Thursday 4 February 1993

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

Ontario Medical Association

Dr Ted Boadway, director, health policy

Barb LeBlanc, manager, health policy

Carol Jacobson, manager, health policy

Ontario Association for Community Living

John C. Miller, consultant, long term care policy

Ontario Association of Non-Profit Homes and Services for Seniors

Sandra Pitters, president

Michael Klejman, executive director

Dan Oettinger, president-elect

Municipality of Metropolitan Toronto

Norman Gardner, councillor

Joan Barltrop, chair, advisory committee on homes for the aged

Sandra Pitters, assistant general manager, homes for the aged

George Coleman, general manager, homes for the aged

Ontario Nurses' Association

Ina Caissey, president

Carol Helmstadter, government relations officer

Lesley Bell, associate director, government relations

Seppo Nousiainen, research officer

Federation of Provincial Non-Profit Organizations Working with Seniors in Ontario

Bob Morton, president

Dr Gordon Romans, member

Chester Village

Allan Day, vice-chairman, Broadview Foundation

Paul Klamer, administrator


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

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

Drainville, Dennis (Victoria-Haliburton ND)

*Fawcett, Joan M. (Northumberland L)

Martin, Tony (Sault Ste Marie ND)

Mathyssen, Irene (Middlesex ND)

O'Neill, Yvonne (Ottawa-Rideau L)

Owens, Stephen (Scarborough Centre ND)

*White, Drummond (Durham Centre ND)

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

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

Witmer, Elizabeth (Waterloo North/-Nord PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Carter, Jenny (Peterborough ND) for Mrs Mathyssen

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

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

Jamison, Norm (Norfolk ND) for Mr Gary 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

Wiseman, Jim (Durham West/-Ouest ND) for Mr Martin

Clerk / Greffier: Arnott, Douglas

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

The committee met at 1005 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 meeting of the standing committee on social development to order. We're meeting again to review Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: Our first deputation this morning is from the Ontario Medical Association. If you would please take your seats at the table and be good enough to introduce yourselves for Hansard, then proceed. We have a full half-hour, even though we're a tad over 10 o'clock.

Dr Ted Boadway: Thank you very much, Mr Chairman, and thank you for having us today. My name is Ted Boadway. With me are Barb LeBlanc and Carol Jacobson, and we're from the Ontario Medical Association.

You have a brief that we've brought for you today. The brief that we brought follows the format of the legislation, for the ease and convenience of those who would be reading it, but our presentation will not. In our presentation we will hit some highlights, rather than try to do the entire brief, to give you an indication of a couple of the points we think are particularly important that we'd like you to address, if you would.

We'd like to say at the outset that we're pleased we've been part of the process of long-term care reform and have been active in that, and in fact we support this legislation. We think this legislation has the possibility of simplifying access and making a scheme which is more understandable and perhaps fairer, and we think those are all worthy goals which we hope will be achieved through this legislation.

We are going to address some issues in this legislation that are of particular concern to physicians. We think these are relatively minor issues that have come into the legislation which we hope you'll be able to see through with us. But generally speaking, we support the direction of the legislation.

First of all, I'd like to talk about entry to physicians' offices. I realize this isn't an issue in the legislation really at all, it appears, but in fact it is an issue when you look at the legislation and we hope you'll consider it.

The powers of the inspector allow the inspector to have a warrantless entry to physicians' offices, as it turns out, if you read the legislation carefully. We are firmly supportive of the fact that inspectors must be able to see the records -- that's not a problem -- and we're supportive of the fact that physicians must give up the records to appropriate authority -- that's not a problem -- but what is a problem is that in the physicians' offices in the community, and this does extend out into the community, it can be a problem.

It comes in this way: How many people can walk into a doctor's office and wave a piece of paper and get access to medical records? If you take the conscientious, careful family physician in your town, in your community, who would like to do it right, who would like to get it right, who does not like to make mistakes and give inappropriate access but who would like to give access to those with appropriate authority, what he needs is clarity and understanding of how that access will come about.

At the present time, if someone has a properly executed warrant, there's no question that this is appropriate access. We will shortly have a situation where advocates can, without a warrant, go into physicians' offices under the new legislation and see physicians' records as well. Under this legislation we will now have another person who will have a piece of paper that he will be able to come in with and look at physicians' records.

We think this should be clarified. If there is a clear, overriding public purpose in allowing this, it should be so stated and we should make sure everyone understands it. Quite frankly, we think this could be accomplished by using warrants.

It's a problem for physicians in that most of the family doctors in your community will not understand this legislation well -- I think they can be forgiven for that; that's not their business -- and they don't know what we're doing here today. When they don't understand it, and the more people you have that can get access, the more likely there will be a mistake.

There will also be confrontations when physicians will not want to give access to people they don't really understand have appropriate authority. We get questions at the association all the time, rather urgent calls from physicians, because of people seeking authority and they wonder about seeking access and they wonder about their authority.

I'm afraid to tell you that scams in physicians' offices from various people are commonplace -- people trying to seek entry, showing things that aren't real -- and we help doctors sort this out. We would like it to be as clear, as unequivocal as possible so that physicians do not make mistakes.

I think if you look at sort of an industrial model, what you'd like to do is design a system that helps people get it right as opposed to designing a system which introduces any confusion where it's more possible to make a mistake.

The second issue I'd like to address is that of the appeal board. We have a specific question that has to do with subsection 20.4(4). It specifically says, "Not more than one of the appeal board members holding a hearing under this act shall be a physician." We wonder why this specific exclusion. When we look through the papers presented explaining this act, we can't find why this specific exclusion or where it is explained. It seems to be not a useful thing to us.

First of all, one member may be a hearing's sitting -- it only requires one member -- and one member may be a physician, so it appears that one physician can be an appeal board and can make a just and fair determination. However, to get two or more of the varmints together is when the trouble begins.

I really wonder where this is coming from. What is the attitude behind this that gave rise to this? Quite frankly, the wording, as it sits, is deliberately and precisely discriminatory. It is causing needless bitterness and is unnecessary. The appeal boards will sit at the pleasure of the chair. If there is a problem with the membership, I am sure the chairs of those committees will see it is looked after, but to name it so specifically in legislation is not wise, in our opinion. We hope you will see fit to clarify this quickly and remove it.

The next area I'd like to touch on briefly is the hearings: who can be a party to a hearing. We think it should be stated in the legislation that health care providers can be a party to the hearing. Quite frankly, it's unlikely that health care providers will want to be party to the hearings most often, for obvious reasons, but there are times when in a patient's best interests or on behalf of a patient, perhaps the health care provider, being the person who knows the patient best, by being a party to the hearing could be of assistance to the patient and of assistance to the hearing board. We think it should at least be possible for them to apply to the board to become parties to the hearing and it be at the appeal board's discretion rather than having an absolute right.

There are two more issues I'd like to touch on briefly. The first is the words "examinations" and "tests" that occur in the legislation. When I first read this part of the legislation, I must confess I read it differently than it's intended and that's because of my health care background. You read things kind of where you are, and examinations and tests in health care mean you sort of invade people's bodies often, take bits and pieces of them and things like that. On the other hand, in the legal sense, I don't think that's what's meant at all.

Bear in mind that many of the people who will be reading this legislation will be health care providers, and they will come from the same background, bias and vocabulary that I do. So we were wondering if it would be possible to clarify this language. I don't think the intent of this legislation is that inspectors, whoever, can go in and take blood samples or biopsies or perform physical examinations. I do not believe that's what's intended, but I think in the context of health care, clarification could be served.

The Chair: It gets a bit ghoulish.

Dr Boadway: Access to records in physicians' offices, one more time, from a slightly different point of view: We agree that physicians should provide access and probably should provide intelligible records, a challenge for some of us. We only have one request, and that is that it be at a mutually agreeable time. We wonder if it's possible to signify this kind of cooperation in the legislation so that it would be a convenience for all in the future and prevent misunderstandings.

Thank you very much for listening to our presentation, and we'd be prepared to answer questions as you see fit.

The Chair: Thanks very much, both for the presentation and also for a series of, I think, quite specific questions.

I wonder if the parliamentary assistant would want to begin. He was very enlightened yesterday and I wonder whether he feels that same light in terms of responding to some of those questions, or wants to note them for further review.

Mr Paul Wessenger (Simcoe Centre): I think it might be helpful if we perhaps asked counsel to indicate some of the more technical answers with respect to the questions raised, if we might ask legal counsel here today.

The Chair: Fine. We'll just pause for a moment.

Mr Wessenger: On the advice of legal counsel, it's suggested that perhaps we should undertake to provide them with a response, perhaps in writing, to some of their concerns, rather than attempting to do it today.

The Chair: All right. Did you have any questions at this point that you wished to raise? Mr Hope does, but because I started with the parliamentary assistant --

Mr Wessenger: I would just like to make a comment and thank you for your very specific and detailed recommendations with respect to this legislation. It's not often that we get these detailed suggestions for changes and I'd like to thank you for them. Certainly, the issues raised are somewhat interesting from a legal point of view, and I appreciate your having raised them today.

Dr Boadway: Thank you.

Mr Randy R. Hope (Chatham-Kent): There are a couple of areas which I want to touch on, the areas dealing with the warrants. What type of warrant would you be looking for, one that's approved by the crown or justice of the peace in order to access, or what type of warrant would you be looking for to access information?

I understand what you're saying. You've got to be careful that you're not giving out somebody's personal information. I'm wondering about a control mechanism. Do we go to a justice of the peace? What type of document would you be looking for for that access paper?

Ms Barb LeBlanc: We would be considering justice of the peace.

Mr Hope: Justice of the peace. Now, you were making mention about appropriate times to meet with doctors. In rural Ontario I find it very difficult. It's even hard enough to get a doctor's appointment, and I'm wondering, how are we ever going to come up with a compromise to that effect?

Mr Jim Wilson (Simcoe West): You guys have too many doctors. I thought there were too many doctors.

Mr Hope: Forget about the comments that are made over there. How do we actually come up with a compromise? Is there an appropriate time? I know with most, even my own physician, it's usually two weeks before you can get in to see him and stuff like that. What are we looking at as regards appropriate? You're looking for lenience in making accommodation, and I'm saying there has to be at least a maximum.


Dr Boadway: I agree, and I think that would be appropriate. What is not appropriate is that I arrive now and I'd like to do it now. Very often, you'll inconvenience a whole lot of people when you do that, especially if you want a couple of hours --

Mr Hope: That's right.

Dr Boadway: -- so your office will be even worse than it was when you started, for you too. It would be reasonable to consider that it has to be accommodated within so many hours -- I don't know if you said 48 or 72 hours -- so that the doctor couldn't put you off for ever if the doctor was unreasonable. We want both sides to be reasonable here.

Mr Hope: That's right.

Dr Boadway: I think working on something like that would be a fair way to do it.

Mr Hope: I know in other pieces of legislation they specify in certain professional areas that there only be one on appeal boards. I'm wondering why you find that offensive. If I heard you correctly, on the appeal board it says not more than one can be a doctor. I'm just wondering why you find that offensive.

Dr Boadway: It doesn't say not more than one can be a health care provider. It doesn't say not more than one nurse, not more than one lawyer. It doesn't say anybody else. It's physicians in particular, and we have difficulty coping with that.

Mr Hope: So you're saying if we were to maybe broaden the scope, how do we put control mechanisms so it doesn't become -- and I'm speaking from a client perspective; my wife has a grandmother in there and my parents are old enough too. How do we allow that we're not getting locked up in a professional model aspect of a doctor -- nothing against doctors; just how do we make sure we're getting a balance in an appeal process?

Ms LeBlanc: The appeals process is set out under the health appeals that are already in place, and under that it clearly specifies that there be balance between lawyers and physicians as it sits now, but that could certainly be expanded upon.

Mr Hope: I don't know how much time I've got left, but in general what you might be saying is that there has to be, instead of labelling specifically, not more than one profession -- would that be appropriate? -- on an appeals board.

I'm looking for ideas. You're asking us, why did we label it? I don't know the answer why it was labelled specifically, so I'm trying to say, okay, you don't want it labelled that way; what are the alternatives to us? Do you put in the legislation maybe that not more than one specific profession be allowed on the appeals board? How do we phrase it?

Dr Boadway: Remember that the subcommittees or the sitting appeal boards are chosen by the chair of the whole process. It's the chair's responsibility to find balance, and at the present time the chairs do find balance as they strike the appeal boards. I can't imagine that they'll abandon that role, because it's mandated that they do so in the legislation, so I think you can leave it to them; or if you want, you could put in that there be a balance of types of people, if you want professionals, health care professionals and non-health care professionals. You could put that in. You could remandate balance, so to speak. That wouldn't be a bad thing.

I suspect part of the problem comes from the fact that a fair number of people who sit on the appeal board are either doctors or lawyers. I really think you should at least put lawyers in. At least everybody could agree on that one.

Mr Hope: Not me.

Ms LeBlanc: I think, to just add an extra comment there, you have to realize the legislation also specifies that one person alone may constitute a hearing, so you've got to be a little bit careful about how you start to specify who those persons are.

Dr Boadway: And with the number of appeals you're going to have, if you don't have an ability to strike relatively small panels, you will not be able to handle the volume.

Mr Hope: Yes.

Mr Jim Wilson: Thank you, representatives of the OMA for, as usual, an insightful and very useful brief to members of this committee.

I just have a couple of questions; actually, I've quite a few questions. I'm having déjà vu all over again when it comes to inspectors and warrantless entry. I recall, as other members will, the debates we had with this type of material that was contained in the advocacy and consent to treatment legislation and I understand your point very well. You'd probably also like a "reasonable grounds" test, probable and reasonable grounds as a basis for the warrants. We will endeavour to do what we can in my caucus to try to push the government towards that position.

I did want to ask you a bit about the placement coordinators. You made the point, I guess more contained in your written submission than in your oral submission, about who would do the pre-admission assessment. I'm surprised at this point in the process that you wouldn't have an answer from the government on that. It seems very clear to me that it would require a physician and that it should be clearly spelled out in the act. Do you want to elaborate on what you're looking for in that part of the act?

Ms Carol Jacobson: The way the legislation is written, it refers to the eligibility. The eligibility for admission would be done in accordance with the regulations. The concern we have is that we're not sure what those eligibility criteria are. The way it is stated in the legislation right now, the way it is written, it suggests that the placement coordinator is doing the assessment. Whether they'll be utilizing information from the physician is unclear. We wanted to ascertain and to ensure that the impairment data, the impairment status of the individual, would be received and would be available in order to facilitate the placement coordinator's determining eligibility, so we had concern because of the lack of clarity at this moment, the way the legislation is written, as to how the determination would be made.

Dr Boadway: Quite frankly, Mr Wilson, it was difficult for us to know what to recommend. We talked about this a fair bit. We wanted to make a more concrete recommendation, as we did for other things, but because most of this will be handled in the regulations, according to the legislation, it was difficult for us to know what to recommend to be put in the legislation. We can't recommend what goes into the regulations to you folks, so we didn't know what to do and decided to flag it as an issue -- you rightly picked it up; it's in our brief -- and hope that we can work it through as time goes on.

Mr Jim Wilson: I gather you've been involved in the process, the 10 criteria spelled out in the draft manual for eligibility. Did you have any comments there?

Dr Boadway: We believe that the role of the physician is not yet well enough fleshed out. The role of the physician and what he should and should not be expected to do is, we think, important. It may come as a surprise to you, but physicians do not want to be the gatekeepers to this system. There's some idea about that physicians are the gatekeepers, number one, and that somehow they're tenaciously hanging on to this role, number two. We are not the gatekeepers now, and about the last thing we'd like to be is to become that. But at the same time, we think that the role of the physician and the information that he should appropriately supply need to be more carefully defined. We believe it is not yet.

Mr Jim Wilson: You also talk about a reassessment if someone's been on the waiting list for a while.

Ms Jacobson: There is concern with the population that will be dealt with. The condition of elderly people can change very rapidly in a short period of time, so there is even further concern if they are on a waiting list for a period of months and feel that the assessment or the determination of eligibility might have to be reconsidered and that, again, this is not clarified within the legislation as written.

Mr Jim Wilson: Thank you. Your comments make perfect sense. I think I understand the rest of your comments and we'll leave it at that for now.

Mrs Barbara Sullivan (Halton Centre): I have a number of questions to put to you with respect to your presentation, which, once again, is welcome. I think the issue you've raised with respect to access to records is one that the government must consider, having the experience that we all are familiar with from the consent-advocacy legislation. Clearly, the argumentation has been made. The issues are very well known. Recent court decisions have added to those. The entire issue of consent to the records is another issue that has to be included there. We will certainly expect to see some movement and clarification in the legislation with respect to access to records.

There's a double use of the word "records" in the bill, it seems to me. One of them is with respect to access to records by the inspector; the other is access to records by residents' councils and so on. The use of the same word, it seems to me, is also confusing for what I think is an intent that is quite different. I think there is going to have to be some clarification in that area.

I want to ask you, on the placement coordinator issue and the request for admission and so on, have you been consulted in the development of the manual?


Ms LeBlanc: No, assuming we are talking about the large manual that's now --

Mrs Sullivan: Yes.

Ms LeBlanc: We've been asked to comment on the first draft. We were not involved with the development of the manual, and we're pretty much expected to confine our remarks to the medical standards, so at this point we have not had a lot of input into the development.

Mrs Sullivan: Clearly, once again the lack of knowledge that we have as a result of so much of the information being in regulations is problematic for people on this committee and for others and for professionals as well, but as I look at the draft form, which we now have, which is basically the request for admission, the listing of services which have been asked for is very sketchy: List the institutional care received by the applicant, which kinds of professional treatments have been received by the applicant on what frequency.

One of the things that I think would be useful to have clarification of is where in fact the actual medical assessment of the person is taken into account. We see the sections 1, part (a), part (b), part (c), part (d) really affecting the social surround of the person in somewhat less of an effective manner, I think, than a lot of groups want, but where the medical determination fits in in terms of classification, there's got to be that element in the initial assessment of the person so that the placement coordinator has information. I just don't know that these forms -- and I don't see Mr Quirt here today, but perhaps somebody else from the Ministry of Health can talk about how that medical assessment and experience is going to be included in the assessment process. These forms are pretty thin.

Dr Boadway: That is the point we're making, in that we realize that the medical assessment is only one part of the spectrum of things that need to be considered, and in some people's case it would only be a narrow segment; in others it'll be a much larger segment of what needs to be considered. We think it needs to be fairly clearly defined, though, how it will be handled, and we find that lacking at the present time. So our concern is in that regard.

Mrs Sullivan: The other records issue then as well becomes the access to the individual patient record by the placement coordinator, and if the placement coordinator is more than one person, to perhaps an agency. That has to fit into that surround as well.

Could I just have one more question? We've had some discussion with respect to the entire inspection scenario. The quality assurance wording that's used in the bill we suspect is a drafting error, that a quality management program was envisaged. That, however, leads into a different enforcement mechanism. Nursing homes have been using a compliance monitoring system. There has been discussion about whether the legislative wording can be altered to ensure that it isn't a jackboot kind of enforcement but there is peer review and the multidiscipline service approach can be taken into account in that compliance. I wonder, given your experience with change in terms of inspection monitoring, if you'd like to comment on that issue.

Ms Jacobson: We actually did make comment in our submission and talked about the fact that we thought the legislation should be written so that there is flexibility, rather than mandating the methodology that's used, so that the various institutions etc would have the flexibility to ensure that they had ongoing quality improvement activities that were happening rather than having one set method, because, as you say, of the changes that are happening and the ongoing nature of care that is needed. It should be a dynamic process as opposed to just one methodology.

Mr Larry O'Connor (Durham-York): Could I ask one brief question, following Mrs Sullivan's comments, on the medical report?

The Chair: Very brief.

Mr O'Connor: Would you suggest we put something on the application form or something that might make it as easy as possible for the doctor, the physician, to send some recommendations to the placement coordinator? Would it be a form?

Dr Boadway: Yes. I think what we need to do is to look at the specific kind of information that should be requested from physicians. We think physicians are very good at providing impairment information. That's their business. They're good at assessing that and telling you about it. Quite frankly, we're prepared to work on that with people to get that result, but that's the nature: the impairment information that should be transmitted. What needs to be determined is the kinds of impairment information that would be useful to the eligibility determination process, and then we can tell you how we can provide it.

The Chair: I think there have been a number of questions and issues which you have raised and which also have come up in the questioning by all members of the committee. Those, of course, are part of Hansard. We'll be dealing with those, and the parliamentary assistant as well has noted that they'll be responding to you on those. We want to thank you very much for coming before the committee.

Dr Boadway: Thank you, Mr Beer.


The Chair: I now call our next presenters, the representatives from the Ontario Association for Community Living, if you would be good enough to come forward. Welcome to the committee. Would you be good enough to introduce yourself for Hansard, and then please proceed.

Mr John C. Miller: I first of all apologize for being on my own this morning. It was intended that our president, Cheryl Easton, would be here with me this morning, but the government aren't the only people who are reshuffling this week, so we're having to make some adjustments this morning around our lobbying to find out who's who, and we felt that was probably more important.

I think the presentation we want to make has been distributed this morning. Really our intention is to raise four particular issues.

The Chair: Maybe I missed it, but did you introduce yourself?

Mr Miller: I'm sorry; I didn't. My name is John Miller and I'm one of the community living consultants with the Ontario Association for Community Living. I have a specific policy focus on long-term care and the multi-year plan.

The four issues we would like to address at this point, a year after having made our presentation last February to the consultation process -- some of them specifically relate to activity and suggestions contained in Bill 101, and I'll get to those at a later part of the presentation. The others really appear to us to be, at this point in time, questions that we feel there are really no clear answers to. I think this is not necessarily a matter of reiterating the issues that we raised in our first response to the consultation process, in the sense that we feel now that some of the issues that were present then may be now more acute. I will go through them one by one.

On the interministerial activities related to long-term care, I guess our comments would be both positive and negative. One of the things we're encouraged by is the fact that a number of ministries are now actively involved in planning together around possible implementation. One of the comments we would like to make is that possibly that team isn't quite wide enough, and there seems to be an obvious emphasis around the ministries of Health, Community and Social Services and the new long-term care division.

We see the Ministry of Housing being very specifically involved in a lot of the implementation, in particular with reference to recent changes around delinking of residents and the care component of the residential and housing services. We feel that if that linkage and that team planning doesn't take place, what will happen is that policies that relate to the key ministries may not move at the same rate, so that when we come to implementation we may find that we've got some further ahead than others and the changes that need to be made in tandem may not be considered, unless there is a kind of holistic cross-ministry approach to the developing implementation.


The other aspect which we feel is now more critical than it was a year ago is that when we responded to the long-term plan consultation paper, things were different from where they are right now. There are two significant points we'd like to make. One is that the economic climate wasn't quite as acute as it is, but I'll come to that later when we talk about sustainability. The other, more dramatic part of our concern is that community-based services, and especially those that relate to people who have been identified as having developmental handicaps, have been seen traditionally, probably for about 35 years -- and we accept a major part of this responsibility -- as being specialized segregated services in the sense that we have given the community, and maybe other ministries, a clear impression that you have no responsibility, that we will care for those people.

That has dramatically changed. Over the last two years, we have been listening to the people we advocate for and many others in the community. The whole concept of community inclusion and people with developmental handicaps being seen as Ontarians in this context, rather than people with other labels -- we feel is inappropriate and must actually form the basis of probably not just a delinking process for us, but over the next 10 years a possible dismantling process.

A very large amount of the provincial budget, especially the MCSS budget, almost reinforces that. In fact, it's almost an indictment of the whole idea of labelling. When you look at MCSS's budget, out of the big chunk of social assistance, people with developmental handicaps are the only people who are recognized as having a section of that pie. There is no other labelled group in Ontario. We talk about adults, we talk about children, we talk about other people in that MCCS budget, but the only group of people identified by their label are those people with developmental handicaps. It's known as the DH services budget.

We feel that we have to move, and we are moving, away from that process. Our organization's vision and our direction is that people with developmental handicaps have a right to have available what we would refer to as the ordinary resources of the community, and in that respect we see long-term care becoming one of those ordinary resources in its modified form.

I'll move on from the interministerial activities to sustainability, and this is another area we feel is probably now more acute from a couple of points of view. There are a number of current community-based social and health services which are at risk. I think that situation has deteriorated considerably since a year ago. As Mr Beer will remember, a number of us were on the lawn here a few months ago trying to tell the Premier about the effects that other suggested major cuts in social service spending may have on those existing community services.

One of our major concerns is that as we move towards a redirected system of long-term care, there are a couple of things that are absolutely crucial to people. One is that people, as in any other service, can or will become dependent on the services that are currently available or the promise of services that are to be redirected or reallocated. There's a great level of responsibility that says to myself and yourselves that if people are to be dependent upon them, those services must be sustained. I guess we have some very serious concerns about possibilities of major cuts, not just to future services but to the existing services.

We see a possible solution to this, recognizing the real world that we all live in, as being some very solid transitional steps towards that change. In other words, don't let us move into a new system by removing existing systems and leaving people unsupported in the transitional process. In simplified form, that is really what we're saying.

The third point we want to raise is around the question of inclusion of persons with developmental handicaps. The first thing I want to say is that I really do appreciate the support we have had by, in fact, the gentleman just coming in right now and Margaret Marland and a number of other people who have raised a number of times that in the definition of "disability," people with developmental handicaps appear to have been omitted from long-term care.

What I would like to do this morning is clarify our position on that. We are not asking that the label "developmental handicapped" be included in the definition of "disability." What we are saying is that all Ontarians, no matter what their labels, should, based on presenting or self-expressed need, have long-term care available to them.

People with developmental handicaps become old, some of them are physically handicapped in addition, and what we say is, please, let's develop a system at this point in time that doesn't respond to labels but responds to people's needs. In simple terms, that is what we're saying, but we do appreciate the comments that have been made.

I went through the copies of Hansard a few weeks ago looking over the last year or so at the number of points that have been raised about our apparent exclusion. The fact that I am here this morning means that obviously we feel we are included, and we are making that assumption because the people we support we recognize as being Ontarians first, maybe Canadians first.

The last point I want to raise is about person-centred funding and planning. Here again, one of the pieces of Bill 101, part IV, which is the suggested amendments to the Ministry of Community and Social Services Act, we really applaud. Our organization and many others have been pushing for a number of times for a system that does not provide agencies with the money to provide individual services, but in fact can provide people with the money so that they can purchase those services and supports as they deem most appropriate. So we really do applaud that suggestion.

The major point we want to make around this is that there's been a great deal of discussion about community-based services. The buzzwords that seem to be connected with them over the last year have been "portability" and "flexibility." We don't wish to be cynical about that, because in fact we applaud that process. What we're saying is that they must go further than portability and flexibility. They must be self-directed, self-administered where possible, maybe with the addition of the support of an advocate in the case of many of the people we support.

In this person-centred funding, and mainly because it's another part of my professional portfolio, we wish to make comment at this time, as we did a year ago, about the lack of news about where the first nations aspect of long-term care is at. We understood that there was to be some separate discussion and consultation process with the first nations.

The Ontario Association for Community Living over the last two years has made a great deal of progress in attempting to support people of the first nations to provide their own programs within their own context and in their own communities. We feel this person-centred planning approach to the delivery of service responds very favourably to the context in which native people live.

I think the last comment I would like to make, and I'd be very happy to answer questions, is that I guess if we're disappointed about anything, I think we were looking forward to something a bit more than Bill 101 at this point in time. I think what we were really looking for was some suggested legislation that gave the broad brush strokes of what long-term care would look like.

We recognize that the purpose of Bill 101 was to amend some of those acts that need to be brought into line with the new system of delivery of service. That's fine. I guess we're maybe in a little more hurry than others might be in that regard, and we recognize some of the other things that are on the floor of the House that obviously have to take priority, but perhaps we could make that comment and have that registered.

We are looking forward in the next six months to a year to some clear indications about what long-term care will begin to look like and what sort of legislative support it has.

The Chair: Thank you very much for your presentation. We have a number of questions. We'll begin with Mr Jackson.


Mr Cameron Jackson (Burlington South): Thank you for an excellent brief. It's sort of hard to ask you questions about the process when in fact you're on the outside looking in, but there are some ripples -- the fact that you're not included, and without dwelling on the other aspects impacting on differently abled people with community living. The multi-year plan has been abandoned; there's complete uncertainty now about deinstitutionalization which is a parallel policy issue to long-term care. There's no question about that.

But what I'm hearing from my local association and the meetings we've had over the last couple of weeks is that for the current community-based model for community living there is now a door being opened so that members of the disabled community are going to come in and start utilizing those precious few spaces.

You understand what I'm saying, but for the benefit of the committee, the fact that there's been no decision or inclusion of community-living clients -- and now we're starting to see that the few community-based beds out there available, we're being told, should be shared with somebody with muscular dystrophy, multiple sclerosis, or whatever. This has caused shock waves among those associations who read the recent policy changes of the government. I wanted to raise it and I'd like to get some feedback for the Hansard record.

At no point has this been raised yet in the Legislature or in a committee, because this is very recent that the adjustments in the contracts with community living, the group-home-type community-based settings, exist. So it has the potential of a double exclusion. Could you comment about the at-risk of access for a community-living candidate?

Mr Miller: What you've raised is extremely complex. A couple of points I'd like to make in response -- one of the reasons my job includes both the multi-year plan and long-term care in my policy work is because we consider them to be interlinked. The draft plans for multi-year plan 2 have a statement in them that in fact indicates that the success of the plan is contingent upon working together with a long-term care development. That is the only piece of paper I've seen that linkage made, outside of my own organization.

I didn't comment on this, but it's in my brief. One of the parallel concerns we have around long-term care and a multi-year plan is that they were both based on the same assumptions of sustainability, and that was that you can close institutionally based services and move that money to community-based services. I think we have proven, without a shadow of doubt, that those assumptions made five years ago in 1988 when the multi-year plan started, have proved to be somewhat false. I don't mean totally false.

We have now been left with a major problem, as Mr Jackson has indicated. I hope you're not right about the MYP being abandoned, but it is certainly in difficult times. I recognize that. The assumption was made that money would simply flow as people flowed from institutions into the community. That turned out not to be true. Increasing costs of running facilities; to some extent union protectionism of trying to keep people's jobs intact and the facilities that were housing those people; on top of that, the provincial and federal economy -- I hope we've learned something from the multi-year plan that will affect those issues in long-term care.

To get to your last point, there are some aspects of what is happening right now that we support. I think it has to be clearly understood why we support it. For instance, this de-linking of residential care and the care component, we support that process. However, we recognize that again a process of that magnitude -- the implementation in transition from the point we're at right now, which is a very specialized and segregated system already overtaxed. We have people with developmental handicaps who are still on the waiting list for community associations.

If transitional steps aren't made and we simply do open up and we become, maybe the best word is more "generic" in our support, we obviously are concerned about how we weaken the system for the people we specifically advocate for right now. I think that can be done and I think that can be done successfully, but it needs people to sit down and make some very good plans and have slow, incremental successes so that you move from where we're at now to where we --

Mr Jackson: One more brief question, and that has to do with the importance of linking long-term care with, for want of a better expression, the multi-year plan and the philosophy of that. We get many requests from the typical family where there is a child with Down syndrome. The child is now 40 years of age, the parents are 60, and the parents become prime candidates for intervention and care. They're both having difficulty because of all the work involved with caring for a child at home with Down syndrome.

The vision was that we were finally to give some relief and that the community intake would occur in tandem with deinstitutional intake and that we'd provide some relief and some hope. Now we know of some severe cases where the family collapses, you have to hospitalize the two parents, and the state walks into the living room and says, "We've got to put this person in a nursing home."

We know that's what's not going to happen, but what will happen is the question. Therefore it strikes me that we have a large number of Ontario residents, families with a Down syndrome member, for whom it seems almost foolish that we'll have a system in place to go and look at the needs of the parents and not look at the needs -- but if we'd provide the care and integrate the differently abled member of the family, then the need for the heavier care for the parents would be relaxed.

It just seems more economical, more fair, more just and more humane, and yet we're not moving in that direction. We just don't have answer, and I think that's a flaw in this legislation. Would you like to comment?

Mr Miller: Just one short comment on that. One thing that we feel exacerbates the progress with the MYP and the long-term care is the growing concern we have, not only for aging parents of people with handicaps but for aging people with developmental handicaps.

Mr Jackson: Yes.

Mr Miller: At the moment we have no clear messages whether or not responsibility for care and support of those people rests with the multi-year plan or with long-term care.

Mr Jackson: Or just with the state.

Mr Miller: Exactly. It makes it very difficult for us to plan when we don't have those indicators.

Mr Jackson: Exactly. Thank you very much.

Mr Drummond White (Durham Centre): There are a couple of areas which I just wanted to try to touch on. As you know, the minister and the Premier met with the group just before going out on to the lawn and some of us didn't have the opportunity to speak to the group. But I think it was clear from the indication of the Premier and the minister that there is clear support for the multi-year plan and the long-term care as being in conjunction. Now how does it fit and how does it work in the model?

We also know some of the developmentally handicapped have a number of physical problems, so there are avenues which will accommodate. I know in the ministry we've been very supportive in consultation and working with the groups and making sure that positive steps are put forward.

But when I was looking at your presentation, what you very clearly put out was your support for the independence of individuals to choose services. There was a presentation made to us here in this committee, and you know we're hearing all points of view, but one of the groups had made reference that we ought to put provincial standards in place for the care that's going to be provided for the individuals.

I'm wondering as an advocate who is out there supporting developmentally handicapped and also supporting a number of others -- your role probably as a volunteer just expands after that -- do you see provincial standards as being a part of criteria that have to be in place? Doesn't that affect the independence of an individual?

Mr Miller: Off the top of my head, the first thoughts that went through my mind when you raised this was, it would depend on who developed those provincial standards and what they looked like.

One of the things that we are trying to do, and have been doing for some time, is include the people we support in giving us ideas about where things should be. In fact, our organization right now is going through a process where we're rewriting our standards and quality of care and quality assurance stuff right now. We are including very heavily people whom we support in that input.

I'd be very cautious and very nervous about that in the sense that sometimes provincial quality assurance can be meaningful, very insightful and very useful, and sometimes it can be extremely bureaucratic and impersonal. I really don't have a direct answer to that. It would depend what it looked like.


Mr Hope: Right. I just wanted your viewpoints since you're an advocate on behalf of those people. I want to make sure that I'm clear in trying to balance out the arguments that are coming before this committee on how we really draw up standards and how we put in regulations and legislation. But I'm just curious; you've indicated the one true support that I've seen you've brought out. In the legislation, are there other major areas that you find are approved?

Mr Miller: In Bill 101?

Mr Hope: Yes.

Mr Miller: I guess the other parts of Bill 101 don't directly relate to our mandate. The one thing that excited us was the section the Ministry of Community and Social Services changed, because that is something we've been fighting for for a long time. I obviously am optimistically cautious about that because I haven't seen what the proposed regulations and the implementation of that might look like.

But it maximizes for us the use of the Ministry of Community and Social Services Act in what we consider the most appropriate manner in the sense that it has always been considered by us as one of those acts that's got very few limitations to it, and now you've actually removed one more by not having to go through the process that was in the MCSS act before Bill 101 suggested it be changed and the other part removed.

We see the other parts as government's necessary readjustment of the current system to try and get all of this working together, and I really have little comment on the rest of Bill 101 other than the overall one because we hoped it would have a bit more in it than it does.

Mr Hope: Just to put to rest some fear out there that the multi-year plan, if I heard it right, was being abandoned. To my knowledge, it has not been abandoned. As a matter of fact, there are working groups out there trying to establish the phase 2 aspect. That just shows the government's commitment to long-term care.

I have a new minister and I have to wait to talk, but I believe it's the same government policy. I don't believe it will change. It's making sure that we can cover the elements of disability, because not only do we have developmentally handicapped, we also have brain-injured and autistic children. We have a number of disabled categories, but I know the government support is still there and I think that was clearly brought to the association today.

Mr Miller: This discussion isn't around the multi-year plan, but in terms of a comment on that, I recognize Mr Jackson's comment and yours, and I'm not trying to take a middle-of-the-road approach here. It isn't abandoned, because over my dead body and a number of other people's will it be abandoned. However, it is in real trouble, and I think the slowing down of the deinstitutionalization process is largely as a result of two things: the state of the economy and some not particularly good planning in the early stages of the multi-year plan.

I'm not criticizing anybody or any group in particular, but there was a bit of lack of forethought in the early stages. For instance, a lot of the large institutions that are not closed really don't have target dates to close, like Huronia Centre and Rideau Regional; they are some of the very large ones. Muskoka Centre and a few of the others will be closed probably within this year, and that is really important. I don't think it's totally abandoned, but I think it's going to need a lot of support and advocacy to keep it alive.

Mrs Sullivan: I couldn't agree more with your comments with respect to the transition phase and the difficulty of moving from an institutional base where that's appropriate to community-based services when there's a lack of incremental enhancement of the infrastructure for that move.

I want to ask you specifically about Bill 101 and the direct funding; it's provided for disabled in Bill 101. I was disappointed that the minister indicated that even for a pilot project she required legislative change to a different act and that the pilot could not proceed.

We've had some testimony in front of the committee that is strongly in favour of direct funding, not only of people who are from the disabled community but also for seniors, who ought to have the right to choose their own services and the place where they receive them.

I wonder if you could describe for the committee any models that you have seen with respect to direct care. I am frankly disappointed that the pilots did not go ahead. I think there would be many models that would have been useful, and it would be useful for you to describe some of the models with which you have familiarity and how they can be put into place.

Mr Miller: I would say one of the most successful models we have seen is probably special services at home. The process and the manner in which that is undertaken -- something like 8,000 individuals and families in the province of Ontario are now making use of this, and it has almost all of the essential ingredients of a good person-centred, individualized funding approach. It is limited, by and large, to children. But that model and that implementation approach has nearly all of the ingredients of a successful system in it.

Again, one of the concerns we have about that is, how sustainable is that? But it is extremely successful and it answers one particular question, one very specific question, and that is that nearly all of the other services that are not individualized tend to become static. In other words, a person has to almost live where the services are.

The other aspect of it is this, if I can draw the analogy: If we all have vision problems and we all need glasses, we don't all need the same glasses. That tends to oversimplify it, but to me that is sometimes how service delivery is produced. Individualized funding and planning means that the person, maybe with the help of an advocate, can help to develop a plan, cost the plan, find out from whom he or she would like to purchase it and maintain it along those lines. Special services at home is probably the best model I could suggest to you.

Mr Hope: Mr Chairman, before you go on, there was a point brought up about the pilot project again and I thought we clarified that through legal counsel, that the legislation needed to be changed. I just wanted the record --

The Chair: That was raised. I think Ms Sullivan was just simply noting it. We've got that on the record. I don't think we need to go back.

Mr Hope: I just wanted to make sure that we're not --

The Chair: I think there's a difference of opinion and we'll just leave it at that.

I have not often, as Chair, made comments or asked questions, but I wonder if the committee would mind, given that at one point in my life I had a fair bit to do with your association. I was going to just raise the point which you just raised. My experience, in the short time I was minister, was that the program that really did seem to have a tremendous amount of flexibility to it was the special services at home. In those early days when we had started the long-term care process -- and I can say quite openly, I think, with the multi-year plan having, as I think the present government finds, a clear sense of direction -- but there were some problems and I wouldn't want to suggest that everything we did was perfect.

But it was then trying to say, okay, what do we do then with respect to the developmentally handicapped and, as you noted, both the seniors as well as the problems around senior parents of no longer children but perhaps developmentally handicapped who were in their 30s or 40s, and so in particular a lot of specific services where the family could then, in effect, direct and define the nature of care?

My comment, if you would care to comment on it, is that it seemed to me that in some ways it didn't matter so much, from the point of view of the developmentally handicapped or their families necessarily, whether that ended up being under long-term care or the multi-year plan; the problem was often getting left out in terms of the planning or the thinking on the long-term care side, or with respect to the multi-year plan, the issue around sustainability: Was it really going to be able to go forward?


I think my question, then, would be this: I take it that what you would like to see is some specific reference within the long-term care, whether it's Bill 101 or in the plan, to particular needs and concerns that the developmentally handicapped have, while at the same time ensuring that the multi-year plan continues to go forward. Is that a fair assessment?

Mr Miller: I think from our perspective -- I hope to answer your question -- one of the things that concerns us is that major initiatives like long-term care and multi-year plan and other major initiatives tend to stand alone very often and identify a particular group of Ontarians, who might be a homogeneous group, that they are aiming at. What we're looking at is that most of the services that we are suggesting come together in the planning of this initiative, long-term care and the things that affect it, go across the whole spectrum of social and health services, which really does cover most of the aspects of a person's life with the exception of education.

The issue that you've raised is one that we really don't have a clear handle on, and that is the issue of an aging population. This is not just a demographic issue; it's an issue for our organization. People with developmental handicaps are living longer because we know how to care for them better, and we have many people with developmental handicaps who are seniors. That is a new issue because hitherto most of the people were institutionalized and remained so until they died. They weren't part of the community responsibility. Now they are and we hope they will become more so.

But the point of the aging parent or the parent of an aging person or a middle-aged person, developmentally handicapped -- we don't want to differentiate. We say they are both people, they are both Ontarians, and we would like to plan around people or with people in the context of that family. In other words, don't let's take the aging couple on the one hand and say, "What you need is long-term care," and the aging son or daughter and say, "What you need is something else." It has to be done in the context of the family. That's where individualized and person-centred planning can give us the right clues. What is it that this family really needs and how could we best respond to it?

The Chair: Thank you very much for the presentation. I think the issue is clearly before us.

Mr Miller: I really appreciate the opportunity. Thank you.


The Chair: I now call on our next delegation, the representatives from the Ontario Association of Non-Profit Homes and Services for Seniors, if you would be good enough to come forward and take a chair, a glass of water -- as the morning wears on, you may feel you need that. Once you're settled, would you be good enough to tell us who you are.

Ms Sandra Pitters: We're very pleased to have this opportunity to appear before you to speak about Bill 101. I'm Sandra Pitters, president of the Ontario Association of Non-Profit Homes and Services for Seniors. In addition to my volunteer role as president of OANHSS, I'm employed as assistant general manager of the homes for the aged division in Metropolitan Toronto.

Michael Klejman is executive director of OANHSS. Dan Oettinger is president-elect of OANHSS and the administrator of Idlewyld Manor, a charitable home for the aged in Hamilton, Ontario. We have another director with us today, Doug Hutton, at the back of the room, from Lambton county, and other members of our association. I think this is indicative of the importance that we give to Bill 101.

In addition to the brief that we have presented to you, we'd like to take a few minutes to convey some more specific views on the bill and its implication that we see to both consumers and our members. Michael and I will be sharing the presentation.

Mr Michael Klejman: The Ontario Association of Non-Profit Homes and Services for Seniors is the oldest provincial long-term care association in Canada. For the last 73 years we have represented and supported non-profit providers of services for seniors. Our membership and focus of our activities in the past three decades is like a microcosm of evolution of services for seniors in Ontario. In the very beginnings all of our members were facilities caring for seniors. Today our members provide a wide variety of services, from long-term care beds to seniors' apartments to day programs to emergency response services and other services reaching out to seniors living independently. Nearly 250 non-profit member agencies and municipal departments serve well over 100,000 seniors, or about 10% of Ontario's elderly. Our record of innovative and consumer-sensitive services is second to none.

We have brought with us and distributed to members of the committee our formal brief, which consists of an analysis of Bill 101 in light of the principles for redirection as announced by the government. It also includes appendices which contain specific amendments we submit for the committee's consideration, a copy of an OANHSS report on revenue sources and a copy of our most recent annual report.

We, as an association, and many of our members find ourselves in a real bind in speaking with you today. While we remain committed and supportive of the intent and the principles of the redirection effort, we find it impossible to support a number of provisions in the proposed bill. We find incongruity between the government's principles for redirection and much of this bill. This bill is also incongruent with the government's and ministers' past commitments to fund care to the level of need, and we find much of this bill's content to be so non-specific that it makes it almost impossible to know how the system will work.

Ms Pitters: Although our written brief is much more detailed, we'd like to spend a few moments highlighting several implications of Bill 101 which cause us concern. We hope that this overview will lay a foundation for dialogue with the committee at the end of our presentation. We do see several negative implications of Bill 101 in the areas of consumer choice, funding, community accountability and quality.

First I'd like to address consumer choice. Although the discussion paper on the redirection of long-term care valued the primacy of the individual and the right to dignity, security and self-determination, we don't see evidence of this in Bill 101. Bill 101 reduces consumer choice and reduces the control that consumers have over making decisions that affect their own lives.

We believe that consumer choice is reduced in a number of areas: related to access; related to the right for them to decide where to live; related to the right to reside with a spouse when one partner meets the rigid eligibility criteria and the other doesn't; related to the right to reside in a home that can provide services that are ethnoculturally, religiously and linguistically sensitive; related to the right to negotiate the purchase of goods and services which the consumer himself desires; and related to the right to appeal decisions on a number of issues.

Looking specifically at access, the unilateral power vested in the placement coordinator allows this placement coordinator to act independently of both the consumer and the home. Consumers must retain the right to choose the type and provider of care. They must be able to choose options, based on their individual needs, preferences and financial resources.

We believe that many consumers, having weighed their options, would prefer to reside in a non-profit facility. They're aware of the broad scope and range of programs that non-profit facilities provide and they're aware of the strong emphasis we have on a multidisciplinary approach to care and service. Many would prefer to reside in a home with a certain ethno-specific or religious sponsorship because they know that home has a unique understanding of their needs. Bill 101 provides no guarantees in the area of consumer choice and self-determination and therefore we believe is fundamentally flawed.


Second, funding: The funding proposed for long-term care is not driven by consumer need but rather by the funds currently available. Disregarding current financial constraints, we are about to create a funding system which will not serve consumers well and which will not allow us to equate care needs and funding. I understand that when the previous Minister of Health addressed this committee on February 1 she reaffirmed the government's goal to achieve needs-based funding. Bill 101 does not achieve that goal.

The proposed funding formula also shifts significant dollars from the non-profit sector to the for-profit sector, in spite of the government's stated preference for non-profit service provision. In addition, the burden for financing the new system falls heavily on consumers. Many consumers will see a significant increase in user fees.

We have several concerns. First, residents and their families have not been notified of this plan, and we find it incredible that this bill has been referred to your committee without giving you the opportunity to hear an informed reaction from the consumers most affected by it. Second, we believe that the government has significantly overestimated new revenue expected from increased user fees.

We urge you to recommend to government that additional dollars be infused into the long-term care facility system as a priority in order to achieve the stated goal.

Next, accountability: We understand the dilemma faced by government in trying to draft legislation to ensure that all participants of the long-term care facility system are fully accountable, but what seems to have been forgotten in Bill 101 is that community accountability already exists in municipal and charitable homes for the aged, through their municipal councils and boards of directors. Instead of building on and strengthening this current system of community accountability, Bill 101 undermines and ignores it.

Last, the impact on quality of care: Bill 101's well-intentioned but overzealous effort to ensure quality in long-term care facilities misses the mark. The bill addresses provincial controls and penalties rather than quality and may actually act as a disincentive to ensuring and managing quality.

The bureaucratic inspection system proposed will be a costly one, and those dollars would be better used to increase funding for direct care and service. Consumers in non-profit facilities would be better served by a provincial commitment to collaborate with municipal councils and charitable organizations' boards of directors to develop quality indicators, to agree on a process which supports rather than undermines these representatives in ensuring quality, and to agree on the level of funding necessary to support and sustain quality. Given these three criteria, non-profit boards can manage their own quality and can provide the government with the reassurances desired that facilities have achieved the quality indicators.

Last, it's worth pointing out that Bill 101 demands service that the government is not prepared to fund. This incongruence needs to be corrected, but most importantly, if consumers are going to have a quality system, we need to work in partnership to determine what quality is and to determine the funds necessary to sustain it.

I can assure you, if the province commits to funding to meet the actual costs of providing care, non-profit providers can commit to meeting all the province's service demands and to meeting consumers' expectations for quality. We can do it through effective local governance and because of our commitment to our communities.

We urge the government to closely consider these implications of Bill 101 and take steps to realign the bill more closely with the previously stated principles of redirection.

Mr Klejman: We see the provisions within this bill as giving the government unprecedented controls over facilities, the scope of which we have not previously seen in the government's dealings with non-profit transfer payment agencies. Conversely, we think that we have enjoyed a relationship of mutual respect and mutual support. Bill 101 is threatening to eliminate that spirit of collaboration.

The provisions give almost unchallengeable power to provincial inspectors, but they do not place any responsibility or burden on the government to provide adequate resources to meet its expectations. Because of this failure to tie performance requirements to resources, this bill will, if passed unchanged, deny consumers an option of care which, for some, would be the best choice. In addition, the quality of care for those few who will get into facilities will be inadequate. The seniors of Ontario deserve better.

Seniors and their needs must be the focus of the new long-term care system. The new system must build on the strengths of the current system and must accommodate the system of community accountability unique to the non-profit sector. As the former Minister of Health said this week, this bill is a once-in-a-lifetime opportunity to get it right. We want to make sure that in getting it right we don't lose sight of the underlying principles of the redirection. If, on the other hand, the intent of this bill is to give the government total control over facility services and the ability to restrict the funding, then this is the bill to do it.

We hope, Mr Chairman, that you and your committee will seriously consider the real implications of Bill 101 and recommend amendments to the Legislature in order to ensure that seniors of Ontario get a system that is based on principles and is sensitive to their needs.

This ends our formal remarks. We'd be pleased to answer any questions.

The Chair: Thank you very much for the presentation and also for the additional material you've provided to the committee members. That will be very helpful. We'll begin the questioning with Mrs Sullivan.

Mrs Sullivan: This is a very useful package of information you've provided to us. I think we will all find the appended material of value as we go through this process.

Like yourselves, we find ourselves a bit at a loss in that we have an implementation bill without having the full policy surround. In the course of dealing with this bill, we see extraordinary authority and power placed in the hands of the placement coordinator and, as you have pointed out, little choice left with the consumer, the potential resident of a facility. We have raised that. The ministry has indicated that this is not the policy intent. So we are going to certainly be insisting on changes to ensure that consumer preference and choice is included in the wording of the legislation itself, that this is a parameter around which the placement coordinator must work. We have had poignant presentations from representatives from the non-profit and profit sector with respect to that point and a very poignant one yesterday afternoon from the multicultural organization of non-profit homes.

I think that in that circumstance you will find general agreement around the table, perhaps even with the government, and we're hoping that we're going to see some words that will allay some of the concerns that have been put.

The funding issue that you've raised is one of some concern to us, because your analysis -- and I am pleased to see that you have attached a paper with respect to the revenue sources -- would indicate that of the $150 million the government expects in revenue from residents themselves the government will receive only two fifths of its potential revenue or the revenue that it has analysed.

Yesterday we spoke in committee about this issue and asked the ministry for an analysis of your analysis, first of all. Second, we were also informed that for those homes which were substantially out of line in terms of funding when the weighting comes in, there will be a freeze. There has been no decision made about an economic adjustment. And that freeze will go in perpetuity until everybody's equal.

I'd like to ask you how you see that affecting your membership. Clearly, there is a policy shift here. My party accepts, and in fact encourages, the move to level-of-care funding. We are seeing parts of the system, though, that believe they will suffer in terms of care delivery. I'd like you to discuss that.


Mr Klejman: Just a couple of quick comments, then just to go back to your earlier remark with respect to placement coordination. We also believe there was a need for a function that ensures that the consumer applicants are treated fairly and there is an effort to identify those with the greatest need. However, how it's translated in the bill is where we have problems.

Looking more specifically at the impact of the funding provisions, there's no doubt in our minds that some of our members and the residents in the facilities those members operate will suffer, not on the first day when the freeze is imposed, but when we look at the effect of the freeze in six months or 12 months, there is no doubt that the costs, whether they are salaries, whether they are operating costs, the cost of buying food, will not freeze. Those costs will continue to increase and those members, whether municipal homes or charitable homes, will have to decide whether they can now come up with additional 100% dollars to sustain -- not increase but just sustain -- the level of service they provide. In many cases they will not be able to sustain it so we will experience reductions in services. Some homes may be contemplating some other kinds of changes.

Mrs Sullivan: Can you describe for the committee why there is a substantial difference in the operating costs of your facilities? We were told yesterday, by example, that nursing homes average $77, charitable homes $90, municipal homes $118, and some homes, I think in the charitable category, are at $150.

Mr Klejman: Some of it is certainly based and rooted in how the legislation has established the two systems. We have one type of funding, one type of provision for nursing homes in this province, whether they are for-profit or not-for-profit, and then we have two other pieces of legislation going back much further in Ontario's history which established the foundation for funding for municipal and charitable homes for the aged.

What those two pieces of legislation, in effect, provided for was the flexibility for each organization, each home, to determine the level of care they would provide, the services they could offer and then negotiate, on a home-by-home basis, with the province, with the ministry, the levels of funding that they would receive from the province and the level of their own contribution that they would make.

What is really misleading is to assume that every municipal home is operating at $118 or that every charitable home is operating at $90. They do not. They're as different from each other as they are from nursing homes. It simply is the result of the kind of funding that was introduced when the Nursing Homes Act was passed and the extended care program was introduced.

But what we're contending is, let's not destroy the best of what the non-profit sector has today by simply pursuing, almost blindly, the goal of uniform funding, and we agree with the need for uniform funding and we agree with the need for funding that recognizes the levels of need existing in those facilities.

On the other hand, let's not start to dismantle the kinds of services that all of us talk about and admire and wish that every other facility had.

Ms Pitters: If I might add to that also, focusing a little bit on the difference between nursing homes and homes for the aged, and I think that has a lot to do with the mandate and the importance and the strength that we see in our local governments, we have been in the fortunate position that we have a very strong history of believing in a multidisciplinary approach and a real vision of long-term care that doesn't just meet nursing or medical needs but rather meets the social, emotional, psychological and spiritual needs of residents in facilities.

So I think we've tended to have a very broad-brush approach and probably a more comprehensive approach to what is needed to sustain quality of life for residents in long-term care facilities. I think you cannot just compare costs facility by facility, but you need to look at the quality and scope of services that are coming out of each of those facilities. That, I think, is a strength in non-profit service provision, as Michael has pointed out, that we don't want to lose with the implementation of Bill 101.

Mr Dan Oettinger: If I might add just briefly to that, Michael's reference to the legislation is also impacted by the fact that the Ministry of Community and Social Services has discretionary authority to approve or not approve extended care services for certain residents regardless of the level of documented need for care.

Where those approvals are not given, there may be significant reduction in revenue and that shows up simply in per diem costs.

The Chair: Mr Wilson.

Mr Jim Wilson: Thank you, Mr Chairman. May I begin by talking about my colleagues and congratulating them on a very thorough and well-presented brief. I particularly appreciate the background material you provided. I've just read through the revenue document and it contains many things that I was frankly quite unclear on, so it's indeed very useful. I've met with the non-profit homes in my riding. They have brought some of these points to my attention.

I also appreciate the comments in your brief about consumer choice, increased government intervention in the operation of your homes, and I want to touch on, before I get to funding -- on page 6 in the written brief you talk very briefly about accountability. Being a great believer in the county system of governance that we have in rural Ontario and knowing of the good works of the county government and its excellent relationship with our non-profit homes, I want you to just expand on what dangers you see in Bill 101 with respect to that accountability process we now have.

Ms Pitters: I'll start and then ask either of my colleagues to add. Fundamentally, there is so much control given to the province in this bill that the ability of municipal or charitable homes to establish their own mandate, to develop their own care and service programs and indeed to monitor and improve the quality of those services is eroded.

It goes right back to the establishment of a rigid placement coordination function, which Michael has already addressed, and which we believe needs to be flexible and built on the needs of each individual community and built on the strengths of the existing community resources. If that function is built in such a way that it ignores the mandate, the resources and the skills of individual homes and indeed the mandate that was established by municipal council and charitable organizations' boards of directors, we're getting to the fundamental issue of who is actually governing the facility. Is it the board or, quite bluntly, is it the province?

Looking at the issue of quality, and we address that also in our brief, we believe that many of our members already have established systems of quality management that they are managing well, and the system being proposed not only erodes their authority but puts in a different layer of bureaucracy that is not necessary to sustain quality in the non-profit sector.

Mr Jim Wilson: Thank you. I very much appreciate those comments. With regard to the revenue sources document, do you still maintain that the finance intake of the copayments to the government will be $60 million, which is far short of $150 million the government intends?

Mr Klejman: Yes. We have not heard back from government officials whom we've been communicating with and conveying this to for quite some time. We have not been shown that there was an error in our calculations.

Mr Jim Wilson: What we're presented in this bill, of course, is necessarily levels-of-care funding but not necessarily levels-of-care funding --

The Chair: To coin a phrase.

Mr Jim Wilson: -- to coin a phrase, yes -- because of the limited pool of money that's been committed by the government. Have you any idea how much money might actually be required if we're not to have an erosion of services and move towards levels-of-care funding?

Mr Klejman: Off the top of my head, I'd probably be guessing, but I know that we have done some estimates of the shortfall for our own members, looking at their current operating levels. We could provide it to the committee fairly quickly.

Mr Jim Wilson: I think that would be very useful because we haven't, of course, seen a true justification of the $206 million that's been committed by the government -- as far as I think committee members would know, the figures were pulled out of the air -- as we've not seen a justification of the total $647 million commitment to long-term care reform.

With that, I thank you for your comments.

The Chair: Just before passing to Mr Jackson, Ms Sullivan, you just wanted one short question.

Mrs Sullivan: To be fair, I think the intervention that we had from Mr Quirt yesterday afternoon was very valuable in terms of discussing the schedule to the standard agreement and how the scope and cultural sensitivity of each individual home would be taken into account in terms of its agreement with the ministry. I think that was very valuable. It's something we wouldn't have seen without that testimony because of the way the legislation is drafted; everything is unseen in it, frankly. But I thought that was useful and when Hansard is available you might want to look at that particular discussion.


The Chair: Hansards are always important.

Mr Jackson: Has the government shared with you the service agreement, the contracts? Have you had a look at them? Are you familiar with them?

Ms Pitters: We did have the opportunity to see the service agreement in draft form in draft 1 of the long-term care service and programs manual, yes.

Mr Jackson: How long ago was that?

Ms Pitters: Draft 1 was finished in August but it was still the draft the provincial staff were working with as late as January. We have not seen a revised version of it, no.

Mr Jackson: Very quickly, isn't one of the more unique features of homes for the aged that they do have access to municipal funding? Could you comment -- because I know we certainly did -- about that distinction and the opportunity to meet your care levels by increasing the property tax base, by turning to the property tax base? That makes you unique since the nursing home sector in certain non-profit homes for the aged don't have that access, whereas the homes for the aged, municipally run, do have that option and I think that shouldn't escape -- the obvious shouldn't be escaped here because it does have implications for your meeting those service levels. What are your thoughts on that?

Ms Pitters: You are quite correct that indeed, in non-profit facilities operated by municipalities or charitable organizations, the governing body of those facilities has the option of infusing 100% dedicated dollars to bring those services at a higher level of quality than the provincial government is able or willing to fund. However, there needs to be a point where, I believe, municipalities need to look at what is a realistic tax burden to pass on to municipal taxpayers, also when health services and long-term care services are a function of the provincial government.

Mr Jackson: Mr Chairman, are we hearing from AMO? Is AMO making a presentation?

The Chair: Yes, I believe they are.

Mr Jackson: And we will be talking to the Metropolitan Toronto community services department and Norm Gardner this afternoon, so we can raise some additional questions there. But I clearly think that's part of the government's plan in a period of disentanglement. It seems we're about to wrap ourselves up in it again.

Mr Klejman: Just as a point of interest for the committee, we estimated that about $90 million is contributed by municipalities towards homes for the aged, and that figure's about a year old. Somewhere between $15 million and $20 million is put up by charitable homes towards their operations as well as over and above the consumer contribution and the provincial share, so there's a fair chunk of money already committed.

Mr Jackson: Thank you very much, Mr Chairman.

The Chair: I may have misled you. I'm not sure AMO is on the list, so we'll just doublecheck. I thought I had seen them but I'll let you know this afternoon.

Mr Jackson: To be proactive, as a suggestion, that they be contacted -- I certainly hope that since there are disentanglement discussions under way, I'd like to make sure AMO is aware of the legislation and is offering some comment, because it does impact.

The Chair: We'll doublecheck. I did think they were. We'll go on then. I have --

Mr Hope: Before you move on with the questions, I just want some clarification here. Mr Jackson, I believe, is asking AMO to come before the committee, or just to make written comment on the legislation.

Mr Jackson: Either one. If there's an opening, we can either sit here or --

Mr Hope: Okay, forget it, there is no sense breaking into a conversation with him because there is no sense listening to him.

Mr Jackson: Well, the committee can direct itself any way it wishes, Mr Hope. I wanted, first of all, to find out if they were making presentation and then if we could get written or oral presentation, but --

The Chair: Thank you, understood.

Mr White: Again I'll defer to my colleague Mr O'Connor, but I do have some questions later on I would like to address.

Mr O'Connor: I want to thank OANHSS for coming. Indeed, your package is very comprehensive. I noticed you have some suggested recommendations to the legislation that no doubt our legal people within the ministry are certainly going to have a good look at.

You've raised a number of different and some new issues and some issues that have been raised before: inspections, no resources will be added. It's important to talk about this. I guess what I'd like to suggest is that the quality management system -- and there are some problems around the wording of it that the committee has had -- isn't meant to totally eliminate the system we've got now but to improve it, support it and enhance it and perhaps put in some accountability that doesn't exist now or maybe improve that.

The boards and the municipalities, I realize you've got some concern over them. It's the intention that they will continue to have a major role in homes for the aged and charitable homes. I know Mr Wilson had raised some concerns about the funding, and of course in your presentation you've included some comments. Maybe we can get someone from the ministry to come forward just before lunch, after this presentation's left, to get some further clarification, because again this discrepancy has shown itself.

Just one short question, and then I'll defer it. You have suggested ways of possibly putting into the legislation a way of taking a look at the cultural aspect of the clients, the consumers we're trying to service. I appreciate that. In the draft manual that was circulated and that you've commented on, I know in the admission form there's one line talking about cultural sensitivities, and ethnic.

What would you suggest that we put in there to improve that if, for some reason, we can't get that into the legislation? I'm sure legal counsel will talk to us and we'll have a full discussion on that, but if that's not possible -- because we can't put everything into the legislation -- what would you suggest we put into that admission form?

Mr Klejman: I'd just take a stab in the dark a bit. We sometimes talk to our legal counsel too, and the suggestion that you have in there we've actually looked at from a little more legal perspective. The preference would be to see references to it first of all in the act itself, eventually, or as part of the bill now, or in the regulations, where it enshrines in a more formal way that this is an aspect that has to be considered during the placement determination process, rather than leaving it just to a manual or a portion of the manual.

Ms Pitters: If I might add, we did have an opportunity as an association to participate in the joint working committee that looked at draft 1 of the manual.

Mr O'Connor: The second draft probably won't be ready for a few weeks yet anyway.

Ms Pitters: We did at that point submit alternative language, so that we hoped that language would be incorporated to assist with issues such as spousal admissions, social admissions and admissions where the consumer has a specific preference related to ethnocultural and religious needs. We'd be more than able to share that language with you. We do hope it will appear in draft 2 of the manual.

Mr O'Connor: Thank you very much.

Mr White: I should admit from the outset my bias. I've worked for many years in a home for the aged. Although I was not employed by that home, I was the only person working there in that unique position. I've seen the high quality of care that was available to seniors from my community, the intense level of interaction between the community at the volunteer level, at the municipal level etc, the high level of accountability. In fact, during an accreditation process, something which I thought people would find to be a really adverse situation, the workers from the floor level up were excited and participating in it, because they had a direction, which was the improvement of quality of care to their residents.

The issue about accountability, which I think you bring up, is a very significant one, very real. It will be a costly inspection service. Frankly, I don't think there will be a need for any real change in terms of inspections of homes for the aged, but there will be in other areas. Effectively, what we would have is the same model applied for two different systems. Of course, the non-profit system will be subsidizing the for-profit system, because you won't need inspections; you've already got the quality of care worked out. How would you suggest that the accountability issue be dealt with in legislation?

Ms Pitters: If I might start and then turn it over to Michael, first off, to focus on your comment about accreditation, our members do see that as a much more positive and helpful process in assisting them to maintain quality services in their home. The approach has an entirely different focus; that is, to work in collaboration with the facility to act as a resource to identify areas that may need strengthening but to allow the facility to identify its own actions and allow it to implement the action to improve the quality in that area. It's a very mutually supportive process and one that is developed with a quality thrust and looking at what is best for health care in Canada and, quite frankly, developed by peers and professionals in the field.

Our fear is that the inspection system that is being introduced is going to look at a more punitive approach. We have had a chance to look at the indicators, to look at the draft inspection tools, and we don't believe they're the right tools to assist facilities to sustain and improve their quality.

We mentioned in our verbal presentation that we would like the opportunity to continue to work with provincial staff to develop more appropriate quality indicators and ones that are going to result in a better outcome for residents. We're not fully convinced that the tools put forward in the program manual are the ones that are going to do that.

Mr White: Fair enough. I'm wondering, though, what you would suggest to deal with the broad spectrum of long-term care. What kind of mechanism would meet your needs in your situation and others?

Mr Klejman: The suggestions we have made in the brief itself and in some of the amendments identify specifically provisions whereby the relationship of the province in its inspection role ties into the board of directors or committee of management, that there is that focus for accountability now. Let's ensure that it is clear what is expected of it vis-à-vis its relationship with the government, but they should be able to maintain the scrutiny and the systems that they need to have in place in their individual homes.

How one translates this principle into settings which do not have boards of directors onsite in their local communities, do not have municipal council committees onsite in their communities overseeing operation of homes for the aged, frankly we feel a little stymied in knowing how to recommend how you distinguish between that for-profit operation which has that distance between a corporate structure and an individual nursing home in a community, and a home for the aged, where the owners, the operators, are the community in which these homes operate.

But we read that as the obstacle that the government is facing throughout the bill: How do you create one legislative means to ensure a high quality of service -- care -- in all of the homes in this province? There are some homes that just don't mix well in the same legislative pot.

The Chair: Thank you very much for your presentation. As I said before, we really appreciate all the attendant material. I believe we may see at least one of you later today.

Ms Pitters: Thank you, Mr Chair.

The Chair: Everybody wears a number of hats.

That brings to a conclusion our morning sitting. I will adjourn the meeting. We reconvene at 2 o'clock. If I could just remind members of the subcommittee, a brief meeting here around scheduling, the committee stands adjourned.

The committee recessed at 1154.


The committee resumed at 1403.

The Chair: The meeting of the standing committee on social development will reconvene. We're here to consider Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: Our first deputation this afternoon will be representatives from the Metropolitan Toronto community services department. We invite you to come forward and make your presentation. Would you be good enough to introduce yourselves. I suspect some of you have been here before, even as recently as this morning. We're delighted that you could come. As I say, would you introduce yourself for Hansard and then please proceed with your presentation. We have a copy.

Mr Norman Gardner: I'm Councillor Norman Gardner and I'm chairman of the community services and housing committee at Metropolitan Toronto. With me here today are Ms Sandra Pitters, who is the assistant general manager of the homes for the aged division, Mr George A. Coleman, general manager of the homes for the aged, and Mrs Joan Barltrop, chairperson of the advisory committee on homes for the aged.

I'm pleased that we are here today to address the standing committee on social development on behalf of the municipality of Metropolitan Toronto and to share with the committee some of our observations and concerns about Bill 101.

Metro has been in the business of long-term care since its inception in 1953. We operate nine homes for the aged, a large satellite home program and a large number of community support programs. We are the largest provider of long-term care services in the province, operating close to 3,200 beds and providing services on an annual basis to over 25,000 consumers living in the community.

Metro contributes approximately $31 million annually to the provision of long-term care services and we are currently covering provincial shortfalls because of the province's prior decision related to capping.

We have seen a lot of changes in long-term care over the past 30 years and we have continued to improve and expand our care and service delivery because we have a strong commitment to community services. But this commitment is threatened by Bill 101. Bill 101 significantly reduces consumer choice, erodes municipal accountability, threatens our current community partnerships and shifts a greater funding responsibility to the municipality.

In spite of these concerns, Metro shares many of the province's own goals with respect to the future of long-term care services and we want to see Ontario's system of long-term care improved. However, there are many strengths in the current system which need to be preserved within the redirected system. We believe that a responsive and effective long-term care system is one that is flexible and adapts to the varying and changing needs of seniors.

Metro has an excellent history in providing high-quality services to a diverse population. We have developed strong partnerships with ethno-specific groups and have been able to deliver services that are ethnoculturally and religiously sensitive. Bill 101 restricts the current freedom of seniors to select care and service in a site that is understanding of their ethnocultural, linguistic and religious needs.

I can assure that Metro shares the province's commitment to the four principles outlined in the discussion paper on the Redirection of Long-Term Care and Support Services in Ontario: the primacy of the individual and the right to dignity, security and self-determination; promotion of racial equity and respect for cultural diversity; importance of family and community; and equitable access to appropriate services.

However, in developing the specifics of redirection, the province focused so much on ensuring equitable access that it lost sight of the first three principles. The result is that Bill 101 is fundamentally flawed and doesn't sufficiently protect the rights of individuals. We will be proposing some amendments that we believe will align the bill more closely to the intent of the original discussion paper.

We also think there is a need for a fifth principle focusing on quality of care and service provision. The government has to make a commitment to quality and be willing to work with its partners -- the municipalities, other care and service providers and consumers -- in order to achieve it. Bill 101 emphasizes provincial control, rules and regulations rather than quality.

At the outset, I must advise the committee that we found it difficult to respond to Bill 101. The bill leaves so much to regulations that the actual intent and impact of the bill cannot be accurately analysed. I hope Metro will be given another opportunity to provide input once the regulations themselves have been developed.

I'd now like to provide some specific observations about Bill 101 as it relates to the four principles.

First, the primacy of the individual and the right to dignity, security and self-determination: The need for consumer choice is not recognized in Bill 101. The unilateral power vested in the placement coordinator does not respect consumer choice and allows the placement coordinator to act independently of both the consumer and the home.

Consumer choice is forgotten in other areas too. Bill 101 limits the frequency with which applications may be made. This provision is wrong. Changes in the consumer's situation and health status are unpredictable and they shouldn't be denied the right to apply whenever such a change occurs.

Many other sections of Bill 101 also weaken consumer choice. Our concerns are clearly detailed in our written brief. An example could be someone who is turned down, breaks a leg, is now admissible but cannot reapply because of a time frame limiting his particular application.

Bill 101 defines a faulty and incomplete appeal process. There need to be expanded provisions for appeal to cover a number of circumstances. I'd like to point out to the committee that Metro currently has an appeal process which far exceeds the provisions suggested in Bill 101.


Second, the promotion of racial equality and respect for cultural diversity: I've already talked about our partnerships with various ethnocultural and religious communities. It is our opinion that people choose our homes because we take into account people's different values, languages, religions and customs. Through our work with community agencies, we have developed a unique understanding of the cultural needs of their constituencies. We don't want the redirected system to restrict the community partnerships that Metro has been able to create.

I'd like to distribute -- I think you already have it -- copies of a letter sent to Premier Rae from Esto Link, one of a number of groups we collaborate with.

Third, the importance of family and community: Metro could not agree more about the importance of family and community. We have strong concern that the consumers most directly affected by the restructuring of facility-based long-term care, that is, residents and their families, have not been adequately notified of the developments.

Many consumers will face a significant increase in user fees if Bill 101 is implemented. Metro has on several occasions asked senior bureaucrats to notify consumers of this fact in a timely fashion so they themselves might make presentation before this committee. No such notification ever occurred. I suggest to you that for this standing committee to make recommendations to the Legislature without the opportunity of hearing an informed reaction from the consumers directly affected by Bill 101 is in direct opposition to the principles of the primacy of the individual and the importance of family and community.

Metro is completely comfortable with community involvement and accountability in the delivery of services to seniors. We have played a leadership role in areas such as residents' rights and quality assurance. We adopted a bill of residents' rights and responsibilities developed by the residents' councils themselves. We have a strong commitment to residents' councils and family committees. All our residents' councils and family committees have seats on our various advisory committees.

The requirement for a residents' bill of rights and residents' councils did not have to be regulated by the government in Metro's homes for the aged. Community accountability is working in Metro's homes, and this strength of the municipal system is not acknowledged in Bill 101.

We have a strong history in actively involving our community in our quality assurance program. For quality assurance to be effective, it needs to be owned by the municipality and the home and not regulated by the province. Bill 101 makes an incorrect assumption that increased quality will result from a strong provincial inspection and sanctioning process. That is not the case. Quality will only result from the commitment of municipal governments and boards of directors to ensure quality in their own operations.

Accountability and responsiveness are part of Metro's history, and we would like to see some recognition of the effectiveness and unique partnerships that have evolved within Metropolitan Toronto. It is not in the public's best interest to establish a costly, inflexible, system-wide inspection process if it is not going to result in a better outcome to the consumer. Although the province has a stated preference for non-profit service provision, the proposed inspection process ignores the mandate of our elected representatives and our success in local governance.

Bill 101 should introduce flexibility, clear standards and control to the inspection provisions to support municipalities in fulfilling their accountability to the community, rather than interfering with it. Bill 101 ignores the role of municipalities in planning, managing and delivering long-term care. Our written submission includes a number of suggestions to support the municipality in controlling its own mandate and fiscal resources.

Fourth, equitable access to appropriate services: Metro strongly endorses the principle of equitable and simplified access to long-term care services through the establishment of the service coordinator function, but we believe the new function must build on the strengths of existing structures and models that are already working efficiently. It must also have a sensitivity to the rights and legal obligations of both the consumers and the homes, and result in a less complicated and more timely system.

We currently have a division-wide access and service coordination function which is working well. We respond immediately to emergencies and have a system of authorizations for admission which considers those at highest risk. It has the capacity to be easily and cost-effectively adapted to a Metro-wide system for all long-term care facilities.

The introduction of a rigid, provincially imposed system will decrease our ability to respond to community need in a timely and effective manner. We urge the province to reconsider the decisions related to access and coordination and introduce a flexible system that responds to each community's needs and utilizes each community's existing resources in the most effective manner.

Bill 101 is missing some of the detail necessary to ensure equitable access. There must be standards to govern assessments, user fees, placement decisions and service delivery thresholds for both community-based and facility-based care. These standards must ensure that assessments are conducted fairly and impartially and that referrals respect the needs, preferences and financial resources of the consumer.

Fifth -- this is the principle added by Metro -- the issue of quality: Although there is a public expectation that the redirection of long-term care will introduce true level-of-care funding, this is not the case. The proposed funding scheme does not fund to level of care, but is simply level-of-care-based -- that is, relative to allocated dollars.

It is a fact that in the past, Metro has been able to negotiate funding that more closely resembles level-of-care funding than the proposed funding formula. We should not be penalized for that. Now, because the province is not infusing enough money in the system to bring all long-term care facilities up to Metro standards, Metro's homes and Metro's residents will be forced to suffer from reduced quality. Loss of quality is going to be an outcome of Bill 101.

Metro does not want to lose its excellent reputation for providing a range and scope of high-quality programs and services, but Bill 101 is threatening this. Insufficient funding is forcing us to look at a number of options, which may include closing beds or facilities, reducing service and reducing quality. The only alternative, without a clear provincial commitment to increased funding, is to unfairly pass on an increased burden to Metro taxpayers, and we just can't do that.

Bill 101 is interesting, though. It introduces explicit requirements for care without providing a funding commitment. The requirements in Bill 101 related to "service agreements," "quality assurance" and "plan of care" need to be linked to the provisions in "operating subsidy." Simply stated, you have to fund the care and service you demand. Our written brief offers considerable suggestions in this area.

The province can't undertake redirection without making a commitment to provide a stable, reliable and adequate funding system which allows homes to sustain or achieve quality. Seniors in Ontario deserve no less.

There are several other issues that I want to bring to your attention today.

First, our calculations indicate that to support the redirection initiative as proposed, significant dollars will transfer from the non-profit sector to the for-profit sector in the government's attempt to equalize funding for all long-term care facilities. This is wrong, especially for a government with a stated preference for non-profit service provision.

Second, the proposed resident copayment scheme is based on an income test only rather than on the current formula of income and assets. This direction ignores the fact that many seniors who have the resources want to contribute to their ongoing costs and ignores the fact that the taxpayers' burden will increase significantly for residents who are asset-rich and income-poor.

Third, a standardized, inadequate funding system such as the one proposed places an unfair hardship on employers such as Metro. We incur higher labour costs than any other jurisdiction in the for-profit sector due to government-mandated pay equity. To deny us recourse, for example through additional grants, is unfair and will force us to reduce our quality even more.


Last, the province is proposing an amendment to the Municipality of Metropolitan Toronto Act as it relates to indigent persons in nursing homes. For reasons explained in our brief, that provision is no longer needed. Section 186 of the act should simply be repealed.

In conclusion, Bill 101 as proposed threatens Metro's history of quality and responsiveness. It will require us to look at options of reduced service or quality in order to avoid an unfair tax burden to Metro taxpayers.

The proposed inadequate funding scheme will force a reduction in quality that seniors don't deserve. We urge the government to reconsider the restrictions on funding to long-term care as a priority.

Metro cannot be forced to be caught between public expectations for high quality and the level of care for which the government is willing to pay. We need a commitment from government to provide a stable, reliable financial environment in which we can ensure continued quality. Funding must be congruent with the actual cost of providing care and service to meet the identified needs of the residents.

The restructured system must more accurately reflect the four principles included in the government's own discussion paper. It must build on the strengths of the current system. It must be more responsive to the unique cultural, religious and linguistic needs of consumers.

Seniors must be given as much autonomy as possible to remain in their own homes for as long as possible, but when facility-based care is needed, it must be administered in the least bureaucratic manner possible. The average age of those people admitted to Metro homes is 86.

The new system must accommodate the system of community accountability already established in the municipal sector.

Provincial action alone is not enough to improve the long-term care system. A strong partnership is needed to provide a framework for future planning and to preserve high standards and levels of care. Metro welcomes the opportunity to participate in the redevelopment of Ontario's long-term care system. We want to ensure that changes are made only if they are the right changes and only if they truly improve the quality of service and quality of life for seniors.

The Chair: Thank you very much both for the presentation you've made and also for the longer submission, including your proposals for amendments to the bill which are very helpful to the committee. Could I just ask as a point of clarification if those proposals have been made to the government?

Mr Gardner: I believe this is the first time we've put this forward.

The Chair: Thank you. Then we'll move to questions and begin with Mr White.

Mr White: Thank you very much for your presentation. I have a couple of questions. I think late this morning and early this afternoon you hit on the very obvious issue that we're talking about: pulling together residential services for the elderly and disabled. Previously, they were controlled by different acts and regulations, some for-profit, some not-for-profit, some blends under one act and some blends under another act. Obviously, it's a very difficult thing. In some ways, it's a bit like having two totally different medical care systems, the American and the Canadian system, coexisting in the same community. Obviously, it will be difficult to do that.

I would think the points you make are very valid and that the movement Metro has made and its reputation for offering quality services will be respected, but obviously you still have concerns. You don't see that reflected in the legislation at the moment.

I'm wondering, in terms of some of the consumer feedback issues, some of the oversights, some of the accountability such as we discussed this morning, how does the advisory council work?

Mrs Joan Barltrop: Each of our individual homes has an advisory committee. Sitting on that committee we have representatives of the residents' council -- generally the president -- a representative from the volunteer association in the home, a resident, a representative of our family committee in each home, plus community representatives. Depending on the community, often service clubs or local health care officials are involved.

We act in an advisory capacity to the administrator of the home. In addition, we try to act as strong advocates for residents for their concerns within that specific home, and we also play a role in quality assurance, in part, of the individual home. Also, our homes are accredited and as such they are surveyed, and one of the survey mandates is quality assurance, so we follow up areas of concern. In addition, we have a divisional home advisory committee, in which representatives sit from the volunteers, the residents, the individual homes plus community representatives.

Mr White: When you say "divisional," do you mean in terms of the homes for the aged division of Metro social services?

Mrs Barltrop: Yes.

Mr White: To whom does that committee report?

Mrs Barltrop: Community services, of which Mr Gardner is the chair.

Mr White: So you would report to them on a regular basis, make your comments and advice known in public session of that committee?

Mr Gardner: Yes.

Mr White: So you have the opportunity, then, where there are issues that are still outstanding after advice has been rendered to the local administrator, to bring that forth to the committee. At that point, in some sense it's a very public level of accountability, just as the members of that committee are publicly accountable.

Mrs Barltrop: Yes.

Mr White: How long have you been working with that committee, volunteering?

Mrs Barltrop: I have been chairperson for -- I'm just completing my second year, and it's a three-year term. I sat on the committee approximately six years in total. Prior to that I was on an individual home advisory committee and prior to that I was very active in the volunteer sector within that home.

Mr White: So a very long history yourself.

Mrs Barltrop: Yes.

Mr White: So you've been familiar with pretty well all of Metro's homes? And you feel that system works reasonably well?

Mrs Barltrop: Very well.

Mr White: Thank you very much.

The Chair: Thank you. Ms Carter and Mr O'Connor.

Mr O'Connor: Just for the committee members here, I'd just like to make a couple of points and then I'll refer it to Jenny.

The government has made a commitment not to reduce the level of support, and I'm sure you realize that. There is the cap in place, and we acknowledge that. For a long time, Metro facilities have been at the high end in the province, I guess the highest. In looking at that and looking at the services you do provide, if we were to consider trying to bring everyone right up to your level, it's estimated that it would cost the province about $800 million. I just want to share that with some of my colleagues who might not know that. Of course, your recommendations will be brought forward to the minister, so I appreciate that and I just refer the question to Ms Carter.

Ms Jenny Carter (Peterborough): I want to raise one specific point you brought up. You mentioned that residents are going to be assessed on income only and not on assets, and I think there's a very specific reason for that, that I would like your comments on. That is that this is not a one-way street; we certainly don't want it to be.

Sometimes a person can need care in a home and can be rehabilitated and returned to the community, and we certainly don't want people to burn their boats, as it were. So if somebody's house could be sold in order to provide money for their upkeep in a home, then they would lose that option of returning to their previous lives. I think the intent was to avoid that and to make sure that people still had that integrity and that possibility of going back to their original life. Could you comment on that?

Mr Gardner: I'd like Sandra to comment first. I'll get the staff comments first and then I'll pop in.

Ms Sandra Pitters: I understand your position; there's no question about it. We do know, from talking to some of our family members and some of our residents who do have considerable assets and do not have the income, that they are willing to continue an income/asset test because they are willing and desirous, actually, of continuing to contribute to care when the assets are available. I understand your perspective, but from Metro's perspective we feel that those assets could be used to offset the provincial contributions.


Ms Carter: But is there any reason why people couldn't do that voluntarily?

Mr George Coleman: I'm not sure.

Mr Jackson: The answer is no.

Mr Coleman: I would like to think they would, but I would doubt very much they will. In some instances where a spouse would stay living in the community in the home, we assume that eventually, when that home is sold and the spouse no longer requires it, then the funds from that -- some people actually sign a lien against their own facility so that those funds can be used to cover the costs of care. I guess it's a question of, do you burden the taxpayers or should that money be made available for basically the estate? I guess that's where you have to come down on, those large sums of money. In Metro Toronto, because of the real estate values and what have you, there are people with a lot of dollars.

Ms Carter: Do we still have a moment?

The Chair: If it can be short.

Mr Gardner: Could I just respond in addition? One of the other things in regard to your question is that there are a lot of people coming in who require a heavy level of care, and at the average age of 86 -- that's the average age -- many of them will not be going back to their own home. Once they're in, we're going to have them, and that's one of the reasons we're looking at utilizing other assets, other than just the income alone.

Ms Carter: I remember attending a lecture by a medical man who specializes in gerontology saying that rehabilitation is more often possible than has been realized and that we seriously need to keep this in mind.

I just wanted to raise the question of choice and people going to the ethnic home or whatever. Certainly, the intention of the legislation is that this will be enhanced, rather than lost. We're hearing people say that the placement mechanism is going to deprive people of choice, that they're just going to be sent left, right and centre, that homes are going to have to receive people whether they like them or not type of thing. But I think it's very clear that that is not the intention and that even if it means sending somebody from, say, a small town into Metro or a long distance to be in a home that is suitable for his or her particular requirements, that can still be done and will be done.

Mr Gardner: It may be the intention of the legislation, but the way the legislation reads, there's nothing anywhere near a guarantee that would happen.

Ms Carter: Have you suggested wording that would supply that deficiency?

Ms Pitters: If I might comment also before that, just to add a few comments about Metro systems, you are correct in talking about ethno-specific homes, but one of the strengths we believe we have in our division is that we've been able in a number of homes to create units working with specific community groups, for instance, the Japanese Canadian community, the Armenian community, and the list would go on. So it is possible to have a mainstream home that has developed a program that is very sensitive to the ethnocultural and religious needs.

Our concern is that the placement coordination function needs to be very flexible and adapt to the systems and the needs in each individual community. You can't put a system in place across the province that looks the same in every local community because the needs of the communities are different, and that placement coordination function needs to be responsive to those resources and know enough about the facilities themselves to match them up. We just do have concerns that unless that flexibility is introduced into the system, we're going to lose the opportunity to work with the ethno-specific groups that are so prevalent in Metro Toronto and that we think we work well with.

Ms Carter: I'm sure we'd all wish that to continue.

The Chair: We could turn then to Mr Jackson.

Mr Jackson: Are you not going to recognize your colleague?

The Chair: Well, I was, but I thought --

Mr Jackson: Oh, we're going this way.

The Chair: Given the order of entry after the noon repast, I thought I'd go to you second.

Mr Hope: We thought we'd go the left, Cam.

Mr Jackson: Well, listen, you've been doing that for years, Randy.

First of all, thank you for the brief. I especially want to thank you for the compendium, because we don't get a lot of effort put into specific wording of amendments and that's extremely helpful to the committee. I've had a chance to look at both documents, so thank you.

I want to centre my questions around the uniqueness of Metro, but I wanted to pursue, before I do that, this business of the income testing. I think some of it also has to do with the fact that legislation and rights for spouses have changed and what's deemed to be -- the spousal home is only owned half by the spouse, so when you get into asset calculation and having to liquidate, you're literally forcing another person out of a home. Also, the government has clearly indicated that it sees inheritance taxes for general revenue purposes, so to preserve as long as possible that which is to be transferred so it can be taxed is a far more important issue to the Treasurer than --

Mr Jim Wiseman (Durham West): Make it up as you go along, Cam.

Mr Jackson: Mr Wiseman, you're picking all this up, I hope. It's when you're really quiet that I know you're not catching any of it, so I'm glad you're getting the picture here.

The Chair: Order, please. Mr Jackson has the floor.

Mr Jackson: Obviously, the Treasurer's interest in these matters is more important than, say, the Minister of Health's in terms of long-term care because we're basically talking about participation in the funding here. That's basically what was at the root of your concern: access to the opportunity to direct those funds at that point. No one wants to talk about it, but in fact that's part of the underlying aspect of that.

To move to the point you make on page 8, I want to pursue that. I need you to help me elevate my understanding of how your division-wide access and service coordination occurs. Are you doing that solely for your sector or are you doing that for all residents of Metro Toronto, and that across all facilities? That's my first question.

Mr Coleman: Currently, we're only doing it for our own 3,200 beds. We did have a pilot project with about five or six charitable homes for the aged in Metro that we started about two years ago. We ran it successfully for a while. The charitable homes for the aged couldn't sort of pick up the funding from the province they needed to carry on, and it never got --

Mr Jackson: Was there ever an evaluation done?

Mr Coleman: Yes, there was, and it was very positive.

Mr Jackson: Could we get a copy of that evaluation? What we're obviously leading to is that you are the first municipality to come forward and specifically say: "Look, we're already doing 75%" -- we'll say for a figure -- "of all the placement coordination work in Metro Toronto now. Why not give us the responsibility for the remaining 25% and cut out a whole level of government intervention?"

Mr Coleman: We can supply you with that information.

Mr Jackson: I'd like to analyse it from that point of view. It's unfortunate the government saw fit not to proceed further with the funding in that area. I guess this is a question for Norm: Would you see difficulties arising from Metro undertaking placement coordination services -- and what's implicit in your brief is inspections etc, the whole gamut -- for the non-profit sector? Because that's what's implicit in not creating a second level. Otherwise, the province would be left to just manage the one sector while you manage the major sector in Metro.

Mr Gardner: That's along the lines we would like to be involved with.

Mr Coleman: The Metro housing company has a central registry in Metro, and the thought behind it is that you would take it away from the day-to-day operation of the Metro homes for the aged and it would be operated with advisory committees from the various ethnic groups on it, but as part of the community services committee and not so that -- it wouldn't be sort of an indication there was a conflict between who got placed where.

Mr Jackson: Do you envisage maintaining your current access and service coordination processes in tandem with, or would you be eliminating yours?

Mr Coleman: No, it would be rolled into a larger --

Mr Jackson: Have you been told that or is that just what you surmise from the legislation?

Mr Coleman: You mean if we don't do the coordination?

Mr Jackson: No, if the province comes in with its top-down approach, which you're concerned about, would you run this in parallel or would you just disband that aspect?

Mr Coleman: It's my understanding that we would have somebody referred to us and we would have to accept him, and that would be the end of the story, so there would be no need for it.

Mr O'Connor: Not intentionally.

Mr Coleman: That's kind of the way the bill is worded.


The Chair: Perhaps we would allow the witness to respond. I appreciate that others may have comments, but let's keep it to question and answer. One more question, Mr Jackson.

Mr Jackson: Recognizing, then, this role -- and I'll use an inappropriate phrase, but it's one that's being used in health care more frequently -- this person becomes the gatekeeper to the system. You're basically suggesting to us that the most sensitive and appropriate gatekeeper to the system is at the local municipal level.

Mr Gardner: Yes.

The Chair: Just before passing to Ms Sullivan, with respect to the request that was made about the document, Mr Coleman, if you would be good enough to send it to the clerk, then we'll get it to all the members.

Mr Coleman: Thank you very much.

Mrs Sullivan: I'm rapidly moving to the bill, but I'll ask the question anyhow. On the last point, with respect to Metro continuing to operate a placement coordination system, am I misreading the bill and understanding incorrectly that the minister would not have the option of appointing Metro as the placement coordinator?

Ms Pitters: No, that is correct. The bill would allow that designation to an individual or any agency. We have heard informally, and I stress this is informal, that there is concern regarding the government having a direct service provider performing that function, and that's why the municipality, not just our division but the broader department in the municipality, has looked at moving it at arm's length away from the division in order to have a system that would work well for the whole long-term care facility system in Metro.

Mrs Sullivan: So, within that, you have already examined that potential conflict between provider placement.

Ms Pitters: Yes, we have.

Mrs Sullivan: You may welcome it indeed if a new system is in place that you in fact have already recognized as being an appropriate one, and the minister said that should be it.

Ms Pitters: Of having placement coordination function --

Mrs Sullivan: Separate from the provider but still under the auspices of the regional municipality of Metro.

Ms Pitters: That's correct, and our premise would be that our system is there, it's working, it's a system that could be built on, and we believe we have an understanding of seniors' needs in facility-based services.

Mrs Sullivan: My second question concerns Mr Gardner's remarks on page 11, the one place where he departed from the text, where he said, "A standardized, inadequate funding system such as the one proposed places an unfair hardship on employers such as Metro," and then you added the words, "due to government-mandated pay equity." Could you clarify that for us? I know it wasn't in the original text. My understanding was that the non-profit sector was being aided in terms of pay equity requirements through funding from the province, whereas the private sector was not receiving that assistance.

Mr Gardner: Metro has pay equity implemented. Consequently, the people we are hiring are under that section and are higher-paid than the people in the for-profit sector. Also, when you combine that with what Mr O'Connor addressed, with what we feel is a higher level-of-care service, our costs to operate are much higher than in other parts of Ontario. Is there anything else you'd like to add?

Mr Coleman: My information may not be 100% accurate, but I don't believe there is any mandated pay equity at the present time other than at the municipal level of government. The only bill that has been passed and the only organizations that have been required to implement pay equity are at the municipal level of government. So I don't think it applies to your charitables, your non-profits, your private sector. I suggest that there's a substantial difference in pay between an employee in a Metro home for the aged and somebody in an Ontario home.

Mrs Sullivan: In terms of the schedules, there has been information before the committee that the intention of the province was to assist in the transferring of funds to the non-profit sector to deal with its pay equity adjustments, and that same funding would not flow to the private sector at the appropriate time of the implementation of pay equity. I just wanted to clarify where you're coming from.

Mr Coleman: I guess my only comment is, we need the cheque then.

Mrs Sullivan: I wanted a further discussion of the next issue, because you are the first municipality that's been before us. I think it will be of value. In both of your documents -- they are both useful to us -- there's an indication that quality assurance is a mandate of the governance of the municipality. As a consequence, you take issue with "quality assurance." We have objected to the use of the words "quality assurance." We think "quality management," a more generic term with greater flexibility, is an appropriate term to be included in the legislation. Assuming we get the term right, are you saying that even if the words were "quality management," that is not the appropriate link in the legislation and the standard for each home; that that is the judgement of the municipality?

Ms Pitters: We used the term "quality assurance" because that was the term used in Bill 101, so to keep the jargon together. I appreciate your comment on quality management. Indeed internally, in the division, we tend to focus more on the other acronym of CQI, continuing to improve the quality of our services.

What we're really saying is that the issue of quality is one that the governing body we believe should be managing. If the governing body and our advisory committees are managing the quality well by providing us with recommendations -- by the way, we do have very clear quality indicators for all our principal functions and topics in all our areas of operation within the division -- we can provide you with the assurance that quality is there in the system without having a superimposed provincial model. We can provide you with that without having to have the same type of inspection system that historically has existed in nursing homes.

Mrs Sullivan: What you are suggesting then, I take it, is that an amendment to the sections of Bill 101 that would specifically refer to the charitable and municipal homes would be required to recognize either the board of directors or the municipality form of governance, as compared to the Nursing Homes Act where there is a heavier reliance on the private sector, with one operator, one home.

Ms Pitters: Yes, that's correct.

Mrs Sullivan: Interesting.

Mr O'Connor: Mr Chair, if I might just enlighten the committee --

The Chair: The committee is always open to enlightenment.

Mr O'Connor: I know there has been some discussion here about pay equity and I just wanted to let the committee know that the Metro homes have yet to incur any cost as far as pay equity. All the homes for the aged that have incurred pay equity costs have had these costs subsidized through the regular cost-sharing avenues, even those homes that have been capped, as we've talked about here. I just thought I'd share that with the committee as we have discussed that.

The Chair: As members may be aware, the 2:30 deputation was not able to come and our 3 o'clock group is not here as yet, so if you are agreeable to remain with us for a few more minutes, I would open it up for some more questions and try to do it in a fair manner with another question from each caucus, if that's okay.

Mr Jackson: I had a question for Mr O'Connor.

The Chair: For the parliamentary assistant?

Mr Jackson: Yes. Last week I was doing the pay equity hearings. We asked for information on the costing and the government members voted against us getting that information. Do you have the information on the pay equity amounts transferred from the province to that sector? I thought Mr Gardner was very restrained by not referencing the shortfall in the moneys promised to the municipalities for pay equity purposes. If you've got those numbers, just how much information did you want to enlighten us with?

Mr O'Connor: The information I have is just for homes for the aged. It's not for the broader sector.


Mr Jackson: It's just been handed to you.

Mr O'Connor: I don't know about whatever you referred to in that other committee. I know we're just dealing with that one issue Ms Sullivan has raised.

The Chair: To try to be clear here, Mr Coleman, I understood from what you said that you had not seen any money. I'm just a little unclear, as the Chair. You're supposed to receive money but haven't? Or are you saying, Mr O'Connor, that they --

Mr O'Connor: They haven't incurred any extra cost as a result of pay equity programs. Through the regular cost, they've been able to --

The Chair: Mr Coleman, could you make a comment on that, please?

Mr Coleman: Just to clarify, the pay equity program at Metro has been finalized and negotiated and the numbers are available, but we don't have a firm commitment from the province that it's going to pay its share. At the Metro council meeting about two weeks ago, Metro council said that it would pay its share and then the Metro chairman was to get a firm commitment from the province to make sure the provincial share was going to be paid. That firm commitment has not been received.

Mr Wiseman: On a point of clarification, Mr Chair: With respect to what Mr Jackson indicated, in the pay equity hearings last week, the Conservative caucus put forward 11 or 12 requests. On examination of the staff from the ministry by the member for Oriole, it became quite apparent that while some of the information could be forthcoming readily, basically what would have happened is that there would have been a lot of time put in scurrying around trying to find information that was not as readily available and therefore it would have been very difficult.

The members of the government party who voted against the Tory request were joined by the member for Oriole with respect to voting against that, not because we did not want the information to be forthcoming but because of the considerable burden it would have placed in order to find out what that information was at this time. However, the staff did make it known that they would endeavour to put that information together for the Tory caucus, and they'd know that.

The Chair: I'm going to ask Mr Gardner to comment.

Mr Gardner: Mr Chairman, AMO was talking with the provincial government with regard to disentanglement issues. To be quite frank with you, nobody has been able to give us an idea about whether the provincial government, in view of disentanglement, will be providing that difference as far as pay equity is concerned for ever or whether it's going to be on a very short-term basis and then the municipalities will be less stuck with higher amounts of salaries regarding pay equity vis-à-vis the for-profit sector. So there are a lot of things here that we don't know anything about and nobody can give us an answer to.

Mr Jackson: Mr Chairman, on a point of clarification: Mr O'Connor attempted to clarify that point. I'm not sure he did. Did he indicate that the funds will be forthcoming?

Mr Hans Daigeler (Nepean): I don't think he can speak for the government.

Mr O'Connor: Perhaps we can try to explain this a little bit better than I've been able to explain it.

The Chair: Just briefly, because the issue here is not what happened in another committee, it has to do with this specific issue.

Mr O'Connor: Exactly.

The Chair: If you have a comment about a cheque that is either on its way to Mr Coleman or might be on its way, I'm sure he'd be delighted to know. Please go ahead.

Mr O'Connor: Thank you, Mr Chair, for those thoughts as well. My thought was that we could ask Geoff Quirt to come up and perhaps explain for the committee what I tried to explain. It might just enlighten the committee somewhat, if that would be agreeable to Mr Jackson.

Mr Jackson: Mr Chairman, I'm prepared to accept it in writing. I was just contrasting that when we requested a simple bit of information, we were unable to get it. I'm happy to get it if we can have it written out. Mr Quirt's in the room. He can respond, it can go through the clerk and be distributed. I think it's important information.

Mr Wiseman: You're just trying to make a political point, that's all.

Mr Jackson: Mr Wiseman, I deeply resent bureaucrats running to a parliamentary assistant with information which is thrown out on the table. We're expecting that it comes from a reliable ministerial source. I have the right, as a member of this committee, through the Chair, to ask that that information be formally presented and not thrown in as a political message. That's what I objected to. So I would ask that it come in the form of a report -- we can interview the ministry official once we get the information -- but not to have it thrown out after it's whispered in your ear during the course of a discussion. That's what I think is wrong about what's been going on here.

Mr O'Connor: Obviously, he doesn't want the information right now. I thought it would useful to the committee to have somebody come forward and talk about that while we were in the midst of a discussion, as brought up by the opposition members. Should they not want to get that, we can get that in writing.

The Chair: I think that would be fine, because really what we are trying to do this afternoon is hear from the delegations. We can get that and then if we feel that there is a need for further discussion, we can do that.

If I might thank you; you have certainly raised a number of issues, one in particular which has elicited some response. If I'm permitted, I would say to Mr Coleman that it probably won't be surprising to you to know that Green Acres is still there and still a matter of some discussion. That's sort of an in joke, but we'll leave it at that.

Mr Coleman: Thank you very much, Mr Chair.


The Chair: Our next witnesses are from the Ontario Nurses' Association, if they would be good enough to come forward and take a chair. Welcome to the committee. We have a little more time and I'm glad that you're here. We can start a bit earlier. That will allow us more time for questions. If you would be good enough just to introduce yourselves for the committee members and for Hansard, and then please go ahead.

Ms Ina Caissey: We're missing one person but I will start. With me are Carol Helmstadter, who is a government relations officer with our government relations department; Lesley Bell, associate director of government relations; and Seppo Nousiainen, who is our research officer. My name is Ina Caissey and I am the president of the Ontario Nurses' Association. I am here today to represent the views of over 50,000 staff nurses in this province.

The Ontario Nurses' Association, as the voice of these registered nurses who work in hospitals, community health, industry, nursing homes and homes for the aged, brings a unique perspective to these committee hearings. The union congratulates the government for this proposed legislation. There has been a need for uniform standards in this sector of the health care system for a long time and we are pleased to see that the government has taken this action.

ONA also welcomes the act's strengthening of the existing legislation in such areas as compliance and accountability and the provisions for a more equitable admissions process and stronger appeals system.

However, ONA does have a number of comments and concerns which I would bring to the attention of this committee. I will restrict my comments to the sections of the bill dealing with the Charitable Institutions Act, recognizing that these comments also apply to the amendments proposed for the Nursing Homes Act and the Homes for the Aged and Rest Homes Act.

The first area that I would like to touch on is under section 9.3, where the act states that the charges for various classes of services, goods and programs shall not be in excess of amounts determined by regulation. However, the government's discussion paper Redirection of Long-Term Care and Support Services in Ontario has made much of the fact that residents will not have to pay for nursing and personal care services in a home for the aged or a nursing home. If that is what the government intends, then it would be much clearer if the act stated that directly. Our concern is that as the act is currently written, nothing would prevent the government from charging for such services through its regulation-making powers.

Again, the same sort of situation applies to adult day programs which may be offered in a nursing home or a home for the aged. If they are to be provided without charge, as the discussion paper suggested, then this proposed legislation should reflect that.


On the question of funding, ONA would like to make it clear that the government must provide sufficient funding so that all homes are able to provide a satisfactory level of nursing and other services without asking health care workers to accept substandard wages and benefits.

Over the years, our union has heard from both private and public sector employers that they have an inability to pay registered nurses and other workers satisfactory compensation. Also, employers have attempted to replace registered nurses on staff with less qualified and less expensive workers. This naturally increases the workload on the remaining registered nurses, since they are ultimately responsible and accountable for the quality of nursing care given. The biggest losers in these situations are the residents of the homes.

While the province is currently engaged in the development of a funding formula for all long-term care facilities and services, there is yet no guarantee that any of the possible extra funding to the long-term care sector will actually find its way into providing better care for residents. For example, it may go into accommodation.

Other areas that we would like to address are sections 9.5 through 9.10, which deal with admissions to homes and the appeals procedure. Under subsection 9.5(6), we have difficulty understanding how it is possible for a placement coordinator to force an institution to accept an individual if there is no space available in this institution. This situation will no doubt occur with even more frequency as the province constrains institutional bed capacity. If in fact the intent was to have the placement coordinator prepare an alternative community-based care plan for individuals who are refused admission to a facility, then this section should be expanded to include that specific direction.

Another option could be placement in chronic care institutions. Yet at this point in time, the future of these facilities remains uncertain. Of course, it could well be that the government plans to introduce legislation which governs admissions to facilities and services such as community-based home care in the non-homes sector. If this is the case, it points to an inherent weakness in the province's planning process, which seeks to govern admissions to the homes on the one hand, without improving access to the community-based, long-term care sector on the other hand. Yet this is precisely what seems to be happening, since we do not yet have corresponding legislation for community-based, long-term care programs.

I would now like to refer to sections 9.7 and 9.8, which speak about applicants. Since the reality is that some applicants could well be incapacitated, it would be helpful if consideration were given to additional wording which would give a representative or agent the ability to make applications and appeals on behalf of the client. We question whether the 30 days set out for a hearing is sufficient time to apply for a hearing, given the many reasons that could delay a response to a determination notice. Preparation of an appeal may be an extremely involved process, since there will be a need to consult with the applicant, who may be impaired, with family members, physicians and other professionals. Likewise, under section 9.8, it is arguable that some time limits for hearings should be imposed on the appeal board itself.

The next area on which we would like to comment is clause 9.12(a), which covers plans of care. We believe it is essential that the requirement for ongoing assessment of each resident stipulate specifically that the assessments be done by registered nurses and physicians. We believe it would be useful for the committee to strengthen this area even further by considering that a multidisciplinary approach be used in needs assessment, keeping in mind the need for nursing input and expertise in developing plans of care.

It has often been noted that services to patients in long-term care settings should involve caring for the whole person. We believe that clause 9.12(b) also needs to be strengthened to state that all care plans should consider the patient's psychological, social, emotional and spiritual needs as well as medical and nursing needs. It is also important that the resident and family be involved in the development of the care plan. We believe that it should not be necessary for a resident to ask to see the care plan; it should be provided automatically.

ONA would like to stress at this point that registered nurses are being placed in an increasingly untenable position as homes are making greater use of health care aides and other non-regulated personnel. As the College of Nurses of Ontario has clearly pointed out, the registered nurse retains overall responsibility for the decision to delegate, the instruction provided and ongoing supervision.

Although ONA has been told that while the college would make allowances for the lack of control which an individual nurse has for following a resident, the college has every intention of holding the individual registered nurse responsible for the performance of the delegated act and the safety of the resident.

Clearly, something must be done to correct this situation. If a registered nurse is working on an understaffed ward or with colleagues who have no experience in that kind of work, or if the ward is staffed with a high proportion of underqualified personnel, even the most competent nurse in the world would be unable to deliver safe care.

We fully support clause 9.12(d), which requires that the provision of care outlined in the care plan is in fact provided to the resident. We sincerely hope the government recognizes that this care cannot be provided without adequate and appropriate staffing levels which match the care requirements of the resident with the skills package of the provider. As the solution, ONA would recommend that this legislation be amended so that the primary responsibility for the creation of safe conditions for good nursing care would be placed squarely with the employer.

Under section 9.13, we would recommend an expansion of the core areas to be covered in quality assurance plans. They should include nursing services, medical services, rehabilitation, social work, recreational and pastoral services. Other programs could be added later or as needed through regulation.

ONA would like to recommend that the principles of continuous improvement should be applied to quality assurance plans. The current system of quality assurance in most health care agencies rests upon the measurement of the performance of individuals. Unfortunately, the standards for these measurements are often extremely narrow; for example, whether the handle used for raising a bed was left sticking out.

When a complaint arises, the blame is assigned to an individual nurse. However, with the continuous improvement system, quality assurance becomes an integral part of the management system, which aims at improvement of the performance of the organization as a whole, not just at identifying a few bad apples. All members of the organization accept responsibility for their behaviour, not just the individuals at the bottom of the hierarchy.

In nursing, this would mean that researchers, educators and administrators would also be accountable for their performance and would also aim at positive support of the practitioners. The outcome would definitely be better nursing care. ONA believes quite strongly that the continuous improvement system of quality assurance is empowering and would result in far better and safer nursing care than the present complaint-based system.

The last area of the act that we would like to discuss is under clause 10.1(5)(d), which covers inspections. We are troubled by the proposed wording. While we agree that an inspector should be able to question health care workers on relevant matters, there is a need to protect that worker or any other worker from reprisals by employers or even from discipline proceedings which might be brought by third parties such as the College of Nurses of Ontario.

ONA would suggest that this section of the act be changed so that any information received by an inspector remains privileged and shall not be communicated to any other persons. Indeed, we believe that if this kind of privilege is not provided, the inspector's ability to do his job will be severely compromised.

As a general comment, we would like to point out to this committee that registered nurses are beginning to suffer from a certain amount of accountability fatigue. Besides being accountable to their employer, registered nurses are compelled to answer to their professional body, the College of Nurses, not only for their own actions but also for the actions of those whom they supervise. Then with the introduction of the Advocacy Act another level of accountability was created, and now it is proposed that registered nurses should also be accountable to an inspector from the Ministry of Health. The cumulative effect of this is quite oppressive for us as professionals, and ONA would greatly appreciate anything the committee can do to relieve this burden.

In conclusion, on behalf of the registered nurses represented by the Ontario Nurses' Association, I commend the government for the creation of these new common standards for nursing homes and homes for the aged, and for strengthening of the compliance systems and the mechanisms for accountability.

However, much work remains to be done. The Ontario Nurses' Association urges the provincial government to move forward on its commitment to health care reform in a coordinated way, which will address not only long-term care homes but also the shift from institutional to community-based care. We look forward to commenting on these initiatives in the not-too-distant future and would be happy to address any questions.


The Chair: Thank you very much for your brief and particularly for a number of very specific suggestions. I'd like to think we planned the presentations, in that yesterday afternoon they all seemed to be on similar topics and today, this afternoon, we've had two with very specific proposals around amendments or changes. It is helpful to have that. We have a number of questions, starting with Ms Sullivan.

Mrs Sullivan: I heartily agree with your comments on the quality assurance issues. I think that yesterday or the day before we had a fair commitment from the parliamentary assistant to the Minister of Health that the words "quality management" would be used, rather than "quality assurance," to take into account the CQI programs or continuous quality improvement approach I think we all want to see. Certainly, if we don't have that concurrence from the government in terms of amendment, we will be putting an amendment to that effect forward. We think it's the appropriate way to go.

I'm interested in the approach you speak of in terms of developing a plan of care. I assume the ONA was part of the consultative process in terms of the development of the manual and the standard agreements and so on. Have you had access to the first go-round of the draft of the operating manual? No. Okay. Well, that's interesting.

I suggest, then, to the ministry that the ONA would be a useful organization to be consulted on the manual, since many of the members of this organization are in fact involved in care delivery in homes, whether municipal nursing homes, charitable homes or whatever.

I don't know if my question's going to make any sense now if you haven't seen the manual, but in the course of the development of plan of care, one of the issues you have raised is the multidisciplinary approach. That issue has also been raised in terms of the placement coordinator's role in being the sole assessor. Where, then, does the other multidisciplinary approach come in in the first place as the care requirements are determined?

The OMA has suggested, by example, that the medical records and consultation should be included for the impairment issues, that others should be involved in terms of the social needs and rehabilitative needs and so on, in terms of the placement in the first place, along with the resident's own choices.

I thought that was an important aspect and I didn't think the standard agreement or the assessment forms in the Draft 1 of the manual took that into account in the depth they should have. But if you haven't seen them, you don't know what I'm talking about.

So then we move on, once the person is in the home, to the plan of care, and you have spoken about the multidisciplinary approach to the plan of care, which you can speak about without having seen the manual, I think. How do you see, now, the legislation directing how that plan of care will be devised under Bill 101?

Ms Carol Helmstadter: How it will be devised?

Mrs Sullivan: Yes. Who is the assessor?

Ms Helmstadter: I think we would say it was the nurses. The people who certainly are most familiar with the residents are going to be the staff nurses, because they're there all the time and they are the ones who are also responsible for coordinating the care, for seeing that the patient gets to the physiotherapist, that the occupational therapist comes in and that sort of thing.

There has to be a team approach, obviously, but the staff nurses are clearly the ones who are there with the patients for the greatest length of time and therefore are most familiar with what their capabilities and their other problems are.

Ms Lesley Bell: I can't speak to the manual but I can certainly say that, as it relates to the placement coordinator and the development of a care plan, we feel that nursing has to play an important role in that and feel that placement coordinators in fact should be nurses. I know we're not always fully supported in that point of view, but that's certainly our position, because what normally happens with these people, with these residents, is that often what they're there for, if they're in an institutional-based setting, is nursing care. It's one of the requirements, and we feel that nurses provide that ability to determine when there are changes needed, based on input from other people.

One of our concerns is that we don't know who the placement coordinators are going to be as yet. Another concern is that a number of the things as they relate to Bill 101 are left up to regulation. The problem of regulation is, who knows what that's going to be and will we have any say in it?

Mrs Sullivan: I think we all have that same problem, because the regulations haven't been drafted. We asked even to see an initial draft of them and were told that it has not been done. We received as a committee the copy of draft 1 of the manual yesterday, and some organizations, such as yours, which I think should have had a look at it, have not seen even draft 1. I think there are problems in knowing in fact what's on the table here, and particularly when we don't know the broad ultimate policy and strategy that's coming forward and won't be coming forward until next fall, we're told.

The Chair: We'll turn next to Mr Hope.

Mr Hope: Thank you. You do have a copy of the manual now?

Ms Bell: We do, thank you.

Mr Hope: And we do await your opinions on the manual, and I'm sure the organization will do that.

I'm just curious, before I forget, I noticed while you were doing your deputation you forgot one area. I think it's just before your conclusion on the copy we have, something about non-profits? I notice you overlooked that or didn't want to put that on the record, or just made a mistake maybe. I just thought maybe you would like to reiterate that area of that.

Ms Bell: Actually, thank you, Mr Hope. One of the reasons it wasn't in the verbal presentation was because the submission got changed at the last minute and it wasn't included. Seppo, did you want to speak on this particular matter?

Mr Seppo Nousiainen: No.

Ms Bell: All right, fine.

Mr Nousiainen: We'll just leave it.

Mr Wiseman: It seems like something nobody wants to talk about.

Ms Bell: Actually, no. We're very concerned with the comments in the section you're referring to. It says that the director may authorize an increase in bed capacity of a nursing home, and what we're concerned with is that this doesn't mean that it will only be for-profit beds that are increased. We don't support the increase of for-profit institutions in any matter. We think there's enough out there and we should be dealing with not-for-profit.

Mr Hope: I notice in this legislation we're talking about, we're talking about an act with a lot of regulations, but in order for us to meet the needs of people -- and I guess, coming from the nursing profession, you know modern medicine changes quite frequently. You need government to change quite frequently. As you see, these acts are a little outdated. I guess that's why the intent of so many regulations are in there.

But when you talk about stuff we should put in the act, how can we put things in the act that you've brought out here that's not there or needs to be cleared up but allow the flexibility for regulations?

Yes, I remember sitting in the exact same spot you are, and when the government used to tell me, "We've got it in regulations," I used to scream and holler. But it was on different areas, where it could have been in the act and it wasn't. I even made recommendations of what the wording could be and I know they totally refused those comments.

Mrs Sullivan: That was then.

The Chair: Isn't it true that confession is good for the soul?

Mr Hope: Anybody can read through Hansard and find out. But as we try to define an act, yet allow the ability to meet the important needs of the consumer, which you have indicated, and we're trying to do a balancing act, do you know how long it takes to put legislation through the House in order to do what you need to do in regulations to meet the emergency situations that we're all talking about? I'm just wondering about your viewpoints on that.


Mr Nousiainen: Yes. Listen, I just want to point out --

Ms Bell: I think I said it backwards. I think Seppo's going to correct what I said.

Mr Nousiainen: No. This is correct. I think you have to enabling legislation, but I don't think I saw anywhere else in Bill 101 a sort of explicit reference to expanding bed capacity in the non-profit sector. It seems that this is sort of identified individually, and we wondered why that would be.

Are there other reasons why you can't put something into legislation which sort of says that the minister may enter into agreements, I assume with municipalities and charitable institutions, to deal with this issue? It may be covered somewhere. Perhaps I missed it, but I didn't see a specific mention of that.

All we're really saying is that we've had a lot of problems with the for-profit nursing industry over the years, and suddenly we find that the bill highlights the potential need to increase for-profit beds and we're wondering why that is. We also note that it has never been the government's intention to do that. At least, that's been the policy of the government.

We're not saying that you should get rid of non-profits; we're sort of saying let's just hold it for the time being and let's sort out the problems we've got there, and before we proceed with any further approval of for-profit nursing homes we've got to sort these problems out. We just wondered why this was in the bill.

Ms Bell: If I can go back to the question that you then went on to, as it relates to enabling legislation and trying to keep it open enough and using regulations, I suggest that maybe if the legislation came with accompanying regulations, we could then comment on the package. It still would allow the government in future to change regulations based on, as you put it, changing technology. I'm not suggesting that's easy, but it's very difficult to only address a piece of legislation without knowing what the ramifications of the regulations are going to be. But that's, of course, your job.

Mr Hope: Just as was said in the act about the services, I'm just wondering, because the services will be part of the regulations, how do we put -- and I know what you're coming at. You want at least the minimum protection that the employer can't take away from them. The minimum protection has to be there and it's in the act, the regulations.

Mr Nousiainen: Are you talking about private --

Mr Hope: I'm talking about page 2 in the presentation that I have, and I guess it's somewhat different than what you've got. The written presentation, on the top part there, first paragraph.

Ms Bell: Our comments were that our understanding is that the government does not intend to charge for nursing care and personal care and that you're going to deal with the other charges through regulation. All we're saying is that if those are exclusions, then write them out. If your intent is at some point in time to charge for nursing care, then I suggest that should be debated and that that part of the legislation should be enshrined.

Mr O'Connor: I want to thank Ms Sullivan for pointing out an error on our part, and so I accept that. I'm pleased that my colleague has given you a copy of the draft manual. It may raise your comfort level somewhat knowing that a nurse was, I believe, involved in the writing of that draft, but for sure we'll make sure that you're at the table when we do discuss it further. I appreciate that and thank Ms Sullivan for pointing out our omission.

The Chair: We're always indebted to Ms Sullivan. Mr White.

Mr White: Just a couple of very quick follow-ups from earlier questions. You have nurses who work in both the for-profit nursing homes and the not-for-profit, community-based services --

Ms Bell: Yes, we do.

Mr White: -- yet you came up with a fairly clear position in response to my colleague's question. You're saying that some of the problems with for-profit centres really need to be looked at prior to this kind of reform.

Ms Bell: What we're suggesting is that you don't increase anything in that. We have some concerns with that because of the argument of inability to pay. With that argument, it's very difficult, when these people are attempting to make money, to determine where the inability to pay falls in and where the profit level falls in. So it's just a general comment that Seppo mentioned, that it specifically says to that we don't see it in the general case.

Ms Helmstadter: The former Minister of Health was very concerned about the expansion of the for-profit sector, and she said it was seen that very few companies were expanding rapidly in urban centres where the care was cheaper and it was more possible to make a profit, and in the rural areas and in the north and so forth, the ministry was left. I think this is a real problem, which has a potential for expanding. We're not saying that these for-profit homes should be put out of business; we simply want them to run fairly and without making an undue profit. They shouldn't be allowed to expand while the non-profit homes cannot.

Mr White: I certainly hear you saying that you have no slant in opposition to for-profit nursing homes, nor, obviously, does our government.

Mr Jackson: Your nose is growing, Drummond.

Mr White: But you're saying at the moment the expansion is very unequal and creates a greater imbalance than previously existed.

Ms Helmstadter: Yes.

Mr Jackson: I have to recover from that last statement. I'm encouraged to hear from Mr White that his government has no difficulty with the private sector nursing home. I don't want to quote you out of context.

Thank you for your brief. There are some labour aspects here which I'd like to explore, but my understanding, just to go back to the point that was raised earlier, of the enabling aspect of expansion of nursing homes has to do with the collapsing of nursing homes and the ability to merge licences and the exact number of bed mix. It also has implications for overbedding and authorization from the province for overbedding and stuff like that. That's my understanding of it. I don't see it as much as a serious issue as it is a management tool.

I've participated in discussions to save a couple of nursing homes from folding, and that was part of the discussion. That was in the current legislation under the Nursing Homes Act and is being transferred over to here. I shouldn't be the one explaining that, but I believe that's in effect what it's about. So I don't think it's as much a risk factor. I know it's not implicit of expanding the total number of beds; it's more specific to a certain facility. If you want to amalgamate two nursing homes and have one administrator, those kinds of things, essentially your licence flows from the building.

Anyway, leaving that for the moment, I want to pursue the concerns you've raised about the utilization of paraprofessionals. Can you enlighten me further on how extensive the practice currently is in the not-for-profit sector.

Ms Caissey: We are hearing from more and more of our members all the time that with the current layoffs, what is happening in a lot of areas is that the registered nurses are being laid off and replaced with other classifications of care providers. Our real concern is that with fewer registered nurses in the building, the responsibility on the ones who are left is overwhelming. As well, we are concerned that the residents in these places may not be getting the care that they deserve because of the lack of registered nursing staff on the premises.

Mr Jackson: Which of the acts currently addresses this issue, which of the ones that we should be strengthening? Bill 101 is the changing of seven or eight different bills.

Ms Helmstadter: It's essentially a technical bill trying to establish equitable funding across the board. Our suggestion was simply that in quality assurance there should be some standards set for a minimal number of registered nurses, because if you could see what the populations of these homes are like now, in 10 years, the average age level has gone from 72 to 85.

People are living much longer, with a great deal more support from drugs and other technologies, and they're requiring a very much higher level of skill to look after properly. We feel it's putting too much burden on one registered nurse, with some health care aides and an RNA who gives out the medicine, to really try to be certain that her residents or clients or whatever are getting an adequate level of care.


Mr Jackson: That's helpful. What I'm trying to get at is that currently the practice is growing, and the practice of bringing in paraprofessionals, in your view, is a process of not maintaining appropriate levels of supervision and professional care. That is currently, now, happening. Where is it that a home is able to get away with that? What allows them to do that? Because there is a complete absence of guidelines in this regard?

Ms Helmstadter: Yes, I think that's right.

Mr Jackson: The regulations currently are silent? They just simply say a certain amount of care by time, but it doesn't clearly define --

Ms Helmstadter: A number of hours of care is what's defined.

Mr Nousiainen: It says "nursing care." Nursing care could be lots of other kinds of care, not necessarily by a registered nurse, so it's quite open.

Mr Jackson: Mr Chairman, have we heard from the minister on this question, how specific the regulations may be in this regard? Because I was not here the day of --

Mr O'Connor: No.

Mr Jackson: So she hasn't responded to that question. Could I ask you then, have you currently been invited to participate with the ministry directly in assisting it with writing of those regulations?

Ms Helmstadter: No.

Mr Jackson: So you've not been invited by the government to participate. Can the parliamentary assistant tell us when he expects to have those regulations maybe?

Mr O'Connor: That won't likely follow for some time, because the staff that we've got assisting us in going through this process will of course be the staff involved at the other end of the process with the regulations.

Mr Jackson: So we have absolutely no idea when these regs might be available?

Mr O'Connor: It won't be until after the bill --

Mr Jackson: I don't mean specific to February 8. I mean this year, next year, before 2001?

Mr O'Connor: This year some time, I would hope.

Mr Jackson: Is there a process in place, Mr Chairman? The PA's very helpful in this regard.

Mr Wiseman: You have to wait for the bill to be passed.

Mr Jackson: Has the minister advised the PA whether there is a process in place --


The Chair: Mr Jackson has the floor.

Mr Jackson: Has the minister advised the PA if there is a process in place which will involve this organization in the development of those regulations? That's generally the norm, because if the regulations flow from these public hearings, they certainly won't be the regulations that the government is about to draft.

Mr O'Connor: I'm sure Mr Jackson realizes that in the course of creating regulations, for any areas of concern that have been brought up that could be reflected within the regulations by any group, including ONA, then of course the ministry would then go to them as well for some comment.

Mr Jackson: Some comment, but after the fact. Okay.

Mr O'Connor: I appreciate his concern.

Mr Jackson: I just wondered if there was a process set up. That's all I'm really asking. I've sat on enough health care bills to know that with regulations, more often than not, the principal players, the OMA or whomever, are invited to participate and assist in the drafting only from the point of view that in the interests of time -- and certainly we're told that we really want to get on with long-term care, not draft it and then send that out for public consultation. That's all I was getting at. I just wanted to know if you could formally state that you had a process in place that did that.

The Chair: Excuse me. Just on the specific question of the regulations, Ms Sullivan had a supplementary, and then I'll recognize Mr Wiseman after Mr O'Connor has his final one.

Mr Wiseman: Just a quick comment. One of the difficulties, it would seem, is that to try and write the regulations when the bill is still out in committee and you don't really know the final text of the bill would be very difficult, so the regulations will come at a later point.

Mr Jackson: I don't think quality assurance will be eliminated from the bill. That's what we're building the regulations around.

Mr Wiseman: But how do --

The Chair: Order, please. The point is noted. Ms Sullivan.

Mrs Sullivan: I think this question about the unregulated workers, the paraprofessionals and so on, speaks to two issues. One of them is partly in the scope of practice in the regs under the RHPA. I don't know if this bill is the right place for those issues, but it's a very interesting matter you've brought forward.

I think Mr Jackson's question relates to the consultative process with respect to the development of the regulations under this act. I think what we would like to see is a response from the ministers, particularly the Minister of Health, who has carriage of the bill, as to what the consultative process will be in the development of the regulations.

We feel, and I think most of the intervenors have felt, that we are at more of a loss because so much of this bill is included in the regulations and we are unable to see the full intent of the government. What we are hearing is kind of ad hominem statements of policy, if you like, with respect to the intent, and the general reading of the bill, we are told, is not what the intent is.

I think it would be useful for us to have a clear direction from the minister on how she will proceed in terms of the development of the regulations.

The Chair: Mr O'Connor, one last comment, then I'm going to speak to our witnesses.

Mr O'Connor: I will take what my colleagues have said here under advisement. As far as coming up with a definite plan, deadlines and what not, I'm sure that's not possible because it would be too difficult to arrange, but as for some sort of a sketch to perhaps allow some discussion as we get further into clause-by-clause, I'm sure that would be possible.

The Chair: Would you like to add anything to this, whether you're clearer?

Ms Bell: Yes, I'd like to just finally say that one of the reasons we expanded our submission to include areas a little outside the technical aspects of the bill was to get our points across as it related to what may be required in regulation. We would be very happy to be involved in the regulation formatting process and that whole thing, but one of the reasons this bill is a little wider than the scope of Bill 101 is in fact to capture those issues that are currently occurring in the system. Our fear is that they're going to get even worse before the long-term care reform is finalized.

The Chair: Thank you again for coming. I see we are sending you away with more weight in terms of documents.

Ms Bell: And we appreciate getting them.

The Chair: We thank you very much for a lot of very specific points, and the committee will be addressing those.


The Chair: Could I next call upon the representatives from the Federation of Provincial Non-Profit Organizations Working with Seniors in Ontario. Would you be good enough to come forward. Welcome to the committee; please make yourselves comfortable. Would you first of all identify yourselves for Hansard and then please go ahead.

Mr Bob Morton: My name is Bob Morton. I'm the president of the Federation of Provincial Non-Profit Organizations Working with Seniors in Ontario. It's probably the longest name of any organization. With me is an executive member of the federation, Dr Gordon Romans, a member representing the Senior Talent Bank Association of Ontario.

We'd like to begin by giving a few comments about what the federation is and then just share with you our thoughts with respect to a couple of general philosophical areas or issues that are raised by Bill 101.

The Chair: If I might just note, I see some members searching for text. There isn't a text.

Mr Morton: As a voluntary organization, we are not blessed with staff resources. The members of the board represent various provincial organizations. We will, however, subsequent to our presentation today, prepare a summary of our remarks and distribute that to the members of the committee.

The Chair: That's fine. We welcome you and we are glad you have come today.


Mr Morton: The organization has three kinds of members, all being provincial organizations: consumers, providers and advocates for services for seniors. The consumer members are a very important component and include organizations like the Canadian Pensioners Concerned, Ontario division; the Senior Talent Bank Association of Ontario, which Gordon represents; the Older Adults Centres' Association of Ontario, which is also a service provider in that a number of home support services are provided by OACAO members. Concerned Friends of Ontario Citizens in Care Facilities is a very active member of the federation.

The provider members as well represent a diverse range of service providers. Some provide services exclusively to seniors, others have as part of their broader mandate seniors as consumers of their services. The provider members include ALOHA, the Association of Local Official Health Agencies; the Canadian Hearing Society, Ontario division; the Canadian Red Cross Society, Ontario division; the Ontario Association of Non-Profit Homes and Services for Seniors whom you heard from this morning; the Ontario Community Support Association, an organization that has brought together three provincial organizations, Meals on Wheels of Ontario, the Ontario Home Support Association and the Ontario Association of Visiting Homemakers -- those are three sets of initials that you can forget now because of the new provincial organization -- the Victorian Order of Nurses and the Association of Community Information Centres in Ontario.

The federation was formed not to lobby government with respect to issues, though it certainly has become part of its activities over the past few years, but the member organizations came together to share ideas, to look at the opportunity to share services, to build upon each other's strengths.

We were able to respond to the former government's strategies for change with a major document called Managing the Transition, and you, as members of the Legislature, would have received our most recent publication, An Emerging Public Policy, our response to the redirection paper that the present government proposed.

What we would like to do today with that introduction -- and I should add to the introduction two other representative member organizations that are represented today by people sitting in the gallery: from OANHSS is Mary Jane Large and from the Ontario Community Support Association is Val Barkey. They're here to lend some support to Gordon and myself.

There are three issues we want to cover, two of them to a degree of depth and one of them briefly. I'll ask Gordon to speak about the first area of concern that we have with respect to Bill 101.

Dr Gordon Romans: From the perspective of the consumer, the proposal gives a minimum of consumer choice. It does not offer the consumer choice of facility re ethnic culture or religion but only nursing and personal care. The system of appeal is confusing and bureaucratic and needs to be easy and simple and consumer-focused. Admission criteria do not recognize psychosocial needs but only those needs concerning nursing and personal care.

We have great concern for the people who may fall in the cracks, who don't really fit in any system. There will be such people. You're going to deal with seniors who are frightened of bureaucracy and they will tend not to want to get involved. Quite often, these are the people who really need help. Also, we would like to know how the needs are met with people who don't score high enough for facility admission. Will there be any clear indication of these things? What happens to the person who does not want to go where he is sent? This is certainly not addressed in the bill.

Community-based services are currently severely restricted by funding restrictions and the availability of trained staff and volunteers. The bill will limit accessibility to care without growth in the community support service and makes no allowance for volunteer involvement in the system, for example, money for volunteer training.

The bill prescribes relationships between provider and consumer that do not seem to result in the integrated system that is required of proper long-term care.

In closing, I'd like to draw to your attention the submission of the federation concerning volunteers. With your permission, I'll read it to you:

"The federation of non-profits envisions in any successful community model a significant role for volunteers. There is no reference in the paper to volunteer groups, associations or individuals, who play such a large part in care and support services, nor is there any reference to those seniors who are not only looking after themselves but who are now active care givers. This dismissive attitude is not conducive to a positive, cooperative partnership.

"The federation of non-profits cautions the ministers not to professionalize the system so completely that there is no need nor place for volunteer involvement."

Mr Morton: The issue I would like to speak to is one that is introduced by the name of the federation of non-profit organizations. Government policy for a number of years has said that preference in the health and social service sector would be given to non-profit organizations. This policy is not new. The Progressive Conservatives made that a statement of policy some years ago. The Liberal government followed up with similar statements about growth and expansion, ensuring that there would be a preference for non-profit service providers. Then in the current government's policy statements, the preference for non-profits is stated again.

I guess we're disappointed as a federation to look at Bill 101 and not find any way in which this policy direction is supported. We believe there are lots of good reasons to initiate a system that is fully supportive of the not-for-profit service system.

When we look at the fundamental difference between non-profit organizations and for-profit organizations, looking at their missions, if I'm a for-profit provider, my initial mission is to generate revenue, a profit, a return on my investment. If I'm a non-profit provider, the reason I'm in the business is because I recognize the community need and I want to find ways through my organization to meet those needs.

Certainly there's lots of evidence by the organizations represented by the federation that this has been what they've been doing. The members of OANHSS, back in the homes for the aged days, back in the homes for refuge, were in the business of providing social services. The Red Cross and the VON are humanitarian organizations that were structured not because government funding was available to enable them to provide a service but because they saw the need for service in a community and did what they could to rally resources to meet those needs.

Our organizations recognize that there are real challenges to provide service to the diverse aspects of the province. Our rural areas tend to be underserviced, but where there are services, they're by not-for-profit organizations, not by the proprietary sector. That's because there are additional costs. So the mission of wanting to serve becomes the reason for being in business in those areas.

In reading Bill 101, we're disappointed to see no reference to the role of boards of directors of not-for-profit facilities. I think the important role of boards of directors is to underscore how organizations can be accountable to the communities they serve. Boards, as we see them evolving over time, are continuing to look at new ways of engaging their consumers, of understanding the needs of their communities and responding to them.

I guess when we look at the accountability measures that are proposed, we look at another major sector of our not-for-profit service system, the public hospital system. Public hospitals are essentially the same as a non-profit, long-term care facility. They're providing health services. They're meeting the needs of vulnerable individuals. They are accountable to their communities through boards of directors. They're not inspected in the way that is being proposed for the non-profit, long-term care facilities under the legislation.

Quality of care really is the focus of a non-profit organization. Over time, non-profit organizations have been the leaders in developing the standards that we're now asking government to enshrine in legislation and regulation, and I think we firmly support that. We look into the community sector, for example, and know that the initial standards for the delivery of home support services were developed largely by the current non-profit providers of services, along with the support of government in that endeavour. So quality is ensured through a non-profit service sector.


Then we come to the issue of financial responsiveness and financial resources. I think as we look at how our non-profit service agencies are working now, we know they only survive as a result of a commitment by their communities to what they're doing. It's not just government funds that make home support agencies work; it's other sources of revenue that they develop. Those are real challenges.

As we look at how our system has evolved, we must not lose our ability to have our agencies connect to the communities they serve, because it's in that connection that they gain great support and through that connection that they also are able to demonstrate accountability.

As members of the Legislature, accountability is certainly most important to you. You are responsible for the funds you raise and you're responsible to the public to ensure that they are delivered. That responsibility is really little different than the responsibility that municipal board members of municipal homes for the aged hold or the charitable organizations that operate charitable homes for the aged or the board members of the community service organizations as well.

As you are giving consideration to this bill, I urge you to recognize that there is little within Bill 101 that supports a current social service system that has a strong connection to the community. I would not want to imply that the system is perfect. The system does need changes and those changes have been advocated by those providers of service for a long time. We look forward to the changing system.

Just a few final comments on a third issue we see. We raise this as perhaps a caution for you. There is a proposal within Bill 101 that direct funding be provided to the disabled, involving amendments to part IV of the Ministry of Community and Social Services Act. I guess we're concerned that the way in which that is worded appears to discriminate against senior consumers who may be able to manage their care, who may have the cognitive resources to do that. The way in which the legislation appears to us, that is limited to younger people who are physically disabled. Just because you've turned 65 doesn't mean your disability may have gone away. In fact age brings many challenges in many disabilities that individuals need to cope with.

That's the conclusion of our brief remarks. We're not here to speak in strong opposition to Bill 101. We're here to give you our thoughts with respect to the bill and perhaps to state very firmly that redirection of long-term care should proceed. The field, the consumers, the individuals who are involved in the system really need the improvements that have been promised, so we look forward to that.

The final comment we're making is that we do see some lack of congruency between Bill 101 as it's proposed and the policy statement that was made through the redirection document.

The Chair: Thank you very much for your presentation. We have some questions and we'll begin with Mr Wilson.

Mr Jim Wilson: Thank you for your presentation. I think when you use the term "not-for-profit" or the "non-profit sector," what you're talking about in the cases of homes for the aged or charitable homes, I'd agree with you that that is a sector that's been proven to have the confidence of the public and that yes, successive governments -- it doesn't seem to matter which party's in power -- have moved in that direction.

I guess to clear the record, though, when you hear my party in 1992 and 1993 complaining about the not-for-profit sector, it's in some of the new, emerging not-for-profit programs like day care where we find the new executive directors of non-profit day care are making far more money as "bureaucrats" than the previous owner of the day care, who might not have ever made more than $18,000 or $20,000 a year as profit. So that's where we have a bit of a problem.

I want to ask you, along that line, do you not feel that there should continue to be a mix in the nursing homes and homes for the aged sector between the private sector and the not-for-profit sector? For instance, what comes to mind immediately is the tremendous capital that the private sector has invested in nursing homes. We could never afford to buy them out, it would be my guess. Perhaps in a Utopian society we could, but I think there is a strong role for the private sector and I would suggest that we need its involvement.

Mr Morton: I would like to sort of make my response to that by cautioning that I don't want to speak just on behalf of homes for the aged. You've had a presentation from OANHSS, which is representing the homes for the aged, and we've tried to be more global in our approach. I guess I could say that a mix of for-profit and non-profit providers within the system is important or is probably reasonable. But when we look at the service system, the long-term care system in particular, and we see that over the past 10 and 15 years the only growth in that system has occurred in the for-profit sector, we see that balance has changed.

Mr Jim Wilson: Yes. In spite of government policy.

Mr Morton: There are more beds in the for-profit nursing homes than there are in the non-profit homes for the aged, charitable and municipal and the few not-for-profit nursing homes. The balance is off, and at the very least we need to ensure that the balance is appropriate. I recognize the issue of major shifts within the system. We believe that the principle of non-profit service delivery is really most important.

Mr Jackson: First of all, Bob, good to see you. Just on that point, though, part of the reason for the non-growth in one area and the perceived growth in the other is because the government does control expansion plans for homes for the aged. There is a whole series of facilities in Ontario badly needing redevelopment moneys that have been told, "You reduce the number of beds and we'll give you redevelopment money," from chronic care hospitals, which were discussed yesterday, to homes for the aged.

Halton Centennial Manor in Milton, in order to get $4 million out of the provincial government, had to drop 125 beds. You just can't keep doing that everywhere in the province and meanwhile the private sector is relinquishing its licences, so the imbalance will continue. Unfortunately, the trend of the downsizing or rightsizing, as some people are referring to it, of the chronic care sector will continue.

Anyway, I just wish to state that Mr Morton and I went to school together and I currently work with his father. This is sort of an intergenerational thing. His father manages a seniors' residence through his work with Rotary, and they've recently done some wonderful leading-edge work in Halton region. Certainly the benefits of the son and the benefits of the father are appreciated in our neck of the woods, even though I know Bob's facilities are down in the peninsula.

Mr Morton: No, in Huronia, Penetanguishene.

Mr Jackson: Sorry. Huronia, the Penetanguishene area.

The Chair: We're always delighted to get these links. We'll move on to Mr White.


Mr White: I want to thank you both, Mr Morton and Dr Romans, for your presentation. Just before you presented, we heard from nurses who represent people in facilities such as the ones that you represent. We've heard from workers and unions which represent people in both profit and non-profit facilities. They came down pretty clearly on one side of the picture, and they had some real strong concerns about accountability which I believe are addressed in the legislation.

Your centres, though, the ones that you speak of, don't have that need for accountability because you're already accountable; you're accountable through boards of directors, through community input, through residents' councils and through incredible numbers of volunteers who are actively involved in the centres. So there's been a bit of a conflict between some people who are saying, "Why should we be accountable when we already are?" and others who have not had that level of accountability in the past. I'm wondering if you had any comments on that issue.

Mr Morton: I don't think any service provider would ever be able to state that they should not be accountable. There are different ways in which accountability can be demonstrated, and I think we need to find the right accountability mechanism for each different organization. You can't, in my view, develop a single accountability mechanism and apply it against all different types of service providers.

One of the best ways, though, for government to ensure accountability, the most effective and efficient way, is to build upon those existing accountability structures. So if an organization is able to demonstrate its accountability to its community, then government should be able to recognize that and not start from square one with that organization to try and find a way of proving that it's accountable.

Mr White: Indeed, very sensible. The other issue I want to pick up on is the fact that people from many facilities such as the ones you represent -- and of course you also have many advocates, concerned pensioners, concerned friends etc -- talked about not just the medical needs, not just the pharmaceutical needs or whatever of residents, but of a wide variety of needs, psychosocial issues, religious and cultural issues, which I haven't heard from other presenters. I'm just very struck with it. It was from the non-profit sector that the recognition of psychosocial needs came forth. I'm wondering if you had any comment about that and how you'd like to see those issues recognized in legislation.

Mr Morton: I don't propose that I could write legislation; that's a difficult task at the best of times. But I think if we look at legislation that allows organizations that are responsible to their communities and responsive to their communities to grow and flourish, and those tend to be non-profit organizations with cultural roots, ethnic roots, religious roots, then they'll be able to grow and respond if the legislation enables them to do that. So we have the particular concern about the placement piece of legislation that may not take into account what the individual consumer wants, and if we don't look carefully at that, then we're going to perpetuate what's essentially been a provider-driven system: Providers make the decisions for consumers, providers slot consumers into boxes and then the consumer is stuck there.

We need to have a major shift in our providers so that they start to work with consumers and recognize how important it is for consumer input and consumer activity with respect to that decision. The legislation as it's proposed really doesn't do that. It perpetuates really a medically driven type of system: You go to a professional who will assess you. I really don't wish to speak against professionals -- their role is very difficult at these times -- but it will require among professionals a shift in their focus as they start to work with their clients, the residents of a facility or the patient of a physician, to ensure that the individual's needs are met, not the systems' needs.

Mr Hope: Mine's very short. I didn't catch the whole presentation -- I apologize for that -- but your last comment, dealing with the Ministry of Community and Social Services Act being changed: You said something about the disability not going away at age 65, and I just wonder, for my own clarification, what you meant by that.

Mr Morton: The point that we were making is, the legislation proposes to be able to fund disabled persons directly to manage their care, and that is a discriminatory clause in that it implies that direct funding is only available to people who are disabled, not to all individuals who may wish to avail themselves of a direct-funding model of achieving services.

Mr Hope: Okay, I just thought you meant that at age 65 they got cut off, and that's why I wanted some clarification.

Mr Morton: The way the legislation appears, it would imply that that would happen.

Mrs Joan M. Fawcett (Northumberland): Thank you for coming and presenting your concerns, concerns that I think we all have. One area, and you briefly mentioned it, is rural care. I think we would like to assume that everyone is going to be covered under this, but I wonder too whether or not this bill really directs itself to rural people. Their service delivery could be slightly different. It could be harder to obtain psychogeriatric services, for instance, and just any other kinds of services that they could maybe have access to in their homes to keep them in their homes, as well as then the issue around the placement coordinators and their choice, because we know that rural people like to remain in the rural community and we feel that's very important. So I wondered if you had any comments around that, again whether or not this is going to be all in the regulations rather than what we see or do not see in the bill.

Mr Morton: The federation certainly recognizes that Bill 101 is not comprehensive long-term care reform legislation; it looks after some pieces of it. We're most anxious to receive the government's policy statement that was anticipated late January or early February, dates that we're wondering about these days. Long-term care reform cannot be instituted incrementally. It's a large system with many interrelated parts to it, and if we just do a little bit at a time we'll never achieve the integrated system that was envisaged by Strategies for Change or by Redirection of Long-Term Care and Support Services in Ontario.

So in response to your question, Bill 101 doesn't do anything for rural people, and there are different delivery systems that are required in order to meet their needs; not necessarily more expensive, just different, something that's appropriate for different parts of the province. I'm not sure that Bill 101 supports that in any way in particular.

Mrs Fawcett: Or that we will see anything forthcoming.

Mr Morton: I remain hopeful that we will.

Mrs Fawcett: I know people in the farm community in their book Rural Roots certainly made some recommendations that they wanted to see, because they realize that possibly they've been omitted or overlooked, and we certainly hope that's not true.

The Chair: I have a short question from Ms Sullivan, and I inadvertently omitted Ms Carter so we'll go back and pick her up when you finish. It might be a long question.

Mrs Sullivan: My question isn't particularly to this presentation. It's to request additional information.

The Chair: Okay, we can go to Ms Carter, and I'll come back then, Ms Sullivan.

Ms Carter: Only two points at this time. First of all, you said that there's no allowance for volunteers' involvement in the legislation. I was just wondering what you might suggest could be in there that would solve that problem.


Dr Romans: I think the bill eventually has to realize that in order to develop home care and other aspects, there's going to have to be a large number of reasonably well-trained volunteers. There's no provision in the bill to show that the necessary things for developing trained volunteers are in it. Certainly, as an example, in home care -- I think the bill implies this -- people will be able to get a weekend off, so you're going to need a large number of reasonably well-trained people to go in and look after a stranger for a week. I think you all realize it's getting more difficult to get volunteers. There isn't a hospital in Ontario that doesn't have a waiting list for volunteers. Certainly, none of the volunteer organizations have enough. I think that whole framework has to be expanded to be consistent with the demands that are going to be put on it.

Ms Carter: I certainly agree with you about the need for volunteers and how vital they are. I'm just not quite sure how you can legislate for that, though.

Mr Morton: I think you can establish funding legislation that recognizes that a key piece of this is that the organization needs to be able to support volunteer services.

Ms Carter: Pay costs and have somebody to organize them.

Mr Morton: Yes. You need a structure, a bureaucracy, if you will, in order to have an appropriate volunteer service, to recruit, to train, to recognize and reward the work that volunteers do.

Dr Romans: I think a quick statement to that is that it's well known that volunteers are cheap but they're not for nothing. In order to train volunteers and enlarge the volunteer organizations in the province -- this is particularly true in the rural areas. There's going to be a higher proportion of help coming from those people in the rural areas than perhaps in the built-up areas.

The Chair: Thank you very much. We appreciate your coming before the committee today. I believe you mentioned there will be a text following and we look forward to that as well.

Mr Morton: Thank you, Mr Chairman. We look forward to responding to you, and thank you for the opportunity.

The Chair: I'm going to call the next witnesses from Chester Village to come forward. As they do come forward, Ms Sullivan, you had a request to make and we can deal with that.

Mrs Sullivan: Yes, I do. Mr Chairman, I think through about three or four presentations, witnesses have referred in their briefs to the sanctions that the government can impose if the service agreements are breached. We have not asked questions of them just because of the time element. I wondered if we could have a further briefing note from the ministry as to the effect of the sanctions that are funding-based.

The bill provides that subsidies can be reduced or withheld completely if the service agreements are breached. I think the concerns that have been raised are: What happens to the care of other people who are in the home if the funding is withheld or if the funding is simply taken away; what becomes the liability of the home for the provision of the contractual service and the liability with respect to the resident, and what then becomes the liability responsibility of the ministry which has taken the action that may put people at risk in the longer run?

We have not asked any questions on it. It was in the Metro brief, it was in a couple of briefs yesterday, and I think we should have some more information on that.

The Chair: Could I pass that on?

Mr Hope: On that area, it sounds like it's being presumed that this is going to happen, that it'll be automatic. It's a first reaction. I believe in order to get a proper picture, we need the process of what would be the stages before that even happens. I think in order to make the picture full, we need the full synopsis of what might happen to that.

The Chair: I think that would be fine because I think it is what is envisaged -- am I right? -- in terms of how that would work. Could we pass that through the parliamentary assistant, and perhaps you would raise that with ministry officials?

Mr O'Connor: Mr Chair, as the question was brought up, I noted that our people from the ministry were writing that down furiously to make sure they caught the intent behind it and so noted the friendly amendment, the suggestion by Mr Hope.

The Chair: We furiously accept.


The Chair: Gentlemen, thank you for coming to the committee. We welcome you this afternoon. Would you be good enough to introduce yourselves for Hansard and then please go ahead with your presentation.

Mr Allan Day: I'm Allan Day, vice-chairman, Broadview Foundation.

Mr Paul Klamer: My name is Paul Klamer. I'm the administrator of Chester Village.

Mr Day: This is our submission to the standing committee on social development regarding Bill 101, the long-term care reform bill. I might start, by way of introduction, by saying that the Broadview Foundation owns and operates a 174-bed charitable home for the aged called Chester Village, which is operated by a 12-person voluntary board. Chester Village provides living accommodation for persons 60 years of age and older in accordance with the Charitable Institutions Act for the province of Ontario.

The Chair: Sorry to interrupt, but could I just ask you again, for Hansard and those people who will be reading it, where Chester Village is located.

Mr Day: At 717 Broadview Avenue, at Broadview and Danforth in the city of Toronto.

Chester Village shares many of the government's own goals with respect to the future of seniors' care and would like to see Ontario's system of long-term care improved. At the same time, Chester Village would like to see many of the strengths of the current system of long-term care preserved within the new system.

Chester Village appreciates that a responsive and effective long-term care and support system is one that will be flexible to the changing needs of seniors. Our board believes that it has demonstrated its commitment to this principle over the past years by providing a continuum of care to our residents.

It is the philosophy of Chester Village that individuals must have access to the service which will allow them to remain in their own homes for as long as possible. However, policy trends must also recognize that a proportion of the population will always require medical, social and psychological services within the facility sector.

Chester Village and the long-term care reform bill: As a member of the non-profit sector, Chester Village shares the government's commitment to the four principles outlined in the government's discussion paper, Redirection of Long-Term Care and Support Services In Ontario, namely, the privacy of the individual and the right to dignity, security and self-determination; promotion of racial equity and respect for cultural diversity; importance of family and community; and equitable access to the appropriate services. In our view, however, Bill 101 does not reflect these principles. The following section is a brief assessment of Bill 101 as it relates to the preceding principles.

As far as the privacy of the individual and the right to dignity, security and self-determination are concerned, while we agree that seniors do not wish to sacrifice their individuality or dignity, we also affirm their right to participate in determining what services they require and how they are provided. We accept this premise as outlined in the discussion paper. We feel, however, that the need for consumer choice is not fully recognized in Bill 101. Currently, seniors face no restrictions in choosing the care services which best suit their needs and resources. Our concern is that the service coordinator's function of the bill may restrict the choice available to them.

Seniors must be able to choose the type and provider of care. The service coordinator functions must provide seniors with as much information as possible on the full range of long-term care organizations, and enable seniors to choose options based on their individual needs, preferences and financial resources. It should be recognized that seniors, perhaps for personal reasons, may request a certain service or organization -- they may, for example, have been a volunteer or a supporter of Meals on Wheels or a home for the aged in the past -- and these preferences must be respected as much as possible.

It should also be recognized that seniors, having weighed the options, may decide to live in a non-profit facility. They may appreciate that our sector considers the needs of the whole person, including the psychological, social, emotional and spiritual needs, as well as medical and nursing needs. They may recognize that our sector offers a sense of security and safety, which is very important to all of us, and they may note that a non-profit facility offers a continuum of care, which means simply that the changing needs of the seniors can be met in the same homemaking setting, thus minimizing the amount of disruption and change in their lives.

The eligibility criteria for seniors seeking admission to a long-term care facility clearly limit the person's right to choice. For example, many applications to our facility are from married couples or siblings who have lived together for a number of years. Most often in such cases only one of the applicants would meet the eligibility criteria for admission. The well spouse or sibling, who has acted as the primary care giver at home, often chooses to make a joint application for admission to optimize the couple's quality of life. The new eligibility criteria as set out will now preclude such admissions, negatively impacting the quality of life for some seniors.


The promotion of racial equity and respect for cultural diversity: Chester Village supports the goals of long-term care reform, as stated in the discussion paper, to provide services that take into account people's different values, religions, languages and customs. We feel that our sector, representing municipal and charitable organizations, has met these needs on an ongoing basis. It is our experience that seniors and their families are most comfortable accessing services through familiar organizations, including cultural and religious groups. This is because these organizations have a unique understanding of the cultural needs of their members, including their senior members, which allow them to provide appropriate and sensitive service.

Our concern with Bill 101 is that it may unintentionally restrict or thwart the current freedom enjoyed by these multicultural, linguistic or religious organizations. The bill as written does not provide explicit guarantees and implicitly does not recognize the important contribution of these groups in the delivery of care to seniors. These groups must be included in the service coordination function and in all aspects of planning and management, and we seek an explicit amendment to remedy this situation.

The importance of family and community: We could not agree more that it is important for people to maintain relationships with family and friends within the broader community. We also agree with the discussion paper's goal to involve community in the new system of long-term care.

As an organization committed to helping seniors, we agree that individuals should be given as many options as possible to allow them to stay in their own homes as long as possible, with adequate services where necessary, and provide facility care where appropriate. We want to stress the importance of the whole range of services available to seniors.

The non-profit sector has historically provided support to families and care givers. We feel that the long-term care reform should recognize the contribution of families through their resources and care, by providing support services including counselling and support groups as well as basic training.

Chester Village is completely comfortable with community involvement and accountability in the delivery of service to seniors. Our organization has a tradition of community involvement and openness in the delivery of services to seniors. Non-profit organizations were founded by their respective communities and remain responsible and responsive to the needs of the community through direct community representation on their boards of directors.

We welcome the accountability provisions in the act but we do have some concerns about the inspection provisions. As we said, accountability and responsiveness are part of our history, and we would like to see some recognition of the unique partnership that has evolved through our history and has served our members very well. At the same time, we recognize the need for accountability to the province and taxpayers and do not see these goals as incompatible or mutually exclusive.

To this end, we propose that the ministry establish clear rules and controls for inspection activities, including an appeal process for these monitoring and sanction decisions. We suggest that inspections be motivated by a focus on the needs of seniors and that a full report be filed within a specific time period, like 30 days. We feel strongly that inspections should be limited to those activities and services funded by the province.

Equitable access to appropriate services: Finally, we concur with the government's fourth principle, that there should be equitable access to service for seniors throughout the province. Chester Village fully supports the principle of equitable and simplified access to long-term care services through the establishment of the services coordination function. This coordination function must be responsive to the existing structure and models that are already working effectively. The new function must build on the strengths of the current model and, if possible, result in a less complicated and more timely system. It must take into account the diversity of the communities through Ontario, including the geographic, linguistic and ethnocultural differences as well as the unique resources available.

At the same time, standards must be in place to ensure consistent and equitable distribution of resources. These standards would govern the assessments, user fees, placement decisions and service delivery thresholds for community-based and facility-based care. These standards must ensure that assessments are conducted fairly and impartially and that referrals respect the needs, preferences and financial resources of the individuals.

Chester Village is concerned that the anticipated growth in the seniors' population in the next 30 years will require a network of supportive housing and comprehensive guidelines for the future needs of seniors. We strongly support the principle of universal access to a range of services, regardless of where seniors live in Ontario. We also urge the government to define a range of services to be provided in all communities.

We are deeply concerned about the funding arrangements in Bill 101. In recent years, the financial contribution by the provincial government for long-term care facilities and beds has not kept pace with the increasing demand for care. The system of funding facilities based on classifications made approximately 10 to 12 months earlier only heightens our concerns. Having said this, our more immediate concern is with the probable delay in the actual implementation of the new system. Such a delay in funding may cause organizations undue financial hardship in the first half of the next fiscal year.

Specifically, the current funding model provides organizations with a cash advance in subsidy payments. This allows organizations to meet the day-to-day operational costs incurred by the facility, pending approval of annual budgets and allocation of funding. We understand that the implementation of the system may be made several months into the next fiscal year, with funding being given retroactively to April 1, 1993. Although such a commitment is commendable, the operational shortfall in cash must be addressed.

Another area creating concern is the availability of capital funding for upgrading physical plant. We understand that under the new system, a facility will have virtually no right to refuse an applicant. The admission for seniors requiring special needs or types of care, like cognitively impaired seniors requiring a locked unit or seniors with psychogeriatric problems, will require funding for upgrading and renovating the physical plant of many facilities. If such funding is not forthcoming and facilities are required to admit seniors with needs that cannot be met, the question has to be, where does the responsibility for liability rest in the event of an accident or incident? We believe that a process for appealing inappropriate admissions is required in cases deemed to pose risks that may jeopardize the health and safety of other residents and staff.

Although the province is imposing provincial standards on homes and services for seniors, it has not committed itself to adequate funding arrangements, which are necessary for a high standard of care. We fear that this signals a future decline in provincial support for long-term care. An amendment is required to directly link quality assurance plans with provincial funding commitments.

In addition, Chester Village believes that fixed accommodation and program costs should reflect the levels of care required by seniors. At present, only nursing and personal care costs are based on the levels of care required. Special nutritional, accommodation and programming costs can vary greatly, depending on the care needs of seniors, and funding should reflect that reality.


Chester Village believes that user fees for community support services, as well as for accommodation and facilities, should be based on ability to pay. In fairness, we feel that the discrepancy between a no-user-fee policy for in-home care and a user fee policy for facility-based care must be resolved. There should be congruency between fees for chargeable services for seniors in facilities and for seniors receiving in-home service. Clearly, the promotion of no user fees for service in the community contradicts the government's fourth principle, equitable access to services for seniors in the province.

Chester Village also fears that the government's emphasis on in-home services will eventually lead to an increased number of heavy-care seniors turning to facility-based care. Unfortunately, the proposed funding arrangement in Bill 101 will not provide adequate funding for this eventuality. The funding formula for facilities must recognize and support this reality.

Chester Village believes that seniors and their needs must be the focus of the new long-term care system. As well, the restructured system must fully reflect the four principles included in the government's discussion paper on long-term care reform. We feel that certain constructive amendments are necessary to improve this bill, and we urge the committee members to seriously consider our suggestions.

In particular, we feel that the system should build on the strengths of the current system. It should be more responsive to the unique cultural, religious and linguistic care needs of people. Seniors must be given as much autonomy as possible to remain in their homes for as long as possible, and where facility-based care is needed, the system should be administered in the least bureaucratic manner possible. The new system should accommodate the system of community accountability unique to the non-profit sector.

Consumers must continue to have the choice of access to a full range of care options, and services must be relevant to each community's need. With respect to funding, there must be adequate support for all components of the long-term care system, and user fees must be fairly applied.

Chester Village is grateful for the opportunity to participate in the development of Ontario's long-term care system. We offer our expertise, experience and understanding of seniors' needs, and hope that changes to the system will truly improve the quality of service and the quality of life for Ontario's seniors.

The Chair: Thank you very much for a very full brief. In looking at the kinds of problems and issues that you see, I think it's particularly useful for the committee to have a presentation by a specific home. We appreciate the time and effort that clearly went into this. We'll begin questioning with Mr Hope.

Mr Hope: In going through your presentation, dealing with the sensitivity of the consumer, how do you see that? We support what you're saying; it was in the discussion paper, as you indicated here. How do we put this into some type of legislation that covers this without getting into discrimination clauses and everything else, just putting in something that takes being sensitive to consumers into consideration?

Mr Day: I think that our administrator, Paul Klamer, who's with me today, and the other administrators we have had and the admission teams that the respective administrators have put together over the years have done an excellent job of doing that. To come up with a suggestion, I'd just say, if it isn't broken, why try to fix it? We do allow for those differences in our admissions, and I think that our residents feel very well suited and at home at Chester Village. I don't know if Paul has something to add to that or not.

Mr Klamer: I think the key here is the need of the individual coming into the home. If a person wants to come to Chester Village for whatever reasons, that they like Chester Village, then why not let them into Chester Village, regardless of some individual sitting out there looking at some criteria that perhaps would preclude this person from coming in?

We know the province is establishing a Japanese home for seniors, a Chinese home for seniors. If we allow consumers to have more say in their selection of homes, then I think we would basically eliminate human rights problems to a large extent, because I'm sure this placement coordinator really perhaps does not have the in-depth experience to know what a consumer really wants, and why shouldn't consumers choose the place where they wish to live out the remainder of their lives? I think that answers the question.

Mr Hope: As you know, through these hearings we hear different points of view, and I notice in your presentation you talked about the ability to pay. This afternoon, I believe it was, we had the question of moneys that are available, or assets, and that debate that we should tap into the assets and properties and stuff like that. I would just like to hear what your viewpoint is. I know you've probably discussed it a number of times.

Mr Day: On a senior's ability to pay?

Mr Hope: Yes. I just want your viewpoint, because I know it was a part of it.

Mr Day: My own viewpoint, and I guess this is more as a taxpayer, is that government subsidies to our place will probably double, by our preliminary estimates, and here again it gets back to the current system where people come in, they have the ability to pay, they want to pay. We provide a full continuum of care. We also provide subsidy beds which are subsidized by the residents who do have the ability to pay. So you really have in that regard, I guess, seniors financing seniors. What in essence this is going to do is force the taxpayer to pay, as opposed to the user of the service, which is the political question that you have to wrestle with.

Mr Hope: One of the things that comes up when we talk of rural Ontario, let's say the husband -- and that's usually the case -- is inside the home and the wife is still living in the community and it's very tough for them to make ends meet, because there's still the home to provide for for the spouse, the wife, to live in, and also because of the ability to pay they say, "You've got a $40,000 or $50,000 or $60,000 home there and you still have moneys available." I'm just wondering, and I know as an administrator you're probably faced with this decision about actually making sure of the ability for the senior to still live in the community and then the senior to live in the institution.

Mr Day: I may defer to Paul on that.

Mr Klamer: I don't think anyone's saying that you go to some elderly person and say, "You sell your house to support your spouse in a facility." I don't think we're saying that at all, but on the other hand, if someone has assets of $500,000 or $600,000 in stocks and bonds sitting somewhere or other, I don't see what's wrong with perhaps having that person cash in $100,000 of the $500,000 and use that to support the spouse in that facility. I don't think we're saying that you go in and hold them up and make them sell their home and eat dog food, but at the same time, there are many people in our facility who want to pay and have the ability to pay, and I see nothing wrong with that philosophy.

Mr Day: And not only are they wanting to and have the ability to pay, but by doing so they are helping fund our subsidy residents and residents who are requiring heavier care. Under the new system, it will all be funded by the taxpayer instead.

I guess our philosophy is that if we have people out there who want the service that we provide and can fully pay for it on their own, as well as paying extra to subsidize the people who are less fortunate who cannot afford it or the people who are heavier care and cannot afford the heavy-care loads, why should they not be permitted access?

Mr Hope: Just one final question that I have. You talk about capital and how the government can help you out, and I notice you're a non-profit. Wouldn't we then get hammered by the private saying, "There you go, bailing out the non-profit again"? We've been hearing that quite often.


Mr Day: They may say that but I don't really think that's a reality, and I don't know that we're saying, "Just look at us in that regard versus the public sector." No matter where you are, when you make changes like this and you're forcing heavier care residents into the building, we're going to have to undergo extensive structural changes, as are the private sector participants to their facilities.

Different facilities are of a different vintage and a different building code for seniors. What we try to do, which gets back to the problem with the admissions, is that when we control our own admissions we can control a care level that gives us an optimum nursing cost. Getting back to keeping a balanced population, not only in terms of activities around the home, but we can also keep the mix to run on all 12 cylinders the whole way through and keep on a financial even keel. If we're suddenly deluged with heavy-care residents, everything becomes inefficient because our home was originally designed for well seniors and initially did not provide any care at all. When you get into heavy care and have to install nursing systems and you get more of the equipment that goes around the halls and corridors and elevators, it can very quickly become an inefficient, high-cost producer of care for seniors. The problem we get into, if you give us high-cost seniors to administer care for and on the other hand fix our revenues based to a norm, it may not take in the unique characteristics we have had to go through for that.

You're going to find that in the public sector as well. Maybe you'll just say, "It's for profit, so we don't care what happens to them," but they're obviously going to have to undergo costs, depending on the design of their facility, to meet the needs and the balance of the people being sent to them for care.

Mr O'Connor: Just one brief statement and a question. Maybe you can help me out here a little bit. I don't believe that right now you would have to take people even through a system of a placement coordinator if you weren't physically able to within the structure of your home. It's not the intention to force that upon you either. I know that seems to be a concern.

The question I've got -- and you've raised the issue and we've heard it from other people making presentations to us this past week -- has been the care for couples. Of course, the problem is when, I guess, more in some of the larger homes-for-the-aged settings that have different continuums of care, the space is limited and in dealing with limited spaces within the facilities and trying to deal with the needs of the people we're trying to serve -- could you give us a suggestion as to how we could try to fulfil the human need of a couple, to try to keep that couple together, given the limited space that we have? You might be able to make a suggestion that we could somehow transpose into a change.

Mr Day: Paul, if you want to answer that.

Mr Klamer: To answer your first question, a document was shown to us. It was some form of a draft admission criteria document consisting of two sections. The first section: to get into the facility the resident had to meet one of X number of criteria; the second section: they had to meet all of the criteria. When you looked at what the criteria were, they were basically all health-related. There was not one quality-of-life issue addressed within those criteria.

So all we would be able to take in were people who were physically ill. We have in our facility a number of people, perhaps, whose husband or wife has died; they're well but they have decided they don't want to live in their home. They don't want the hydro going out in the middle of the night and then being by themselves. They want the social activity we can offer those individuals, the freedom of having a meal prepared for them, the freedom of knowing there is a nurse in the building, the freedom to go out into the community and live their lives the way they wish. The existing document precludes those people from coming into Chester Village. Not everybody wants to live in their home until they are so sick and near death that they have to be carted out by an ambulance to one of our facilities.

What was the second part of your question?

Mr O'Connor: It segues nicely into what you've been saying. It's recognizing the need for couples, given that we're talking about limited space.

Mr Klamer: In any home, we have semi-private rooms; we have private rooms. We have a number of couples living in our building, husbands and wives, and in a number of instances one or the other may be fairly sick. On our floors, because of the organizational structure, we put our heavier-care residents and staff on lower floors from a safety perspective. The husband may live separately upstairs on a lighter-care floor, but every day the husband and wife eat breakfast together, lunch together, sit in the sunshine, talk together. They haven't been interrupted. But now he has to travel 20 blocks or 20 miles by public transit to visit his wife and he may not be up to that. So I would see that the funding would pay us for that heavier-care person and we would get less money for the husband, but then he requires less care and less staffing and I see nothing wrong with that.

Again, this admission document would break up that ability of husband and wife or brother and sister to come in together, help out and live a life of still being close to one another. I think this whole document perhaps could be considered insensitive to the quality-of-life issues. It's not the quality-of-care issues -- it addresses those quite readily -- but we're talking of quality-of-life issues.

The Chair: We have a number of people who want to ask questions. I want to be fair and allow everyone in. I have Mr White and Ms Carter briefly and then we'll jump to the other side.

Mr White: I will try to be brief. You've mentioned the quality-of-life and the quality-of-care issues. Frankly, I agree it's a real concern that it's not in the legislation, that the psychosocial needs of our population aren't described. However, what I'd like to ask you about is that under the previous legislation, under the Homes for the Aged and Rest Homes Act or the Charitable Institutions Act, is there any description whatsoever of quality of care or the level of care?

Mr Klamer: No, there isn't.

Mr White: Not at all?

Mr Klamer: If you compare it to say the Nursing Homes Act, no.

Mr White: You've made arrangements with Comsoc and you are funded for the level of care you're providing, with some problems of course. I understand, certainly from the testimony we've heard, that the level of care that's necessary in the present non-profit homes or nursing homes has really increased incredibly in the last decade. The age of the residents is much, much older on average.

Mr Day: As I mentioned, when we opened 20 years ago, we didn't provide any care at all; maybe one nurse for the whole building. Now there's probably an average of half an hour of care per resident.

Mr Klamer: To put it in perspective, when we first opened, the average age of admission was 63. Today it's 87. The average person coming across our threshold is 87 years old and is not that well. We're finding it very, very difficult to find a well elderly person. Unfortunately, the funding for those individuals has not kept pace with the care those individuals require. I don't think there's one charitable home or one municipal home in this province that can say it's adequately funded. The municipals perhaps are better off than we are because they have a tax base to draw from which we don't.

I would say to you that the funding currently is below the care we're providing. We provide the care, but it's through being very ingenious. Now we're finding that we're going to have to take those quality-of-life issues and reduce those quality-of-life things in order to find the money to put into the nursing department to enhance the levels of care required.


Mr White: That's basically something that has not been there before and is now described in legislation.

Mr Klamer: That's right.

Ms Carter: I'd just like some clarification on the point you raise on page 11. You say there's a discrepancy between a no-user-fee policy for in-home care and a user-fee policy for facility-based care that must be resolved. Surely, what the resident is going to be paying for is accommodation. So by definition, if they're in their own home, they're paying that anyhow. I'm just wondering what it is the person at home is getting free, as it were, that the person in a facility would not be getting.

Mr Klamer: I would assume that if you're going to start keeping people in their homes longer, that means perhaps someone has to help bathe them, do their shopping, take care of their medical needs. So you would have people like the VON or the St Elizabeth Visiting Nurses. We see coming out of this whole process what we would call a health care aide.

Ms Carter: But then that's free in the facility, isn't it, or it's going to be?

Mr Klamer: We will be funded for that.

Ms Carter: The government's paying either way but through different channels, so I'm not quite sure what your problem is.

Mr Klamer: We think that if we equate cost for cost, the government will be paying more to keep the person in his home than it will to keep him in our facility.

Ms Carter: I would have thought the opposite would be the case. In fact I thought that was definite. They're covering their own accommodation.

Mr Klamer: You asked for an opinion; you got an opinion. I'm not going to debate with you on that.

Mr Day: I think part of it is just simple things like bathing. If you have to have somebody get in their care, drive to one house that's three miles from the other house, it's going to take a lot more time to perform the same task than it is to go from room to room.

The Chair: We'll move on to Mrs Fawcett.

Mrs Fawcett: I was interested in the part of your brief that pertains to the new system of funding. I'm sure ministry officials will not be surprised that I picked up on that. Yesterday, we were told by Mr Quirt that the funding cannot start to flow until the bill is passed. However, this does leave you in a dilemma: How do you budget? How do you get ready? What really is going to happen? When will the money start to flow? How will this suit your particular facility. Do you have any recommendations?

Because things are now being pushed ahead, it looks like possibly the spring before the bill will again come before the House, be passed and things can start to be sorted out there. I would assume you're budgeting on the old model right now, or are you trying to work into the new method? Could you explain just exactly what you're doing and if you have any recommendations? Maybe it needs a bridge or something.

Mr Day: Paul's been working extensively lately, because we're just doing some budgets right now. Maybe he could just bring us up to date.

Mr Klamer: We have a number of budgets. What we've tried to do is to sit and plan the various scenarios that may or may not come out of this whole process. We've come up with a number of them. Unfortunately, we are not diviners so that we know what's going to happen. We call people in the ministry, we call people in facilities, and everybody we talk to seems to have a different idea of what is going to happen and when it's going to happen.

The latest scoop is that we won't be seeing any dollars until maybe September or October. Granted, perhaps we'll get those dollars retroactive to April 1, but perhaps we won't. In the meantime, how are we going to provide the care and pay the dollars out on salaries and food when we don't have those dollars flowing in but we do have the residents flowing in? Once we accept a resident, we take that responsibility for that resident.

Under your admission criteria, we can't refuse residents except for very stringent, specific things, like they need operations. We don't perform surgery at Chester Village, so we wouldn't have to take someone like that. But the central placement will be forcing on us individuals who require such a level of care that we're going to have to increase our staffing patterns immediately to meet that level of care, and we're not going to be funded on this until six, seven, eight or nine months down the line. We don't even know right now what our per diem is going to be.

This case mix index was supposed to be out to us in January. Well, we haven't got that. The residents are all upset because they've heard rumours that their rents are going to drop and the letters are going to be coming out on that. Well, we haven't got that either. So we're sitting there with a new-age budget and an old-age budget. Both are horrible because we don't know what we're doing. We're in a real predicament. The cost of this is going to be on our residents. They are the ones who are going to suffer in the short term, if in fact this thing happens at all. I would say to you that somehow -- you've got the case mix index. It's there. My sensing tells me that you've run the figures through the computer and you have found out it's going to cost you a hundred times more than you thought it was, and you're now having to try to work those case mix indexes down to meet the dollars available. That's just a guess.

Mrs Fawcett: Well, there are others who agree with you.

Mr Klamer: I would suggest to you that if we have a case mix index, then give us the dollars. Give us an advance, like you did under the old system, based on our case mix index, so that at least we have some dollars flowing in until some time in September when this thing settles down. If you've given us too much, take a little bit back. If you haven't given us really as much as we need, then give it to us effective April 1. But don't constrain us now to be admitting heavy-care people and bringing in staff and having to pay for them without having the ability to have the funds flowing to have the money to pay.

We don't have a tax base like the municipal homes where they can go off and get Metro Toronto to pay some tax money in. We don't have an ability to get a deficit. We have no deficit funding. In order for us to have deficit funding under your rules, we would have to lose $250,000 immediately. After that we would perhaps get 50-cent dollars under the existing deficit arrangements, because your deficit funding does not take into consideration mortgage payments and interest payments on the mortgage and those things.

Municipal homes don't have mortgages. Their capital dollars are paid for out of the capital budget of the municipality. That's why they have more money to spend, because they don't have to pay their mortgages out of the money flowing into their units. We do. Therefore, at Chester Village we would have to lose $250,000 before we could even start tapping into deficit funding of 50-cent dollars. It's not fair. You're expecting us to take all these heavy-care people in. We may get our dollars or we may not get our dollars some time down the line. I would suggest that's insensitive and unrealistic. I guess that's my only comment.

Mrs Fawcett: I thank you for that broad-brush painting.

The Chair: Mrs Sullivan and Mr Wilson, and would members just be mindful of the clock.

Mrs Sullivan: Thank you. I was interested because it's the second time, I think, that the issue of capital funding for improvements to the non-profit sector has been raised in the hearings, with your presentation. Would you just advise me, did the last government, before it left office, flow something like $140 million for capital improvements in the homes-for-the-aged sector, or did the government change before that money actually flowed? Do you remember?

Mr Klamer: I can't answer about the $140 million. I do know that a number of years ago we had to do an upgrade of our second floor in order to meet the heavier-care needs and we got some relief from 50-cent dollars, but that $140 million doesn't strike a bell with me and I don't think I could answer that question.


Mrs Sullivan: The Chairman might recall whether the $140 million from --

The Chair: How to be put on the spot.

Mrs Sullivan: I'm sure the Chairman will recall. There was $140 million for upgrading which was to flow, for capital improvements, to homes for the aged. What I'm trying to recall is whether the government changed before that money flowed or in fact that money did flow in 1990.

The Chair: I'm sorry; I don't remember.

Mr O'Connor: Mr Chairman, if I might just help. From quick consultation, the period was between 1987 and 1992 and the figure is about right. It was over that extended period of time and it was 50-50 dollars.

Mrs Sullivan: It was 50-cent dollars, but what I'm saying then is that there is provincial capital money that has gone into the upgrading of the non-profit sector. As I recall, it was because many non-profit homes were exactly as yours are. They began as residential facilities, basically, and then as the population aged and the acuity of residents moving into the homes increased, the need for additional specialized facilities also increased. Plus, as I recall, there was also a recognition that ward accommodation wasn't necessarily the best approach and there was funding for private and semi-private accommodation at that time.

Where do you, as a home for the aged that has a history of beginning as a residential home, see the homes that are now rest and retirement homes that work as your home did in its initial phases and which also are accepting residents that require nursing care, in the long-term spectrum, and should they be in fact included in this kind of an approach where there is a continuum? I'm interested in that.

Mr Day: I think it's appropriate for inclusion in the system, but I think that as facilities become less adaptable to the type of care you expect them to give, you have to allow for more flexibility within the system, whether it means capital dollars that fit that or, in the admission process, the types of people that are admitted to the specific institution. You just have to allow for it, but I think inclusion would be good.

Mrs Sullivan: Rest and retirement homes as one facet of the spectrum?

Mr Day: Yes. But as long as the system is flexible enough to recognize the physical plant and equipment that you're in fact placing people in and their ability to give the care and provide the service.

Mrs Sullivan: From an old briefing note, once again going back to capital, I recall that the capital spending, the cost to build a bed in private sector nursing homes, was about $60 -- these might be old figures but the comparable ratio would be similar -- whereas the cost to build a bed in the home for the aged ranged from $80 to $105. Why?

Mr Day: You're saying the cost to build?

Mrs Sullivan: Yes, to add a new bed. I'm looking at the capital component.

Mr Day: The daily expense, the per diem for keeping a person?

Mrs Sullivan: No, the capital component.

Mr Klamer: The cost to actually construct a building?

Mrs Sullivan: Yes.

Mr Klamer: I really don't know. I could guess. Do you mean to renovate, or to build a brand-new building?

Mrs Sullivan: I think it's to add; yes, to build.

Mr Klamer: I don't have an answer for that one.

Mrs Sullivan: It's interesting; I had it in an old briefing note and couldn't understand why. But as we're looking at equalizing costs, and you've raised the issue of injecting capital into the non-profit sector, I think it's something we should be looking at.

Mr Klamer: The capital I think we're talking about there is not to build a new building. We're a seven-storey building with roughly 30 beds on each floor. To have to staff that with heavy-care residents is not a good mix of beds per floor. What would be better would be to have 60 beds per floor. You can staff it much better.

At our facility, in order to take heavier care in, we're going to have to construct nursing stations on our floors. We don't have the square footage at this time for those nursing stations, so that means we'll most likely have to go and take one or two bedrooms out of our home and make that a nursing station, which reduces the revenues of that facility. This is the type of capital cost we're talking about, to renovate our facility to accommodate the levels of care that are now going to be coming in. What we did on our second floor we'll most likely have to do on the other floors, over a period of time, as heavier and heavier care comes in.

Mrs Sullivan: That would be comparable in any facility, whether it's a home for the aged, charitable or municipal, or a nursing home, because the acuity is increasing, I would assume.

Mr Klamer: If they were built for a lighter acuity rating at inception, that would be correct.

The other thing that you get into with the efficiency of the floor after the capital dollars is that, as Paul said, because we have a long-range planning committee we have figured it out and through our analysis we figure that the optimum heavy-care floor plate should be about 60 beds a floor. We're nowhere near that. We've reviewed it. If this goes through and we are heavy care, can we add on and put 60 beds on the lower two floors or something of that nature to adapt to the new system?

When you get into the capital side it may mean, if you add up the hours of care per floor, that you need three and a half nurses on each floor. You can't get half a nurse so you hire four, and over seven floors, you have 3.5 or four extra staff that if you're efficient you wouldn't have to have, so here again it impacts your overall financial operations.

Mr Jim Wilson: Thank you very much for your excellent brief. On behalf of my caucus, I think we agree with many of the points you've raised, and where you've pointed out that specific amendments may be necessary, I look forward to working with you perhaps to put those forward to the committee, because many of the points you've raised have been raised by other non-profit groups.

I have a couple of questions. One is regarding the eligibility criteria. You correctly point out that, in the draft manual, criteria 6 through 10 are heavily medically based and, secondly, may make it very difficult for seniors who for many other types of reasons may prefer to be admitted to Chester Village.

I know in my own riding at our municipal home for the aged in Beeton, called the Simcoe Manor, when we held a public discussion on the Redirection paper, two ladies who were residents of the home came up to me at the end and said, "Does this mean we have to go back to the farm?" I guess we'd scared them so badly -- the ministry that gave the presentation -- that they really felt that under the criteria being discussed at that time, they wouldn't even qualify to be in the home they were currently living in. I said, "No, no, no." She said, "Good, because I've peeled enough damned potatoes." It was an eye-opener in that regard, that they were having the time of their lives in Simcoe Manor. My own grandmother, just a couple of months ago, was admitted there and she just absolutely loves the place.

When the minister made her opening remarks to this committee -- it was Frances Lankin at the time, of course -- I asked her, where we could possibly get agreement that we would try and put some meat on the bones of these sections in the bill that call for a great deal of work to be done through regulations. For instance, eligibility criteria, which in the bill itself simply says "as per the regulations" and you have to go to the draft manual and figure out what that means. Would you prefer, where possible, that we spell out the admissibility criteria? Hence, it's more politicians making the decision than bureaucrats behind closed doors through regulations, and then leave a clause that leaves some flexibility for regulation.

I gather that's a yes? If we can do it in the bill and keep it up front so everyone knows publicly what the admission criteria are going to be, you'd prefer that?

Mr Klamer: As long as you don't exclude that group of people who come in for other than medical reasons.

Mr Jim Wilson: That's what I mean, in an attempt to ensure that they're included, because I feel the way they've been drafted now, it's excluded. In fact, we just got this manual ourselves in the middle of this week.

Mr Klamer: I think the appeal process is key. A licensee, such as our home, should feel free that it has an appeal process if a central placement coordinator says, "You've got to take this person," and it feels, for safety reasons or whatever, that it can't adequately take care of that person. I think there should be some mechanism whereby it can raise a red flag and say, "Hold on now, let's talk about this," without being penalized in some way for not doing what the central placement coordinator wants us to do. It's a very powerful position.


Mr Jim Wilson: Yes, it is.

Mr Klamer: One can put oneself, I think, in a fairly negative light, depending upon whether you are agreeable or disagreeable with this person's decision-making process.

Mr Jim Wilson: Yes. You'll want to get along well with the placement coordinator.

Mr Klamer: Exactly.

Mr Jim Wilson: If I may also ask you a more direct question dealing with Chester Village, how much money would the foundation contribute to the operation of the home on a yearly basis, for example, outside of government money and copayments that are in the system?

Mr Day: We've always operated on a balanced budget. We don't run on losses.

Mr Jim Wilson: In terms of that, does the foundation raise money through fund-raising?

Mr Day: Yes. We do have other operations, but our operation is standalone. The care we provide and the costs the resident causes the facility to incur are all covered within our population.

Mr Jim Wilson: I see. I gather from your presentation and others that this is in jeopardy.

Mr Day: Very much in jeopardy, and it's a very fine line. I should say that we did run into a financial problem one year when the union came in. There was a huge retroactive union settlement that we were forced to take. Actually, that required us to take some government funding, but once we had the higher structural costs and were able to offset them with either cost savings or increased revenues, we've been able to maintain a balanced budget since then.

Mr Jim Wilson: Very good. Thank you.

Mr Day: I might just quickly add, just to reiterate the input we have in continuum of care, the placement agency and the sensitivities, when we take a resident in, our philosophy has been that continuum of care. They would come in as a well elderly, or as close to it as we typically get these days, and we can go right through to the extended care. If we have a central placement coordinator putting in a different care level at a different point, it could mean that the beds are full, and somebody who comes in at an early stage no longer has a bed as their health deteriorates because we've had a heavier-care individual come into the facility. So we don't get this continuum managed as well as we can manage it internally. That is going to cause displacement of residents, which at that age of life they find very disconcerting. So that's something else.

I don't know how the placement coordinator is going to build that in so the continuum can be continued for these residents. It's a very disturbing thing that we wrestle with now. We bend over backwards to make sure that somebody who has been there for 10 years, because he or she has take a turn for the worse, isn't relocated in another facility but we can find a heavier-care floor to move them to. When we don't know what's coming in next, I don't know how we're going to administer or make those changes.

I just throw that out. I guess a lot of our problems, as you said, centre on the placement coordinator and the impact it's going to mean on our population. I think the whole thing has to have more flexibility and more correspondence with the homes where they're putting these people. Let the individual home make the decision that it's been making for the last 20 years and doing very successfully.

The Chair: Thank you very much. I think you've given us a look into a specific facility this afternoon in terms of how you operate and the kinds of issues that you're facing, and that's been very helpful to the committee. Thank you again.

Just before we adjourn, if I could have the committee members' attention around our future schedule, you should by now all have received the schedule for our next two weeks, not this week coming where we are not sitting but beginning on the 15th. I'm informed that the clerk will have the air tickets tomorrow morning, so they should be to your offices by early afternoon. If you could, arrange through your offices to get them. We'll just be sending out the tickets for that first week, and then we'll get the ones for the second week.

One issue that I'd like to report on is that the subcommittee met at noon. You'll recall that in addition to the various groups which had applied, we had some that arrived a day or so after the deadline. What we were wrestling with was that we, as a subcommittee, had wanted to try to include as many of those as we could, and outside of Metropolitan Toronto we were able to accommodate that.

We have proposed, and I will be signing a letter to the House leaders, to request that we sit on Monday, March 22 and Tuesday, March 23 to do our clause-by-clause so that in the week of March 8 we would in fact be able to hear all of the deputations that were in touch with us.

Obviously, that requires the approval of the House leaders, and we will await that. I think this is good and was the intent of the subcommittee, that we wanted to try to accommodate and be able to hear from all of those who had applied. So, through the subcommittee, I will be in touch specifically on whether or not that will in fact happen.

Mr Hope: Just for some type of clarification and to make it a little bit clearer, as we all know, the parliamentary calendar says we return March 22 and March 23. I don't know anything other than what the parliamentary calendar says, that we return on the 22nd, so I'm taking it that this is when we are returning. That's why I think it's appropriate that the letters go to the appropriate people for their decision.

The Chair: That's quite true. While we may all have views as to just when we're going to be coming back, I think that will provide an opportunity for us to complete our work. At this point, then, the committee stands adjourned until the morning of February 15 in Thunder Bay.

The committee adjourned at 1717.