs Steffler. I'm afraid we're at the end of our time, but we appreciate again your coming before the committee, and your presentation.

Mrs Steffler: Thank you very much. Good luck.



The Chair: I would now like to call upon the representative of the Oshawa Deaf Centre, if you would be good enough to come forward. Welcome to the committee. Have a glass of water, if you would like one, and perhaps you would be good enough to introduce yourself for the purposes of Hansard. Please go ahead when you're ready.

Mrs Betty McPhee: I'm Betty McPhee. I'm the executive director of the Oshawa Deaf Centre. I'm here today speaking as the executive director of the centre, where they're offering, as you can see in our mission statement, quality programs and services that promote self-reliance within the deaf and hard-of-hearing community. But I'm also here speaking as an individual who has deaf parents, of whom my mother is 86 years old, so that directly impacts our own family in that situation as well.

The deaf centre takes a very strong role in advocacy related to issues that impact the deaf community, and on our board we have up to 50% or often more deaf representation, so we have very strong consumer representation.

I'll just briefly outline the first part of the brief. As you probably are all aware, the deaf community has a very strong cultural base and shares a common language and culture. English is a second language. The deaf community doesn't define deafness as a medical condition and does not treat deaf people as pathological. Rather, the deaf community is viewed culturally as a community that shares common values, customs and language. The important aspect is that a deaf person can do everything that a hearing person can do except hear, and the important question is, how does this affect the ability to communicate? The answer is that it simply doesn't. The communication is different. It's visually based. It may make the person different but certainly not inferior.

In providing services to meet the needs of the deaf community, it's imperative that cultural and linguistic needs are considered top priority. For many people in the deaf community, their real family is not their birth parents and siblings, but other members of the deaf community, and that's simply because, how can you form a deep and lasting relationship with somebody you can't communicate with? Family members may try to learn sign language and some become fluent, but unfortunately it's a small minority and at best families communicate on a very superficial level with their deaf child, brother or sister. So we find that deaf individuals are continually trying to adapt to a society that makes few exceptions for their differences.

Parents of deaf children have often not accepted the fact that their child can't hear. They spend most of their energies directed towards fixing the problem and trying to make their child hear. Deaf children have been placed, as you are probably all aware, in settings that sometimes are set up to educate them orally, often without success. Case after case has been documented where a deaf child finally feels at home when he's given the freedom to communicate naturally through visual language, and this most often occurs in residential schools or with other members of the deaf community.

Children of deaf parents have grown up in a deaf cultural environment communicating through American sign language, and I'm one of those children. Children of deaf parents in the past have often been expected to be the family interpreter and the go-between for their parents. In the past, they've often had to take responsibility in terms of bank transactions and dealing with medical and emergency situations. Children of deaf parents often feel resentment over having heavy adult responsibilities placed on them at an early age. Although the role of professional interpreters has changed the situation, the shortage of interpreters and lack of awareness and education often means that this situation continues to exist.

When an adult child of deaf parents marries, the hearing family often has very little or no knowledge of American sign language. Communication barriers then influence the relationship between family members -- between the son and daughter-in-law or the grandchildren.

In this context, biculturalism means just simply hearing and deaf. Members of the deaf community often comment that at family gatherings they feel very isolated and lonely. When my mother comes to visit me, she can communicate with me alone, but she can't communicate with any of my family, my husband or my children, just very basic, "Hi, how are you," you know, a very superficial kind of relationship they can have. So it's very difficult for hearing family members, and when communication happens, it's usually an abridged version. This is a really difficult and frustrating experience for deaf persons, resulting in isolation and alienation from their own family.

It's unrealistic to expect hearing family members to take the responsibility to care for deaf members in their old age. For many, this is a very stressful situation, and having to be responsible for their own hearing family and then perhaps being the only one to deal with their parents who are deaf, this is intolerable and sets up a situation where it opens the door to elder abuse.

An environment without access to communication is linguistically bankrupt. Oliver Sacks, who is a famous neurologist, says in his book Seeing Voices that an environment without language can lead to short-term and long-term memory loss. Again, this is an extremely isolating experience comparable, if you will, to solitary confinement.

Deaf adults look to other deaf adults for family support, and sharing the same culture and language, they form very close family connections and lasting relationships.

It's with that in mind that we've come to look at some of these recommendations that we've proposed for long-term care in Bill 101. In March of last year, we had a consultation to deal with some of the changes that were identified in long-term care.

(1) Proposed service coordination agencies must be sensitive to the psychosocial needs of the deaf senior and focus not only on medical needs. This most important factor which contributes to health in the life of a deaf senior just cannot be ignored. While this isn't such a critical issue for a hearing senior, it's of utmost significance for a deaf senior. It can't be compared equally to an ethnic group, since an elderly French- or Spanish-speaking person has access to that spoken language through hearing. But a deaf individual relies on visual communication, on American sign language, and doesn't have equal access to the learning of a spoken language simply because they're unable to hear. Deaf seniors require care within their own culture and environment to meet their physical, social and language needs.

Bill 101 states that placement coordinators designated by the minister will determine whether an applicant for admission is eligible. We feel eligibility requirements for deaf seniors must be different than for the hearing population. They must be extended to include psychosocial needs.

In terms of criteria, criterion 4 states "consumer at immediate/ongoing risk of financial and/or emotional and/or physical abuse if left in current situation." For the deaf community, being in an environment where there's not full access to communication must be considered a factor contributing to emotional abuse.

Criterion 6 states "community services are not available or sufficient to enable the consumer to remain at or return home and there is no sufficient residential or supportive housing alternative." It must be clear that for the deaf senior the only sufficient community services are those which are fully accessible, where staff can communicate with fluency in American sign language and where there is access to interpreters. These services must also have the expertise and understanding of deaf culture.

Criterion 8 states that additional supports are not available, sufficient on their own or sufficient in combination with other services to eliminate the need for admission. Additional supports must include communicator and interpreting services and technical devices, for example, TTYs, flashing alarms etc. A TTY hotline set up specifically for deaf callers would be appropriate.

Criterion 10: To focus only on medical needs for the deaf senior is to ignore one of the most basic of human needs, to be able to understand and be understood, to communicate. For a deaf individual who does not have a medical need but is isolated within a hearing world, this is far worse. This contributes to loneliness, despair, depression and a sense of hopelessness.


(2) How will the process itself be accessible to deaf consumers? How will the needs of the deaf and deaf-blind be met? Who will pay for these services? And will the process of determining eligibility and admission rely on written English? We don't believe that these were addressed in the document.

A designate placement coordinator, preferably culturally deaf, knowledgeable of the deaf community and fluent in sign language would ensure this process is accessible. The appointment of this person should be approved by the deaf community. An assessment tool needs to be developed with consumer involvement.

Policy needs to be formulated outlining communication standards required and how to assess or evaluate communication ability. Policy needs to be formulated outlining qualifications required for professionals working with the deaf community. Consumers must be consulted when formulating policy and setting standards.

Committees involved in policymaking processes or recommending recommendations are not valid unless 50% to 75% of the committee members are deaf adults, those who are very familiar with deaf culture, ASL and the general life of deaf people as well as the person's immediate family members.

In the past, government and community service officials -- usually hearing -- made decisions on behalf of deaf children and adults. We must not continue to revert to past practices, but we must involve the deaf community in the important decision-making process. The definition here of "deaf community" would also include family members and friends and those people who are knowledgeable about deaf culture and American sign language.

(3) Centres such as the Bob Rumball Centre for the Deaf and the Oshawa Deaf Centre have the knowledge and expertise that the government requires in defining, assessing and serving this unique population and must be consulted. Funding must be available to meet those needs.

We're aware of the high cost of providing specialized services, and we also know that there's a shortage of qualified sign language interpreters and trained health care professionals fluent in sign language. It would seem that given the shortage of government funding, it would be cost-effective to allow agencies such as the Bob Rumball Centre for the Deaf and the Oshawa Deaf Centre -- however, we know that the Bob Rumball Centre is specifically providing services to seniors -- to continue to provide a continuum of care for all deaf seniors. This will enable deaf seniors to be independent within the community and will provide the services necessary to access the community.

Ultimately, deaf seniors should have a choice where they choose to live. They have a right to fully accessible services. There will be those who choose not to live in a centre such as the Bob Rumball Centre; therefore, local community centres should be accessible to them. However, it is important to note that for many in the deaf community, the community is where the other deaf live.

Deaf individuals will often travel a long distance to events throughout a city, a region, a province or even nationally to attend other deaf community events, so it's entirely consistent that deaf individuals would make the same choice when choosing where to live in their senior years. Do we impose limits as to how senior deaf members of our society define their community?

For those who are able and who choose to remain in a particular geographic location, it would be cost-effective to purchase necessary services from community-based agencies providing services to the deaf community.

To become fluent in sign language is a lengthy process. For a hearing person it's more difficult than learning another spoken language such as French or Spanish or whatever. Taking one or two courses doesn't make one fluent and certainly not an interpreter. Interpreting is a skill that takes at least five to seven years. You can compare that to asking someone who knows a little bit of French or Spanish or whatever to interpret in court, or for a doctor, making a diagnosis or prescribing medication. It's a very dangerous situation.

It's entirely unrealistic to think that many professionals in local communities can be trained to do this job. What about staff turnover? Training and retraining costs money, without any guarantees that appropriate standards are being met. It's practical and realistic to provide funding to allow the experts to continue to do their job.

For those individuals who do choose to remain in their homes where it's difficult to access interpreters and where there's a communication barrier, one solution would be to provide transportation to bring the seniors to centres for programs. Positive solutions would be wheels to meals, volunteers such as friendly visitors from the deaf community, and setting up a deaf human service worker program. There is one in Winnipeg currently, and it could be introduced at the community college level.

Finally, consumers must be involved and consulted and it must be an ongoing process. Consumers must be fully represented to ensure that the needs of the deaf community will continue to be met. Planning must ensure that there will be representation from groups such as the Ontario Association of the Deaf in order to plan ahead so that they can ensure that there will be an interpreter available.

In conclusion, the three most important things we want to bring out that need to be included are full accessibility, eligibility criteria to be expanded to include the psychosocial needs of the deaf senior, and finally, that the deaf community must be involved and consulted in the decision-making process and in formulating policy and setting standards.

The Chair: Thank you very much for a very full brief. I think we have a couple of deputations with respect to the needs of the deaf, but you have really outlined a full agenda. We'll begin the questioning with Ms Fawcett.

Mrs Fawcett: Thank you very much for your very full, descriptive brief. I think this is indeed a different look for us, and we need this because there is that community, and especially the deaf seniors who do require specialized care in their own culture and environment to make sure they are comfortable in all ways.

I wondered as you were going through your brief whether you feel that there was consultation around the long-term care reform as far as the deaf community is concerned. I'm not really familiar whether the Bob Rumball Centre was consulted. Were they very much involved here? If not, I guess we should make sure that in future they are.

I wonder, too, what services are currently in place, if any. Are they very sketchy or are they available to seniors right now? Because certainly there are a lot of things we take for granted, and that's not right.

I wonder, too, if the deaf should be included in the new suggested funding formula for the disabled where the money would be directed to them so that they can then purchase the necessary services that they need.

Those were a few thoughts that I had as you were going through, and then I think my colleague has a question as well, or did I take your question? I'm sorry.

Mrs McPhee: There has been consultation. As I said, the Oshawa Deaf Centre had a meeting to talk about long-term care.

Mrs Fawcett: Are any of the results in the bill?

Mrs McPhee: Not really. Well, it's vague. It's hard to know, in terms of the placement coordinator, who's going to make the decision, and the eligibility criteria are still a problem. For example, my mother is 86 years old. She's in good health; she's probably in better health than I am. She's living in her own apartment. She's very lonely; she's in Vancouver, and no one can communicate with her. There is the Bob Rumball Centre for the Deaf, which provides residential care to seniors, but you don't have to be sick to move there right now and she would like to move there.

Mr O'Connor: Where is that?

Mrs McPhee: On Bayview near York Mills. She would like to move there. She can come and live with me and our family, but that's not going to be good because I'm not there all day long, and no one in my family can talk to her. Even when I am home, I'm so busy in my home doing everything else that it's unfair. When she comes to my place I'll be talking to my family and she'll ask me, "What were you talking about?" Then I have to stop and I have to go through it all. Of course, it's not going to be the whole conversation, and she's very frustrated, feeling that she's been left out. It would not be fair to her.

From what we understand, the eligibility criteria would change and she would have to be in poor health, sick, needing medical care in order to move in, so that now her needs are not going to be met. She will not be able to move into the Bob Rumball Centre.


Mrs Fawcett: Either we should certainly make sure that the placement coordinators are in tune or we should have a person fully interpretive and so on as a placement coordinator for this group.

Mrs McPhee: One very positive solution to that would be to designate someone at the Bob Rumball Centre who would be a placement coordinator for the deaf community.

Mrs Fawcett: For the deaf community.

Mrs McPhee: That would be one of our recommendations. We mentioned that someone who was culturally deaf would be most appropriate.

Mrs Marland: I'd like to congratulate Ms McPhee. Obviously, the Oshawa Deaf Centre is very fortunate in having you in your position as executive director. I appreciate your sharing with us, on a personal basis, your own family experience because I think it helps all of us understand if we haven't had that experience. It just means more when we hear that from you directly.

I must say that I'm absolutely floored that you're here with your conclusions and with your recommendations saying that the deaf community must be involved in the decision-making process. It would have been my assumption that you would have been involved. I don't know if you've never been involved or you just haven't been involved in this piece of legislation, but it's common sense.

Right now I'm advocating on behalf of a constituent who has some other disabilities, including the fact that he needs two hearing aids. When he was on general welfare assistance, the government paid for his hearing aids. Now he's got a little part-time job. He's actually developmentally disabled. His mother's pleading for the $600 for his second hearing aid and they've discontinued the funding for the moulds and the batteries. I'm thinking, if you need a hearing aid to function, it's really the same as needing insulin. We go through all these arguments about -- it's a little bit off long-term care, Mr Chairman, but I'm just expressing my frustration because I feel anyone of these communities who come under the whole system of long-term care or our health care planning in the province, which includes long-term care, as far as I'm concerned, it floors me every time I come across one of these major gaps where somebody needs two hearing aids and they pay for one. I can't believe that's the situation we have in the province today.

I don't have any questions for you except to say that I'm very glad you're here. I hope that the government is glad that you're here and recognizes that you shouldn't have to be here saying we need to be involved in decision-making in terms of policy and future planning for the deaf community of this province.

Mrs McPhee: I think one difficulty is that often the deaf community is lumped with the disabled. The needs are very different and you cannot lump the deaf community because of the communication needs. You just can't lump them with the disabled.

Mrs Marland: No, I agree.

Mr White: I'm very glad you are here, Ms McPhee, representing your community and mine. There were a number of things I wanted to pick up with you on. I'm not going to be able to have time to do them all, but one of the issues I wanted to address briefly, first off, was the mention you had of the need for housing for seniors from the deaf community. I'm wondering if some of those people, like your mom, might be accommodated in the supported housing that the ODC is lobbying for in Oshawa.

Mrs McPhee: That's one of the reasons why we have a housing project proposed for Oshawa, because it would give an opportunity for deaf people to live in close proximity to other people they can communicate with, and that's very important, and then the Oshawa Deaf Centre can provide services as needed.

Mr White: That makes those services available and accessible to those people who otherwise would be too far away.

Mrs McPhee: Right.

Mr White: I'm sure that Ms Carter and Mr O'Connor heard you.

You've mentioned the Oshawa Deaf Centre and the Bob Rumball Centre, which offer excellent services, but is that kind of advocacy available in other areas, such as Lindsay, Peterborough, Timmins, at the same quality?

Mrs McPhee: That's why we feel there's a need to do community outreach and to have the friendly visiting program. We're aware right now of deaf seniors who are living in existing homes for the aged in the Durham region and they're there, to my absolute disgust, really without any communication support at all. I don't know how the people who run the homes accept them because there's no communication support there for them at all. They basically live in an environment where no one with whom they live can talk to them.

Mr White: I think the issue --

Interjection: Solitary confinement.

Mrs McPhee: That is solitary confinement.

Mr White: I think the issue you bring up, the psychosocial needs as opposed to the medical needs, is very important here.

Mrs McPhee: It's critical.

Mr White: Absolutely. Thank you.

The Chair: Ms Carter, you can have a short question.

Ms Carter: I certainly don't quarrel with anything you've said. I think Gary Malkowski, who is not on this committee but I have shared a lot of the news with him, has educated us all as to what the true nature of being deaf is. I think the real point is to understand that it has to be treated more like ethnicity than it does like a disability.

If deaf seniors could go to appropriate placements, in theory this would not be any more expensive than placing anybody else. They would just have to go to a place where their culture was present rather than the hearing culture. I think the question of funding doesn't really arise once the appropriate centres are there.

But if all deaf seniors could have access to appropriate accommodation where they could use sign language and so on, how much expansion would be needed to accommodate that? Would we be looking at very large changes there?

Mrs McPhee: I think increased funding would be required for interpreters to access the community.

Ms Carter: Once they were outside the institutional environment, yes.

Mrs McPhee: I think it's difficult to project at this moment because we know that the population of seniors is growing and so the need is going to continue to grow. We know that, and the demographics are changing.

Ms Carter: Is time up?

The Chair: Time up, I'm afraid.

Mr White: How unfortunate.

The Chair: Thank you very much again for coming and for your very thorough brief.

Mrs McPhee: Thank you.


The Chair: I'd now like to call the representatives from the Multicultural Alliance for Seniors and Aging, if they would be good enough to come forward. Welcome to the committee, gentlemen. Once you're settled, if you would be good enough to introduce yourselves for Hansard and then please go ahead.

Dr Fred Sunahara: Mr Chairman, my name is Fred Sunahara. I'm the present chairman of the Multicultural Alliance for Seniors and Aging. I'm also the president of a Japanese Canadian health care group called Momiji Health Care Society and we are part and parcel of the MASA organization.

This afternoon, the three of us would like to make a very brief presentation on some of our concerns with Bill 101. I'm joined by Mr Sam Ruth. Many of you would know Mr Ruth. He's been associated with the Baycrest Centre Foundation of Baycrest Centre for Geriatric Care for many, many years. He has also been the chairman of the Metro homes for the aged advisory committee. He is the past president of MASA. Also with me is Professor Dimitrios Oreopoulos who is the president of the Hellenic Home for the Aged, which is right now in the process of building a nursing home. He is also a professor of medicine at the University of Toronto.

First, I'd like to ask Sam if he would give you a very brief background on MASA and the sorts of things that we are attempting to do.


Mr Sam Ruth: I'll try to cover 46 years in a very few minutes.

The three of us really represent 75 years of collective professional and volunteer work in the field of aging. As Dr Sunahara said, our work goes beyond our own specific organizations. For the purpose of our organization, some of us have been long-standing. We've been here for many years just to assist newcomers. This province of Ontario will always be getting newcomers of different ethnic groups. We are more than aware that all parties, Conservative, Liberal and NDP, have supported multiculturalism. We want to be sure that this is not in any way diminished, so we want to present some of our points to you to help you help us to keep these organizations going.

The ethnic groups and religious groups go back to the 1800s, when the Sisters of St Joseph started Providence Villa. At that time, there was no money, there were no funds and no capital grants. However, the idea was that this was needed and the ethnic groups had flexibility and they did that. Thereafter, I think the Jewish health agency came on stream in 1918. Once again there were no grants; it had to be done. After that, we found that there were a number of other groups. We represent 25 ethnic groups.

In the province of Ontario, you've been told before, there are about 60,000 long-term care beds, about half of them profit and half non-profit. A good majority of those in the non-profit have been developed by religious and ethnic organizations. Because of our backgrounds and because we formed a partnership with government, we were allowed to develop services. There were no strings attached. There wasn't government money available. We were given permission to go on our own and start services which came out of the partnership of our communities and government -- a good deal out of our communities.

We're now faced with many people growing older. I'm long past 65. I look very good; thank you. I think as a group we really brought vitality. We developed programs for long-term components. Part of this was done because we had the flexibility to support. What we're worried about, and Dr Sunahara will talk to that, is, will we be boxed in by all of these regulations? We don't understand these, because none of this goes into effect till the regulations are written, and how they affect us, we don't know, but we're concerned about that.

We don't want to be homogenized. We come from different backgrounds. We come from different cultural groups. We are Canadians. Many of us have fought for this country, for our country. We're not second-class citizens. We know that we're Canadians. On the other hand, our parents and some of our fellow people have specific cultural needs. Most people coming to this country now will have them in the future. We feel that all of us want to protect that and we want to be sure that we assist you in doing that.

Looking at the regulations, to the best of our ability, we know you're trying to balance budgets and you're trying to do a number of different things. I think the contributions that the ethnic groups have made -- we talk about going into the community. That was developed by ethnic groups. Day care programs, home care programs, special day care programs -- we were able to do this because we had the flexibility. No one told us, "You can only do this." We always felt we could do more.

There's no doubt a nursing component in our homes for the aged and our ethnic homes and we certainly don't want to warehouse them. That's where ethnic groups come in all the more responsible to meet their cultural needs.

We say that even though there's a nursing home component, there's still a lot of living and that's related to their cultural values. We want to reinforce that and we want to assist you to do that.

Dr Sunahara and Dr Oreopoulos will indicate to you that on the point of Dr Oreopoulos, there's some hope we have of some capital grants to non-share capital groups. We want to support you on that. Dr Sunahara will indicate to you the problems we think we might face in these placement centres.

I think as evidenced before, we want to thank the previous speaker. I don't hear too well. I thank her for her presentation on hearing and also the fact that she spoke about her aged mother. That's what we're here to talk about, to be sure that the very special services that ethnic groups need are not in any way homogenized or taken away from them or diminished, especially when they have more growing needs and there are more of us.

Dr Sunahara: Thank you, Sam. I want to thank the committee for hearing us out. We appreciate the work that you've done on Bill 101. I think there are a number of points which you brought out and clarified for us and I think this is a help. There are a number of serious concerns that MASA has with regard to some of the stuff that Mr Ruth has pointed out, and I wish to elaborate on just one item in the next few minutes.

Mr Chairman, we're very concerned or troubled by the proposed implementation of the placement coordination services. According to this act, "The minister shall designate one or more persons...or other entities as placement coordinators for the purpose of this act." For each long-term facility the minister shall designate the placement coordinator who may authorize the admission of persons to that home. A person may be admitted to the facility only if the placement coordinator has determined that the person is eligible for admission and the placement coordinator designated for the facility has authorized the admission of that person to the facility.

The final point I wish to comment on is that the long-term care facility shall admit a person who meets the requirements of the previous section, unless a ground for refusal of admission prescribed by the regulations exists.

We're very concerned that the proposed placement coordination system will erode the multicultural nature of many of our long-term care facilities in this province. The legislation suggests that the admission will be based only on the applicant's health care requirements with little or no consideration of social needs, such as need for an environment which is sensitive to culture, religious and linguistic preferences.

Our experience is that the Senior Central Housing Registry in Metropolitan Toronto supports this interpretation. While designated to coordinate applications for tenancy with vacancies in the subsidized housing, the registry's decisions are based only on the applicant's need for financial assistance and shelter. The registry's criteria pay absolutely no regard to the ethno-specific environments which the multicultural communities have developed. We fear that this system will be introduced into the long-term care process.

Since we have no knowledge of the proposed regulation, we believe that it is instructive to examine the new application forms contained in the draft Long-term Care Facility Programs and Services Manual. This is a 19-page document. It contains all manner of questions concerning the applicant's need for physical care, record of hospitalization, use of community services etc. There are only two questions related to the applicant's ethnic background or his linguistic ability, which takes up four lines in this 19-page form, and this is sandwiched between two questions about the individual's alcoholic beverage or smoking preferences. I think this is ridiculous.

The guide for completion of the new application form states, "The program and services of long-term care facilities are developed primarily for elderly persons with functional and/or behavioural problems and insufficient supports who require or could benefit from these services, programs and/or secure environment." This does not speak to the religiously, culturally or linguistically sensitive environment which communities have developed for their frail elderly.

Bill 101 further states that the long-term care facilities must admit applicants approved by the placement coordinator unless grounds for refusal exist in the regulations. We would like to ask what these grounds for refusals are. What assurances can you give the multicultural community that the multicultural fabric of organizations and facilities they have developed, to which they have contributed hundreds of millions of dollars and hundreds of thousands of volunteer hours, will be sustained? We see no evidence that this is the intent of the proposed legislation.

If we cannot service our ethnic clients in our respective communities, the latter will be reluctant to respond to the needs of their frail and aging. The volunteers may disappear because there is little incentive for them to contribute their unique talents. Finally, a very significant monetary contribution from our respective ethnic communities which we presently enjoy will dwindle. All of these factors will no doubt increase the cost of services of seniors' care to the government.

In short, we fear that the ethnic seniors will be abandoned by this legislation, that the system of care we have worked so long and so hard to build will be dismantled. We would respectfully request that this aspect of Bill 101 be revisited and revised so that it will ease some of our deep concerns.

Now I would like to ask Dr Oreopoulos if he would make a comment.


Dr Dimitrios Oreopoulos: I did not come up with a written presentation, but I was impressed with the comment that Ms Margaret Marland made to the previous speaker that personal experience is something worthwhile to present, so I will share with you how I ended up being in front of you today.

I am a very busy practitioner and work at Toronto Western Hospital. Back in 1986 they asked me to come and see a Greek patient with whom they couldn't communicate. She was an 80-year-old lady with a stroke, and she couldn't communicate. I saw over her bed four terms, the Greek for, "I'm hungry," "I'm in pain," "I need the bedpan" and "I'm thirsty." The nurses were trying to understand what she was saying in Greek, and that was all her communication. That was going on day after day. We couldn't place the lady in another centre, but the situation would have been the same.

That was the moment, the turning point in my life, when I decided to get involved in community work. I wanted to do something to change the situation, at least for my Canadian compatriots.

There was an organization in the Greek community to try to build a nursing home. There were just plans and dreams, and they had raised some money, but that was when I got involved with the organization. That was at the time that the previous government had announced the multicultural beds allocation. We have been very busy to convince the government that there's a tremendous need. We're the only large community in the area for which there is no nursing home. We applied for 60; the government recognized our need and gave us 80.

That was all great, but then I was faced with the problem that I realized we had to raise the money to build this nursing home. For an 82-bed nursing home, we had to raise $4.3 million -- that's what our consultant told us -- and the government wouldn't give a penny for that.

So I went out to the community, and I really enthused the whole community that we had to raise money. It was a great thing to see more people get involved. There was an enthusiasm: "Let us try to care for our own people." We put a target of $2.5 million to raise. Our consultant told us, "No matter how stingy an operation you do, you cannot raise enough money to put aside for a mortgage for the rest," and I thought, "After all, we have to provide the $4.3 million."

So we have been successful in raising $1.2 million, and we're still working. There is tremendous volunteerism -- a lot of us enjoy working to provide volunteer services -- but I find it's really very unrealistic to expect us to put up all this money. No matter how much enthusiasm there is -- after all, there is only so much money in the community, and I have been fought in the community: "Why should we raise all this money for that? We have other goals, to develop a community centre for youth and to develop a chair of Greek letters in the universities. Why should we direct all this money? The government should really give all this money."

I'm trying to convince the community that volunteer work is a great thing to spend some hours for. I do get a response, but I want to make that a collaboration, a partnership between the government and the community. Unless you help us, I don't think we can help this one. I think it's great and I'm enjoying it -- it's the greatest thing to be a volunteer, to do work -- but we need some help.

I was really thrilled to see, and I want to congratulate the government for this capital funding, although it's still just an open door: The minister "may" approve some capital funding. I would like to encourage the government to consider very seriously a kind of matching. We don't want the government to give all this money. I want the community to continue working and I want to be involved. At least give us one for one, or some way we can show that we're working together.

But with all this enthusiasm of people -- "Let us give our money; let us give our time to work for the community" -- I'm worried about what Professor Sunahara said, that if I ended up building a nursing home and instead of having 82 Greeks, I have 82 Japanese there, that will defeat the whole purpose. So I think this is very critical for us. If you want to keep us enthusiastic to work on that -- and I think it's very important and we enjoy doing that -- help us at least to fulfil that goal.

Those are really the two things I wanted to say.

The Chair: Thank you very much for that experience and also for the presentation. We have a number of questions. We'll start with Ms Marland.

Mrs Marland: Mr Chair, I'm sitting here smiling because I want to tell Dr Oreopoulos that my Greek name is Bouboulina, and you and I both know what that means.

The Chair: Who are you telling?

Mrs Marland: Well, I'll tell you some other time.

Dr Oreopoulos: She's a very famous Greek heroine. The Greeks always supported the females who contributed to their fights.

Mr Jackson: And she's quite a fighter.

Mrs Marland: My Mississauga pan-Hellenic community gave me that name because she headed the admiralty 400 years ago, I think.

I'm so impressed with the presentation from all three of you this afternoon, because you each bring a very important focus. I'm completely familiar with the nursing home you're presently in the middle of building because I attended one of your fund-raising dinners with Bill Kanelopoulos and Louis Valiano from Mississauga and Brampton.

The point you're making really hits home, and you said it so beautifully with your final comment about Dr Sunahara. You're wondering what the regulations are going to say and whether you're going to have the kind of protections you're looking for. You expressed so beautifully about being involved in the community and the fund-raising. I don't know whether I'm exactly right, but it was close to $2 million that you raised in one night, or $1.5 million; it was quite remarkable anyway.

Dr Oreopoulos: It was half a million in one night.

Mrs Marland: Half a million in one night. But that's what we Greeks are like.

Anyway, the point is that the government can't on the one hand say to our individual cultural communities, "Go out and do this," and then not give the protection for that investment. In fairness, and it doesn't matter which cultural group we're looking at, those people have to be cared for somewhere. Isn't it wonderful that they have an opportunity to be cared for in a community that is not only linguistically suited -- I didn't want to say "matched" -- for them, but that there are all the other aspects, let alone the food? It isn't just the dietary, it's everything, and it works beautifully.

I've always said to people who suggest that, "Of course, the ongoing operational funding comes from all the taxpayers," that sure it does. But the point is, it's so much easier for everyone -- the staff, everybody who's involved, and most importantly for the individuals who require the care -- that they're able to communicate and, hopefully, maybe get out of these facilities because they're able to communicate accurately what their medical and physical needs are.


I just want to say that your questions about the powers of the placement coordinators and the kinds of decisions they'll be making are very well placed. The parliamentary assistant, Mr Wessenger, is here today. If you ask him what the regulations are going to be, he'll probably tell you that he doesn't have a clue either. We would love to know what the regulations are, because the regulations are shrouded in behind legislation, and we never know what those are. The worst part for us in opposition is that we have no ability to debate them, to improve them, to question them. We're powerless.

Dr Oreopoulos: I thank you for your comments. The main concern is that we should not lose this enthusiasm. If we don't have a binding way for the placement coordinator to allow us to offer our services, we're going to lose that, and I think we're all going to lose with this.

Mrs Marland: That would be a tremendous loss to the people in this province with those special needs whom you've so well identified this afternoon.

Mr Jackson: Very briefly, earlier I referenced when the government opened the Nursing Homes Act back in 1985 and a nursing home residents' bill of rights. We had made some inquiries into having it published in languages and having codified multicultural rights in terms of communication and the list of concerns you've articulated.

Because of the silence in the legislation, it causes one to question whether or not we're seeing a change in multicultural policy without specific consultation. More specifically, we may be having a different multicultural policy for long-term care or for seniors. Do you feel that we as a committee should be exploring blanket protections in this regard, or should we be looking at some sort of grandfathering of existing facilities? I'm nervous that it's silent. I'm prepared to work towards some change, but I wanted your guidance in terms of a grandfathering, so that we could create in regulation circumstances which protect the ethos of the buildings and the people who make them that special.

Mr Ruth: Whereas that sounds good and we'd like to see that done, we as a group feel that mainstream organizations which deal with the overall population, by the nature of their staff and their volunteers, can't really meet the basic ethnic needs of our older people.

Mr Jackson: I'm with you on that. There's agreement on that. What I'm asking you is, what legislative approach are you recommending to us if we can't get the government to agree that protections should be there: that there are strict guidelines for placement coordination, that there is respect for the mission statement of the given facility? If we can't get that, a fallback position would be to grandfather all existing facilities. We would advise the placement coordinator, "That's a facility that was built prior to 1995," we'll say, "and therefore you have a different set of circumstances." I wanted to get a feel from you, because if we approach this and we're getting nowhere, that would be a fallback position. I think you follow where I'm suggesting we go here.

Dr Oreopoulos: Yes, it would be a good idea to grandfather, but we are still many new groups that are coming up, and you don't want to stop us. If you grandfather something from 1993 -- I mean, our nursing home hopefully will be open by 1994, or at the worst 1995, but there are so many new groups coming up. In our association we have 25, and out of them only three or four have their own.

Mr Jackson: But some protection is better than no protection. My grandmother is in a Ukrainian facility. She speaks fluent Ukrainian; her English is reasonable. But that's my background.

Mr Ruth: She's a member of our group.

Mr Jackson: Yes, and I'm familiar with the facilities. I'm simply saying that if it's the political decision of the day that people are going to be homogeneously mixed when they become of age, we'll say -- that's a political decision and it's reflected in this legislation. For those who support the notion of cultural support in old age, then we would have to fight for that as a fallback position.

Dr Oreopoulos: Is this a political decision to forget about this multicultural aspect?

Mr Jackson: It's silent in the legislation.

Dr Oreopoulos: Because if that is the case, then we are losing the battle. I mean, the whole idea is that we want to protect, give the opportunity to cultural groups to serve and help. If I hear you saying that there may be something like that, really I'm scared, because then there's no point in trying to raise more and more money for my community in order to build something there to help the Canadians of our descent. This is something where, really, we want to hear that you're going to protect us.

Mr Wessenger: First of all, I'd like to assure you that the whole purpose of this legislation is to ensure that people are placed appropriately, and in determining whether people are placed appropriately, it's clear that social, cultural, linguistic and religious factors are very important. Also, I'd like to assure you that for the individual seeking a placement, it's obvious that a person has the choice of going to a place or not, and that has to be the prime factor. I'd like to assure you that definitely you should have no concerns about the government's intention with respect to the question of ignoring multiculturalism, any question about the failure to take into account social, cultural, linguistic and religious aspects.

Mrs Marland: Are you going to allow them to continue their own homes?

Mr Wessenger: What I would like, if Mrs Marland would not interrupt me, in view of this intention, I think what we're looking at is what is the best mechanism, as far as you're concerned, to give you some assurance with respect to this matter. Would you feel more comfortable, for instance, with some general criteria being set out in the legislation, and in general terms along these lines, or would you prefer something more detailed in a regulation aspect? I'm asking for your specific advice on this area of how you would feel the most at ease, because I can assure you there is no intention of the government to do anything but recognize the multicultural nature of institutions in this area.

I must say I'd like to also commend you for your suggestions with respect to matching grants with respect to the new projects. I think that's an excellent suggestion and I certainly appreciate it.

Dr Sunahara: I'm a little leery of the understanding you may give us that yes, it is incorporated. We haven't seen this. It's not in print. We have to go by your word. The experience we've had with the central housing registry is very clear to us. They do not consider ethnicity, linguistic or any other thing. They're criteria are on straight financial and shelter needs, period. This has to be addressed.

Mr Wessenger: What I'm asking you specifically --

Mr Ruth: I can give you a specific suggestion, if I may, sir. I would say that, if this has to go into effect, if a Japanese person goes to the placement coordinator and says, "I want to go to a Momiji home for the aged," the placement coordinating centres automatically send him or her there for review, and the same for any other ethnic group. If there's an existing service in an ethnic community, they must go centrally and then immediately send them back to their local group, and that local group has to assure you, sir, that it meets your requirements of admission.

Mr Wessenger: If you're going to have placement coordination, one of the suggestions, of course, is to have the placement coordination related, to have the same provincially for, for instance, all persons of a particular -- anyone of Greek background could apply to one coordinator.

Mr Ruth: That gets to be difficult, doesn't it? If it has to be geographical, what we're saying is that automatically, in Metropolitan Toronto, a Japanese person goes to the placement coordination centre and they say: "Oh, you're Japanese. I'll refer you right to the placement person at the Momiji home, or the Greek one, the Hellenic home. Therefore, the placement coordinator does not determine where that person goes. The determination is their ethnic background, and we have to satisfy you, sir, that we meet the needs for admission in our respective institutions.


The Chair: We'll have to move on. I'm sorry, Mrs Sullivan, we're tight on time.

Mrs Sullivan: I'm going to follow in a very similar vein to the parliamentary assistant. On the first day of hearings, when the minister was here and ministry officials were here, we were asking very similar questions to the ones you've raised. I think it's useful for us to see people who have been very involved in the development of homes which have a particular emphasis on a religious or ethnic surround for residents.

At the time of the initial hearings, ministry officials indicated, in response to a protest I had made about the wording of the bill, that the policy intent was not what the bill provided. My understanding of the bill is that the placement coordinator can determine where the person will go, and the person in fact has no right to express a preference or even to refuse to go there. Ministry officials indicated that was not the intent.

I am not certain if we are facing a drafting problem or if we are facing a policy problem, because we haven't seen the overall policy. But the ministry and the parliamentary assistant have agreed to come back to the committee with a clarification of where the government, intends to go.

I think there still is a problem, though, in that the bill suggests that the placement coordinator is attached to a facility and is designated on the one hand by the Ministry of Community and Social Services, and on the other hand by the Ministry of Health, with responsibility for each individual facility, and yet as we go into the placement coordination system and look at the provincial base and how we're going to integrate care to develop a continuum of care so that people can move in and move out and aren't locked into a long-term care facility, by example, if they don't need the care that's provided in that facility and can be treated on a community base, then we have to look at the community, the geographic area.

I have yet to understand how this placement coordination system is going to work to ensure that the preference of the potential resident will be acknowledged and indeed guaranteed, and how we will also be able to ensure at the same time access to the continuum of care outside of the facility. We are certainly looking for additional clarification on that. I think it's an extremely important issue.

I disagree with my colleague's suggestion about grandfathering. I see new ethnic groups that are becoming part of our communities -- my own riding is now starting to receive more of a Sikh population, by example, that hasn't even begun to look at the issues of long-term care. But that will certainly be on their plate at a point, I would think.

I'm quite concerned when the parliamentary assistant suggests that it's obvious that a person -- and I'm using his words here -- has a choice of going or not going to a home. If persons choose not to go to a specific home because it isn't their choice of where they want to be cared for and perhaps spend the rest of their life, or only an interval, then what other choice do they have if the placement coordinator -- there's no appeal provision in the bill. What other choice is there? To stay in a situation where their cares are not adequately met? Is that the other choice? If the choice is going or not going, that isn't an appropriate choice.

I think we have problems here. I'm glad you've brought them to the table in an informed, involved way, but I do want to say that we have asked for the clarification and I expect we'll get it and we hope that certainly the clerk will ensure it's shared with you.

The Chair: Thank you very much. If you wish to respond briefly, I'm afraid we're over time.

Dr Sunahara: If it would help, we'd be very happy to sit with the parliamentary assistant in discussing some of this aspect and at least get our input into it.

The Chair: I sense a coalition.

We want to thank you very much for coming today. I think you've made your position very clear, and as has been said, I'm sure the parliamentary assistant will sit with you and we'll work this out.

Mr Ruth: Could we table anything with the committee?

The Chair: If you have a document, perhaps you would table that with the clerk of the committee, please.


The Chair: I now call the representatives of the Tabor Manor Senior Citizens' Home. Welcome to the committee. Please make yourselves comfortable. If you'd be good enough to introduce yourselves to the committee and to Hansard, then please go ahead.

Mr Peter Warkentin: I'm Peter Warkentin and this is Rudy Siemens, the administrator of the home. We're here to present a brief that is fairly similar to what we just listened to, only we will be a little shorter. However, the discussion we just heard is interesting to us because our concerns are very similar.

Our home is located in the Niagara region. The brief is two pages long and I will read it for you, and then if you have questions, we're happy to answer them. We're part of the OANHSS group, the Ontario Association of Non-Profit Homes and Services for Seniors and we've done this in consultation with it. I'll start from the top.

Tabor Manor Senior Citizens' Home is a charitable institution owned and operated by the Ontario Conference of Mennonite Brethren Churches. Twenty-three churches with a total membership of 3,000 elect a board to govern this home for its seniors.

Tabor Manor was constructed in 1969 to provide accommodation and care where the German language, Mennonite culture, ethnic foods and religious uniqueness would be provided for seniors within the Mennonite Brethren constituency. All of the Mennonite Brethren churches participated in this project. Many hours of volunteer work and individual donations were contributed to improve quality care for seniors in a familiar setting.

In 1990, conference members from across the province contributed $250,000 to renovate the extended care wing, plus add a new wing with lounge and dining facilities for extended care. After almost 25 years in operation, the constituency still provides strong support in terms of donations and voluntarism.

We stress the ownership of Tabor Manor and the commitment to our conference members, being aware of pending changes in long-term care legislation.

Having attended a number of meetings with respect to the report on Redirection of Long-Term Care and Support Services in Ontario, it appears that the commitment made with our constituents re admissions and the right to governance is in jeopardy. Bill 101, in our view, undermines our ability to function as a conference project and threatens the viability of Tabor Manor. Our main concerns may be summarized as follows:

Admissions: With respect to access to facility services, we strongly believe that the needs of our owner-members are well met. A central placement agency, as presented in Bill 101, is the beginning of the destruction of the ethnic-religious uniqueness of Tabor Manor. While such an agency may serve other seniors well, a way must be found to modify Bill 101 to exempt unique charitable homes like Tabor Manor from central control.

Our arguments to maintain control of admissions are not based on discrimination or exclusion, but on the rights of owners to maintain the religious and ethnic uniqueness of their home. While we agree in principle with the philosophy of admitting the most needy, we feel that occasionally individuals may want to be admitted to our facility for social reasons. A central placement agency will likely not be as sensitive to such needs as small admissions committees governed by a private board.

Reassuring comments have come from the ministry that religious-cultural uniqueness will be protected. We feel, however, that this is impossible if control of admissions is taken from us. As owners of our home, we feel we must have the right to determine admissions. We heard that again just a few minutes ago. We're concerned about the word "control."

Governance: The power given to the placement coordinators is disturbing. An appeal mechanism must be built into the system to make the process more equitable. Under the proposed amendments, the power of the day-to-day management is significantly eroded, as is the power of the governance by the boards.

Funding: While Bill 101 does not speak to finances specifically, the reform changes include funding envelopes for regions. Regional funding would, under the proposed program, no doubt favour local seniors to the detriment of our constituents in other parts of the province. A way must be found where conference members who have supported Tabor Manor are guaranteed admission when a need arises regardless of the district in which they live.

Voluntarism: Over the years Tabor Manor has enjoyed the support of a large group of volunteers -- approximately 40 per week -- who assist in a variety of ways to improve quality of life for seniors. These come from our Mennonite Brethren churches, each taking its turn. This support would quickly disappear should access be restricted to Niagara region residents.

We hope that our comments in this paper will be taken as constructive criticism and that changes will be made to Bill 101 to help us better serve our owner-constituents and seniors. We want to continue to work in partnership with our ministry and our government, a partnership in which quality care is the focus of our service.


The Chair: Thank you very much. We'll begin the questioning with Mr White.

Mr White: Gentlemen, I think you've made a very succinct presentation. Your points are very well taken. Obviously, there should be respect not only for the individual who's applying for admission and who needs services, that senior or disabled individual, but also for those institutions that are already constructed, such as your own, that are sensitive to their needs.

We just heard recently from someone from the deaf community how it's important for services that may be outside of the region to be accessible to people from that community. In the same way, Mennonites from Barrie and Kitchener could obviously go to your facility. I think that very clearly should be accessible in the legislation, that kind of sensitivity, and I really appreciate your coming forth.

While I agree with all of the points and the request that you make, I'm wondering if you could share with us your relationship with the other seniors' facilities in the Niagara region, what that's like.

Mr Warkentin: We operate, I think, very well with the other groups. In fact, I was at a meeting a week ago to sort of go over this paper and discuss with them, and they're all putting together their own papers, so there are a lot of papers being put together.

Our relationship as far as operation is concerned is that we meet very often with them. The comment we make is that we do not want to be seen as exclusive, in the sense that if we have an opening and someone else needs to come in, we are open to that idea. What we are very concerned about is the control aspect, where someone says, "There's a list and you fit that list," and then you end up with whatever situation. If it ends up that your name comes up and the French home is open and that's where you're going to end up, well, my mother does not speak French. She speaks German and so she has a problem. At 80 years old she's not going to change. I have enough trouble myself, let alone her. I think that is what we're concerned about.

I think our working relationship back and forth is good, and we're open to that. We do not want to be seen as closed-minded, that kind of thing. That's not what we're after. But we also do not want to see it taken away from us so that we cannot put in the people who originally put the operation in process.

Mr White: Obviously, there's a difficult balance between cultural sensitivity and of course not being exclusive. I think you articulate that balance, that fine point very well and I hope the final draft legislation would reflect that and allow for accommodations for facilities such as yours. Thank you very much for your presentation.

Mr Hope: I have two areas which I would like you to elaborate on for me. It was a short presentation, you were right, but I need some more clarification. It's under the governance. You talk about an appeal mechanism. I wonder if you could elaborate on that. And could you elaborate on dealing with the regional funding for me?

Mr Rudy Siemens: As we understand the governance situation, the placement coordinators would control the placement of individuals in the home. I listened to the comments of the parliamentary assistant as I was sitting back there and I understand that's not what you're intending to do. However, the wording doesn't seem to say that, so we'd like to get the same response that the last committee had. If we get it, we'll be happy for it.

The way it is now, the placement officer, as we understand it, has control of who comes into the home but has no responsibility after that. We, as the board of governors of Tabor Manor home, are controlled by a huge number of acts in the legislation, either federal, provincial or regional. We have a lot of responsibility. I, as a board member, if something happens at Tabor Manor, have some liability. The way we understand the legislation, the placement officer at this point has no liability, so I'm not sure why I would want to be on the board, taking responsibility, when you can come in and put somebody into my home and I have no control over that situation. So that's one concern.

Mr Warkentin: Let me add one other point to that question. It has to do with inspections. We don't have a problem with the standards that the government proposes and wants to inspect and monitor. However, it appears to us, again reading Bill 101, that inspectors also have immunity. There seems to be no appeal mechanism or so on. Again, it's the way it's worded. We're not sure that's what's actually meant, but if that's the case, then the governance is taken from the boards and given to the ministry, so to speak. We don't have a problem with partnership, but we have a problem with one-sided or almost central control of it.

Mr Hope: I'm wondering if you'd elaborate on funding. You've missed that.

Mr Warkentin: Yes.

Mr Siemens: On the area of funding, our concern is that our constituency is province-wide and we see funding going towards regionalization; in other words, that the Niagara region would get X number of dollars per capita to fund the homes in that area. The pressure that would come then is that if we have a person coming in from Leamington, the region may not want that person to come in because it infringes on the dollars that it has. Now, whether that is the way it is written --

Mr Hope: No.

Mr Siemens: If it's not, we don't have a problem, but that's our reading and that's our concern.

Mr Hope: Just to let you know, it's not done by regional funding mechanisms.

Mr Siemens: Okay, good. We've only got three concerns now. That's not too bad.

The Chair: We'll try to keep working on them.

Mrs Fawcett: Thank you for coming with your presentation. Certainly we have heard this before. I think the whole thing centres around choice, and you're worried about the choice of the particular seniors who would want to come to your facility and make sure that they would gain access. Right now, this board that you have decides all of this. Is there one person, or is it a joint decision of the board for admission?

Mr Siemens: No. There's a committee of four on the board and they meet on a monthly basis. The administrator brings us the list of people who have applied, those who are approved, and then we make the choices as to the needs as they come up, and that's done on a monthly basis as rooms become available.

Mrs Fawcett: Possibly you would agree with the placement coordinator being one of those people or that that would satisfy the government as to the placement coordinator for your facility. It might be an interesting idea, if, of course, that would suit --

Mr Siemens: I don't think we would oppose having a coordinator be a part of our discussion, and as I listened to the discussion earlier, again, if the government is going to clarify this for us and say, "No, we're not coming in to just blanket you," okay, we understand that. But right now the assurances need to be in writing, I guess, is what we're asking for. We've heard them verbally, and it's not that we don't trust people, but then governments change and people change and then the rules are read to you the way they're written or how somebody wants to interpret them, and that's all we're looking for.

Mrs Fawcett: I was particularly interested around the numbers of volunteers that you have. Could you just enlarge a little on how that could possibly be in jeopardy under Bill 101?

Mr Warkentin: I'm not saying that municipal homes or other nursing homes don't have volunteers, but we have very strong volunteer participation from our constituents because they are particularly interested. The churches that own this place take ownership and come and do a lot of things. When we say 40, that's many hours, and we think we can run -- well, not just run the place more efficiently, but we can also improve the quality of care by having that constituency being there to support us.

We have owned some other organizations within Ontario -- we still do -- where control has been taken and the constituency immediately backs off. They still own the places, but they say, "Well, we don't really have a stake in this any more, so we don't really have to deal with it; the government can take care of it," whereas now certainly they appreciate the part the government plays, but they're saying, "We also have a stake in this and we need to continue to be part of that."

If the governance is taken away -- and I know that it may be denied that that's what will happen, but that's what we understand, to some extent at least -- I think constituents would say, "Well then, let them do their job and find their volunteers from somewhere else."


Mrs Fawcett: So your costs would go up.

Mr Warkentin: I would say that certainly the quality of care would deteriorate.

Mrs Fawcett: Would go down.

Mr Warkentin: Yes.

The Chair: Thank you very much for your presentation. It was by fluke that yours and the previous one focused on similar issues, but I think that has helped to make those clearer to the committee and I can assure you that we'll be looking at that very carefully. I'm sure the parliamentary assistant would probably want to have you sit in the same seating as that is discussed, so he --

Mr Siemens: If he's going to invite us, we'll be there.

The Chair: Thank you very much for your submission.

Mr Warkentin: Thank you. I think it was good for us to be right after the last group because basically we were following the same track and so we're going to help you catch up on your time and, as long as you hear us, we're happy.

The Chair: Thank you.


The Chair: I would now like to call upon the representatives of the Unionville Home Society. If you'd be good enough to introduce yourselves to the committee and for Hansard, then please proceed with your brief. We all have a copy in front of us.

Mrs Marie Hogan: Good afternoon. My name is Marie Hogan and I'm a member of the board of directors of the Unionville Home Society. With me are Lloyd Dennis, another member of our board of directors, and Margaret Hill, the administrator of the Unionville Home Society.

Our situation is very similar to the two previous presentations. I'll tell you a little bit about our home society; you've already heard our concerns about the care and the continuity of service. These are the two points we want to identify, as you can see in our report.

We want to start by saying that we are very pleased to be here and to tell you how much we appreciate the direction that long-term care is taking. Our position is a very positive one and we just want clarification in terms of probably two words in the whole matter.

Unionville Home Society is a community-based organization that was established 25 years ago by a group of churches and, as a result, it has never really lost its concern for the community. If you read through our formal presentation, you will see that we have on campus a number of structures or a number of services that we provide.

Union Villa is a CCHFA-accredited charitable home for the aged accommodating 162 seniors, providing extended care services to most residents. At Heritage Village there are 92 affordable, independent-living, rental bungalows for seniors, one third of whom receive additional subsidy support. At Wyndham Gardens we house 122 independent-living, lease-for-life apartments for seniors.

Our newest program is UHS home and community services. It provides a range of in-home and individualized social and health services to campus residents, a day guest program offering day activation programs to older adults with special needs, and Heritage Centre, a multi-purpose older adults' centre with more than 450 members, serving both the UHS on an 18-acre campus and the community at large.

So that's a brief overview of our campus and the people we serve, and the wide range of people we do serve.

In correspondence to the Honourable Marion Boyd we stated that on the whole we're most supportive of your new direction in long-term care and, in particular, the strong community focus, the commitment to rationalization of the relevant legislation, as well as the delivery system. We welcome the new resources for expansion and improvement of services, but we do have two concerns, as I identified initially, and they are the consumer's choice for care and the continuity of care.

We are worried about the choice of care because of our 25 years of experience, knowing that the folks we have served have had the opportunity to choose over and above the services provided. We would want to make sure that these residents still have that option to choose extra services if they so wish. I don't think I need to elaborate too much more because you have heard it, I know. This is your third time on that particular point. So it's that concern for the wording of the bill. We would like to be assured that you are taking into consideration that one day we will be those seniors and we would want that choice ourselves. It's more a matter of clarification with regard to consumer's choice.

Our second is a little more complex: the notion of continuity of care. It relates both to how we provide service and how you, the government, plan to provide placement. We have difficulty, from our mission mandate -- we would like to provide a continuum of service, and as I've indicated to you, we have residents living on our campus in rental units.

They have moved there with the intention that when they need it, they would be able to move into our extended care facility, which we call Union Villa -- and we have another, the lease for life, where we have promised the same sort of idea. It is our mandate or our mission statement to provide this continuum of service, and we are concerned that we won't be allowed to do that.

Our second concern in this regard is that the applicants for placement will not have a choice of placement. We're serving the large region of York South and we do not think it's feasible that somebody living down in the southernmost corner would be placed, let's say, in Newmarket, 30 kilometres away. We would like very much for you to consider changing the wording, again in terms of having us working with the placement coordinator to ensure that our seniors are placed where they are happy.

That really is a brief summary of our presentation. I know that you have heard very similar presentations today. In closing, I would just like to reiterate our concerns.

We would encourage you to recommend that the Long Term Care Statute Law Amendment Act, 1993, be reconsidered in light of defining more clearly the right of consumer's choice, that every effort be made to accommodate the wishes of the consumer, and that continuity of care be fundamental in making placement decisions.

The Chair: Thank you very much. Let me just note, as a member from York region, that the reputation of your organization comes before you and that all of us certainly who are from the region are delighted that you are there and that you're here today.

Mr Hans Daigeler (Nepean): Have you got your application in?

The Chair: That's right. I'll get my application in.

We'll begin the questioning with Ms Fawcett.

Mrs Fawcett: I thank you for coming before us. It certainly sounds like you have covered all of the bases with your wonderful campus facility.

Mrs Hogan: Thank you.

Mrs Fawcett: I think it's clear that the choice of the consumer is of paramount importance. I guess as we hear presentations the words are not clear in the bill, because there does certainly seem to be the fear out there that people will not have the choice of where they want to go -- that is clearly something that is of great concern to seniors, there's just no doubt about that, and we do want them to be happy in their final years -- and also this continuity of care.

If I could just ask you a specific question around the funding formula that has been promised, I would assume that would affect Union Villa. Have you received any information as to just when the new formula would be in effect? We had heard January and then we were told by the minister that it would be maybe April, and I have heard that now it may not be until September. I'm sure you're trying to budget, as most people are, and just wonder if you have heard anything.

Mrs Hogan: I will refer that to Margaret Hill, our administrator.


Mrs Margaret Hill: We have heard the same, other than that it is very discouraging to hear your comment of its being moved forward to even September, because it is causing great duress not only for Union Villa, Unionville Home Society's home for the aged, but all the other homes for the aged in the province.

Mrs Fawcett: Right. Could you just enlarge a little on how this is really providing, you know, combining --

Mrs Hill: At the present funding levels we are working on a 1% increase budget for 1992-93 over 1991-92, and in the upcoming budget preparation we are working on a zero increase and at no increase to funding, meaning that for a facility that is presently underfunded, we are continuing to provide services by underfunded dollars.

Mrs Fawcett: Do you have an added problem of contract negotiations at all, or are you settled?

Mrs Hill: We are fortunate at this point that we do not. However, that's not to say that couldn't be the case. But maybe Lloyd would like to speak to that.

As a fair employer, we would certainly like to be addressing the salary rates; also, I think not only the salary rates but the number of staff to provide for the level of care we are servicing, which is far in excess of what the home was built for and what the home is currently funded for. Out of 162 individuals, extended care funding is only applied to 118. So for the 44 residential, we are providing a level of care for which we are not being funded.

Mrs Fawcett: Around the classification system, I know there have been hints that possibly there are more in the high-level care than was maybe anticipated and that this also could cause some problems around that whole area.

Mrs Hill: Indeed. We would be most anxious to hear the results of the classification which took place last October --

Mrs Fawcett: With definite time lines for you.

Mrs Hill: -- and of course residence circumstances have changed.

Mrs Fawcett: Yes, and as yet you have not heard.

Mrs Hill: That's right.

Mrs Fawcett: I understand that is hopefully forthcoming. Maybe the parliamentary assistant could enlighten us on exactly when that classification system is going to be made public, the results there.

The Chair: Can the parliamentary assistant enlighten us? For sure he can.

Mr Wessenger: Unfortunately, I think it's something that will have to be taken note of to see what information we can get.

The Chair: An enlightened note.

Mr Wessenger: That's right.

Mr Daigeler: I was just wondering whether it would be possible for you to make an estimate of how many of your residents would currently take advantage of paying for certain services which could be considered additional in relationship to your first point about the ability to choose.

Mrs Hill: The cost for services?

Mr Daigeler: Yes.

Mrs Hill: I would say that in the home right now, as a guesstimate, around 30 or more individuals whom we have not approached for additional services. This would be additional services in terms of the care level, because the funding isn't there to meet the staffing required to care for the person at the higher end of care.

As a result of that, in a home where you are funded at an extended care level, you have a mix of light extended care and heavy extended care. Because individuals are staying in the community longer, admission to the home is at a higher level of care need. Therefore, the individuals who are already in the home are moving into and close to the chronic care level need, and there is no placement for those individuals, so they remain in the home.

We're not staffed to service that number at that high end. It would be approximately 32 individuals at that high end. But if funding were appropriate to their need, which is what the classification system was based on, it's highly improbable that those individuals, if the dollars were available, would need those extra services. On our campus we have 40 individuals.

Mr Daigeler: What I was kind of referring to was more the points that you made in your presentation. You quote here, "contracting for a massage, for a companion, for supplementary personal care," even to ordering a pizza. I just want to get a sense of how many of your residents are currently taking advantage of these what you might call frills.

Mrs Hill: Additional services?

Mr Daigeler: Yes.

Mrs Hill: We have not proceeded to bring in additional services, other than for nursing services. I'm saying right now that we have 12 families that are taking and expending exorbitant numbers of dollars to have their loved one assisted with the additional nursing services, and they cannot continue to do that under our current funding, if I don't have the finances for that.

Mr Lloyd Dennis: There is also a concern in the legislation that we will be unable to provide that in the future because there is a limit in the legislation. It essentially says that we will not be able to provide that service to our residents, that there's a standardization of service and that's all we will be allowed to provide. That's a very specific concern that we have.

Mrs Hill: And I think it's important to realize, although we're using the term "we," this is applying to all homes for the aged, all long-term care facilities in the province.

Mr Jackson: You expressed concern about the placement coordination service. What's your understanding of how this may work as it affects your organization?

Mrs Hill: We are in the fortunate situation right now of working closely with the placement coordination services in York region and, as it is functioning right now, we work with the placement coordination services. They have individuals who come to them for placement. If the individual requests placement at Union Villa, then that information on the individual is forwarded to Union Villa and it goes through the Union Villa admission review committee, which is a multidisciplinary committee.

The concern with the long-term care statute, Bill 101, as it currently exists is that it does not define the role of the placement coordinating officer's duties and responsibility. I think whatever control that is going to be, it needs to be defined more explicitly and more clearly.

Is that placement coordination officer going to work with the family and give consideration to that consumer's needs? You mentioned that your mother was of an ethnic background. In that instance, would that placement coordination officer give consideration to the needs of someone who needs and wishes placement in a specific home, or is it going to be absolute, in that a placement coordination officer is going to evaluate the needs and make a placement because there is a placement available in another region, in another area?

Mr Jackson: Currently, there's a lot of flexibility and there's ability to move, even in this period of restraint and waiting lists. Is your fear that in a given facility it's very easy, with the amount of control being given to a placement coordinator, that he or she can change the mix or the acuity levels of the residents very dramatically and affect certain outcomes, so in effect buildings become predetermined as receptive to a certain type of client by virtue of the consistent placement of certain individuals in certain types of facilities?

Mrs Hill: If the responsibilities and duties of the placement coordination officer or services are not clearly defined, yes.

Mr Jackson: I see that there are two real issues here as I work with placement coordination in my community: whether the facility is appropriate to the family, in concert with the client, or whether the facility has a program and "We'll fit the client to that." There's a world of difference between the two of those.

Mrs Hill: Bill 101 does not address that either way.


Mr Jackson: Yes. Currently, a variety of people, loosely referred to as advocates, are allowed to impact a decision as to where the individual goes: It takes into account the age of a spouse, who may need to get to a bus route in order to provide additional touch and warmth and so on, or it could include costs; it could involve a variety of issues.

So your concerns are twofold in that regard, in terms of strengthening the guidelines. We've heard as well the issue of the appeal mechanism having more than one person responsible for appeals, more than one person responsible for the actual placement coordination; that kind of thing. Is that the other aspect of it?

We can make it a lot more clear, but it may not be what you want to hear, so is there not something more specific that you could recommend? Could you go one step further and suggest something? The solution is: You can appeal the decision or you can impact the decision. I'm sorry to be so basic here, but I'm trying to ask of you what you'd like to see done differently, other than to raise the question that it lacks clear definition as to who's in control and how you can impact the decision.

Mrs Hill: I think the consumer needs to be in control, and if the consumer chooses and wishes to go to a facility for placement, that consumer's wishes have to be given priority.

Mr Jackson: We have a process in place. I used to chair a housing authority in this province, 15 years ago, as a matter of fact, and we had a practice: You were given three choices of a building. If you turned all three down, then you were put to the bottom of the list. I'm not saying that, and I don't want Ms Sullivan to suggest that that's what Mr Jackson now suggests we do. I am posing it because I have extensive background in how bureaucracies operate around this building. When people talk to me about choice, bureaucrats will say to me, "When does the choice end?" and so on. Have you thought through the process of choice and where it all ends up?

Mrs Hill: First, I think we need to realize that when we are speaking of the consumers who are seeking placement in a long-term care facility, they are there to make a choice because they have to make a placement. Their first choice is to stay in the community. If they then have to make a choice of going to a facility for a placement, then they are going to choose a placement that is going to meet their multicultural, linguistic and social needs; they want to stay in a community which they are familiar with.

If the point has come, as you raised, that an individual, a consumer, after the third opportunity of placement turns it down, in this day, that tells me he or she doesn't need placement. I think we need to look at the whole system, if that's the point we've reached.

We need to realize that we're talking about consumers who are at a point in their needs -- of course, that's if we understand the government's direction; that is, to provide funding to people who are staying and enjoying independent living in the community longer with the support services that are to be provided. By the time an individual has exhausted those community support services and needs placement in a long-term care facility, let's give him or her the minimal choice he has left. That minimal choice is --

Mr Jackson: Am I out of time?

The Chair: I'm sorry, we have to move on.

Mr Wessenger: I'd like to thank you for your presentation. In response to a question about the new levels-of-care funding arrangements, I'd like to indicate that they will come into effect as quickly as possible after the bill is passed. We'd require the bill, of course.

With respect to the matter of patient classification, they expect that information will hopefully be available by the end of February. That's the target date for that.

I'd like to follow up with a question with respect to these enhanced services you've referred to. In your brief you've already indicated, I believe, that some of the enhanced services are paid for by the individuals themselves. You also indicated that there is some additional funding to your organization which provides an enhanced level of service overall. Is that correct?

Mr Dennis: That's on an individual basis. That's families.

Mr Wessenger: There's no sort of overall enhancement that is any other source of funding?

Mr Dennis: Families come in and do things for their mothers, fathers, relatives.

Mr Wessenger: But I take it that one of your questions was, could an institution itself, if it had another source of funding, provide a level of enhanced care? It would not make any sense to prohibit such an institution, if it had its own other sources of revenue from providing an enhanced level of care.

Mrs Hill: Your point is very well taken, because it comes in under our first point in the presentation, on page 4. If I can recall, I think it was point 6 of the summary notes regarding Bill 101. It is not clear and it doesn't explicitly indicate in the bill, in that it proposes that residents may not be charged more than certain maximum amounts for basic accommodation, preferred accommodation, other care services, programs and goods. This restriction could impact negatively on the operation of long-term care facilities. I won't read through that, because you have that in the brief.

I think the point to address here is that the statute is not clear as to whether residents will be unable to acquire such goods or services only from the provider organization which, in agreement with the crown, is providing certain services, or whether the restriction is absolute. That's the point we're trying to make: "absolute" meaning that the consumer who is a captive under this arrangement would not be able to source and pay for any other services, goods, etc. That was where we were concerned.

Mr Wessenger: I understand that point.

Mr O'Connor: Like the Chair, I represent part of York region. I have also heard of the fine work -- and I'm sure you're aware of it -- of Parkview Village up in Stouffville in the southern part of the area I represent; I go right up to Georgina Island in York region.

I have a comment, and perhaps I can glean some information from you that might be able to help us.

During the consultation period, when the ministry had sent out for further consultation, a consultation paper went out. Clearly, right in that consultation paper, there was a statement of renewed vision. I'll read from the very first line of it: "The new directions presented in this paper have made the needs of the consumer the most important consideration for long-term care and support services." So it puts the consumer at the very beginning.

It also went on to say "the promotion of racial equity and respect for cultural diversity." There was a whole paragraph on that, just in the vision statement. I'm sure that was reflected in the presentation you made when the consultation period was going on.

Right now -- I don't know whether you realize it or not -- there's a draft document out there. My colleague and I are both parliamentary assistants to the Minister of Health, but he's taken the lead in this, so perhaps you can work with Mr Wessenger on this. You've talked about special needs and the importance of recognizing cultural diversity in placement coordination. There's a draft of an application form for a placement coordinator in the draft manual that was circulated -- I don't whether you've seen it -- circulated in a limited fashion, but trying to get some information.

Perhaps through the parliamentary assistant you could get a copy of the draft admission form and you might be able to suggest ways in which we could improve that, because this afternoon we have heard from many different cultural communities, starting right off from the deaf culture, saying that the needs of different cultures must be respected. If you haven't had an opportunity to comment on it, perhaps you could take the opportunity. We'd appreciate that, because I feel it is important -- we certainly heard this afternoon from a number of presenters on that very importance -- on how you think we might be able to improve that.

Mrs Hill: Thank you. Certainly we would pleased to do that.

Mr O'Connor: I just made some more work for you, Paul.


Mrs Hill: I think we still have to be very cautious in understanding that the statute, Bill 101, is the letter of the law, and we want to ensure that the letter of the law is giving us the tool or the instrument to work with to put in place that which we want, to ensure that the consumer has the opportunity for choice and that the consumer has the opportunity for continuity of living and care services. I believe those are the two basic pillar foundations to Bill 101, and if those two issues are thoroughly and carefully looked at and dealt with in Bill 101, then the whole multicultural, linguistic and social aspects will also fall into place.

Mr O'Connor: It might not be quite as simple as that, because we've heard from the other communities which aren't as fortunate as you are to have that whole continuum of care already within the community. They are looking at it from a beginning point. You're very well established and are able to provide a continuum of care that isn't reflected in many other cultures and communities. They haven't got to the point you're at: That's why I'm asking if perhaps you'd help us out in trying to help those other people as well.

Mrs Hill: They do have a continuum of care in that, for example, Tabor Manor is drawing province-wide. They've got people in different parts of the province who are being supported in housing areas who, when the time comes to come into a home for the aged, are coming to Tabor Manor. That's the problem: Their problem actually is a greater expanse. So we're fortunate.

The Chair: I'm afraid I'm going to have to stop our discussion and I'm sorry for that, but we do want to thank you very much for coming in and for bringing your presentation. I think it elicited some more interesting information in the line of a number of the presentations this afternoon, so that's been very helpful to the committee.

Mrs Hogan: We do thank you for this opportunity.

The Chair: I draw to the attention of the members of the committee two documents from Alison Drummond, our research officer, that were done at the request of members. One is on attendant care in Bill 43, the relevant pages from Hansard; second, at Mrs O'Neill's request, information on the existing arrangements for attendant care. That has, I believe, been passed out to the members.

Mrs Fawcett: Mr Chair, could I have clarification on the information the parliamentary assistant gave me on the funding formula? You're saying that the money cannot go out until the bill is passed?

Mr Wessenger: That's right.

Mrs Fawcett: But can't the formula go out to the homes so that they know how to budget? Are they budgeting the old way? Do they have to wait for this new formula? You wonder around estimates.

Mr Wessenger: It might be of assistance if I asked the staff person to perhaps clarify that for you. Or would you like to hold it to the end?

Mrs Fawcett: Yes, I would.

The Chair: Just so we could allow the next representatives to speak.


The Chair: I call the representatives of Belmont House, if they'd be good enough to come forward. Welcome all, to the committee. If you'd be good enough to introduce yourselves to us and to Hansard, thank you.

Ms Mary-Jane Large: Thank you very much for seeing us today. My name is Mary-Jane Large, the executive director of Belmont House, and I would like to introduce some members of my board: Anne Stinson, who is the president of the board; Joyce Marsden, who is past-president of my board; Johanne Ratz, who is the chairman of finance for my board.

The Chair: Just before you continue, I'm wondering, Hans, would you be good enough -- what I see is a talking water jug. Could you get that?

Ms Large: How's that?

The Chair: Please go ahead.

Mrs Marland: It never bothers you when it's in front of me.

Ms Large: Belmont House is a charitable home for the aged. We're located at Davenport and Bay, so we're almost in sight of this building. We began operation in 1852 and have a long history of responding to the changes in the needs of many communities over the years. This has ranged from women who were in trouble with the law in the 1850s to people with mental disabilities during the 1870s and 1880s and actually right up until the 1940s, and for the past 120 years we've cared for seniors.

We currently have 315 beds, made up of 204 residential care and 111 extended care, with an average age of 87 years. We are planning renovations to 25 of the residential care beds for respite care and transitional care, which will occur as soon as we get some assistance with capital funding.

The members of my board and I are here today to say that although we understand the underlying principles of Bill 101, we have concerns and would like to make recommendations on some parts of it and on the proposed regulations. These concerns also reflect the wishes of our residents, who have been well informed about what is going on and expressed some of these concerns during the consultation process.

On reading the draft legislation, it would appear that the service agreement which is mentioned will be a standard document. We would like to see the service agreement tailored to the individual homes, because I think only in that way can it reflect the cultures and individuality of the homes and also reflect the kind of atmosphere boards of directors wish their homes to have.

There's obviously been some discussion recently about the funding and where the money is going to come from and how much money we're going to have to run the home, so I won't discuss that at the moment.

The service coordinating agency also is of some concern to us. The board of Belmont agrees that individuals should be encouraged to remain in their own homes as long as possible. However, access to community services is not easy and at the present time it is not ongoing. We're concerned that during the transition period, when Bill 101 comes into effect and before the other community services are implemented, many seniors will suffer unnecessarily.

Residents in homes for the aged are usually older than 87, are frail and have many chronic problems. Many, however, are not physically unable to look after themselves, but they do benefit from the physical, social and spiritual activities provided in homes for the aged. It's one of the things the admission criteria would appear to eliminate, being able to be admitted to the home for something other than physical needs.

Bill 101 has stated that individual choice is important, but as it is presently written it does not allow the individual any choice, nor does it allow the home for the aged to admit those whose care they can give safely. This is not compatible with the primacy of the individual as stated in the legislation.

Many institutions have waiting lists. Belmont's is extensive. There's uncertainty about whether people who are presently on our waiting lists will be able to stay on our waiting lists, or will they have to go through a whole new assessment process with the SCA? Or will they continue to stay on our lists and be admitted as vacancies occur as they do at the present time? This information causes some anxiety for us, but it causes an enormous amount of anxiety for those people who are on our waiting lists and wondering what's going to happen to them.

We would also like to question, once the SCA has approved somebody for admission to a home for the aged, what happens to that person? Do they just sit on some waiting list controlled by the SCA or will the homes themselves be able to have a waiting list of those people so that they can orient them and start the admission process even before a bed becomes available?

We have a concern that a senior may have decided that he wishes a certain service and the SCA will restrict that choice. We've found that when people apply for admission to a home, they've already considered their options and they've made a choice. The SCA has a major role in ensuring that individuals are well informed and understand the options available to them, but the individuals should also be allowed to make the choice, and not the placement coordinator. The placement coordinator, according to the legislation, is the only person who will assess and determine an individual's eligibility for placement in a facility, and we feel that really imposes a limit on the person in the community, on his or her choice.


We have several changes that we would recommend you consider:

(1) That the criteria for admission be expanded to include psychosocial needs as well as physical needs.

(2) That individuals wishing to enter a home for the aged be able to do so if they're willing to pay the full cost of care. It could be that somebody might not fulfil all the criteria as laid out by the coordinating service but might be able to pay the full cost of care anyway.

(3) That the requirement to admit an applicant also be based on the ability of the home to provide that care. Many homes with a large residential population are unable to deliver any kind of heavy nursing care because we don't have call-bell systems, we don't have accessible washrooms, we don't have nursing stations. The buildings physically are not able to do that. Renovations to those buildings can take place, but that's over a period of time at quite a high cost.

(4) That the procedure for appeal of a decision rendered by the placement coordinator be simplified so that an applicant who may be frail or confused by the process will be heard quickly to be reassessed for either admission or for community services.

(5) That the placement coordinators be required to ensure that if an applicant is ineligible for admission to a home for the aged, the placement coordinators will have the responsibility to ensure that other services will be put in place for that person so that he is not left in some vacuum, not being able to go into a home for the aged but also needing other services that he doesn't know how to get.

Finally, we have concerns about the procedures for the implementation of this legislation, that during that process some seniors will fall through the cracks because there are just enormous gaps in service now. We are concerned that those gaps be filled for the people who are out there who are at risk.

The Chair: Thank you. Did anyone else want to make a comment before we start questions? If not, okay. We'll begin with Ms Marland.

Mrs Marland: Ms Large, do you have a concern about the overall approach that Bill 101 brings to long-term care?

Ms Large: I think the whole approach to Bill 101 is a good idea. I think there's no question there needs to be an overhaul of the system and I think that even the placement coordinating services is a good idea, because it helps those people who want service to be able to have one point of entry into the system. My concern is that once they get into the system, especially in the city of Toronto, there are so many people to deal with that somehow the individuals wanting to enter homes or needing services will get lost.

Mrs Marland: Are you concerned about the omnipotent power of that placement coordinator?

Ms Large: Yes, I am. I think the appeal process as laid out in the bill would be very confusing to an individual who didn't have somebody to speak for him.

Mrs Marland: Which is probably almost the majority of people, isn't it?

Ms Large: I think so. I think even families don't necessarily know how things work or how to push the right buttons to make things happen.

Mrs Marland: Based on your own experience, do you have any comments about the thrust and the direction towards the non-profit sector for long-term care versus the private sector and giving future and present people who need long-term care a choice of where they procure or access that care?

Ms Large: I think the first priority is that people have a choice of where they access the care. I don't have the problem that a lot of people have with the for-profit sector. I think they deliver good care, as the non-profit sector does. It's important for the people who need care that it be given in the best possible place for them and that they should have a choice. I think the funding is another issue. It would appear that a great deal of the new money that's being put into the system will end up going to the non-profit system providers rather than the for-profit providers.

Mrs Marland: We can probably guarantee that you're correct in that statement. The now former Minister of Health, as of this morning, when she was before the committee, said that the government definitely does have a preference for the non-profit sector. We have a concern because we don't feel there's any evidence to suggest that the private sector has anything less to offer than the non-profit sector. In fact, the irony is that for years the major inspections have been done in the private sector nursing homes and have not been done in the government or non-profit sector ones.

We feel very strongly that the choice has to be there from a purely practical point of view too. Suddenly, the non-profit sector can't provide all the accommodation that's needed. We've got waiting lists now which are unbearable for some families, but it's the same ideology that's putting private day care people and other service agencies out of business. So we're not surprised to hear that from this current government, but we have concerns about it because there's no evidence that if homes are licensed, if day care centres are licensed, the public is protected.

Ms Large: I think that in measuring the quality of care, each individual home or facility has to be measured on the quality of care that it provides, whether it's for-profit or not-for-profit.

Mrs Marland: That's a very nice way to put it.

Ms Carter: One point I was going to raise: You said the service agreements would be uniform for the homes. But I'm just looking at the explanatory notes at the beginning of the bill and it says, "Service agreements must comply with the regulations and may contain additional provisions agreed to by the parties," so it seems to me there is scope there for different facilities to have different agreements. I'm not sure whether there's somebody here who could enlarge on that, but I thought that was a relevant point there.

Also, I think it has been made clear this afternoon and previously that there will be choice as to where people go. I know that is the intention. If it hasn't been made clear in the bill, then I think we're all agreed that something additional must go into the bill to clarify that.

Of course, each person has to have his plan of care, and I would hope that he would be consulted on that. If that also is not clear in the bill, then I think we ought to be open to suggestions as to how it can be made clearer that this is not something that's going to be imposed on people.

Ms Large: Certainly, in homes at the present time, there is a plan of care for each resident in which they take part in developing. But I think, not having seen a sample of what the service agreements are like, this was one of our concerns, so I'm reassured to know that they will have the flexibility to be able to reflect the culture of the various homes.

Ms Carter: But we've seen, throughout this afternoon particularly, that there is a fear that homes are going to be homogenized. I think this is really the opposite of the intent. The intent is to make sure that every individual gets the most appropriate care possible. As somebody, like others here, who's been involved with the Advocacy Act and related legislation -- I can see Mrs Sullivan flinching -- the whole heart and soul of that legislation was to give individuals the right to say what their own preferences were and have those preferences honoured. I think it would be very strange if we suddenly went in the opposite direction and said, "Right, everybody's got to have some standardized treatment that somebody else thinks is good for them."

Ms Large: I guess the changes in that advocacy legislation, from the first draft to the final writing, show that this concern has been recognized, though, that the legislation changed considerably.

Ms Carter: That was the original intention, but maybe it wasn't ideally drafted.

Ms Large: That's right. It didn't -- not in the first draft.

Mr Wessenger: If I remember correctly, you said that your home is not equipped for heavy care. Is that right?

Ms Large: We have 111 extended-care beds in a new wing, which opened last January.

Mr Wessenger: Oh, your new wing is equipped?

Ms Large: That's right, and it is all extended care. The residential part of the building, which was built in 1969, is not equipped to provide care.

Mr Wessenger: So it's the residential portion that you have the concern about, not the extended care.

Ms Large: No. Our new wing was built with a good deal of assistance from the provincial government, for which we thank you very much.

Mr Wessenger: Right. That actually answers my question. Thank you.


Mrs Sullivan: We haven't talked much, in these hearings, about the standard agreement -- I don't know what date of service agreement -- which would be appended to the manual or part of the manual. The agreement itself is very standard and really reflects whatever will come out of the regulations. Of course, none of us have seen those, and we were told that we will not see them. But attached to that is a program description which is the schedule, and the schedule becomes an integral part of the agreement.

When Mr Quirt comes to the platform again, I wonder if he might, in addition to answering the question about the flow of funds, also respond to questions about how the capabilities of the individual facility will be reflected in the schedule. I see that there is supposed to be a program description, but it doesn't speak to the particular culture or facilities available or services available within the individual institution. I think that would be helpful to us all as we look at whether this is an appropriate agreement or whether there should be some enhancements, specifically in the legislation.

I like very much your suggestion of the orientation while on the waiting list as well as sitting with the placement coordinator. It seems to me that's a very practical approach to that. I'm not sure that there's a legislative amendment that can be brought in, but I just think it's something that's worthwhile to underline.

I was also interested, and I want to ask you a question about this, in the average age of your residents being 87 years. In both the residential and the extended care facilities, certainly what we're seeing throughout long-term care is increased age and increased acuity of people as they're moving into nursing homes or other facilities. People who used to only be cared for in, say, a chronic care facility are now being cared for in nursing homes and homes for the aged.

Many of the problems that these facilities are facing are psychogeriatric or behavioural problems such as violence. I wonder how you see, by example, the influence of the increased acuity affecting your funding needs and whether you see an annual assessment of patients being appropriate in terms of funding the services that you need as people die or move out or go back to the community or whatever.

Secondly, do you see as appropriate chronic care facilities being included as a separate level for dealing with long-term care patients who have more difficult problems to deal with, or do you see what appears to be the current move of the government, to move what are now chronic care patients into the nursing home/home for the aged environment, as being an appropriate move?

Ms Large: To answer your first question first, the annual assessment, the mortality rate in a home like Belmont House, with 315 beds, is about 30 people a year, so over time it will take about 10 years for the whole population to change. The annual assessment is probably not enough, because the general health of those people who are already there deteriorates over the year. As well, it would certainly appear that the new admissions will require more care than we have previously given. So each year our requirements for care and for funding will increase.

The appropriateness of chronic care facilities in a separate building depends, I think, on the level of chronic care. There are a great number of people in chronic care facilities who require some kind of heavy nursing care but don't require the specialized facilities that hospitals provide. They may need a little bit of oxygen; they may need a little bit of specialized care. But I think that homes for the aged are not the appropriate places for people who require tube feeding, intravenous; catheters are probably okay. The reason for that is that the staff resources would then be spent delivering the nursing care rather than the psychosocial care that so many people need. A lot of them, even when they're physically unwell, need a lot of time just spent talking, getting them dressed, leading to their quality of life, and if the nursing resources are all put on delivering physical care to people, there isn't going to be an awful lot of time left to deliver that kind of quality-of-life stuff that is so important to our residents, that makes the difference between a good home for people to live in and a bad home.

So to answer your question, chronic care facilities, some of them I think have done a good job in specializing in certain types of care, but I think there are a lot of people in chronic care who could easily be cared for in a home for the aged.

The Chair: Thank you very much for coming forward. As you noted, you're not that far from Queen's Park, and I suppose it is one home that many of us are aware of simply from wandering around this city, and we know the fine job that you do. Thank you very much for taking the time to come in and speak to us.

Ms Large: Thank you. And I'd be very happy to tour any one of you around the home if you'd like to come and see it at any time. Thank you very much.

The Chair: If I could, then -- to the parliamentary assistant -- I wonder if we could just deal with those two issues that have been raised by Ms Fawcett and Ms Sullivan.

Mr Wessenger: Yes, if I could get staff to comment on it.

The Chair: Again, Geoff, if you'd be good enough just to reintroduce yourself for Hansard and then you can go ahead.

Mr Geoffrey Quirt: Thank you, Mr Chairman. My name's Geoff Quirt and I'm the acting executive director of the long-term care division of the Ministry of Health and the Ministry of Community and Social Services.

The Chair: I think the first question related to the funding, both in terms of when it would flow and then also, I believe, around the formula that would be used and when one or both would be made available.

Mr Quirt: Ms Fawcett was quite right when she indicated that our original target date for implementing the new funding arrangements for nursing homes and homes for the aged was January 1, 1993. When it became apparent that the legislative schedule didn't allow for passage of Bill 101 by that time, and at the point in time that the bill was introduced to the Legislature on November 26, Minister Lankin indicated that the new funding arrangements would be implemented in the spring of 1993. She was cautious not to pick a particular date, because of course implementing the new funding arrangements is dependent on passing the bill before the committee at this point in time.

With the blessing of the committee, the bill would go back to the Legislature when it reconvened, and it would be our intention to introduce the new funding arrangements as soon as possible after passage of the bill, dependent on the pleasure of the Legislature at that time. That's why we indicated the spring of 1993 and, if the bill passes, as soon as possible after that we'd be implementing the new funding arrangements and adding $206 million to the budgets of the existing nursing homes and homes for the aged.

With respect to exactly how much money is available to be distributed with the new funding arrangements, we are hoping to meet with our funding focus group, in other words with the committee we've been working with to develop the funding formula, which includes representatives of provider associations, the Ontario Nursing Home Association and the Ontario Association of Non-Profit Homes and Services for Seniors, around the end of February or 1st of March.

As the members of the committee would be aware, the estimates process within government is ongoing currently. The estimates for the Ministry of Community and Social Services and the Ministry of Health have to be confirmed before we know precisely what the Legislature is comfortable with in terms of expenditures in those programs. The commitment is still there to add $206 million to the approved amount that the government has available. We hope to share those specific figures with the provider associations as soon as they are confirmed. We expect that would be towards the end of February, first part of March.

At that time as well, we hope to present to all 500 long-term care facilities in the province -- 511, I believe it is -- their individual ranking or their scoring. We refer to that as a case mix index, technically, the information that allows them to know how the nursing and personal care requirements of their residents compare with the provincial average. We'll also be providing information on various categories of home so that they'd have a better picture of how their care requirements related to other charitable homes or municipal homes for the aged or nursing homes in their area.

So that would be the schedule for allowing facilities to understand not only how much money was available provincially but how they scored in relation to other facilities, and in addition to that, how much money would be available in the accommodation section of the budget, how much money in the quality-of-life programming section of the budget and how much money available in the variable nursing and personal care component of the budget.


The Chair: Ms Fawcett, further on that?

Mrs Fawcett: I'm just wondering what administrators of the facilities should be doing now so they can get their budgets in order, because I know the one in Northumberland was waiting for this formula, and she's under stress from the municipality too, because the municipality has a portion of that budget, and how that all works. I mean, could something not have been said to them so that they could know that, "Go on last year's," or "Go the way you've always been going," or whatever?

Mr Quirt: We've written to each facility in the province to indicate that January 1 would not be the implementation date and that implementation would happen in the spring.

Mrs Fawcett: I realize that.

Mr Quirt: In my discussions and correspondence with particular facilities and with both provincial associations I've suggested that their best practice would be to budget on the basis of their existing budget for the previous year and not to plan on a major increase until the individual case mix index and their individual funding arrangements could be confirmed. Facilities have recognized the economic climate and have generally budgeted on a flat-line basis, spending the same as they did last year, or have perhaps planned on a modest 1%, for example, economic adjustment for their own operations. That's been an individual board decision, recognizing that the majority of facilities will receive a funding increase, but there will be some of the higher-cost facilities that are currently spending considerably more than the average, for which a commitment has been made that the existing level of support from residents and from the province will be maintained. In other words, no facility will get less money than it did the year before. So the safest and most prudent way to budget would be based on the existing level of expenditure in the facility, as is the case with hospitals and others.

Mrs Fawcett: If the bill passes, let's say, by the end of June and things then go into the new fiscal year, then possibly they would have to relook at their budgets and --

Mr Quirt: For the vast majority of facilities, they would be planning how to spend an increase in funding and they would have a commitment at a particular funding level until January 1, 1994, and then a new budget would be established based on the results of our classification in the fall of 1993. So facilities can either count on an increase in funding, the vast majority, or for a small percentage, if their current level of expenditure is quite a bit higher than what they'd be entitled to under the new funding arrangement, the commitment is there not to reduce the level of support and they would continue at the level of operating expenses they're at currently.

The Chair: Are there any further questions on this particular point before we move to the other issue? Ms Sullivan, on this?

Mrs Sullivan: Yes. I wanted to clarify the position of those homes which are now operating on a more expensive level than what the average will be. The guarantee is that they will not receive less funding than they have in the past. The question is I suppose relating to a freeze on further funding, and I think it was Baycrest that particularly raised that in our hearings, but of course there will be other significant homes -- I suspect Providence Villa would be one of them -- that would be operating at a higher level than what the average would be, and there will be others. What will be their position then in terms of the length of time that the freeze will last, and how are you negotiating with them in terms of future funding? Are you simply saying, "You are at the current level in perpetuity until everybody else catches up"?

Mr Quirt: There are cost control measures in effect now for about 38 of the highest-cost homes for the aged in the province -- 38 I believe is the figure -- of 181 homes. Those 38 high-cost homes have had their cost increases limited to the provincial inflation factor for the past three years, I believe; it's either three or four years. My memory doesn't serve me well enough to know precisely.

Those facilities are probably among those facilities that would be red-circled or would have their current level of support protected under the new funding arrangement. A decision has not yet been made on the extent to which an economic adjustment factor would be passed through to those red-circled facilities. That decision can best be made once we have the individual funding levels of eligibility for funding for each of those facilities and the province is in a position to understand how many facilities have to be red-circled and what is the size of the discrepancy between the level of expenditure they're making now and what they're entitled to under the new system. I wouldn't want to speak about individual facilities until we understand the care requirements of the residents who live there and understand the amount of funding they would be entitled to under the new system.

The economic adjustments for our transfer payment programs this year, as you're all well aware, have been modest. No decision has been made about next year, but certainly small economic adjustments have been required because of the economic circumstances in the last two years. Those homes that are now subject to a cost control measure have been held to a maximum subsidizable rate, and for the most part they have operated below that maximum subsidizable rate.

The Chair: Are there any further questions on this? We'll move to Ms Sullivan's other point.

Mrs Sullivan: I think this would be useful to understand even if we don't have the specific figures: What is the kind of percentage discrepancy between the high-cost homes and what's probably the average cost?

Mr Quirt: I think I can best answer that by saying that each nursing home in the province receives approximately $77 a day for the provision of programs and services to residents. On average, charitable homes for the aged spend about $90 a day, and municipal homes for the aged in 1991 spent on average $118 a day. Some individual municipal homes for the aged and some charitable homes for the aged spent in excess of $150 a day, so there is a factor of two in some circumstances in terms of the level of expenditure. Without me knowing the specific care requirements of the residents in those facilities, I wouldn't want to comment on the extent to which they'd be eligible for that level of support under the new system. In global terms, our studies show us that there's no significant difference in the care requirements of residents in nursing homes and municipal homes for the aged.

Mrs Sullivan: The second question relates to how the schedule attached to the service agreement will reflect the capacity of each individual home to provide services and will also reflect the particular nature of the home that presumably would be preserved in a new agreement.

Mr Quirt: As you've pointed out already, Ms Sullivan, the first couple of pages of the legal agreement would be a standard agreement that would oblige the province to do similar things for all facilities and oblige each facility to adhere to the act and the regulations and the program manual. But the majority of the service agreement is specific to each particular home.

As you mentioned, there are three schedules proposed for each service agreement. All three of those would be tailored to the individual facility, and the schedules, of course, become part and parcel of the legal agreement. The three schedules are as follows.

There would be a schedule that would reflect the level of funding that the province was committing to for that particular facility, based on the size of the facility, of course, the number of beds in the facility and the requirement of the residents of that facility for nursing and personal care. That schedule would commit a certain amount of funding for nursing and personal care that could only be spent on nursing and personal care; commit an additional amount of funding for quality-of-life programs, things like social work, volunteer coordinators, occupational therapy, physiotherapy and spiritual care, that could only be spent on those things; and thirdly, would commit a certain amount of funding for accommodation services like administration, maintenance, laundry and housekeeping. That's the first schedule that, obviously, would be specific to each facility.

The second schedule would be a staffing schedule that would reflect the agreement of the province and the facility in terms of how many RNAs would be hired, how many RNs, how many health care aides and whether it was a full-time social worker or a half-time volunteer coordinator who would be on the staff of the facility during the year.

This would be in keeping with the third schedule, which would be a description of the program to be delivered to residents; if you like, the program purchased by the province from the facility on behalf of those residents.


That program description would, with respect to nursing and personal care, talk about the ratio of RNs to RNAs to health care aides. It would talk about staff coverage on evenings and weekends and so on and reflect the understanding that the facility and the province had in that regard. It would go on to talk about the quality-of-life programs that would be delivered, and in this particular area it will be important that the agreement reflect the particular cultural or religious environment the home was intending to provide to its residents and also reflect the community that the home was serving -- community in the context of within the facility as well as the community the facility was located in. It's in this area that we would hope to extend a fair bit of flexibility in facilities to tailor those programs and services to meet residents' needs.

To give you an example, the program and services in a rural northern community would be quite different, perhaps, from the programs and services offered in a Metro-area facility, where there are other recreational resources close by and so on: Spiritual care may be a more costly aspect of the programs and services or have a justifiable emphasis in a home that was offering a particular spiritual environment for people. So a mixture of things like social work, physiotherapy, occupational therapy, volunteer coordination and spiritual care and recreation would be noted in that program description as well.

During the consultation process, we heard from two different camps in that regard. Some people recommended that the province be very specific in terms of laying out what types of quality-of-life programs should be available to every resident regardless of which facility they were in and which part of the province. Another body of opinion held that we should be very flexible. I think in the final analysis there would be some basic expectations in terms of perhaps core services like social work or recreation, but some latitude would be provided in terms of how the rest of that budget was spent and how facilities best responded to their own individual and unique characteristics of the residents.

Mrs Sullivan: Let's speak specifically about a resident who is the only person in a home who requires, say, speech pathology. Would the program description in the schedule discuss not only what are the basic elements within that home but also what other services will from time to time be purchased?

Mr Quirt: Yes it would, and there would be a difference in how therapies like speech therapy would be provided. If, for example, a large facility had a large number of people for whom physiotherapy or occupational therapy was an important service, it may well decide to hire its own and show that position on the staffing schedule and use the programming portion of the budget to pay the salary of that person.

In the example you gave, if there was only one resident who required speech therapy, it would probably be most appropriate to contract for the services of a local speech therapist on an hourly basis or to purchase the services of the speech therapist who worked at the hospital down the road.

In some communities, Brockville for example, I know there were discussions going on between the home for the aged and the nursing home across the road on sharing, pooling their resources in that regard, to hire some therapists and have them work in both facilities: One facility would look after the administration, but the staff person would be shared between facilities to make the best use of that position. So that would depend on how many people needed the service.

Quite frankly, in some communities the availability of those types of professional services is going to limit to some extent the ability to which homes can respond in precisely the way they wish. But those options are the kind of thing that would be discussed in negotiating the service agreement, and hopefully our staff would be able to facilitate that type of cooperative usage of scarce professional resources among facilities.

The Chair: I just want to check: Are there other questions others have on this agreement, or does anyone else have --

Mr Hope: Are we questioning or asking for clarification?

The Chair: I think it was to get clarification around the nature of the form that was being used.

Mr Hope: Now we're leading into some type of questioning though, aren't we?

The Chair: To me, this is informative in terms of how that would function. I think Mr Quirt is being very helpful to the committee.

Mr White: With respect, Mr Chairman, we have 11:30 tomorrow free.

The Chair: But if we can bring this to a conclusion now, I think it would help. I just wanted to see if there are any other questioners. If not, Mrs Sullivan, perhaps you could ask a final question.

Mrs Sullivan: I think this is the final one. I think it is useful to find out how these service agreements will work.

Mr Hope: You should read Hansard. Most of it is in there from yesterday, talking about the forms and everything.

The Chair: Mrs Sullivan has the floor.

Mrs Sullivan: Thank you for your intervention.

On the purchase of services with respect to, say, something that would not be an ongoing part of the services normally offered, would that be included in the program description so that in the event a resident required those services, that is a basic part of what must be considered available in that place, or is that something that would be added from time to time? What I'm trying to get at is, where is the flexibility in this schedule?

Mr Quirt: In the program description, it's very likely that there'd be a description of the range or kinds of therapy services that the general population would require. The program description wouldn't list each resident and say, "We expect Mrs Smith is going to need X physiotherapist visits and a couple of visits from a speech therapist." It would talk about a particular amount of the funding for programming earmarked for therapies.

It's conceivable that a resident who didn't need speech therapy one month would the month after. Where that particular service would be described would be in the care plan for that particular resident. Through a multidisciplinary review on a regular basis of the services a particular resident requires, the care team, with the resident's involvement, if at all possible, and the family's involvement, may determine that now speech therapy might be an appropriate service intervention. So at that point in time the staff of the facility would make that arrangement from whatever source was available in the community and have the program component of the budget available to purchase that service for that resident.

The Chair: Thanks very much. I think that has been helpful in making clear some of those arrangements. The committee will now stand adjourned until 10 o'clock tomorrow morning.

The committee adjourned at 1718.