Monday 22 February 1993

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

Regional Municipality of Sudbury Health and Social Services Committee

Mila Wong, vice-chair

Mark Mieto, director

Persons United for Self-Help, Northeastern Ontario Region

Joanne Nother, chair

Seniors of Espanola Nursing Home

Stella Rooney, representative

Lynda Carey, representative

Victorian Order of Nurses, Northern Branches

Sharon Baiden, executive director, Sudbury Branch

Antoinette Blunt, executive director, Algoma Branch

Ontario Finnish Resthome Association

Lewis Massad, executive director

Royal Canadian Legion, Branch 23, North Bay

William Sexsmith, provincial service officer

Paul Richmond, president

Algonquin Nursing Home; Ontario Nursing Home Association, Region 1

Dennis L. Boschetto, representative, ONHA, Region 1

Nancy Foreman, director of care, Extendicare/Falconbridge


*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:

Bisson, Gilles (Cochrane South/-Sud ND) for Mr Drainville

Caplan, Elinor (Oriole L) for Mr Daigeler

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

Jackson, Cameron (Burlington South/-Sud PC) for Mr Jim Wilson

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

Wessenger, Paul (Simcoe Centre ND) for Mr Gary Wilson

Also taking part / Autres participants et participantes:

Czukar, Gail, legal counsel, Ministry of Health

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

Wessenger, Paul, parliamentary assistant to the Minister of Health

Clerk / Greffier: Arnott, Douglas

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

The committee met at 0908 in the Northbury Hotel, Sudbury.


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): Good morning, ladies and gentlemen. I call the meeting of the standing committee on social development to order. We're glad to be here in Sudbury. There were moments last night when we weren't sure we were going to get out of Toronto, but here we are and we're very pleased to be here to begin a day of hearings on Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: Our first presentation will be made by the regional municipality of Sudbury health and social services committee, if the representatives would be good enough to come forward and make themselves comfortable. If you'd be good enough to introduce yourselves to the committee and for Hansard, and then please go ahead with your presentation. Could I just say to people, don't touch the mikes or you'll self-destruct, and we wouldn't want that to happen.

Ms Mila Wong: Good morning. We'd like to welcome you to Sudbury. My name is Mila Wong and I'm the vice-chair of the health and social services committee for the regional municipality of Sudbury.

Mr Mark Mieto: My name is Mark Mieto and I'm the regional director of health and social services for the regional municipality of Sudbury.

Ms Wong: We're very pleased that the standing committee on social development is allowing different municipalities, different stakeholders, to participate in this process, and I guess in the true spirit of democracy, we wish to be heard.

Today, my presentation will cover the following topics: client choice, involvement of the home, medical director's involvement, monetary issues and operation of residential services. To facilitate notetaking, we will be able to provide you a copy of our presentation today.

Under client choice, the current act states that a choice of accommodation in the long-term redirection was always addressed as the client's right to choose. It states: "Any person who is over the age of 60 years or...because of special circumstances...cannot be cared for adequately elsewhere...is eligible for admission...[and] may be admitted."

There is a promotion of racial equality and respect for cultural diversity. Services take into account people's different values, religions, languages and customs. This is stated in the discussion paper on long-term reform. However, Bill 101 as written does not recognize the importance of the contributions of these groups that they provide in the delivery of care to seniors.

Under the current act, primacy of the individual and the right to dignity, security and self-determination are responded to. Seniors do not wish to sacrifice their individuality or dignity, and we affirm their right to participate in determining what services they require and how they are provided. However, under Bill 101, the suggested new roles for and the power of placement coordination services could very well undermine the rights of long-term care residents.

Bill 101 states: "A person may be admitted to an approved charitable home for the aged only if (a) a placement coordinator has determined that the person is eligible for admission...and (b) the placement coordinator designated for the home...has authorized the admission of the person to the home."

The proposed section 9.5 designates great power to the placement coordinators to determine if and where a senior may be placed. That is one of our biggest concerns. The rights of the seniors are not acknowledged. The bill does not grant applicants any say in the determination of which home they may be admitted. Only the placement coordinators have this power.

Regarding the appeal process, the right of the applicant to have a say in the placement does not occur prior to the placement, only after placement coordinators have their decision, and then their only avenue is through an appeal process.

The terms of reference for an appeal are limited to simply appealing the placement coordinator's rejection of their application. It states: "An applicant for admission . . . who is served with a notice of determination of ineligibility...is entitled to a hearing by" an appeal process. We're saying that if this is the only reason why they can appeal, you're actually stressing people who don't want to stay in that specific home.

We recommend that the legislation should be amended to clearly provide for the consumers (a) the option to make direct application to a facility of their choice; (b) the appeal mechanism in section 9.7 should be expeditious with a minimum time period of 30 days. Furthermore, there are no grounds specified in Bill 101 for the consumer to appeal other than if their application is rejected. The rights of appeal should include language, custom, religion and also respecting cultural diversity.

The next sector is home involvement. Under the current act, the homes are responsible for safe and competent care of the residents. The homes should have access to information regarding the applicant's health status to ensure appropriate care can be given. The current regulation does require the director's involvement in the admission of applicants. It states: "An administrator...shall admit persons to the home in accordance with section 18 of the act and with this regulation."

However, Bill 101 does not identify the director as one of the persons involved in authorizing the admission of a person to their home. Bill 101 states: "A placement coordinator...shall determine in accordance with the regulations whether to authorize the person's admission to the home." Consequently, the homes would have great difficulty maintaining safe and competent care for the residents if they are receiving new residents whose needs and health profiles are unknown.

Under the current act, the director is responsible for the programs in the home. It states: "An administrator...shall organize a continuing program of varied and meaningful activities designed to stimulate the interests of the residents including continuous learning, activation programs . . . recreation and entertainment, handicrafts...in such a way to enhance the residents' lifestyle," and further, "shall allocate proper accommodation to residents taking into consideration the type of care needed."

Section 9.12 of Bill 101 requires the homes to develop their own plans of care. It states: The "home for the aged shall ensure that...a plan of care is developed for each resident to meet the resident's requirements," and "the plan of care is revised as necessary when the resident's requirements change," and "the care outlined in the plan of care is provided to the resident."

Furthermore, section 9.13 of the bill requires the homes to develop a quality assurance plan: A "home for the aged shall ensure that a quality assurance plan is developed and implemented for the home...for monitoring the quality of the accommodation, care, services, programs and goods provided...to the residents of the home."

These requirements would be difficult to meet given that the bill provides no assurance that the needs of new residents can be met by the home to which the applicant has been directed by the placement coordinators.

We offer three possible scenarios:

(1) The homes could develop plans to meet all possible needs, thereby diluting the quality of all programs;

(2) Homes could continue with their current programs in order to ensure their quality is high and choose not to make available any other programs, thereby refusing to meet the needs of some residents; or

(3) A home could cut or discontinue discretionary programs in order to make room and/or time for other programs.

We see a solution for this and would like to offer that the homes should have the legislated right to appeal or stop actions which are deemed to place the homes' safe and competent care in jeopardy. Otherwise, what rights do the homes have?

The next sector would be medical director involvement. Under the current act, the current regulations involve the physician of the home in the assessment of an applicant. It states: "Where, in the opinion of the physician of a home and the administrator, the mental and physical condition of an applicant is such that the applicant cannot be properly cared for in the home the applicant shall not be admitted to the home."

Under Bill 101, the medical director's involvement in the admission process appears to have been eliminated, as there is not explicit identification of any involvement that the medical director may have in the admission of a senior to a home.

Bill 101 states: "A person may be admitted...only if...a placement coordinator has determined that the person is eligible for admission . . . and the placement coordinator designated for the approved charitable home...has authorized the admission of the person to the home."

It further states: "A placement coordinator to whom application has been made...shall determine in accordance with the regulations whether the person is eligible for admission."

The bill explicitly states that two levels of placement coordinators will be in place. The first level of placement coordinators serves to determine whether or not an applicant is eligible for admission to a home, and the second level of placement coordinators who are placed at the individual homes determines if an applicant is eligible to enter that home. There is no mention of a medical director at any time.

Furthermore, the current pre-admission assessment serves as an opportunity for bonding between the client and the physician.

The next sector is immunity. The bill explicitly states that the placement coordinators are immune from liability for any and all mistakes they may make. It states: "No proceeding for damages shall be commenced against a placement coordinator or a member, employee or agent of a placement coordinator for any act done in good faith...or for any alleged neglect or default in the performance...of the person's duty."

We ask: What are the implications of this power?

Obviously, this section of the bill leaves the home liable for the actions of placement coordinators. The options are either that the homes also be immune from liability or that everybody be responsible and accountable for their actions and therefore this section should be removed from the bill.

Under monetary issues: Long-term care facilities are different from residential facilities. Pioneer Manor is a home for the aged run by the regional municipality of Sudbury. If it's to become a long-term care facility, there are certain items that will have to be installed, such as a call bell system, a bedpan flusher room, a nursing station and lifting equipment.

Under the current act there is provision for subsidy for up to 50% of capital expenditures. The act states: "When the site and plans of a building to be acquired, erected or altered for use as a home...the minister may direct payment...of an amount...not exceeding 50% of the cost."


Bill 101 does state that additional grants may be given to the home as a result of an extraordinary event. The bill states: "The minister may, out of money appropriated by the Legislature, make a grant...to assist in defraying the costs incurred or to be incurred ...as a result of the occurrence of an extraordinary event." What does "extraordinary event" mean, and what are your criteria for this?

So unless upgrading a residential facility to a long-term care facility is considered an extraordinary occurrence, it is likely that no grants will be issued to Pioneer Manor to assist the home with the four items that we would be needing: a call bell system, a bedpan flusher room, a nursing station, and lifting equipment.

Staffing requirements are another concern. The standards are different for long-term care and residential care facilities. Currently, Pioneer Manor staffing just passes the minimum staffing level for extended care. Should Pioneer Manor be required by the placement coordinators to accept some long-term care residents, they will have to increase the staffing complement in order to meet the minimum staffing level required. It is not clear whether the province will be able to pay for this increase.

Another sector is the operation of residential services. Section 9.5 of the bill gives a great deal of power to the placement coordinators. Nowhere in the section does it provide power to the home to admit residents.

Pioneer Manor is operated, as I said, by the regional municipality of Sudbury. It has 176 residential beds out of a total of 349 in this facility. Pioneer Manor is rather unique because its residential per diem costs are $46, and given the $38 copayment mentioned by the Ministry of Health last December, plus the supplementary fee for preferred accommodation of $10, we will have $48, which provides a $2 margin. So it is viable; Pioneer Manor can continue to afford to provide residential services. I think our biggest threat is that the home will have no more powers to admit residents.

We have some questions. Will homes for the aged be given the right to admit our residential clients? If not, who will advise the 80 families in Sudbury already on the waiting list for residential care? Have they been advised of the proposed changes to the Homes for the Aged and Rest Homes Act?

To conclude, I am certain you will be hearing from many concerned organizations regarding the proposed Bill 101. We believe it has been drafted too hastily and has not been thoroughly thought through. Secondly, we are certain that many of the persons and families to be affected by Bill 101 are not aware of its contents, and every effort should be made to ensure that this very important legislation is thoroughly discussed with the stakeholders.

Thank you for the opportunity to present our concerns to the standing committee on social development. We are certain that after you have prepared your summary, the government will give it the time it deserves to address the specific concerns.

The Chair: Thank you very much. We're pleased to have the views of the regional municipality, because obviously this bill has an impact on your programs.

I'm going to begin just with the parliamentary assistant. He wanted to make a few clarifications. After that, we'll move to questions. Mr Wessenger.

Mr Paul Wessenger (Simcoe Centre): Thank you for your presentation. What I thought is that we'd have some clarification with respect to the admission procedures and with respect to the long-term care facilities, which I think might help clarify some of your questions.

One thing I might add with respect to the question of refusing clients admission: There would be grounds provided under the regulations, and the basic premise on which those regulations will be based is that the facility would not be in a position to service the client, whether that would be for physical care needs or for perhaps particular social aspects as well.

With that, I'll ask our staff to indicate the procedure with respect to the admissions.

Ms Gail Czukar: I'm Gail Czukar, counsel with the Ministry of Health, and I thought I would just clarify the admission procedure.

You're right that there are two roles that the placement coordination services play. One is to assess the eligibility of the applicant for facility services, and that can be done anywhere in the province by any placement coordination service, a basic determination of eligibility for our facilities. Then the placement coordination service that relates to the particular home determines the admission to that home.

The first level of determination is appealable -- that is, the basic eligibility for service -- which is based on an assessment of the person's needs and so on. The second one, regarding admission to the home, is not appealable under the bill because it's basically a priority-setting exercise among all of the people waiting for placement in facilities in that region. It's done on the basis of highest need, so that people with the greatest need get the beds first.

The placement coordination service, in determining whether to authorize admission to a particular home, obviously will take into account, first and foremost, the preference of the client. There will be different waiting lists maintained for different homes, so that no one can be required to go to a home that he doesn't choose. That would be the first criterion once they are able for placement, that they would choose which home to be placed in.

The home, likewise, can refuse admission to an applicant whom they feel they're not equipped to serve in the way that Mr Wessenger mentioned: that they don't have the physical facilities that are appropriate for the person or they don't have staff who are adequately trained to take care of the person. That would be taken care of in the normal negotiations between the placement coordinator and the home before the person's admission is authorized.

So the placement coordinator can't authorize admission to a home for someone who doesn't choose to go there.

Ms Wong: Where in the legislation is that addressed? Where is the wording in the legislation that will tell me that it's there? It's not specified.

Ms Czukar: The criteria for eligibility. As it says, the placement coordinator is to determine eligibility "in accordance with the regulations." So the criteria for eligibility will be spelled out in regulations, and likewise, the criteria for authorization of admission will be in the regulations. Legally, it wouldn't really be possible to admit someone to a home or to force them to go to a home, because there's no authority to do that. You'd need legal authority to admit someone involuntarily, but you can't really force someone to go somewhere without his consent.

Ms Wong: I will take your word then that this will be addressed in the new legislation, that clients have the right to choose.

Ms Czukar: In the regulations. The parliamentary assistant may wish to say more about that.

Mr Wessenger: Yes. I'd just like to indicate that we are looking at the situation of whether we can give some more assurance of the aspect of consumer choice in the statute itself, as distinct from the regulations. We are looking at that to see if there can be some way of giving some more assurance in that area. But I can assure you that consumer choice is a very essential part.

Of course, the person who makes those choices probably would go to the placement coordinator and say, "My first choice is going to institution A, and second is B," and when an opening occurs at the place of first choice, that person would then have the opportunity to go there.

The Chair: Mrs O'Neill.

Mrs Yvonne O'Neill (Ottawa-Rideau): I want to thank you. I didn't think I'd see you quite so soon again, but here I am.

I'm very pleased that you brought forward the concerns you did. We certainly heard them from several others. But you were specific about the appeals being time-limited to 30 days; I think that's a very important intervention. The role of the medical director being highlighted is also helpful. And I'm very pleased you were as specific as you were about the capital expenditures that will be necessary in facilities that you are responsible for.

Municipalities have been coming forward. I think I'd like to see them come forward in larger numbers, because there's certainly a very important partnership that has been always in existence here.

Your last page is where I want to ask the questions, because I feel, in certain communities more than in others, that you're right, that people aren't aware of the contents of Bill 101. It's not an easy bill, for one thing, and, in amending six or seven other bills, it is never an easy piece of legislation to get hold of. Could you give us some suggestions on how we could be sure that it is being more accessible to the public? You were suggesting further discussions with the public; you hope there won't be any unnecessary haste here. Could you give us some suggestions about how, beyond these hearings, we as legislators could help this happen?

Ms Wong: I realize that there is an earmarked time to pass this legislation, and I wonder if you still have time to have a public forum. Like, how many people are in there who are not service providers, and how many people actually have clients or families involved using the service? That's the group that should also be reached. I think we service providers always seem to know what's happening, but I think people who actually use the service should have this kind of process so that they can express their fears and their concerns.


Mrs O'Neill: Have you noticed the role, or let's say non-role, of residents' councils in this particular bill, that there is not a real thrust towards residents' councils?

Mr Cameron Jackson (Burlington South): They're not mentioned at all.

Ms Wong: But on the timing, it's too fast. Everything hasn't been thought through thoroughly.

Mrs O'Neill: Well, if you can think of ways in which we can communicate better with the people in the communities, I would like you to forward them to Mr Beer, our Chair, and I'm sure that with this challenge you will respond, because you're a pretty active thinker, Mila. Thanks.

Mrs Margaret Marland (Mississauga South): It's interesting that Ms O'Neill raises the non-reference to residents' councils, because one of the most detailed, most professional and also most poignant briefs that I have seen was written and presented to the minister by the residents' council of the Mississauga Hospital, which happens to be chaired by a woman who is a registered nurse who is a quadriplegic through -- goodness, I should remember -- but she's been living in the hospital, by necessity, since she was 34, and I think she's about 47 now.

It's a very different perspective that the residents' councils bring to this bill, but I think, like everything else, that brief was received by the minister and totally ignored by the minister and her staff, unfortunately, because it was received before the bill was drafted. It was during the public hearing process.

I just wanted to congratulate you on your presentation this morning. You have really touched some very important areas, and I think when you talk about the criteria for eligibility, it's a tremendous frustration for those of us, especially in opposition, when we deal with any legislation for which we cannot see the regulations. The problem is that all legislation has regulations, but in this case the regulations are terribly important. Not only do we not see them, we never have a chance to debate them on the floor of the House. We're really strangled by that fact, and very terribly limited. We can't bring that back in the House except as a reference during a debate, but we're never in the position to say, "Look, this regulation is totally unjust," or "This one won't work."

So we are very frustrated, and agree with a lot of what you've said this morning. We really appreciate your being here.

Mr Drummond White (Durham Centre): I was very interested in your lumping together the appeal issue and consumers' choice at the beginning of your presentation. Frankly, I'm not sure I quite agree with Ms Czukar. I think that people should have the right to appeal a decision; not the issue of whether or not they are placed or not placed, but where they're placed, how they're dealt with, what level of service they're given. It only makes sense to me that while no one is going to be forced to go into a home that they don't want to go into, in many situations people will go into an inappropriate home simply because there's a space there. I think that in the meantime, that individual should have the capacity to appeal.

Ms Wong: Right.

Mr White: I'm wondering, do you think that should go to every decision made by a placement coordinator?

Ms Wong: I think that should only go to that point if the client, or the resident, the potential resident, doesn't want to go to that home. I think the biggest thing here is that that person must have the choice. And if the decision of the placement coordinator is different from the choice of the client, the appeal process should not be after the fact.

Also, the criteria where you can make the appeal are very specific, only upon the rejection of the coordinator, and that doesn't give a lot of leeway for the clients. You know, when you're dealing with people this age, that's an awful lot of stress. That's an awful lot of stress with people who are not too well and kind of frail. You subject them to that.

Mr White: Conversely, for those people in their midlife who are dealing with those folks, who may urge them into whatever decision the placement coordinator might offer simply because it relieves that relatively young family of an extra burden.

Ms Wong: Right.

The Chair: In Thunder Bay and in London we heard about the placement coordination services that exist right now and it's one of the questions we've wondered about. How do you handle that right now in the region? Do you have a group of the different agencies and so on that come together, or how is that function carried out at the present time?

Mr Mieto: Perhaps I can answer that. We have a placement coordination agency in this community administered by the VON. We and the home for the aged from the region are also participants on that, on an advisory committee, and it's working very well in terms of the services and opportunities and information it provides to the consumers and their families. They have an excellent staff. We work very closely with that organization in its present mode and format and see no problems with it in its current structure.

The Chair: Is that region-wide?

Mr Mieto: I believe it covers two districts, the districts of Sudbury and Manitoulin, which are much greater than the regional municipality of Sudbury.

The Chair: Thank you very much for coming before the committee today with your specific suggestions. I can certainly assure you that the committee will take those under advisement as we go about our deliberations.

Ms Wong: Thank you.


The Chair: I now call the next representation. I believe on our schedule it says the Ontario Advisory Council on Disability Issues but the representation is really being made on behalf of Persons United for Self-Help, northeastern Ontario region. Is that essentially correct? I want to thank you for coming before the committee. I think we had some of your colleagues in the Middlesex area before us last Thursday from PUSH. If you'd be good enough just to identify yourself for the committee and for Hansard.

Ms Joanne Nother: Good morning. My name is Joanne Nother. I am a member of the Ontario Advisory Council on Disability Issues and I represent northeastern Ontario. I also am the chairperson of Persons United for Self-Help here in northeastern Ontario.

The Chair: So it's a multifaceted presentation.

Ms Nother: Exactly. The views I will state this morning are the views that are reiterated by my fellow colleagues on the advisory council and have been stated by Shirley Van Hoof, the chair, who you may have heard in London.

So good morning, everyone. I thank you for the opportunity to speak to you this morning. What I'd like to do is, I'm here to tell you that generally we support Bill 101, the redirection of long-term care, and welcome the shift in focus from the institutionalization of the elderly and persons with disabilities to supporting people in their own homes.

Direct funding to enable physically disabled adults to self-manage service empowers people with disabilities to make the choice to remain in their own homes. Direct individualized funding will allow me to choose the following: who assists me when I need and want assistance; where I will get assistance, ie home, work, travel, should I choose to stay at home; and with what I need assistance. I would be able to hire, train and manage my own worker. I could then schedule and pay them accordingly. I could choose to do all of this for myself, but for those who cannot or choose not to, an advocate can be appointed.


There are many people, both physically disabled and elderly, in chronic care wards, extended care facilities and nursing homes who may not need to be there. Given the proper supports in the community, they could be living at home. If they are given the choice, some will choose not to leave the facility, but some will. The important factor here is that people be given the choice.

Having the choice will give me and others like me the chance to live a more normalized lifestyle. It will definitely give me and others like me more control over the day-to-day routine of our lives. Family relationships, which often are ignored or exaggerated by the sole care giver's role because of the dependency, may now have a chance to approximate normalcy. Having more choices definitely means that the disabled will not be tied to their homes but will have more mobility, provided, again, that transportation is not a factor.

We applauded the Minister of Health when she announced on December 2, 1993, the expansion of the integrated homemaker services program into Sudbury. This will make home care services available to consumers regardless of whether or not they need professional health care services. This part of the redirection strategy begins to address the issue of available community supports. It is very important these supports be in place prior to any deinstitutionalization. If not, the long-term care redirection will not succeed.

As I stated earlier, PUSH northeast and the Ontario advisory council support long-term care redirection as embodied in Bill 101. However, we do so with the following caveats: that the community support services must be strengthened and funding increased dramatically; that institutionalization of the elderly and persons with disabilities be an option accessed at their discretion when necessary for their continued care and at the level needed to maintain that care; and that amendments to current legislation proceed quickly to allow universal availability of the direct funding option for attendant services.

Further to this, we would like to see any pilot projects considered to test the option of direct funding abandoned. We see no need to continue to test a system that has been in place and working for years. By this I mean that orders in council to allow direct funding have been used by individuals with disabilities for at least 15 years that we're aware of and we feel that they have been sufficient tests of the process. We see no further need to spend government time and money on piloting an idea whose time has certainly come, and by that I mean the direct individualized funding.

We have lived through two governments proposing this long-term care redirection and we definitely think it's time for its fruition. I trust you will consider the concerns I've addressed with all due consideration. If you have any questions regarding any of the issues I've raised, I'll be more than willing to answer them. I thank you again for allowing me to speak to you today.

The Chair: Thank you very much for coming before the committee and for speaking in particular to that issue that is in the bill. We'll begin our questions with Ms Marland.

Mrs Marland: Thank you, Joanne, and congratulations for the fact that you are sitting on the advisory council. That's a very important organization -- body, I should say -- in the province. I am very familiar with PUSH because I am the spokesperson for our PC caucus in Ontario for people with disabilities.

I too support the direct individualized funding. My concern is that, while that is one of the aspects of this bill and one of the present promises of this government, this same government is currently ignoring a section of our disabled community very badly, so of course I perhaps don't have quite the faith and confidence in the government that I might otherwise. This current Bob Rae socialist government has cancelled the funding for sheltered workshops, so our developmentally disabled people in this province had to rally to the front lawns of Queen's Park in November; 4,000-plus people had to come to try to tell this government that couldn't understand what any cuts to any section of our community with disabilities mean. So I'm trying to be optimistic about the individualized funding because I think it's just purely common sense. You did refer to the fact that funding would have to increase substantially for this to be achieved.

I want to mention also that another member of your advisory council on disability issues, Mr Van Hoof, spoke I think in London and he talked there about the concern of repeating the mistakes that were made in the early 1960s and 1970s when our government decided to remove people from another form of health care, namely, psychiatric hospitals, without having community-based services. My concern about this legislation is that it's very dependent on the community-based services being in place and I would like to ask you if you share that concern, particularly in the north, because I have heard that the access to these community-based services have to be such an integral part of giving people the choice and being able to manage at home rather than being in a chronic care facility. Do you share that concern?

Ms Nother: Yes, I do. We do have grave concerns with regard to the disparity we suffer in the north. We have fewer health care professionals so we have less services when it comes to physiotherapy, occupational therapy. I guess it makes it more contingent upon having a community-based service everyone can access.

We suffer too and I'm concerned with regard to government cutbacks in the home care hours, in that whole arena, because if we don't have that community support, then it will be very difficult to maintain a residence in the home and to be able to stay in the home. I'm also concerned with funding for transportation for the disabled. It all ties in. We're not just talking about money to be able to pay an attendant to work with me; we're talking about all the rest of the community supports, and my fear is that we rush headlong into direct funding. I think direct funding is necessary. I know myself, from a personal viewpoint, I could begin direct funding tomorrow. But for all the others who need a greater amount of community support, I worry for those, because in this community and in many communities in the north, the systems are not yet in place, and I don't know when they will be, to begin this kind of direct service.

Mrs Marland: Mr Chairman, I'd like to correct my own record. I did not hear Dr Van Hoof in London, I had received a brief, and I've just been advised that it's Dr Shirley Van Hoof, so I would like the Hansard to refer to her in that correct gender. Thank you.

I just want to say finally, Joanne, when you're talking about the cuts in funding, the respite for the care givers, where there is not an independence of the person who has those special needs, is a major area of concern and it's the respite program that has also been cut for the developmentally disabled by this government currently.


Mr Randy R. Hope (Chatham-Kent): Good morning, and thank you for the presentation. I'll speak a little bit differently than what Margaret had. I'd put a little bit more positive attitude towards this legislation. I know that the organization, through PUSH, played an active role for a number of years, because in the presentation given to us in London, they went through a number of reports that were put forward to other governments that never acted on those. So I think this is one positive step.

There are two areas where I'd like to touch base with you. The first one is about pilot projects. I know in Thunder Bay they were lobbying, saying, "We'll be the pilot project." In Windsor, I believe, they'd just started up and they weren't sure about the pilot. In London they were talking about the pilot project. Today, your comments say: "No pilot project. Let's begin. We've done enough studies. We have the example." I just wonder if you could elaborate a little bit more about why you feel, other than that it's been going on for years -- but I just wonder if you could elaborate just a little bit more on accountability and other aspects.

Ms Nother: I guess to some extent the feeling is that we've done orders in council for many years which have covered the issue of direct funding for individuals to be able to pay for attendant care and whatever services they required through funding given to them through this order in council. It's our feeling that these have been a sufficient sense of how the process will work. To our understanding and for the people whom I know who have been involved in such a process, they have worked.

We still, to whatever extent, do not, again, have any regulations on how direct funding will be proposed. We don't know about accountability. We don't know who will cover Workers' Compensation. We don't know whatever. We'd like to see more, for sure, but we would also like to begin the process right away. We really think enough has been said with pilot projects and we'd like to start right away.

Mr Hope: There is one other area. As we listen to this public hearing process, we hear different viewpoints on different things. One of the areas which you were talking about was a minimum standard that had to be met for individuals that you wish to hire. I wonder if you would comment on that for us please.

Ms Nother: Sure, I can comment. PUSH Northeast right now is in the throes of working with Cambrian College and various other agencies and organizations in Sudbury looking at preparing an attendant care training program which we will use through the colleges. We've been in contact. We've just begun contact with a policy adviser with the long-term care division. We would like to work through MCU or now the superministry with regard to creating a standard and a training program for attendant care.

Mr Hope: But one of the concerns that was brought up to us during the presentations was, if we teach them in the academic field or in the college, then they're going to come in and tell me how they should bathe me, how they should lift me. That was one of the concerns that was brought up. If you have too much of a model for attendant care, then they take that model that they were educated on and bring it to your home, tell you how to bathe, not listening to you orders. I'm just wondering, do you see that possibility of a fear?

Ms Nother: We're proposing a program whereby attendants and persons with disabilities could be trained at the same time. What we're looking at is, say, a 16-week program to train individuals as independent living assistants or whatever and a 16-week self-advocacy training program for people with disabilities whereby we can teach them how to train, how to interview, how to work with an assistant and an attendant.

For the most part, many individuals have not been involved in the process of hiring or interviewing attendants; they've been sent an attendant from an agency and that agency decided what person would work or not. You never had a chance to really work on a fit. Working with an attendant is such a personal relationship. It's more than slotting somebody into your house to wash your face or change your clothes and that type of thing, so there has to be some sort of fit.

What we'd like to do is develop a program whereby we could work one with the other so the attendants would be able to work with the actual individual needing the service, plus we'd be able to build in from experience and from people like myself -- and the programs would be consumer-driven -- as to where the problem areas would be with the attendants.

Communication's a big factor. How do we train independent living assistants to work with people with disabilities? Let's get away from the medical model and turn it more towards a personal care model so that someone who works with me isn't standing over me with a white coat telling me I should do things in five minutes, tapping their feet, grabbing my cereal bowl and that type of thing when they think I should be finished. We want to work it out so it's a little bit of a better fit for us as individuals.

Mrs Elinor Caplan (Oriole): I was in London and I heard the very excellent presentation that you referred to and I'm aware of the frustration that many people have about how unbalanced this legislation is. After two and a half years, we still don't have a long-term care policy framework. After two and a half years, the chronic care hospital review is not complete, and this legislation, with the exception of the opportunity for individual funding, really is institutional legislation.

We have seen, in my view, over the past two and a half years a remedicalization not only of the delivery of health services but also of long-term care policy because of the development of this legislation in the absence of the overall policy framework. So I understand your concerns. I know that as I've been making my points, Hansard cannot record the fact that your head has been nodding in agreement, so if you'd like to make any comment on that before I continue, I'll give you the chance to do so. Is that a correct assessment, in your view?

Ms Nother: Yes, I agree with what you stated.

The Chair: That is the sound of nodding heads.

Mrs Caplan: It is important. It's been three years since Mr Beer announced the initial funding for 500 directly funded -- at that point I think it was announced as a pilot, but in fact the numbers were there and the dollars were committed, and we have yet to hear what is actually going to be committed under this policy by this new government. I know that there are many concerns, not only from PUSH but others in the long-term care field.

I don't have a lot of questions for you, but there is one point I would like to make to Mr White, who's looking quite uncomfortable sitting in his seat at this moment, and I think he should. The point that I want to make is, as a member of the advisory committee, you would know that staff of the ministry and advisory committees and so forth advised the government, is that correct?

Ms Nother: Yes, to some extent.

Mrs Caplan: But that it is the government, the ministers in particular, who make the decisions?

Ms Nother: Exactly.

Mrs Caplan: So that when Mr White says he doesn't agree with Ms Czukar, what he really is saying is he doesn't agree with the policy decision made by his government, because they would have been the ones who decided on what rights of appeal, what the framework of the legislation looks like. Is that fair?

Ms Nother: Yes.

Mrs Caplan: And it's not just not a good idea, but I think it's very unfair to blame the bureaucrats or to blame an advisory committee if your minister and your government have made a wrong policy decision. I would point out that this is the opportunity for this committee to correct some of those policy decisions that have been perhaps misguided. Some of the things that we're proposing at this committee and will be proposing will be some amendments to perhaps, if possible, convince the government that this legislation could be significantly improved.

But my own feeling -- this is the one question I have for you -- is that we have had an undertaking from the parliamentary assistant that the long-term care policy framework should be out in March; that the chronic care role study should be completed and ready for public discussion in March. In light of all of that, is it your view that this legislation, hopefully with some positive amendments that will ensure residents' councils and reinstate the rights of appeal not only for consumers, but I believe institutions should also have the right to refuse if the placement coordinator's decision is going to result in inappropriate care -- I believe as well that that should also be subject to appeal. If we can fix this, is it your view that this legislation should go forward because the disabled community has been waiting for so long? Or should this, in your view, wait?

Ms Nother: No, I agree. With the amendments as indicated and from, I'm sure, all the presentations that you've heard to date, with those amendments taken into consideration, I think the long-term care redirection should go ahead as proposed.


Mrs Caplan: I know many people share my disappointment that this legislation is really incomplete. It's been advertised as long-term care legislation, but really it only relates specifically to a very small component of overall long-term care reform. Did you want to comment on that?

Ms Nother: No. With regard to what you're saying, I agree, and I think long-term care reform is more than just some of the amendments as we've stated with regard to institutions.

With regard to the direct funding, there are many other concerns and recommendations that we've seen through committees and consultations we've held at community and municipal levels, so I really think, with proposed amendments, we may have a framework with which we can then work.

The Chair: Final question, Mr Bisson?

Mr White: After Mr Bisson, Mr Chair.

Mr Gilles Bisson (Cochrane South): Just very quickly, one of the things that you touched on is the whole question of the depopulation of our institutions that we have across the province, something that started quite a few years ago, and as a premise, I just want to say that initially I was very much opposed to that move because of what it meant in regard to the institutions.

But through personal experience -- my sister's a schizophrenic and for the past four years or so has probably been served as well, or even better in some cases, outside of the institutions, within group homes etc, to get the kind of service, quite frankly, that she couldn't get in an institution-type environment. So I'm a latecomer to support.

I too fear some of the difficulties around the whole question of funding about how, if we're going to get people out of the institutions over a long term, we provide for the proper services within the community. I know that your group and others have been dealing with that question for a long time, and the question I have for you is, what kind of advice can you give in regard to -- there's no magical solution. I don't care who the government was, today, dealing with this issue, we'd all be grasping with trying to do that in as user-friendly type of way as possible, and I'm just looking for a bit of advice.

Ms Nother: Yes. With regard to the bit of advice, we definitely do need to have all the consumer-based services in order for us to make a go of living at home, and I really think that it's only fair to expect and hope that they will be in place before I make the decision.

With regard to any further advice, I'd like to say that consumer involvement is extremely important in being able to say what should be accessed and how it should be accessed, because there is nothing more frustrating to me as a consumer than having a group of service providers and administrators determine what I need and how I need it and how I should access it.

The Chair: I want to thank you for coming before the committee and making your presentation. We appreciate it.

I'm going to call the next witness and then recognize Mr White. If the representatives of the Seniors of Espanola Nursing Home would come forward, and as they are coming forward, Mr White?

Mr White: Thank you, Mr Chair. I just wanted to clarify the record in regard to some comments that Ms Caplan made.

Mrs Caplan: No. You clarify the record according to what you made. Start by an apology to Ms Czukar.

The Chair: Order, please.

Mr White: I would like to simply clarify that while Ms Czukar is absolutely correct that no one can be forced to go into a nursing home beyond their wishes, the issues within a social milieu, within a placement milieu, I think go far beyond that, and that's the point I was trying to make, that the bill should be sensitive to those issues. I'm not at all in disagreement with Ms Czukar's interpretation of the law nor our government's policies.


The Chair: I want to welcome the representatives from the Seniors of Espanola Nursing Home. Thank you for coming to the committee this morning. If you'd be good enough just to introduce yourselves for the committee members and for Hansard, and then please go ahead with your presentation.

Mrs Stella Rooney: My name is Stella Rooney.

Mrs Lynda Carey: I'm Lynda Carey.

The Chair: Welcome.

Mrs Rooney: We are here today to represent the residents of the Espanola Nursing Home. There are 30 residents in the home. We have come with the full support of the residents and their families as well as the full support of the municipal council.

They feel that the pending increases are totally unacceptable. We are here today to present their objections and concerns regarding the amendments to Bill 101. We feel that the amendments are aimed at a vulnerable group. Many of the seniors are unable to speak for themselves and their families are at a loss as to how to deal with this situation.

What the Rae government is about to do to the seniors is unconscientious. They have stated that, "Those we have targeted are able to afford it." The full increase is to be applied if a senior's annual income reaches $10,680. The new rate is to be $37.12 per day. That amounts to $13,548 a year. That is a difference of $2,868 a year or $239 a month. Where is this difference going to come from? Some of the information that we have received indicated that residents who receive the Gains supplement to their pensions would be entitled to a rate reduction of half the increase, or $5 per day. That is about $150 per month. Where is this money going to come from? Even if the comfort allowance is used up by this increase, there is still a shortfall. Where is this going to come from?

There are many concerns about how the increases will be met. There is a struggle now for some families to meet the expenses because when their loved one was placed in the nursing home they were not able to get the accommodation of their choice. They were forced to accept semiprivate or private accommodations in order to have their family member placed in the home. In turn, this has put a financial burden on some residents and their families.

One major concern for some of our seniors is what happens when they can no longer afford the semiprivate or private room and there are no ward rooms available to accommodate them. Will they be forced to move out of the room? Will they be forced to move out of the nursing home? Will their families end up paying the difference? What happens if the family is unable to make up the difference? For many, their pensions do not cover the additional costs of a semiprivate or private room.

In a letter from Mr Rae to Algoma-Manitoulin MPP Mike Brown, he states that, "Accommodation costs will be based on an income test, that assets will not be considered in determining the fee that a resident will pay." Our residents are not convinced that their personal savings will not be considered on a means test.

The NDP government is making life very uncomfortable for a group of people who have done their part for society. They worked hard all their lives, paid taxes and supported government programs via those taxes, and now the government wants them to continue to pay at a time in their lives when they should be relieved of that kind of financial stress. The NDP will be taking away what little security some of these people have. The government is telling the seniors that they will have to take care of them if they cannot afford to meet the new copayments. Our seniors are not convinced, nor are the families who see to the interests of those who cannot speak out for themselves.

Lynda will continue.

Mrs Carey: I spoke to a gentleman from the Royal Canadian Legion, and he reminded me of another section of our aging population that should be addressed. These people are the war veterans of this province. Many of these people reside in nursing homes. Some of them are there due to injuries suffered in the various wars that Canada took part in. These people risked their lives for this country, some of them are still suffering physically, and the country is now repaying them by making their lives more difficult to bear because of continuing high costs to stay in the only place left for them to stay. Any small increase they may get in pensions is quickly taken up by these high costs.

The Rae government indicated that it would be a Robin Hood for the least fortunate of this province, to have the more affluent section of the population pick up the tab, so to speak. This is not what is happening. Where is this government's social conscience?


We also have some complaints as to the way these hearings have been set up. We feel that there have been attempts to discourage people from attending. First of all, the memorandum dated December 21, 1992, from the standing committee on social development in regard to these hearings was not received in our MPP's office until January 18. I have been made to understand that there were advertisements in the newspaper, but these were placed in the newspaper on January 1. I don't know whether that was the only time they were put in, but it seems like an awkward date. How many people really do pay attention to a paper on January 1?

The memorandum existed for almost a month before we were aware of it. We were informed by our MPP's office that we had until January 21 to decide if our committee wanted to be represented at these hearings. We had only two days to poll the seniors and their families and put together a committee to represent the residents of Espanola Nursing Home. There should have been more notice given.

To compound the problem, the dates of the hearings in Sudbury were changed and we had to rearrange our schedules in order to be here today. Other supporters had to cancel out. The memorandum gave no indication of where the hearings were being held. I had to call around in order to find out where they were being held and at what time. The agenda for the hearings today was sent out on Friday.

We feel that there has been a deliberate attempt to discourage people from attending these hearings. There has been very little in the news media about these increases. We feel the government has deliberately tried to push the bill through without properly consulting those affected. If there hadn't been such a protest, this may well have happened.

Another concern is this: Are we just getting lipservice from the NDP government? Are we just wasting our time, or is the government really going to listen to us and take our concerns into consideration?

What we are saying to the Rae government is that we don't trust it. When I first found out about these increases, I felt that Mr Rae was just shaking the tree to see what falls out. That's my own personal opinion. We feel that his government is out to relieve the seniors of their hard-earned savings, savings that give them some comfort at a time in their lives when finances should not be a major concern. Our seniors expect their savings to provide them with some comfort in their lives, comfort that comes from knowing they will not become a financial burden on their families. The Rae government has set out to relieve them of that comfort.

We hope the Rae government will pay attention to what we are saying. There is a tremendous need for this government to take the financial worry from this section of the population. I wish they could see the mental stress they are creating for some of these people. It would certainly make them think twice before proceeding with the amendments to Bill 101.

The Chair: First of all, as the Chair of the committee, I think it's important that I address your questions around the committee hearings. I really want to make clear that we have tried very hard to make sure as many groups could come before the committee as possible and in fact extended the deadline, and in terms of communicating with the groups that had been involved in the various consultation processes earlier, we were concerned that in some areas we weren't getting as much of a response.

The ad should have been in on January 8. That's when it was in all the other papers. There's always a problem with ads, in that, do people see them on the day they're there?

I certainly apologize if there wasn't sufficient time for you, but I can say that we as a committee, and I'm involved here with members from all parties, have tried very hard to contact as many groups, organizations and individuals who are interested as possible.

In terms of the earlier memorandum before Christmas, that was to tell people this was going to happen. At that point we didn't know where the hearings would be held in each of the different communities, but then once we had that information, again that went out to all the members as well.

My experience in the five or six years I've been a member -- and I say this, and perhaps you don't know, but I'm the Chair of the committee but I'm not a member of the government party; I'm with another. I just want to make clear that --

Mr Stephen Owens (Scarborough Centre): You don't have to backwater that fast.

The Chair: No, but I think it's important in terms of there wasn't any attempt to dissuade people from coming before this committee. In point of fact, we all felt very strongly that --

Mr White: Wouldn't that happen if the Chair was a government member too?

The Chair: But I'm making the point in support of everyone on the committee that we really did try to get as many people to come forward as possible. It has been a continuing problem in my years in the Legislature that no matter how hard you try, somehow inevitably there always seems to be groups or a region where people have not heard about it. That's not acceptable, obviously, and, as the Chair of the committee, I am sorry you weren't aware earlier. But I do feel that, on behalf of all the members of the committee, I do want to say there certainly was no deliberate attempt to try not to reach people and we're very glad that you in fact have come, even though you didn't have as much time to prepare as you would have liked.

Mrs Carey: When was it decided to hold these hearings?

The Chair: At the end of the debate in the Legislature, this would have been -- I forget the date in December.

Mrs Carey: That would have been around the 17th, 18th of December.

The Chair: It might have been a bit earlier. I forget when --

Mrs Marland: We rose on the 10th.

The Chair: The 10th? There's a decision made then that this bill would go to committee. Once that happens, then it comes to my attention as the Chair of this committee. I then had directed that a memorandum go out to as many groups as we could identify. We asked for input from all three parties. That memorandum went out. We then sent that as well to local members, and in particular, in early January, when we started to look at who had responded, I then sent a special note to all the members in the areas we were going to be coming, asking them if they would also check around and see if people had heard. The problem of Christmas and New Year's can often be a difficulty here as well in terms of reaching people.

I just wanted to put on the record that the purpose of these is to make sure that people do come forward, and when that doesn't happen, I think we have to continue to review our procedures and how we go forward, but I just wanted to make clear that if people didn't hear, it wasn't through any deliberateness on the part of the committee. We really wanted people to be here.

Mrs Carey: Is it procedure to arrange for the hearings after the debate and not prior to it?

The Chair: No, after, because one never knows whether in fact the bill is going to go to committee or not. This is a decision that is made in the Legislature. There are some times when that's known, but generally speaking that is done at the completion of the debate, and that's why we got the memorandum out before Christmas, because we were just concerned that it go out.

Mrs Carey: We didn't see or hear of the memorandum until around January 17 or 18.

The Chair: I'm sorry about that. As I say, we wanted to reach more people more quickly. But we are glad that you have come today.

Mrs Caplan: Mr Chair, I'd like to just explain that I moved the microphone because of the static that was being caused and I hoped that it wouldn't interfere with your presentation.

Mrs Carey: That's fine. Okay.

The Chair: With that, and if I could just leave that with you, I just felt that I wanted to make it clear that if there had been some problems, they've been inadvertent and not through any plan. As I say, we're very glad that you did come today.

We'll move now to questions and we'll begin with Mr Wessenger.

Mr Wessenger: Thank you for your presentation. I'd just like to comment on some of your comments with respect to the legislation. I think, first of all, we should remember in this legislation that I don't think ever in the history of Ontario has there been such an extensive consultation with respect to any legislation.

Mrs Caplan: Wrong. We spent 10 years on the health professions review.

Mr Wessenger: Over 75,000 people were consulted with respect to the long-term care policy, so I think that was a very extensive consultation.

Mrs Caplan: It's a bunch of rhetoric.


Mr Wessenger: With respect to your comments on the payment aspect, what we're attempting to do is basically to provide a system of payment that is fair and equitable, based on ability to pay. As part of that, one of the aspects is that every resident will be left with at least $112 per month as a comfort allowance, so that no one will have to go into their comfort allowance in order to pay their accommodation costs.

Mrs Carey: The numbers aren't adding up. People on Gains are allowed to apply for a reduced rate of $5 a day. According to the information that I've been given, they are still going to have to come up with an additional $5 a day.

Mr Wessenger: I'm told that that's not accurate, but I'll ask staff to explain that to you.

Mr Geoff Quirt: Geoff Quirt. I'm the acting executive director of the long-term care division.

The new resident payment system would work as follows: The rate of $38 and some odd cents will be set in direct relation to the level of income that someone would have to have to be no longer eligible for the guaranteed income supplement. So residents would be asked the question, are you in receipt of the guaranteed income supplement? If they said no, they were not, then we would know that their income from other sources would be sufficient for them to be able to pay the $38 and still have $112 a month left over.

If anyone said that yes, they did receive a portion of the guaranteed income supplement from the federal government, then they would be entitled to a rate reduction. Their rate reduction would ensure that they paid a rate that would still allow them to have $112 a month left over.

Anybody who received any portion of what you referred to as Gains, which is the supplementary cheque from the Ministry of Revenue in Ontario for very low income seniors, would still pay the basic copayment as you know it now, the $26.26, so that even he would have $112 a month left over for his comforts.

Mrs Carey: Now, I referred to assets. As you mentioned before, Bill 101 is a cumbersome document, and I was unable to find anything in there that would indicate that their assets would not be considered.

Mr Quirt: There's nothing in the bill that speaks to it. I think the bill simply says that the copayment resident payment system would be defined in regulation.

But the Minister of Health has been very forthcoming in saying that the new system would not take into account people's assets. In other words, as is the case now for residential care residents in municipal and charitable homes for the aged who are asked to pay the full cost, not only their accommodation but their nursing services and their other programs, their assets are taken into account to the extent that residents with limited income but who have assets, like a farm or a house, have run a big bill or run a tab, if you like, at the home for the aged, and that bill accumulates. When a resident passes away, a claim is made against the estate, against the value of the house or the value of the farm, by the municipality or by the charitable group, under the current system.

Under the current system, those residential care residents are asked to declare all their assets -- for example, money in the bank or an insurance policy -- and their entire worth is considered in determining whether they can pay the full cost of their care in residential care. Under the new system, only income, as declared to the federal government in their application for the guaranteed income supplement, would be considered in determining their resident payment.

Mrs O'Neill: I'm very pleased you came in and spoke so forthrightly. I want to say that I am supportive of what our Chair has stated.

I do feel, however, and I continue to remind people at Queen's Park, that there are communities in Ontario that do depend on weekly newspapers, and I know that's a very difficult bridge between the dailies and the weeklies. But in the north there are communities that are relatively isolated. I think the north has special needs, and I don't think we always are very sensitive to them in so far as communication is concerned. Communication was expressed by others in presentations already this morning.

I have difficulty with the present government's statements, from the minister on down, that there has never been so much consultation on a piece of legislation, because the consultation that is quoted as the 75,000 is what people hoped would be in the legislation. They were discussion papers that were placed before communities. The discussion on the actual legislation has certainly not been any more outstanding than any other consultation that I'm aware of.

I'd like you, if you could, to respond to a couple of my inquiries. The role of the residents' council seems somewhat neglected in Bill 101, to say the least. I'd like you to say a little bit about that, if you could. What is the percentage of residents that you feel in your facility would be affected by the changes regarding the copayment? Large number? Small number?

Also, again we're being asked to take a giant leap of faith regarding regulations, and I'm very pleased you've done as much homework as you have because I think you're trying to define exactly what effect Bill 101 will have on the financial flexibility of, in some cases, very vulnerable residents. So if you could tell us a little bit about how many will be affected and then the role that you see for residents' councils, I think that would be satisfactory for me this morning.

Mrs Rooney: I believe that there will be a large number at our nursing home affected.

Mrs O'Neill: Half?

Mrs Rooney: More than half.

Mrs O'Neill: More than half?

Mrs Rooney: Yes. Much more than half. We have several people, my mother-in-law included, and I believe Lynda Carey's father-in-law, who were given a choice. You know, "You take this bed or you go somewhere else," like Thessalon or some far away place. Well, that's not a very nice thing to deal with. When you have that before you and you're sitting there with two members of the family to decide this with another person and you have your loved one, your mother-in-law, who has had a stroke and cannot speak for herself and you have to speak for her, you have to think quickly. We don't want her 150 or 300 miles away, we want her close to home. We want her at home if we can keep it there. The same thing for the men who are there and the other women.

There have been a few instances where this has come up, and so we have had to take the semiprivate room, whereas there are ward rooms. Ward rooms are identical. Elinor Caplan is very well aware. In fact, she and I toured the building together. These ward rooms and semiprivate rooms are identical, but the rates are different. My mother-in-law, for one, is a widow receiving $910.89 total. That's her senior citizen's pension, her supplement and a $10 Canada Pension cheque. That's all she gets. But to stay there it costs $1,104. I think that's very unfair. She has no assets like many of the others who are there. I'm speaking for many others, but I'm taking her as a very good example. They have no assets and they have no bank account and they are depending on their children, but their children are getting older. There's 10 years between my mother-in-law and my husband. He's much older than I am. He will be a senior citizen next year. Maybe he'll end up in a senior citizen's home too. I guess he won't end up in Espanola if he has to go there.

It's the same thing with many others. There's a long waiting list. They're all worried about what's going to happen to them. They don't have the money. They don't have family that can give any more money. They don't have any assets that they can sell. So where is this money coming from? Where are we going to grab it from, if we can grab it? If the NDP government can grab millions of dollars somewhere -- I won't mention the projects -- and a few million dollars from somewhere else to do something else, why couldn't they have reached out somewhere in the air and gotten millions of dollars to keep our senior citizens happy, healthy and well taken care of?

Take their pensions, if that's what it has to be. But if they're going to raise this increase, where is it coming from? Where will they get it to stay in that home? They can't stay in the home, can they? Or will you allow them to stay there? Will the government allow them to stay there?

Mrs O'Neill: Well, we are sure hoping so.

Mrs Rooney: And you know yourself, as each year goes by, you get progressively worse. Is there anything else?

Mrs O'Neill: I guess our time is short. I did want a little comment on the residents' councils, if I could, and the role they play in your facility.


Mrs Carey: The lady who was to represent residents' council was unable to come with us today.

Mrs O'Neill: Okay. Well, thank you so much for being as forthright as you've been in bringing very concrete examples of the concerns, because we know they're there.

The Chair: Mr Jackson.

Mr Jackson: This is a very strong brief you've presented. Words like Bob Rae being --

Mrs Carey: Unconscientious.

Mr Jackson: -- unconscientious, thank you. "Where is this government's social conscience?" "We don't trust them." These are very strong words. Were you concerned that a year and a half ago, when this government got into difficulty -- nursing homes were starting to close, banks were putting them into receivership -- and all through that debate, not once did the Minister of Health mention, "I'm going to find this money on the backs of seniors"? She promised that she would increase the cash flow to nursing homes.

Did you ever anticipate that these socialists would bring in increased user fees, even when they campaigned so heavily in the last election? The Liberals and we, as Conservatives, took it in the ear, in the backside, everywhere from the socialists campaigning, who said we were the devils because we were going to talk about user fees. How do you feel now that this is one of the first major promises that were broken by this government affecting this issue of user fees?

Mrs Carey: I wish that some of the people who are involved in the amendments to this could see what kind of stress it's creating for some of the people. They're not in there on a one-on-one basis trying to calm their fears. There's one resident in particular whose big concern is, "Will I have to move out of my room?" She loves her roommate, she loves her room, she's very happy there, and just the thought of moving even across the hall has got her in a tailspin.

Mr Jackson: The fact that this government has said, "Trust us, we're going to put it in regulations" -- and the minister has consistently said that. Well, after this government -- and I don't think they really, honestly lied to us two years ago at the polls; I think they believed that was the system they wanted. But as soon as they got in there, they realized that they're not going to ask unions to take a cut, they're not going to ask everybody to participate; it's the senior who have to take the hit, and they've protected themselves very cleverly by not allowing amendments. You said you're hoping for amendments. We can't amend this to include the structuring of the fees and the protection of the asset bases and so on and so forth.

Do you believe any more today the assurances of the parliamentary assistant over the previous assurances of the government that there wouldn't be user fees to assist those facilities that are nursing homes?

Mrs Rooney: Definitely not. Today I feel like "the Robin Hood of two years ago," because someone else said this before I did -- "liars," is the word. Liars, liars, liars. Let's put it to rest.

Mr Jackson: They won't put it to rest.

Mrs Rooney: Straighten it out.

Mr Jackson: They want the flexibility -- they call it flexibility, which is a buzzword for control. They want to ensure sensitivity. That means they want to be able to protect the rules of the game. Those are the buzzwords that governments use.

I wanted to commend you for raising the issue of our veterans, and we are going to hear from one of the legions this afternoon. I just wanted to share with you that my colleague, our Health critic Jim Wilson, has written to the Royal Canadian Legion assuring them that we were presenting an amendment to this legislation. It's one of the amendments that would be deemed acceptable by the Chair and legal counsel as fitting in the legislation, but it may not be supported by this government, which controls this committee in terms of numbers. But we are prepared to acknowledge in legislation the promise we made our returning veterans, that the cost of their sacrifice would not go unnoticed during their lifetime, and this would represent a watershed change in that understanding to veterans, all previous veterans of known record in this country's history. We in no way wish to disrupt that and we want to commend you for looking upon your residents with a keen eye to understanding the various mix and the various backgrounds of your residents and that there are a significant number of veterans in your care in the Espanola area. I wanted to thank you for mentioning that and I wanted to at least give you that assurance, that we would be presenting that amendment to ensure that on a need basis doesn't mean that a veteran with less acuity would be passed over and told, "I'm sorry, you don't fit the politically acceptable mix of residents in this home any longer." Those are words we should never have to say.

The Chair: Do you have any final comments you'd like to make?

Mrs Carey: No.

Mrs Rooney: I'll just get into trouble if I say any more.

The Chair: No, not at all. The purpose of public hearings is to set out what people honestly feel. This is the place to do it. We are here as legislators from the provincial assembly and that's why we're here. I want to thank you for coming. Again, I'm sorry that there were difficulties around coming, but we are glad that you came and we thank you very much.

Mr Bisson: Mr Chairman, could I just make a comment? I think it's important.

The Chair: Order, please. I'm just going to thank those who came. I'll call the next witness and you can make your comment. Thank you again and I call the Victorian Order of Nurses, Sudbury. Mr Bisson, with a short comment.

Mr Bisson: The comment was in regard to some of the facts that came before us in the last presentation I think were well-meaning but somewhat misinformed. What scares me about that is that if we're going back into our nursing homes in Ontario and talking about issues like this in the way they were here before seniors, I think it puts them into a state they don't need to be in. I go into my nursing homes on a very regular basis in my riding, as all of us do within our own ridings, because seniors are an important part of our community, and it's not to say there aren't problems, it's not to say that legislation can't be made right, but I think it's very important that we clarify some of the misconceptions around some of the points that were made in this last presentation, because I think if we went into nursing homes and talked to people the way some of this was, we could scare the bejesus out of them.

Mr Jackson: Truth has a funny way of doing that.

Mrs Caplan: They just don't trust you. They see you taking from the have-nots and giving to the haves. They just don't trust you Gilles, and with cause.

Mr Owens: That was so transparent.

Mr Jackson: Are you calling the previous deputants --

The Chair: Order, please. Mr Bisson, I think that is open to all members to do, but what we are doing with the committee is having members come forward.


The Chair: I call the Victorian Order of Nurses, Sudbury, please, if you would be good enough to come forward. I want to thank you very much for coming before the committee, and if you would be good enough to introduce yourselves. Do you have a submission there? Do I see copies? Perhaps the clerk -- oh, here we are. We'll get those and just circulate those. If you would be good enough just to introduce yourselves for the members of the committee and for Hansard, then please go ahead.

Ms Sharon Baiden: Good morning. On behalf of Victorian Order of Nurses, northern branches, Algoma, Kirkland Lake, North Bay, Porcupine and Sudbury, we are pleased to come before the standing committee on social development. My name is Sharon Baiden, executive director of VON Sudbury branch, and with me this morning is Antoinette Blunt, executive director of the VON Algoma branch. Together we will be presenting a VON northern perspective on Bill 101 and the proposed amendments.

VON welcomes the opportunity to comment on the amended statutes of Bill 101 dealing with long-term care with respect to provincial subsidies for nursing homes, charitable homes for the aged and municipal homes, service agreements with operators and facilities, admissions by designated placement coordinators, plans for residents, quality assurance plans, inspections of facilities and grants to assist persons with a disability to obtain the required goods and services.

At the outset, we wish to express our respect and commendation to the standing committee. The result of the comprehensive review and concrete proposals for change will likely affect the nature and future of our health care system for decades to come. Bill 101 represents the initial reform of the long-term care system.


Ms Antoinette Blunt: The Victorian Order of Nurses is a national charitable organization dedicated to providing health and related services to communities across Canada. As a major provider of nursing and other services in the home and community, VON believes that individuals have primary responsibility for their own health. The maintenance of health directly and positively affects the quality of their lives. The value and dignity of human life is respected. Individuals have the right to accept or refuse health care, to obtain information about their health and health care and to participate with professionals in making decisions about and plans for the provision of their care. Individuals and families are supported so as to enable them to live and to meet death in comfort and with dignity.

Access to comprehensive, compassionate, family and community-centred health care is the right of all individuals regardless of their ability to pay. Health care providers collaborate to develop, implement and evaluate services which respond to the expressed needs of individuals, families and communities in keeping with the principles of primary health care.

Volunteers make a valuable contribution by extending and complementing the services provided by health professionals. At the local, provincial and national levels, volunteers help to identify needs, formulate policy, plan, promote, support and provide community health services.

Community health services of assured quality are essential. VON has a responsibility to expand knowledge through ongoing research, program evaluation and education.

Ms Baiden: Since June 1990, VON has carefully considered the government's proposals for reform of the long-term care system. Through the change in government and the ongoing review of the long-term care system, VON has continued to be involved in ongoing discussion and response to the proposed changes.

VON branches across northern Ontario, covering Algoma, Kirkland Lake, North Bay, Porcupine and Sudbury, have a cumulation of more than 400 years experience. Over the years, our branches have worked closely with the community in identifying needs for services and developing programs to meet these needs. Through the participation of VON staff, volunteers and board members, our local branches adhere to the VON Canada mission, goals and objectives, and ensure the maintenance of professional and administrative standards.

Governed by a voluntary board of directors, VON is represented by a cross-section of the community with a wide range of skills, expertise and commitment to directing the branch. The boards are fiscally responsible for branch activities and are responsible for overall directional planning.

Ms Blunt: VON employs a range of professional and support staff in the delivery of community-based services. VON is moving to an expanded role of registered nurses in primary and secondary care. Nurses have a key role in long-term care both in facilities and in the community. The unique role of the nurse focuses on individual and family response to illness and disability in long-term care and has a key role in health promotion and prevention. Nurses are equipped to respond to the diversified needs of the long-term care client. Registered nursing assistants are assuming an expanded role with less complex, stable cases still involving skilled nursing intervention, and home support workers are providing personal care under the supervision of a health professional. Thus, we have a multidisciplinary team working to assess needs and to develop care plans in partnership with clients.

As VON looks to the challenges of the future, we continue to examine a range of models for in-home service delivery in order to ensure the best services for the consumer. Consumers requiring long-term care services to promote their health and wellbeing should have a choice of needed services, delivered in their preferred location by their preferred provider within available resources.

In responding to the feedback received through consultation, we believe the government is committed to a continuum of services offered both in the community and in long-term care facilities. VON, too, fully supports a full range of services from which consumers may choose in order for individuals to be independent for as long as possible.

Our primary services have been in home visiting nursing with an ever-expanding role as needs of individuals have changed and the focus to community-based health care has increased. VON has noted a shift in nursing complexity to include high-level assessment and skill in areas such as palliative care, enterostomal therapy, diabetic education, advanced foot care, in-home intravenous therapy and pain pump management in both acute and long-term care conditions. Many of VON services are provided to the age group of 65 and older. Maintenance of health and restoration of health to optimal levels of functioning through teaching, wellness promotion and supportive care are the aims of VON programs.

Family involvement is critical to all aspects of service provision. Through teaching and support by nursing and other professionals, family are provided the skills to manage the elderly or chronically disabled.

Trained volunteers are critical to supporting professional providers and family members in an environment where high-quality, cost-effective services are essential. Some branches in northern Ontario offer volunteer palliative care services as a means of providing ongoing support.

Ms Baiden: Programs presently offered by VON throughout northern Ontario include: in Algoma, visiting nursing, enterostomal therapy, shift nursing, palliative care speciality nursing, palliative care volunteer program, placement coordination service and foot care; in Kirkland Lake, visiting nursing; in North Bay, visiting nursing, early post-partum discharge, palliative care, shift nursing, Meals on Wheels and insurance company assessments; in Porcupine, visiting nursing, occupational health nursing and a seniors' safety program; and in Sudbury, visiting nursing, early post-partum discharge, palliative care, shift nursing, foot care services, adult day centre, placement coordination service, volunteer palliative care services, home support program, in-home respite services and insurance company assessments.

Our future directions include new and expanded community-based programs to meet the challenges of promoting a healthier and more independent senior population.

VON recognizes and supports the need for institutional care of the elderly as a necessary component in the continuum of long-term care services, and from this perspective we speak to the proposed amendments in Bill 101.

Ms Blunt: Bill 101 is an incremental improvement in empowering the consumer. In recognition of the consumer's right to self-determination, the consumer has the right to participate in decisions affecting him or her. VON believes that more emphasis should be placed on the right of the consumer to be a full partner in the planning for his care, including choosing the delivery model and the provider best suited to meet his needs. With this direction, we must also recognize the right of the client to accept reasonable risk in his or her preference of where services are delivered. VON recommends that consumers have the choice of location of services, in a facility or community setting within an envelope of available resources.

In order to ensure that the citizens of Ontario have reasonable access to services, it will be necessary to have core services in place in each community across Ontario. In many areas of northern Ontario where community and facility services are limited, VON questions the level of choice consumers will actually have. As such, we recommend that the government initiate core services, including both in-home and facility-based care, needed in each community in order to truly empower the consumer around choice.

Further, in considering the development of core services, VON suggests that the government evolve provincial standards to ensure the outcome and quality of service and programs delivered. Such standards would promote a high level of accountability. Development and implementation of standards should be encouraged in conjunction with consumers, government, professionals and agencies involved in the delivery of service.

The regulations to be developed to support Bill 101 are to establish guidelines which provide for facility rights regarding type of service delivery. We suggest caution be exercised such that regulations do not negate any possibility of consumer choice in northern Ontario, particularly for service delivery to multicultural groups and natives.


Services to seniors and disabled adults have tended to be viewed from a one-way directional flow from home to nursing home or a chronic care facility as aging and disability progress. Provision of services in this matter lacks consideration of consumer need and choice. In providing a full continuum of long-term services, flexibility and multidirectional flow is necessary to meet clients' changing needs. Some individuals may require only short-term care in a nursing home or chronic care facility and with appropriate intervention may be able to return to home-based care with supportive services. Both consumers and service providers have the responsibility of ensuring appropriate planning is done to achieve smooth transition between and within the long-term care system.

Ms Baiden: The amendments start to standardize legislation for long-term care facilities but do not replace separate legislation. We note that the legislation does not address chronic care beds and are encouraged that the government will receive and review the report of the chronic care role study to address this role in long-term care.

The legislation allows for the government to designate the number of beds, to require certain types and capacity of beds for certain levels of care and service, but does not reference these requirements in terms of any planning process provincially, regionally or locally.

Planning responsibilities should be clearly defined. Decisions should be made at the level of service delivery so as to ensure all factors are considered, particularly multicultural and geographic diversity. We believe the decision-making authority should be close to the people. Planning provincially, regionally and locally, with clearly defined responsibilities, will improve efficiency. For example, provincial responsibilities could include the definition of core programs and the definition of a quality management framework, including standards, outcomes and reporting requirements. Regional responsibilities could include specialized service planning; for example, geriatric assessment and specialized rehabilitation resources. Local planning could include the continuum of care from health promotion, through rehabilitation to chronic-level care; in-home, community- and facility-based.

VON supports the lead role for local planning being expanded to the local district health council. In the past, planning has occurred at multiple levels with little coordination, which has caused fragmentation and duplication in some cases. District health councils are well-positioned to assume the role of leading comprehensive, coordinated planning for long-term care services.

While VON recognizes the complexity of the long-term care system, we believe that moving ahead with implementation of certain areas before the entire policy framework is debated may further fragment the system. We envision a fully integrated system of reform, with a strong emphasis on community-based services.

For example, the proposed changes to residential care may lead to deinstitutionalization for some. In order to manage this group and those presently on waiting lists for residential care, we must stress the necessity for the implementation of community support services and health and personal support services.

In moving ahead with Bill 101, institutional care becomes the focus, rather than developing health promotion and community-based options. VON recommends that the implementation of the legislation be deferred until the policy framework is released and consultation has been heard.

Ms Blunt: Today in Ontario, the resources allocated to institutional care -- for example, chronic beds, extended beds and residential beds -- far exceed resources spent on community and in-home services.

We believe that the health care system as a whole is sufficiently funded. The rate of growth of health care expenditure must be contained if universal health services are to continue. A provincial plan is needed to define funding allocations based on strategic priorities and a system of accountability around cost-benefit and consumer satisfaction.

The legislation promotes fiscal accountability by a control on resource utilization, rather than on measures for resource outcome. For example, there will be controls on the number and types of beds, as well as associated costs, rather than evaluating the benefit of facility versus other types of care from a systemic and consumer perspective.

While a payment system has been identified based on consumer acuity, VON believes it is not an incentive for wellness, but rather an incentive for illness. Funding formulas are needed that will address the full range of consumer need and care provision, rather than acuity only. The funding formulas further lack incentives for discharge from institutional care back to community-based care and lack incentives for rehabilitation to other levels of care.

Cost-effective service provision is essential and VON recognizes the need for regionalizing specialty services in order to ensure a comprehensive package for all consumers. However, in northern Ontario, geographic dimensions must be considered when viewing services from a regional perspective compared to those offered in southern Ontario. Thus, we recommend that services be considered and planned for locally, as distance to regional centres could cause accessibility problems in northern rural areas. Innovative delivery methods, such as travelling consultants, could be considered appropriate.

Ms Baiden: VON fully endorses a total quality management approach to both care for in-home, community-based and facility-based services. The approach promotes consumer choice and empowerment through their involvement in the evaluative process of programs provided to them. The proposal promotes a control/regulatory model, rather than that of quality management. Control through inspection does not promote quality care nor achieve desired outcomes. Inspection has been shown to promote lack of trust in quality care from both the provider and the consumer perspective.

Empowering consumers in a total quality management approach strives to ensure the right services are offered at the right time, in the right place, by the right provider. VON encourages the government to consider the concept of quality improvement to ensure high service standards and consumer satisfaction.

Ms Blunt: While there may be several agencies providing service to a client, the system must be structured in a way to ensure that the services are delivered to the client in a seamless model. The government should promote collaboration among existing community organizations to reduce fragmentation. In order to accomplish this, service providers need to look at creative ways in which they can work together towards the common goal of meeting client needs through a multiservice agency. In considering options for service delivery, it should be noted that VON is currently a multiservice provider of services and would be prepared to sponsor pilots. VON suggests that the long-term care management agency also provide community-wide information and referral services, as well as screening for eligibility of needed services.

The proposed legislation speaks only to facility-based services. As indicated earlier, VON views the reformed long-term care system as a fully integrated system of both community-based and institutional services. We wish to emphasize the need for collaboration and partnership between all groups involved in the delivery of long-term care services. Bill 101 does not speak to linkages or partnerships with community agencies. We believe this to be necessary so as to ensure smooth transition through services and to ensure a seamless provision of service to consumers. Flexibility and simplified access is critical to responding to consumer needs.

Prior to expanding facility services, other community-based options should be explored. Additionally, utilization of community-based services in facilities, such as speciality consultation teams, should be considered in rationalizing resources and manpower.

Family care givers form an integral component in the continuum of service providers. Ninety per cent of the care and support received by people who live at home is given by family and friends. In order to optimize family involvement in the care of the long-term client, it is necessary to have available respite care services. Bill 101 includes short-stay accommodation availability in each facility. This is a respite option which is necessary in some case. VON further recommends that the government consider the use of community-based respite service. Such intervention would allow for continuity of care and is conducive to a wellness approach to support services. In some instances, respite is most appropriate in the home setting, an area not currently funded. Presently, when care givers need a break, institutional respite becomes a costly must.

Ms Baiden: Serving consumers through a centralized, independent and objective placement service will assist to ensure equal and equitable access to both information and placement. Directing all placements, for example, through placement coordination services will streamline the admission process for facilities, consumers and families. We wish to emphasize the consumer's right to choice when working with placement coordinators in seeking facility living.


In order to fully ensure equity around access, eligibility criteria must be precise and consistent across the province, and regulations around admission to the facility must be concise and consistently applied. We are pleased to note that the regulations allow for an appeal process regarding eligibility for service.

VON recognizes the need for short-stay accommodation in each facility, as we recommend that this be utilized for respite in some cases and/or care during periods of exacerbation of illness.

VON supports the expanded role of placement coordinators and the availability of this program on a province-wide basis. In the districts of Sudbury-Manitoulin and Algoma, VON administers placement coordination service.

In concluding, VON wishes to emphasize our interest in long-term care reform and to acknowledge the government's initiative in consulting with communities across the province. We look forward to working with the government in planning and implementing an enhanced health care system which will provide a quality continuum of care within available resources.

Thank you for your time this morning. We are prepared to answer any questions you may have.

The Chair: Thank you very much for a very full brief. You touched on a number of issues. I think I should also note that we've had a number of VONs come forward, and I think probably everyone has said they'd be happy and willing to participate in a pilot project, so we note that as well.

We'll begin the questioning with Ms Caplan.

Mrs Caplan: I'd like to repeat the Chair's comments about your excellent brief and also acknowledge the important role that VON plays across the province. From my experience, your members and service providers have always lived up to the values that you expressed in your brief today.

I'm not going to ask a lot of questions, but what I would like you to do, however, is speak a little bit about the total quality management approach as it works and has been working the last little while. I know that VON has been a leader in moving to that new approach, and I'm very aware that the NDP had been opposed to the whole compliance management approach, for example, within the nursing home branch at the ministry. They've much preferred an intrusive government inspection model, which I think many people we've heard before the committee and experts agree is outdated.

I'm hoping that at this committee perhaps the policy option that was rejected will be reconsidered, and perhaps an amendment would come forward that I'd like you to speak to. If there was an amendment to this legislation which required accreditation of programs, coupled with a requirement that you had a total quality management program in place, do you believe that would give the kind of accountability that would be in the consumers' interests and in the interests of those who wanted to protect the public interest?

Ms Blunt: I certainly think that moving towards total quality management is also a much more cost-effective way of providing services, something that I think we're all fully aware of that needs to happen in our health care system. We can very often be providing a lot of services and programs and doing them very well. But unless we base our analysis and evaluation on these services and programs, on outcomes and consumer satisfaction, then maybe we're not doing the right thing. I think that's one of the areas that's most critical to total quality management. We can then find out if we're doing the right things for people. If we focus our spending on the right programs and services that enhance consumer satisfaction, the system in the long run will become much more cost-effective.

Mrs Caplan: You used a couple of words that I know were very deliberate because they are part of the whole total quality management approach, and that is, doing the right thing to the right person in the right place at the right time right away. Doing it right the first time, I guess, is the whole concept.

Ms Blunt: Yes, that's right.

Mrs Caplan: Could you just speak a little bit more about that? The reason I'm asking you to do this is that I'm hoping you'll convince the government that this is a better approach than the enforcement model with the inspector. The overall understanding is that inspectors are an after-the-fact intrusion and do not allow for the focus on outcome and consumer satisfaction and getting it right the first time. Have you had experience in that?

Ms Baiden: Particularly I like your use of the words "after-the-fact outcome." One of the key focuses of quality management is that it's a continuous process, it's ongoing, and it doesn't look at service delivery and programs being offered in the absence of some form of evaluation.

The other area, to add to what Antoinette has said to you around quality management and looking at consumer satisfaction, is not only to go to consumers to seek their satisfaction with existing services but also to identify gaps and close those gaps. So when we look to doing consumer satisfaction surveys, we look not only to the clients we serve but, for example, to the owners of facilities so that they have an opportunity to have input in terms of where they see areas for improvement, again, commenting on their satisfaction with existing resources and services available to them, but providing an opportunity to offer suggestions for improvement and where some of those gaps need to be closed. So very much in terms of the after-the-fact inspection, quality management through VON's approach is to look at just a continuous system of monitoring and evaluating how we're actually providing services.

Mrs Caplan: And you would be comfortable with the level of accountability if this legislation required a quality management program and made mandatory accreditation, whether it was for a facility or some body to look at the program that was in place, on the basis of outcomes?

Ms Blunt: Yes, I would certainly support what you're saying as far as on the basis of outcomes. The whole direction of total quality management is one that very much involves the consumer, and it has been noted by many consumers across this province that they want more involvement. They want involvement in the decision-making process for what programs and services are to be offered, and looking at service provision from this perspective will truly give consumers the power that they need to be a full partner in the system.

Mrs Caplan: And enforcement models and inspectors don't do that, do they?

Ms Blunt: No, they don't.

Mr Jackson: Thank you for a very thorough brief. We're hearing the overall theme of limited time for response to the bill and the absence of guidelines in the legislation, but, "Trust us, it'll come out in regulations at some point," and maybe we should delay till we see the whole picture. We're getting that message from a growing number of front-line service providers and it's interesting and appreciated that you've focused in on that as well.

Could you share with the committee -- and I wanted to ask this question of an earlier deputant -- about the current role of placement coordination and how it's working and how you would see that changing, if at all? You offer a wide variety of services. There are some placement coordination services currently occurring in Sudbury, but that may change. Could you directly respond to how it's working here and how you see a change?


Ms Blunt: In Algoma, VON has administered the placement coordination service for approximately 12 years, so we did have one of the earlier programs in operation. Prior to the existence of placement coordination, one of the problems was lack of information on how many people needed to access the system. Many people's names were on one or two different waiting lists at different facilities. There was a lack of knowledge by service providers and for government to be able to be able to determine how many people were awaiting placement for the various levels of care. Providing placement coordination provides a centralized area where people can access the system for long-term care facility placement.

Mr Jackson: I'm sorry.

Ms Blunt: Is that what you're asking?

Mr Jackson: No. We understand the process of placement coordination.

Ms Blunt: Okay.

Mr Jackson: You have a patchwork, with some of your VONs doing the placement coordination service and some aren't. Do you feel you're going to be removed from this responsibility and that some superboard of placement coordination's going to replace it? I see that two out of your four VON services are conducting placement coordination services. Is that the sole placement coordination service in the city of Sudbury? I don't know these things. That's why I want to know from you, who does placement coordination service in Sudbury and Algoma? It is you, according to this brief.

Ms Blunt: Yes. There is no other --

Mr Jackson: Do you see that changing?

Ms Blunt: Do I see that changing?

Mr Jackson: Have you had any discussions with the government about it changing? I was just wanting to get a sense of, do you think you're going to be the placement coordination service or do you not think you're going to be the placement coordination service?

Ms Blunt: I think that's a very difficult question to answer, given the day. I'm not really sure what the future will hold. I believe that the current placement coordination service as it is administered is an effective service. I feel the role of the coordinator does need to expand somewhat to meet all the needs that have been identified in Bill 101. I'm not really sure whether or not in the future it will be a part of VON. I can't answer that question.

Ms Baiden: In Sudbury, VON does administer the placement coordination service and we've been running the program for coming up to four years now.

Your initial question was, how do we see placement coordination service changing as a service? Not to defer your question on whether or not it will be VON that administers, in terms of how the program will change, right now participation through placement coordination service, particularly by facilities, is on a voluntary basis. In some of the noted changes in Bill 101, I guess one of the things we would support is that the participation through placement coordination service not be voluntary. I don't like to use the word "mandatory," but all facilities and individuals seeking placement would be coordinated through one central location.

The reason for this particular type of move really looks at some of the areas such as standardization so that we are looking at standard methods of data collection, data analysis and that this can be centrally looked at through the province so there's a better understanding and determination around the need for additional beds or decreasing beds. The system which in the past used to do some of that tracking on beds is no longer utilized, and in order to really have good information around bed utilization and waiting list pictures, we believe that it is critical that one service placement coordination service would well serve that function, particularly to have readily available information, and that there would be some very clear reporting requirements from placement coordination services into a central location so those data are available on an easily accessible basis.

Mr Owens: This is my first day on the committee, so I hope you'll forgive me if I ask you questions your group has already answered.

In terms of your comments with respect to total quality management, I think that in a Utopian society that would be the way I would like to go myself in terms of people proactively looking at issues with respect to care, to ensuring that residents are challenged appropriately with respect to activities and things like that. But I guess in terms of my experience with the group Concerned Friends, the seniors' group that monitors residential care facilities, it's their view that currently there are serious difficulties within the system.

How would you address those difficulties as they arose without having an inspection model? Maybe I'm misinterpreting what the total quality management approach means, but having an experience with what was called the internal responsibility system under the Occupational Health and Safety Act, people are basically allowed to do what they need to do until someone complains, so how would you intervene in a process before a resident was either hurt or perhaps wasn't given the appropriate level of care that was necessitated?

Ms Baiden: I'm not familiar with the group Friends that you've mentioned.

Mr Owens: Concerned Friends. It's a group of seniors that have been involved in advocacy for seniors. Perhaps it doesn't have a northern affiliate group, but it's been around for quite a number of years and has advocated on behalf of seniors in a number of situations in Toronto. When complaints have been made by residents, this group will become involved with the other residents and their families. They've acted as de facto advocates with the lack of advocacy legislation.

Ms Baiden: Just based on what you're saying and how I'm interpreting what you're saying, the total quality management approach would ensure that groups such as Concerned Friends would have systems and processes in place whereby it's not a cumulation of information or outcomes that is reported to them, and then it's, "Where do we go with this information?" or "Where do we turn to have assistance with our problem?" but rather, there are some systems and processes in place whereby there's a continual monitoring and collection of information to determine if in fact there are problems.

The group has an opportunity to be working with an advocate or perhaps problem-solvers so that they can jointly work together to address the concerns of the residents they represent. I don't know if I've understood Concerned Friends correctly, but I think many times we have systems in place that there is a location where complaints can be made, and then the question becomes, what happens to the complaints once they've been lodged? In a total quality management approach, there are very clear systems to ensure that when there are complaints or suggestions for improvement, feedback is given. There's a very clear direction with where you would go with that information so that there can be change, improvement made to existing systems.

Mr Owens: In terms of the regulation-making process that is currently taking place under this legislation, would you see a need for the government to perhaps make regulations regionally sensitive to northerners, for instance, in respect to the services that may or may not exist in the area?

Ms Blunt: One of the things we mentioned in our presentation that we would fully support is that there would be provincial standards to ensure that a certain level of services was available to all consumers in all communities across the province. We do recognize that you can't offer everything to everybody in the same location. I think we wanted to make this group today aware of the sensitivities of the very large geographic diversity in northern Ontario, such that there might have to be additional innovative ways of service delivery to meet some of those needs. But what is essential right now is that basic services and some core programs and services are not available in every community throughout this province. That needs to be determined by the setting of provincial standards, and then we would move on from there.

Mrs Caplan: The standards would be the basis of accreditation?

Ms Blunt: Yes, they could.

The Chair: The parliamentary assistant had a couple of points that he wished to clarify. If it's not quite as clear, you may engage in your own questions with him.

Mr Wessenger: Thank you very much for your presentation. I always enjoy presentations from the VON because they're so well thought out.

First of all, I'd like to refer to your comment about deinstitutionalization. I'd like to assure you that no person is going to be forced out of an institution; that's not part of a policy. Secondly, with respect to the policy statement, it is expected out in the month of March, hopefully as early as possible. Of course, as you know, the local planning process of the DHC will determine the whole aspect of service delivery and also, in respect to the role of your placement coordinating service, that it will continue to be under your jurisdiction unless the local -- it depends on, of course, the result of the multiservice agency model that may be evolved as a result of a local consultation.


Mrs Caplan: We have a subtle change of translation for that.

Mr Wessenger: You made one other comment about the question of the respite care. The preferred option for respite care will be in the community; that will be the preferred option.

One last point is, in the bill there's reference to quality assurance, which apparently is not the right language, but there is a commitment to the concept of quality management, and the necessary amendments will be made in the legislation to ensure that. I can also assure you that certainly as far as the policy is concerned, we do believe in the compliance model. However, I would suggest that if the compliance model doesn't work, you do need some underpinning with respect to ensuring that changes are made.

Ms Blunt: Just one final comment: "Total quality management" is more than a change in language from "quality assurance." That must be stressed.

Mrs Marland: Exactly.

The Chair: I want to thank you both for coming. It has been noted in terms of the content of your brief and also in answering our questions. We very much appreciate your coming here this morning. Thank you.

I now call on the Victorian Order of Nurses from Sault Ste Marie, if you would come forward please.

Ms Blunt: That is me. What we did was, we joined together to provide a joint perspective from the north.

The Chair: Oh, you did?

Ms Blunt: Yes. Thank you.

The Chair: I'm sorry. I misunderstood.

Mr Owens: We have another half an hour.

Ms Blunt: We've almost used our full hour.

The Chair: With that, because the 11:30 group cancelled, I will allow each caucus, if that's all right with you, one more set of questions. I was starting to call it to an end because I thought we were going to have another submission. Ms Marland?

Mrs Marland: Actually, Mr Chairman, I was going to raise a point of order. I'll wait until we finish the deputation.

The Chair: All right. Ms O'Neill? Is that all right? Sorry, do you mind?

Mrs O'Neill: I'm really pleased that this has happened. I would like to clarify something from the parliamentary assistant, though. There are two or three things he said that I'm not sure about. The respite care: Did you suggest that the suggestion that's been put forward this morning would not be considered because there's a preferred option, and would you explain that?

Mr Wessenger: No, I made no such suggestion. I just wanted to assure the presenters that although we're providing under Bill 101 with respect to the opportunity for respite care within the institutional setting, the preferred option from a policy point of view is for the respite care to be delivered to the community.

Mrs O'Neill: I still don't know the answer, but I guess that's okay.

Mr Wessenger: Perhaps I'll ask ministry staff, then, to respond.

Mrs O'Neill: Yes, I think that would have been better in the first place, probably.

Mr Quirt: As the presenters have pointed out, Bill 101 allows for respite care to be delivered by each long-term care facility for the first time, and funding arrangements currently are such that there's a disincentive to nursing homes and homes for the aged to leave beds open for the purposes of offering respite. Bill 101 allows us to have a respite care capacity in each long-term care facility.

But as Mr Wessenger was pointing out, that's only one of a number of ways in which respite care can be delivered. From our perspective, respite care is the objective of delivering service and respite care can be delivered to family care givers by a volunteer going in to allow a care giver to go out for an evening; it can be achieved by sending in a Red Cross homemaker for a period of time if other services need to be done in the home while care givers are away. The province would pay 100% of the cost through the health and personal support program delivered through the home care program.

As you're well aware, often a VON nurse going in for a visit allows a degree of respite, so depending on the circumstances clients find themselves in, and their families, respite care can be achieved by making respite care a valid reason for delivering the services of volunteers and other professionals in the long-term care system.

You would be familiar with a problem with the home care program currently, where the patient is the patient and the family situation can't, as often as would be advisable, be taken into account in determining what that family needs. So the objective is to make respite care for family care givers a bona fide, legitimate reason for the service system responding in as flexible a way as it can.

The Chair: There was a question back just on that answer. I wanted to allow Ms Blunt to comment.

Ms Blunt: I think it's encouraging that the government is willing to pay for respite. I just wanted to expand on something that you actually said. It is important to have respite in a cost-effective manner provided at the level of need of the individual. In many situations a volunteer, a health care aide or a homemaker is appropriate. There are other situations where family is looking after very chronically ill people or very high-level care family members in their homes. So when the government is looking at funding, it should consider a broad perspective of needs to meet the level of need of the particular person, and that could go as high as an RNA- or RN-level care.

At this point in time, there is no funding to support higher levels of needs of respite in the community and often these individuals, if their families can no longer support them, will end up being the more costly ones in an institutional setting. So when the government looks at funding respite, all levels of needs of individuals should be considered in order that their care at home may be maintained as long as possible by the family.

Mrs O'Neill: I am really pleased that we have got that issue so well explained from both sides.

I would like to say, in my opportunity, that I am very pleased with the tone of your brief. I like the statements and I think we can't say it too often, the reasonable risk that seniors have a right to take. You show, as Ms Caplan said, the deep respect for decision-making on the part of the consumer. I really think we have to continue to remind ourselves of that.

You express a fear that many of us have that this document is really leading towards further institutionalization in maybe insipid ways, and that is a concern.

You didn't say very much about the DHC, other than you approve of the role it will take in Bill 101. Can you give us anything from any of your own personal examples that would say how that's happening in your communities? That's my only question. Have you begun, I guess is what I want to know?

Ms Baiden: I can speak not on behalf but from my experience with working with our local district health council. Certainly we feel that the district health councils locally are well positioned to assume a leadership role in terms of coordinating comprehensive planning. In our area, through the long-term care committee, for example, the committee has undergone review in response to the government's decision that long-term care leadership would fall to district health councils and has looked at terms of reference in terms of committee representation.

Our district health council well represents a huge geographic area: representatives from Chapleau, Manitoulin Island, Espanola, Sudbury district east, the regional municipality of Sudbury. Particularly in the north, it's critical that all the various points of view are well represented and heard at the planning level so that there isn't duplication and there aren't certain groups that are left out or assumptions made that services can be delivered in such a way to meet the needs of a particular geographic area. I can't stress enough that geography in the north, particularly to the rural areas, must be considered in any of the proposals around long-term care services.

When we look at the core services that we've spoken to, we are clearly committed that those core services need to be in place across the province, and that would include as well the rural communities so that our rural areas are well served and will have the choice available to them around services.

The Chair: Ms Marland, did you have any questions you wanted to ask? No. Then Mr Bisson.

Mr Bisson: You raised in your brief, I thought, a point -- let me take it from this way. What you're talking about is basically trying to find some way of ensuring some standards in regard to the whole question of care through Bill 101. Then there was a bit of a discussion between Mrs Caplan and yourself, and I thought it was rather interesting in regard to the whole question of, how do you ensure that standard levels of care are provided for within the community and within the care givers?

The discussion was around, well, there's a problem in having sort of the enforcer come in and tell you that you're doing something right or doing something wrong, because I think we all understand that as human beings we hate to be told we're doing something wrong, especially if we think we're doing everything possible in order to make it right. Unfortunately, the view sometimes of an inspector as to what's going on and what's actually happening may be a little bit different. I think we've all lived those experiences.

How would you see that kind of system being established, where you didn't have to do it through sort of an enforcement type of process, rather than having some sort of incentive process or something? I'm just curious about that.


Ms Blunt: Under a system of total quality management, when you look at the development of standards, you would certainly involve a high percentage of consumers in developing those standards for programs and services.

I think an earlier speaker mentioned the role of the residents' councils. Residents who are residing in facilities would also have the opportunity to speak up in regard to the outcome of services and programs, to discuss with facility operators as to whether or not they feel the standards are being met from their perspective. So it's very much a joint initiative between consumers, professionals and government working together to ensure that the standards are met, but from the very beginning you have to involve the consumers in the development of the standards and gain from their perspective what services and programs are needed as core services in our communities.

Mr Bisson: I see that as the easy part of it. The difficult part, and I guess the one I'm struggling with, is, what do you do in those cases where something really needs to be done and for some reason it's not identified by the consumers, or maybe they don't want to identify it for some reason? It somehow slips through the system. What can you do in order to make sure that you have a system, that you ensure care, without having to do the enforcement thing? Because I have the same concern.

Ms Blunt: First of all, from my experience in working with VON in the community for the past 14 years, consumers are not afraid to speak up if they will be listened to, and I believe as we continue to empower the consumers, give them some of the responsibility in making decisions, that we will have that input. That's certainly not an area that I'm very concerned about.

Mrs Caplan: It might be helpful to Mr Bisson if you explained the fact that TQM involves ongoing monitoring and evaluation and feedback.

Mr Bisson: No, I understand that, I do, because we've had this discussion with nursing homes and Extendicare units within my own riding. There are cases where things will fall through the system, like, they'll slip through the crack, and that's one of the things the enforcement part of it is able to do. Anyway --

Mrs Caplan: Enforcement doesn't do that; enforcement is after the fact.

Mr Bisson: No. I realize that, but I just have --

The Chair: The parliamentary assistant and then Ms Marland.

Mr Wessenger: Just one quick question. I would like to know who you think should have the ultimate responsibility for ensuring that standards of care are maintained in the facilities. Should it be the facility itself, or should it be the government, representing the taxpayer, that has that ultimate responsibility?

Ms Blunt: There has to be something put in place to ensure that the standards are met, and I believe that can be measured by looking at the outcomes and also by putting something in place such as accreditation. I think that could certainly be one tool that could be looked at as far as measuring the outcomes in a total quality management system is concerned.

The Chair: Thank you again for coming before the committee. Just so our records are clear, I guess really for my own information, the VON in Algoma encompasses Sault Ste Marie?

Ms Blunt: Yes. Sault Ste Marie, the district of Algoma.

The Chair: The whole district, fine. Again, thanks very much for coming before the committee. Ms Marland.

Mrs Marland: Mr Chairman, it's my understanding that committee proceedings come under the same rules and etiquette as any proceeding in the chamber, in the House. Am I correct?

The Chair: I believe so.

Mrs Marland: I think that if the clerk were here, he'd probably --

The Chair: Probably you're able to be a little more informal at times in a committee setting, but I believe in essence it goes on the same --

Mrs Marland: -- on the same, but it's my understanding that the same rules abide.

I've been in the Ontario Legislature for eight years now, and some time in the past two years, for the first time, we had some government members who were using their telephones during the proceedings in the House. Speaker Warner made a ruling that those kinds of equipment were not permitted in the House. He made that ruling, which I totally support.

I just have to raise the question, Mr Chairman, that if every one of the committee members sat here with laptops in front of them, how intimidating or uncomfortable that would be for our deputations before this committee. So I am surprised to see one of the government members this morning sitting here using a laptop computer during the hearing proceedings.

Mr Bisson: Can I just clarify, because I did ask --

The Chair: Just one moment, please. Does that conclude your point?

Mrs Marland: That's what I'm asking you to make a decision on, whether that's acceptable.

The Chair: Okay. Mr Bisson?

Mr Bisson: I was just going to say I asked, coming into the committee meeting, the Chair this morning for the permission, and it has been allowed in other situations on committees that I've sat on. Normally you ask the Chair and the Chair makes a decision, which I did this morning.

The Chair: I am informed that the Speaker did indicate that laptops should not be used by members during committee hearings. So I was not aware of that, but perhaps I could ask all members to abide by that ruling. Mr Bisson.

Mr Bisson: I will do it, but we should move to the 21st century as quickly as possible.

The Chair: It is certainly a question that can go forward.

Mrs O'Neill: It has been ruled out of order in the federal chamber as well.

The Chair: In any event, I understand that that is so, and I'm sure the honourable member will abide by it.

Before we break, I just want to thank everyone who has been with us this morning, both the participants and those who have been watching the proceedings. We will reconvene at 1:15 here, okay? Reconvene at 1:15. The committee now stands adjourned.

The committee recessed at 1137.


The committee resumed at 1302.

The Chair: Good afternoon, ladies and gentlemen. I call the afternoon session of the standing committee on social development to order. Again, we are continuing in Sudbury.


The Chair: Our first deputation this afternoon is the representative from the Ontario Finnish Resthome Association. We have the briefs; they're just being circulated. Perhaps you would be good enough to come forward. Welcome to the committee. Thank you for coming over from the Sault. We appreciate your making the time and effort to do that. If you'd be good enough to introduce yourself for Hansard and the committee members, then please go ahead with your brief.

Mr Lewis Massad: Thank you, Mr Chairman. My name is Lewis Massad. I'm the executive director of the Ontario Finnish Resthome Association in Sault Ste Marie. Our association -- this is included in your brief -- is a non-profit, charitable organization. It offers services to seniors within Sault Ste Marie. We operate a recently opened 60-bed extended care nursing home facility, a 111-unit charitable institution which serves aged people, plus as well a 132-bed seniors' apartment complex.

I'll keep my presentation fairly short. You have our brief in front of you, which includes an executive summary.

To start with, our association and our board of directors offer support towards Bill 101. Certainly, it has a major directive that will improve the care offered to seniors throughout the province. The major thrust is to standardize it and that is welcomed by our facility.

We do offer some concern at this point. The concern is that we hope the Legislature will ensure that adequate funding is provided vis-à-vis the levels of care funding and hopefully that the levels of care aren't going to be adjusted to reflect the dollars available, because with that will only come continued shortfalls of funding for all facilities within the system.

Of significant concern to our facility, which I would like to address, is the principle we support that there is consistent application to revenues, to operations between charitables, homes for the aged and nursing homes. In reading through 101 and all the various pieces of legislation, there's one major flaw that we find, and that's that in the future accommodation costs will be standardized throughout the province. However, the flaw is that one of the most significant costs facing these three facilities in terms of accommodation is not standardized, and that's municipal taxes.

Our facility is very concerned that as it stands right now, nursing homes, both for-profit and not-for-profit, will continue to be found taxable for municipal realty and business taxes, whereas homes for the aged, municipal homes for the aged, and as well charitable institutions will be found tax-exempt.

Realty taxes account for the largest non-controllable accommodation cost for any facility. Other items such as housekeeping, maintenance, those items are controllable and variable, but this is a non-controllable item. Our facility, if anything can come out of my presentation today, would ask that the Legislature give the utmost consideration to that fact, that equality is to be provided, and that's the principle, for these three types of facilities. But you have to look at standardized costs, and that is one item that is of particular concern. There are many other items that are variable, such as, within northern Ontario we face higher utility costs, as an accommodation expense.

The principle of standardized accommodation costs is flawed unless there is some allowance and some consistency given towards -- I go back to municipal tax exemption status. That is the premier concern our facility holds towards Bill 101 at this point.

Another item I would hope is ensured by the Legislature and the Ministry of Health is that levels-of-care classification is sound. It will only be sound if it is undertaken on an annual basis. As you'll identify in levels-of-care funding, which I believe is page 2, unless the levels of care classification which took place in September-October of this past year happens on an annual basis, inequities will again creep into the system. That must be a requirement with levels-of-care funding.

As well, many of the other aspects that I speak to on levels-of-care funding are supported. Truly, over the years there has been a hodgepodge of rates and fees for all residents across the province in the different types of facilities, and hopefully that will be rectified.

Our facility supports, as well, the concept of service agreements. It's nothing new to the nursing home industry and we'll continue to work with the Ministry of Health when service agreements are put in place.

As well, we support the concept that non-profit nursing homes will be provided capital towards their operations. That is new. It's certainly welcomed. Until we see what the actual funding arrangements are, as identified in the regulations, it's difficult to comment further, but the concept is clearly supported.


In terms of the coordinated facility access, residents within our complex have offered some concern that they may lose the option of choice as it is identified currently. Facilities such as the Ontario Finnish Resthome Association, which has been built upon and is owned and operated by an ethnically operated association, have some concern that at least until we see what's in the regulations, it's difficult to offer total support to the placement coordination services, and the ability of any facility to reject an admission is yet to be identified.

As well, we hope that through the placement coordination services, organizations which offer services to seniors that have been based on an ethnic background will not lose their ability to maintain that ethnicity as placement coordination service will govern and manage the admissions process.

I express concern from some of our residents to date as to the accommodation cost per diem that they will be faced with, not knowing how, if any, there will be income testing. They're concerned with that process, just being in the dark at this point in time. I just pass that on as well from our residents' council.

Another item as it relates to our facility and probably many others is the concern that the requirement that dictates how much a facility can charge a resident will be governed by statute law. However, nowhere in Bill 101 or within the various pieces of legislation does it address the requirement under statute law that the residents must pay for their accommodation cost. That, as well, is a matter of contract law between the facility and the resident or the resident's family or responsible person. That is of concern because under contract law it's very difficult, it's very expensive and it's an embarrassment many times for many administrators to have to take a family to court, while the resident is still in the facility, to secure funding.

As well, if it continues, then our facility would hope that greater flexibility be afforded administrators, that when there is a breach of contract that they will be able to act appropriately.

In terms of enhanced accountability, support is given towards the requirement that all homes provide resident care plans. Certainly, a resident care plan in any facility is the basis on which care is provided. Within our complex we have striven, and it is a policy of our board and it is implemented at the staff level, so that our care plans not only reflect the current day-to-day needs of the residents -- what do they need today? -- but as well our care plans reflect what we can do for them tomorrow to make the next day better. That's an important principle that as well should be written one step further in Bill 101. It's not just day-to-day maintenance, but ongoing and futuristic and proactive. Resident care plans are important. That has been in place in our facility and we will continue to work towards the betterment of the care for all our residents.

Support is as well given towards quality assurance plans and the added powers offered to inspectors. Within our complex we've only been in operation for about two years. We've had the Ministry of Health inspection branch in, I'd say, at least six or seven times, and each time we have welcomed them. I feel that facilities that are non-supportive of that concept -- if their administration is open-minded and progressive, they would utilize the expertise offered by inspectors as they come in. They see many different facilities across the province and they're not coming in heavy-fisted. Many times they come in and they leave us more information than they've actually found on non-compliance. We support the added inspection powers offered to inspectors.

In summary, Bill 101 is a good step forward. We certainly would hope that it's just a start to make all these three types of facilities standardized. I would hope that the utmost urgency of the Legislature be given to repealing the various acts that govern the three types of facilities and that for lack of a better term, maybe one long-term care facilities act be put in place. It's a rather piecemeal approach as it stands right now, but yet it certainly is a welcome start.

Just to summarize, the Ontario Finnish rest homes facilities' major concern is that of consistency as it relates to accommodation costs, and that being that non-profit nursing homes, which are a support of the current government and a direction I believe it wishes to proceed in, be afforded the same tax-exemption status that is currently received by homes for the aged and as well charitable institutions and homes for the aged.

Thank you for your attention. I can address any questions you have.

The Chair: Thank you very much for the presentation and for a number of specific issues that we haven't necessarily had addressed before the committee up until this point. We'll begin our questioning with Mr Jackson.

Mr Jackson: This brief contains several new areas we've not dwelt on at length, so I want to say up front that we appreciate your long trip from the Sault and the information you've brought us.

Mr Massad: Thank you very much. That rather concerns me. These are very broad issues that we would hope would have been addressed previously.

Mr Jackson: Well, they have been, and certainly your three main points have been persistently and consistently. but there are ones that you raise are rather new for someone who's been on this committee at length.

On the issue of municipal taxes, I guess I would like to leave with the parliamentary assistant and/or our researcher to determine -- I thought the legislation on municipal taxes was flexible enough that they could receive and review an application for exemption because they were charitable, non-profit. I know the distinction and the language of the legislation as it relates to homes for the aged which are municipally run. That's a given. But I'd like further information, because I think it's a very valid point, and I'd like to pursue it.

There's no need for further comment there perhaps, but the other one was the notion of breach-of-contract responsibilities, and perhaps in the presence of the deputant we might ask legal counsel for some clarification. Is there anything in this bill or these bills which purports to strengthen the ability of the administration to -- for the item raised, the breach of contract. The bill speaks at length to the added powers of the province in enforcement and removal of licence, but I think if we use the rent control analogy, every time a tenant skips and doesn't pay, the other tenants have to pay.

We certainly don't want an arrangement where the integrity of the legislation is diminished because we haven't looked at this issue. Perhaps you could let us know if there's anything in this legislation which addresses the concerns about strengthening an administrator's right or ability of accountability with its revenue base.

The Chair: Before we go on with your questioning, and just so it's in Hansard then, can those be looked by the ministry? Did you want an answer now or just that you wanted that --

Mr Jackson: No, I think my direction was clear. The one, I believe, takes it partially out of the realm of legal counsel, and I have left that part with the assistant director of legislative research. I believe legal counsel can respond directly to the question which flows from the bill, so I'd be comfortable getting the one answer, but on the other one, I'm sure, we'll get additional information, because it really is a Municipal Affairs and Revenue issue.


The Chair: We'll get clarification from legal counsel.

Ms Czukar: No, there's nothing in the bill that specifically requires residents to make payment to the home, because it is a matter between the home and the resident. The only provision in the bill that addresses the issue of what the charges are to the resident is the provision that doesn't allow the operator to charge over a certain amount, which will be the maximum amount for the copayment and for preferred accommodation. So it's true that it is a matter of contract law between the home and the resident.

You didn't really ask this, but I might go further to say that the reason it's that way is that the only way it would be meaningful to put it in the statute to require residents to pay the home is if the province was going to get involved and then enforcing that in some way. That's not currently the situation and we weren't instructed to change it. So it's basically the way it operates now, which is that it's a matter between the home and the resident. It maintains that situation.

The Chair: Have you any follow-up question or does that clarify?

Mr Massad: The only aspect, then, is that if it is not to be written into the bill, as I had suggested, that greater flexibility through the bill be afforded to administrators to respond to residents or to residents' families that are in arrears -- it's a very awkward position when you have a resident that certainly is $8,000, $9,000 or $10,000 in arrears without going through the court system. Many administrators just don't want to discharge residents because of that. It's not great publicity.

Mr Wessenger: I might just follow that up and ask you if you have any suggestions for the committee on how this might be dealt with, without having to bring the province into the enforcement aspect, some flexibility that will allow you to have a greater ability to collect.

Mr Massad: Under the current Nursing Homes Act, the discharge of a resident can only happen if the administrator can find alternative accommodation for him or her. That's the only other way. Otherwise, we spend many hours in the court system to try and secure ongoing moneys as a result of their breach.

Mr Wessenger: Do you have this as a problem existing right now?

Mr Massad: Absolutely, and it's not just one resident.

The Chair: Mr Jackson, you may continue.

Mr Jackson: In that vein, we now are injecting into this process a placement coordination service which ultimately the home would have to fall on the mercy of in order to remove one resident to another facility because of his or her inability to pay. There is a role that affects the financial circumstances of the institution, and by extension all the remaining residents, by virtue of the gatekeeper who can maintain the blockage or the non-removal of the individual. That strikes me as an appropriate role for the government since it will be controlling admissions and movements within institutions as the circumstances regarding their acuity and their financial matters change.

I wish only to state that for the record. I've heard clearly from legal counsel what her position is. Just being familiar with the Nursing Homes Act, I was rather concerned that you can essentially leave a non-paying resident there at the peril of the financial integrity of the institution, and yet we are mandating levels of care and other aspects of the operation in the absence of their ability to pay.

I don't have the answer at the moment. I just wish to bring to the parliamentary assistant's attention that we have a catch-22 here, which we're placing nursing homes in. That perhaps should be addressed while we have these bills open in a legislative setting when we can amend them, because once they're closed we're not going to have much of an opportunity to change them.

The Chair: I have Mr Wessenger next, who may also have something further to say on that point, I'm not sure, but you have the floor.

Mr Wessenger: Thank you very much for your thoughtful presentation. It's quite true that you have raised some points that haven't often been raised or pressed. I'd like to explore a little further this whole question of the non-payment by the resident. As you say, right now you can only discharge a resident if you find another place. Would you want to see the legislation amended to give you the right to discharge for non-payment, just an absolute right in the sense that this would give some flexibility in trying to negotiate with either family or someone else a method that would secure payment of the payments that are obliged to be made?

Mr Massad: I think if it's written into the bill, certainly in discussions with families that are in significant arrears, and discharge as a result of non-payment is an allowable consideration, that we can discharge, then yes, I would welcome that concept.

Mr Wessenger: I'd also like to add some clarification with respect to your third point about funding formula and per diem amounts for resident programming and activation. I'm going to ask ministry staff perhaps to clarify that point for you.

Mr Quirt: The presenter is quite right that at this point in time the government hasn't indicated to long-term care facilities precisely what the average per diem for long-term care facilities will be. It hasn't gone further to divide that per diem into the three categories the funding formula covers. We'll be in a position to do that once the estimates process confirms for 1993-94 what funding is available for long-term care facilities, in other words, what the base of the program is, to which $206 million would be added.

It's our hope that in mid-March we'll be meeting with our funding focus group, a group of people who helped us design the funding formula and looked at costs among the three categories, to show them the funding available and how that works out on an average basis and to propose to them how it might be divided up among those three categories. We hope some closure can be brought to that as soon as the estimates process confirms how much funding is available for the program in the coming fiscal year.

Mr Massad: Thank you.

Mr Wessenger: I think that's all my questions.

Mrs Caplan: My first question is, what you just heard, does that give you any comfort in your concern?

Mr Massad: There's comfort that, yes, it's being looked into. If there's any concern, it's that the government may be going at it in the wrong direction, that it would be adjusting the formula based on the amount of dollars available rather than saying, "This is the level of care that's required throughout the province and this is the amount of hours or time or dollars," or whatever you want to call it, "that we expect to be provided," and then establishing the formula. That's a concern there.

Mrs Caplan: That's very helpful and I think a very important insight. I'm also familiar, as you know, with your association and with your homes. It's nice to see you here and to be able to say that I think you provide an excellent model for the provision of care in your community.

One of the things that you didn't mention -- I hope I didn't miss it -- is that this legislation does not take into account, by statute, the multicultural, linguistic requirements or choice for individuals as they make the selection. We've had some discussion about an amendment or a statement of principles that have been suggested that could be enshrined in the legislation or, it's also been suggested, by regulation, which would embody the principle of consumer choice and sensitivity to the cultural and linguistic environment that the individual would want to choose, as well as the need for appropriate care.

Do you have any comment on that? I know you serve a specific community in meeting those needs.


Mr Massad: We serve a specific community, although our facility has never put a fence around it. Only approximately 45% of the residents within our complex are of Finnish background. We would hope that as a Finn requires care in the community, the placement coordination services would be sensitive to that need, and possibly through the amendment that you spoke of that could take place; flexibility would be given to them to allow for that. I'm not just speaking for the Finns. I'm speaking for many of the other ethnically owned facilities throughout the province.

I think your principle is sound, that if you're looking at it in a global sense, the placement coordination service be given that flexibility in its mandate. Certainly, speaking to many families that come and approach me, either in the malls or wherever, about entering a complex or institution, having to institutionalize a family member, the best advice I can give them is that in our municipality we're very fortunate. We have an excellent place coordination service, and for many of those residents, for the lack of a better term, one-stop shopping is the way to go. I was really surprised that they're not all throughout the province.

Mrs Caplan: I know it won't surprise you, but what we've heard virtually everywhere we've been is that where there is a placement coordination service in place, everyone who's come, in the places we've been so far, has come to the committee and said: "We think we're unique. What we have here really works and it works well." Where we've heard fear expressed has been in those communities that don't have placement coordination services. I think the suggestion of an amendment, as far as the principle and the mandate of the placement coordination service is concerned, that was suggested by a placement coordination service, perhaps would give comfort to those who don't have them and act as a reminder for those that are already functioning under exactly that method.

Mr Massad: Exactly.

Mrs Caplan: So you'd support that?

Mr Massad: Yes, I would. We have an excellent rapport with our placement coordination service in Sault Ste Marie and it recognizes the ethnicity issue informally. That is not to say though, that people don't change, and attitudes may change, but if it is written in the amendment you speak of, it's certainly welcomed.

Mrs Caplan: One more question, or is time up.

The Chair: I'll give you a very short final.

Mrs Caplan: It's a two-part question. First, do you have in place a quality management program within your facility, because you mentioned the good relationship you have with the ministry?

Mr Massad: Yes, we do.

Mrs Caplan: The discussion has been here that where that good relationship takes place and where there has been -- are you voluntarily accredited? Are you part of the accreditation program as well?

Mr Massad: At this present time, we are not an accredited facility. We're required to be in place one full year. We had some change of our senior staff and the timing just didn't allow for it. Although speaking to the current inspector who came, she said that her estimation would be that we would receive at least a two-year accreditation status if we were to apply. It's a very expensive process for facilities to go through. I've recommended to our board that we not become accredited until we see the total dollars that we're going to be working with in the future, and if it's going to be requirement as a part of quality assurance that you become accredited. I'm being rather cautious at this point.

Mrs Caplan: We've been talking here at this committee about an alternative to the enforcement model and that this alternative would be accreditation plus mandated quality management programs. Do you have any problem with that?

Mr Massad: No.

Mrs Caplan: Thank you.

The Chair: Thank you very much for coming over from the Sault today. I'll echo Ms Caplan's comments about your association. I certainly enjoyed my contact with them. You do a wonderful job in different parts of the province, and we thank you very for coming today.

Mr Massad: Thank you very much. I'll stay till the end, and if anybody has any questions, especially as it relates to the municipal tax issue and how that is affecting our facility and what the province to date has offered to our complex, I certainly would welcome any discussion. I thank you again, and hopefully you'll consider our brief in your deliberations.


The Chair: For committee members, we're going to move next to the representatives of the Royal Canadian Legion, and I would ask them if they would be good enough to come forward.

The representation for 1:30, the Algonquin Nursing Home, is going to be done by the Ontario Nursing Home Association, region 1, which is going to read the brief from the Algonquin Nursing Home. The people or person who was to come to do that was injured this morning -- I gather it's not a matter of life and limb -- and is unable to be with us. They have made these arrangements. We thought we'd take the Royal Canadian Legion first as they were here, and I believe one person is going to be making his way back to North Bay and the weather is not the greatest.

May I say first of all, gentlemen, that we welcome you to the committee, and if you'd be good enough to introduce yourselves for the committee members and for Hansard, then please go ahead with your presentation.

Mr William Sexsmith: Thank you very much, Mr Chairman. I'd like to introduce myself. My name is Bill Sexsmith. I am the provincial service officer with the Royal Canadian Legion with offices located in North Bay, Ontario, and at this time I'd like to introduce my colleague to my right, Mr Paul Richmond, president of Branch 23 of the Royal Canadian Legion, also from North Bay, Ontario.

We have distributed, Mr Chairman, with your permission, a copy of the brief. I realize our organization has already been in front of this committee on two other occasions, so with your permission, we will go down through the brief outlining some of our concerns for the north. We have strayed a bit from the original brief.

The Chair: That's fine, and I think having the context of the north would be very helpful for the committee. Please go ahead.

Mr Sexsmith: Thank you, Mr Chairman, we don't want to be repetitious.

I would like to just enter, for the purposes of Hansard, the background. You are no doubt aware of the Royal Canadian Legion's national community involvement. Our main concern is still, after 67 years of existence, the veterans' age, knowing our average age of World War II veterans is 71 and the Korean veteran is 60ish. Our mandate remains the same: veterans service.

The difference in our level of service is not declining; it is in fact growing exponentially with the veterans' increasing age. In 1990, the Legion provided $5.5 million of support to needy veterans, and another half million volunteer hours have gone to veterans, ex-service personnel and their needy families.

With that, I'd like to pass over on to the next page. You've already heard our information on the estimates of Ontario command. I'd like to skip over veterans' care. I believe you're already well versed on that as well as concerns regarding long-term care and legion care housing projects.

I would like to start in at the closed beds at Sunnybrook. We would now like to refer to closed beds at Sunnybrook Medical Centre. We recognize that Bill 101 does not apply to chronic care and the closed beds at Sunnybrook in K wing are chronic care beds, but we wanted to ensure this issue is raised in the context of long-term care. The 45 priority beds for veterans in K wing have remained closed for over two years after assurances that the situation was temporary.

Long-term care beds in northern Ontario: We now would like to take a few moments to talk about the priority access beds which are not being used but were guaranteed.

We in northern Ontario strongly recommend it is now time to consider the feasibility for the reassignment of the unused priority access beds to northern Ontario communities. This would serve a two-fold purpose:

(1) There is a need for veterans and/or their dependents to have close proximity to hospital care and their loved ones as opposed to travelling hundreds of miles, for example, from Hornepayne to Toronto, to receive care.

(2) Every community has been exposed to a bed closure in one form or another, and the reallocation of these beds would reopen closed beds for long-term care, which would also be of benefit to the local medical community.


Possibilities are municipalities that already have high level of treatment services such as North Bay, Sudbury, Timmins and Sault Ste Marie. The transfer of the London Phychiatric Institution patients to Parkwood Hospital resulted in a reduction of the availability of the priority access beds in Ontario. These were beds that were formally available to the veterans of the community which were set aside for the use of the transferred patients. We would like to see consideration given to the transfer of these unused priority access beds to northern Ontario.

We would now like to refer to the coordinated placement services. Our organization remains concerned that the right of veterans to be recognized and receive all levels of care authorized by the veterans care regulations might be jeopardized by Bill 101. The veterans health care regulations provide for residential and nursing home care, and partial funding of these cares is provided under the veterans independence program administered by Veterans Affairs Canada for certain eligible veterans.

We want to ensure that the admission policy will continue to provide for social admissions and necessary adult residential veterans.

Finally, the Legion is concerned that additional budget restraints may result in further erosion to veterans in Ontario. We would like to establish a commitment by this government to ensure that this special group will be protected from future restraint measures.

We in the legion in Ontario are committed to the prevention of the closing of any veterans' long-term care beds while simultaneously requesting the expansion of long-term care facilities for those who have earned the right to access to the best hospital care. The Sunnybrook K wing situation must not happen again.

Our organization extends its thanks to you for your consideration of this brief.

I understand, Mr Chairman, that there were questions and answers given in the other two briefs that were presented, and we will, if at all able, try to answer any questions this committee may have.

The Chair: Fine. Thank you for the brief. I think you're the third or fourth group from the Legion who has come forward, and we're glad that you have. We'll begin our questioning with Mr White.

Mr White: Thank you very much for bringing forth these issues and for so well representing your membership. As the Chair mentioned, this is the third presentation from the legion. We'll have another one tomorrow evening in Ottawa.

On the the Sunnybrook issue and the chronic care point, the provincial president spoke with me,and we were able to secure a meeting with the senior ministry officials. This would have been about a month or so ago. I don't think the issue is dead and you have to keep on plugging, but thank goodness there are people like you doing that.

Mr Sexsmith: Thank you very much.

Mr Hope: I just want to go to the one about the long-term care beds in the north. How would you do that? How would you allocate those beds? Would you allocate them to a specific home or allocate them to a certain region or area? I'm just curious how you'd do that because there would be a number of facilities wanting these beds and I'm wondering, how will we control that?

Mr Paul Richmond: If I may, I think our expertise does not lie in the field of allocation of health care; I think our expertise is in coming to you people and saying we want the health care.

We do know, and I'm sure you people are aware, that there are numerous beds that have -- transfer payments have been made for many years by the Department of Veterans Affairs and the beds are not available to veterans. These beds are closed, they're inactive, call them what you will. Our concern is that these beds be reactivated. They're being paid for. Let's put them back in place and let's put them back in the communities where the veterans and the veterans' families have access to them. It is ridiculous to continue to contemplate people travelling from Hornepayne, Hearst, Kapuskasing, Sturgeon Falls as a matter of fact, to London, Ontario, to visit a person who has been in bed for many, many years.

Due to the budget restraints that we're all working under, we know that beds are being closed. The possibility of some of these beds being reopened in medical facilities in the north and being assigned as veterans' priority beds is not an unrealistic request. The money's there, you're being paid. We really feel -- let's be down-to-earth about it without being a little bit facetious or anything -- that these are people who have earned the right to the best of hospital care. They're the people who have earned the right for this commission to be established. They deserve the best possible health care that can be given.

Mr Hope: We have to keep consumers sensitive around it, so I guess we couldn't lock it right to a facility. We'd have to make them kind of floatable so that if the consumer chooses to go to a certain area, who is a veteran who wants to go to a certain nursing home or home for the aged or charitable home, it has to be flexible enough to allow that veteran to have the sensitivity of choice.

Mr Richmond: I believe there's somewhere in the neighbourhood of 1,400 priority beds allocated to Ontario; I think it's 1,365 or something like that. There are roughly about 200 not being used right now. If a percentage, even if you tied it into population, were assigned to northern Ontario -- for example, say 30, a percentage, could be put in the Sudbury communities, a percentage in Timmins, a percentage in the Sault, North Bay, Huntsville, someplace where the veteran would have much more access to his family and his family would have more access to the veteran. That's our main concern.

Mrs O'Neill: Yes, gentlemen, Mr Richmond and Mr Sexsmith, thanks so much for coming. I think the advice you were given that you must continue to pursue your issue is very well given, and I'm glad you've accepted it. I just want to say that the veterans always, I think, make us stop and think. First of all, you have not forgotten those who have preceded you in death, and you certainly haven't forgotten those who are in need around you. Sometimes that's not just veterans, but the youth in the community as well. I don't think we can be reminded of that any better than through your efforts.

I think you have given the government a very interesting challenge. I'm very happy you've done that. I think we are, all of us on this committee, working in a vacuum regarding chronic care and the chronic care beds. The chronic care study, I feel, should be very much a part of our own deliberations. As you know, we do not have that yet.

You skipped over veterans' care, and I presume the reason you did -- I couldn't resist reading -- was that you are now in discussion with the Ministry of Health on the issue. Could you say a little bit about Sunnybrook, the unassigned priority beds? Have you been able to bring that forward in any discussions to this point at any level with the Ministry of Health, or is this the first time you're basically presenting this as a need for the north?

Mr Richmond: I believe you're speaking of the Sunnybrook beds that we would like to see --

Mrs O'Neill: Yes, the area you spent most of your time on in your presentation.

Mr Richmond: We don't advocate taking the beds away from Sunnybrook itself. The MPP on my left indicated that he had met with the provincial president in the continuing discussions on the reopening of K wing. I'm suggesting that there are additional beds around, and if those deliberations to reopen the beds at Sunnybrook are unsuccessful, then maybe the assignment of those beds might be to the north. But there are other beds in Ontario right now that are being paid for that without touching the Sunnybrook situation, very well could be reassigned to the north.

Mrs O'Neill: Have you begun discussions at any level with the ministry or indeed with politicians on that particular issue, or is this the first time you're presenting this challenge?

Mr Sexsmith: If I could answer that, the veterans' affairs committee of Ontario provincial command are in the midst of discussions with the Ministry of Health on the 45 beds in Sunnybrook.

Mrs O'Neill: I just want to say that there's one area I don't think you've highlighted enough, and maybe you will in your continuing discussions: I think the spousal support that veterans have had throughout their lives is somehow also overlooked if we do not bring the priority access beds to the communities where they're needed. Often two people, particularly in the age groups you're talking about as average age for veterans now -- I have one personal case in mind. It's most unfortunate that the spouses can't even be in the same city, and how hard that is on the families, let alone on the two individuals who have sacrificed quite a bit in their lives to this point. So perhaps you'd like to highlight the whole family structure in your presentations as you continue them.

Mr Sexsmith: I think that's going to be addressed tomorrow evening in Ottawa, partially anyway. Of course, we tried to touch on it here by bringing forward the point that we would like to see a redistribution of hospital beds here in the north, which of course would bring the spouse and/or dependants closer to the veteran.

Mrs O'Neill: Thank you so much for your time.


Mrs Marland: We often sit in this committee and hear the government members address deputations as Brother So-and-so and Sister So-and-so. I feel, as a member of branch 82 in Mississauga, that I'm going to say Comrade Sexsmith and Comrade Richmond -- indeed, with a great deal of pride, as the daughter of someone who gave his life in the Second World War in the Royal Navy.


Mr Jackson: We know "comrade" means something different to you.

Mrs Caplan: When you say "comrade," it has a different connotation.

The Chair: Order, please. We have harmony.

Mrs Marland: I realize there could never be enough said about the contribution of our veterans and there can never be enough said in complimenting the work that is ongoing with the Royal Canadian Legion and the fact that you are here doing something that isn't easy to do. I know can be difficult and somewhat intimidating. You're both very fine examples of people who are committed and do continue to serve.

I found it very interesting to hear one of the government members, Mr Hope, talk about sensitivity of choice, because that is something we as Progressive Conservatives have been talking about for a long time while we've been trying to protect the private sector in the provision of nursing home beds and retirement homes.

Of course, this becomes even more acute as a problem when you get into the north and the east and the west extremities of this province, and the further you get away from the densely urban areas. It's fine for a government member to talk about sensitivity of choice when they're doing everything they can to put the private sector out of business. They want nothing but non-profit beds, which doesn't mean that it actually costs the government or therefore the taxpayers any less; in fact, in a lot of situations, as with the provision of other services, such as day care, it ends up costing the taxpayers more.

But to focus on what I think is the sensitivity of choice is to say what Ms O'Neill was saying, which is that choice has to address where the beds are available for the families to do their continuum of visiting. I guess I have to say this: I don't have any faith in the government's ability to listen and negotiate, or else we wouldn't, after all the public hearings around the province on this bill when it was in a discussion paper form, have ended up with the legislation we have before us currently. It obviously chose not to listen.

It's pretty difficult, isn't it, for us as non-medical people to understand really what the difference is between long-term care that could have included chronic care beds and doesn't in this legislation. In sharing the concern you have for the example of what has happened with Sunnybrook since this government has been in office, I want to ask you whether you could have designated beds or some kind of guarantee that beds would always be available where they would need it -- in your case you're speaking for the north, but in these more remote areas of the province, if we could have guaranteed, even a single bed. We were talking earlier this morning about respite beds. In your discussions with the government, have you heard whether that was something it would ever consider, so that there was always the security of knowing that the surviving spouse and other family members, who may well be adult children at this point, would have access to keeping their loved one close to them?

Mr Sexsmith: I don't think to this point it has entered into any of the discussions that Ontario Command is presently having with the Ministry of Health, but it certainly is a point that is intended to be brought forward in the ensuing discussions that Ontario Command has with the Ministry of Health.

Mrs Marland: Maybe we could ask our permanent -- I'm a substitute member on this committee today, but maybe we could ask our permanent members from our caucus on this committee to see if there is a way of securing that this is addressed on behalf of the veterans of this province, that it could be addressed in the regulations which will follow the legislation, or if we could possibly get the government members to support an amendment that we might like to make, to make sure those concerns are addressed in the legislation itself. Certainly, Mr Jackson and I will give you our assurance that we will pursue that.

Mr Sexsmith: Thank you.

The Chair: Thank you very much for coming before the committee today. As you noted, we are meeting in Ottawa tomorrow and will have the provincial command.

Mr Sexsmith: Thank you very much, Mr Chairman and committee members, and for those whom it applies to, thank you, comrades.


The Chair: Perhaps I could then ask the representatives from the ONHA, region 1, and the Algonquin Nursing Home -- I may have expressed that incorrectly in terms of exactly what is going to happen, but perhaps you would be good enough to explain to the Chair and to the committee members. We want, first of all, to welcome you to the committee, and if you would be good enough to introduce yourselves and then explain the nature of the presentation, certainly I would be grateful.

Mr Dennis L. Boschetto: Thank you very much, Mr Chairman. In the interest of time and not repeating items that would go through both presentations, we sat down over lunch time and have combined the two. Vala Belter, who is the representative from the Algonquin Nursing Home, was going to be here this morning, and as you were told, was injured, it was an eye injury and she couldn't drive to Sudbury today, so she faxed us her presentation and asked us to present it on her behalf.

My name's Dennis Boschetto. I'm the administrator of a 235-bed Extendicare/Falconbridge facility here in Sudbury. I'm also the Ontario Nursing Home Association, region 1, representative on the local district health council long-term care committee.

Mrs Nancy Foreman: I'm Nancy Foreman, the director of care at that same nursing home.

The Chair: Just for our information, region 1 comprises --

Mr Boschetto: Region 1 comprises the area of Sault Ste Marie, Sudbury, North Bay, Cochrane, Timmins, Hurst, Kapuskasing and so forth; the far north also.

What we're going to do is that Nancy Foreman is going to read the presentation from the Algonquin Nursing Home. I will interject with overriding comments from the Ontario Nursing Home Association and from Extendicare itself to clarify points and to make recommendations, and then we'll both be available for questions. Unfortunately, the items that Nancy is presenting are directly from Vala's presentation and we wouldn't be able to answer any questions as to what her comments were.

The Chair: Thank you very much both for the explanation and for coming, and now please go ahead.

Mrs Foreman: On behalf of the 72 residents of the Algonquin Nursing Home, the 65 staff who care for these residents, and the management of this facility, I am here to present some of our concerns about parts of Bill 101.

On the whole, we are pleased that the Ontario government is moving ahead with the reforms to the long-term care system. For too many years, nursing homes have been regulated differently from other long-term care facilities. Bill 101 attempts in many ways to develop the same set of rules and regulations for nursing homes and homes for the aged. Bill 101 indirectly acknowledges nursing homes to be a necessary and vital part of Ontario's long-term care system. Many of the regulations put forth have been standard practice in nursing homes and will now only start to be met by other long-term care services.

Algonquin Nursing Home is part of the Ontario Nursing Home Association. Algonquin has been accredited for over ten years by the Canadian Council on Health Facilities Accreditation. Our residents, their families, the community and the staff are a team that have made this nursing home a home, first, where nursing care is provided.


Throughout the following pages, please remember that it is for these residents and their families that the recommendations have been made. Many of the suggestions have been made by the staff caring for the residents and by the families involved in looking after the residents' personal affairs. Many staff who look after the residents know at first hand what is necessary and workable. Often, philosophy looks great on paper, but the human aspect must be applied for philosophy to be practical.

The service agreement, which has not been made available for evaluation, must be reviewed by this committee and by the people providing the care, to ensure that the agreement is workable and understandable by the public, and possible to fulfil equitably by government and service providers.

Mr Boschetto: On this issue, the Ontario Nursing Home Association would like to address the issue of moving from the insurance model under OHIP to a contractual model with the nursing homes. They go on to state there is a very serious public policy ramification with Bill 101's move to put long-term care facilities into a contractual agreement model. This means that there will no longer be a universal, accessible approach to health care in these facilities, since the extended care program will no longer be an insured service under OHIP in Ontario.

This bill avoids any government responsibility to fund these homes equally in order to provide the same level of service to everyone across the province. The government could treat many of the facilities differently, and has, through this legislation, provided the vehicle to fund some programs in some facilities while not doing the same in others.

In the area of capital and other funding, such as pay equity, it enables the government to continue to discriminate against private, for-profit sector homes. Already, non-profit long-term care facilities have received pay equity funding, while staff in private sector nursing homes have been told that government, at present, decided not to pay for pay equity in their homes.

Each year, the service agreements must be renewed and government will have no obligation under this act to fund the level of care required by residents or to continue to fund programs if it chooses to change the agreement.

There is no arbitration or appeal mechanism in the service agreement, so homes will simply be subject to the government's whim regarding policy and programming, regardless of its ability to fund these services adequately or if it funds them at all.

It is recommended that the government must be held accountable to maintain equitable and consistent services in all long-term care facilities throughout Ontario, regardless of whether they be for-profit or non-profit.

The Chair: Could I just make it clear, because of Hansard, people later on reading the testimony, that when you're speaking, that's region 1. Otherwise, it's the people from Algonquin.

Mr Boschetto: Yes.

The Chair: Fine. Thank you.

Mrs Foreman: Bill 101 sets out a new placement function called "placement coordinator." The details of how the placement coordinator will function must be specified. Consumer choice is not given priority, and an applicant's ability to appeal a placement coordinator's decision is limited. Further, facilities are not given an opportunity to match potential residents' needs with the facility's mission, services and programs. Placement coordinating agencies should be managed at arms length from service providers, or there must be equal representation on PCA board by all service providers.

Algonquin Nursing Home is located in the small northeastern Ontario town of Mattawa, population 5,000. Our nearest city is North Bay, 40 miles away. The communities are different in language, economics etc. Placement coordination services need to be located in all communities. They need to be open 24 hours a day, seven days a week and be available to all citizens for all types of care.

Both the potential residents and the long-term care facility must be given the ability to refuse admission for reasons such as the potential resident or the potential facility do not suit each other, for example, smoking residents and non-smoking facilities; shouting residents in a small nursing home where the residents must share one lounge; age differences, a young resident in facility with a vastly older age group, and so on.

If a facility has empty beds and is aware of another area in the province in which there is a waiting list of people willing to relocate, the placement coordinator must seek these potential residents to fill the beds. Empty beds directly result in decreasing a portion of the revenue that pooled together, provides certain resources that the entire resident population shares, and therefore, empty beds indirectly affect resident care.

Placement coordinators must be required to identify a substitute decision-maker for the applicant and a responsible party in the event that there is a default on the financial obligations of the resident, and to establish the applicant's ability to pay the copayment. Bill 101 states no explicit authority to collect payments from residents, nor obligation for the resident to pay. Unpaid bills directly affect the ability of the care giver to provide the necessary care to all the residents in a facility.

Placement coordinators must also be responsible for the discharge planning and coordination involved when residents of long-term care facilities need to be moved to other locations.

Mr Boschetto: ONHA, in looking at placement coordination, has three specific recommendations that it would like to make in addition to these comments.

(1) We recommend that the existing resources be used for placement coordination function and that no new level of bureaucracy be created for this purpose.

(2) Applicants must have an appeal mechanism with respect to placement, and this appeal mechanism be accessible in a timely and efficient manner. In a previous presentation, it was suggested 30 days and I believe that would be too long, that for people who are under this type of stress and who need placement in a facility, 30 days can seem like a very, very long time.

(3) Facilities must have an appeal mechanism to challenge placement coordination recommendations when the facility believes that it cannot meet the care needs of the applicants properly and safely. This appeal mechanism must be accessible in a timely and efficient manner, and we believe, because of the dangers that can occur from admitting residents to nursing homes where the admission is not appropriate, that this must also be much quicker than 30 days.

Mrs Foreman: On behalf of the residents of a facility and its staff, many of the suggested sanctions for facilities in breach of their service agreement are immoral. In many cases, the sanctions such as freezing admission or withholding payments will in fact jeopardize the provision of care to existing residents in the facility. There must be an efficient appeal process. Surely, with proper inspections and the proper application of regulations and the normal follow-up of inspections, there should be no reason for any harsh measures to be implemented. Any measures taken must not affect the ability to provide resident care.

Mr Boschetto: ONHA, when looking at sanctions, says that the sanctions should only be implemented as a final resort, and that facilities must have a right to appeal sanctions implemented. We would prefer that appeal could occur before the sanction is implemented.

Mrs Foreman: The bill also sets up a more adversarial approach to inspections than under the current Nursing Homes Act, an approach which the government's own study had already proven to be a poor method of monitoring facility care and services.

In the 1970s and early 1980s, nursing homes were policed by the nursing homes branch. This system was non-productive, did not result in improved resident care and created ugly confrontational relationships which suggested the government was incompetent in managing health care.

In the late 1980s, the system was changed to include compliance officers. I can assure you that this harmonious working relationship is the best for the residents of long-term care facilities. It encourages the ongoing improvement of resident care and services. It continuously fosters increased staff knowledge and management efficiency. It has resulted in trust by the residents, their families and the public.

The bill leaves too many issues to regulations. It provides too much power for the government and its inspectors without requiring a corresponding measure of accountability. The bill holds facilities accountable for providing for all residents' needs, without ensuring that funding will be provided to make this possible.


Mr Boschetto: The ONHA would like to bring the government's attention to the Woods Gordon report of 1986, commissioned by the government, which examined the effects of the enforcement approach versus the consultative approach. It stated that the adversarial climate between inspection branch and nursing home was detrimental to solving problems, that the Ministry of Health, with its scarce resources, was unable to focus its efforts on issues of greater importance to the residents' health and safety. In fact, the Ministry of Health has an existing compliance management program that has proven to be very effective in monitoring resident care and programs.

The amendments that cover the area of inspection are clearly designed for a worst case scenario, putting in place very broad powers that would result in inconsistent and potentially unfair application of the sanctions and inspection process. The legislation sets up a very adversarial approach between government and facility. This adversarial approach, together with the contractual model of service, may result in increased litigation and civil action between government and long-term care facilities, and an unnecessary waste of scarce resources.

ONHA continues to support accountability for all aspects of care to government and the public on the part of long-term care facilities, and recommends that the powers of inspectors not be increased and that the existing compliance management program be continued.

Mrs Foreman: The requirement for a care plan that is set out in Bill 101 is specific. Neglectfully, the government's commitment for funding to ensure that the care plan be carried out is not specified or even mentioned in Bill 101. This renders the intent of the requirement for a care plan immaterial. This will make the legislation ineffective, the end result not progressive and still continue the discrimination against residents of long-term care facilities. As a result of this oversight, care plans will not truly reflect the needs of a resident as there will not always be the necessary funds to ensure proper care.

Mr Boschetto: ONHA would like to bring its concerns regarding resident care needs and meeting those needs to the committee. The bill is being introduced in a vacuum. There is no requirement that funding be established and maintained at the level required to provide adequate services and programs to meet the care needs of residents. There is no information on the service agreement and too much is left to regulation.

The bill requires each home to have a service agreement between it and the government, a plan of care for each resident and a written notice for each resident describing what services are being provided under the service agreement by the operator of the facility. The service agreement has not been made available to long-term care facilities or this committee for their review.

There is no accountability for government to provide the funds to meet the needs of the service agreement. The service agreement could change annually depending on the funding available for that year. The proposed classification system will only be used to allocate available funds for nursing and personal care. Quality of life programs and accommodation will be funded under another, to date unknown approach.

The resident classification process does not measure actual resident care requirements. It only enables the government to develop a case mix index, a way of scoring each facility's care level relative to another. Only the case mix index is established. Government will simply use it as a formula for distributing funds between facilities. This approach will not guarantee that funding will be sufficient to ensure the assessed needs of residents. It merely is a process by which the government distributes limited available funds to each facility.

The requirement for a care plan is set out in the legislation. As well, the legislation requires that the care outlined in the plan must be provided. There does not appear to be any flexibility should the resources not be available to provide the services outlined in the care plan. In fact, the legislation may discourage accurate and detailed care plans due to lack of resources. Because there is not enough money in the system to meet all the needs of assessed residents as identified in their care plans, facilities will automatically be in breach of the contract.

The ONHA is concerned that the legislation focuses on paper processes and not the outcomes of care. Delivering care to residents is more important than filling out paperwork, and an over-emphasis on paperwork reduces the amount of time available for care.

Further, the bill provides an immunity clause for acts done in good faith by placement coordinator and inspector, but does not for facility staff. Facility staff require the same protection.

ONHA recommends that the legislation should not require facilities to provide all services as defined in the care plan unless the government assumes responsibility for funding these services. If, as we believe, funds are not available, then priority setting and flexibility in interpretation must be provided for.

Mrs Foreman: Long-term care services in small communities must share resources. Home support agencies with wheelchair accessible vans must share their transportation with the residents of nursing homes and homes for the aged that do not have such transportation.

In the area of capital and other funding like pay equity, Bill 101 allows for discrimination to the residents who live in nursing homes by not providing the same funding that not-for-profit homes already receive and will continue to receive. This does not make for an equal, just or honest system.

Mr Boschetto: Around the issue of quality assurance, ONHA would like to make its viewpoint known that Bill 101 requires each home to develop a quality assurance program. This is a very restrictive term which describes one particular management process. Management systems are constantly evolving and changing. The more prevalent management system in use today is total quality management and continuous quality improvement.

ONHA recommends that rather than specifying a specific management system, the use of a generic term such as quality management be implemented. ONHA would expect that the quality assurance management records will be treated in the same way as set out in the Advocacy Act. These records are for the facility's use to improve its services and not for use by inspectors to criticize a facility's delivery of care.

ONHA recommends that inspectors should not be entitled to have access to personnel records or to the record or part of a record dealing with quality review activities, peer review or performance review activities, or quality improvement activities within the homes.

Mrs Foreman: Thank you for having given me the opportunity to present this paper. I urge you to pay heed to its recommendations. The staff of this home and most other homes provide good, loving, effective and efficient care. We know what type of care is necessary, available and supportable.

The people of Ontario deserve a good, long-term care system, they deserve good care. The families of the residents need to trust that their relative is receiving the best care available in the province, and that care giver facilities and the government have worked together fairly and cooperatively to ensure that the long-term care services do not discriminate against people.

You have the ability at this time to determine Ontario's future fairly. Please do not do disservice to the people.

Mr Boschetto: On behalf of ONHA and Extendicare Health Services Inc, I'd like to thank the committee for allowing myself and Nancy Foreman to be here to present to you today, and I hope we haven't confused things too much by combining the two presentations.

The Chair: Not at all, and we thank you for taking the time to put the two together in a way that was informative and helpful. If we might, back through you, I want to make sure I get it, was it Vala Belter?

Mrs Foreman: Yes.

The Chair: Perhaps you would convey to her our best regards for a speedy recovery. We'll move then to questions, and Mrs O'Neill.

Mrs O'Neill: I guess it's two briefs, but it's certainly a very strong statement. You've given what I consider are some very practical points for the committee to work upon. I'm very happy that you have used the term "worst case scenario" and that the inspection in this bill seems to build on that, because that's our opinion on this side of the table.

I'm glad you talked about the nursing home inspections because I don't think we should forget that. It hasn't come up very often in the hearings what an unsatisfactory system that was. We have had a couple of presenters talk to us about the happy relationship they've had with the compliance officers in their regions and I'm glad you reiterated that. The vacuum regarding funding is also something that concerns us greatly, and it must concern you greatly because you're the ones who have to administer in the field.

You said that the care plan is a problem. You didn't say very much about that. As a result of Bill 101, it will definitely, I think, be on, what should I say, thinner ice. Do you want to say a little bit more to us from your own experience, or from the brief you presented, about the care plan problem of Bill 101?

Mr Boschetto: The one issue with the care plan is not the development of the care plan, because our facilities all have care plans in place and we believe the care plans are good. The problem around care planning comes that if you identify issues within the care plan that must be dealt with and you do not have the available resources to deal with those issues, you then, under this new legislation, are in breach of your contract and then subject to sanctions.

What we would like to see is a system where there is some flexibility and some allowance for not being able to meet the needs of the care plan.

I might give you one small example that may occur, and that is that in the 26 Extendicare nursing homes in Ontario, there are only two that have a social worker in place. There are many issues that could be dealt with for family members and residents that require a social worker in the nursing home. If those facilities are not contracted to provide social work services and the government does not pay for social work services, how do you then go about meeting the needs of the resident that are social work intervention requirements?


Mrs O'Neill: Do you see it tied in at all with capital?

Mr Boschetto: With capital funding of the nursing homes? The issue of capital funding has been a big one between the for-profit nursing homes sector and the government. There was out west up until recently, in Saskatchewan and, I believe, Alberta, a formula where the government provided 75% of funding for capital over a 25-year amortization basis, which is something we would like to see here in Ontario. What you have to realize is that facilities today are taking care of residents who are at a significantly higher level of care than when the institutions were built some 20 years ago -- and many of them were built at that time -- and there may be issues around the capital costs of renovating facilities.

You are probably aware at this point that the compliance plan for structural compliance is due in June 1993, I believe, and there are many facilities in Ontario that are not structurally compliant. I guess the question would be to the ministry: Is it planning on closing these facilities down after June 1993, or is it willing to provide some funding to assist these facilities in meeting structural compliance?

Mrs Marland: Even doing your presentation as a joint presentation as you did, which I'm sure wasn't too easy for you, you ended up with a very powerful presentation and you made some very powerful statements as a result. I hope the government members are listening, and if not, I hope that perhaps the government staff will be able to convey your very serious concerns back to the minister. I don't expect the minister to wade through Hansard and extract some of the comments that are being made, as I've heard from you, very constructively. I think it's obvious that the district health council is very lucky to have you serving on that board.

You touched on the inequities that exist today, the fact of the pay equity funding going to the non-profit staff. I have never asked any of the presenters to this legislation something directly about that as an example of what this government has been doing, because obviously they've been doing the same thing in providing pay equity adjustments to the non-profit day care centres as well. But from your experience -- either or both of you -- do you find that this kind of decision made by the current government has a very adverse effect on the morale of your staff?

Mr Boschetto: Just a couple of issues: First of all, I would like to make it very clear that the Ontario Nursing Home Association, Extendicare Health Services and the Algonquin Nursing Home in Mattawa, and all others that are members of the association, are looking at Bill 101 not as in trying to tackle the government on any issues, but rather that we support the implementation of Bill 101 with certain amendments, and the suggestions we've brought to the table today, in order to make Bill 101 a fairer bill and an equitable bill for everybody that is involved.

Around the issue of government funding of items such as pay equity and capital, once again -- because that is another issue around monetary and how it affects staff morale -- we and all of the groups I previously mentioned have worked with every government that has been in place since the mid-1960s, when I believe legislation first began to increase in power. We have worked with the PC Party, the Liberal Party and now the NDP that is in power.

What we have found is that because of delays on promises by all governments through history, it does affect morale within the facility, most recently being the delay of the implementation of levels-of-care funding. We increased staffing levels in 1992 in anticipation of January 1 funding of levels-of-care funding, and as you know, the levels-of-care funding has been postponed. We believe that it is supposed to be some time in 1993, but we do have serious doubts as to whether it might be before January 1, 1994.

When it comes to the morale of our facility, we went in last year in the spring, increased staff in our particular facility, as many others did, and the staff are very happy. Because the level of care has been increasing over the years, we do see the need for more staff in the facilities, and we do see the staff happier and more relaxed when they are able to provide the care they feel they should be able to provide, and also having those few moments to sit with residents and talk; not just doing their work.

As a result of the delay of the implementation of levels-of-care funding, there are some nursing homes in Ontario that will now be cutting staff back to December 19, 1991, levels. That, for those facilities, will be a very detrimental action towards staff morale, and it is a direct result of levels-of-care funding not being implemented on time.

You may take that and you may also apply that to other issues. Our staff look at other facilities and say: "Why are they able to do it and why can we not? Why does Pioneer Manor have a bowling alley in its facility and why do we not?" That's the simplicity of what you need to look at in facilities.

Mrs Marland: I like your recommendation about using existing resources and not setting up new bureaucracies. I thought that made a lot of sense.

When you were talking about how there must be an appeal mechanism for the placement decisions, you went on to emphasize that the appeal mechanism must be available for both sides, both the client and the facility. Have you any suggestions about how an appeal mechanism could be established that would work, to use your own words, without waiting 30 days to have somebody hear an appeal and make a decision?

Mr Boschetto: It could be done through the local communities and possibly through existing organizations, where two organizations that differ in their opinions such as placement coordination service and a facility such as ours would have a predesignated single arbiter, and that arbiter would be available to look at specific cases on an as-need basis; not that there would be a new position created within a community.

I think it can be a very simple process. I think that what happens within legislation such as this and within the operation of nursing homes and governments is that we tend to make things more complicated than they really need to be. A family member who is disagreeing with a placement decision or an eligibility decision who has to wait any more than a few days is going to be very stressed out. They are already stressed because they are looking at placement. They possibly have some internal conflicts about what they are doing with their family member and what their responsibilities are as sons or daughters or mothers or husbands or wives. Making them wait up to 30 days or possibly longer for an appeal process is unfair. We believe on the facility level it is also unfair and that it should be as quick as possible. I don't see any reason why, with a single arbiter in place, it couldn't be done within a day or two.

Mrs Marland: A single one from each side? You mean two arbiters?

Mr Boschetto: No, the same way that it works in labour relations, and that is, if you have a union and an employer who disagree, the two of them get together and agree on one arbiter, somebody whom they trust to make a decision. The person would hear arguments on both sides of the cases and make a decision. After all, the decisions will not be complex in nature. A review of documentation, medical assessments and the assessment tool would indicate very quickly, I think, what needs to be done.


Mrs Marland: I think it's interesting, Mr Boschetto, that you also referred to -- I don't know whether it was in your brief now or the one that Nancy Foreman presented on behalf of the Algonquin Nursing Home, but one of you said that too much was left to regulation, and that is something we've been stressing our concern about, from the beginning of this bill, in our PC caucus. We're asking all the time to see, if possible, what some of the regulations at least might be, but of course we're not making any headway with the government on that score. That relates to another statement one of you made about the vacuum re the funding.

The whole thing is that none of this will work. It will all be pie in the sky and totally impractical if the funding problem isn't resolved. I'm not terribly optimistic, with a $12-billion to $13-billion deficit, that new money is going to be coming from anywhere very quickly. We've already heard that some of it, we feel, is going on the backs of the seniors themselves. We heard that from one of our earlier presenters here today, about the concern about the copayments and where seniors were going to have to be finding more money to support that particular form of care for their family members. There isn't an easy solution, so as great as some parts of this bill might sound in theory, I do share your concern about the vacuum re the funding issue.

Mr Bisson: Just two quick questions, not a long preamble: On the question of the appeals process, an interesting comment, would you suggest that if you went to a system like that, you would have to go through a formal process of reappointing the arbiter every year or so?

Mr Boschetto: I think that's something that could be discussed between the placement coordinating services and those people they service. I could only speak for Sudbury and area and how it might work here.

Mr Bisson: Just to be direct with the question, let's say that was put into the regs. As a concept, it's not a bad idea. But it was written in that every year or two or something like that, both parties would have to get together and agree or disagree on a new arbiter. You know how arbitration goes. Maybe you'll get all the decisions and the other side's not happy and vice versa. Would that be acceptable?

Mr Boschetto: I think that would be something we could look at.

Mr Bisson: The other thing I want to come back to is that you're affected, I think, similarly to one of the other presenters prior to that in regard to the whole question about, not so much levels-of-care funding, but the question around -- the Extendicare units pay municipal taxes, right?

Mr Boschetto: Yes, we do.

Mr Bisson: Okay, we're not going to get into a whole bailiwick on this one, but you're also faced with the same problem in regard to, if somebody doesn't pay, what do I do? What is your suggestion on that? It's not as easy to solve as saying the government put it into regulations, because we'd almost have to get into the collection business or something to be able to deal with it. Have you given it any kind of thought?

Mr Boschetto: I'll speak from an Extendicare perspective, from Extendicare nursing home services. We have a very intense system for aging of accounts payable. We have had in the past severe problems with attempting to collect payments for residents staying in the nursing home. As you're aware, the regulations state that if I want to move somebody out of the nursing home, I must find another place for him or her to stay. That's not a possibility in most cases, so that you have to deal with the person who is in the nursing home. That's why we have developed contracts that are signed between the nursing home and the resident or the resident's family, responsible party, whoever's taking care of the finances. We do not hesitate to enforce those contracts.

As opposed to the other person who presented here who says they're somewhat uncomfortable approaching families, we believe that there's a contract established there between a person who is requiring services and ourselves who are providing the services, and therefore we require payment in order to provide those services.

Mr Bisson: Any seizure around assets and things like that?

Mr Boschetto: No, we do not go into assets. Unlike the municipal homes, we don't deal with residents' assets at all. However, we have in the past filed, in either Small C1aims Court or provincial court, an order to obtain payment. I can tell you that at this time in Sudbury, we do have some very significant collections problems. People who learn the system do find ways around it.

There must be something in the future to help us collect bills or to move people out of facilities who do not want to pay, because we know the Ontario government guarantees that every person over the age of 65 can afford a ward accommodation in a nursing home. We know they are receiving at least that amount of money, plus $112, and there's no reason for not paying for the accommodation. If a person doesn't pay the accommodation, his or her stay at the nursing home could be terminated. After all, if you are being provided money to buy goods, and you buy the goods but don't pay for them, what should happen?

The Chair: I'm going to turn to Mr Wessenger, and just note to committee members that the next presenter, the Medical Society of Sudbury, is on its way, but is not here yet. After Mr Wessenger completes his questions, in the event they're not here, I would be prepared to allow one or two more questions, if you will allow the Chair a little flexibility until the society representatives are here.

Mr Wessenger: Thank you for your presentation. One thing I'd just like to clarify: This question about the 30 days, it's the client who has 30 days in which to make an appeal. That doesn't really apply to the question when the appeal will be heard. It's 30 days after the decision, but I'd like to sort of pick up on that point with respect to the situation concerning a dispute between the placement coordinating agency and the facility with respect to the admission of a client. I'd like to ask, does that happen very much now at present under your placement coordination system?

Mrs Foreman: I would say, rarely. Our placement coordination service in this area is relatively new and is working out very well. It's a pick up the telephone association; it's not a formal -- they're as close as the telephone.

Mr Boschetto: I'm sorry. If I could just add, the one difficulty that has arisen that we have three documented cases on over the past six months is that when somebody is admitted to the nursing home, and is admitted beyond our level of care because of a situation that has arisen in the meantime while he has been on the waiting list, we see that this situation could be corrected with the efficient use of a placement coordinator where the assessment is done, prior to the admission, so that we would avoid those types of cases. However, there are two issues that come about as a result of doing that.

First of all, if you do obtain an admission that's inappropriate, how quickly can a placement coordinator move them out of the facility so that you don't jeopardize the safety of the residents who are there, or the resident himself. Second of all, if a placement coordinator has the power to admit or discharge from a facility because of those types of problems, how does the nursing home get paid, if as a result of its decision, we would lose resident days in payment for those resident days? For example, if a bed remains empty for a day, two days or three days, right now there's no provision by the government for paying us to maintain a bed vacant while we're waiting for an appropriate admission, so we would have to deal with that situation.

Mr Wessenger: Before I continue my question, just in respect to your question, I think I'll let ministry staff respond to that specific --

Mr Quirt: Under the current health insurance approach that you mentioned earlier, you're quite right. There's an issue with funding flowing to a nursing home if no client receives service. One of the advantages of moving away from a health insurance approach is that we can, for the first time, have a direct relationship with the nursing home funding-wise. Currently, we don't fund nursing homes directly; we have to insure the clients who live there.

With a direct contractual model, we can set an occupancy expectation for each facility, and depending on the demand for respite care services in your community, accommodation expectation would be set in accordance with the extent to which you were called upon to deliver respite services. So in effect, we can fund you to keep beds open for respite purposes and also fund you appropriately so that you're not under undue pressure to admit someone when a vacancy occurs.

Mr Boschetto: Just in response to that, one of the things the Ontario Nursing Home Association has been a strong advocate of is the facility's plan for the future, that we be able to count on resources not only from month to month or year to year, but for years in the future. Changes in legislation and the activities of government over the past 15 to 20 years have left us in a situation where we are for-profit operators who were encouraged to open beds and to operate in the province, and now are being put in a situation financially where we are literally going from month to month and year to year, and as you know, some of our operators have not been able to make it that far.

When you talk about going to a contractual model and providing direct funding and being able to work with the nursing homes, I take that as a positive and an encouragement that in the future the government is looking at allowing for-profit facilities that are able to operate more efficiently -- I think that has been proven to government -- to be allowed to operate in this province and that we are allowed to make a reasonable level of profit for providing services from those accommodation fees that are paid.

We are not interested, as you know, in making profit on the personal care or the program services, but we are interested in continuing to be a healthy organization and a health care provider in the Ontario system.


Mr Wessenger: If I just might follow up on my questioning concerning the situation of the disagreement between the placement coordinating agency and the facility, it would seem to me that going directly to an appeal process is perhaps not the most satisfactory in the sense that it would be better to go to some sort of dispute resolution model at the local level, which would involve negotiation and mediation. Would you agree with that?

Mr Boschetto: I would always agree with mediation before going to an arbiter. I would say, though, that this process has to be simplified. I believe that it could be simplified to the extent of whoever has the objection makes a phone call and has access to somebody who can make a decision who both parties have agreed to talk to.

We all know that this type of mediation system is in place in labour relations and that it can take anywhere from a few months to a year and a half to get to a decision. That is the type of situation that we don't want to have to have happen within the nursing home sector and within communities.

I do firmly believe that within a city like Sudbury, or the Sudbury-Manitoulin district, there should be access to somebody who would be able to go in, look at the documentation and make a decision with very little effort on everybody's part.

You're dealing with, in our case, a facility that has a lot of experience in nursing home services and the acts with the ministry and dealing with government services. On the other side, you have family members who are totally new to the situation. They need something that is very quick and very fair and they need answers in that manner.

I agree with mediation. However, in this case, I believe we can shorten that process and do it all under one.

Mr Wessenger: I have just one other question with respect to the whole question. I think it has been made quite clear at other hearings that certainly the compliance model that now exists is intended to be continued under -- and in fact it's interesting that our present legislation on the Nursing Homes Act and as it continues on the new legislation has the same sort of statutory model. Are you concerned that there might be a change in policy from the compliance approach? Is that really your concern?

Mrs Foreman: This is the feeling we have been given, that we're going back to a police-type approach, in making sure that the regulations are in place. I've worked under both, both the inspection process and the compliance process. My experience with the compliance process is that whatever areas of deficiencies they may find, they have a wealth of information that they can share with us. These people go from home to home to home and collect a lot of good ideas and a lot of problem-solving skills, and they would share that with us and are in fact doing that now. Under the inspection process, they would find us in violation for whatever and that was the end of it and then we had to do all sorts of digging and trying to find out how to correct it.

I like the compliance process and I welcome any external audit. I want that process to stay in place, but with a professional approach to it.

Mr Wessenger: The only thing I can do is that I can assure you that certainly the compliance model, as it presently is working, is intended to be continued. I don't know whether I can say anything more than that. The last item is the whole question of the --

Mr Boschetto: If I could just add one item to that, with the inspectors, the power of inspectors is also a question, and of real concern are quality management or quality improvement documents within the home and our records as they relate to personnel records.

That is something we feel must be protected under this legislation, and that the inspectors not have access to that information, because it has been known in the past that this information can be used against us in a court. We would want that information protected, because either we need the information protected or it can't be there, but it can't be both.

Mr Wessenger: Just one final comment: I noticed you had some concerns about saying lack of consultation with respect to the service agreement. I was curious about that, because the information provided to me is that the Ontario Nursing Home Association was a working group participant with the service manual. The draft service manual was circulated in October and in fact we have received actual comments with respect to the service agreement from your association.

Mr Boschetto: We haven't received copies of the service agreement within the facilities locally.

Mr Wessenger: Oh, the specific facility, you're talking about.

Mr Boschetto: Yes, the specific facility. We haven't received them. It's just as with notification of this meeting; we found out about this meeting by accident on Friday morning. In the past the ministry has sent us a fax, has called us, has followed up with documentation by mail. If it wasn't for the fact that I was listening to the radio on Friday morning, I have received no documentation in my office about the existence of this meeting today. I don't know how other people received notice of it, but we did not and neither did our sister facility.

We are looking specifically at the contractual-type agreements and what is going to be required from the nursing homes, the service agreements. We understand there was a presentation to be made on March 5 here in Sudbury on the new manual. However, that same presentation will not be made to the Ontario Nursing Home Association until later on in March, so the time frames don't seem -- they were quite surprised when we told them we were going on March 5, noy to the consultation but the information sessions, when theirs has been postponed to later on in March. I don't know if communications have faltered a little bit in this area.

Mr Wessenger: Thank you very much.

The Chair: In terms of communications, I continue to be amazed at how, supposedly, we have tremendous communications in the world these days, and yet people aren't aware of things they should have been, and for that I apologize. I said this before, but I don't know whether you were here: There was quite an extensive process at least that we tried to put in place in the committee.

I'm just curious, but would not the provincial nursing home association have let all of you know that this was going on as well? I'm not saying that they're the ones responsible, but I'm just wondering about, perhaps, internal communications as well.

Mr Boschetto: Their mailing did go out last week and we had to request faxed copies in order to prepare for this meeting today, so I think there may have been some confusion around dates.

The Chair: A memorandum was sent in December to all the major province-wide associations, informing them that these would be taking place, and I'm just concerned. There have been enough comments that when I get back, and we have completed our hearings, I think we need to look at how we inform people, because inevitably, whether it's an ad in the paper or letters to different associations, it just seems that some people who you would think would be aware aren't, and that's not good enough.


Mr Boschetto: We do not feel that there was any attempt to exclude us from the proceedings. However, we receive a multitude of documentation letters from the Ministry of Health, and we found it strange that this wasn't forthcoming also. There's never any hesitation from the Ministry of Health or local MPPs to come into a nursing home when there's a problem or a complaint.

Mr Bisson: I've gone to visit you three times. I want to put it on the record that I have gone to visit you three times. I'm not even a local member, and I've gone three times to see you.

Mr Boschetto: That's because you're a friend, Gilles.

The Chair: One of the reasons perhaps is that this is a standing committee. This is not a function of the ministry, so it wouldn't necessarily be communicating about it. I think it does go back to just looking perhaps at how, as standing committees, not simply this one but others, where there are a large number of groups and organizations, how we make contact because for those who are deeply involved in it, they're aware, but I just wanted you to know we take that issue as an important one and want to try to improve on it.

If I could just say to the committee, the next group, the Medical Society of Sudbury, is to be here in a few minutes. They aren't here. The Chair is prepared to entertain a question or two, if there is a question or two. I don't mean to keep you at the table, but Mr Bisson is going to tell us about his travels through Ontario.

Mr Bisson: Just two things: One is with regard to the presenter and the other one is around the next presentation. So members understand the story, we go back to days before I was a provincial member and we had this exact discussion about government members should be travelling around talking to people in institutions, and after being elected, I followed up on that three times and unfortunately you weren't there. So don't say we don't, because we do.

The other thing is on the other presenters with regard to the association. Normally we're not in the process of waiting around. I just find this a little bit bizaare because I've been in a lot of committee hearings. If they're here, they're here; if they're not, they're not. We're prepared to wait a couple of minutes, but at one point we have to put that --

The Chair: They're scheduled for 3 o'clock and it's not 3 o'clock, in fairness --

Mr Bisson: Okay, because I didn't have him on my schedule; that's why I was wondering.

The Chair: Right.

Mr Bisson: Okay, as long as we have a time on this.

Mrs O'Neill: Am I to understand that St Joseph's General Hospital now will not be able to present? Is that correct?

The Chair: They phoned and said they would not be here.

Mrs O'Neill: I'd like to say a couple of things, if I may, and I'd like to ask one more question, if I may.

The Chair: You may, in each case.

Mrs O'Neill: I really do think we have to examine our communications with the north. Even on the plane coming up yesterday, a member of OPSEU, who is a member of the long-term committee of OPSEU, did not know about these hearings, even though she's a resident in the city of Sudbury and has a special interest. There is an extra need of people who are in the field and who are not being somehow informed that we're coming, because we don't come, in my humble opinion, often enough. It's very easy to get very tied to Toronto and I understand the concerns, maybe not the same extent, being from eastern Ontario.

In any case, I think you've all stated that very clearly today and we will have to, as a committee, examine that, and I think our Chair will be very cooperative in our doing that. You said the case mix index is also of very grave concern to you because of the way the funds will be so dependent. Can you say a little bit more about that, just for our own understanding from the practical point of view?

Mr Boschetto: The case mix index, when you look at the levels-of-care funding, what is happening is that the residents are being assessed and from the assessments that were received, they developed the case mix index which will tell the ministry how to divide up the available funds, so that if the case mix index is based on one, that person will receive one percentage of the total amount of funds available for the province.

The problem with the case mix index is that it does not fund according to the level of care required by the resident, but simply as a percentage of the total funds available. Therefore, if a case mix index is developed and the medium is determined to be 2.25 hours of care per day, then that is how the funds will be distributed among the system, even though you may have all your residents in your facility who actually require more than 2.25 hours of care. You see, there isn't a direct funding of levels of care.

Mrs O'Neill: Are you also worried about -- others have brought to our attention the kind of snapshot picture on the day on which that's determined.

Mr Boschetto: That is not a grave concern unless the level of care that is within your facility is increased significantly over a year. We understand that the assessments will be done on a yearly basis and hope that to be true. But the snapshot would come into effect if, over the period of that year, they decided to reduce the number of chronic care beds within the community and that we would be receiving a significantly higher level of care within the facility, or if we were discharging residents who were at the F and G level in the matrix, and were not allowed to admit the same level but were required to admit a higher level of care, as in chronic, or if we were discharging people at the A and B level and were required to admit people at the D, E, F and G level. That would be a significant concern to us.

The Chair: I believe ministry staff have a clarification they wish to make on one of your points, which might be of help.

Mr Quirt: I just wanted to clarify the case mix index and how it's used. The ministry has been very clear to date that the Alberta resident classification system, modified for use in Ontario, is a tool that allows us to fairly distribute the resources the province makes available for nursing and personal care in long-term care facilities.

In reference to 2.25 hours earlier, under the current funding arrangement, which provides approximately $78 a day in insurance coverage to each nursing home for each day of service provided to a resident, there is a requirement that nursing home staff, at 2.25 hours, in order to be eligible for some additional enhancement funding -- but under the new levels of care funding formula, there will be a requirement that the nursing home spend the amount of money provided for nursing and personal care, and that amount of money will vary in accordance with the measurement of nursing and personal care requirements in the facility.

It is not an attempt to define precisely the right amount of nursing and personal care that should be provided to each resident in each facility. The amount of money made available by the province for funding long-term care facilities will continue to be a provincial decision, a decision taken by the government and ultimately by the Legislature.

If one were to look across the country, you would find 10 different "right amounts" to be spent on care in nursing home and homes for the aged. The purpose of the Alberta resident classification system is to distribute as fairly as possible the funding that the province makes available for long-term care facilities, and through the redirection, there will be $206 million more spent on care in long-term care facilities in Ontario.

Mr Boschetto: I have a question, if I might. From the assessments that were done in September and October, is it not possible for the government to determine what the actual care requirements are in the nursing homes, and instead of taking a pool of money and dividing it among 59,000 residents, go in and supply funds to provide the level of care that's actually required?

Mr Quirt: The Alberta resident classification system does not tell us that a particular resident requires a definitive amount of nursing and personal care. As you're well aware, a similar client in Ontario, in a nursing home or in a home for the aged or in a chronic hospital, all with identical care requirements have, by a factor of three, a tremendous different amount of programs and services delivered to them.

In your facility, your client would have $78. The facility would have $78 to spend on that person. The identical client in the average municipal home for the aged would have $120 spent. There are those who would argue that the identical client in a chronic hospital might have $225 spent. Somewhere in that range you would have an opinion on what the right amount is. Others would have varying other opinions on what the right amount is.

The redirection initiative allows us to distribute the funds the province makes available for care in nursing homes and homes for the aged in as fair a way as we can find to do that. In addition to the existing level of funding for nursing homes and homes for the aged, an increase of $206 million will be added to the budget as an equalization fund, to bring much closer the relative amount of support provided by the province for residents in the three categories of facilities that the bill deals with.

Mr Boschetto: Could you tell me when that's going to be implemented?

Mr Quirt: Yes. It will be implemented with the pleasure of the Legislature: if it passes Bill 101, as quickly as possible after that.


The Chair: Thank you. You've been very patient and not only answered our questions, but I think have provided information as well on your own operations which has been helpful to the committee. We want to thank you for coming and making your presentation as well as that of the Algonquin Nursing Home. Thank you again for being here today.

Mr Boschetto: Thank you.

The Chair: I will just say to committee members that we will adjourn for just a few minutes while we wait for the medical society. Is there a question, Mrs Caplan?

Mrs Caplan: I would like to ask a question of the ministry staff. I'd prefer that it be on the record in Hansard if you wouldn't mind.

The Chair: That's fine.

Mrs Caplan: The committee may remember -- I believe it was in London -- that I raised the case of a constituent of mine who's having some difficulty receiving appropriate care in the appropriate place or, as they would say, the right place at the right time. What I've been told is that at the chronic hospital where the person is right now, they've told this constituent that he must be an inpatient in order to receive the rehabilitation speech therapy service that he requires, and that if he does not sleep in the bed he's not entitled by ministry regulation to receive the care.

It was always my understanding that chronic hospitals were globally funded and that they had the flexibility to deliver services either inpatient or in whatever way, that the ministry didn't require head counts on a nightly basis to determine what the inpatient capacity was.

The reason that I raise this is that the people who were just here talked about that incentive being in place for nursing homes. I'm aware that this is the case and nursing homes fill the beds and keep them full. Does the same situation apply to chronic hospitals at this time?

Mr Wessenger: I'll let the staff answer that.

Mr Quirt: The short answer to your question is that I see no reason why a chronic hospital would be required to have a policy that allowed for specific therapy services to be provided only to inpatients. As you are well aware, the position of the Ministry of Health is to encourage hospitals to look at how they deliver services generally and become more of a resource to the community, and try to do more on an outpatient basis if that's the appropriate way to deliver services to that particular client.

Mrs Caplan: So the ministry would have no objection to this patient receiving a nightly pass so that he could sleep at home and still be entitled to the inpatient service? You would have no problem if the hospital administration wanted to allow this person to sleep at home?

Mr Quirt: I don't know the individual circumstances or the particular hospital in question. There may be an entirely different point of view from their end of it. In general terms, I don't think the Ministry of Health has a policy that would preclude someone receiving hospital services on an outpatient basis. As a matter of fact, in general terms, we would encourage that. If you'd like, we'd be happy to look into the individual circumstances, by my colleagues in the community hospitals branch. They would provide you with an answer specific to that particular facility and the concern you've raised.

Mrs Caplan: I don't want to belabour the point. The reason I want to have it on the record is to make sure I've heard clearly the advice that you've given me, and that is that you cannot think of any piece of legislation or any regulation that's in place right now that would require this person to sleep in the bed in the hospital in order to be able to receive the service he requires from that chronic care institution.

Mr Quirt: I am not aware of a regulation. There may well be one that I'm unaware of, but I'm not aware of one myself.

Mrs Caplan: But would you say that given the policy direction you've just announced, which is that this government and the government before was encouraging hospitals to allow for greater shift to outpatient and ambulatory and flexibility, it's your view that the ministry would not in any way penalize this hospital if it permitted a patient to remain classified as an inpatient if he didn't sleep in the bed at night?

Mr Quirt: I am unaware of any regulation that would penalize a hospital for specifically that. I would remind you that I'm not an expert on the acts that govern acute care facilities and if there's a particular concern with this --

Mrs Caplan: Chronic care facility.

Mr Quirt: Well, it's the same bill that funds them both. I would be happy to find out more specifically what the problem is in the particular circumstance that you're raising and get you a more complete answer from someone who is more familiar with the acts and that program.

Mrs Caplan: Thank you. My question of the Chairman or perhaps of the clerk is whether there's any flexibility in tomorrow morning's schedule in Toronto. Do we have any time or is it totally booked?

The Chair: It's totally booked.

Mrs Caplan: Okay, thank you.

The Chair: Mr Wessenger, did you --

Mr Wessenger: I was just going to indicate to the member that if there's a problem in this regard, I'd like to know the specifics and be able to follow through, because certainly the policy is to provide ambulatory care. The policy is to provide care for the people in the community and it doesn't seem to make sense in overall health strategy if there's a refusal to provide those types of services.

Mrs Caplan: I actually suggested to the medical chief of staff in this particular chronic care hospital that they allow the patient to leave a teddy bear in the bed and let him sleep in his own home at night if they had an obligation to keep the bed full. he said that they were concerned about reprisal from the ministry or that they would not be meeting regulations. So I wanted to clarify that today.

The Chair: The committee will stand adjourned briefly. If members could just be present, we're just trying to find out what has happened to our last presenter.

Mr Bisson: It's past 3 o'clock, Mr Chair.

The Chair: I appreciate that, but we're here and we can wait for a bit. Our van won't be here until a little later. So we'll just have a brief recess.

The committee recessed at 1507 and resumed at 1517.

The Chair: Members of the committee, because of our schedule today and flight arrangements, we've not been able to make contact with the 3 o'clock presenter, but it being now --


The Chair: We thought we spied one of the presenters, but I'm afraid at this point I'm going to have to close our hearings today; otherwise we will not be able to make our flight. With that, I want to just say that we thank all the presenters, not only from Sudbury but from North Bay, the Sault, Espanola, Timmins and other areas who have come down today. We've found, as we have, I think at every location, a great of substance in the presentations that were made. The committee will certainly be considering those carefully. We want to express our thanks to everyone in this area for coming. With that, the committee stands adjourned.

The committee adjourned at 1518.