Wednesday 24 February 1993

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

Sisters of Charity of Ottawa Integrated Health Service

Michel Bilodeau, president

Regional Municipality of Ottawa-Carleton

Peter Clark, chair

Guy Cousineau, chair, homes for the aged management committee

Garry Armstrong, commissioner, homes for the aged

Perley Hospital

David Webber, treasurer, trustee and board member

John Lupton, executive director

Mimi Lowi, assistant executive director

Council of Family/Community Advisory Boards

James Lumsden, chairman

Victorian Order of Nurses, Pembroke and South Renfrew Branches

Joan Booth, president, South Renfrew

Joan Lemay, executive director, South Renfrew

Mary McBride, executive director, Pembroke

Ontario Hospital Association; Council of Chronic Hospitals of Ontario

Dr Wilma Dare, past chair, OHA

Michel Bilodeau, vice-chair, CCHO

Stephen Skorcz, vice-president, chronic care and mental health, OHA

St Patrick's Home of Ottawa

Maureen Goodspeed, chair, board of directors

Sister Mona Martin, administrator

Ontario Long Term Residential Care Association

Don Francis, regional president

Alain Brunet, member

Ontario Home Health Care Providers' Association

Lucie Kean Frank, member

Claire Gonthier, member

Kanata Beaverbrook Community Association

Fred Boyd, president

Council on Aging--Ottawa-Carleton

Sylvia Goldblatt, vice-president

Greg Fougére, chair, institutional long-term care committee

Canadian Council on Health Facilities Accreditation

Elma G. Heidemann, assistant executive director, standards, research and development

Gerontological Nursing Association of Ontario, Ottawa Chapter

Frances Doyle, representative

Royal Canadian Legion, Ontario Provincial Command, District G

Jim Margerum, district chief commander

Jim Mayes, chairman, district veterans services committee

Hillel Lodge

Dr Gary Viner

Stephen Schneiderman, executive director

Victorian Order of Nurses, Ottawa-Carleton and Eastern Counties Branches

Diane Raymond, president, Eastern Counties

Charles Armstrong, president, Ottawa-Carleton

Jean Courville, executive director, Eastern Counties

Heidi Jaeggin, director, placement coordination service, Eastern Counties

Arbor Living Centers

J. Michael Bausch, president

Ottawa-Carleton Placement Coordination Service

Suzanne Smith, director

Lucy Carrière, chief coordinator


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

*Acting Chair / Présidente suppléante: Fawcett, Joan M. (Northumberland L)

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

Drainville, Dennis (Victoria-Haliburton ND)

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

Carter, Jenny (Peterborough ND) for Mrs Mathyssen

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

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

Rizzo, Tony (Oakwood ND) for Mr Drainville and Mr Owens

Villeneuve, Noble (S-D-G & East Grenville/S-D-G & Grenville-Est PC) for Mrs Witmer

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

Also taking part / Autres participants et participantes:

Czukar, Gail, 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: Drummond, Alison, research officer, Legislative Research Service

The committee met at 0906 in the Westin Hotel, Ottawa.


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. Bonjour à tout le monde. I want to welcome everyone to the morning session, our second meeting here in Ottawa, to review Bill 101, An Act to amend certain Acts concerning Long Term Care. Encore une fois, nous sommes très contents d'être ici pour étudier le projet de loi 101, Loi modifiant certaines lois en ce qui concerne les soins de longue durée.


Le Président : Notre premier invité ce matin, M. Michel Bilodeau, services de santé intégrés. Monsieur Bilodeau, vous êtes le bienvenu au comité. Welcome to the committee. Bien sûr, vous pouvez nous parler soit en français ou en anglais, nos deux langues officielles.

Mr Michel Bilodeau: Merci. Alors, mon nom est Michel Bilodeau. Je suis le président-directeur général des Services de santé intégrés des Soeurs de la Charité d'Ottawa. Ma présentation sera en anglais, mais mon texte est disponible en français et en anglais, s'il y a des gens qui le désirent en français.

The Sisters of Charity of Ottawa Integrated Health Service is an organization that has just been created and integrates under a single board of trustees and a single chief executive officer. The four institutions owned and operated by the Sisters of Charity in the Ottawa-Carleton area include: St Vincent Hospital, a 516-bed rehabilitation and continuing care hospital; the Résidence Saint-Louis, a 186-bed charitable home for the aged; the Elisabeth Bruyère Health Centre, a 225-bed rehabilitation, palliative and continuing care hospital, and the Villa Marguerite, a 70-bed nursing home. With more than 1,000 beds, this organization is one of the largest in Canada that provides long-term care.

The government's long-term care redirection in Bill 101 will obviously have a direct and immediate impact on these facilities, particularly on the Villa Marguerite and the Résidence Saint-Louis. Today's presentation will focus on two specific aspects of the bill -- the funding of long-term care facilities and the admission process for new residents. Of course, we have a lot of other things to say, but these are the two points that are of greater concern to us. These points will be looked at from the point of view of how this new legislation is a bureaucratic nightmare.

In an article published on January 10 in the Ottawa Citizen, Mr Robert McLean, who's defined as executive director of Ontario's Premier's Council on Economic Renewal, said:

"Each part of the bureaucratic organization has a mandate and operates within a set of rules. Lacking an objective assessment of outcomes, conformity to those rules becomes the measure of performance. This is what bureaucrats call accountability. The typical response to suggestions that we might get more done with fewer rules is that the rules are necessary for accountability to the public. This is false. The rules are all about accountability for inputs -- the approvals required for spending. There is almost no accountability for the outputs, or in other words, what that spending achieves."

We wish Mr McLean would work for the Ministry of Health or the Ministry of Community and Social Services. The rules that the government wants to impose on long-term care facilities are a clear illustration of the bureaucratic mind at its best, or rather at its worst. Funding will now ostensibly be divided into three components, one for nursing and personal care, another one for programs and the third one for support services, within which categories transfers of funds would ordinarily not be permitted. Within the first two categories, the money provided by government will actually represent reimbursement of expenses for which very specific standards will apply. There is no provision for generating surpluses within these two categories, which will be permitted only in the third sector pertaining to support services. The authorization to generate surpluses in the latter sector, of course, will apply only if funding is sufficient to make this potential feasible, which is far from obvious.


Ladies and gentlemen, managing a facility requires flexibility. A funding scheme based on reimbursement of costs prevents managers from demonstrating initiative and creativity, limiting them instead to complying with rules. For example, if the actual cost of raw food is reimbursed, as we have seen in draft regulations, the manager will have no incentive to look for suppliers who could provide food at a better cost or to profit from the savings generated by group purchasing.

The Sisters of Charity of Ottawa Integrated Health Service is a 1,000-bed organization which has a purchasing power that could generate savings on raw food purchases. In turn, these savings could be used to improve the programs provided to the residents or even to establish new programs, but this will be forbidden by new regulations.

Here's another example of the negative effect of this lack of flexibility. Let's imagine that a new piece of equipment becomes available on the market that permits, let's say, baths or transfer of disabled residents with one employee instead of two. With the proposed regulations, the facility would have to use the surplus generated in one area, which is the support services, to buy the new equipment and maybe then face a deficit in this area, but then could not reduce the staff on the other hand to pay for it.

In summary, the proposed regulations are a disincentive to good management and could even translate into poorer quality of services to the clients.

Global funding helps the facility react to the needs of the clientele by using the surplus generated through good management practices to improve existing services or to establish new ones. For example, the two hospitals of the Sisters of Charity of Ottawa Integrated Health Service which currently benefit from global funding have established geriatric rehabilitation programs and respite care programs within their respective chronic care bed allocation. These programs assist elderly persons to remain in the community or return to it, but the Ministry of Health has never recognized these programs for funding. So the two hospitals have used the surplus generated by global funding, by good management, to start these new programs in spite of the fact that they were more costly. If they were submitted to the current regulations that are proposed by the government, we would never have been able to do something like that in response to the needs of the community. That's why we need a form of global funding.

In view of the alarming practical implications of the bureaucratic process and framework proposed by the government for long-term care, we recommend that a global funding formula be developed for long-term care facilities based partially on the type of care required as proposed by government but which will allow the facility more flexibility to organize its programs and services. What we say is, it's okay to base the funding formula on the level of care and other criteria, but then once you transfer this money to the facility, let them manage it according to their needs.

Of course, we recognize that the government does not want facilities from the private sector to make profits at the expense of the quality of life of their residents. None the less, not all facilities are for profit. Moreover, it would be more meaningful to monitor the outcomes rather than the process. We believe the government must ensure that residents of long-term care facilities receive appropriate care and services, that they are well fed and that they have a good quality of life. We do not believe, however, that reimbursing the cost of raw foods, to continue that example, is an appropriate way of monitoring the quality of the meals. The same result could be achieved if the government took steps to verify the quality of the food actually served to the residents through unannounced inspection and client satisfaction surveys.

We acknowledge and support the standards established by the Canadian Council on Health Facilities Accreditation, which will present this afternoon to you, upon which the government intends to rely. The problem stems from the fact that the government now wants at the same time to control expenses line by line as well as outcome, which doesn't make sense.

In closing on this topic of funding, we wish to add that the proposed legislation does not address the problem of inequity in taxation. Some categories of not-for-profit long-term care facilities are exempt from the local taxes, some others are not. The St Vincent Hospital, the Elisabeth Bruyère Health Centre and the Résidence Saint-Louis do not pay any municipal, regional or school taxes, but the Villa Marguerite, a not-for-profit nursing home which serves essentially the same clientele, paid close to $60,000 in taxes last year. We therefore recommend that either all of them don't pay taxes or they all pay taxes and then that this be part of the funding.

The second part talks about the admission process. The proposed legislation says that a facility cannot refuse admission of a client unless a ground for refusal prescribed by the regulations exists. We understand the government wishes to avoid favouritism and discrimination and wants to ensure that access is guaranteed to those who need it the most. We are, however, concerned over what the regulations will consider to be grounds for refusal.

There are several legitimate reasons why a facility would not want to accept a specific candidate, and it is unlikely that the regulation will be able to identify them all or even that the coordinator of admission would be in a position to appreciate the validity or the rationale for refusing admission due to linguistic or cultural factors or based on structural design or staffing considerations. Here are a few examples.

The reason I'm saying we operate in French only -- when I say French only, it's not a bilingual institution, it's French, period. All the staff is French. All the residents are either French or operate in French and function in French. There's no bilingual sign, no bilingual documentation inside. Everything is in French.

On the other hand, the Villa Marguerite, our nursing home, while operating in French and English, is mainly French and creates and maintains a French atmosphere and character. This is facilitated by maintaining a majority of French-speaking residents and having a majority of francophones as employees, and we wish to preserve this character. Will the new regulations allow us to maintain in our institutions this French character that we thought was guaranteed under Bill 8 on French language services?

The physical layout of the facility clearly has implications with respect to the type of residents who can be admitted. For example, it may not be possible to accept more than a specific number of wheelchair-bound residents on a particular ward, and the location of the nursing station may not permit the monitoring of more than a specific number of wandering residents. Will such constraints be taken into consideration under a centralized admission process? We feel it will be extremely difficult for a director or coordinator of admission to know all of these specifics.

Even if, in principle, funding will be based on the level of care required, changes in the staffing pattern cannot always be accommodated immediately. A certain number of employees are required to care for a certain number of residents. A rapid increase in the number of heavy cases, for example, may not always permit an immediate adjustment in the staffing level, nor will funding commence immediately.

By contrast, if a sharp and uncontrolled reduction occurs in the average level of care required, it may not be possible to reduce the level of staffing immediately. If you want to attract competent and dedicated staff, you cannot bounce them from one place to another and change their hours of work all the time.


Also, these people get specialized. At the Résidence Saint-Louis, for example, we have a unit specialized for demented patients. We have another specialized for people who have heavy physical requirements. If we cannot control who comes in, then we lack that specialization of the staff.

Will the new regulations allow the facility to refuse admissions on such grounds without having to face a very bureaucratic appeal process as provided in the bill, or will facilities be given the right to appeal? Right now, it doesn't seem they are given that right.

In summary, the bureaucratic and punitive approach of the proposed legislation, and of the draft regulations that have emerged to date, leads us to believe that the facilities could lose the flexibility fundamental to efficient operations. Since funding will be largely associated with the level of care required, we believe that this will create an incentive strong enough for the facilities to admit heavier and more complex cases. Potentially, some facilities will wish to specialize in lighter care, which should be their choice, and their funding will reflect that choice. However, other settings may wish to specialize in handling heavier care because they're better at that and more efficient, and there's nothing wrong with that. This should be encouraged.

Instead of legislating the obligation of facilities to accept all the residents referred by the coordinator, the law should provide for exceptions. Facilities could be authorized to deny admissions based on their own constraints and priorities. However, the coordinator should have the option of compelling admission of a resident against the will of a facility in instances where the personal circumstances of the prospective resident warrant admission on an urgent basis or would face an excessive waiting period.

Another important point is that the proposed legislation seems to have forgotten the right of the consumer to select the institution of his choice. This was a key feature of the government's long-term care redirection published in the fall of 1991.

In closing, I wish once again to quote Robert McLean's article: "Government should be a catalyst. It should mobilize private resources to accomplish public objectives...government should seek to empower communities rather than serve them...competition in public service has the same effect as competition everywhere else: quality gets better and costs go down...we need results-oriented government, which means funding outcomes, not inputs."

The Sisters of Charity of Ottawa have been providing health care in Ontario since 1845, long before governments started to be interested in this field. For the sisters, it's a work of charity and compassion that they intend to continue. We ask and recommend that the services provided by the sisters, and by the other long-term care providers, be judged on the merit of the results achieved; that is, on the basis of the quality of care and the quality of life of their residents rather than on the counterproductive basis of an organization's degree of compliance with bureaucratic regulations which are not tied to the outcome and complicate the management. Thank you very much.

The Chair: Thank you, merci, for your presentation and we'll go straight to questions and begin with Ms Caplan.

Mrs Elinor Caplan (Oriole): Thank you for an excellent brief with many excellent recommendations. I particularly like the bottom line, which I agree with and have been discussing at some length at this committee over the time that I've been here, and that is that the basis of quality of care and quality of life is not tied to compliance with bureaucratic regulations, but in fact results-oriented output measures of total quality management and continuous improvement as a value would produce better results and more cost-effective results.

The question is how this legislation can be changed to do that. I think there are some suggestions here. Some of the concerns that we have with this legislation as well are that it's just really one part of the whole picture, but you focused on two things that we've been hearing repeatedly. One is lack of flexibility and lack of choice.

The lack of flexibility and the lack of choice are both for the institutions and for the consumers. You've been very clear in how you would see some of those amendments that would allow for greater flexibility, but what I'd like to hear from you is, if this legislation were to permit global budgeting for the institutions, can you think of the other change that would have to happen to ensure outcome accountability without the big stick and the tone of a punitive enforcement model, which we all know in the modern world doesn't work.

Mr Bilodeau: I have of course no easy solution, but I think that first of all, all facilities should be asked to require accreditation from the Canadian Council on Health Facilities Accreditation. Our four facilities have a three-year accreditation right now and that brings people to work very hard to comply with outcome standards. That's the first step.

Second, I must say that my experience with nursing homes -- we have a nursing home -- is that the inspection process so far has been fairly good. We have inspections three times a year. They come and try to work with us at improving the situation, and I've never heard a threat of saying, "If you don't do that next week, you're going to lose beds. We are going to stop admissions," and things like that. It's more saying: "Wee see what type of snacks you give to the patients. Don't you think you should have more fresh fruits and things like that?" So we do these types of things, but it's an approach of helping us, instead of an approach of saying: "Hey, listen. If you don't do that, we cut funding next week." That's what worries me with the approach that I've seen in the manual.

Of course there's a big difference between the legislation and the regulations that come afterwards, and I must say that the legislation usually shows a lot of goodwill, but when you see the regulations, that's when you really face the problem and I'm more concerned with the regulations than the legislation.

Mrs Caplan: If there was an amendment to this legislation, and we've discussed it here before, that required accreditation on the basis of outcome, not just management, that required a quality management program within the institution which the ministry could then support through the kind of compliance approach of the change that occurred, I think it was about 1988, and that a residents' council was also a requirement, do you feel, provided institutions were able to comply with those three and if that was mandated by legislation, that there would be sufficient outcome accountability that would then permit things such as global budgeting or exemption from the kind of punitive enforcement model that is even suggested by this legislation?

Mr Bilodeau: On one hand, I'd be tempted to say yes, but on the other hand, I feel that it may not be exactly enough in the sense that if you have accreditation every three years, a lot of things can happen in three years. So I think, yes, recourse to accreditation should be mandatory and the report should go to the ministry, but at the same time there should be some kind of inspection mechanism in the meantime, once a year or something like that.

In fact, I'm not dissatisfied with what we have now. I'm just concerned about what is proposed with the approach that they have. Someone from, let's say, the nursing homes branch right now comes once a year to look at how we serve the patients, what type of food they have, how the quality of life is. I have no trouble with that; they're welcome.

I have a problem if they will tell me, "Oh, you spent $5 less on raw food that you should have had and so, because of that, we'll deny you admission next week." That's totally ridiculous. Let's check whether the food is good or not. If the food is not good, we have a problem that needs to be corrected. If the food is good, whether I pay 50 cents for the carrots or 45 cents is totally irrelevant.


Mrs Caplan: What if you included in that proposal the requirement of client satisfaction surveys of both the residents and their families on a regular basis?

Mr Bilodeau: Absolutely. We've been doing that for years and I think it should be mandatory. I have no problem with that.

Mrs Caplan: If that became part of the overall accountability, so it wasn't just checking off an accreditation standard -- and there was no requirement for residents' councils in the legislation nor for client satisfaction surveys -- you'd be quite comfortable with an amendment that did that?

Mr Bilodeau: Absolutely. We have residents' councils. At our board we're creating a community advisory committee with representatives from the families and the residents and they will elect their own chair and have a seat on our board. So we are quite comfortable with everything that relates to residents' councils, satisfaction surveys and all that.

Mrs Caplan: There are two other amendments that I'm going to wrap into one question and ask you to respond to because the Chairman is already telling me to be short.

One is an amendment that would permit the institution the right to refuse on the basis that it could not provide appropriate care, the appropriate care could then be defined by regulation and you would then allow an appeal mechanism; and secondly, a statement of basic principles upon which the placement coordinator and the framework of the legislation would be based which would guard, or at least clearly state, linguistic, social, multicultural, cultural in general. Would you support those kinds of inclusions in the bill?

Mr Bilodeau: Sure. Yes, absolutely.

Mrs Caplan: Any comment on how those could be framed that would give you comfort?

Mr Bilodeau: I think what I said in my brief is that I feel that generally speaking these aspects should be reasonable grounds for refusal. But then the coordinator of admissions should have a right in exceptional cases to make sure that someone doesn't stay on the waiting list for years, and that if someone is refused everywhere and cannot have access, then he should have the right, but based on exception, not the general rule.

The Chair: Thank you. Mr Jackson.

Mr Cameron Jackson (Burlington South): Michel, thank you for your presentation. I very much appreciate you referencing on page 3 the concept of the inequity of local taxes. A comparable facility in Sault Ste Marie made a presentation in Sudbury, and I've asked that this matter be researched.

If I may, Mr Chairman, for the record, request that some contact be made with the NDP so-called Fair Tax Commission to determine if this matter ever came to light or was ever discussed by the appropriate subcommittee. I'd like to add that to the three questions I raised within that bundle of an inquiry, and if we're to be given some briefing on whether or not this is being looked at because --

The Chair: I'll just note for the record that through legislative research we will do that.

Mr Jackson: Thank you. I thank you for raising that because we've seen the home in Sault Ste Marie had a $100,000 operating deficit and its taxes were $85,000 a year.

Mr Bilodeau: I'm sure you will support our private members' bill for Villa Marguerite this spring when Mr Grandmaître brings it then, thank you.

Mr Jackson: No problem. I'd be pleased to assist.

I appreciate the way you've given us a fresh look at the funding and its implications to your need for flexibility and to break down the three categories very clearly and how you're boxed in. That is helpful to us in terms of understanding some of the traps in this legislation, but I want to move to the one that concerns me the most and that is on the issue of admissions and appeals.

There are people who cynically believe that the government is in the process of redistributing the current inequities of placement of individuals in this province, that through growing acuity and lack of mobility, as we empty our bed-blockers out of hospitals, they're going into these kinds of facilities. There are some who even go so far as to suggest that the government will not relinquish its control of being able to have absolute control over where people will go and where it can block them from being removed from, which is probably a really key point here, that it can block the removal or the departure of a resident from one facility.

Given that this is the case, I don't want you to debate that but let's just presume for a moment that's the direction we're going in, then this discussion shouldn't spend too much time on appeals if we're not going to have it, but rather the concept of overbedding and the kinds of horse-trading and the negotiations that occur between placement coordinators, facilities and government funding.

I'm asking you to look at living with this legislation as it is, because frankly, I sense that's what we're going to have to do. I'm not a member of the governing party. I'd like to see it amended, but they control the total number of votes and ultimately they'll decide what the final look of this will be.

If you put your mind around the concept of overbedding and their discretion to provide additional funds if you're forced to accept someone who has higher-end needs, when you skew your Alberta classification system and you find in that sweepstakes you do poorly, can you talk to the committee about how it will be to operate a facility in that environment where you're actually competing with other facilities to fiscally survive?

Mr Bilodeau: First of all, I must say I have a tendency to believe that people, both in facilities and government, wish to do the best thing. I don't think there's any plot or cynical approach, I just think they're misguided. That's different.

Mr Jackson: I don't mean to interrupt you, but the document clearly states that we're going to do all of this without any increase in chronic care beds in this province. So you're looking at a contracting system with a growing acuity rate and controls. I'm respecting the insights you've shared in your brief and I respect your optimism, but frankly, in the eight or so years that I've been working with the Nursing Homes Act, I have a rather more cynical view of things. We just heard last night that a 100-bed licence may disappear from the Ottawa region. Those people have to go somewhere. Those are the kinds of emergencies this legislation anticipates being able to react to, and you won't be able to.

Mr Bilodeau: Let me say first, in this case there are also more than 200 acute care beds closed in this region. You could relocate these people, not necessarily outside of the region but you could reopen some of these beds and place them there, which will be far from ideal, but you can have reorganization and you will have a restructuring of the beds in any region because of closure in acute care.

I must say that for the facilities themselves, what you raise is not likely to be a big problem. The problem will be for those who cannot get in the facilities. I think you're right in saying that the freeze in long-term care beds may have a dramatic impact. The idea that people should stay in the community is fantastic, but the reality is they have nowhere to go. Families are not there any more. People have one or two children, these children are all over the place and there's nobody to take care of them. In an ideal world, I would take care of my own mother, but she lives in Quebec City and I'm here, so I won't. That's the reality of things.

Will government take residents from one place and force them to go to another? I would doubt that this will happen. What I think will happen is that they'll have no place to go in this region. They'll eventually settle for something, be on a waiting list to come here, and that will take years. So there will be tradeoffs from the waiting list.

I'm not very keen on the disaster scenario. I think it will be problematic. The placement coordination services have been, in this region, rather good at coordinating placement and taking care of everyone's interest. I think though, as the bottleneck increases because of lack of beds -- the district health council thinks this region will need more than 800 long-term care beds in the next five years just because of the aging of the population -- we may face the same situation that we faced with psychiatric patients 15 years ago. That's a great concern.

What all the reform doesn't take into consideration is that one of the main problems of the elderly is solitude. Living in their homes is often the worst place for them because they're all alone. We should recognize that. Certainly, those of us who work in this field are concerned about the fact that the government seems to think that elderly abuse happens mainly in institutions. In fact, it happens mainly at home, and accidents happen there too.

We feel there is a danger. I don't predict catastrophies. I think there is a danger that if we don't react fast enough there will be a long list of people who will be less well than they are now. Whether in fact we're going to have a dictatorship that will bring people from one place to another, I doubt this will happen, quite frankly. I think at the local level people who work in this field all know one another, and a director of admission who would act that way could not survive. The region would rise and stop him or her from doing that.


Mr Paul Wessenger (Simcoe Centre): Thank you very much for your presentation. I'd just like to explore a couple of items with you.

One issue that's often been raised is the whole question of social needs for congregate living. It would seem to me that having adequate support of housing options would solve that social need for many elderly people and also provide the light care that's needed. Do you see that as very much an important part and a way to relieve the problems of long-term care facilities?

Mr Bilodeau: Yes, certainly. I think it is certainly an approach that will help the elderly face the solitude problem I just mentioned, certainly an approach where cost is lower.

For those of us in facilities, we are not looking for more clients. In fact, we have quite enough. Our occupancy rate is already full. We have a waiting list of two and a half years in our hospitals. We would very much welcome more initiatives to bring people to live in small groups in the community. I think it's an avenue that needs funding and needs help as much as possible.

What we say, though, is that with the rapid increase in the aging population, we do not believe this will replace long-term care institutions. We just believe it will help us limit the growth in the number of beds. So if there's an investment to make, it's quite likely better for government to invest in that type of project than to invest in a large, large number of increased beds.

What we say also is that it will be a little naïve to think that you can just take huge amounts of money from one place and transfer them to the other, or that you can totally freeze the number of beds. It will be impossible. The number of elderly is growing too fast.

How do we do it all at the same time? I have no answer. That's why I don't go into politics. But certainly, I think this is a good avenue of solution that should be part of the global approach to helping the elderly in the future.

Mr Wessenger: I think we'd all admit that global funding approaches on their own do create problems of certain programs not being adequately developed. I'd particularly refer to quality of life programs, which I think are extremely important to have. If you had a different funding model, how would you ensure that such programs like quality of life programs could be ensured in the long-term care facilities? Could you elaborate on that?

Mr Bilodeau: First of all, as I mentioned, I think how funding will be arrived at should take into consideration the weight of the residents; a mechanism, whether the Alberta classification system or another one, to evaluate the personal needs of the patients; then some kind of funding criteria on how much we spend for quality of life activities, and then some type of criteria for how much we spend on building and support services. What I say is, once you have established this, then let us organize it and have criteria such as the criteria of the CCHFA to evaluate the quality of life.

We were just accredited two weeks ago at the Elisabeth Bruyère Health Centre. When they came, they said, "Oh, you have so many recreologists but you have less social workers." So that's a choice we made. We traded social workers for recreologists because we insist more on that type of activity. That should be part of each facility's approach and personality and type of care. I think the council of accreditation has a number of criteria for quality of life, and if you have a satisfaction survey, if you have a good residents' council and family involvement, you'll be able to do it and to control the quality of life.

There's no magic solution, once again, but if you control the amount of money you spend on each activity -- for example, how does someone know outside of the facility that it's better to have two more recreologists and two less social workers. What we say is, let us decide that with the residents.

Mr Wessenger: Yes. I just might add, there are really only three categories, as I've said -- nursing care, personal care and quality of life programs. So you do have that flexibility.

Mr Bilodeau: This one we do.

The Chair: Thank you very much. There are many more questions, I know, but unfortunately I'm going to have to close.

Mr Bilodeau: I'll be back this afternoon with OHA.

The Chair: Very good. Merci d'être venu.


The Chair: I would then call our next presenters, representatives from the Regional Municipality of Ottawa-Carleton. Would you be good enough to come forward. The Chair would like to recognize another chair but a more important one, the regional chair of Ottawa-Carleton. Peter, it's very good of you to come down with your colleagues and join us this morning.

Mr Peter Clark: Mon cher Charles, and I owe the title of being chair to my friend Yvonne. Randy, good to see you.

Mr Randy R. Hope (Chatham-Kent): Good to see you.

Mr Clark: And Noble and Madam Minister -- oh, excuse me.

The Chair: Flattery is always wonderful.

Mr Noble Villeneuve (S-D-G & East Grenville): It will get you everything.

The Chair: Would you be good enough just to introduce your colleagues and then please go ahead.

Mr Clark: I fully intend to. I have my colleague who chairs our homes for the aged committee management, Guy Cousineau, mayor of Vanier. I have my chief administrative officer, Merv Beckstead, and I have Garry Armstrong, who is the commissioner for the homes for the aged.

I have listened with some interest to Michel. I have a brief that I will present to you. You'll get a package of them, and then we will hope to have a few minutes where we can perhaps have some discussion.

I thank you for the opportunity. We have a formal brief which addresses four areas: funding, access to facilities, accountability and integrated planning. There's a booklet in there about the care and services provided in our homes and a map of the region which identifies the location of facilities and the 65-plus population by municipality.

The region is supportive of the basic principles of redirection: integration of long-term care, health and social services -- this covers, in our view, some of the gaps -- improved access to quality services and funding equity across the province -- also very worthwhile principles -- creation of community alternatives to institutions; greater consumer choice or participation, and promotion of racial equity and cultural sensitivity. I think those are all valid and worthwhile objectives.

The region plays a major role in the planning and delivery of health and social services in Ottawa-Carleton and wants the system to be responsive to the community's need, sensitive to ethnic and cultural diversity, fiscally responsible and built through partnerships among public, community and private sectors.

We operate three homes for the aged -- 607 beds -- community support programs and linkages with community college and university education programs. The homes employ close to 900 full and part-time people. We had 470 volunteers coming in from the community to help our residents in 1992.

Until 1989, the region paid about 15% of the operating cost of the homes. In 1989, the regional share jumped to 30% when capping was imposed. Regional council was prepared to live with the increase on a temporary basis until long-term care reform, as it was then called, was implemented.

The government had made a commitment to fund care to the level of need, because what we were experiencing was essentially a larger and larger medical component. The average age of people who were being housed in the homes was growing rapidly. I'm sure you've found that in your travels. We anticipated that when the government's commitment was met, we would see a return to a reasonable level of funding.


I would point out to you that the proposed funding level is flawed. It's driven by available funds, not by consumer need. Strange for a politician to tell you that, but the truth of the matter is that those constraints exist for all of us.

Funding will be based on an assessment system that was not adequately tested, and therefore it cannot be seen to be accurate and impartial. I'll talk to that a little more on some other things that I may want to share with you. Initial funding will be based on assessments conducted last fall, using data that probably is out of date. The turnover in our home since October 1992 is 71 residents; that's more than 10%. In the course of a year it may be as high as one third of our residents, in terms of turnover.

The funding formula proposes to raise $150 million from increased resident user fees. Our position, supported by the Ontario Nursing Home Association and homes for the aged, is that $60 million is a more reasonable figure to anticipate. So where's the other $90 million coming from?

The revised resident copayment is based on an income test only. It ignores the fact that many seniors have assets and desire to contribute to their living arrangement costs. This copayment also, because of that, increases the taxpayer's burden for those seniors who are asset-rich but income-poor. It assumes, as well, that municipal contributions will continue at current rates. We do not accept this assumption.

There's no legal reason why we should operate chronic care hospitals without proper funding, make no bones about that. We urge the government to revisit the funding proposal and consult consumers and providers about the basic assumptions. If there's no change in the funding arrangement, we're going to have to consider what we would call unpalatable options: Cut programs, close beds, lay off staff, perhaps close one or more of the homes; this, at a time when waiting lists are growing and the population is aging. I'll have more on that later. No one's looking forward to making these tough choices, but if forced, we'll make them.

The placement coordination service is doing a good job in coordinating access to long-term care facilities in Ottawa-Carleton. It's funded by the province, it has a community board, and while the system may need some fine-tuning, for the most part we believe it's serving clients and facilities well. It's been doing a good job for many years.

The placement system proposed in Bill 101 is a nightmare. It appears to reduce consumer choice and impose rigid eligibility criteria which could see spouses separated when one meets criteria and the other doesn't. It would deny regional council and the committee of management the right to define the mission of the homes. It would deny the homes the ability to maintain culturally and linguistically unique units and facilities; par exemple, le Centre d'Accueil Champlain.

Le Centre d'Accueil Champlain est un foyer francophone, dont la mission est d'offrir un milieu culturel et linguistique franco-ontarien aux personnes âgées de langue française. De forts liens le rattachent à la collectivité de Vanier, et il fait partie de la famille de Vanier. Nous ne voulons pas perdre cette identité et cette relation, qui ont tellement d'importance pour les résidents et leurs familles.

It would lead homes into the admittance of individuals whose needs are not compatible with those who are already there. In other words, to reduce the average care component, we'll bring in a lot younger people. You're well aware that this is a problem.

The residents of our homes are vulnerable. Quite clearly, their sense of security, their sense of comfort, their real comfort, can be threatened by admitting more mobile, younger people with different interests, different needs. We've developed an expertise in geriatric care and feel that if again pushed to have to redress the balance to a lower medical care component, there would be a major effort to prepare staff and the homes for dealing with a new type of clientele.

We have a system, today, that works, for consumers and providers. Why impose a new and costly bureaucracy? Why not build on what we have and let the community decide what it needs to meet provincial objectives? Our homes have an excellent reputation in this community. It's been developed over many years. We've adapted our facilities, designed programs, educated staff. We do provide quality geriatric care, and we're concerned about the impact on the younger clients and the residents we presently advocate for if we're not allowed to define our admission policy.

We don't have a health care dollar to waste if this province is to get costs under control. We don't understand why the province is planning to put in place an expensive inspection system to ensure accountability in municipal homes for the aged where a proven system already exists. The Ottawa-Carleton homes are publicly accountable through the the committee of management, executive committee and regional council. They are advised by public appointees who are members of the committee of management advisory committee. They are accountable to the programs supervisor. And we have consistently received three-year awards from the Canadian Council on Health Facilities Accreditation. It ain't broke.

We urge the committee to recommend that the government build and strengthen the existing system, not ignore it. If you want to build a quality system, look at bringing other homes up to our standard, not bringing us down to the lowest common denominator.

I want to briefly touch on an area not directly related to Bill 101, but important to the successful restructuring of the health care system. We don't believe any single part of this system can be looked at in isolation. We urge the government to look at the big picture when it's making decisions and to consider impact on the whole system when it's making changes.

For example, fewer acute care beds means that the percentage of inappropriate beds in our acute care institutions will increase because there's a certain inflexibility in those beds. Therefore, that's going to end up in longer waiting lists for acute care. Fewer institutional long-term care beds in an area like Ottawa-Carleton, which is already underserved, will result in greater demand for home care, 24-hour respite care and supportive services. The chronic care hospital role will change to specialized care, resulting in ever heavier cases.

I just see the snowball rolling down the hill here, and it really bothers me a little bit that we can't sort of create some doubt in your minds that you're going down the right path.

It's important to note that chronic care hospital per diems are significantly higher than our homes, for essentially the same consumer group. There's not a big difference today between homes for the aged clients and chronic care hospital clients because of the demographic shifts.

A failure to provide supportive housing options will result in individuals seeking more costly and intrusive services than they really need in order to live independently. We're already seeing these impacts here. We recommend that the committee ask the government to consider all aspects of long-term care, including health, social services and housing, when making these decisions for the short and long term. It's only by taking a comprehensive approach that we can achieve a rational, responsive, cost-effective system.

In summary, the region asks the committee to consider how to improve the funding arrangement to ensure it funds to needed levels of care; how to return the municipal share to 15%, the historical level; how to build on the strengths of existing access systems such as the Ottawa-Carleton Placement Coordination Service; how to recognize and build on the public and community accountability system in place for the homes for the aged; and, how to develop integrated planning and implementation of health, social and housing policy at the provincial and local levels. We're prepared to work with the government on all these issues.

The region is proud of the responsiveness and innovation in our homes for the aged. We're very conscious of the trust that the residents and families have placed in us to deliver quality care. We want to be able to continue. However, we have an obligation to the citizens of Ottawa-Carleton to use their property taxes wisely and appropriately. Health care is not a municipal responsibility. We want to work with the government to find a fair and reasonable way to return the region's contribution to an appropriate level, while maintaining quality programs for our residents.


In so far as it might be useful to have the perspective of why we feel it's important for linguistic, I would ask Mayor Cousineau to talk a little bit about Centre d'Accueil Champlain and how that is of value and need in this community and is being met.

Mr Guy Cousineau: Mr Chair, members of the committee, Centre d'Accueil Champlain is one of only two wholly francophone facilities in Ottawa-Carleton. There are 54 francophones waiting for placement in a long-term care facility in Ottawa-Carleton. The wait can be up to one year.

The district health council reports a shortage of services for the French-speaking elderly of the region. The region has a plan to expand Centre d'Accueil Champlain by adding 44 beds that are out of service. The 44 beds were removed from Island Lodge to reduce overcrowding and improve the quality of life of residents there. Unfortunately, we have been unable to proceed with the Champlain project due to the lack of capital funding from the province.

Centre d'Accueil Champlain is a unique home. It is supported by the Vanier community and provides a home-like, familiar milieu for Franco-Ontarians. We ask the committee to recommend to the government that it make capital funds available to meet the needs of the French-speaking elderly in this community.

Mr Clark: Just at the risk of overdoing this, taking up some of your question time, a demographic forecast of this community: In 1991, there were approximately 72,000 people over the age of 65 in this community. It's predicted that by 200l to go to 90,000 and by 2011 to go to 114,000. More dramatically, though, for people 80 and up, it's going to go from 14,000 to 24,000 to 31,000, and that's the age category we're talking about. The growth in those cohorts is phenomenal and it's projected to actually be accelerating over the next 20 years. In other words, the problem is going to get larger and it's going to make it even more critical than I know you sense. You wouldn't be spending your time going around the province if you didn't believe it was critical. So anyway, anything you'd like to elaborate on or have us elaborate on?

The Chair: Thank you very much. Your reference to a snowball earlier, I think the committee feels that it's been either in front of or behind a number of snowballs as we've travelled around this past week. So we will try to deal with snowballs and we'll therefore begin the questioning with M. Villeneuve.

Mr Villeneuve: Peter, thank you very much, with your group this morning. Your population democraphics are most interesting. You tell us 607 beds are available, and I know I have some people within the constituency that I represent who are on the waiting list.

Centre d'Accueil Champlain has a list of 54 immediately ready to occupy a bed, if indeed it were available. Would you know, Peter, how many are on the waiting list of the other --

Mr Clark: Garry.

Mr Garry Armstrong: Probably an active waiting list of about 150, but because of the existing situation and shortage of beds, we try to maintain it at a reasonable level. Our turnover is about 100; so we work with about 150 regularly. If we opened it up through the PCS, we could fill 300 without a problem.

Mr Villeneuve: Those are interesting statistics and certainly I think Peter and you people have sounded an alarm here; 607 beds are presently available. It certainly sounds like that number is going to diminish, Peter. Could you comment on that? Just how do you foresee it in the next year and a half, two years?

Mr Clark: We have a relatively old and inefficient facility in Island Lodge. There's been some talk about perhaps building a new one, but there is no particular reason that we're now spending $6 million or $7 million of the local taxpayers' money in addition to what our share was in 1989. Frankly, I don't intend to continue to do that. So the answer is yes, we'll just close Island Lodge or a good part of it as a way to eliminate the problem.

We're in a situation where more and more of our customers have dementia. It requires specialized care; it requires a lot more tolerance than the current funding arrangements for the homes for the aged supply. So while we're doing what we consider to be more than our share at the moment, we don't see anything in this bill that's going to resolve some of the problems. We've raised that. Frankly, by just freezing entry and not taking on any more, we can close 100 beds in the next 12 months and 100 beds in the 12 months after that, and eventually, because of the inadequacy of this particular facility, reduce the number of homes we have by probably 50%.

Mr Villeneuve: You see no one picking up the slack?

Mr Clark: I certainly don't see any encouragement anywhere, and since it is really a provincial government responsibility, I see no particular reason for me to continue to shoulder it.

Mr Gilles Bisson (Cochrane South): You talk about Ottawa as one of the areas in the province where there is already a model of the placement coordinator in place. How does that work? I have an understanding, but just from you, because you're in the business directly. But the thing I'm really interested in is the question of appeals. If somebody is not happy with the decision, do you have any kind of an appeals process in place for the resident or the future resident or the home?

Mr Clark: Yes, I think there is a whole system in place. It's a fairly complete system, Gilles. Historically, my connection with the PCS has been as a member of the district health council and sort of peripheral, and you'll probably get some detail from Garry about that. But I think you may well later on get some, if you really want it, from Billy Dare, who is the former chair of the thing.

Mr Bisson: If Billy is there, could Billy put his hand up? Okay, now I know who it is. Thank you.

Mr Clark: She'll be in front of you later today. But I think what we'll do is ask Garry to give you an outline, and if that's not enough, we'll have something put together to send you independent of this.

Mr Armstrong: I have in fact served as president of the placement coordination service and as a member of the board for many years. One of the keys to the Ottawa-Carleton area has been, and I think Michel spoke to it a bit earlier, the sense of community that we have. Even just looking around at the people in this room, we can probably set up a meeting of the continuing care board of the district health council or the council on aging just using the people here. We seem to work very closely together.

As a community, we decided some years ago that the traditional approach to waiting lists wasn't working, and I think the chair referred to tradeoffs etc between institutions, and we agreed as a community to establish a system of a cooperative board whereby we would all establish and utilize the same admission forms for chronic care hospitals, nursing homes and homes for the aged. We spent many years developing that.

We also developed the centralized waiting list, so that when people asked Ottawa-Carleton, "How many people on the waiting list?" we didn't add up all of the institutions and come up with 20,000 when we knew there were about 3,000. So our waiting list is fairly factual, which is a real key issue, and the system has worked strictly on a cooperative basis. We have agreed not to accept individuals into our institutions without going through the PCS process and utilizing those forms. One of the problems we're facing now with shortages of beds, however, is that people are very quickly starting to look at other options, so I'm very supportive of a placement model.

I think the question with respect to appeals is a good one. Indeed, under our process, the individual is encouraged. In fact, through the council on aging, we have developed ways of going to institutions, and we encourage visits, and the individual makes that choice. The placement service helps them in terms of determining whether the institution they have chosen is in fact appropriate to their needs. The assessment is then done and referred to the institution, at which time the institution deals with the client and the placement officer. At that time, the decision can be made in terms of the appropriateness. Finally, there are waiting lists in every institution, and as a result, the individual then becomes very aware of how long it may take, and the decision through the placement service then can be made for an interim placement. So that aspect works quite well.


The key, I think, that Michel referred to earlier had to do with the interim placements, and unfortunately what we're seeing with the shortage of beds is that many of those interim placements now are being made by necessity outside of our community.

Mrs Yvonne O'Neill (Ottawa-Rideau): Gentlemen, you can be very proud of your brief. You've said quite a bit with quite a few words, but I think that's kind of characteristic.

Mr Villeneuve: That's a low blow, Peter.

Mr Clark: That's okay. I'll get even.

Mrs O'Neill: I am very pleased that you mentioned the placement coordination. You've just had a chance to explain that. We've had some very good reinforcement that there are many good systems across the province, and they should be recognized. The municipalities have come forward, and not in the numbers I would have wished, but I'm very pleased that you have. You've also reminded us of the level of accountability that's in existence at the present time, and I don't think that should be overlooked. You reminded us, too, that these facilities we're looking at now have already got mission statements; they have commitments to their communities. We're not starting from scratch.

Another thing that I'm pleased you mentioned, and I'm surprised it isn't mentioned in more briefs, is the effect that some of these new regulations seem to impose on spousal relationships, on familial relationships, and I think we have to be very conscious of that as we proceed to put some things in writing on this piece of legislation.

I am happy, too, that you talked about the series of appeals in recommendation 3 -- appeals that we hadn't heard of in my recollection of our hearings to this date -- the facilities being able to appeal the monitoring and sanctioning decisions and the right of the governing bodies to determine the mission, as I stated earlier. That's new, I think, if I recollect correctly.

I'd like you to please expand on two of your recommendations if you could. The frequent assessment process is certainly a concern of mine and of others, that we're only going to be taking a picture on an annual basis, a snapshot picture. Your figures of a one-third annual turnover are rather frightening. I didn't think they would be that high. Could you say a little bit more about the end of that recommendation 1, "should take into account regional differences and special circumstances," just expand on that? In number 5, I wanted you to talk a little bit more about how you feel the support of housing sector integration could be highlighted better or take place more directly in this legislation.

I could ask a lot of questions. You have told us that you want to put doubts in our minds, and I think you've challenged us regarding the need for change. I'd just like you to expand on a couple of those points you've made.

Mr Clark: To be honest, we accept the need for change. We think that something has to be done. It's more a question that we think it needs to be done a little bit more collaboratively than this appears to.

I guess the assessment process, because of fairly high turnover and because of trending -- and we clearly are trending to more and more of a care component -- has been pretty consistent. So if you're assessed in October and that assessment is used six months later to determine your level of funding, we're already at an 18-month gap by the end of that funding year, and with that much turnover, there could be a considerable difference in terms of the care component.

So the option is, if you're not funded to the appropriate level of care, that the residents won't get it. They may need it, but because your funding is a year and a half old and based on a different population and a different mix, it would mean that we would have to start to discriminate against clients in order to be able to meet the care needs; in other words, try to keep the mix at where it was even though we already know that the mix is going to shift towards more care. Having said that, it would put us in a position of forcing certain things that, in my mind, would be wrong. Garry, do you want to expand on that a little if I haven't understood it properly?

Mrs O'Neill: Is that what you mean by special circumstances and regional differences? I guess that's the part that I think is new to this presentation in your recommendation 1.

Mr Armstrong: Certainly, in terms of looking at the individual municipalities, I think Mayor Cousineau has spoken, for example, to the francophone situation. With the age group of our particular population and the growing number of people with dementia and as well the existing facilities that we have, I think one of the areas that's not addressed yet, although Michel spoke to it briefly, has to do with the whole issue of the need for psychiatric intervention. It's one of the major areas that we're facing in terms of this particular region. It's a slightly different issue if we're looking at the Brockville situation, where our psychiatric population moves to.

Again, we have a very cooperative group here looking at that as a specific situation in Ottawa-Carleton in terms of either dealing with that population within our existing facilities, which relates back to a previous issue we discussed, or in fact adding to the existing population.

So I think when we're looking at the type of placement of individuals and the type of accommodation that will be allowed under this funding formula, it makes it very difficult to react to specific community needs that may exist. In the regional homes, for example, we traditionally started with what were euphemistically called special care units and then worked up to developing specific programs for the demented. Now, with the possibility of younger people and particularly with a psychiatric mix and with, as the Perley Hospital has indicated and will address, the change in professionalized staff, we're concerned about our ability to react to specific needs in our community that may not be similar to other areas.

Mr Cousineau: If I may add, our plans were to downsize Island Lodge like I mentioned before, and the plans were to transfer 44 francophone clients over to Centre d'Accueil Champlain. Of course, we didn't have the extra beds at Centre d'Accueil Champlain, and that would also have meant a longer waiting period for people waiting to get into Centre d'Accueil Champlain. So because we cannot answer these needs now, it created a problem, but we still downsized Island Lodge, so that means there are 44 fewer beds there than we had previously.

The Chair: Thank you very much again. I regret that we don't have more time. I know there are other questions, and the Chair always has to be the heavy.

Mr Clark: I can only tell you, Charles, that we have appreciated at least the opportunity to try to raise some issues. We share with all of you the concern for the cost of the system and the concerns for recognizing the needs of the elderly, especially since the problem is going to get bigger; it's not going away. We hope that your deliberations result in a more sanguine model, if you want, and maybe there'll be some creative new ways to do business. We're not opposed to any of them. Thanks again.

The Chair: Thank you all very much for coming today.


The Chair: I would now like to call on the representatives from the Perley Hospital if they would be good enough to come forward. Good morning and welcome to the committee. Please make yourselves comfortable. Once you are settled, if you would be good enough to introduce yourselves for the members of the committee and for Hansard and please proceed with your presentation.

Mr David Webber: My name is David Webber. I am the treasurer of the Perley Hospital, a trustee and a member of the board of directors. With me is John Lupton, the executive director of the Perley Hospital and also Mimi Lowi, assistant executive director of the Perley Hospital.

I guess the Perley Hospital represents the next stage in the evolution of long-term care from homes for the aged to chronic care. I know many of you around the table have actually visited the Perley. You're aware of the physical states of a lot of the people who are in the Perley Hospital and realize that, with an average age of about 85, the people in the Perley Hospital are well advanced on the normal process of dying in many cases.


For those of you who haven't been to the Perley Hospital, the Perley Hospital was founded in 1897 and is a 202-bed chronic care and rehabilitation hospital which has a long history of service in the Ottawa area.

As treasurer and chairman of the finance committee, I can assure you that the Perley Hospital is a frugal and low-cost facility. Around the finance committee, I think we've coined our slogan as "frugal but caring." Our cost per patient day is the lowest of any chronic care hospital in the province of Ontario.

We have received accreditation from the Canadian Council for Health Facilities Accreditation and last year, on October 1, 1992, the hospital also accepted responsibility for running the 150-bed Rideau Veterans Home on Smyth Road and thus the board is now responsible for a total of 352 beds.

As many of you are aware, the Perley and Rideau Veterans' Health Centre is being planned. It's a new 450-bed facility for the Ottawa area which has been approved. It's to replace the 75-year-old Perley building and the Rideau Veterans Home, which like many of the buildings was built as temporary accommodation in 1944 and is still there as temporary accommodation in 1993.

Construction is expected to begin later this year with completion slated for 1995. We aware that it is the Ontario government's wish that the new health care centre be designated as one of the first long-term care centres. This in itself has presented a number of challenges in the planning process and in many ways the new Perley-Rideau veterans facility will be the leading edge of the new wave of long-term care.

We appreciate the opportunity to comment on Bill 101. At the Perley, we support the five objectives set out in the former Minister of Health's statement to your committee. We applaud the government's objective to develop community programs which will enable the elderly and others to stay in their homes. At the same time, I don't think we should forget that there will always be a proportion of Ontario's population who will be too frail or too sick to be cared for in their homes. These citizens make up about 5% of the elderly and we will always need services in facilities such as the Perley Hospital.

It is also important that our senior citizens have the opportunity to choose which option best suits their individual condition and circumstances. We had proposed to comment on four key aspects of Bill 101: governance and accountability to the community, funding, the access and appeals process and standards and quality assurance.

On the first issue, governance and accountability, hospital boards have worked hard to make sure that we represent our local communities, and this is something we always have to work at. It's not something that happens automatically. We go out and search within our communities to ensure that we represent the communities of both our patients and our future patients.

Unlike our colleagues at the hospital boards, conservation authorities, municipalities or government agencies, hospital directors serve without remuneration or reimbursement of any kind. We serve because we are committed to the mission of the facilities which we govern and it is our goal to ensure excellent patient care. We represent local citizens to see that the facility is accountable to them and that the taxpayer is receiving good value for funds spent. An opinion poll shows repeatedly that the public is well pleased with the performance of hospital trustees in Ontario.

Bill 101 makes no reference to governance, and we believe that it's important that the accountability and link to the community be maintained. Many of you are aware of the hearings that went on throughout the province last year -- I see Paul Wessenger smiling -- on changes to the Public Hospitals Act. I'd like again to reinforce my congratulations to Paul for his patience for the long process of going through changes to the Public Hospitals Act.

Many of the briefs during those hearings focused on this issue of governance. I think there were many good issues brought up. We were made aware of the extreme sensitivity of many communities and many organizations involved in the governance of hospitals to this specific issue of hospital governance and how they relate to their communities. Again, congratulations for your fortitude.

In our opinion, neither the proposed regulations, service agreements nor a government-run system of rigid inspection can really replace the knowledge and experience of community-based trustees. As well, community-based volunteer trustees also serve with distinction on district health councils. We agree with the government that the role and responsibilities of district health councils should be strengthened. We would like to see that happen right away. Local councils are much more attuned to a community's health care needs than sometimes the public servants based in Toronto, and long-term care offices are, in our opinion, an unnecessary level of bureaucracy which would divert badly needed funds away from care for the elderly. We believe these functions should be transferred to the district health councils.

The Perley believes that the new long-term care facilities should maintain governance structures which compare now with those in place in chronic care hospitals and homes for the aged.

The second issue is funding. We commend the government for establishing a new funding system based on levels of care in nursing homes and homes for the aged. However, there is no mention in Bill 101 about funding for long-term care facilities such as the new Perley and Rideau veterans' home, so we cannot really comment on the funding implications. However, we believe there is a very real danger that standardized levels of reimbursement will lead to standardized levels of care for the elderly.

Certainly, in our dealings with the government regarding plans for the proposed Perley and Rideau Veterans Health Centre, it is clear that your planners are looking for even lower costs than the present frugal levels of expenditure of the Perley. The Perley's operating costs are at the moment approximately $215 per patient day, and with the new Rideau Perley veterans' centre, I think the Ontario government is looking at approximately $185 per patient day. Given that the Perley is already at the lower end of the scale, I think that's the direction which we're getting in terms of reducing the costs even further, not even taking into account inflation.

There is no doubt that redirection of long-term care has developed high levels of expectations among Ontario's elderly. We commend the government in calling for the development of a care plan for each patient or resident, but once written, there must be some assurance that the services needed can be provided within the funding available. All of you have probably heard of this figure of between $85 and $90 per patient day being mentioned. We question whether in fact facilities will be able to deliver what the care plans call for.

We understand that all long-term residents will be assessed once a year and funding will be tied to the classification of residents, but we know from our experience at the Perley that a resident's condition and care needs change, often seriously, much more frequently. The funding system must be flexible enough to take such changes into account and not just rely on an annual assessment.

The third issue is coordinated access and appeal process. According to Bill 101, individuals will be provided with a local single point of entry to the long-term care system. A mechanism will be created for coordinating and managing access to facilities. Facilities will be required to accept eligible persons whose admission has been authorized by a designated placement coordinator. We find it difficult to comment on the full scope of the placement coordinator until the details of the regulations are issued.

As you heard from the presentation of the region of Ottawa-Carleton, Ottawa-Carleton already has a well-established placement coordination service which since 1976 has successfully promoted collaboration among all health care facilities in the region, including acute care hospitals, nursing homes, homes for the aged, chronic care hospitals and rehabilitation centres, and has ensured effective and efficient placement of individuals requiring care in long-term care facilities. The placement coordination service acts as a gatekeeper and provides for screening of applicants, maintenance of waiting lists, advice to individuals and families on access to health care facilities and assistance to those who require priority access. Thus, Ottawa-Carleton region doesn't really need any new process or individuals to achieve the objectives of the amendments to Bill 101.


There are two elements of the current system that Bill 101 I think ignores, which we think should be maintained.

First, consumer choice of location and type of placement should remain a key factor in selection of an appropriate placement. Legislation suggests that admission should be based only on the applicant's health care needs with little or no consideration of the social needs, preferences and resources. Preferences of individuals along cultural, religious, ethnic, linguistic and geographic lines, should be preserved.

The second issue is that now facilities have the right to define their own admission criteria. These criteria are not developed in isolation, but through consultation with the community and other health care facilities and through gathering data. The right of determination by facilities should be preserved. Facilities should be able to refuse an application based on the facility's physical and human resources and the ability to meet an applicant's individual care needs.

For example at the Perley, as I said, the majority of patients are very old and frail. I sometimes think it is grossly unfair to suggest moving in some terminally ill younger patients in the 30-year-old age group and putting them in the same ward or the same system as individuals who are in their 90s, making all sorts of noises. It really is not fair on either of the patients, in our opinion.

We also think the legislation fails to address the issue of planning. Local collaborative planning among key players, including community health, social services, home care, acute care, chronic care, rehabilitation and long-term care is vital in determining the scope and type of programs and services offered by each facility. The planning process should lead to the establishment of specific admission criteria for each facility covering the range of needs of the community. This integrated planning approach has been used by the region of Ottawa-Carleton through the regional geriatric program and also the continuing care board of the district health council.

One final point about the placement coordinator is to raise the following questions which should be addressed by Bill 101 or the regulations to the bill. Who accepts liability for placement of an individual? The bill relieves the placement coordinator of this liability. We believe the coordinator should not be exempted. Second, what are the qualifications of the placement coordinator in his ability to assess accurately the individual's care needs? Third, if the placement coordinator is to be the new gatekeeper, will the placement coordination service be accessible 24 hours a day, seven days a week? It should be.

On the question of appeals process, we support the government's efforts to provide equal access to facility services through the proposed placement coordinator. We do believe that the appeal process is inadequate. It fails to address the rights of the individual to appeal the selection of a particular facility and it also fails to address the right of a facility to appeal the decision of the placement coordinator and question an individual's appropriateness for admission.

We recommend that the appeal board should have at least three members constituting a quorum, should hold hearings locally, should be able to receive an appeal from either an individual or an institution and make a decision within 30 days. We believe this approach would reduce the agony and trauma to an individual and family awaiting placement, reduce the cost of a lengthy hearing process and reduce the potential arbitrariness of decisions by one individual.

On the fourth issue of standards and quality assurance, according to Commissioner Lightman in his report, A Community of Interests: A Report of the Commission of Inquiry into Unregulated Residential Accommodation, he stated a number of compelling arguments against extensive and comprehensive government regulation. These comments are relevant to the government's attempt in Bill 101 to increase the role of inspectors and enforcement:

-- Rules and standards determined politically and bureaucratically and enforced by government inspectors leave no opportunity for residents to be involved in decisions about their care.

-- The more extensive the inspection, the greater the staffing and administrative costs to the system.

-- Standards imposed by government are usually the basis for minimal requirements and there is no incentive to improve the quality of care and services.

-- Government sanctions are not imposed, even though standards are not met by facilities because of difficulties in satisfying legal due process requirements and the unwillingness of government to force closure of such desperately needed long-term care facilities.

I'd like to quote Dr Lightman, who said, "We must ask if scarce public funds are best spent in building an endless regulatory system given that every dollar spent on a regulatory system cannot simultaneously be devoted to community-based programs in service delivery and, I would like to add, devoted to services and programs to residents in long-term care facilities."

The Perley would like to provide its strong support of Dr Lightman's concerns about overregulation.

The Auditor General's report of 1990 stated, "Monitoring of quality of care in nursing homes requires significant improvement and violations of many provisions cannot be successfully prosecuted." So rather than expanding the adversarial application of a rigid, bureaucratic system of inspection, we recommend that accreditation, peer review, adherence to existing standards for health professions and continuous quality improvement be used to ensure the accountability of long-term care facilities to the government and to the public.

We further recommend that the independent Canadian Council on Health Facilities Accreditation process be used as the primary mechanism to measure compliance with nationally established standards for long-term care facilities. The council's process is an extremely positive one, emphasizing education and coaching. The objective of the accreditation process is to have facilities strive to continuously improve and enhance the quality of care and services it delivers to its residents.

We suggest that only when a facility fails the Canadian Council on Health Facilities Accreditation should Ontario require a facility to be inspected by government inspectors. On an ongoing basis, the government should provide assistance to facilities to adhere to standards by providing consultation services by the existing government administration.

We would also raise a number of issues about the proposed inspector and inspection process: For example, what are the qualifications for the inspectors; who will be liable for the results of the inspection; will the inspectors be locally based and familiar with resources available in a particular community?

To conclude, we've only commented on four areas contained in Bill 101.

In governance and accountability to the community, we emphasized the strong need to maintain excellence through the continued use of voluntary trustees drawn from the local community.

In funding, we stressed the importance of providing flexibility in funding to reflect varying levels of care.

In access and appeal process, we spoke about the need to recognize the elderly person's opportunity for choice and preference along cultural, linguistic and religious lines, and we also questioned the appeal process.

Finally, in standards and quality assurance, we opposed vigorously the proposed rigid system of inspection and suggested instead that accreditation by the Canadian Council on Health Facilities Accreditation is a much more acceptable and modern alternative.

On behalf of the Perley, we'd like to thank you for this opportunity to appear before you. For those of you who haven't visited the Perley Hospital recently, we'd be delighted to have you visit at some point in time if you're in the Ottawa area.

The Chair: Thank you very much. As you noted at the beginning, your organization is in the forefront of change. I think I can tell you that it was with some anticipation that committee members were awaiting your presentation today. I know there are a lot of questions and I regret at the outset to have to say to members that we are very tight today on time. I would ask, and I know members are skillful at getting many questions into one --

Mr Jackson: The Chairman is very liberal, there's a difference.

The Chair: A good thing, too. But if we could just be aware of that so that we could maximize our time, and we'll begin with the very skillful Mr Wessenger.

Mr Wessenger: Thank you very much for your presentation. I have a number of questions and I'll try to be short. First of all, with respect to your present placement coordination agency, I'd like to assure you that the consumer choice aspect will be continued and in fact that agency will be designated to continue that role. Is it now available 24 hours a day?

Mr Webber: It is not available 24 hours a day at the moment, but that is in fact a shortcoming of the system, in my opinion.

Mr Wessenger: With respect to your concerns with respect to funding, I understand that the funding will continue at the same levels for the three institutions that are going to be continued. I would just like to throw out to you that it seems, with the new facility and the combination, there ought to be funds freed up to enhance services because of the increased efficiencies of a single institution. Is that not fair to say?

Mr Webber: Perhaps I'll refer that to John because there will be a number of new features in the new facility.


Mr John Lupton: I think that's a fair statement. We're certainly playing a new ball game with the ministry's long-term care division. In general, there's been a meeting of the minds. We're going to be expected to run the new facility with a lower per diem cost and we think we can do that.

I don't want to go into the details this morning, but we do have some difficulty over the cost of the new beds. There are going to be some new beds in the facility, more than the present total of the Perley, the Rideau Veterans' Home, the veterans in the military hospital, but that's a different issue. I'm sure we can resolve that.

We're going to see a per diem of about $185, as our treasurer said. I hope none of you saw me on television last night, but if you did, what I said on television last night was that this called for a new approach, a different mix of staff, probably less professional staff than we've been accustomed to in the past but, by and large, I believe the new centre will provide the same tender loving care kind of approach that we have for nearly 100 years in this city.

Mr Wessenger: Just one last question. There've been a lot of concerns raised with respect to the accreditation process, the fact that it's only three years. The fact is that the experience in nursing homes is there have been several accredited homes that have had many problems and complaints. Would you agree that there should be an inspection process but it should be more complaints based? Would you agree with that aspect?

Mr Webber: There will always be a few facilities that may cause problems. By and large, the vast majority of facilities are operating well and get very good results out of the accreditation process. It would seem to make sense to focus the attention on those ones which require close monitoring, but have a general system of the accreditation process which seems to work well for the vast majority. I think in the province of Ontario, in the system, people have a reasonably good idea of which institutions need more review perhaps.

Mr Wessenger: Is it fair to say the present system, as far as you're concerned, works fairly well?

Mr Webber: In our opinion, it does, yes.

Mrs O'Neill: I'm pleased that you spent as much time as you did on the inspection and your attitude towards the new thrust which we also have a great deal of concern about, and fears. You have explained your affinity for the accreditation and I think that's good.

I have a couple of questions that I'm going to roll into one. The Alberta classification system: I wonder if you've studied that, commented on it and seen it transferred into Bill 101. I'd like you to tell me where you've been with the district health council in Ottawa-Carleton on Bill 101, its role there, and how you see the district health council continuing, because you seem to have a feeling that's going to be a new higher-profile role for the DHC.

Mr Webber: Can I refer that to Mimi Lowi who is very involved on that side?

Mrs O'Neill: Certainly.

Ms Mimi Lowi: First of all, in terms of the Alberta classification system, we were classified as a facility and felt that the classification system did address the personal and nursing care needs but not the other kinds of needs of the patients, of which -- one was addressed before, the issue of quality of life -- there are other aspects, such as the rehabilitation-restorative care needs. Really, the classification system does not address that specific aspect, so from that point of view, we've got some concerns because of the focus for nursing and personal care. It deals primarily with activities of daily living and doesn't deal with some of the specialized nursing needs and care needs of an individual; so from that point, concern.

The other aspect is the district health council and I think in Ottawa-Carleton we're very proud of the role the DHC plays in coordinated approach to planning of a continuum of care and we've seen it work very well with the establishment of the regional geriatric program and the coordination of services through placement coordination services, as well as overseeing, meeting the needs and the collaboration between different types of facilities. So from at least my point of view and from the board's point of view --

Mrs O'Neill: Have you begun the work on Bill 101?

Ms Lowi: Yes, we have. We've started to look at a multiservice agency just recently and began to look at reviewing the terms of reference and membership of the continuing care board of the district health council.

Mr Jackson: Am I to understand, Mr Webber, that you haven't consummated your negotiations with the government about your redevelopment plans?

Mr Webber: The Perley-Rideau Veterans project has been in the works for a long time.

Mr Jackson: I'm trying to get a freeze-frame of where we are at this very moment.

Mr Webber: It's hard to know in this whole process at what point in time you say, "Everything is in place." The funding is in place from the province and from the federal government, which is a major contributor to the project. The pre-construction operating budgets have been approved, and I say more or less, because there is still some negotiating on certain elements of it.

Mr Jackson: I have a sense of that. Can you share with the committee briefly the shape of the new configuration with respect to which numbers of beds have been reclassified?

Mr Webber: All of them, but perhaps I'd like to ask --

Mr Jackson: Absolutely every one of them?

Mr Lupton: Very briefly, this project started off, it was approved -- I don't know if one's allowed to say the word in the room -- in the Liberal era.

Mrs O'Neill: We are here. We still exist.

Mr Lupton: I think it was when the Honourable Murray Elston was the minister in 1988, something like that.

Mr Jackson: In fairness, in the briefness of time we have, I want to get a snapshot today and not the history of this. I know the facility.

Mr Lupton: Cam, I just want to say it started off as a 450-bed chronic care facility. Today it is a 450-bed long-term care facility. When we were first told to change in 1991, the board chairman said to me: "What is a long-term care centre? What are long-term care beds?" I said to to him: "I haven't the slightest idea. I've never heard those terms used in Ontario before."

Mr Jackson: I recall; we've had this discussion before. But at this point, you must have gotten some indication from the government as to what that means and what that translates into, the level of care and staffing needs of the patients as reconfigured. I don't wish to build on your comment to the media last night, but in the practical world, discussions with the government couldn't have occurred without some clarity as to levels of care required when dealing with a redeveloped, reconstituted facility.

This is our only opportunity since we've been to Windsor and didn't have the same opportunity to talk to a chronic care hospital there, because it's not quite comparable. Unfortunately, we're under time constraints, but I've been waiting for this meeting for some weeks. I want to get from you for the record the nature of those discussions with the government. What clarity, what assurances, what have have you been given? There are a lot of chronic care hospitals in this province that want to know what's happened and want to get a sense of what their new frontier is. Your new frontier is fairly clear. Their new frontier is completely without any real awareness of what's going to happen.

Mr Lupton: Let me say it has been very cloudy in the past. It's very clear the government policy about long-term care centres has been developing, really, as we've tried to develop our plans and as our architect tries to design the building. The long-term care division has been developing policies as we go along and we're still in that state now.

The first question we said to government was: "What do you want us to do in this new building? Who are we going to look after? What's the difference between a long-term care centre and a chronic care hospital?" They said, "You will be looking after exactly the people you do now," the people David referred to, average age 86, very old, very frail and very sick. With the last one, the long-term care division sometimes, I think, has some difficulty realizing just how sick. We are not just a home for the aged.

In addition -- this is what I think really surprised us and pleased us -- we got the government's confidence. We were also told there were six or seven new categories of people we would be expected to look after in a long-term care centre, and these are what Mimi and I and David would call subacute -- patients who are in need of dialysis, intravenous therapy, tracheotomy care, irrigations and medical emergencies like pneumonias, heart attacks, urinary tract infections. Some of those we don't look after now.

We are delighted to do it, but we've had some difficulties, and I think these are ongoing: On the one hand to be told we're going to do what we do now, plus all these new categories, which are pretty challenging, some of them -- tracheotomy care, for example, dialysis -- yet clearly we are going to be expected to do it at quite a substantially lower per diem cost than we're doing it now.


The way I tried to deal with the question on the media last night was to say that we are going to have a different mix of staff. We are going to have fewer professional staff. All I can say is, if you're at the leading edge of the reform of long-term care, then you have to give it a try. We are prepared, and at the moment our board I think is prepared, to give it a try. We're a bit nervous about it. It seems to us the demands that are going to be made upon us -- we have a long tradition to maintain in the Perley -- seem to be a bit incompatible with the resources we are going to be given, but the present policy of the board, with the support of the long-term care division, is "Well, we'll give it a try." I don't think we have any other alternative, but perhaps I should defer to a board member. In effect, Mr Chairman, I don't think we have any other alternative, so we're going to give it a go.

Mr Jackson: I appreciate your candour. There is no question that the Perley is between a rock and a hard place. The government's chosen, for whatever reason, to make you its watershed, and in so doing the experiment begins and may end there.

I have very grave concerns about the future role of chronic care hospitals in this province, and for a whole cohort of our seniors who are receiving quality-of-life assurances in that environment which cannot be met in a long-term care facility. I see nothing that will relieve my concerns in this area, but I thank you for your very candid responses. I'm not trying to be testy. I'm very, very concerned about the future of our chronic care hospitals in Ontario.

The Chair: Again, I regret that time constraints won't permit any further questions. We thank you very much for coming. If I could play upon the marital theme of Mr Jackson's comments in terms of consummation, we hope as things go forward, they do work well. We certainly recognize that you're headed down a most interesting road and we wish you all the very best.


The Chair: May I next call upon the representatives from the Council of Family/Community Advisory Boards.

Mr James Lumsden: Thank you for affording us this opportunity to speak with you this morning on long-term care, with particular reference to its delivery in a nursing home/home for the aged setting. Our council represents some 1,400 residents.

The Chair: Could I just ask if you would identify yourself for Hansard.

Mr Lumsden: My name is Jim Lumsden. I'm the chairman of the Council of Family/Community Advisory Boards.

The background of our group is set out in the attachment to the written submission you have received. I will try to cover most of the points in there within the general time frame allotted to me, but I will certainly stress what we see to be the most important ones.

In the 20 months we have functioned, we've recognized three significant matters:

First of all, there is a need for some organized effort to interface with the management of the home on issues which relate directly to the operation of that particular home.

Second, we see a requirement to maintain contact with external agencies whose policies and sphere of influence affect the quality of life and the care of the residents in these homes.

Finally, we've concluded there seem to be some deep-seated prejudices and differences among the care providers which are in large measure the outgrowth of vastly differing and inequitable funding arrangements. We consider this condition to be detrimental to the most effective operation of the homes from a financial perspective, but more importantly, it is detrimental to the delivery of the best possible care to the residents.

In general, we support the basic thrust of the redirection. The emphasis of increasing the community-based services so that seniors may remain in their communities for longer periods is a laudable objective. It must, however, be properly and equitably managed and funded and it must not be undertaken at the expense of those who, of necessity, require care in an institutional setting.

Our aim is to ensure that all are able to avail themselves of the highest quality of care. Its achievement though we believe to be dependent upon four factors: First of all, a funding formula which is directly related to the required care resource input; second, universally applicable standards, varied only on care requirements as opposed to the present profit/non-profit orientation; third, a single source funding beyond the consumer copayment input, and finally, a set of mechanisms that will assure universal accountability and compliance.

In the introduction of the bill in late November, the then minister set out four goals that she considered necessary to achieve this improvement of quality care for residents. They were: first of all, to establish a fair funding scheme in a not-for-profit delivery system; improved accountability to residents, families, workers and government; a consistent resident payment policy, and provision for coordination of eligibility and admission decisions. I believe if you consider those two positions, there is a general constant in the objective of achieving the best quality of care.

We see this bill as the platform leading to the attainment of that objective and thus we welcome it. There are some differences of course in our approaches, and that's what I hope to talk about or touch upon this morning.

The present myriad of varying funding formulas has produced inequity and serves certainly as a serious impediment to laypersons such as myself to a reasonable understanding of the means whereby we care for our elderly. Fair funding will no doubt require some additional funds. However, we believe the point of departure in accessing this must be an examination of the redistribution of the total existing public funds now supporting such care, regardless of whether they are provincial funds or municipal funds.

We believe the province is doing such a review. Its fairness and equity of course can only be totally judged when the full details are available. However, there are indications of red-circling which are already raising our fears that the desired level of equitable distribution of the available funds will be marred even before this project is launched.

This fear is further strongly reinforced by the December 1992 ministry-commissioned consultants' study by Atkinson, Tremblay and Associates. I will concede at this point that the documentation in there is hypothetical. However, when one considers looking at the detail there, the data in there and the timing of it, one has to conclude that it is as close to reality as we will likely ever get.

A document outlining the conclusions that we've drawn from that report is attached to this written submission. It is an extremely interesting but distressing document. It suggests the province is contemplating an input of $4 million less this year than last, rather than the much-touted increase of $56 million.

We talked about redistribution. However, there is no such redistribution under way or even contemplated in relation to the municipal funding. Mr Clark referred to this earlier. In 1991, $9.8 million -- my calculation -- was directed to the support of 679 residents in Ottawa-Carleton's municipally operated homes. They house some 22% of the total residents. The remaining 2,300 received not one cent of those municipal funds, while the favoured minority each had their care subsidized by $14,000 annually.

In addition to this, the 1,643 residents in nursing homes see an average of 5% of their funding contributed to the coffers of the municipality in municipal and business taxes to support this subsidy of the few. This latter levy upon the elderly is certainly inequity at its most iniquitous. Rather than provide for equitable participation in these tax-derived funds, it appears this inequity is going to continue and it seems as if it is going to be encouraged.


The inequity seems to be rooted in the private not-for-profit debate on the delivery of care. Let's remember that the primary matter for concern is the equal treatment of all who must avail themselves of institutional care. The Ottawa-Carleton example demonstrates that the pursuit of the not-for-profit delivery mode seems to pre-empt the primary concern, as well as staggering the imagination in relation to the wide gap in provided funds. Let me elaborate.

First of all, a nursing home functions on $77.50 a day per resident, while Ottawa-Carleton's municipally owned homes for the aged require $146 to deliver the same service. The provincial average, I understand, is somewhere in the range of $119 a day. This difference is not a function of serving vastly different clienteles. The similarity of the client base was answered in the pilot study on the funding-to-care project and is accepted in the December 1992 study referred to earlier wherein the modelling assumption is that the case mix index is highest in nursing homes. This 90% difference justifies a presumption that both ends of the scale represent some form of injustice.

Why does such an inequity exist? Why would its continuation be encouraged and what remedial measures are needed? As I say, it taxes the imagination.

The goal of fairness cannot be met so long as that inequity is allowed to continue. It can only be achieved by having a single funding source beyond the resident copayment issue. When the issue of municipal funding is raised, I am told it's not a matter for provincial authorities. It may not be at this time, however, it is our belief that innovative, objective, courageous thinking and leadership on the part of you as our legislators can bring that change about. I would suggest to you some radical brainstorming on this issue. You would not be out of order.

There are no doubt some legislative barriers to such redistribution. Whatever barriers exist now must be examined and removed to facilitate more equal and fair treatment. It won't be easy to achieve, but if anyone had told me two years ago that the province and its municipalities would cut a deal on how they were going to fund welfare, I would have scoffed, and I am sure there will be people who will scoff at this particular idea as well.

The bill is the vehicle towards a fairer funding formula. It will require single-source funding to achieve that desired degree of funding. You, as the committee on social development, must be the engine of that change and demonstrate the political will to insist that it include provisions for single-source funding. It's goal is fairness. Amend it to facilitate achievement of that goal. You will contribute in large measure to ensuring that the present disparities in funding in the different areas of this province are overcome.

We, therefore, recommend that all public funding for long-term care facilities be derived from a single source, that source to be the Ministry of Health. To give effect to this, all funding now provided by the province, any of its institutions and any municipal or regional government established by or under the Legislative Assembly, would be placed under the control of the Minister of Health for distribution, in combination with the funding now provided by the province, solely on the basis determined by the funding-to-level-of-care process recently adopted by the province.

Second, we would recommend this committee initiate a review to determine the effect on care delivery caused by the inequity in funding between nursing homes and municipally operated homes for the aged. The disparity in Ottawa-Carleton could serve as a fine focus for such a review.

No matter what though, we will always arrive at the matter of dollars generally and the increase in the residents' copayment in particular. The reports of this proposed increase range from $10 a day in October, 1991, to $11.95 in January, 1993. This is a percentage increase ranging from 38% to 45%.

We are not insensitive to the fact that there is a fiscal crisis. We would certainly love to not go to the lowest common denominator, as Mr Clark suggested, but to bring the others up. I wonder if that's reality. We have accepted that there is a fiscal crisis, that costs are rising and that residents and the residents' families are going to have to shoulder a portion of that increase.

Remember, though, that the copayment increases quarterly by an amount equal to the increase in the old age security guaranteed income supplement payments from the federal government. That process has seen the copayment rise by 149%, from $10.52 in 1980 to its present level of $26.31. Presumably, this has been insufficient, and a decision has been made to impose an unconscionable single-step increase. Where is the justification for an increase of such a magnitude? We've sought it during the long consultation process that preceded this; we sought it through correspondence with the provincial bureaucracy; we sought it in meetings with provincial officials and finally through the access to information and privacy act process.

To date, no such justification has been forthcoming other than generalities and platitudes, never ever mention of a zero-based review that would give us, the families representing the residents, some idea of what generates a need for such a raise. We believe that such evasion is unsatisfactory. Such a cavalier disregard for the rights of the individuals, those individuals being the residents, to receive this information certainly repudiates the current fashion in bureaucratic euphemisms when we talk about empowering, individual rights, living at risk and the right to be wrong. These are the terms that are in vogue in dialogue and prose. If they are in fact going to be empowered, if they are going to be able to live at risk, then they have to have some information upon which to base the decisions that they are going to take some risks upon; that is not available to us.

However, despite this dearth of information, we've taken a positive position in the belief that responsible persons -- and we believe that provincial officials are responsible persons -- would not undertake such a radical step unless the justification was available. Accepting that premise, we propose that the increase be implemented over a period of some five years, the same time in which the government proposes to inject its total increase of $647 million.

We provided tables suggesting the means of implementing that. This has been dismissed on the basis that the government needed the money now and a phase-in was not acceptable. One would think that such a refusal would generate some financial data to support this crushing one-year increase. We have not received it yet.

In any case, a senior member of the government has indicated to me that the actual copayment dollar requirement was not the significant issue. The prime motive, rather, was to create an incentive for persons to opt to remain in the community. The increased cost would hopefully persuade them to seek community support facilities rather than institutionalization.

The thrust is thus to promote the community-based aspect of the program, and the interests of the present residents seem to be secondary. We support the matter of the incentive to community living, but it must not be done at the expense of existing residents of long-term care facilities who cannot avail themselves of the incentive yet will pay the penalty in additional costs that it will impose. If this is the plot that's wanted, then grandfather in the existing residents at their present copayment and increase the rate for those who are admitted after the date of the proclamation of the act.

The ministry's goal is a fair funding scheme. Fair to whom? The government? The taxpayer? The service provider? The resident? All have a stake in fairness, and fairness must be relative and consistent with other similar undertakings. We see rent control as being a similar and relevant undertaking.

You have the opportunity and the obligation to examine what fairness means in this case. We recommend to you that the bill be amended to deal with some limitation on how the copayment aspect of fair funding is to be achieved. We suggest that it continue to permit the cost price index quarterly increases and that this amount be supplemented by an annual amount no greater than the increase authorized under rent control legislation in that particular year. A table showing the results of such a proposal is attached to our written submission.

In her first goal, the minister also referred to the guarantee of non-profit delivery of nursing care and program components of the care. As a council, we fully support this. We do, however, if the current proposal of the three envelope system remains, interpret this as recognition that the private sector is a full and equal partner in the provision of long-term care accommodation. That premise must now be given some meaning.

The private sector operates facilities valued in excess of $1.1 billion. These were built with privately funded capital. The municipal homes were funded entirely with public funds on a provincial-municipal cost-sharing basis. Charitable homes receive up to 50% of their capital funding from the province.


In Ottawa-Carleton, 69% of the extended-care beds were funded by the private sector at no cost to the taxpayer. This begs the question: Would the province and/or the municipality have filled this void if the private sector had chosen not to do so? We'll never know the definitive answer to that.

The reality of the situation suggests an allowance for private capital investment to provide facilities is clearly justified. What reality also dictates is that the matter of the private sector versus the not-for-profit operation must become a secondary issue, at least for existing facilities. Our primary concern is the equal treatment of persons who must avail themselves of the services of a long-term care facility. Let us never ever lose sight of that particular objective.

It is immaterial to us whether the delivery system is 100% not-for-profit, vice versa or some combination between those extremes as long as it totally respects the primary concern of quality care delivered in an equitable manner throughout the province. Neither you nor I have the right to allow our personal philosophies to detract from the attainment of that primary goal and our responsibility to the elderly who require care in these types of facilities.

We recommend to you that the bill be amended to provide that all regulations and standards arising from it or pertaining to the delivery of long-term care must be universally applicable. They must be designed with equal and quality care for the residents as their primary aim, and if variation is deemed essential, that variation must be based on the assessed levels of care identified in the classification process as opposed to the present non-profit orientation.

Accountability: The minister's second goal refers to accountability. There have been some excellent measures proposed. A consistent inspection process which has been discussed at length here this morning is envisaged. This is a process now in being in nursing homes. Its broader implementation is welcomed. The total effectiveness, however, will depend upon the philosophy of inspection with which the inspectors are imbued. In must be one which provides for privileged communications between the inspectors and the staff members. It must not be an adversarial choice for inspectors but rather one which sees inspection as an operational assistance program. There would be objective reviews and an opportunity to share the best management practices that inspectors encounter throughout their tours of the varying facilities that they deal with. We recommend to you that the regulations be developed to support an inspection process that reflects a positive, constructive, self-initiated and compliance-oriented philosophy of inspection.

There's a requirement for quality assurance plans as part of the accountability. These should be designed on a continuous improvement philosophy as opposed to a tendency to assess blame. It's a process that requires everyone, including the administrators, the directors of care and the supervisors, to be accountable and to accept responsibility. It's not a process for blaming just those people who are down at the coal face.

The plan must be seen as a portion of the service providers' responsibility to the residents. The sections providing for quality assurance should be expanded to reflect that accountability, and they should be part of the notice to residents that reflects this requirement and not left to the regulations.

There's also a requirement for notice to residents. In homes for the aged, the requirement is simply to provide this information to the resident. In the case of nursing homes, the notice must be provided to the resident and to the residents' council. We are not able to understand the rationale for this difference. We can only conclude that boards of managements and boards of directors are seen as providing a means of advocacy for residents in homes for the aged, and the closest match to this in nursing homes is the residents' council.

Regardless of this rationale, one must really consider the situation with regard to residents' councils in many nursing homes. They make a significant contribution on a day-to-day basis to the internal operations of the home. However, their ability to advocate on behalf of residents is minimal. Nursing home residents thus lack the representation that should be offered by boards of directors and boards of management in homes for the aged. After all, these residents are the primary group to be affected by the proposed changes to this environment which is their world. It is imperative that the means for such advocacy be established immediately.

We see the family-community advisory board as providing such a means. They represent the interests, concerns and rights of the residents and their families to bodies involved in the implementation and governance of long-term care, to governments at all levels and to the public in general.

Our intention here is not in any way to ascribe the advocacy function that is foreseen in the recently passed advocacy legislation to the boards. Rather, it would see problems solved in a milieu of sensitivity between families and residents and with facility management through rational discussion and problem understanding without the intervention of an advocate. This minimizes the need to seek the more formal form of individual case advocacy without denigrating the value of the formal process when it is truly merited. It would also minimize the possibility of antagonism which might arise when the formal process is misused.

This role must be recognized in legislation now so that those who are greatly affected by the contemplated policy redirection will have an officially recognized voice in its formulation. We therefore recommend that the bill be amended to include provision for mandatory establishment of family-community advisory boards in all long-term care facilities.

The matter of accountability also presumes that the person to whom accountability is owed must have a clear understanding of his rights and expectations. The Nursing Homes Act declares in very clear terms that the home is primarily the home of its residents, and it enunciates the need to fulfil the physical, psychological, social, cultural and spiritual needs of the residents. It does this in the "Residents' bill of rights." Such a clear and unambiguous statement is not present in the other primary acts. The minister's goal of accountability would be greatly facilitated if that statement of rights was universal in all three primary acts.

The third goal foresees the establishment of a consistent resident payment policy. We've addressed the issue of how the resident input into that consistent policy should be established under the goal of fairer funding. However, these goals are not mutually exclusive. When one seeks a consistent policy and a fairer scheme for funding, we presume that this is on the basis that service delivery is so similar as to justify the consistent and fair funding arrangement. The regulations under the various acts have variations which make one wonder at this time if they really have a relevance to the same aim. These regulations must be consistent and have equal application.

Standard care delivery must commence on the same day that standard charges are imposed. The present regulations under the Nursing Homes Act provide the greatest level of clarity, and they are an appropriate point of departure to facilitate this standardization. Regardless of what you follow, the principle must be consistent, and fair funding must be accompanied by consistent and fair delivery of service.

Failure to balance this common copayment level with common delivery standards will convince many of the sceptics that the fairer funding concept is merely a funding grab at the expense of the elderly. This belief has ever-increasing currency as the increase in copayment increase rises to meet the funds available.

There's also a need for common interpretation. Let me give you just one small example. The term "extraordinary event" is referred to in all of the three acts that are going to be amended. What we would see here is that the same set of circumstances would be regarded as an extraordinary event under all of the acts. For example, if an overexpenditure of a budget at the end of a fiscal year in a charitable home for the aged is seen as a circumstance which would merit special allocation of funds, then a similar event in a nursing home would elicit a similar response.

We see placement coordination provisions as a progressive move. It must, however, exercise some degree of choice by informed prospective residents. It must also respect to the greatest degree possible and desirable ethnic or religious affiliations or expectations in a particular facility. We also note the appeal process has been strengthened to the point of going to the Divisional Court. Our only concern there is that in some way it must not be allowed to become a litigation nightmare. The elderly do not have the time to wait for those sorts of decisions.


If the present plans for implementation are put into being as they are conceived, it will represent a downloading in a single year of 75% of the total funding increase to residential care, and 23% of the total proposed increase to the overall program, on to the shoulders of the residents of long-term care facilities. This is unconscionable. It is even more so when you consider that they will be the only persons in the long-term care continuum to have a user fee or copayment imposed. Residents are prepared, where possible, to shoulder fair cost increases which have been justified and that are implemented in a fair and phased manner.

In conclusion, I would ask you to try to envisage that you lived through the Great Depression of the 1930s, as most of our residents have, and all the hardships that it imposed upon those people. Envisage the values that those who lived through this depression and period of material deprivation came away with. Now envisage that someone has suddenly told you that your costs are going to be increased by $333 a month, or almost every spare dollar that you receive. You'd have to forgive the elderly if they thought the Great Depression had returned and they were no longer living in the age of social enlightenment.

The elderly of this province are looking to you to help to ensure that funding of care in long-term care is placed on an equitable basis. Their goals and the goals of this bill, which I initially set out, are quite clearly in consonance. It is the process leading to their attainment where there are some differences. The suggested adjustments to Bill 101 will provide the basis for reconciliation of those differences. I believe that open and good faith dialogue between the government and the most important player -- that is, the consumer or resident -- can function to their mutual advantage.

Ladies and gentlemen, on behalf of my colleagues and the residents whom we represent, I'd like to thank you for granting me the privilege of speaking with you this morning.

The Chair: Mr Lumsden, I want to thank you for a very full presentation as well as for the document and some other material that you've attached. You have dealt very clearly with a number of issues, and I just regret very much that our time is up and we're not going to be able to get into questions. But I think the nature of your brief, the specifics of your recommendations, have been very clear for the committee, and I want to thank you for coming.

Mr Lumsden: Fine. Thank you very much, Mr Chairman.

The Chair: If I could then invite the representatives from Para-Med Health Services to come forward. And I'd just say to the representatives of the VON, please do not despair; we will be with you shortly.


The Chair: Are there representatives from Para-Med here? If not, I would ask the representatives from the Victorian Order of Nurses, South Renfrew and Pembroke -- if you're ready, it seems our previous presenter is not here -- to come forward, we would be delighted to have you. As I understand it, this is a joint presentation by South Renfrew and Pembroke. We welcome you to the committee. If one of you would be good enough to introduce the others for the committee members and for Hansard, and then have some good Ottawa water, and please proceed. We have a copy of your submission.

Mrs Joan Booth: Mr Chairman, members of the standing committee, thank you for the opportunity to address this committee today. We are presenting in support of the VON Ontario briefing paper regarding Bill 101. We represent the two branches of the Victorian Order of Nurses in Renfrew county. May I introduce Elsa Dann, board member of the Pembroke branch, and Mary McBride, the executive director of the Pembroke branch; Joan Lemay, executive director of the South Renfrew branch, of which I, Joan Booth, serve as president.

The Victorian Order of Nurses is a national, not-for-profit health care organization dedicated to providing health and related services to communities. 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, to participate with health care workers in making decisions to plan 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 and support services is the right of all individuals. Health care providers and consumers 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 and home support workers. 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.

The VON has been providing services in Renfrew county for the past 80 years. Today we provide about 80% of visiting nursing in the county. The volunteer boards of directors of VON in Renfrew county represent the geographic areas and provide a variety of skills, expertise and community focus in the governing of the branches.

Insert B, which was handed out to everyone I believe, outlines the demographics of Renfrew county as 100% rural; that is, all settlements are under 20,000 population, as defined by government for funding review. Renfrew county is inhabited by a high percentage of elderly persons. Younger people have moved away for higher education and employment. Older adults are also moving into the area for retirement. All projections indicate that a larger percentage of the population will be older adults and that a smaller percentage of family members will live in the area to fulfil the role of care giver.

Our comments regarding Bill 101 are also based on input from Renfrew county participants in the consultation on the Redirection of Long-Term Care and Support Services in Ontario carried out by the government from November 1991 through March 1992. The issues we will address are vision of Bill 101, planning, allocation of resources, quality of care, placement coordination.

Vision of Bill 101: Bill 101 is an incremental improvement in empowering the consumer in that Bill 101 allows for direct-funding grants to the physically challenged; starts to standardize legislation for long-term care facilities but does not replace separate legislation and does not address chronic care beds; ensures consumer access to key information regarding facility services, care, accommodation and consumer knowledge of care plan; allows for appeal process regarding eligibility for service.

VON in Renfrew county supports these incremental improvements and recommends that these changes be expanded to include similar requirements for chronic care beds and facilities, and requirements for a residents' council in all long-term care facilities.


Recommendations: VON recommends that consumers have a choice of whether to receive needed services in a facility or community setting within an envelope of available resources. In short, the consumer has the choice of service location within a dollar capitation.

VON recommends that if the consumer requires and they or their surrogate decision-maker chooses facility care, they have the choice of what facility to enter, rather than this being the decision solely of the placement coordinator.

While supporting the incremental changes proposed to protect and increase the involvement of the consumer in their care, VON believes that the tone of the amendments are incremental and not comprehensive and could be interpreted as paternalistic rather than empowering. It would be most unfortunate if this happened. Therefore, VON recommends that the Bill 101 amendments be delayed until the publication and public debate on the government's long-term care redirection policy framework.

Planning: The VON branches in Renfrew county recognize the government's plans to reform long-term care legislation and commends the government for its efforts. We expect that Bill 101 is the first piece of legislation in the provincial strategic plan for long-term care. However, this legislation stands alone and does not envision a fully integrated system of reform. Rather, it fragments the long-term care system into sectors dealing with nursing homes and homes for the aged while completely ignoring other institutions, for example, hospitals with chronic care and community agencies.

By moving ahead with facility legislation outside of the long-term care policy framework, and prior to local district health council planning, the government is not supporting its own direction for a strategic, policy-based approach to the health care system based on consultation.

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, service, programs etc, but does not reference these requirements in terms of any planning process provincially, regionally or locally.

Recommendations: VON recommends that the legislation be deferred until the policy framework is released and debated and the district health councils' planning for long-term care be referenced in the legislation in terms of the designation of numbers and types of facility beds; and, the newly formed district health council in Renfrew county be given time to develop its strategic plans to address the fragmented services in Renfrew county.

Allocation of resources: The people of Renfrew county are concerned about the availability of facility services in rural areas where it is difficult to provide the same level of community services as in urban areas. Renfrew county has a population of 87,000 spread over 763,870 hectares compared with Metro Toronto which has a two million population over 630,831 hectares. The placement criteria for admission to a long-term care facility should consider not only the care needs of the client but the social needs.

There was also support for the relocation of beds for long-term care to local communities to enable the client to stay in contact with family and friends. Bill 101 appears to ensure continuation of centralized funding and the status quo of current facilities. For residents of Renfrew county this means leaving your small community and moving 50 to 100 kilometres to Arnprior, Renfrew, Pembroke or Barry's Bay when this level of care is required.

The people of Renfrew county support plans to include all long-term care facilities under a common funding system and common legislation. Such legislation was seen to allow, indeed require, a facility to provide multilevel care for an individual as needs change and would eliminate the need for the individual to move to another facility when level of care changes. We are somewhat disappointed that this was not addressed in Bill 101, and it would appear that the individual may be required to change facilities to obtain appropriate level of care.

We understand that the government may consider level of payment directly related to acuity of care of the individual within the level of care defined for the agency service agreement. If this funding concept is instituted, we may be encouraging the continuation of the illness and the medical model, resulting in higher costs. VON supports a mechanism to provide for consumer needs and care which go beyond the illness needs, to include rehabilitation, discharge and support to maintaining wellness.

Recommendations: The government should consider a funding system responsive to the resources required to rehabilitate, maintain or improve the level of wellness of individuals or provide care during illness.

Quality of care: The continuation and expansion of the inspection process of homes for the aged ensures compliance with the regulations but does not ensure continuous quality management or customer satisfaction. Bill 101 provides for access by the consumer to key information regarding facilities' services, care, accommodation, consumer knowledge and explanation of care plan and an appeal procedure in the eligibility for service process. There appears to be no provision for an individual's involvement in choosing whether or not to receive a service or in determining the goals and use of resources to achieve these goals, nor an appeal process if the consumer is not satisfied with the care plan or service.

Recommendation: Consider expanding the content of the quality assurance plan to include total quality management which provides the opportunity for a consumer or surrogate decision-maker to have significant input and influence as to care received and an appeal process for consumers who are not in agreement or satisfied with the individual care or services.

Placement coordination: This is the area of greatest concern because Bill 101 speaks only of placement coordinators in relation to nursing homes, charitable institutions, homes for the aged and rest homes.

Recommendations: The relationship between the district health councils, home care, placement coordination services, service providers and their roles in the continuum of care and spectrum of needs should be studied in a more comprehensive manner, as proposed in the redirection of long-term care consultations.

In summary, on December 2, 1992, the Honourable Frances Lankin stated, "The framework for this restructuring is a product of one of the most comprehensive and democratic consultation processes ever undertaken by government...the consultation told us that our long-term care redirection was too narrowly focused...."

Rather than rush piecemeal amendments through legislation, please keep sight of the more comprehensive picture which emerged during 1991 and 1992. Provide the promised report of policy decisions on the redirection of long-term care. Provide the promised implementation framework in the spring. Provide for more discussion and input at the proposed March conference if that is what is needed to built the system the honourable member and her colleagues envisaged.

If the concern is about caring for persons, there will be differences, alternatives and choices within that system. If the concern is about limiting the caring to caring for people, the management has already been replaced by control.

Again, to quote the honourable minister on December 2, 1992, "The government, together with its partners in this endeavour, will be laying the foundation of a system that will serve us for decades to come." Strive for those foundations. Strive for total quality management by funders, service providers and consumers with special needs. Striving for those ideas while adapting to ever-changing social order, while addressing the fluctuating health and wellness needs of individual citizens is something the VON has been learning, practising and perfecting for 97 years in this province.

We need the courage to be caring for persons in a system where there will be local-regional differences, community-institutional alternatives and personal involvement and responsibility in choices; a two-way street in which there will be respect, participation and management as opposed to the cul-de-sac in which people are cared for by placement and control. Thank you for receiving us today. We would be pleased to invite your questions.


The Chair: Thank you very much for your presentation. As you're perhaps aware, as we've wandered about the province we've met a number of representatives from the VON, and I know I express the view of the committee in saying that each and every presentation, including your own, has not only given us a much better sense of what the VON does in our communities, if we didn't know it already, but has also shown that it's particularly important in addressing a number of regional issues, concerns that would not necessarily exist in perhaps a large, builtup urban area -- you come from Renfrew, for example -- and that's extremely valuable to the committee. I just wanted to put that on the record before we begin with questions and Ms Fawcett.

Mrs Booth: Thank you.

Mrs Joan M. Fawcett (Northumberland): Thank you for coming. I certainly agree that rural and urban delivery of services are indeed different and that the difference is important. I think we know that the VON invented home care and certainly continues to provide such a good service; also included in that are the numerous volunteers who are encouraged.

Your brief, with the recommendations, is excellent. There was a disturbing report on W5 on Sunday night, and I just wanted to ask you about that. Apparently, Saskatchewan has moved to government-run home nursing care. In particular, they highlighted the Regina health board association, which has taken it over; the VON will no longer do it. I believe that the nurses hope they will be employed by the government now, but most of the volunteers have said they will not work for the government.

I wonder about that whole scene because apparently the government in Saskatchewan has said that it will deliver the services better and cheaper, and I personally cannot see that at all. I don't think that will happen. I just have to think now, with the socialist government here in Ontario, are my fears justified? Do you fear anything like this happening here in Ontario, and if so, do you really think that the services will be delivered better and cheaper? I'd really appreciate your thoughts on that. What do you feel would happen to your volunteers?

Mrs Booth: If I may begin, I don't know whether it's cheaper or not, but cheaper isn't always necessarily better.

Mrs Fawcett: I agree wholeheartedly.

Mrs Booth: I'll pass to my nursing professionals.

Ms Joan Lemay: There is a concern, when you see it happening in other provinces, that the same trend will happen in Ontario. We have a large number of volunteers. Each VON branch is made up differently, but the volunteers start with the governing body of the branch and then some of the branches have programs that are run entirely by volunteers. It is a concern that this aspect would be lost if it was taken over by another organization or by the government.

Mrs Fawcett: I suppose volunteers are very important wherever, but I would think that in rural Ontario this is also a deep concern if you lose volunteers. The providing of services in rural Ontario sometimes can be very difficult because of the distances you have to travel.

Mrs Booth: And that's only as a volunteer? Please, I hope we are valuable.

Mrs Fawcett: Oh, definitely.

Mrs Booth: I believe we are.

Mrs Fawcett: In so many areas, we couldn't exist without you. There's just absolutely no question.

Mrs Booth: Particularly in a rural area, because one of our concerns, which has not been addressed fully, is transportation. You take away your volunteers and you take away the volunteers' cars. I think you may be solving one problem, but you may be creating a monster.

Mrs Fawcett: I couldn't agree with you more. Thank you very much.

Ms Jenny Carter (Peterborough): Thank you, and I'd like to reiterate what people have been saying about your organization. I think it's an extremely valuable organization, and I don't know what we'd do without you. I think we're going to be asking more and more of you in the future.

You're suggesting that this legislation be delayed, yet we've had people presenting to us, representing facilities, saying that their funding is in total disarray until this legislation goes through. I just wondered if you could comment on that. It seems that this is urgent from some points of view at least.

Mrs Booth: I think we are asking you to delay until what was promised has been provided so that we can see this small part as a section of a much bigger, a much more complete and much wider picture, which was what we had all hoped for. Hope and adrenaline, believe me, were running very high at the end of last year.

Ms Carter: Of course, that is what it is, part of a much wider picture. We're assured that there will be more legislation to come, and I guess we're expecting a policy framework document. Certainly, what we've been understanding from these presentations is that there are gaps in Bill 101 in the sense of what it doesn't say. I think what we can do at this point is assure you that a lot of your concerns are certainly the same as the concerns of the government, and I hope that this will come out more clearly in some of the subsequent documents and legislation.

For example, consumer choice is very high on the list. Expanding community care is very high on the list. Obviously, that doesn't appear in Bill 101 because that is not what it's dealing with. Also, of course, you raised the question of the difference between urban and rural communities as far as delivery of health care goes, and I know from what I have heard in discussions and so on that this again is one of the issues we are aware of and that we're looking at and that part of the intention of the legislation is to spread available resources more fairly.

Some areas are very well looked after at present, but we're hoping to make sure that those areas, maybe such as your own, which have not done so well are going to be more fairly treated in the future. Hopefully, that should come through as time goes on.

Mrs Mary McBride: One of our concerns is that the term "hopefully" is used, and that's sort of why we're here today. We do understand, at least we believe, that this is part of a bigger picture. These are some of the things that we feel maybe will come in legislation, but we would like to draw your attention to those particular things. Certainly, based on the concerns expressed by the Renfrew county residents in the consultation process, if that is lost, then I think we have lost a great deal in health care.

The Chair: Thank you very much for coming before the committee and also for both presentations. We now have copies of both. We wish you all the best as you go forward in Renfrew in putting together this -- I don't know whether to call it this beast of long-term care or this structure. We know that however it evolves, the VON is undoubtedly going to be at the centre of everything. Thank you again.

I'll just say to committee members before breaking that we will reconvene here at 1:15 sharp. I have indicated to the 1 o'clock presenters that we would start at 1:15. We have a very full afternoon, and we have a full evening. If members could organize their time accordingly, thank you. We now stand adjourned.

The committee recessed at 1150.


The committee resumed at 1317.

The Chair: Good afternoon, ladies and gentlemen, and welcome to our third session here in Ottawa, the third session of the standing committee on social development. We're here to discuss Bill 101, the government bill dealing with long-term care.


The Chair: Our first presenters this afternoon are the representatives of the Ontario Hospital Association. I welcome them to the committee and would ask them to come forward. I note that this is a joint submission of both the OHA and the Council of Chronic Hospitals of Ontario. Is that correct?

Dr Wilma Dare: That's correct, Mr Chairman.

The Chair: Fine. It's a pleasure to welcome the past chair of the Ontario Hospital Association. Perhaps, Ms Dare, you would be good enough to introduce your colleagues, and then please proceed.

Dr Dare: It's my pleasure, Mr Chairman. First, I would like to tell you how much we appreciate the opportunity to make this joint presentation to your committee. As you mentioned, I am the immediate past chair of the board of the Ontario Hospital Association. As co-presenter, I have with me today Michel Bilodeau. You heard from him this morning in another capacity. He is the vice-chairman of the Council of Chronic Hospitals of Ontario. Also with me is Mr Stephen Skorcz, the Ontario Hospital Association vice-president for chronic care and mental health. I'm looking forward to their assistance, particularly during the question period.

The Ontario Hospital Association and the Council of Chronic Hospitals of Ontario represent facilities providing chronic care to 12,000 individuals and their families. Chronic care is provided in a wide range of hospital settings across Ontario, including 18 freestanding facilities and units of chronic care in 70% -- that's 133 -- of the province's 190 acute care hospitals. However, all public hospitals in Ontario have an interest in long-term care developments such as Bill 101 because they must be able to shift patients to appropriate levels of care as their needs require, and I emphasize the term "needs."

OHA and CCHO fully support the government's resolve to reform the long-term care system in Ontario. This was stated in our position papers prepared in response to the government's consultation paper Redirection of Long-Term Care and Support Services in Ontario one year ago. Redirection is based on the concept of a continuum of care where patients and families can find the most appropriate services to support their needs over time. Sometimes I feel that we've used the term "continuum" for so long that maybe we have lost the essential meaning. The continuum that we wish to provide, all of us, really must respond to what is a progression of needs, and I think I would like to insert that terminology into our consideration.

During the course of these hearings, you've heard from a number of our members about their individual concerns. You heard from the SCO services integrating from the Perley Hospital. I know that you've heard in your other committee hearings from hospitals of different sorts. We believe the best contribution we can make to your proceedings is to provide a focus on the overall strategic approach that we see being optimal for long-term care redirection. To make redirection work, there must be active collaboration with providers. Consultation by itself is not enough.


The OHA and CCHO strongly believe in the need for a coordinated continuum of care in Ontario, because at present it is so fragmented and uncoordinated. That's the principle we've all been working on since the concept and need for reform was first introduced. The key result of long-term care redirection should be to improve care for the people of Ontario. The redirection should therefore provide for closer relationships among care providers, the creation of clear admission criteria for each category of facility to help determine each facility's role in the provision of care, similar approaches to governance and accountability, and similar approaches to ensuring that certain standards of care are met province-wide in both community-based and facility-based care.

The former Minister of Health, the Honourable Frances Lankin, stated in her comments to your committee on February 1: "What we are attempting to do is understand that there really is a continuum of care that is required, and while we have pieces of it in Ontario now, we don't have good linkages and we don't have the sense of the continuum, that people can enter and exit various points of the system at appropriate times to get the care that they require at that point in time."

We are very concerned with the approach that the government has adopted to achieve these objectives.

In OHA's response to the Redirection paper, we outlined principles to be embodied in the redirection, and this included 10 steps for "doing it right." We have provided you, in an appendix to our brief, a repeat copy of that document. I will refer to each of these 10 steps with a short extract to focus our attention on what we meant by "doing it right." We thought we were most relevant a year ago. We still think that these are very relevant, particularly when we see Bill 101 and fear that it is the beginning of a fragmented approach to implementation of long-term care reform.

Step 1: We should not proceed without adequate information. "The heart of our concern with the proposed reforms is that the government does not know exactly what it is reforming or precisely what resources are, or will be, needed to implement such reforms."

Step 2: We feel that it is vital to work from a blueprint. "Central to any such planning is detailed and accurate information. To date, there is no indication that even a fraction of the information needed in order to draw up a valid blueprint for the new system has been collected."

Step 3: This was mentioned this morning. Build on what already works. "Is there a rationale to change any hospital-based program that works," especially if the government doesn't know if the alternative is going to work as well or be more cost-efficient?

Step 4: We need to build a genuine spectrum of care. "If any part of the system is inadequate, it will increase the pressure on the other elements, thus endangering the entire system."

Step 5: Quite naturally, "Our primary concern is that these [long-term care facilities]" -- or I heard the terminology this morning of long-term care centres, such as the Perley -- "are meant to replace chronic care hospitals solely as a cost-saving measure, based on inadequate knowledge of the essential care that these facilities provide." It would seem to us that borders on a recipe for disaster.

Step 6: We should acknowledge the importance of health professionals. "Not only will physicians be needed to treat seriously ill people, they will also be needed to care for recovering patients."

That's something we at times lose sight of. We think all of the older people requiring care in an institution are going in, are going to stay there, and there's no recourse for them to exit the system. When we speak of the community level, too many of us forget that older people get sick. Sure, they may require longer periods of treatment, but they also get well. We want to provide the environment, the services, to at the very least maintain their state of health, but also to capitalize on their potential for recovery. This cannot be done without the professional care that is required.

Step 7: Strive for a balanced system. "If it is to function well, each part of the spectrum of care will need the other parts to be working well, too."

Step 8: "We further believe that it would be reckless to implement any new system without first introducing pilot systems in a variety of community settings."

I know that Ottawa-Carleton, as we are very proud of the system we have in place now, would be only be too willing to be one of those pilot settings.

Step 9: We proceed to another rather obvious principle -- don't shut down the old system until the new one is in place. We all have the rather startling memory of what happened in the field of psychiatry when countless patients were discharged without appropriate services in the community, and I think this is the danger that applies to the care of our elderly and to disabled young adults.

Step 10: We should ensure that long-term care is part of the overall health care system. This is very vital. When we think of the very major restructuring that is going on in the hospital-based part of the system and in the health care system generally, long-term care reform must be considered not in isolation from that restructuring, but as part of it.

We believe that the long-term care redirection effort has not as yet effectively addressed the 10 steps. As a result, we are here today to tell you that we do not see the blueprint by which the overall process should be directed.

We are concerned that all of the activities currently under way -- the long-term care policy framework, a document which we are now promised for later in March; the chronic care role study, which is still under way, final report pending; the conversion of chronic facilities to long-term care centres; and Bill 101 -- are not based on sufficient information to undertake the total direction of this sector.

This lack of information places in jeopardy the former minister's desire to ensure that a continuum of care is developed for all people eligible. Also, this lack of information will not allow us to address the issues that we have raised at the outset of this paper; namely, the relationships among care providers, determination of each facility's role, similar approaches to governance and accountability, and province-wide standards for long-term care.


We then come to our recommendations. In order to ensure that redirection continues in a rational way, we recommend to you the following:

-- That the enactment of Bill 101 be limited to only those aspects which are crucial to immediate administration of homes for the aged and nursing homes and payments to adults with disabilities to purchase services.

-- That all items related to provider relationships, roles of facilities, governance and accountability, and standards of care be delayed for incorporation in the next piece of long-term care legislation, which the former minister has stated is to follow shortly.

-- That in order to address the above, the government, as soon as the policy framework paper and the implementation plans are available, immediately consult with provider groups in a collaborative manner to discuss the adequacy of information in these areas to determine the process by which an information strategy can be established and the blueprint drawn up.

The OHA is following its own advice. We are planning a chronic care leadership conference for March 8 and 9 next where we will address the issue of information and the next logical steps in the process of developing a future vision for chronic care. We hope that our efforts in that conference particularly will be complemented by the government through it's pausing to consider with all of us together, all the major provider groups and the consumers, our strategic direction before proceeding with the long-term care implementation plan. We think we should be partners in that implementation plan.

Thank you, Mr Chairman. We will be happy to answer any questions the committee may have. I've referred to the strengths which I bring with me to handle those questions.

The Chair: Thank you very much for your presentation and for the specific recommendations. Let's move immediately to questions.

Mrs Caplan: Thank you for coming to the committee today with an outstanding brief, as always.

This morning I had the opportunity to ask some very specific questions about specific amendments. The line of questioning for this afternoon that I would like you to think a little bit about in your response to the committee has to do with the four concerns you have about what's going on and what's not there.

You've pointed out that there's no blueprint. If I were predicting, I would assume that since we've heard that March is going to be the time for the framework policy document, perhaps it will appear magically at your conference on March 8 and 9. I'm assuming the minister will be there, and that will be a good time for her to table and announce the policy; similarly, the chronic care role study, if it could be available, since they told us March at the same time. That might be -- they don't think it's possible. So the two. We haven't got the blueprint. We don't have the chronic care role study information. We have Bill 101, and it's here after two and a half years of consultation.

The one that I'd like you to address for us, if you would, is the conversion of chronic care facilities to long-term care facilities. The OHA is very aware of that which is going on. I'd like you to share with the committee the information that you have. Also, has there been a clear definition of long-term care facility? And do you see any consistency or part of that blueprint vision that's taking place in the province?

I know there are many things that the individual facilities couldn't tell this committee, because of course they have to get up in the morning and work the next day. But as the umbrella organization, perhaps you could be candid with us as to some of the concerns you have about the directions that those conversions are leading us in.

Dr Dare: I'm very pleased to have an opportunity to address that. As you know, we only have the two concrete examples. You heard from the Perley Hospital this morning, and there's a similar conversion going on in the building of a new facility in Windsor. I think that the chronic care hospitals of Ontario have given more definitive consideration to this, keeping in close touch with developments, and therefore I'd ask Michel to refer to that and respond.

Mr Bilodeau: I have no definitive answer about what a long-term care centre will be. We heard through the grapevine that the government has already made up its mind about a number of facilities -- we heard 10 -- a number of chronic care hospitals being converted into long-term care facilities. As this morning I tried to give you some specific examples of the results, I'll try with long-term care facility also.

John Lupton was telling me, for example -- he came this morning but I don't think he addressed that -- that what the new Perley will get for programs, and that's basically for professional services, will be $3 per resident per day. I'd like to convert that to what it means for one of our hospitals, Élisabeth Bruyère, compared to one of our homes for the aged, Résidence Saint-Louis, because I have all the types of facilities. Right now, if we had $3 per resident per day for programs, we would be able to hire five people. That's for physio, OT, social workers, recreation, psychologists. We currently have 41 of these, compared to the five.

At the Résidence Saint-Louis, which is our home for the aged, we have three for 186 beds, compared to 41 for 225 beds at Bruyère. Maybe some people think there are too many at one place and not enough at the others. Maybe. When we consult the families and the residents, they tell us we don't have enough at the hospital. That means there are a lot of different things you do with these residents. That also means that in spite of what a lot of people say, the type of people who are cared for are extremely different, and I would certainly offer you to come and visit the Résidence Saint-Louis and compare that with the chronic care hospital. These are two different worlds, and you just cannot do the same thing.

If we want to build warehouses for the elderly, fine, but we're not going to be able to rehabilitate them with that type of funding. Again, maybe I'm wrong. Maybe by coming down to $185, as John mentioned, we're going to be able to do miracles with less money. I don't know. But quite frankly, I don't know how we're going to do it. We're very concerned about that because we don't believe -- for example, we still don't have the results of the classification that was done last year. We don't know what the result is, so it's very difficult. How can we build a system without knowing what type of people we have in our beds?

Mrs Caplan: What I've just heard you say also is that the consultation that has been going on has been perhaps an exercise in talking heads, that information has not been shared that would allow for the meaningful collaboration as these new approaches are even taken or piloted or modeled. I have some concern about that because you've used the words "consultation" and "consult" as well as "collaboration," and that collaboration model is one of working together. Obviously, you haven't had the information that's required.

Mr Bilodeau: Well, I'll let Steve answer that.

Mr Stephen Skorcz: I would say the collaboration has not been there. I guess the way I view this process going is that to make any change of direction in the health care system, you really need more than consultation with the providers who deliver the care; you must make them partners in that change. And as we have spent the last six months trying to look at the roles of chronic care institutions, prepare them for the future and work in their vision, clearly one of the things we have looked at is these long-term centre developments. It is very unclear as to what information base there is as to what patients these will serve, and how well this has been identified.

I would also suggest that the Ontario Hospital Association, and I don't know if this has been purposeful or not, has seemingly been out of the loop in terms of the communication and collaboration on which -- supposedly a number -- of our members might become these facilities.

I'd say one example of this has been the policy and procedures manual that has been developed and has never been referred to the OHA for any review or comment. It is very difficult to work with our member institutions on a major issue which may confront them for the future when quite frankly we appear a fair bit in the dark about some of this activity.

Mrs Caplan: The framework document, the policy framework for long-term care that we're expecting in March -- and I would point out for the purposes of Hansard that today is February 24 -- is it possible that document could have been compiled without the data and the information that you're saying is not available? I can't believe it's not available; in fact, it has to have been available for the policy document to have gone forward. That hasn't been shared with you?


Mr Skorcz: If it has been available, it has not been shared with us.

Mrs Caplan: Do you know if it has been shared with your chronic care committee?

Mr Bilodeau: The members of the chronic care role study have had a copy of the manual, yes. But certainly those people who have had that in hand were, I don't know, instructed or otherwise not to share it. I know that someone from our home for the aged has a copy, and that's why I read the manual, but it has not been widely distributed.

Mrs Caplan: You mentioned the --

The Chair: Last question?

Mrs Caplan: Yes, last question.

You mentioned the concern that you have and that I think many of us also share in, this change to warehousing of people as opposed to the kind of support for care that a continuum of care would suggest, and rehabilitation make possible. In the planning of some of these facilities, there have been some concepts that I think are pulling at opposite ends and would leave one to be concerned that perhaps a long-term care facility will become a warehouse as opposed to an institution or a facility that would meet the needs appropriately.

For example, we heard that the institution here in Ottawa that was before us this morning is going to be dealing with the same population that they're dealing with today -- a very high level, the highest level of care -- and adding to that some medically complex procedures: tracheotomy, dialysis, that sort of thing. Yet in the original planning for that institution, it did not permit trays of food to be taken to the patients, but had a requirement that all patients have their meals in a central dining room with regular chairs and that kind of thing. I know that your association is familiar with that and concerned about it. Can you tell us, is that still what's going to happen in this long-term care facility?

Mr Bilodeau: Obviously, I'm not familiar enough with that, although when I hear what you say, sometimes I would laugh if it was not sad.

We have four beds for dialysis patients at Bruyère. These beds cost us $175,000 per bed per year to operate. Now, if they want to operate these beds with $185 per day, they're just not going to be able to. We're not throwing money out the window; we're trying to serve these people. Last year, the ministry gave us $100,000 for four beds in addition to our regular funding, and we cannot make it. We haven't gone back to ask for more. We just said: "Okay, cost us $135,000; we'll do it with that." That's not possible. You have to be out of the system to think it's possible.

The Chair: Thank you. Mr White.

Mr Drummond White (Durham Centre): A couple of questions, and I want to thank you very much for your presentation.

I'm sure, as you are aware, we're getting advice on both sides of the spectrum. This morning we had people saying, "Well, you shouldn't possibly be talking about institutions. You should talk about the community first," whereas your first recommendation is, essentially, let's deal with the institutions first and when we have the rest of the package, we should move ahead.

But the issue about the quality and level of services is, I think, very important. You brought forth, Michel, the concern with $3 a day and what that will pay for when you have social workers, occupational therapists and quality nursing staff.

I'm wondering about two things, and they follow from each other. My first question is, we've heard that in the homes for the aged and the nursing homes the level of care is increasing; the heaviness of the duties is increasing exponentially in the last few years. In fact, the average age of patients on admission now is higher than the average age of the residents in those facilities because of that exponential increase in the need of those patients. I'm wondering what your experience is in the chronic care hospitals. Is the same thing happening there?

Mr Bilodeau: Exactly the same thing. As the homes for the aged and nursing homes have people who require more care, chronic care hospitals have also been modifying their admitting criteria to admit people who are sicker.

Just a few examples: We have in our chronic care hospital 23 people on morphine right now, we have four on heroin, we have people with AIDS on AZT, we have people on dialysis, we have people who suffer from amyotrophic lateral sclerosis, and next week one is going to be on a ventilator and will require supervision 24 hours a day because there's nobody to take care of them at home. They can't go home. So of course our level of care has gone up also. It's a phenomenon. We have a two-and-a-half-year waiting list, so people get sicker and sicker.

Also, we now have rehab programs. That's not something that's not looked at, but we have, for example, people who have had an operation in an acute care hospital come in for four months to get intensive rehabilitation, go back to their homes and come in once a week for follow-up in a clinic. Out-patient clinics are not funded, but we fund them from our global budget because we need to. So of course, we face exactly the same reality.

Mr White: Following along those lines, specifically to the psychogeriatric and Alzheimer issues in chronic care facilities or for that matter any general hospital, you had some of the capacities, some of the resources to deal with that kind of clientele. I'm wondering if you perhaps have any knowledge of or experience in how generalized those resources are in the community.

Mr Bilodeau: It's difficult to say. In this region we have relatively good community services. We have, for example, a regional community psychogeriatric program, we have several memory disorders clinics, we have community-based home care programs for psychogeriatric patients, for Alzheimer sufferers, we have a couple of day-away programs for Alzheimer sufferers who remain in the community and we have a couple of day hospitals for those who require more care.

So yes, there are pretty good services, but we all face the same situation as the province is facing. That means budget freeze and numbers going up. So what was probably an excellent service three years ago is now a good service and will be a poor service in three years' time.

Mr Wessenger: Thank you very much for your presentation. Staff would like to clarify some aspects about the comments that were made.

Mrs Caplan: Why don't you clarify whether you are going to give them the information.

The Chair: Order, please.

Mr Geoff Quirt: With respect to the definition of long-term care facilities, I think it's reasonably clear that it's our intention, through Bill 101, to convert nursing homes and homes for the aged to what we call long-term care facilities. We now have separate acts, the Nursing Homes Act and the Homes for the Aged and Rest Homes Act, and hence there are different titles associated with these facilities. Our intention is to create a new, consistent program with consistent funding arrangements and provincial expectations for existing nursing homes and homes for the aged.

Mr Lupton was quoted as having said that $3 per day would be available for programs at the Perley Hospital or the new Perley long-term care facility. I'd like to clarify that the commitment to the new Perley Hospital is to continue to provide all the funding associated with the Perley Hospital's budget now, to continue to provide all the funding associated with the Rideau Veterans Home and to continue to provide all the funding associated with the National Defence centre chronic hospital beds that will also be included in the new 450-bed Perley long-term care facility.

We do not see a reduction in financial support to the facility and, given that the funding associated with the veterans in the Rideau Veterans Home is at a considerably lower level, when you add all three pots of money together and divide that by the new number of beds, the per diem comes down. It's a question of mathematics, not a question of a reduction in financial support of the facility.

I'd also clarify that there are currently planning activities related to six long-term care facilities, chronic hospitals considering their future and opting to redevelop a part of their operation as a long-term care facility. I'd like to read off, just for the record, those facilities that to my understanding are planning in that regard: the Perley in Ottawa, Riverview in Windsor, St Mary's in London, a portion of Chedoke-McMaster, St Joseph's in Guelph and Riverdale in Toronto.


In all these cases, the decision to pursue the development of a long-term care facility was a decision taken, as is the case with Perley, by the board of directors of the Perley Hospital and the other two facilities involved, and in all cases the result of some fairly extensive local discussions, as was the case in Riverview and in other communities to move in that direction. All these facilities have been given the option to await the results of the chronic role study before moving ahead with the redevelopment project, and these facilities have opted to pursue the development of a long-term care facility.

The long-term care facility manual is available to anyone who requests it. It's been provided to the members of the chronic role study steering committee and provided to over 40 provincial organizations for their review and comment. I'm not sure if the representatives from the OHA and the council of chronic care hospitals have shared that document with the organizations they represent on the chronic role study steering committee, but they're certainly free to do so. We'll be happy to provide additional copies if that's warranted.

Mrs Caplan: That's very helpful.

Mr Quirt: Every nursing home and home for the aged, I understand, has a copy of the manual from their association or from requesting it from our offices, so it's certainly a widely distributed document. A second draft is coming out shortly based on the input provided by those 40 organizations with whom we consulted.

I'd also like to clarify the issue of dining in the discussions with the Perley. It is our position that residents in long-term care facilities should have the option available to them to take part in a dining activity with other residents and engage in some social or recreational interaction at mealtimes. We do not support the notion that all people would be served all the meals for the rest of their lives on a tray in their hospital beds, and we obviously do not support the notion that people who are unable, for whatever medical or health reason, to move from their room to a central dining area would be forced to do so. It would be ridiculous to expect someone who could not take advantage of that opportunity to socialize and have a meal with a group of people -- to force them to do so. There will be dining areas in numerous locations in the new Perley facility and, in keeping with the philosophy that long-term care facilities are people's homes for the rest of their lives, 75% of the people who will live in this facility will have their own private room.

Clearly, the long-term care division, with a tradition in long-term care services, and the people representing the Perley Hospital with a different tradition have learned a lot from one another in the planning process. As Mr Lupton mentioned this morning, while there have been disagreements, there has been some progress and there has been some movement towards the creation of what we hope will be a much better place for the people from the Perley Hospital and the veterans in both veterans' facilities to live in the near future.

The Chair: Any comment or further questions on staff's response?

Dr Dare: I don't think it's an appropriate time to go into the history of the differences that have had to be resolved. From the position of the Council of Chronic Care Hospitals of Ontario and the OHA, we are awaiting the additional information, which we have pointed out is not available. We do not have a characterization of the patient population which the long-term care division feels can be served in this new type of facility.

I think everyone will agree that the population at the Perley Hospital could not be looked after at the present time, except for maybe a portion of it. We do not deny that there may be a portion of, say, the patient population at St Vincent or the Élisabeth Bruyère that might be taken out of the global budget and put into a certain regimen of care with all of that involved: the staff mix, the specialized personnel and so on. These are the things we lack information on. I think we need that information before we can say that the new centre to replace the Perley Hospital will look after the patients who are now being served in any one of the chronic hospitals which may be targeted.

This is the sort of information gap we have before we can draw conclusions either on behalf of the Perley or on behalf of -- and we question whether the long-term care division has had that information on which to base some of the things it is putting in fairly concrete fashion to guide the reform of long-term care and to implement it.

Mrs O'Neill: May I ask a question of staff to clarify one thing that was presented?

The Chair: I did recognize Mr Jackson first and then I'll go to you, Ms O'Neill.

Mr Jackson: I'll yield to Ms O'Neill, since I'm in her backyard, but I do with to get to the points I want to raise of staff.

Mrs O'Neill: Michel brought forward the point about the day programs and the outpatients. I just wonder, in this new level-of-care funding model, is there going to be any consideration of those kind of programs, because there's certainly a very different kind of budgeting than the global budgeting they're used to now?

Mr Quirt: Yes, there would be opportunities for that. For example, with the Perley Hospital, it's proposed that the Perley long-term care facility offer a day program for seniors and that the funding for that program be provided separate from and in addition to the per diem that's been mentioned for the operation of the long-term care facility.

Many homes for the aged in the province now offer community support service programs like day programs, meal programs or transportation programs. They are funded now, and will be funded, separately, and it's our intention to expand those programs with a portion of the $441 million to be invested in community services.

The Chair: Mr Jackson.

Mr Jackson: I'm concerned that this process involves staff clarifying matters at length that shouldn't require being clarified either to this committee or to deputants. I wish to register with you, Mr Chairman, my concern that an increasing amount of time is being taken away from our inquiry and being utilized by ministry bureaucrats to clarify or put their spin on what's happening.

Having said that, I want to ask Mr Quirt if he was saying that the merging of nursing homes, homes for the aged, the varying acts, the varying funding mechanisms under a single piece of legislation with long-term care facilities -- are we to take it then that we are pre-empting the chronic care role study and that in fact Perley for sure, and the five others that have been announced, are now going to become and be funded in a fashion similar to nursing homes and homes for the aged and that this is not going to be -- I mean, if it's funded like a duck, if it serves the community like a duck, then it is a duck and it's no longer a hospital. I'm quite concerned that we're not given an ample enough opportunity to explore this information. I want to ask the deputants about the number of beds that were surrendered in order to work out a deal with this government when I've been told -- and we may as well get it on the table -- that the attitude at the table was, "Well, we're going to get hurt badly if we don't roll over and comply with the rules of the game as they're now being constituted."

This process is going on behind closed doors, it's not being done with any knowledge of this committee and we have staff allowing those snippets of it to race across the floor and in Hansard as they see fit. I, for one, am very angry about the process. I'm hopeful that we will be given enough time to explore the meat and the potato of these issues. I want to be able to ask questions about bed losses, bed tradeoffs, the levels of care that are coming out of these discussions now that these decisions have been made. All we're being told is that we have no chronic care role study, but we now have six chronic care hospitals secretly negotiating with the government out of fear that the government might suffer them with some sort of retribution if the terms and conditions of those negotiations become public. It's wrong. Otherwise, this whole process is a sham.


The Chair: If I might, before allowing Mr Quirt to respond to your questions at the beginning, it is 2 o'clock and I am concerned just in terms of what is a very full afternoon. I appreciate the points that are raised.

Mr Jackson: Mr Chairman, not to interrupt you, sir, but I sat here patiently without interrupting during about a 12-minute presentation by the government when the deputants didn't even ask the question. This is going on extensively. I would hope you'd respect our role as a committee. You do not accept calls for points of order, and no one's challenged you on that, but I think we have to be a little more fair in that we're a legislative committee in the process of listening to deputants and asking questions and not constantly have the government's spin on this thrown across the table for Hansard, the media and the public, which want answers.

The Chair: I appreciate that and I think I've tried to be very fair, both in terms of questions from members and also just what I would hope would be clarifications at times, which have then brought forward questioning back and forth. I'm quite prepared to allow some discussions. I simply want to indicate that we do have a very full afternoon. I'd like to ask Mr Quirt if he would respond, and if there is a further question or response from the deputants, I think then we're going to have to move on.

Mr Quirt: I'll try to respond as quickly as I can to Mr Jackson's questions. In terms of the Perley process, there were not beds surrendered to the government; I think there's an overall increase in the number of beds as a result of bringing those facilities together. I don't recall offhand how many new beds would be involved, but I could certainly find that out for the committee.

The planning process in these six communities has not been secret. It's involved the boards of the hospitals affected and other community players with an interest in the long-term care system. Certainly the Riverview project was the result of a long and quite open-process community report that recommended that shift.

Mr Jackson: My question, was, is the Perley Hospital now in the same category in this legislation as a nursing home and a home for the aged?

Mr Quirt: It will be when the new facility is constructed.

Mr Jackson: That's what I thought I heard you say and that's what's causing me some concern.

Mr Quirt: Yes, it will no longer be a hospital; it will be a long-term care facility. That's correct.

The Chair: Would any of you like to make a comment?

Dr Dare: I would like to say that we're very pleased Mr Jackson asked that question, because this has not been clear to us. When we see the draft manual on policy and procedures, which we have suspected was going to apply to these new long-term care centres, now we know how to approach it. As a member of the OHA -- and I don't believe the CCHO has received that manual from Mr Quirt for comment, not officially -- we'd be most anxious to do so before it goes further. We are really quite concerned on the subject. You will be hearing later this afternoon from the Canadian Council on Health Facilities Accreditation. We're very concerned because it's really quite out of date, even in its terminology. It's still talking about quality assurance. We've gone long past that now. The concept and the principles are now involved with quality management and measuring outcomes, not, as that draft manual talks about, quality assurance. We are very concerned.

The Chair: I'm sure that manual will be made available to you. I believe there is a second draft we have heard about that is out or about to be out. I think that would be very important to you prior to your meeting on March 8 and 9.

Dr Dare: We would undertake an obligation to respond as quickly as we possibly can. Am I speaking for you, Stephen?

Mr Skorcz: Yes. I would just like to make an additional comment in the sense that I think it's important to remember that long-term care redirection is not solely the purview of those institutions that are identified as chronic care hospitals, but really of all hospitals in the province, because of the need to place patients in the community. I think a critical piece, though, about chronic care also easily forgotten is that of the 12,000 beds in the province half of those are in freestanding chronic care hospitals, but half of them are in acute care hospitals. In fact, one third of the beds in those hospitals identified as small hospitals -- ie, under 100 beds -- are chronic care; 92% of all hospitals under 100 beds have chronic care beds. This is a very important, pervasive province-wide issue. I'm not sure we have the information so that we can look at all these patients and all these designations with one single definition.

The Chair: Thank you. I'm sure we could probably spend the rest of the afternoon profitably. I regret, as the heavy in the chair, having to call this discussion to an end. You have noted your meeting on the 8th and the 9th. I think any results of that would be very helpful and useful for the committee. Again, I thank all three of you for coming and being with us this afternoon.

I next call the representatives from St Patrick's Home of Ottawa, if you would be good enough to come forward. Mr Hope?

Mr Hope: I've got a little bit of a concern here, because I'm looking at the times of presentations. We started at 13:16 and now it's 10 minutes after. We've allowed almost a full hour of discussion. I'm wondering how will we balance that out between the rest of the presenters, because Mr Jackson made a comment --

The Chair: I think if we could just get on with it, Mr Hope --

Mr Hope: There was a comment made by Mr Jackson on this, you know, taking away --

The Chair: No, I'm sorry. We've got to move on and I'm sure we'll --

Mrs Caplan: I have a question of the parliamentary assistant.

The Chair: No, please; I'm sorry.


The Chair: Welcome to the committee. Despite our problems with the time, for which I take responsibility, you will have your full allotted time. We thank you very much for being with us. If you'd be good enough to introduce yourselves, then proceed with your presentation.

Ms Maureen Goodspeed: Thank you, Mr Chairman, members of the committee. I'm Maureen Goodspeed. I chair the board of directors at St Patrick's Home for the Aged in Ottawa. Sister Mona Martin is the administrator of St Patrick's Home.

St Patrick's Home for the Aged, founded in 1865, is sponsored by the Grey Sisters of the Immaculate Conception. Since that time, the home has grown from an orphanage and an asylum for the indigent to today's fully accredited, charitable long-term care facility for the elderly. Throughout its evolution, the element of loving care in a Catholic setting has been constant.

In 1979, St Patrick's Home was the first home in the region to become accredited. We are proud of our stellar reputation in the community, our leadership in the field of long-term care and our partnership with government and community agencies in developing a comprehensive response to the needs of seniors in the Ottawa-Carleton community.

The mission of St Patrick's Home states our commitment "to provide resident-centred, long-term residential and extended care as well as respite and outreach services to persons of all religious and ethnic origins." Underlying this commitment is the belief that all decisions, whether at the board, administrative, management or staff level, must be guided by an appropriate process of ethical reflection, rooted in core values within the Roman Catholic tradition. Over its 128-year history, St Patrick's Home and the Grey Sisters have provided orphans, the destitute and now resident elderly with holistic care, including spiritual care. We believe that to ignore spiritual needs is as much neglect as to ignore any physical or social need.

St Patrick's Home supports in principle the Redirection of Long-Term Care and Support Services in Ontario. Several of the initiatives are positive, and we support the effort to bring consistency to the process and to provide a better opportunity for those who choose so, to live independently. However, we believe that Bill 101 fails to reflect the four principles the government has intended to guide the redirection. They include the primacy of the individual and the right to dignity, security and self-determination; promotion of racial equality and respect for cultural diversity; the importance of family and community; and equitable access to appropriate services.

I will address the areas of prime concern to us: the right of placement choice, funding and inspection.


As a Catholic health care facility, we have a specific concern that consumer choice is not fully recognized in Bill 101. We strongly believe in the principle that individuals and families should be able to continue to choose where and how their elderly will live and be cared for: in an environment which honours the whole person, respecting spiritual, personal, social and cultural needs. The rights of individuals to choose accommodation based on the ethnic population or religious affiliation of the home must be considered as important in placement as other determining criteria. The right of choice is fundamental to the primacy of the individual and to human dignity. It is clear that this right is threatened in the placement coordination plan described in Bill 101, because it is based solely on a medical model. What is acceptable in determining admission to a short-term, acute care facility is not appropriate when considering long-term care.

Equally important are the rights of an institution to exercise some control over admissions. We believe that, guided by our mission, the types and levels of care provided by St Patrick's Home reflect a balance between the requirements of our community, both inside and outside the facility, and the limitations placed on us by physical design and finances. With only limited grounds to refuse placements, and with no guaranteed right of appeal, the ability of an institution to make firm decisions based on long-range plans is severely curtailed. The very character of institutions such as St Patrick's Home is threatened because the boards of directors would have no control over the nature of their institutions. Therefore, the community stands to lose precious resources.

Currently, seniors face no restrictions in choosing the care or services they require. Placement in a home for the aged is a traumatic experience for many people; it comes at a time in their lives when they may be facing a number of losses. In fact, placement in a home for the aged is usually precipitated by the loss of a spouse combined with the inability to function on one's own, advancement of an illness or even a major medical event. It is critical that seniors and their families be able to access services through familiar organizations, including religious and cultural groups, which have a unique understanding of the special ends of their members, allowing them to provide appropriate and sensitive services.

The Residents' Council Association tells us, "Old age is a stage of human development, not a holding pattern or a time for withdrawal from society." People come to a home for the aged for the rest of their lives, not for just a few days or weeks. It is important that they maintain a sense of identity and control over daily life despite losses and change. The need to empower residents must be recognized in long-term care. Seniors should be provided with the supports they require to remain in their own homes as long as possible, but if that is no longer possible, it is important to recognize that facility-based care must be available in a way that takes into account different values, religions, languages and customs.

In terms of right of choice, we are also concerned that seniors who wish to live in a supportive environment and who are not deemed eligible by the service access coordinator and the placement review committee will be left with no other option than for-profit, non-regulated retirement homes. If this is so, the possibility arises that they will be left with few services and no protection.

The issue of funding is a serious concern for St Patrick's Home. For 12 years St Patrick's Home has had to contend with an operating deficit because of the acknowledged failure of our provincial funders to recognize the chronic and extended care provided by the home. In the last two years our financial situation has become acute. We and the ministry have lurched from crisis to crisis. We all know that the current funding doesn't work. We were told that a new funding system would support the care requirements of our residents. We were promised that the new funding would be effective on January 1 of this year. We struggled to meet our operating costs to that date, only to be told that there would be yet more delay, perhaps until January 1994. This is a completely unacceptable situation. It is time to deal with the reality of our budget problems now. Funding reform must take priority as a first step in the redirection of long-term care in Ontario.

The redirection must also recognize the outstanding contribution that various non-profit and religious communities, including the Grey Sisters, have made in meeting the needs of the elderly in our community, years of experience which must not be discounted.

Guided by a mission and not seeking profit, we welcome the development of standards. We do not appreciate, however, the powerful tool of inspection, the intimidation of sanctioning powers and the arrogance of immunity that the province has granted itself in Bill 101. For years, the provincial government has been our adversary in the effort to obtain better care for our residents through its failure to provide adequate funding. Historically, we have worked very hard to raise donations and recruit volunteers to provide quality care for our residents. Threats and sanctions are not necessary, and are inappropriate to a cooperative management model. They are a holdover from the time when jails and homes for the aged and nursing homes answered to the same director. Today, with the safeguards of accreditation and public inspection firmly in place, we should abandon the outmoded, confrontational methods of earlier years.

In light of these considerations, I recommend:

-- That all citizens, including the elderly, living in the province of Ontario be guaranteed the right to participate fully in the faith and cultural community of their choice.

-- That a fair and reasonable funding formula be set up and implemented without further delay.

-- That a system be implemented whereby applicants' disagreements regarding admission and placement decisions be dealt with in a fair and consistent manner with a guaranteed right of appeal.

-- That institutions be granted the right to appeal placement decisions through a process similar to that which is established for applicants.

-- That health care facilities continue to exercise choice concerning service referrals, age mix and retention of residential levels of care.

-- That the local board of directors of the service coordination agency have equal representation from consumers, care providers and political appointees.

-- That the role of the local board of directors be clearly delineated in regulations.

-- That provincial guidelines be established for elections to these boards.

-- That all regulations pursuant to Bill 101 be published and subject to debate before promulgation of the legislation.

We are very concerned that the principle of individual and family choice is being eroded, while at the same time the ability of boards of directors to make difficult and important decisions regarding placement and care is being diminished. As it is currently written, Bill 101 will destroy the freedom enjoyed by cultural, linguistic and religious organizations to provide the supports and services required by their members. It will destroy the very rights it purports to protect. Bill 101 must be revised to rectify these serious shortcomings, and the ensuing regulations must be brought under careful public scrutiny before the bill is enacted into law.

In the meantime, the actual levels of care delivered in charitable homes should be recognized and funded at least at the levels of the 1992 assessment to check the irreversible slide towards bankruptcy upon which we are now embarked.

Thank you, Mr Chairman.

The Chair: Thank you very much for your presentation. We'll begin the questioning with Mr Owens.

Mr Stephen Owens (Scarborough Centre): I'd like to begin by thanking you for your thought-provoking presentation. In terms of your financial situation, I'm not quite sure I understand how and why you've been -- I don't know what the polite phrase is -- jerked around for so long, and why it is now that you're being told that you'll have to wait, you say, perhaps until January 1994 for additional funding. Can you explain in a little bit more detail your comments?


Ms Goodspeed: I'd be glad to. We have a 202-bed facility. Approximately half those beds are taken by people who are extended care or chronic care level, but we aren't funded for that care. We provide the care because our people need it, but we aren't funded at the extra level that's required to meet our payroll. So we have been slowly -- and it has been getting faster and faster as the years progress -- slipping into debt. If we were being funded for the level of care which we provide, we would not have an operating deficit. It's as simple as that.

Mr Owens: Just in terms of your comments on page 7, again I'm not sure how this legislation is going to, as you say, "destroy the freedom enjoyed by cultural, linguistic and religious organizations." I'm not sure how this bill will do that, and in terms of what is happening currently in my own riding, for instance, in Scarborough Centre, that people are being devolved from hospitals into the community, there's not an opportunity to have that choice that you talk about in your brief. It's my view that while this bill is certainly not going to provide for a utopian society that we would all hope for in the care of our elder citizens as well as other individuals in long-term care facilities, again, in my view, it goes a long way to resolving some of the chronic concerns that have plagued the system. So I'm not quite sure how your view and my view could be so diametrically opposed on an individual whom we both care for.

Mrs Caplan: She doesn't share your ideology.

Mr Owens: I wasn't asking you the question.

The Chair: Let the witness respond.

Ms Goodspeed: Well, we run a Catholic facility. We're Catholic in our philosophy, our traditions, our culture, our practice. We run a residential facility and people choose to come and live there because they know, they understand, what kind of an atmosphere they will be living in. They come to live with us whether they're Catholic or not, but they appreciate the ambience that we have created there.

If people requiring long-term care no longer have the right of choice as to where they will go, then the residential mix becomes very, very different, and you could very easily have people being sent to St Patrick's Home because it was the only available bed who would much prefer to be at Hillel Lodge or would perhaps prefer to be in a home where only Cantonese is spoken as a primary language. You would not be meeting the basic needs of the people who are looking for a place to live in comfort and security for the rest of their lives.

Mr Owens: Just a quick question to ministry staff for the purposes of clarification. Maybe I don't quite understand the purpose of this legislation, but my understanding is that this legislation will in fact respect those cultural and linguistic needs that are out there, and that the element of choice will still be there. Is that a fact, or am I going down the wrong road on this one?

The Chair: Parliamentary assistant?

Mr Wessenger: Yes, I'd like to reply to that. Definitely it is a factor. The fact is, the whole aspect is for the placement coordination to work very much as it does at the present time in providing the choices for the consumer, and we don't see a change in that aspect of consumer choice. The consumers will make the decision as to what institution they prefer or which one they want. Also, there will be provision in the sense that if someone has to go into an institution, on an emergency basis, that is the only bed available, they'll still have the opportunity to move to another institution. So that flexibility is built in, first of all, in the consumer choice in the initial institution you go into, and then with respect to the opportunity to relocate to an institution of choice.

The Chair: Mrs O'Neill?

Mrs O'Neill: Well, your reputation precedes you; you know that. I think it's important that I mention, because of the faith component of your facility, that you not only nourish and enrich the faith of your residents but, I think, of the families of your residents as well, and I know that from personal experience. I also know that you keep in touch with your families and consult with them as well as your residents.

It's a very strong brief you've presented. Certainly it's many of the things we've heard, but I don't think presented as forthrightly or as eloquently as you've done. You have hit on two items that I think are of very great concern: the January 1 date not having been met -- we've heard that from several facilities, and facilities such as yours would be those that would be most concerned -- and the confrontational model that seems to be part of this whole Bill 101.

There are some of your recommendations I'd like you to address a little more fully if you could. I'd like you to say a little bit more about the placement and the guaranteed right of appeal, which is your third recommendation, and then, if you could, about the role of the local boards and the election of those boards. I would find it helpful just to put a little bit more meat on those two recommendations.

Sister Mona Martin: Maybe I will address the placement, because we're primarily concerned with the placement. Although Bill 101 is saying that individuals will have choice with regard to where they go, I think the reality of the situation is that if a resident is in need and needs a bed today, he or she is going to have to take the bed that's available. The bed that's available could be a bed even outside the Ottawa-Carleton region, and that is even happening to some of our clients today. In fact, it happened to one of our clients yesterday where the family were very upset about this.

I guess the other aspect is that we're having a hard time believing that if people have to go into a facility not of their first choice, they are really going to get moved to the facility of their first choice eventually. The reason I say that is because at the present time, as Maureen alluded to, we have about 58 chronic care residents which we cannot get moved to chronic care. So the reality of us at the home is that it has not happened for us. We cannot get these individuals, who really should not be at St Patrick's Home because we're not funded for that level of care, moved to another level of care. I think that's where some of our apprehension comes from in terms of moving people.

The other aspect is that when people have to take a choice that's a second choice, the quality of life for that individual means many moves sometimes before they finally get back to the choice that they really made. If there are people who are in need, I don't think the individual who has already been placed is going to be taken out of the facility that he or she is presently in and put into a facility that now has a bed available. I think all of us realize that every day there are people who need to be placed. They are emergency admissions and they are the ones who are going to get the beds.

Maureen, do you want to address the other two?

Ms Goodspeed: Yes. You asked about the membership of local boards of directors for the service coordination agency. Our concern is to ensure that the care providers -- the homes for the aged, the long-term care facilities -- as well as the consumers, the families of the residents of such homes, would be adequately represented in that governing body.

Mrs O'Neill: It was actually your own governance that I was questioning about.

Ms Goodspeed: I'm sorry, I didn't --

Mrs O'Neill: Recommendations 7 and 8: the role of the local boards. Is that not your local board that you're talking about?

Ms Goodspeed: No.

Mrs O'Neill: Oh, I'm sorry. Okay, well, thank you for your very forthright and practical answer.

The Chair: Thank you very much for your presentation, for your recommendations and for coming before the committee this afternoon.

I'd like next to call on the Ontario Long Term Residential Care Association, if the representatives would be good enough to come forward.

Mrs Caplan: Mr Chairman, while they are coming forward, could I ask a short question of the parliamentary assistant?

The Chair: Yes.

Mrs Caplan: I've read this legislation and unless I've missed something, I can't seem to find the definition section where you define "long-term care facility." Would you tell me where to find it in this bill, please?

Mr Wessenger: I don't have the bill in front of me, but I'll ask legal counsel if there is any definition.

Ms Gail Czukar: I'm Gail Czukar, lawyer with the Ministry of Health. There is no definition of "long-term care facility" in the legislation because this legislation amends existing acts. It amends the Charitable Institutions Act, the Homes for the Aged and Rest Homes Act and the Nursing Homes Act, so the facilities are still funded under those acts and are still defined in those terms.



The Chair: Gentlemen, I want to welcome you to the committee, if you'd be good enough just to introduce yourselves and then please proceed with your presentation.

Mr Don Francis: My name is Don Francis. I'm the owner-operator of an 81-bed retirement home in Nepean. I'm also regional president of the Ontario Long Term Residential Care Association.

With me today is Mr Alain Brunet, who is an independent owner-operator of a 72-bed residential care facility in Ottawa that provides 24-hour care to a mix of private-pay and subsidized general welfare assistance residents. The Brunet family has been delivering residential care services for seniors in the Ottawa-Hull area for the past 36 years.

Unfortunately, Mr Tom Howcroft was unable to join us this afternoon.

Mr Alain Brunet: Our purpose in addressing you today is to reinforce those concerns and to share with you our Ottawa experience in residential care. The Ottawa-Carleton region is one of the province's most active residential care areas, with more than 3,100 beds spread out across about 50 facilities. We believe that Ottawa has been a provincial pioneer in the provision of residential care services dating back to the 1960s. The fact that we have one of Ontario's largest concentration of beds and maintain an average occupancy level of around 90% speaks to a system that is quality-driven and highly responsive to the interests and needs of both our regulators and our consumers.

In Ottawa, we have a long-standing history of working closely with a full, long-term care and social service spectrum. Both private and public sector providers work extremely well together at all levels, including placement coordination, district health councils, homes for the aged, municipal governments and social services.

We address you this afternoon, fully confident that local representatives from Ottawa's public health sector would fully endorse our position that residential care is a vital component of the areas' long-term care delivery system regardless of ownership.

Specifically, we would like this committee to consider the impact of Bill 101 on the following areas.

The consumer's choice: We are very concerned that the issue of consumer choice would be severely limited when left in the hands of singular regional placement coordinators. We are especially concerned that as the sole assessment and referral source, the information available through placement coordinators will be controlled. If that precludes full disclosure of available residential care services, we feel the system will not be in the consumer's best interest.

We are equally concerned with the limited ability of applicants to appeal their individual placement decision by the regional coordinator. If choice is truly a priority in our new system, then consumers should understand all their options and have the ability to have input into final decisions that affect their personal futures.

Sensitivity to cultural diversity: In its current format, the bill is deficient in its recognition of Ontario's cultural diversity. Curiously, for us in Ottawa, this is most apparent in the lack of recognition of our francophone community.

The placement coordination role: Although the bill sets out a new placement function, there are no details as to how the placement role will be carried out. This cannot be left in the individual regions, where we're already witnessing area managers interpreting their roles quite differently across the province. In the public's best interests, this role must be defined clearly and consistently across all jurisdictions.

Lack of accountability: In the residential care sector, we have always lived with an accountability to our residents that is unique in long-term care. By moving away from an insured service to contractual agreement, it removes the government's responsibility to fund homes equally in order to provide the same level of service across the province. This is an open invitation for the government to treat facilities differently.

We wonder, given the proposed powers of the regional placement coordinators, whether residents in homes that are not treated equally will have an ability to vote with their feet in a long-term care system that dictates placement.

Long-term care is sharing up to a heavily regulated sector. From experience, we can tell you that a significant advantage for residential care has been our flexibility in meeting the changing needs of our residents, most often on a highly personal level. This flexibility has been in the vast range of building designs, amenities, services, programs and costs across our sector. Consumers benefit most when innovation is encouraged. We believe that a highly regulated system stifles innovation, personal attention and valuable consumer input.

Adversarial direction: The inspections, as described in Bill 101, appear to be adversarial. We do not believe that any purpose is served by inspectors having access to personnel records or records of any sort that deal with quality review activities, peer reviews or quality performance activities. We share the concern of our Windsor colleagues, who explained to this committee our problems with a revised long-term care system that excludes residential care services.

Mr Francis: Despite provider and referral recognition of residential services in the long-term care continuum for several decades, this committee should be aware that the Lightman commission has recommended regulations for our sector under the housing act, as opposed to a health or social services standard.

In Ottawa we have shared Dr Lightman's proposals with many of our residents and families. We note that across the professionally staffed retirement homes in this province, Dr Lightman held no consultation with our staff, residents or families. In fact, Dr Lightman admits that his study into unregulated accommodation was focused primarily on the lowest common denominator, for the most part involving boardinghomes. We cannot emphasize enough the difference between an all-inclusive, 24-hour, professionally staffed residential care program and a boardinghome. The two are as different as night and day.

As experienced operators and involved members of our regional and provincial association, we strongly support the need for appropriate provincial standards governing our sector. But applying a housing act with all its restrictions cuts at our very reason for being. This sentiment is shared by many residents and families, who continue to react negatively to Dr Lightman's highly restrictive approach.

Based on the Ottawa experience, we can also address another important aspect of long-term care which has received limited attention. Specifically, we refer to the needs of younger adults with chronic disabilities and post-psychiatric residents. This municipality has long been a leader in the development and ongoing management of a purchase-of-service agreement that addresses the needs of this often-overlooked population segment.

The agreement between the local social services department and area home owners guarantees the rights of individual residents with respect to care levels, staffing, programming, diet, housekeeping and ongoing inspection processes. It is an agreement that has evolved through mutual understanding between the operators and the regulators and has been consistently driven by changing resident needs.

We urge this committee to review in depth the Ottawa experience as it relates to long-term care service delivery, the contribution of residential care within the continuum and the cooperative relationships that exist between both public and private providers.

In the best interests of consumers seeking quality, long-term care services, we sincerely hope this committee addresses a void that has existed since the outset of the redirection process: that retirement homes play an integral part in the continuum of services. In addition, we ask this committee to consider our recommendations specific to Bill 101.

We believe strongly that this committee's recognition of our suggestions and concerns will provide an optimum consumer choice, protection and quality service delivery. A long-term care system that formally recognizes residential care, offers consumers the full spectrum of options and pools the talents of both public and private sector providers will take us down a path of long-term delivery excellence, something that our aging population needs and deserves. Thank you very much.

The Chair: Thank you very much for your presentation and your recommendations. We'll begin our questioning with Ms Fawcett.


Mrs Fawcett: Thank you for coming before us. This is certainly one area that leaves a lot of questions unanswered in a lot of minds, I think, and I guess mine is one of them. I think there are excellent retirement homes and they provide the services you have listed here. Then of course we hear there are some that are not up to the level of standard.

Right now you are not really regulated, and you mentioned just where you might fit into this or where you might not fit into it, and I agree with you that possibly there needs to be another set of regulations. While you are providing room and board, you are also providing other services, and in some cases medical services that would be available. I'm wondering if you could address just where or how you think you should be regulated, and also, what can we do with the homes that are not up to standard? I think the level of care required -- some of the people who are coming into your retirement homes need more than just room and board.

I have a 94-year-old aunt in one of these facilities, and I know she is presently not getting, number one, even the diet that she requires. In so many cases you're not set up to provide the different kinds of diet available. And yet this was her choice, and I agree with you; there should be a choice there. But you want the best care.

Mr Francis: Our association had proposed draft legislation to define retirement homes and create a system of licensing them. Right now there is no specific province-wide standard. There's nothing defining what a retirement home is -- defining it physically as a building, defining it from a staffing or any other point of view, really. We are subject to the building code, but that's it.

We're very concerned with Dr Lightman's proposal, because his second recommendation is to adopt the premise that a retirement home is principally a provider of accommodation and not care. In my experience, that just couldn't be further from the truth. People do not move into a retirement home for simple housing. In my own facility, people are paying approximately $1,700 a month for a private room with a private bath. Meals, activities and supervision are provided. In our building, the last statistic I saw -- on 73 residents, our nursing office is supervising 638 medications a day and the delivery and the consumption of those medications. People don't move into us for simple accommodation.

Mrs Fawcett: I agree.

Mr Francis: They stay in apartments for a fraction of the price, if they can.

Mrs Fawcett: Yes. That's the one reason my aunt moved in, because she didn't want to be alone in her apartment; she wanted the social --

Mr Francis: Exactly. Right. It's the socialization. I have a number of residents who are healthy, who take no medication. But they couldn't take being alone in an apartment and taking care of themselves totally.

The other end of the spectrum is the people who need the care. We have a lady now who has just gone to a hospital, who would actually be eligible for chronic care, coming out of our facility; her needs and requirements are such. Talking with the discharge planner at the hospital, it looks like she'll actually be placed in a nursing home outside the municipality, which is not very popular with the family.

People want the care. We need some standardizing legislation and the province needs it. Our association --

Mrs Fawcett: The draft report that you have, has that been presented to the government at all?

Mr Francis: We presented it to the government starting in 1985, I believe, and repeatedly advanced it. We hope they look at it and consider it. But the housing act, the Landlord and Tenant Act, the rent control do not contemplate care in any way or sense, so they will not have any impact on it other than to restrict it.

The Chair: Okay. Mr Jackson.

Mr Jackson: Mr Chairman, not being a fan of rent control, I can tell you that would be the worst thing, because in some instances it's just a guaranteed pass-through to tenants anyway. But leaving that for the moment, have you had any indication from the government, any discussions with the government that would indicate its willingness to examine the combination of accommodation and care components of your facilities and somehow finding an accommodation within the bill?

Mr Francis: In my personal experience, which is more limited than Mr Brunet's, in the meetings on the redirection of long-term care we've been actively excluded, with them not wishing to consider us or think about us. The consumers and other providers at those meetings have actually asked why. I've seen them saying, "Why are they left out?" I appreciate that they had to draw a line somewhere. Beyond that, I'm not aware of any consideration, other than the Lightman proposals, to put any kind of regulation on rest and retirement homes.

Mr Jackson: I have an experience in my own constituency. I have some very outstanding facilities that are members of your organization. They are moving to condominiums, so that the condominium owners now have the right to determine that for this fee they will engage this kind of service. We haven't degenerated as a society to the point where what you own can be interfered with by the state saying, "I'm sorry; you cannot have a nurse on-site if you're prepared to pay her."

In the context of a condominium -- I hate to draw the analogy -- it's the same decision as wanting to put in an indoor-outdoor pool. There's capital expenditure, there's ongoing maintenance cost and there are probably staff involved. Where does the state get off stepping in and saying, "You can't do that," if the owners of the condominium in their collective determine that's what makes them a community, that's what meets their needs?

Mr Francis: In the meetings I've had with residents and family, the owners aren't the topic; it's the consumers saying: "Wait a minute. I have come to the decision that home care and other services do not fill my needs. I have freely chosen to purchase the service from you at cost to myself, at no cost to the government. What is the government doing saying I shouldn't be able to buy that service?" I've got 93-year-olds who are just jumping up and down about that. They are really upset that the government would propose to interfere with their right of choice.

Right now, in that sense, they say: "If the government is going to control it like that, whom do I complain to ultimately if my care's not right? Right now, Mr Francis, I walk in your door and I ream you right out if you're not performing. But if you're going to be in a position where you're going to say that the government says no, that I've got to obtain care services from non-profit, community-based services, whom am I going to complain to?" I don't know.

Mr Jackson: I know time is short, but I realize your residents' councils are a very vocal, active component that is -- I know this is a dirty word -- "market-driven." The fact is that the residents very much dictate the terms and conditions of operation and there's a certain empowering nobility to all of that.

Anyway, thank you for your presentation.

The Chair: Thank you very much for coming before the committee. Today, as I think you're aware, a number of your colleagues have presented as well. We appreciate very much your presentation.

Mr Francis: Okay. Thank you very much for the opportunity.

Mrs O'Neill: I'd like to ask the ministry staff, because both the last presenters talked about people having to go beyond the community of Ottawa-Carleton, which is not a small community -- and I've asked this question previously -- is there a definition now or a directive going to either the area offices or the residences themselves, placement coordination units, whatever you want to call them, about the definition of "community"? Because that's the term that's used, as I understand it, in the legislation. What is the interpretation of that?

The Chair: Meaning right now?

Mrs O'Neill: Right now and what is hopefully going to be proposed in the bill. Surely we're trying to get into a transitional model.

The Chair: Very briefly, the parliamentary assistant.

Mr Wessenger: Yes, I'll ask some staff.

Mr Quirt: I don't recall that term specifically being used in the bill, but the placement coordination services now serve the same area that public health units serve or that district health councils plan for, and roughly half the people in the province have access to placement coordination services; the other half don't. But the idea is that regardless of where you live you would have access to the facility of your choice across the province, so that PCSs would have to work together to make sure those preferences were recognized.



The Chair: I now call on the Ontario Home Health Care Providers' Association, if the representatives would be good enough to come forward. Let me welcome you to the committee. If you would be good enough to introduce yourselves, then please go ahead with your presentation.

Mrs Lucie Kean Frank: Thank you for allowing us time to speak. I am Lucie Kean Frank, assistant director of Bradson Home Health Care Services. I would like to introduce you to Claire Gonthier, the branch manager of Para-Med Health Services in Orleans.

We are members of the Ontario Home Health Care Providers' Association, which represents most commercial home care agencies in Ontario. Our members in this community operate through 11 offices with seven member agencies. Our agencies are, with one exception, Canadian-owned and Canadian-operated.

We provide publicly funded home care at a rate that is 4.5% cheaper than the local not-for-profit. We do not incur a deficit for the taxpayers of Ontario to pay off and we must meet the same training standards as the not-for-profits but without going to the province, to the Ministry of Community and Social Services, for training grants. We employ almost 2,000 health and support service workers in this region. Almost all of them are women, many are visible minorities and many are francophones. Most of the managers in these companies are women and many of them are owners.

In Ottawa-Carleton we have closely followed the government's long-term care redirection. Association members attended all the public meetings held in this region and held one of their own with officials from long-term care. Questions to be discussed at the consultation were sent to participants prior to the public forum. We can find no question on the government's stated preference for not-for-profit services in the French or English documents.

A summary report of the Ottawa-Carleton consultations states the concerns and recommendations put forward by participants. There is, again, no mention by consumers of a preference for a not-for-profit delivery system. Also, an OHHCPA director from Ottawa-Carleton was asked to take part in consultation meetings with provincial associations. Once again, there was no mention of the government's stated preference for non-profits. We wonder, then, at the government's continual assertion that this question was asked and answered by the public.

As recently as February 8, 1993, the Premier stated in a letter that a very comprehensive consultation process favoured the government's continued preference for not-for-profit services. In Ottawa-Carleton this question was not asked or answered in any of the aforementioned consultations.

Also, I want to show you this booklet published by the government prior to the public consultations and sent to each area in the province. It's headed Tell Us What You Think. Again, there is no mention of commercial or not-for-profit service provisions. The preference for the not-for-profits appears to be government-driven for ideological reasons. In Ottawa-Carleton it is not the result of public consultations.

The Ontario Advisory Council on Senior Citizens published its annual report in October 1992. This body has a mandate to work in an advisory capacity only. Members are from a diversity of backgrounds and occupations. Most are seniors and all are active in their communities. It is interesting to note that in their review and recommendations on the consultation paper they make no mention of a preference for a not-for-profit service provision. They do, however, discuss the role of women in long-term care, and we support their recommendations. We know that the majority of primary care givers are women, and it is women, again, who will carry the responsibility of caring for those at home. It was recommended that any cost savings that may result from community care cannot be borne on the backs of care givers.

We have asked to appear before you because we have another major concern. Bill 101 is the first piece of legislation dealing with long-term care redirection. This bill controls access to facility care based on the premise that there will be more care in the community. But how can there be more community-based care when the government is planning to severely limit involvement of half the providers of home care services; namely, the commercial agencies? There is no plan or funding in place to expand community-based care to the extent that will be necessary to make home care available as an alternative to facility care.

This is a concern in Ottawa-Carleton where demographics show that the elderly population is growing faster than anywhere else in the province. The disruption of switching to a non-profit system would lessen the accessibility, the availability and the quality of home care as we have come to know it in our region. For example, there would be a loss of jobs at a time of high unemployment. The cost to the taxpayer would significantly increase. The consumer would face a loss of choice and flexibility. It must be understood that if the government wanted to enforce a not-for-profit preference, no legislation or regulation would be needed to force our members out of publicly funded home care. In Ottawa-Carleton many of our member companies would be faced with bankruptcy and many employees would lose their jobs.

In closing, I would like to stress that there is nothing to be gained from a total preference for not-for-profit. We have in the past, and want to continue in the future, to work with that sector to provide quality home care with balance and choice for the consumer in Ottawa-Carleton.

Thank you. We can answer your questions in French or in English.

The Chair: Thank you very much. Merci d'être venus. We'll begin the questioning with Mr Jackson.

Mr Jackson: You obviously didn't read the NDP campaign manifesto of the previous two elections. It contained the consultation within their own party that there shouldn't be a preference for the commercial sector.

Mrs Kean Frank: Are you saying there shouldn't be or should be?

Mr Jackson: No, in its last two election campaigns it's been a cornerstone of the NDP's manifesto. At their last two party congresses they consulted with their own members, and I suppose that in the minds of the socialists that's enough consultation.

Mrs Kean Frank: That's right.

Mr Owens: That's not true.

Mr Jackson: It's the truth, Steve. If I wanted to be disgusting --


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

Mr Jackson: If you think that's a cheap shot, I could suggest to you that when your leader was studying in Cambridge he had occasion to walk down the hall and read the works of another learned scholar at Cambridge. It surfaced in Das Kapital.

The Chair: Okay, let's just direct our questions and answers.


The Chair: Mr Owens, please.

Mr Jackson: That would be a cheap but true shot. Thank you for the interjection, and thank you for bringing some order, Mr Chairman.

Currently, the system works throughout the province in varying degrees. In some areas, that service which determines the amount of money to be allocated shows a preference. In Halton region and they openly suggest a preference. There are other regions where there is -- and we've heard of this in particular in Thunder Bay, where it works very effectively -- a balanced approach in the delivery of services. The two systems work in harmony. They are able to provide varying things so that at least somewhere there is care at certain hours of the day, instead of everybody having to keep those hours. There's that flexibility in a tandem system. Just enlighten us, because we've had a bit of a snapshot, in terms of that level of cooperation and access or even differences in program delivery.

Mrs Claire Gonthier: First of all we are, as a private agency, able to offer 24-hour-a-day service, seven days a week. Some not-for-profit will not be able to provide that. That's the reason that usually they will come to the private sector. We have that flexibility. We are standardized in the sense that we follow regulations from the government. We have followed the salary requirements established by the government. When we go to submit a proposal for being a provider of care, we have to go with the requirements established. I think that in this particular region we have been able to work in harmony with the not-for-profit sector and I think we can continue to do so. I think we play a valid role and an important one that the consumer and the client would be missing if it were going to go only for the not-for-profit.

Mr Jackson: Thank you for that. I certainly can only suggest to you that it's the position of our caucus as Ontario Conservatives that we see diminished access in a single-source system and that patient choice and consumer choice is a right and a protection for the consumer from governments which change in both their philosophy and their levels of compassion. So I thank you for your presentation.


Mr Wessenger: Thank you for your presentation. I'd just like to indicate that a long-term care consultation paper was distributed, about 89,000 copies. It stated the government's preference for not-for-profit, so I just wanted to clarify that certainly it was well out there publicly.

Perhaps you might enlighten me with the percentage share of market you have for both home care and nursing care in this area -- if you could indicate.

Mrs Kean Frank: Home care and nursing care?

Mr Wessenger: Yes, the two areas in the Ottawa region.

Mrs Kean Frank: We do not provide any nursing care in Ottawa-Carleton. The visiting nursing program you're talking about?

Mr Wessenger: Yes.

Mrs Kean Frank: This is provided by VON exclusively here in Ottawa-Carleton.

Mr Wessenger: So you're just talking about home care alone?

Mrs Kean Frank: We're talking here about homemaking services.

Mr Wessenger: Homemaking only? Right.

Mrs Kean Frank: And we are very concerned that we'll be in business --

Mr Wessenger: Perhaps you could indicate to me how much. Do you know what percentage of the market you have?

Mrs Kean Frank: Here in Ottawa-Carleton I believe close to 25% is not-for-profit.

Mr Wessenger: And you have about 75% of that.

Mrs Kean Frank: Yes, it's divided between 11 agencies.

Mr Wessenger: Fine. Thank you.

Mrs Caplan: I'd like to discuss with you your role and participation in the consultation that the government has said has been comprehensive and widespread over the last two and a half years. Has your association ever requested a meeting with the minister?

Mrs Kean Frank: Yes we did, with Minister Lankin, but we did not get any meeting. She refused.

Mrs Caplan: She refused to meet with you?

Mrs Kean Frank: Yes.

Mrs Caplan: Did you write to the Premier, asking if he would get a meeting for you?

Mrs Kean Frank: We lobbied; we sent a lot of letters. We also consulted our employees as well, because that will affect them, that's for sure. The Premier has been replying with a letter, saying that -- actually, I have the letter here that he had sent to some employees. Can I read it?

Mrs Caplan: Please.

Mrs Kean Frank: He says: "We undertook a very comprehensive consultation process to restructure Ontario's long-term care system. Prior to the consultation we stated our goal of continued preference for not-for-profit services in the delivery of government-funded home care. Our consultation did not indicate that there is a feeling that we should change this direction. We are now looking at how not-for-profit services can be put into place over time without disrupting current service."

Mrs Caplan: Do you know of a direction that's been given by the minister in regions across the province without legislation, just by policy.

Mrs Kean Frank: I know that in November we received a formal memo from home care telling us that all the new cases will be given to not-for-profit. We realize the impact it has on us as well.

Mrs Caplan: And you've had no meeting with the minister or opportunity to discuss this?

Mrs Gonthier: No, we've had no meeting. We were told as an association that the Minister of Health at the time was told to meet with us. It wasn't done.

Mrs Kean Frank: We were told also that we are chasing shadows --

Mrs Gonthier: That is not really true, what they're planning to do.

Mrs Caplan: Could you explain that?

Mrs Kean Frank: We were told that we are chasing shadows, that there's really nothing official that came to tell us we're going to be out of business. But, as I said, they don't need legislation, they could just kind of gradually assign all new cases to the not-for-profit and very shortly we'll be out of business.

Mrs Caplan: And you've been told that's happening already.

Mrs Kean Frank: It is happening now, yes.

Mrs Caplan: I'm aware of a meeting that took place between representatives of your association and a policy adviser from the minister's office and the Premier's office. Are you aware of that meeting?

Mrs Kean Frank: Yes.

Mrs Caplan: It's my understanding that your representatives were told there was no place for the private sector in the delivery of services, is that correct?

Mrs Kean Frank: They want us out of human services.

Mrs Caplan: Say that again, please?

Mrs Kean Frank: They said they want the commercial agency away from the human services.

Mrs Caplan: And this is from the same government and the Premier who in a speech yesterday said that all the labels -- that they'd reconciled the left and the right and that they were working cooperatively with business; they were no longer anti-business, private sector. Did you read about that speech?

Mrs Gonthier: Not yet.

The Chair: Final.

Mrs Caplan: I guess the concerns I have are that, one, you're not being listened to. You provide an important service. We have always believed, and I believe personally, that what's important to the people of this province and to the taxpayers of the province is that they have the highest possible quality service at the best price. What seems to be important to the government, its ideology, is more who's providing the service than the result of the service it's providing.

Mrs Gonthier: The cost-efficiency of the service should be a big factor right now with the big deficit we're facing. We are taxpayers as well.

Mrs Caplan: Best service at best price rather than publicly run, government-run services, and you see us moving towards a broader public sector, regardless of what the expense is.

Mrs Gonthier: What the cost would be to thousands of jobs, specially women.

Mrs Caplan: And you're worried about that as private sector employers as well as the taxpayers of this province?

Mrs Gonthier: Definitely.

Mrs Caplan: I share your concern.

Mrs Gonthier: Thank you.

Ms Carter: Do we have any more time?

The Chair: I'm afraid we don't. I want to thank you both for coming forward. J'aimerais vous dire aussi : vous avez exprimé vos remarques en anglais et, si je comprends très bien, vous êtes francophones. Alors, laissez-moi vous remercier de votre participation cet après-midi.

Mme Kean Frank : Merci.

Mme Gonthier : Merci beaucoup. Thank you.


The Chair: I now call on the Kanata Beaverbrook Community Association, if they would be good enough to come forward. I should have said the representatives of the Kanata Beaverbrook Community Association. Welcome to the committee and if you would be good enough to introduce yourself and then please proceed.

Mr Fred Boyd: Yes, I was going to say I'm not the association. My name is Fred Boyd. I happen to be the president of the Kanata Beaverbrook Community Association and chairman of what we call the Joint Committee of Community Associations in the city of Kanata.

I wish to say that this brief has not been approved by the entire association. It has been reviewed by the executives of both groups, but I wish to take full responsibility for the actual words and so forth.

The Chair: What's good belongs to everybody and what doesn't belongs to you.

Mr Boyd: Something like that, yes. I really dislike reading a brief or a paper, but I understand the difficulty here in that you have not had a chance to read it ahead of time. I will do as I think is the practice here, essentially read it, dropping out a few things and perhaps injecting a few points along the way.

First of all, thank you very much for the opportunity to speak to you on this important issue. I guess a bit of a background to comment meaningfully on this bill is really necessary to look at the objectives of the bill and basically what it's trying to do. That includes a couple of basic questions of what are the objectives and does the bill appear to fulfil the objectives or part of those objectives.

As far as the objectives go, we have seen the consultation paper, Redirection of Long-Term Care in Ontario -- I think that's the title -- and in some sense, we feel we should have been commenting on it, but if there was an opportunity to comment on that consultation paper, we missed it. So we're taking this opportunity to come forth. I will try to keep our comments as much as possible on the bill even though, as I say, the context is important.


I also heard yesterday one of your members mention that there is a policy paper forthcoming, or being promised in the near future. Just a quick aside, I find it rather sad that the bill comes out before the policy paper, but that's just a quick injection.

Going back to the background, as I mentioned, I am the president of the Kanata Beaverbrook Community Association and chairman of the joint community associations of the city of Kanata. Kanata is a satellite city in the western part of this region -- satellite in the fact that it is outside the greenbelt and therefore significantly more separated and, I guess I might say to some degree, independent than the typical suburb. In that regard, we have a significant commercial and industrial base which provides employment for about half of our working population, or equivalent to about half our working population.

As I mentioned earlier, the brief has been reviewed by many people -- the executive of my association and people representing the other associations -- and has tried to incorporate essentially all of their comments, but the words are actually mine.

To some extent, just to open a point here, it's a bit of a companion to the personal account by Lesley Cluff last evening. Mrs Cluff is a member of our association in the community. As you heard, I think it was a very eloquent, personal explanation and presentation of what we know many people in our community are facing and hers is perhaps more extreme. I was pleased that she was prepared to come forth and give you that personal account.

The Beaverbrook community in Kanata is the oldest part of Kanata and that reflects one reason why I'm here. Kanata itself is a young growing city and, as a net result, has a younger population distribution than the average in the province. Our particular community, which has been established, was begun about 27 years ago and has been sort of fully established for almost 20 years.

In my perception -- we don't have the actual figures -- it is closer to the provincial average. We have a very significant number of elderly people in our community and our community association reflects that. That is one reason I'm here speaking because this topic has come up several times within our monthly meetings and other arenas, should we say, and there have been repeated concerns about the direction of long-term care.

Jumping over some of that material on Kanata, I'll turn over to page 3. Despite an obvious need, in particular in our community, we do not have any of the long-term care homes being specifically addressed in this legislation. In Kanata we have two retirement homes which provide extended care. I'll be coming back to that particular topic later. Also, we do not have any hospitals. We are now a city of 40,000-some and we must depend upon the Queensway-Carleton Hospital in the western part of Nepean, which is some distance away, and which many of us are concerned about because it has not been allowed to expand at all even though it -- I think they call it the catchment basin -- has expanded by at least a factor of three or more since it was opened.

A particular point about Kanata is that it's surrounded by a rural area. There's a rural sector in the city and it is contiguous to two rural townships, Goulbourn and West Carleton for which Kanata serves as the focal point. A specific expression of that, in this context, is the community resource centre of Goulbourn, Kanata and West Carleton which provides social assistance for this whole area.

The centre offers a number of services: crisis support, abuse counselling, community support and is a source of information for many of the services that have been referred to in your hearing. In a particular regard in this area, it does provide Meals on Wheels and also transportation services for seniors and the disabled to go to medical appointments and so forth.

As a quick aside here, that presumes the elderly and the disabled are able to make the arrangements for such appointments. I would suggest that comes back to a little bit of the question of psychological aid, which was referred to by a presentation last night.

Now, getting specifically on to the bill, in my eyes -- and I have been involved with legislation, regulation and so forth at the federal level over the years -- Bill 101 appears at first glance to be what I would call housekeeping. In other words, it's reworking a number of other laws. It's very, very difficult, even for someone as familiar with legislation, to grasp its contents and its real intent. My own view is that it would have been far better to have scrapped certainly the three key acts on old-age homes and so forth and come up with a brand-new one.

Just reviewing the points which according to the compendium are the points which are being addressed in this bill and which you can determine from a close reading of it, these are the ones that I will be addressing as to our judgement as to how it affects that, and then we'll try to deal with a couple of comments on what the bill does not address.

The bill proposes a consolidation and harmonization of several types of long-term care homes. It establishes a funding system based on the level of care and the creation of placement coordinators, the provision of rules for payment by residents and the requirements of formal accountability and quality assurance programs and the enabling of direct funding for disabled adults.

My comments, as I say, will deal with these particular headings, and just going back to what I just said a moment ago, my personal feeling is it would have been far better to have come out with a brand-new act rather than this extensive modification which is, as I say, very, very difficult to deal with and to read and to fully grasp. I'll now go on to the specific points.

Consolidation: I'd say that given the variations in the various types of long-term care facilities in the province that any of us have been involved with, there's no doubt that this is a very positive move, and we support that even if, as I say, the mechanism appears to be cumbersome.

The funding: The level-of-care system and the service agreement concept that goes with that again seem reasonable, but we're left with a problem that all of the details -- the criteria, the guidelines and so forth -- are left for regulations. I've been involved with the development of regulations. As I say in here, regulations are typically developed by officials and, in our experience -- I presume it's the same at the provincial as at the federal level -- quite often reviewed only in a perfunctory manner by cabinet or their agencies, which leaves no input for those affected by the regulations. The regulations will be what affects people, and not the enabling legislation.

Our first recommendation is that proposed regulations be issued for public comment before being put into force.


On the access to the facilities, the concept of a placement coordinator is presented. There have already been several comments to you on that and I'm sure you have heard it in other localities as well. We are quite concerned. This appears to be an almost heavy-handed situation, if you want to call it that. As I've said, there does not appear to be any allowance for local input into the selection or appointment of the placement coordinators or local involvement in the decision-making process. While this may provide some province-wide uniformity, it does ignore local conditions, disregard what we would consider to be a legitimate role of the local community and, for many of us, imply what I would call a Big Brother approach, which we find demeaning.

When you add that to the words in the consultation paper on redirection of home care and support services that there be no more beds for long-term care for several years, and put that in the context of the rapidly growing elderly population, we can see that there will be a very much of a backlog here, a real bottleneck. We have the fear that these placement coordinators will then have to be applying what I will call draconian rules to restrict access. Then you add to that the appeal mechanism, which in our mind sounds very cumbersome and bureaucratic and to me, because I've been through this, suggests a process similar to the Ontario Municipal Board, which is not easy to use.

We have several recommendations coming out of this:

We propose that the legislation should allow municipalities or community health groups or other appropriate bodies to have an input into the selection and appointment of the placement coordinators.

We recommend that the province provide guidelines for access that would be used by these placement coordinators and make these guidelines available for public comment prior to them being put into force, and that the appeal board should be at least established regionally to make the mechanism easier for people to make the appeal. In the situation where there are expenses involved, we suggest that the legislation provide or allow for the compensation of expenses by applicants, by people making appeals.

We then make our last plea, that there really should be an expansion of long-term care facilities. I'll come back to that perhaps in final comments.

The enabling legislation for payment by residents appears to be a reasonable approach. Again, the concern we have is about the specific regulations and also the effectiveness of the inspection that will ensure the level of care for which the funding is actually provided.

As above, we would recommend that proposed regulations in this context be issued for public comment prior to them being put into force, and that adequate and effective inspection be put into place. I'll come back to that in a moment.

On the broad question of accountability and quality assurance -- and I would add to that inspection -- the bill requires facilities to provide financial records for inspection, to post financial information and to prepare quality assurance plans. It also provides for enhanced inspection powers, which I was pleased to see.

I'd say this is an excellent provision at the legislative level, provided the regulations are put into effect properly and, even more so, provided they are actually carried out. Our concern is that effective inspection requires an adequate inspecting staff and sufficient qualified inspectors to do so. Our concern is that with the current budget restrictions, it is quite likely that this will not come about. Therefore the bill will be what I would describe as a paper tiger, having wonderful provisions but not actually being carried out.

Just as a quick aside, I'd make the comment that we would hope the bill would not preclude -- and it does not appear to do so -- unannounced inspections. I've been in the regulatory business and I can assure you that unannounced inspections are an essential component if you really want to have an effective inspection program.

Our recommendation is that the bill should stipulate the extent of inspections and a minimum number of inspections per year. I say this because this could put an onus on the government to ensure that the inspection capability is actually provided and that inspections are actually carried out. Also, our suggestion is that inspection reports be made public. In addition to the posting of the financial information, I think any inspection report should be posted also.

On the question of funding for disabled adults, just a very quick point. This just sounds like a very desirable move, and no comment on that other than to say that there is also the question of psychologically disabled people. The bill is silent on that, but that's perhaps a completely different topic.

There are a number of areas which are not specifically in the bill and therefore you have to either infer or look for them or look for what is missing. One of them is that we feel there is a definite need for standards for and inspection of home care services. If you're going to go to a system where you're going to have more people staying at home, more people depending upon the home care system, then that system must be regulated to an equivalent degree to the home care facilities.

In essence, we would ask that the bill be modified to require the issuance of regulations governing the qualifications of home care professionals and the standards of home care service, with some provision to allow inspection of those services.

The bill is silent on retirement homes. I was interested to hear the presentation or two before mine, and interested to hear that those operators of retirement homes seem to be prepared to be regulated. In our mind, retirement homes are very much part of this spectrum of long-term care facilities and, as such, should be regulated to make them consistent with the other parts of the system.

There has been considerable mention of for-profit and not-for-profit facilities. Our feeling is that we see no reason why one or the other should be excluded. The primary need is effective care for the people who need the care, and as long as there is an effective regulatory system to ensure proper standards, an effective regulatory system to ensure fair payments, fair costs, then in our judgement there is no reason why you shouldn't have both forms of facilities.


Just as a quick aside, I noticed that in the compendium accompanying the bill it stated that the payments by residents would be based upon, where there is an association with ability to pay, income and not assets. I don't see that any place in the bill. It seemed to me it should be in the bill and not just in regulations.

Our basic recommendations are that there should be provision for regulation of home care services and the professional personnel of those services and that they should establish a regulatory regime for retirement homes.

Just to summarize what I've said to date, I mentioned that we feel that the particular form is cumbersome; there is a need for local input into the appointment of placement coordinators; there is a lack of information at this stage on the criteria, rules and all the regulations that go with that; there is an absence of mention of retirement homes; and there is an absence of provision for regulation of home care services.

To summarize our recommendations, we recommend that the proposed regulations under the bill be issued for public comment prior to being put into force; that there be provision for local communities or municipalities to have an input into the selection and appointment of placement coordinators; that there be a requirement that the guideline for access be issued for public comment; that the bill include a stipulated minimum inspection frequency for all long-term care facilities; that there be a requirement that the inspection reports be made public; and that there be a provision for regulations governing the standards of home care services and qualifications of home care professionals. Further, there should be legislation, whether it be in this bill or not, to cover retirement homes. Finally, our last plea is that additional home care facilities be provided.

If I may just make some final remarks, our real concern is the policy behind this bill. The Redirection paper states bluntly that there will be no more long-term beds created and the bill, as I say, appears to reflect this without stating it explicitly. The argument for not providing more long-term facilities is that most people would prefer to stay at home. Our attitude is: Of course, if you ask people, that would be the answer. But we would say that this ignores what we would call the pressing demographics. The number of people over 85 is increasing by 4% per year according to Statistics Canada and that rate of increase is increasing itself, so you've got an exponential growth here.

A high percentage of those in that age group are now institutionalized. I would suggest our feeling -- not just my own -- is that this is not due to callousness on the part of the family, as has been implied by some, but rather generally because the family, where there is a family, is unable physically, psychologically, financially or otherwise to take care of its elderly relatives at home. This would apply even if home care services were augmented. I might say, just as an aside, that I've been very disturbed, speaking to many different agencies in the area, that there doesn't appear to be any real sign yet of a significant increase in funding for home care services.

If you'll permit me just a personal note, I have an elderly mother in a nursing home in Burlington. She's there because there is absolutely no way that either my sister, who is older than me, or I could look after her. We don't have the physical strength, the mental fortitude, as I put it, or the facilities, as Lesley Cluff mentioned last night, to do so. I know of many who are in the same boat. I know of several people in our community who are actually trying to look after their elderly relatives, either their spouse or their parents and so forth at home, and destroying themselves and their family in the process.

For a government which avows its concern for social justice to use the results of what I would call a questionable opinion poll or a fine-sounding but abstract principle -- ie, that the elderly should stay at home -- as an excuse to save money by refusing to provide more desperately needed long-term care facilities raises thoughts of cynicism and hypocrisy.

The move to harmonize the laws governing the various types of long-term care facilities is laudable. We support that. However, if there's no action to increase home care and community support services and no willingness to recognize the rapidly growing elderly population by creating more appropriate facilities, this exercise could be described as a legislative shuffling of the chairs on the Titanic while the ship of long-term care sinks in the icy waters of budget restraint. Pardon me for the flowery words.

The Chair: Thank you very much for your presentation. We are tight on time, but I will allow one short question per caucus.

Mr Villeneuve: Mr Boyd, thank you very much. You've touched on a number of things that are very important in parts of rural Ontario, in West Carleton and Goulbourn, as they apply in your area. Meals on Wheels, transportation, medical and legal appointments are most important to those elderly people out in rural Ontario. I think it's been found in other areas that whenever the private sector has moved out and it becomes delivered by the public sector, we tend to lose many of these volunteers. Could you comment on that? Because I know your community association is very much a group of volunteers. We also had a presentation this morning by the regional municipality of Ottawa-Carleton with very alarming results: the population and demographics and a number of other things that touch your neighbourhood.

Mr Boyd: May I just ask, was that the one from the homes for the aged group of the region?

Mr Villeneuve: Yes.

Mr Boyd: Yes, I'm aware of that one. I have been in contact with them.

I'm not quite sure whether I caught the flavour of your question. First of all, our community resource centre is staffed by a small number of paid professional people, but much of the work is done by volunteers. It is a not-for-profit operation. I suspect the volunteers would be less willing to volunteer for a private operation; in fact, I think I can express that fairly strongly. The volunteers seem to prefer to help not-for-profit organizations. I'm not sure whether that's the answer you wanted or not, but that's my view and that's the situation.

Mr Villeneuve: Your comments are well taken, but I think the word "not-for-profit" is misleading. The people who preceded you here are private sector deliverers of service for about 5% less than the so-called not-for-profit group. We have to remember that the "not-for-profit" connotation tends to be a little bit misleading at times.

Mr Boyd: As I mentioned earlier, we certainly, in the broad sense, have no feelings for or against. In general, we'd say we support the private involvement as well as the not-for-profit involvement.

The Chair: Ms Carter? Again, if we can just be brief.

Ms Carter: You certainly covered a lot of ground, so I'd just like to make a comment and then a question. First of all, you say on your page 10 that the government used "the results of a questionable opinion poll" as a basis for trying to keep more people in the community. I'd just like to say that there was a most incredibly extensive consultation process with the public and all kinds of interested groups. I forget the actual numbers as to how many people participated --

Interjection: It was 75,000.

Ms Carter: -- 75,000, and the number of briefs. The government issued a document and people commented on it and so on. I don't think it was a questionable opinion poll. I think there was a lot more to it than that.

But what I really wanted to ask you was that we've had a lot of presenters at this committee saying that they didn't like the suggested inspection process. You seem to be in favour of that. Just as a matter of interest, I wondered whether you felt that the other checks and balances that will be in place are inadequate. For example, each resident will now have an agreement as to what care is to be provided to him, and if that is not lived up to, presumably he can complain or call an advocate or whatever. There are residents' councils, not in every institution, but again, that's fairly widespread. Then there's the system of accreditation that was mentioned, I think, several times this morning, whereby institutions are inspected and, if they're accredited, then presumably they shape up. I just wondered if you'd like to comment on that.


Mr Boyd: I know the Chairman is short on time and I'll try to be quick. First of all, I would say that the resident agreement system was not adequate. I really firmly believe, both from a personal point of view of a background in regulation and also involvement with and reflecting other people in this area, that you do need an external inspection service. If you had something you called accreditation, if you had that system applied throughout the whole regime, through all these homes, including the retirement homes I mentioned, to me that's part of what I would call this regulatory inspection system. I think both are desirable, but I would strongly urge that you do need a good regulatory inspection system.

Mrs Fawcett: I was really interested in your idea that rather than amending the present three acts we should move to a brand new one. Having heard the other presenters before you, I'm just wondering if possibly then we could include chronic care hospitals and retirement and rest homes and do the whole thing all in one brand-new bill.

Mr Boyd: There's no doubt in my mind and in most of the other people who have reviewed this with me that this is the way we feel, that it would be far better to first of all have a clear policy laid out and then a brand-new act which would then replace these various acts which are around at the moment. At the moment you will have a very odd situation. You'll have this amendment act and you'll still have all of the other acts sitting there. It's going to be very difficult for anybody to keep track of it all.

Mrs Fawcett: Just around the ideas you put forward on inspectors, we've heard many, many presentations saying that the inspector idea is punitive and there is resentment built up. Rather, we have gone past that and gone to quality management and improvement measures and residents' councils help out and all those kinds of things, as long as the assurance is there.

Mr Boyd: I've been through that, and even if you have a so-called quality assurance system, you have to have a good audit of that quality assurance system, which is almost the same thing. It's not quite the same -- the technique is slightly different -- but you still need this external regulatory overseeing, if you want to call it that.

The Chair: Thank you.

Mr Boyd: I apologize for being longer than I --

The Chair: Not at all. We thank you very much, and also those who worked with you on the presentation. Thank you for coming.

Mr Boyd: May I just say very quickly -- I didn't say it at the beginning -- that our objective was just to come in as a completely -- what do you call it? -- disinterested body. In other words, we're not in the system. Our only concern is our own elderly residents. I've been slightly concerned to see that three quarters or more of the people speaking to you are coming with what I'll call a fixed agenda. I know you'll all be able to weigh all that and sort it out. Thank you.

The Chair: With the wisdom of Solomon.

Mr Jackson: That stands for the members of the committee as well.

Mr Boyd: Oh, yes.


The Chair: I call our next witness, the Council on Aging for Ottawa-Carleton, if you would be good enough to come forward. Welcome to the committee.

Mrs Sylvia Goldblatt: I'm just going to pour myself some water.

The Chair: Yes, please. I wonder if we need some more glasses. We'll just check and see whether you need some more water as well. We want to thank you very much for coming to the committee. If you would be good enough to introduce yourselves, then please go ahead with your presentation.

Mrs Goldblatt: Thank you very much, Mr Chairman. I'm Sylvia Goldblatt. I'm here as one of two vice-presidents of the Council on Aging. In some ways, I represent an example of a 70-year-old consumer who is delighted to have the opportunity to participate in this discussion.

I realize your time is short, and I'll get to my brief. I would just like my colleague to have an opportunity to introduce himself and give you some feel for the Council on Aging as well.

Mr Greg Fougère: My name is Greg Fougère and I'm the chair of the institutional long-term care committee of the Council on Aging, which is the standing committee of the council. The council, as Sylvia will introduce, involves representation from seniors, interested citizens and providers. This institutional long-term care committee is representative in that way.

As a provider, a professional working in the field of long-term care, I've worked for the last 15 years in the community home support area, in the homes for the aged area and I'm currently in a chronic care hospital. I'm here as support to Sylvia, who will be presenting today.

Mrs Goldblatt: It just occurred to me that there is one other thing I'd like to say before starting on this brief. In a former life, I worked for Canada Mortgage and Housing in the area of social housing, which involved housing for the disabled and the elderly, and have been in this gerontology field for about 30 years. I always jokingly said I was involved because of enlightened self-interest. Of course, I never realized the validity of that until I hit 70. I can tell you that yes, this is a great field to be active in when you're younger so that it's there for you when you are older.

Mr Jackson: That's enlightening, yes.

Mrs Goldblatt: That's a message to all those people who don't have grey hair.

Mrs Caplan: For as long it takes for this policy to be developed, we'll all be there.

Mrs Goldblatt: You'll have arrived.

The Chair: Order, please.

Mrs Goldblatt: You can see what I started.

Let me tell you a little bit about the Council on Aging. It's a voluntary planning, coordinating and advocacy organization. It serves 70,000 residents in the Ottawa-Carleton area who are 65 years of age and over. The council is composed, as Greg said, of seniors, professionals working in the field, care givers and other interested persons and has been operating since April 1975. You can see we're aging too. Members study issues of interest and take advocacy stands when appropriate.

The council has been very supportive of government initiatives which will enable seniors to remain in the community for longer periods of time, and yet it acknowledges the importance of the availability of quality care in institutional settings when it's needed. The principles of choice, self-determination and independence -- and I heard these referred to several times this afternoon -- are central to the council's philosophy. You'll recognize this commitment in our response to Bill 101.

In order to prepare our response to Bill 101, the council established a task force with representation from various council committees, as well as from the board of the council. As the vice-president of the Council on Aging, my comments will focus on the implications of Bill 101 from the perspective of a consumer.

Our brief will deal specifically with four issues that relate to the following areas of change to the legislation: funding reform; access to facilities; accountability and quality assurance; and direct funding service model. When we get to that one, I know you have used it as an area that is concerned primarily with the disabled, but we have developed a thought on that score that we we'll discuss a little later.

The first item I'm dealing with is the funding. The council supports a uniform method of funding for charitable and municipal homes for the aged and nursing homes in recognition of the reality that many residents in these facilities actually require the same level of care. We also recognize that former discrepancies in funding formulas for these facilities have resulted in a hardship for many for-profit operators to allow them to provide the level of care that residents require.

However, it is imperative that equalization not result in decreased levels of service in the non-profit sector. That's an important point. For example, the non-profit areas provide social work, patient advocacy and sensitive administration of means testing. These are valued services available in many homes for the aged and necessary in the for-profit sector, but often we're not in a position to provide them.


Bill 101 should be an instrument to establish an appropriate level of funding which reflects the real costs incurred in providing an appropriate range of services which are sensitive to the health, social, psychological and spiritual needs of the residents. A reduction in the present level of services in charitable and municipal homes for the aged would be unacceptable. That little warning, I think, stems from the fact that we realize that where the dollars are going to be placed is always a matter of judgement.

We're simply making the point that it's terribly important that we not lower the standards of service for the elderly across the board in an attempt to provide a greater degree of efficiency or a greater degree of equalization. We recommend that equalization of funding reflect the real costs of providing an appropriate range of services for residents in for-profit homes and that services in the non-profit sector be protected so that we don't go to the lowest common denominator.

The council has concerns regarding the ability of facilities to adapt to the changing care needs of residents following the implementation of a funding process that is based on an annual level-of-care classification. Since the long-term care reform will result in many seniors being able to remain in the community for longer periods of time, in many instances when seniors are admitted to long-term care facilities they are sure to require more care and are apt to decline more rapidly than in the past.

Under the proposed system, residents are to be classified annually in order to determine the funding for the facility. It is unclear whether the facility will be able to provide appropriate care for residents if their care needs increase significantly during the year without a comparable increase in funds. The council recommends that a process be included within Bill 101 to ensure that facilities will be able to provide appropriate care between annual assessments.

Our next point refers to collaboration in the placement process. The fundamental issue, when examining access to facilities, is how to enable the province to coordinate access to, and manage the use of, scarce facility services to ensure that those most in need gain access.

Ottawa-Carleton is very fortunate to have a well-established placement coordination service which has provided quality service to the seniors in our region since 1976. It has been through the collaboration between institutions, applicants and the placement coordination service that the needs of seniors requiring placement have in fact been met. Consumer choice remains central to the concepts of self-determination and independence and is key in the placement process. It is important that this history of cooperation continue in the region. However, it is recognized that there may be occasions where agreement in the placement decision cannot be reached.

The council has several concerns regarding the appeal process under these circumstances. Placement is often an emotional time for seniors and their families. The appeal process is the mechanism by which consumers are assured that in the event that agreement cannot be reached between parties, there is a process outlined in the legislation which gives the consumer an opportunity to appeal the decision.

We refer to subsections 9.8(3), 19.2(3) and 20.4(3) of Bill 101 which state, "One member of the appeal board constitutes a quorum and is sufficient for the exercise of the jurisdiction and powers of the appeal board under the act."

The council believes that consumers' rights may not be respected if the possibility exists, as laid down in the legislation, that one person could conceivably be charged with resolving the placement decision. Our recommendation is that not less than three persons constitute a quorum in order to facilitate an unbiased decision on the part of the appeal board.

We discussed the composition and operation of this appeal board. Under the sections noted, Bill 101 states that, "Not more than one member of the appeal board members holding a hearing under this act shall be a physician."

Now, we're recommending that it be mandatory that a physician sit on the appeal board, since one of the most significant factors taken into consideration regarding placement is the medical need of the client, so the absence of a doctor on that board could be a real deficiency.

The manner in which the appeal board operates is key to its effectiveness. We're recommending that the appeal board hearings be held locally and that appeals be heard and a decision made within 30 working days. We're also dealing with people, like this committee, who are running out of time. With older people there is really very little time available. They can't sit around waiting for a process to provide them with an opportunity to get some kind of reasonable decision.

We're discussing the right of appeal for institutions. The appeal process should be available not only for clients but also for institutions which may not agree with the decisions made by the placement coordinator. The proposed admission process greatly diminishes the right of institutions to refuse clients. Without consideration of an institution's reasons for not wanting to admit certain clients, the care provided to other residents could be jeopardized. The admission criteria should enable a right of refusal by institutions in cases where justifiable reasons exist. Our recommendation is that there be equal access to appeal for institutions as well as for consumers.

Our next point has to do with cultural sensitivity in placement, and I notice since I've been sitting here for a couple of hours that this one's been addressed before. It is important in our community. We have a very large francophone community, and we're very aware of how often that francophone community is underserved. So we're making the point that it's important that francophone seniors have equitable access to long-term care facilities and that placement coordinators continue to be sensitive to their cultural and linguistic needs.

In addition, there are ethnic and religious groups such as Jewish, Italian, Japanese, Chinese, Catholics, East Indian and aboriginal peoples -- I've probably left out a few -- for whom it is vitally important that their religious, cultural and linguistic requirements are respected. When people reach an advanced age, they often feel more comfortable using their mother tongue and sharing their life with those who share their culture.


Our final comment deals with the placement advisory committee regarding the issue of access to facilities, concerns that are known as hard-to-place clients. Here we're referring to people with Alzheimer's, mental confusion or this kind of thing -- is this one making you happy?

Interjection: No, Elinor says Randy --

Mrs Caplan: He's hard to place.

Mrs Goldblatt: Oh, you think he's hard to place. Well, maybe he hasn't quite reached that point yet. These persons often have difficult behaviours -- does he have difficult behaviours?

Mr Jackson: Yes.

Mrs Goldblatt: Yes -- and pose a significant challenge to the placement coordinator when attempting to find an appropriate facility which could meet their needs, while at the same time respecting the rights and needs of other residents.


Mrs Goldblatt: Yes. I can well appreciate that by this time you're all feeling a little bit slap-happy, because you've been here so long. However, I will finish shortly.

It's recommended that a local multidisciplinary committee be established which could be called upon to provide advice and direction to placement coordinators faced with difficult placement decisions. That's a really tough decision call and we feel it really requires a multidisciplinary committee to help the placement coordinators to make decisions that are good for everyone.

It's further recommended that cases should be heard and disposed of in not more than 30 working days in order for the placement advisory committee to be effective. One of the potential benefits of this proactive approach could be a reduction in the number of cases brought before the appeal board.

Here we're talking about planning for changes in legislation. The public has been given the opportunity to comment on Bill 101 without knowledge of the regulations referred to in the bill and to which facilities must comply. In effect, our comments today are based on only part of the legislative package. It's important that the regulations are made available to all interested parties in order that they can understand and comment on what appears to be acceptable or unacceptable. With confidence in the process, I'm very hopeful that the fact that you are giving us this opportunity to talk with you before issuing the regulations is going to make it possible for you to incorporate some of these ideas in the regulations and we look forward to seeing them there.

The inspection process and the role of accreditation: It's recognized that the inspection of facilities serves as an important role in ensuring that regulations are followed for the safety and security of residents. We realize, however, that compliance with regulations is not synonymous with quality of care. Furthermore, extending the inspection process beyond nursing homes to homes for the aged will incur a considerable expense.

Despite the important role inspection plays, the voluntary process of accreditation provides a valuable way to educate and assist facilities in improving the quality of service to residents. Due to the expense of increasing the scope of the inspection process and the merits of accreditation, a process should be stated in Bill 101 which would enable inspectors to focus their efforts on facilities for which the inspection process may be more necessary.

Our recommendation is that inspection should be on a less regular basis for those facilities which have a good accreditation rating and no complaints lodged against them. It's also recommended that the inspection process be of first priority for facilities without accreditation or for which complaints have been lodged.

An outstanding issue which relates to the inspection process is the government's responsibility to act when a facility has been found to be substandard. This is one very close to our hearts. In the past, facilities have been placed under the enforcement branch of the Ministry of Health. However, placements may continue to be made to those facilities. It is unclear under the proposed legislation how such homes will be dealt with.

One of the major challenges of the funding reform will be to ensure that private entrepreneurs meet the regulations without the threat of withdrawing funding. This is a critical issue for the government to address due to the number of nursing homes which are going bankrupt across the province at the present time. The government must come to terms with its position on the place of the for-profit sector in the delivery of long-term care services in institutional settings.

In light of the legislation under review, clarification is needed regarding the term "extraordinary event." When compliance to regulations relates to expenditures for renovations to a building, for example, and compliance is not financially feasible, provision should be made for capital financing for the private sector under certain circumstances; for example, when the facility is providing quality care to residents and the building is worth additional investment. We just don't want the people living in those facilities to suffer and this is one way that issue can be dealt with.

Our recommendation is that structural upgrading of facilities be included in the concept of extraordinary events. It's understood that upon inspection some facilities may need to be closed. In the past, when inspection has shown a facility to be unacceptable, there has been a lack of government action. This set of conditions must not be permitted to continue. We've all heard some of those horror stories and we'd like to see this as the occasion on which that ceased to exist.

This lovely word "exculpatory" clauses in the legislation: A final point regarding accountability relates to certain clauses in the legislation which appear to give unconditional immunity to certain professionals in the execution of their duties, and I heard that referred to by other briefs as well. Section 9.6 and subsection 10.2(1) to be introduced in the Charitable Institutions Act and sections found elsewhere in Bill 101 state that no proceedings for damages shall be commenced against a placement coordinator or an inspector for any act done in good faith.

We think there is no acceptable reason why these persons should not be liable for their actions, as are other professionals who have responsibilities to the public. Our recommendation is that clear guidelines for admission to facilities be established in order to avoid abuse of the system by any of the interested parties.


New sections 9.12, 19.5 and 20.8 to be inserted into the Charitable Institutions Act, the Homes for the Aged and Rest Homes Act and the Nursing Homes Act, respectively, provide that the institution develop a plan of care to meet each resident's requirements. The resident is to have access to the plan of care, but input into the plan has not been stipulated in the legislation, so it's hard for us to see how they are going to have an opportunity for this kind of participation.

We're recommending that provision should be made for the resident, his or her family, attorney or guardian to have input into the plan of care, consistent with the rights of the individual enshrined in the Substitute Decisions Act and the Consent to Treatment Act. The Council on Aging made presentations with respect to those as well.

The fourth and last issue I'm addressing today is the direct funding service model. The council commends this initiative and welcomes the flexibility it will bring to persons with disabilities in the purchasing of services to meet their individual needs. We realize that you're referring really to younger disabled people, like quadriplegics and this sort of thing. I have seen, in Toronto and Ottawa, examples of where this has successfully been achieved and you're able to accommodate quadriplegics in an apartment building in downtown Toronto and have attendant care workers who are hired by the users of those attendant care workers and they can remain in the mainstream of society.

We're saying it's a reality that as people attain a more advanced age, 80 and over -- a little aside: Somebody said old is always 15 years older than you are so, at 70, I'm referring to people 85-plus -- it's a reality that as they grow older the chances are higher that they will experience physical or mental disabilities that threaten to institutionalize them. This is particularly true for those who live alone. Although this section of Bill 101 may have had younger people with serious physical disabilities in mind, there is the potential here to use this concept to address the issue of supportive housing for frail elderly people. It would enable them to live independently with the security of having available the support services they require.

For the many years I worked in housing, it was always a source of great frustration that it was so difficult to get the ministries of Housing, Health and Community and Social Services to sit down together around the same table and solve the problems of the same people each of them was dealing with, but it was so difficult to get that kind of process moving. I would say we are a little closer today. I think we should feel a little bit of encouragement on that score.

Our recommendation is that the government consider broadening the scope of the direct funding service model to include supportive housing for the frail elderly.

In summary, the Council on Aging supports the move towards equitable funding between homes for the aged and nursing homes, but it cautions that revisions to the funding scheme not be punitive to the non-profit sector. I think I explained what we meant by that. We realize that the for-profit people have not been able, in many instances, to provide what the not-for-profit people have done and we don't want everything brought down to the lowest common denominator. It is also recommended that mechanisms be established to enable funding to be sensitive to changes in levels of care between annual assessments.

The council supports the continuing role of the placement coordinator but it suggests that revisions be made in the appeal process. It is recommended that the quorum for the appeal board consist of three persons, one member on the board should be a physician and that the hearings for the appeal board should be local and timely. It is further recommended that a multidisciplinary committee be established to assist and direct placement coordinators regarding hard-to-place clients. It is also recommended that the appeal process be broadened to include the possibility for institutions to appeal placement decisions as well as residents.

The Council on Aging recognizes the valuable role inspection plays in ensuring that facilities comply with regulations. However, the council would like to see an increased emphasis on the accreditation process. The government should be responsible, through the inspection process, to ensure that facilities which are clearly substandard are dealt with in an expedient manner to ensure the wellbeing and safety of residents. It is recommended that options be included to assist with capital renovations if the facility is a viable operation and it is clearly apparent that compliance is impossible. Furthermore, in order for the system to work in the best interests of seniors, professionals involved in the placement and inspection activities must be held accountable for their actions.

Finally, the Council on Aging strongly supports the initiative towards direct service delivery funding and recommends that this process be broadened to encompass supportive housing initiatives for seniors.

On behalf of the Council on Aging of Ottawa-Carleton, I would like to thank you and the members of the standing committee for your attention after all these hours of sitting here, and request that my comments made here today be considered in the revisions made to Bill 101 in light of their value from the standpoint of the consumer.

The Chair: Thank you very much for a very thorough presentation. It is much appreciated. Again, the Chair hates to play the heavy, but if I could just ask for one question from each caucus and just one, please, as I'm afraid we are tight.

Mrs Goldblatt: Also, I'm likely to be long-winded in my answers too.

The Chair: That's why the members, I know, will be brief with their questions and we'll begin with Ms O'Neill.

Mrs O'Neill: As usual, the Council on Aging has done its homework and the task force can be congratulated. I'd like to compliment you on a couple of things: your challenge and your hopefulness that we will have listened to you in the formation of the regulations. We in the opposition won't have much to do with that, but hopefully your message will be carried forward.

I also want to say that the appropriateness of care between annual assessments is another very important issue brought forward, and the quorum of the appeal board I think also needs to be highlighted. I think the clarification regarding capital investment is also something we have to attend to.

I have but one question, as Mr Chairman stated. I would like you, if you could, to expand on what you have a feeling for or what you said about the multidisciplinary committee regarding the placement, what your vision of that is.

Mrs Goldblatt: When we say "multidisciplinary," who are the service providers we are talking about in providing support services for seniors? You have the medical people, the nurses, the doctors, you have the social workers. Always, from a consumer perspective, I would say to have a consumer there as well is an important factor, so when we say "multidisciplinary" we're simply referring to the professions that currently serve the support services for seniors.

Mrs O'Neill: I hope that idea will be given serious consideration.

Mr Jackson: I appreciate the clarity with which you have referenced the sections and the requirement for amendment. That is helpful to us. I was hoping I could further clarify your point, because it will be used in your absence.

Mrs Goldblatt: What point is that?


Mr Jackson: The point about how fortunate it is that the regulations are not before us. You are perhaps the first and only and the last person to suggest that, so I'm going to pursue that with you. I don't wish to go to Kingston tomorrow and have someone say the Ottawa Council on Aging was very pleased that we don't have regulations.

Mrs Goldblatt: Well, you notice that wasn't stated in the brief.

Mr Jackson: Can I put it in the form of a question? I won't get a second run at this?

Mrs Goldblatt: All right.

Mr Jackson: It is quite common for the regulations to be tabled at the same time as a sign of faith. They can always be amended.

Mrs Goldblatt: That's true.

Mr Jackson: Many of the concerns raised would unnecessarily have to be raised if the government had already felt they belonged in regulations, so I wish to ask you to clarify further: Do you believe that, had we had the regulations, it would be more helpful to the process of understanding and therefore supporting long-term care?

Mrs Goldblatt: Yes, I would say it probably would have been.

Mr Jackson: The draft regulations.

Mrs Goldblatt: Right, a draft.

Mr Jackson: Because this is draft legislation.

Mrs Goldblatt: It's draft legislation. You make a good point.

Mr Jackson: It is regular legislation, but it would be draft regulations that could be approved at a future time but you'd give input. So you feel that would be better than not having them at all?

Mrs Goldblatt: Yes. I think your point is well taken.

Mr Jackson: Thank you very much.

The Chair: A final short, sharp question. Mr White.

Mr White: Thank you very much for your presentation. The Council on Aging has reason to be proud of your presentation and of you. I also want to thank you for your generosity. Here you are in the midst of your presentation and there is a minor disruption with our young scalliwag, Mr Hope, and rather than feeling as if people weren't paying attention to you, you said, "Gee, I guess you people have been sitting for a long time." I really appreciate that.

Mrs Goldblatt: I'm happy to hear that. You've got to recognize that at 70, I've had lots of life experience, which has included everything.

Mr Jackson: Scalliwags and patience.

Mrs Goldblatt: Patience, especially.

Mr White: Anyway, the point that Mrs O'Neill brought up in regard to the placement advisory committee, this is actually something which hasn't been articulated in this kind of way before and I found it quite interesting, and there were a number of issues around the appeal process and you talked about cultural sensitivity, the hard-to-place clients.

Mrs Goldblatt: Right.

Mr White: It reminds me of a hard-to-serve or troubled youth.

Mrs Goldblatt: I don't have to tell you how the Alzheimer disease has become something to which we're all so sensitive. For some families the point is reached where they simply cannot carry the burden any longer.

Mr White: I was just wondering: With the importance of, I would suggest, the appeal process and this point you make in regard to the placement advisory committee of what is primarily a psychosocial issue, whether it might not in fact be appropriate for a social worker to be on this placement advisory committee.

Mrs Goldblatt: Absolutely.

Mr White: Someone who can deal with families and with a troubled situation.

Mrs Goldblatt: I'm so glad you said that, since social work is my background. You guessed that, didn't you?

The Chair: On that note, may we thank you again for coming before the committee and for providing us with your presentation. Thank you.

Mrs Goldblatt: Our pleasure. Thank you.


The Chair: I now call upon the Canadian Council on Health Facilities Accreditation. Welcome to the committee. If members are searching, the brief from the council was circulated last evening. There will be a skill-testing series of questions as we leave the room. Thank you very much for coming; if you would please just introduce yourself and then please go ahead with your presentation.

Mrs Elma G. Heidemann: My name is Elma Heidemann. I'm assistant executive director in charge of standards, research and development at the accreditation council. I would like to say thank you very much on behalf of our organization for making available this opportunity for us to present to you.

It occurred to us, when we planned this presentation, that the first thing we should do is to tell you who we are and what we do. We are not an organization, I think, that is well known to most individuals. Perhaps I can start by saying we are a national accrediting body for health care organizations. Our mission is to promote excellence in the provision of quality health care and the efficient use of resources in health organizations throughout Canada.

The council provides organizations within our program with the opportunity for voluntary participation in an accreditation program which is based on national standards, self-evaluation and professional input from the whole health care system. The council was incorporated in 1958 to set standards for Canadian health care organizations and to assess their compliance with these standards. We are a non-profit organization as well as a registered charity.

The council has recruited and trained 268 surveyors who make the onsite visits to carry out accreditation surveys. These surveyors are all practising senior health care professionals who serve the council on an honorarium basis. I can assure you none of them work for the honorarium either, it's so small.

The total number of facilities accredited by CCHFA -- that is how we are known in the health care world -- as of December 31, 1992, is 1,306, including 583 long-term care centres, 643 acute general hospitals, 52 mental health centres and 28 rehabilitation centres. It should be noted that the long-term care centres include nursing homes, homes for the aged and chronic care facilities. In addition, new accreditation programs are being developed for cancer treatment centres, community health centres, northern nursing stations and northern health centres and home care.

There are three different levels of award that are granted by the council's board of directors to recognize health care organizations' compliance with the council's standards: a four-year award, which is our award of excellence, three years and two years. If circumstances warrant, the council may also require a follow-up report from the organization or a revisit as conditions of the award.

In consultation with health care organizations and professionals, CCHFA has identified the following key parameters for the evaluation of an organization. If you'll permit me, I will go through them, because I think it's important for you to know the scope of what we look at.

We look first at resident care. The focus of our standards document is in fact around resident care. We then look at the quality of this care or other services that are provided by the organization; we look at safety; we look at the mission of the organization as it is related to the needs of the community and how those needs are carried out through the organization's activities; we look at the strategic plan of the organization to ensure that the services and activities of the organization are unfolding in a timely and organized manner; we look at communication within the organization, with residents as well as with the community; we also look at how the organization itself is organized and whether it is organized appropriately to be able to carry out the work that it does; we also look at policies and procedures; how resources are used; and how the education of staff and residents and the community, as a matter of fact, is carried out.


We have four areas we would like to comment on regarding Bill 101, if you'll permit me. The first of these is the requirement for a plan of care and a quality assurance plan.

The amendments to the Charitable Institutions Act, the Homes for the Aged and Rest Homes Act and the Nursing Homes Act -- and I think in the document itself we give the specific references to the clauses -- require that a plan of care for each resident be developed and revised as necessary and that a quality assurance plan for the organization be developed and implemented. Both the resident-specific plan of care and the organization-wide quality assurance plan are absolutely necessary if quality service and care appropriate to each individual resident are to be provided. CCHFA commends the amendments for their emphasis on these vitally important components of long-term care.

While commending the amendments, CCHFA would be remiss if we did not point out that those long-term care facilities which currently participate in the CCHFA accreditation program will already have voluntarily implemented, or will be in the process of implementing, both plans of care and organization-wide quality assurance plans. CCHFA standards not only cover the requirement for a plan for care, but also describe what the plan should entail and how it should be completed and used. The plan is to be based on resident need, involve appropriate multidisciplinary providers and be regularly reassessed. The plan of care is to include goals, actions and expected outcomes for the resident.

CCHFA standards also require facility-wide quality assurance activities to monitor and evaluate the quality of resident care and service, to identify and resolve problems, to improve processes, and to take action and follow-up to ensure continuous improvement in resident care and service. In addition, CCHFA standards also require the organization to have in place a process to manage risks to residents, staff and visitors in order to ensure an optimum quality of life and to ensure the safest possible home for the residents and the safest possible workplace for staff. We have taken the liberty of providing each of you with a copy of our standards in case you wish to refer specifically to what we say.

The second thing we would like to comment on is the use of certain terminology, and particularly the term "quality assurance."

Over the last few years there has been a considerable move beyond quality assurance as the major vehicle for quality monitoring in health care to a concept known as quality management. This concept embodies several key concepts:

1. The resident or client is the focus of care or service and as such is the primary focus for quality monitoring.

2. Quality is the responsibility of everyone in the organization and thus everyone must be involved in quality monitoring.

3. Quality care is delivered by teams of providers and thus the monitoring of quality is also best achieved through team efforts.

4. The leadership of the organization must be supportive of organization-wide quality monitoring and facilitate its implementation.

5. Efforts must be made to continuously improve quality, especially of the processes involved in the delivery of care or service, and to determine outcomes of care.

CCHFA will begin to use the term "quality management" and the key concepts just described in all its 1994 standards documents. It should also be noted that the Ontario government, especially the Ministry of Health itself, has begun to use this terminology and has especially emphasized the concept of continuous quality improvement, so we think that its use is in keeping with the government's philosophy.

The next point I would like to comment on is the process for monitoring quality as specified -- or not specified -- in the legislation.

It is unclear in Bill 101 what the government's specific role or roles in monitoring quality will be as a result of this legislation. It will be clearly acknowledged by all that the government, representing the people of Ontario as the funders of care, has a major role to play in ensuring that quality care is delivered. In carrying out this role, however, the government has two major options.

The first of these is to control the total process of quality monitoring, which involves setting the parameters of care for what constitutes quality care, establishing the standards for the delivery of that care, monitoring on an ongoing basis whether standards are being met and, finally, solving any problems which arise from this ongoing monitoring.

The second option is for the government to control only part of the process, particularly its beginning -- that is, the setting of parameters of care -- and its end, solving problems which are highlighted by the quality monitoring process.

The first option clearly provides the government with the most control, but it also obligates the government to provide internal infrastructures to carry out all the steps in the process and, of even more importance, to correct any problems which emerge. It also places the government in a constant potential conflict-of-interest position if it seeks not only to establish the parameters and standards, but then to monitor compliance with those standards and correct any deficiencies which emerge. It would not be hard to imagine, for example, that if funding grew short, lowering of standards or glossing over of problems which arise as a result might occur.

It appears to be preferable for the government to pursue the option of retaining control of the beginning and end of the process. This would eliminate the need for costly internal government infrastructures for standard-setting and ongoing monitoring, yet would provide both the opportunity for the government to define the parameters of quality care within the province and the information which might trigger inspections, clearly the domain of the government, when problems are uncovered. This second option would provide the government with effective control without potential conflict of interest and without a commitment to additional expensive internal infrastructures.

It should be noted that the CCHFA accreditation program now provides a process wherein standards are created through wide national field consultation and quality is monitored on an ongoing basis through a combination of self-assessment -- and we can't stress enough the importance of self-assessment -- and peer review. This process is, for currently accredited long-term care facilities in the province, already providing standard-setting and ongoing assessment.

It should also be noted that CCHFA recently had the opportunity to review a draft of the Long Term Care Facility Programs and Services Manual prepared by the long-term care division, Ministry of Health and Ministry of Community and Social Services, dated October 1992. While we were extremely pleased to see so many of the standards from the CCHFA long-term care standards document appearing in this document, we could not help but wonder at the seeming duplication of effort which the ministry document represents.

The next point we would like to talk about is the precise nature of quality assurance for Ontario long-term care facilities which are part of the CCHFA accreditation program.

The CCHFA, through its accreditation program, currently provides external, objective, national quality monitoring to 294 long-term care facilities in the province of Ontario; that is, 240 nursing homes and 54 homes for the aged -- this excludes chronic care, by the way -- which is approximately 54% of the total number in the province. This figure accounts for 35,567 beds and an annual budgetary expenditure of well over $1 billion. The average yearly cost for a facility to participate in the CCHFA accreditation program is $1,900.

We have provided you in your document a table which elaborates how these figures are arrived at. The yearly cost for accreditation is approximately 0.05% of the total operating budget of participating long-term care facilities -- an excellent return, we believe, for the investment made to monitor quality. It should also be noted that the government has recognized the value of accreditation in the past by offering an incentive of 33 cents per accredited bed per day for nursing homes to participate in the accreditation program. This small incentive -- which, by the way, covers the cost of accreditation -- has resulted in the high participation rate, 73%, of nursing homes in the province in the accreditation program.

These figures demonstrate the considerable extent to which Ontario's long-term care facilities are already involved in effective, efficient and ongoing quality monitoring through their voluntary participation in the CCHFA accreditation program. It should also be noted that the CCHFA accreditation process also provides for consultation and education from experienced peers in their capacity as surveyors. It is hoped that if Bill 101 is passed, there will be continued support for the ongoing participation of these organizations in the voluntary quality monitoring program which they have helped to create and for which there appears to be widespread and continuous support.


Perhaps I can just summarize. Bill 101, if passed, will have significant impact on the organization and delivery of long-term care in the province of Ontario. We have welcomed the opportunity to comment on this legislation. We ask specifically that the four following points be considered:

First, we commend the legislation for its emphasis on the need for a plan of care individualized for each resident and for the requirement for each organization to have a quality assurance plan. We also note that both are already requirements for facilities accredited by CCHFA.

Second, we suggest that the term "quality assurance" be replaced by "quality management" and the concepts embodied in it. We note that we will begin to use this term ourselves, the term "quality management" and its concomitant concepts, within our revised 1994 standards. I might add that considerable national consultation has been done to assess the appropriateness of this change in terminology.

Third, we wish to express our concern regarding the lack of clarity in the government's role in the quality monitoring process. We suggest that the government retain for itself the establishment of parameters of care and the inspection function when problems are discovered, but that the establishment of standards and the ongoing assessment of compliance with those standards to ensure that the parameters of care are being met in care delivery be left to long-term care organizations in conjunction with an external, objective monitoring agency such as CCHFA. What would thus be created is a collaborative quality monitoring process which is both effective and efficient. We would welcome such collaboration.

Finally, we suggest that the current extensive participation by long-term care facilities in the province in the national accreditation program be recognized and supported as an effective and efficient way of meeting the requirements of Bill 101. We further suggest that those facilities not currently accredited be encouraged to enter the accreditation program.

Mr Chairman, thank you very much for allowing me to appear on behalf of my organization today.

The Chair: Thank you very much for coming, both for your brief and also for providing the members with a copy of the form or manual which you use. I would like to move directly to questions. Mr Wessenger.

Mr Wessenger: Thank you very much for your presentation. First, with respect to the language, do you feel that "quality management" would be broad enough to encompass everything you'd like? I know you have requested that we replace the words "quality assurance" plan.

Mrs Heidemann: Yes, I feel it would be broad enough if it embodied the concepts that we mention in the brief, particularly the concept of quality improvement, the concept of total involvement of the organization in quality monitoring and the belief that leadership of organizations has to take the responsibility to promote quality monitoring.

Mr Wessenger: When you do an accreditation process, how often do you do that for each institution?

Mrs Heidemann: The length of time depends on what we find in the organization. If, for example, we find quite good compliance with the standards, then the three-year award would be given. We may find one area or something where we have particular concerns. If that is the case, then we could either request that the facility give us a report on that area or send someone in after three months or six months -- again, depending on the nature of the problem -- to see that the problem has been corrected. If we find more problems, then a two-year award would be given, again with a report or a revisit. If we find significant problems, then we remove the accreditation status.

Mr Wessenger: Do you measure any outcomes with respect to your process at all?

Mrs Heidemann: In terms of our own evaluation of our process? Yes. We believe that the best evaluation of the process is from those who participate in the process itself, so we have quite an extensive evaluation that follows a survey, where the facility evaluates not only the process but also the surveyors and the use of the standards. In addition, all our surveyors are evaluated yearly and are given feedback from all the surveys they participate in. In addition, we do periodic reviews with all facilities in our program. This is generally done through a survey. For some reason, we generally get about 98% response when we survey the field.

Mr Wessenger: Do you also look at consumer satisfaction?

Mrs Heidemann: Yes, we do. These are our consumers. We are just now beginning -- and we're building it into all our surveys in the next few years; we have done it in long-term care for some time -- actually speaking to residents as part of the survey. We also now are looking to other national and provincial organizations to give us feedback as well on the process.

Mr Wessenger: What happens with respect to problems in one of your accredited facilities; for instance, a large number of complaints, other types of problems? Do you have any process where you can take back the accreditation.

Mrs Heidemann: Sorry, I don't understand. If we get a complaint from, say, a resident or a family member?

Mr Wessenger: Yes. If major problems come up with respect to the way the facility is operated, do you have any process where you can remove the accreditation?

Mrs Heidemann: We have a process whereby we can go back into the facility to discuss the problem. Removing the accreditation has to be done by our board and would really depend on the nature of the problem. Our first preference would be to work on the problem. It's very hard without a specific instance to say what --

Mr Wessenger: The reason I asked this is that evidently there have been instances of major problems with respect to certain accredited facilities.

Mrs Heidemann: Perhaps you could describe the nature of the problem and then I might be able to tell you more what we would do.

Mr Wessenger: Perhaps I won't, but I think there was one case where an accredited facility actually had to be closed.

Mrs Heidemann: I think there were some problems some time ago about use of funds within the facility. You will appreciate that because funding is a provincial matter, we do not do a thorough audit. It is felt that this is the domain of the province and would be seen to be overstepping our boundaries. If there is a misuse of funds or something, we would not look at that.

Mr Wessenger: Would you see your role, then, as a complementary one along with a monitoring system, that you'd need both a monitoring system and an accreditation system?

Mrs Heidemann: It depends on what you are monitoring. If you are monitoring quality of care, it's a duplication. If you are monitoring the precise use of funds, it's complementary.

Mr Wessenger: Fine, thank you.

Mrs Caplan: I have a series of short questions.

The Chair: I love a series of short questions.

Mrs Caplan: It's good to see you again, Elma.

Mrs Heidemann: It's nice to see you too.


Mrs Caplan: I don't know if you've been following Hansard, but we've had quite a lot of discussion about an alternative to the punitive enforcement model this bill contains. That really, I think, was the essence of the parliamentary assistant's questions, so I'd like to elicit some responses on what an alternative model could look like, if you had a model or amendments to this legislation that required accreditation both for outcome and management; that required a quality management program as a part of the legislation; that required a client satisfaction survey clearly, so that you had that; that required the kind of residents' council participation so that it wasn't just a question of checking off but in fact you were able to look at what the results or the outcome of the participation of that council would be; perhaps where you even would require financial disclosures as a complementary component to that. In the case where you have complaints, which is what the parliamentary assistant referred to, you're very aware of the steps that the ministry can take under the Public Hospitals Act?

Mrs Heidemann: Absolutely.

Mrs Caplan: If you had that kind of process as a safeguard, do you think that kind of model would give the kind of public accountability and confidence so that the ministry wouldn't have to have what you referred to as option 1, which is a duplication of the kind of process that accreditation and all of these other safeguards could provide?

Mrs Heidemann: Perhaps I can comment on that from a number of different aspects. First of all, our belief is that certainly much has been accomplished through a voluntary quality monitoring system. It may not be perfect, but we have made great strides. We believe that part of the reason we have made great strides is that there is voluntary participation. No one is holding a club over the head of the facilities. If it is the wish of the government of Ontario to enshrine accreditation in the legislation, then so be it, but we would stress to you that so far it has been a voluntary process and has, we think, worked reasonably well.

Mrs Caplan: Would it be possible, from your view, to build in an incentive for that? For example, if a long-term care facility received an accreditation or participated voluntarily in the accreditation program and had an annual client satisfaction survey, had a quality management program acceptable to the ministry, had an active residents' council and perhaps even a community volunteer board -- I mean, you could have a number of things -- it would then be exempt from certain sections of this bill as it related to the inspection model. Do you think that would work?

Mrs Heidemann: You would have to be the judge of that. I think we can describe our process. If you and the government feel that this is sufficient to accomplish what is the intent of the bill, then I think it would suffice. My own belief is that there is a great deal of value from the accreditation process which could be, and is currently, complementary to what the government needs to do.

Perhaps I could just talk a moment about resident satisfaction, since it's been brought up a couple of times. We are currently looking at this and we're not very enamoured with the kind of tools we are finding for assessing resident satisfaction, principally because they don't seem to get at the quality-of-life issues sufficiently well. That is a deficit at the moment. It's a deficit in long-term care, it's a deficit in acute care, it's a deficit everywhere. We just don't have the tools.

But we're beginning to explore something perhaps called "resident status", where you can actually measure the status of a resident, not only on physical parameters, but on psychological and quality-of-life parameters. You can do this measurement periodically to see if there is a change that is either acceptable or not acceptable. We think that may be a more interesting and better return for what's invested, a better vehicle for us to explore.

But at the moment, I'll tell you right now, we do require resident satisfaction kinds of things. We do require, in the acute care setting, patient satisfaction, but we just don't find that it yields that much that is helpful. This is for development in the future, and certainly it will be a major focus for us because it's something we want in the standards.

The Chair: Final.

Mrs Caplan: Final question: I'd like you to tell us a little bit more about the changes your organization has gone through as you have been developing and implementing the total quality management and continuous improvement outcome approach to accreditation, which is very different from what accreditation was even five or so years ago.

Mrs Heidemann: Yes, this is a process that has occurred in the last five years. I think prior to that we were very much an inspection process. Our surveyors considered themselves primarily inspectors and really behaved pretty much as inspectors. But it began to dawn on us that this was a government function, that governments were quite clearly set up to do this reasonably well and that perhaps this was not the chief role or the main role we should be playing, or the most helpful role.

I think what we have shifted to in the last five years is more of a -- if I can call it that -- positive approach, which is to see the standards as guidelines for how a quality facility would operate and then to encourage facilities to implement the standards, really on an ongoing basis, so that you simply don't think about accreditation three months before the surveyors are going to arrive on the scene. This is an ongoing thing that you live with, day in and day out. In fact, whether the surveyors come or not, or when they come, should be immaterial to the whole process.

In reality, of course, it is a bit traumatic when you have the surveyors on-site, but we hope that gradually over time facilities will see this as an opportunity in which they can not only, I guess, air the problems they have, but also show the good things they are doing and get feedback from an outside, objective observer about this and really use the surveyors as a kind of consultant to help them work through whatever it is they want to work through.

What we're looking for now in our facilities is progress over time, so if on one survey you have certain problems, then on the next survey we will hope for and look for progress being made, either to change that or to move in a different direction. So --

The Chair: Thank you.

Mrs Heidemann: Sorry, Mr Beer.

The Chair: Finish your thought; I'm sorry.

Mrs Heidemann: No, it's okay; I'm finished.

The Chair: I've got to play the heavy again. I'm sorry because this is, as I think has been said, a very interesting area that has come up. We want to thank you very much again for coming before the committee this afternoon.

Mrs Heidemann: Thank you very much. I might add that if there is any further information or if anyone wishes to speak with us further, we would be more than pleased to oblige.

The Chair: Thank you very much.

Mrs Caplan: Could I ask one question for Mr Jackson?

The Chair: No.

The Chair: I will ask for the representatives from Gerontological Nursing Association. This will be the last presentation this afternoon. If I could just note for members, this evening we begin at 6:30. The Ottawa-Carleton Placement Coordination Service is coming at 8; that may not be clear on your schedules. There'll be four presentations after supper.

Just very briefly, before we begin, Mr Hope.

Mr Hope: I've got some requested information through legislative research. I notice this is copy-dated 1991. I wonder if there's an earlier copy date. That's why I've raised the question to legislative research, because I know it might have one of the old manuals that it could tap into.


The Chair: Thank you very much for coming before the committee this afternoon. I don't think we've had representation from your association in another part of the province, so we're grateful that you were able to come and be with us this afternoon. If you'd be good enough to introduce yourselves for the committee and for Hansard, and then please go ahead.

Mrs Frances Doyle: Yes, sir. We would like to thank you very much for allowing us the opportunity. I'm Frances Doyle and I'd like to introduce my colleagues: Jean Lindsay-Brown and Gloria Laporte. We represent the Gerontological Nursing Association.


The Chair: Can I just ask you, is this a provincial association and you are the Ottawa chapter?

Mrs Doyle: We're the Ottawa chapter. I was going to introduce ourselves a little bit in the brief. First of all, I'd like to apologize. I had trouble with our printer today, or we would have had copies of our brief for you. But we have the address now and we will send copies of our brief to you in Toronto.

We're going to tell you a little bit about ourselves and make some observations and some recommendations that we noticed throughout the review of Bill 101. We certainly would like to answer any questions you might have at the end of our presentation, but we also would like to say that as nurses we are always feeling that we are advocating for the residents, and certainly that's part of our role. So a lot of our observations will be made around the recommendations for the resident in resident care.

The Gerontological Nursing Association of Ontario, incorporated as a non-profit association in 1979, directs the primary focus on improving the quality of life for older persons. The primary goals, in cooperation with other health disciplines, are to advocate for high standards of nursing care and related health services for older individuals and promote professionalism in gerontological nursing practice through education, research and support to our members.

There are eleven chapters across the province of Ontario, with a total membership of approximately 1,400 nurses. The Ottawa chapter, which we represent, has approximately 190 members who work in acute and chronic care hospitals, nursing homes, homes for the aged, retirements homes and in community health.

The Gerontological Nursing Association commends the government for encouraging and welcoming opinions and advice from consumers, service providers, planners and advocates. As nurses engaged in the governance of quality care practice and in the respect for the needs of all elderly in Ottawa, we read with interest the proposed changes in the legislation and wish to submit some observations and recommendations in regard to the Long Term Care Statute Law Amendment Act, Bill 101.

Gerontological nurses support and applaud a health care system for older persons that is comprehensive and offers a continuum of services that is equally accessible to every older person in the province. We will address our remarks mostly to the following areas of this act: the coordinated access to facility services, the enhanced accountability and the levels of care funding.

First, we wish to discuss the redirection strategy of the coordinated access-to-facility services. We applaud the efforts of enabling a single-point access for services. We are pleased that services will be provided in the community and that all efforts will be made to prevent admission to long-term care facilities. We would question, however, the process of placement coordination services, the only people who are involved in the placement of residents in long-term care facilities.

Currently, the workload does not allow adequate time to review and process applications to their satisfaction. By broadening their scope of responsibility and managing waiting lists, following the legislation to the letter according to Bill 101, we believe this could cause delays for some individuals and place in jeopardy those elderly persons the government has set out to serve.

Also, in regard to the placement of seniors, there are other issues we would like to address. It is of great concern that residents' choice will be disregarded with this act. We believe it is their right to choose a facility where they are going to spend their remaining years. The admission facility should meet their cultural, religious, physical and emotional needs. Not considering these would be, we feel, dehumanizing and would decrease the quality of life for our elderly.

Also, it should be noted this may create permanent separation of the resident from his family or spouse. Residents and their families consider of paramount importance the location of the long-term care facility in relationship to their current address. If the distance between the long-term care facility and the family is great, the resident will receive less support by regular visits. Gerontological nurses acknowledge the central role that families and friends play in the lives of older persons and their health care.

Another potential problem we see is that if a facility cannot meet the needs of a particular client because of workload or untrained staff, the amendments create the power for the director to order designated placement coordinators to suspend admission to a given facility if there has been a pattern of refusal. Being forced to accept inappropriate clients may jeopardize the quality of life for both the new resident and the other residents already in the facility.

We believe that placement services need to act in consultation with long-term care facilities. Our aim in long-term care facilities is to admit compatible residents in the same room to minimize the transfer of elderly residents, as this is so problematic to them. We would also like to indicate that inappropriate and aggressive behaviour is common in long-term care facilities, and here also we try to minimize the risks of injuries by again ensuring appropriate accommodation.

So, as you can see, if there is not good dialogue between placement services and long-term care facilities, we could have potentially a great deal of problems that we create for our residents. Residents should not be placed in circumstances where a facility cannot safely or effectively meet his or her needs, and a facility should not be penalized for being honest or trying to accommodate special needs or circumstances.

We would like to recommend that placement coordination services be given the flexibility to use judgement and, in consultation and cooperation with the long-term care facilities, to facilitate better placement of our seniors. This brings us to the next area of concern, that of enhanced accountability.

The Standards of Gerontological Nursing, published in 1987 and revised in 1991, are specialty standards intended for registered nurses and registered nursing assistants working in the community or in institutional settings. Nurses follow standards designated also by the College of Nurses of Ontario, the Canadian Nurses Association as well as a code of ethics established by the Canadian Nurses Association. These standards require every nurse to assess our clients, develop and implement care plans for each and ensure that they are reviewed and kept current.

All gerontological nurses believe that this plan must reflect the physical, psychological, social, intellectual and spiritual needs. It is the basis of nursing practice. This legislation appears to question the professionalism of registered staff and can only serve as a demoralizing force. Nurses require working environments that support their rights and provide opportunities for them to fulfil their responsibilities. Gerontological nurses need to feel autonomous and would like to feel they are an empowered workforce with decision-making authority over day-to-day practice.

Long-term care facilities, by the very nature of the services provided, are accountable to both the public and the government. We understand and support the purpose of the legislation which is, of course, to protect consumers and enable their needs to be met in a very complex system. We recognize also the necessity of and respect the principles of the inspection process for all long-term care facilities. We also recognize that there is a duplication with the Canadian Council on Health Facilities Accreditation, which in fact you've just heard from.

Our concern arises with the statement in the statute, "The inspection scheme, similar to that which has governed nursing homes in the past." This is of concern to us. Currently, nursing homes are inspected by compliance advisers who ensure that there is compliance with the Nursing Homes Act, but that is not their only function. They act as a resource to the facilities. They offer assistance and education in order to achieve quality of life for the residents. It has become a true consultative process.


Returning to the past inspection process would, we believe, result in the negative policing connotation of the 1960s. This resulted in poor cooperation and left employees frustrated and angry. I also believe it left the inspectors frustrated and angry, and we spent a lot of money on a study that was done that showed this was so. I forgot which government of Ontario did the study now.

It is our recommendation that the process of compliance management currently being used in nursing homes would continue and thus encourage creative management and accountability. Current economic realities demand leadership and working together to ensure consistency in our practice will help to foster the quality of life that we are so concerned about for the residents in our institutions.

Now we would like to talk about the levels-of-care funding. We believe that more attention must be given to funding so that quality care and subsequent quality of life for the residents could be ensured with adequate staffing levels. Staffing ratios between professionals and non-professionals have really not, to this point, been studied or addressed. The classification system being used for establishing funding on an annual basis currently is insufficient to ensure the needed resources required for residents. Residents' needs cannot only be assessed from the point of view of activities of daily living, the behaviours of daily living and their continence care. Can you imagine being reduced to those three categories?

Gerontological nurses play a crucial role in the care of the elderly in long-term care facilities. They provide creative, humanistic and individualized care incorporating the concepts of prevention, rehabilitation and palliation. They facilitate a healthful environment and promote mutual goal-setting and decision-making among older persons to exercise their rights and responsibilities.

Gerontological nurses are also involved daily as managers, educators, consultants, researchers and counsellors. It is our recommendation that sufficient staff will be provided to allow for this so that the desired outcomes for the older person will be best achieved. This can only happen if the government recognizes the dignity and worth of older, frailer adults by implementing such positive action.

I would just like to summarize our recommendations. The first recommendation is that we believe placement coordination services have to be given the flexibility to use some judgement in cooperation and consultation with long-term care facilities that would facilitate better placement of our seniors.

The second recommendation is that if we have to have an inspection process the process of compliance management currently being used in nursing homes would continue. This does encourage some creative management and gives some accountability to the public.

The third one is that we really would like to have sufficient staff to provide for our elderly and to ensure that they have quality of life. We realize that not all individuals end up in institutions and we are very glad the government is looking at other ways of keeping residents out of long-term care. Unfortunately, there are and will continue to be residents who require facilities, so we are hoping that we be viewed as a facility which requires sufficient staff. I don't know how we ever arrived at staffing levels currently in existence, but we really need to have, I think, a good study done which proves how many professionals and how many health care workers are required to give adequate care.

We really thank you for listening to us and we would entertain any questions you might have.

The Chair: Thank you very much.

Mrs Doyle: I'll be all anxious for supper.

The Chair: Thank you none the less. If I can use the old saw, you have given us food for thought.

Mr Hope: Low calorie, too.

The Chair: Yes, low calorie too, that's right. We'll get right to questions.

Mrs O'Neill: I'm very pleased you've come. I've just been through a very personal experience of the loss of my father about six weeks ago. He spent his final days in what was termed, in an Ontario hospital, as critical care geriatrics and I've never seen nursing as I saw it. It included also the family and I'm sure that's part of your training. I want to compliment you because I'm sure those nurses were of your association.

I am very pleased that you highlighted, as not too many of our presenters have, the spousal component and the familial component of aging and the support system that's necessary, and sometimes the flexibility that isn't there, for spousal cohabitation. I'm happy you highlighted the weaknesses as you see them in Bill 101 regarding placement and also the negative connotations of the new policing -- your term -- and its sanctions. I think the sanctions component is very worrisome to some individuals.

I'd like you to say a little bit more because I have felt from the very beginning, from the first briefing and the day I saw Bill 101, that it does, in its tone at least, question professionals. We had some people say that to us today. You've said it the strongest, I think. Would you like to say a little bit more about how you feel Bill 101 questions or at least tests your professional qualities within its own contents?

Mrs Doyle: I think as a professional association, you believe in the philosophies and are certainly brought up to care for the residents, patients, whatever, in your care with and under certain standards, and we do our own policing through our registered nursing association. We are accountable and make sure our nurses are current and licensed etc. I guess when you see legislation that comes along and tells you exactly what you're supposed to do, or legislation that points out things you do in ordinary practice, I guess is what I want to say, it is a demoralizing issue for us.

Certainly, anybody who would talk to nurses -- we're not above auditing ourselves and making sure we are giving the best quality care to residents, patients, whoever they are. That's, I guess, where we are coming from.

Mrs O'Neill: Do you want to give one small example that popped out when you read Bill 101?


Mrs Doyle: Just that it talks about care plans. These are basic nursing ideals that we do. Every resident, very patient has a care plan. In long-term care especially, we try to involve an interdisciplinary team approach to care planning. In fact, just to say they should have a care plan doesn't really cover our standards at all. The care plan should be interdisciplinary and should involve the resident and the family, and the goal setting should be done in concert with that resident and that family.

Mrs O'Neill: Thank you for being so specific.

Mrs Doyle: There are others.

Mr Owens: Thank you for your presentation. It's groups like yours that have worked so hard to bring the specialty of gerontology to the forefront and doing the good work in terms of how we look at our aging population and taking the holistic approach we certainly need to take.

You raised a number of good points and, following on Ms O'Neill's question, I think the challenge is not only that a facility develop a care plan. You're absolutely right, in terms of standards of practice, any facility worth its salt would currently be doing that. I guess my concern is to ensure that the care plan is in fact actioned to the fullest extent envisioned by that multidisciplinary approach you envision.

It's been my experience in dealing with some concerns in my own riding that sometimes that does not happen. This stuff looks great on paper, that Mr or Mrs So-and-so will do this and engage in this activity and it looks wonderful, but in terms of it actually happening, there's some doubt that it does, which leads me to your point about the staffing levels.

I think it's an excellent suggestion that someone somehow undertake a study on what kind of staffing is actually required in facilities or in terms of the home care approach. Again, you hear allegations in terms of hard-to-care-for patients where, because staffing levels are low, security, locked doors and restricted privileges are used in place of staff. I think that's an excellent point that we take a look at: just exactly how we need to staff facilities.

In terms of your comments around the inspection process, I read and re-read the language and, in my view, it's in fact -- I hate to use the word "benign" because it has certain implications. I think we've seen the results, in a rather spectacular fashion -- what happens when processes break down in terms of the abuse at various provincial institutions; some nursing homes in Metropolitan Toronto.

I think this type of language needs to be in place so there's an ability for the government to act to prevent the kinds of situations that have in fact taken place. We're not imagining these kinds of situations. I still believe in my heart that people want to do the best thing and that in terms of the creative management capability, it should still play a large role.

This is, I guess, my second day on the committee and the comments I've heard to date are that people want to do that and people have no fear of opening their doors or their books to the inspection process. I think people like yourselves -- and I worked in a health care facility for almost 10 years. It takes a special person to be involved in dealing with people, especially people living in long-term care facilities, whether they're older people or younger people who are disabled. I think the challenge, as the comment that I made to another person on tour, is to look at the staffing issue, to make sure these jobs are challenging, that they're well compensated, that the training is there and that the highest efficacy of care is delivered to these individuals.

It's associations like yours that are helping to push towards that goal. While there's probably not a question there, I just wanted to thank you again for your presentation and for your excellent work.

Mrs Doyle: Thank you very much.

The Chair: Thank you very much again for coming before the committee. We wish you all the very best and we also wish you bon appétit.

Mrs Doyle: Thank you very much, and you too.

The Chair: Thank you. The committee will now stand adjourned until 6:30 sharp when we will reconvene, and I do have to insist on 6:30 --

Mr Hope: Stress the word "sharp."

The Chair: -- sharp.

The committee recessed at 1726.


The committee resumed at 1834.

The Chair: Good evening, ladies and gentlemen. We begin our final session in Ottawa, I guess our fourth session since we arrived last night. This is the standing committee on social development. We're here to review Bill 101, An Act to amend certain Acts concerning Long Term Care in Ontario.


The Chair: We begin this evening with the Ontario Command of the Royal Canadian Legion, District G. We welcome you gentlemen to the committee. If you'd be good enough just to introduce yourselves for the committee and for Hansard, and then please go ahead and make your presentation, then we'll follow up with some questions.

Mr Jim Margerum: Okay. On my left is Ray Lapointe, the president of provincial level and national capital area Amyotrophic Lateral Sclerosis (ALS) Society, and on my right is Jim Mayes, the district veterans services committee chairman. I'm Jim Margerum. I'm the district chief commander and chairman of the Rideau veterans hospital/housing review committee.

The Chair: Please go ahead. There's always a bit of movement in this room, so don't let it bother you.

Mr Margerum: Our role and a bit of history on ourselves in District G, or eastern Ontario, which spreads from, to the north, Deep River, to the south, Napanee, and along the St Lawrence to the Ottawa River and back up to Deep River. We're the golden triangle.

District G veterans services committee is responsible for and obligated to provide an advisory-advocacy role for matters relating to veterans' care and wellbeing by:

(a) cooperating with other committees of national and provincial veterans' organizations to monitor the activities and the care and services provided to veterans and their dependants by Veterans Affairs Canada and, in this case, the province;

(b) representing the position of veterans and organizations who are involved to provide advice and/or make recommendations on the care and needs of veterans and their dependants residing in eastern Ontario and including the Outaouais region;

(c) providing home and community services for older veterans and seniors in the community at large;

(d) establishing and/or improving domiciliary and chronic care accommodations such as Rideau Veterans Home, National Defence Medical Centre, long-term care centres, nursing homes and semi-independent supportive housing accommodations that will meet the needs of veterans and all senior citizens;

(e) any undertaking that will promote useful projects for veterans, their dependants and all senior citizens.

District G's record in eastern Ontario: Our 68 branches in almost every community and our 30,000 members are actively involved in providing funds, equipment, facilities, programs and volunteer support to the following -- the gremlin snuck in; the first one should have been "housing"; I apologize for that: Meals on Wheels; hospitals, medical centres; scouts, cubs, brownies and girl guides; youth and adult sports; provide canvassers or volunteers for fund-raising such as cancer or heart and stroke; seniors' activities; seniors' care such as foot clinics, transportation, income tax preparation; providing our branch facilities for community activities; members of boards of directors, committees, auxiliaries and sick visiting/shut-in groups of hospitals, youth and senior organizations, nursing homes and other charitable organizations, and other specific projects.

Attached to this brief is a copy of the branch profile survey covering one year, from June 1, 1990 to May 31, 1991, on the role we play and the impact it would have in our communities if we ceased to exist.

Our concerns regarding Bill 101 and long-term care in Ontario:

(1) Eligibility and admission: We are extremely concerned that the provincial eligibility and admission criteria will supersede and override Veterans Affairs Canada Regulations Respecting Health Care for Veterans and Other Persons (August 1990 SOR/90-594). This is clearly indicated in the clauses respecting admissions in the Rideau Veterans Home transfer agreement dated March 25, 1992, and the new provincial standards for eligibility and admissions. Incidentally, we see no reference whatsoever to recognition of veterans' priority regarding long-term care beds.

(2) Coordinate placement services in Ottawa-Carleton: We again are concerned that all levels of care provided under veterans' health care regulations and funded by Veterans Affairs Canada will be jeopardized by application of the provincial eligibility standards.

(3) Closing of beds and lack of beds in northern Ontario: We have seen, since 1987, a reduction of veterans' priority beds from 2,050 to less than 1,100 currently. Although veterans are aging and their needs increasing due to long-term effects of their participation in war and hostile action, it is incomprehensible that priority beds available should be reduced by 50%.

While we understand the concept of returning residents/patients to the community, we do not believe that the community has adequate domiciliary facilities, support systems and health care providers. Where will the veterans go? We are convinced that the province of Ontario, in accepting the transfers and the funds provided by Veterans Affairs Canada or other federal government sources, has the responsibility and obligation to maintain and keep open all beds and that access to these beds and facilities be determined by veterans' health care regulations.


(4) Special interest needs: Adequate facilities for special care and respite care for such conditions as ALS, as an example, and others are woefully lacking and we are concerned that Bill 101 and the provincial health care redirection does not specifically address such needs.

Financial or budget considerations: As taxpayers and residents of the province of Ontario, we are concerned that health care be provided and delivered in a most cost-effective manner and with the minimum of duplication. While we do not believe systems and programs are in place in Ontario to handle extended care requirements in the community, we want to cooperate and work in conjunction with the Ministry of Health and others to develop such an infrastructure and the necessary independent facilities for veterans, seniors and the less fortunate.

In closing, we wish to express our appreciation for listening to our brief and that you will consider its contents and the impact of Bill 101 on veterans and seniors.

The Chair: Thank you very much for your brief and also for the attachments, which I note for the record are at the back of your presentation. We appreciate very much your coming here tonight. I think this is the fourth Legion group that has been before us -- Toronto, London and Sudbury -- and we welcome your input. We'll move to questions. Ms O'Neill.

Mrs O'Neill: Thank you, gentlemen, for coming. I am very pleased that you outlined the activities that you're involved in in the communities. I think many people don't realize how widespread those are, right from the very young to certainly members of your own community and their dependants, and I must say you are always one for the other and even remember often those who went before us. I think we all need that reminder.

Earlier this afternoon perhaps you have heard the Rideau veterans' home was very much a part of our discussions as we talked about the long-term care facility that we're all hoping will meet its expectations. We've waited a long time in Ottawa-Carleton for the facility that will hopefully meet the needs of the veterans in this community.

I would like you to say a little bit more. Every brief has its unique component, and the one I think I'd like you to respond to, because we haven't heard much of, is the special interest needs. Could you expand a bit on the things you've said here in the brief?

Mr Margerum: Yes. That was an example, and I'll ask Ray to explain about ALS, but the special interest we're concerned about is, we're responsible adults in the communities and we see situations with duplication of facilities and we feel they should be amalgamated so that there's a cross-section of needs, not just veterans. We're looking at hard-to-house, battered women, special needs; that if the facility exists there to provide a particular service for veterans and would provide a service for special needs groups, this would be part of the operation. It would not be a single veterans' establishment, but rather a community service development.

Mrs O'Neill: That's certainly admirable and very characteristic. Thank you for helping us understand that better.

I'm very pleased that you mentioned northern Ontario, because we found when we went -- and we only went as far as Thunder Bay and Sudbury and many people don't think that's really the north. We found there were very different needs than we have experienced in the more southerly parts of Ontario. Do you want to say a little bit about why you found that it was important to mention the north in your brief?

Mr Margerum: Yes. This is a letter from Veterans Affairs Canada, and to give you a quick history, in 1987, there were 2,050 veteran priority beds in the province of Ontario. As of today, there are 1,072. That's a drop of 50%.

In London, the psychiatric institute is closing and it's transferring its patients to either Western Counties wing or the very severe cases are going to St Thomas, I believe, to a little more capable facility. That leaves roughly 160 beds that are empty and no where for people to go. We feel that because of the age of the veterans, 75 years old -- and what's the average life a person lives to, 80? -- we have four, five or six years to solve the problem for our veterans, and we feel that those 150 beds, or whatever we can get, should be dispersed across the various communities in the north.

To do it fast and to have them operational, they could be attached to existing facilities that have a good track record and reputation, or beds that are closed could be opened and adapted to provide the services. It could provide some employment, and the cost would be minimal as far as additional staff is concerned. It is the only way in which we're going to resolve the problem for these veteran priority beds and the needs of veterans.

Mr Jackson: Jim, I appreciate your brief and the candour in which you've presented it. Here, in the situation in Ottawa, you don't have a veteran's hospital per se, and that's not been a reality for you. In fact, most veterans go to the Perley Hospital. Have you been involved or has anybody consulted your organization with respect to the reclassification of the beds and some of the discussions around reduced access to those beds?

Mr Margerum: That was the start. In 1985, when I was first approached to get involved with the Perley Hospital, I received a letter from the chairman of the board of the day. By 1987, I was asked by the dominion president and the provincial president to set up a committee to look into and push and pull the various bureaucrats and politicians to try to get a facility.

Everything sounded great. It's been going along. We were assured in a letter from ministers of the province and the federal government that by December 1992 we would walk into a hospital and our veterans would be housed. This is the current status of the hospital. It would be a hell of a job putting 250 veterans in that peg. That is the commitment. That is our concern, that veterans have been used as pawns in trying to get this agreement together, which is the final draft of the transfer.

That money was there at the federal level, and it's been sitting in a bank. I don't know if it gathers interest, but the veterans have been doing without. We are totally dissatisfied with what? With the promise in the first agreement, the draft agreement from Veterans Affairs Canada, and what we have there. What we have was the start of what you call level 2 beds and chronic care beds, which would be level 3 and higher. There were 175 level 2 beds and 75 chronic care beds.

All of a sudden, on July 1, 1991, communication stopped. We were part of what were called the stakeholder -- I think we were pegged to the stake, but we were called stakeholders -- and we were supposed to talk on behalf of veterans. So we go to a meeting, and then of course after the meeting they go upstairs and make the decision. The consultation process was a farce. They've gone through two functional plan studies, and all these promises, all the commitments that were put in the original draft were removed in the final draft. We weren't given the final draft until after it was signed.

Mr Jackson: Can you be more specific about the final draft? That is from the --

Mr Margerum: This is the transfer agreement between the federal government, the provincial and Perley Hospital.

Mr Jackson: So at some point -- when there was the change in government, around 1991, did you say, or 1990?

Mr Margerum: No. I hate to be vindictive, but what happened all along the process, it was like a baby: Every time there was a mess, she changed the diaper; every time there was a problem in this project, they changed staff. We went through three ministers of Veterans Affairs, six ministers of Health for the province of Ontario and we lost track of the --


Mr Jackson: Yes, I read that portion in your brief and in this article by Rick Gibbons of the Sun, but we've been led to believe by Ministry of Health staff that veterans' concerns are being adequately addressed at the Perley. I'm left with an impression that that's not in fact true, that in fact the combination of this backroom deal for reclassifying the beds and the reduction in hospital level care, in concert with this legislation, which doesn't specifically reference any protection for the federal agreement on access for veterans -- those facts are out of sync with what the ministry's trying to convince us as legislators it's actually doing.

Mr Margerum: They didn't convince us, and the record speaks for itself. The beds have been changed from low-level to chronic care in one sweep of a pen.

Mr Jackson: Mr Chairman, if I might then ask, there have been references made to the Perley situation. Could I ask the parliamentary assistant to the Minister of Health, who has been part of these discussions, to undertake some sort of report to this committee with respect to why the government has seen fit to structure the legislation and bypass the federal agreement, specifically to explain why the Perley Hospital discussions, which have been occurring quite secretively, did not include the veterans' interests when in fact they were led to believe they would. I frankly would prefer to get that as a statement from the minister before I'm subjected to 10 1/2 minutes of Mr Quirt's explanation of what he thinks has happened up to this point.

The Chair: Okay, to the parliamentary assistant.

Mr Jackson: I'm asking for --

Mr Wessenger: I'm going to reply to that --

Mr Jackson: Perfect.

Mr Wessenger: -- because obviously Mr Jackson doesn't want to listen to Mr Quirt's answers on that.

Mr Jackson: I've been listening to the man for a month.

Mr Wessenger: However, the reality is that the priority beds are protected in the transfer agreement between the --

Mr Margerum: Excuse me, sir. I don't agree.

Mr Jim Mayes: Might I say something?

The Chair: Yes.

Mr Mayes: First of all, by way of background, I'm a retired public servant of the federal government. I was an arbitrator of contract dispute matters.

The assurances that are now verbally being given by the administrators of the Perley Hospital that priority beds are being protected and the veterans are still being treated and will continue to be treated under the veterans' health care regulations is not supported by the language of the final agreement. If a dispute ever arises or if habits change, the language of the transfer agreement is such that the veterans' health care regulations can be just set aside and the new standards and the admission criteria created by the province will be the only thing veterans will go in under. They will receive no priority, and that is our concern.

All the verbal promises in the world are not going to change the language of the agreement. The language of the agreement can be changed by mutual agreement of the three parties, and that's covered in section 59 of the transfer agreement. If they are willing to give us the protection they claim they are, let the three parties sit down and amend the criteria in the transfer agreement.

Mr Margerum: A word of further explanation: In the draft agreement, in which we were with the assistant deputy minister of Veterans Affairs at that level and we went through this agreement, it said the criteria for veterans to the new facility and the existing facilities were existing veterans' health care regulations This is the language in the signed transfer agreement. "For the Perley and Rideau Veterans' Hospital" --

Mr Jackson: You should indicate you are quoting directly from the agreement at this point so Hansard will acknowledge that. Then we will have it on record.

Mr Margerum: Okay, in quotes, "For the existing facilities there is a criterion that recognizes this." The kicker is:

"The admission process at the PRVH Centre shall be as follows:

"(a) In accordance with the provincial redirection of long-term care (LTC), the admission process to the PRVH Centre will be coordinated through the service coordination agency. The role of this organization, the admission committee of the PRVH Centre and the practices and procedures of the admission process shall be established in accordance with long-term care reform policies and guidelines which may be in place from time to time."

If they are telling us different, which they have in writing, it's not part of the agreement, and in the agreement they have a grandfather clause for people who are currently in the facilities to get in.

Now, the average life of these guys is three and a half years. The place isn't built. They haven't got a shovel in the ground. How many are going to make it into that facility?

They have four clauses and four references stating these criteria. They don't need that if they're telling us that the veterans' health care regulations are a priority. That's a load of crap from them.

In here they have a clause which stops all these letters and promises and verbal agreements, "Entire agreement," clause 57,

"This agreement and any appendices, amendments or addenda executed by the parties constitutes the entire agreement between the parties and there are no other representations, written or oral, applicable to the subject matter hereof except as expressly set forth herein, or as may be hereafter set forth in writing executed by the parties to be charged thereunder."

I suggest to you what's in there is the Bible.

Mr Wessenger: I understand this is a signed agreement, or is this a draft agreement?

Mr Mayes: Signed.

Mr Margerum: Signed. By all ministers.

Mr Wessenger: And that language you find unacceptable?

Mr Margerum: Absolutely.

Mr Wessenger: The only thing I can say is that, as veterans, have you indicated to Veterans Affairs that this language is unacceptable?

Mr Margerum: Yes.

Mr Wessenger: Have they given any response?

Mr Margerum: They sent us a letter. It's not part of the agreement. They said they understand the level 1 could get in, and the letter from the province of Ontario from some of the staff stated that currently they see no reason why a level 2 or a level 1 person couldn't get in.

Our concern on top of that is, they are now converting 24 level 2 beds, which is low-level care, to heavy-care beds. That's 24 coming out of the system for our low-level-care residents. Where the hell are they are going to go? That building is paid for by $36 million of Veterans Affairs money on behalf of veterans, and if those beds are going to be converted and you have no place in society for them to go to as domiciliary care, you shouldn't be taking the money.

Mr Jackson: They're defrauding the public. That's what's happened.

Mr Wessenger: Certainly I can assure you we are interested in protecting your priority access beds and I will certainly ask the ministry staff to take a look at the situation specifically.

Mr Margerum: This is Bill 101, the last copy we got, sir, and nowhere is the word "veteran" even mentioned. There's not one single sentence, not one word that refers to it. Yet those beds and the moneys from the transfer from the federal government were specifically for veterans' priorities. There's no recognition.

We are prepared and we've stated very clearly that we are there to help and to work in the community, but surely the work we do and what those guys did on behalf of the country -- and the ladies -- deserves the respect of this country and what was given in legislation by past governments should be adhered to and honoured by current governments.

Mr Wessenger: I can assure you that we'd be prepared to take a look at an amendment to that agreement, or the bill perhaps.

Mr Margerum: The second part of that is, we have attempted to meet with the Honourable Frances Lankin from the signing of that agreement, from July 1991. We missed the boat because she's no longer Minister of Health. We tried. We wrote letters to the ministers, to the assistants, to everybody to ask to discuss this. As of July 1, 1991, all of a sudden we were put on the stake, not stakeholders any more, and everything just went quiet. The agreement was signed. Then they had the gall to send me the agreement in the mail saying: "Here's the agreement. I know you'll be happy with it."


Mr Jackson: Mr Chairman, I wonder --

Mr Margerum: I'm sorry. I'm on a roll.

The second part that bothered us is the language. As an example, it said the liaison committee "shall" have members of veterans' organizations as part of the liaison committee. The liaison committee was a problem-solving committee. It now says "may" have.

Our concern is, who's going to appoint them, and are they going to be a rubber-stamp to whomever or are they going to speak up to defend the rights of veterans?

It also said during negotiations there would be an ombudsman there, a veterans' liaison officer. That was wiped out.

The low-level beds are being wiped out. There's no recognition in 101 of the veterans. How can we believe? We have to be cynical when you look at a picture like that after eight years and that much money and that's what you've got. These guys are 76 years old, and you look them in the eye and you try to tell them, "Hang on, George, we're going to get you in a facility." It's pretty damned sad.

The Chair: I think Mr Jackson has one last request or comment.

Mr Jackson: I appreciate that the parliamentary assistant has seen fit to look into this matter further and that he has discovered some new information and I appreciate his willingness to pursue it further as opposed to responding at this point.

I simply want to put them on notice, as my colleague Jim Wilson has, that it is our intention to place an amendment when we're in clause-by-clause, and I only suggest that because I want the government to know how deadly serious we are about responding to this legitimate request and are therefore serving notice that recognition of the federal agreement will be in this legislation as far as the Ontario Progressive Conservative Party is concerned. I hope the parliamentary assistant will communicate that to his minister so he knows that this will be voted on as an amendment and that all parties are advised that we'll have to deal with it. I don't think we're prepared to deal with it in a casual way, and I appreciate that the government says it's willing to look into it.

I finally wish to close with this concept, that is, that we heard today there are six additional agreements currently being undertaken with chronic care facility hospitals in this province similar to the Perley. I think the comments the comrades have made tonight apply to those other six facilities as well, to the extent that they involve priority access for veterans, so I would also ask that those it does apply to also be given the same courtesy of involvement and not all of a sudden to be dropped from the process. I leave that for the government to respond to, and we in opposition will continue to monitor.

Mr Owens: My question has actually been asked quite effectively by Mr Jackson. I can tell you that if in fact your interpretation holds true, you've been quite polite about where the stake has been placed in this process. As a person who's been a member of the Legion for approximately six years, I'm well aware of the good works you do and the kinds of facilities you need in order to continue the care of the folks who served this country.

This may not be an appropriate question, but I haven't seen the agreement, either the draft or the final agreement, and I'm wondering if it would be possible for you to share that with the committee, because I'd certainly like to have a fuller understanding.

As I've mentioned to other presenters, this is my first week on the committee, and in Sudbury or Toronto the issue with respect to the beds being downsized in numbers was raised. It's an issue of concern for myself and the veterans in my community, the members of branch 13 in Scarborough, of which I'm a member, and I would appreciate if you could share that with myself and other members of the committee.

Mr Margerum: I have a copy with me.

The Chair: I hope for all of you that it's clear from our discussion tonight that by bringing the agreement here and reading it, and I think giving us a fairly full explanation, you have provided us, at least, in terms of committee members, with new information. I think both Mr Jackson and Mr Owens have indicated, and as the parliamentary assistant has said, that the committee is certainly going to follow this and undoubtedly we'll stay in touch with you, so that clearly the intent cannot be somehow to deny privileges which are there and are owing, and that I think we would all feel very much an obligation to ensure continues to be there.

If you would like a final thought or comment, please go ahead.

Mr Margerum: Yes. To impress upon you or to show you the concern we have about those 150 extra beds being spread across the north, I guess the best example is dollars and cents. I believe anybody who's an MPP who comes from Ottawa or Windsor or the north and goes to Toronto gets an allowance with which to obtain an apartment or accommodation. Is that not correct?

The Chair: Yes, that's correct.

Mr Margerum: Okay. I'll give you a blunt history. Today we got the news -- our people who are in these facilities pay $420 a month, a veteran on pension -- it's now increased to $541.50, a 27% increase in the cost of living. I ask you about the spouse who is out in the community on a veteran's pension of roughly $1,300 or $1,400, being a combination pension of a husband and wife. How the hell are they going to keep a house and the husband in the facility? And what about a person who has to come all the way from Sudbury to Ottawa to visit their kin?

Mr Owens: Or Sunnybrook.

Mr Margerum: Or Sunnybrook, from Hornepayne or places like that? That is the seriousness. We feel very strongly that if they were to provide what we call the 50-kilometre-radius rule, a centre there for 50 kilometres around would be municipalities where they could go to visit a relative, and the cost is feasible. It's the most economical way and, more than anything, it's the most expeditious way, because we don't have a hell of a lot of time for these guys.

If we will address it, we're prepared to work with the ministries of Health or Housing to help. We have Nevada funds that we can work on if we're given the authority to use them for that purpose. We have people who are on boards of directors at hospitals, homes for the aged and different societies. We're prepared to do our part, but we've got to get the legislation and we've got to get the cooperation of politicians and bureaucrats to put that into action, not yesterday or not six years from now, but today, and get it started. That's the summation I guess I would have.

The Chair: You've given us the challenge, and over the course of the committee's deliberations I think you've heard from a number of members that they intend to pursue that. I know you'll be as close as always to it and we'll try to make sure that something changes. Thank you again for coming before the committee.


The Chair: If I could just note for the members, there was some problem in communication and one of the witnesses whom we thought was not going to come in fact always was going to come. I apologize that there was some misunderstanding. With the cooperation of the Victorian Order of Nurses, the Arbor Living Centers and the Ottawa-Carleton Placement Coordination Service, I'm going to ask the Ottawa Jewish home for the aged, Hillel Lodge, representatives to come forward.

They originally were going to be at 6:30, and we've discussed it and it was just a problem in communication. I apologize for that, but the important thing is you're here and we welcome you to the committee. We'll get some more of that delicious Ottawa water set up there and some clean glasses. If you'd be good enough to introduce yourselves and then please go ahead with your presentation.

Dr Gary Viner: I'm Dr Gary Viner. I'm a family physician here in the city and have been for some 13 years. I wear a few different hats. I am, as I said, a family physician with an active practice here. I'm the new medical director of the continuing care centre of the Ottawa Civic Hospital, a new ward that has been contrived for patients who are waiting placement at the Ottawa Civic Hospital and are classified as being at an alternate level of care.


As well, over the past eight or nine months I've also been the chairman of a committee of the Jewish community here in the city, the Jewish senior services committee, which is an umbrella organization that incorporates the very stakeholders looking after Jewish seniors in the city, so namely Hillel Lodge and the Jewish family services agency, as well as the Jewish Community Centre.

My colleague is Stephen Schneiderman, who is the executive director of Hillel Lodge and who will speak shortly.

Our major concern with this legislation relates to the centralized nature of placement services that are indicated in this legislation. Here in Canada, in Ontario, we take great pride in our multicultural community, that we're not actually a melting pot community as those of the south are. As all of you I'm sure are aware, as we age, with declining faculties, there's a real tendency for regression. We certainly believe that the optimal setting for seniors who are in this sort of state is one that is as close to their specific ethnic background as possible. There's no question that there's an ideal sense of comfort there and familiarity.

One of the concerns we have as members of the Jewish community is the loss of control that we might have over those seniors who are unable to be placed in that sort of environment, and frankly, as a physician for a large number of seniors who require placement, you see that very clearly in the variety of different ethnic groups that we care for in the hospital.

The Jewish community in Ottawa and other major centres, as you are probably aware, has a very well organized infrastructure. We provide schools, we have our own social service agencies, we have a home for the aged here in Ottawa. We subsidize these services privately through private donations to the tune of hundreds of thousands of dollars. We have a great pride in being able to perhaps provide services and excellence to the general community, but it's very important to us that we do have some degree of control over the facilities that we do have, and it's very important to us that we have some degree of control over the placement of our Jewish seniors.

Mr Stephen Schneiderman: Mr Chairman, honourable members of the committee, I'd like to thank you for the opportunity to get to speak to you tonight. I know that you've been going since early this morning and you've probably heard most of it already.

I'd like also to say respectfully to the committee and to the government of Ontario, whatever political stripe you are, if you are not a member of an ethnic group, you really cannot fully appreciate what it is that is going on within the mindset of these different cultures. When you speak about the Jewish culture, people have different opinions or ideas as to what they are or who they are, and I will tell you, it is a very complex combination between religious affiliation and ethnic identity. You cannot really appreciate that unless you're a member of a group, and I don't want to make a distinction with Jewish people as opposed to other ethnic groups. Other groups have a similar kind of experience, a similar kind of profile, if you will. What I do want to say is that with respect to placement coordination services, there is a question here of subscription and trust as to whether or not people will actually want to use a one-stop access point and go away from what is familiar.

Hillel Lodge exists for the Jewish community. I want also to tell you that your definition of "community" may be very different from ours, because we define our Jewish community as anywhere Jewish people reside in Ontario, and no other services for Jewish people are closer. It is not defined within catchment areas, it is not defined within rural or urban settings, and consequently, those people feel most comfortable in dealing with a group that they know understands their nuances, their idiosyncrasies, what we refer to as their "schtick." Placement coordination services are not going to be able to handle those kinds of things, not in the way that we would like them to handle them.

I would like to respectfully submit that I don't believe this is going to be a major place for change, this committee, but I would hope that it could possibly be a place for modification, and one modification that I would like to respectfully suggest is using the Jewish community as a partner. If we talk about change, you need instruments for change, you need commitment for change, and who is going to supply that? People, and people in an organized fashion. The Jewish community is not only well intentioned, but it's well organized and well prepared to meet its obligations. It always has, and it always will.

In that light, I'd like to suggest perhaps deputizing committees or using them as panels so that you can have one-stop access within their own neighbourhoods, their own communities. People will then be able to deal with situations on a more local level, and if there are any problems, again, pass them on. If anyone feels they've been treated unfairly, they can always go before a centralized placement committee and complain or take their case before that kind of committee.

I'd like also to talk about the primacy of the individual and, members of the committee, you're probably going to hear the same tune sung over and over again. We're also members of the Ontario Association of Non-Profit Homes and Services for Seniors, and the primacy of the individual has been a key concern of that association. We share that concern.

We feel that one of the things that has not been looked at closely enough is the whole concept of retrieval. With the kind of climate that Canadians have to endure, it's a very noble idea to keep everyone at home, but who is coming into homes for the aged and nursing homes and chronic care centres? People well into their 80s. Perhaps they need a refresher and a pick-me-up, and not to be kept at home for years on end, staring at the television set with maybe just a Meals on Wheels person dropping in once or twice a week or the odd telephone call.

I would submit to this committee, if you've ever been in isolation, you don't have any opportunity to talk to anybody, you start talking to yourself, and things start to deteriorate. There are very well documented psychological studies on what isolation can do, and when you begin to lose acuity with the process of aging, the onset of that can happen much more rapidly and in a much more devastating fashion.

I also want to talk to you about one other concept that PCS cannot really deal with, and that is the archaic design of many of our facilities. With the demands and the pressure of demand that's going to be placed on PCS to place people, it's going to have to fill the beds. People are now being referred to as "bed blockers," not patients or clients or residents any more, and it's starting to sound like Monday Night Football. It's a strategy session -- "How do you move people down field?" -- and it is becoming a matter of concern.

We have a lot of facilities that are not equipped, either, with separate areas for special care, and therefore people are going to be placed in a facility merely because they belong to the same ethnic group. I don't think that will work out very well. Also, the facility itself is best acquainted with matching. I don't think you'd want to match merely for the sake of matching; I think what you want is an accurate and a good fit so that people can live there for many years to come.

I'd like to thank you for listening to us. I apologize for any inconvenience with respect to the communications, but that was a personal matter and I beg your indulgence for that fact. Thank you very much.

The Chair: Thank you, and no problem at all. We're delighted that in fact you could be here, because quite frankly, we thought you would have a particular point of view, and while in some respects, yes, we have heard that in different ways, we haven't heard it in the way that you've expressed it tonight and I think that's particularly helpful.

We'll get right to questions. Mr Jackson.

Mr Jackson: First of all, I appreciate your perspective and your presentation. My Ukrainian grandmother resides in a facility, like yours, with the strength of your religious belief system, in Winnipeg. That's where my mother's family is all from, so I'm familiar with it in visiting my grandmother there.

The dilemma for us, of course, is that we have a system that's in contraction. I'm intrigued by your football analogy, because you're losing ground but you're moving down field. It's just backwards, if I can put a finer point on your analogy.

But the legislation says there will be no new facilities built. You would know the demographics of the aging Jewish population in relationship to the aging balance-of-Canadians population, and I'd hazard a guess that overlay isn't encouraging either.

Mr Schneiderman: Far from it. As a matter of fact, the population's disproportionately senior, and that has to do with the fact that there's just not as much replenishment. The birth rate is not quite as high. Something in the neighbourhood of between 14% and 15% of seniors in the Ottawa area are over 65, and we haven't got the most recent census but we've done our own preliminary investigations and the Jewish community in 1985 was appropriately 10,000. Today it's 17,000. That of course excludes places like Cornwall and Kingston where there are small pockets of people as well.

But one of the follies people labour under is the fact that everyone here in this room's heard of Baycrest, and that's fine for Metro Toronto, but the world does not begin or end with Baycrest. We in this region have our own concerns as to the best ways to deal with multiple problems.

Mr Jackson: But it's conceivable, with the size of the population of Metro Toronto, that Baycrest, even with minor modifications, with a placement coordinating agency, would determine ultimately that it could continue to service residents from the Jewish community. This is not the same in disparate rural areas, and that creates a dilemma here, because we have heard from organizations -- we heard from a group in Sault Ste Marie which runs a Finnish home for the Finnish community, half Finnish community, half other Canadians. But I sense that that's not the direction you're suggesting moving in. Is it the case in your own home in terms of your population mix?

Dr Viner: The population of our home is currently, I believe, all Jewish. I don't think there are any non-Jewish residents.

Mr Schneiderman: We've had on occasion one or two non-Jewish people, but what you're dealing with then is, if you start to go down the pipe with trends now, with intermarriage there will be people who have never actually taken on the Jewish religion who would feel very comfortable residing in that home.

Mr Jackson: I understand that. My mother's not Jewish, but she speaks fluent Yiddish.

Mr Owens: All mothers do.

Mr Schneiderman: Just enough to make you feel guilty, right?

Mr Jackson: But the point I'm wanting to get at is, you're really saying to us that for a variety of factors -- your faith community, your diet, especially with certain practices within the faith, has a hierarchy and a response -- it would be your hope and intention that you could do a better job for your residents if in fact that homogeneity is respected.

That is not necessarily the promise in this legislation nor the way it's structured. We're not sure, in the absence of any regulations that have been exposed to us, that we'll be able to satisfy the specifics of your request. I'm not saying I personally; I'm talking about the government, which is ultimately responsible for tabling the regulations.

I'm not having great difficulty with your request, but I just want to make it very clear for the record that that's what you're saying, because as each of the organizations that bring culture and ethnicity and language, we're getting a range of a cooperative relationship, a reasonable mix, a priority mix or exclusive. I don't wish to put a negative connotation on that; I respect what you're saying. I just want to make it clear for the record, and that the language of the bill or the regulations specifically would have to --

Let me get to the final point. If the government must hold to its position that it has to be on need, then it begs the question of, would you accept a resident or would you be willing not to have the bed filled and suffer the consequences of not getting the funding? That's perhaps an unfair question, but that is a logical conclusion to the question you raise if it's not satisfied by the government. You could say, "Okay, fine."

Mr Schneiderman: I'm respectfully suggesting, number one, to answer your question, that we would be prepared at this point, today, to accept anyone who would feel comfortable in our home. One of the differences you have to understand is that when you talk about a non-denominational service, it is not the size or type of cross on the wall. There are no crosses on the wall. That's one thing.

The other thing I'm saying, respectfully, to the committee is that the Jewish community is interested in being a partner in the process and avoiding all this work going through a central placement committee. We would be very happy to do the work and, if we cannot handle the situation, refer it back to central placement. That's all I'm saying.

Mr Jackson: I missed your point. I'm glad you clarified that because I missed it.

Ms Carter: I would want to pursue the same kind of point. It seems to me we have two things here that may seem to be irreconcilable but I don't think actually they are. The one is the fact that people should have choice and that we should be able to keep the integrity of the different ethnic homes and so on. The other is that we have to give priority to the person with the greatest need, the person who is at the top of the list as being an emergency and so on.

I'm quite sure that there's no intention in the legislation -- and I think this will be made clearer as further material comes out -- to restrict choice, that the intent is that the consumer's choice is going to be paramount when a person is being assigned to a particular institution, so people will be able to say. "I'm Jewish; I would like to go to a Jewish home." But when you say that this means they should do that at the local level, that may be true here, but in my own community of Peterborough, for example, there isn't a Jewish home. Sometimes the need would be to access the system on a wider geographical basis rather than the narrower one in order to be able to find a particular home that would be suitable for whatever reason. I think that works both ways.

Dr Viner: You'll quite commonly find that somebody from Peterborough would want to go to Baycrest, though.

Ms Carter: Yes, absolutely. I think we're all agreed that we have to have this flexibility, however it works in a different place, and that we also have to look at the question of need. I understand that it would be quite possible for somebody to be assigned temporarily to a home which was not the ideal place because that was where a bed was available and the situation could then subsequently be adjusted as maybe a suitable place became vacant in a Jewish home, whatever, and there might be somebody who needed the other place. So I don't think this is impossible.

Dr Viner: Speaking as a physician who watches people getting disoriented as they transfer from ward to ward or room to room in a hospital, the last thing you want to do is have somebody go from one spot to another or a short-term placement and then move on to another for a longer-term placement and as they deteriorate move on to another. You end up with a perpetually confused individual as opposed to one who's stable. The more you move somebody in this age group, the more fragile they are, of course, the harder it is to retrieve them.

Ms Carter: I think we all understand that, but the problem is, the more variety you have, the more difficulty there is in finding the right fit at the right time. I guess that's just an integral part of the situation.

Also, we did have a presentation from Baycrest and it was concerned that it was spending more per capita than would be provided under the new arrangements and that it would be red-circled. I think there again as a government we have to stick to the principle that everybody gets equal treatment in the long run but that communities and groups that maybe want to contribute something to provide a higher standard for their people I would imagine would be able to continue to do that.


Mr Schneiderman: Can I just briefly comment? I know time is of the essence. One of the things that I don't believe has been looked at is, with smaller charitable homes etc there is an economically viable number. For-profit people will talk about numbers. I've heard the number bandied about, and it started out in 1985 at $60. Now it's talked about at around $100. You have to begin at the least altruistic level, the most mercenary, businesslike way, to begin to look at something, that there is only so much of a revenue base you can get for every resident and it cannot be divided out proportionately, because of economies of scale, with staff. We have made this argument on countless occasions.

Therefore, if you have, for example, a $90-a-day portion given out, if it's only times 48 people, you still have fixed costs and a necessary staff ratio for health and safety, infection control and supervision. It becomes an absolute economic nightmare to deliver services under such conditions. Therefore, what we have been told is that augmentation can be done with outreach services. That's not true. You're lucky if you break even on outreach services. What are you going to make, a $3,000 surplus on Meals on Wheels? If you're dealing with a $500,000 deficit, the numbers simply don't add up.

So there are problems in terms of when I talk about archaic design, that facilities are not set up properly and they're too small in some cases -- and I'll stop.

Mrs O'Neill: Thank you, gentlemen. I know Hillel has a reputation that precedes it in the community. You've brought forward some very practical problems tonight and I think that's always very helpful. I think we have had quite a few interventions, mostly I think originating from me, regarding the terminology of what "community" is in the implementation of this legislation. I think we've had some guarantees, at least from staff at the ministry, that in a case such as yours where there are cultural and spiritual values involved, there would be a much broader definition of "community." I think your statements are very true, that people in Peterborough would no doubt be willing to go to another community.

I'd like to say a couple of things. Your statement about isolation really hits home very closely personally to me. You likely know that in this community last fall there was a major survey done in preparation for a publication of the seniors in Ottawa-Carleton. It came out in every single area of this community that loneliness was their first priority of concern. I was amazed at how consistent that was across the community, and I did attend a workshop that followed that survey. As I met the seniors, they all had a different reason for feeling lonely. Most of them were living on their own.

I'd like you to tell me, do you use a placement coordination in Ottawa-Carleton at all? Are you part of that, or do you do all of your own placement?

Mr Schneiderman: Essentially we do our own placements. However, we have worked with a placement service. Occasionally they will get a Jewish person and refer them on to us, and sometimes they refer a person who we really, at least at that point, could not help. It did not mean, because you were Jewish and elderly and were suffering from some kind of difficulty, that we were necessarily the best placement in terms of how we're set up. Some special care issues really hit home on that, and that's forming the cornerstone of some of our future planning in order to have a setting that is secure and somewhat separate from the rest of the population, because those people do regress and whatever is familiar in terms of cuisine and smells and symbols serves to at least keep them going for as long as possible.

We have worked with the PCS and we do work with PCS. However, most of our people, even if we report them to PCS, all knock on our door and they will take that route. I believe they will continue to take that route despite the legislation. We're just going to direct them back if that's the way it has to work.

Mrs O'Neill: You didn't specifically say that you felt facilities should have the right of appeal as well as residents, but I presume from everything you've said that that's what your intent is.

Mr Schneiderman: I think that's implicit, but what I was hoping is that we would not have to deal with that if we could initially do a screening interview orientation process. We do a very involved one at Hillel Lodge. People come for an entire day. We have our physician look at them, our nursing staff, our social work staff and our recrealogist. I meet with them. There's a whole day. They have lunch. They participate with the residents. We have a good opportunity to see how they like it and they have a good opportunity to see how they like us.

Mrs O'Neill: That's the trust we must have in the facilities that exist, in your methods.

The Chair: Thank you very much. I'm sorry that time is always speeding by, whether on a football field or any other place.

Mr Schneiderman: I appreciate it.

The Chair: Again, thank you very much for coming. We really appreciate it.


The Chair: If I could then call on the Victorian Order of Nurses, the eastern counties and Ottawa-Carleton, if you would be good enough to come forward. We want to welcome you to the committee, and thank you for allowing us to play around a little bit with the schedule. If you would be good enough to introduce your colleagues and yourself for Hansard and for the committee, then please go ahead with your presentation. Welcome to the committee.

Ms Diane Raymond: I would like first to introduce my colleagues: Charles Armstrong, president of the Ottawa-Carleton branch of VON; Jean Courville, who is our executive director of the eastern counties branch; and Heidi Jaeggin, who is a director of the placement coordinating service of VON, eastern counties branch.

Before I get into my presentation, I should say we've been here since 11 o'clock this morning.

The Chair: You deserve an award.

Ms Raymond: We're suffering a bit from the same thing you are suffering from and we know where you're coming from.

The Chair: Do you have a prognosis?

Mr White: Just imagine four more weeks of this.

Ms Raymond: Exactly. The other thing, though, that I think was great about being here was that we did hear some views that were completely different probably from what we have been feeling. It's a shame in a way that this sort of information can't be shared with many more organizations. It is a pity. As a veteran of the Second World War -- I've got to get the right war in there -- I was very touched by the presentation the legion gave, because I think there's a lot of my personal feelings that went along with it. That's quite aside from anything I have to say, other than to say we have not given you a long presentation, you'll be glad to see. I'm going to more or less read it, because, as I say, it's later in the day.

As president of the board of VON eastern counties, I greatly appreciate the opportunity to make this presentation to you. I do not intend to review or rehash the material that's been presented by the various interest bodies in response to the consultation paper, Redirection of Long-Term Care and Support Services in Ontario. We have assumed your committee has access to this documentation, and after listening to the first report we heard this morning, VON Renfrew, I know you have heard VON's papers. You have the VON background, so there's no particular point in my going chapter and verse. We fully support, however, the responses made by VON Ontario. We were able to make our own contribution to the position paper and we feel that the main areas of proposals that were of concern to us as a local branch were brought out in the position paper and other submissions.

Tonight I'm primarily interested in providing you with some background on the eastern counties branch and commenting on the concerns the board has -- and if you realize, I'm talking on behalf of the board, which is the volunteer part of our organization -- with the use to which the responses to the consultation paper will be put and to a ministerial remark that was passed on to us that said, "The institutional sector covered by Bill 101 may overwhelm the community component." This concerns us. We are a community component.

First some background on the now 80-year-old eastern counties branch of VON. We are geographically located on the southeast side of the province, bordering Quebec. This is the part of Ontario that never gets noticed. Our branch serves five counties, Glengarry, Stormont, Dundas, Prescott and Russell. Looking at the map, you will see that our land mass lies mainly between Highways 401 and 417. Within this area, we have one major city, Cornwall, with a population of plus or minus 46,000, plus an almost equal number within a 30- to 40-kilometre semicircle, because it ends at the St Lawrence, around Cornwall. With a total population base of approximately 160,000, you can see that the minimum of 50,000 is spread rather thinly through a number of small towns, villages and rural areas.


The two active treatment hospitals in Cornwall and most medical specializations are available. There are three district hospitals, in Alexandria, Hawkesbury and Winchester, and clinics in other locations, so we are relatively well supplied with what one would call the medical needs. Residents in the county of Russell do use Ottawa hospitals, because physically it's close.

A remarkably large percentage of our elderly population is the third and fourth generation of their family. Many still live in the area in which they were born, some in the same house.

We happen to be well supplied with long-term facilities. Unfortunately, some of the extra beds are a long way from the home of the potential residents. To comment on some of the discussion we heard today, we do have in our long-term facilities people from the Ottawa-Carleton area, temporarily, till they can be placed back in the Ottawa-Carleton area.

In a section of Cornwall and in some of the towns and villages, French is the language in common use, particularly among the older population. We therefore provide our services in the language of choice.

The five areas have not had a large influx of immigrants, so we don't face the same kinds of problems that you find in Toronto or even Ottawa. In the rural areas there are pockets of Dutch and Swiss farmers. In the greater Cornwall area there are small numbers from various different ethnic backgrounds among the residents. There are relatively few elderly among these groups at this time, but this will come. No one particular ethnic group predominates.

There is also a large native population on the reserve on Cornwall Island. Part of this reserve is under the province of Ontario jurisdiction, part under Quebec and part is the responsibility of the United States.

Our principal community service program is the visiting nurse program. Over the past three years, we've averaged 100,000 visits throughout the five counties each year. At present we have a percentage breakdown of roughly 80% RNs and 20% RNAs on staff. These nurses work out of the main offices in Cornwall and from suboffices in Hawkesbury, Casselman, Winchester and Alexandria -- and I bet most of those names are names you've never heard. Phone, fax and routine visits by the executive director keep the activities of these offices coordinated and in step with our client-centred objectives. We have computerized all accounting, payroll, data assembling and reporting activities and continually investigate where and if new technologies can contribute to more efficient and cost-effective operations. You may ask why we've put this in the presentation, but we do want to draw your attention to the fact that we are coming from a reasonably knowledgeable, technologically up-to-date community.

We are proud of our professional staff. They are skilled and motivated and able to perform the multiple nursing procedures normally required of the visiting nurse. Through the use of funds received from memorials and other donations, we've been able to send nurses on courses, seminars and workshops. This means we now have a trained staff available to meet the growing special needs in our community for palliative care, IV therapy, enterostomal instruction and support, post-chemotherapy and the highly specialized needs of infants sent home with severe medical problems.

We administer the placement coordination service for the five counties. This program has a community advisory committee chaired by a board member and through this the board is kept aware of PCS operations. PCS in an intricate part of any continuum of service.

The very obvious shortcomings in the present long-term care system identified in the consultation paper, such as fragmented, unequal or non-available supports, differences in eligibility criteria, confusing funding and resources allocation procedures etc, indicate that in today's society collaboration, coordination and cooperation are not only desirable but critical. Our support is for one long-term care policy, one that integrates both sections, community and institutions, with established policies and coordinated planning with appropriate organizational and operation structures. This of course means one ministerial responsibility.

We see a system based on a continuum model for long-term care as well worth a pilot study. We would be prepared to be part of this pilot study. Through the continuous process, the user of service -- elderly or other qualified individuals -- and service providers would have a system in place that moved logically and progressively from an entry point through a range of community-based in-home health and social services, from which selection based on need would be made, up to and including rehabilitation and institutional care where necessary. This could be the basis on which the now separate streams would become one. Through a continuum process, individuals would be able to have better control of their own care decisions and they would be informed of and able to select between alternatives with the knowledge that, if needed, the system has alternatives equally available and that they would have input into the choice of the alternative selected. This would strengthen their sense of independence and dignity. A further value of such a system is that it would overcome fragmentation but still allow for plurality.

We have one further concern, that is, that expediency, political pressure and funding problems may limit the time and resources needed to adequately review, compare and evaluate the counterproposals and alternatives received in response to the consultation process and the proposed amendments to Bill 101.

A move by government to proceed with hearings on Bill 101 before final decisions on long-term care redirection are made puzzles us. This moves flies in the face of government's stated commitments to full consultation, and, one can presume, examination of the responses, and a promise of a policy on long-term care. A policy to us means inclusion of all components of both the community and the institutional sectors, a policy that realistically integrates and provides control of fiscal and human resources and respects the rights of users and providers of service.

I'm going to turn over to Charles now, if I may, so you get both reports.

Mr Charles Armstrong: Thank you very much. I just wanted to take a few moments to perhaps update the committee on what's happening outside of Toronto at the number two VON branch in the province and some of our concerns. You're not really focusing as a committee on what's happening in the community tonight, but we're concerned, because what happens with the institutions directly affects our activities and we can see that in our clientele.

We keep talking about how long we've been around, and I want to reassure the committee that certainly the VON branches across Ontario are focused on the future. We've been around since 1895 and that's behind us and we're quite proud of the history, but we're looking at the future. We're beyond long-term care. I think, if we go back in history, VON really exploded when home care was brought into the province. It's probably the success of home care, which probably far exceeded your expectations and certainly VON's expectations, that is part of the problem in health care generally as we try to figure out how we can curtail the costs.


Certainly VON, in a major market as we have here in Ottawa-Carleton, is directly feeling the pinch from the major acute care institutions as they cut beds, as they postpone receiving patients, as they send them home quicker than they did in the past. We see them, we've got major training, we're taking longer to see more acute patients. As they wait for beds in long-care institutions, they're becoming a more complex client base.

Just to bring you up to date on the size of the activity in Ottawa-Carleton, we see 1,000 clients a day. We are going around the clock, and certainly from a cost point of view, night-time we lose money, significant dollars, because you can't do it as effectively as you can during the day.

With restricted staff, you're driving further to see fewer clients. I guess, in total, we make 320,000 house calls on an annual basis -- and I'm always looking back. The budget in Ottawa-Carleton for VON is approximately $12 million, which is the size of many acute care hospitals across the province, and we do that with a very small management staff. There are no VPs of this and that. I've been in VON a while, so I apologize if I sound proud of the organization.

What VON is focusing on and what our branch is turning itself upside down with is trying to curtail costs, because our fees have been capped and fixed. We are trying to change the mix of staff, to send out more appropriate staff to deal with the needs of the clients. Clients have a difficult time accepting that. We try to keep the press coverage down to a minimum amount. Through computers and voice mailboxes and fax machines in cars, as I say, we are redefining how we keep our staff employed.

The volunteer boards across the province, whether it's VON or the hospitals, the amount of time that we spend trying to figure out the various models that come forward for health care and prepare our position papers -- it's just amazing the amount of time and effort that goes into that as we struggle through.

Change is coming and I want the members of the committee to know that we're prepared to assume a position, in whatever model finally emerges, as a partner, as a provider, or we're quite prepared to play a predominant role in being a coordinating group, if that were deemed appropriate.

By day, I'm a tax accountant, so I don't presume to advise a qualified committee on process, but I would certainly advise, if there are new models being developed, that we don't put it across the province all at one shot and that we do experiment and that we think it through. Certainly we do need some kind of coordination right from the major acute hospitals down to a foot care facility. The members of the community have to decide how they want their dollars to be spent. We do need a comprehensive policy, because what affects the institutions affects us.

I haven't thought it through all the way, but if we're really interested in controlling our costs as a group, and your costs and the province's costs, certainly the envelope approach has its attractions. I don't know how far you go with the envelopes, but that's an approach.

We are operating under a fixed fee. Every time we see a patient, whether it's an hour or two hours or three hours, or 4 in the morning or 9 in the morning -- and certainly in Ottawa-Carleton we are pushed to the point where on a good number of the visits we are not covering our costs and we're at a very crucial point in our history. We are feeling what's happening to the institutions in our client mix.

Thank you very much. We are here to help.

The Chair: Thank you very much and in particular for a snapshot of what you are facing in your own areas. I don't know if other members are going to respond to the challenge to identify the various communities you mentioned in your comments, but when my relatives came to this country in the 1840s, they settled between Hawkesbury and Vankleek Hill, and the old farm is still there. So there's something in the blood that still responds to that call.

Mr White: My aunt lives a mile from Alexandria on the north --

The Chair: This could get bad. We could start a whole series of things here.

Mrs Caplan: We are very competitive.

Mr Owens: Representative, Elinor, representative.

The Chair: To get us back on track, we'll start the questioning with Ms Fawcett.

Mrs Fawcett: Thank you very much, Mr Chairman. My uncle drove ambulance out of Morrisburg to all of those places.

As I said this morning, the VON invented home care, I'm sure of it, and certainly with all of your expertise -- and I experienced some first hand when our son broke his neck and we had the VON, thank goodness, coming in every day, because it took me a few days to get accustomed to that lovely halo that he was wearing for three months.

Certainly we appreciate all of the work that you do, but it is serious in rural Ontario, and I think you alluded to some of the problems that you are experiencing: lack of funds and yet the increase in numbers of people who need the care. Do you see a crisis looming, when we know that the number of seniors is increasing by leaps and bounds, and especially the more acute care people? I just wondered if you would like to expand a little bit on that.

Then, you were here maybe this morning when I alluded to that program on W5 where Saskatchewan VON is no more and I'm very concerned about that. Hopefully, I would like to see you take part in that pilot study, because I think you have a marvellous network. You are all over Ontario. You would be able to really give us a good idea of what works and what doesn't in all sections of Ontario. I've loaded you with a few things there, but --

Ms Raymond: I'm going to ask our executive director to speak to the Saskatchewan situation because she is relatively more knowledgeable about it than probably anybody in this room.

Ms Jean Courville: I was working with the Regina VON back when it had the home care program and then it was taken over by Wascana home care program when the government put in a new program. I don't think it was the Saskatchewan government which now chose not to contract with the VON in Regina; it was the Wascana home care program which did that. So I don't think it really matters which stripe they were wearing at the time; it was the local position that they did it in Regina.

The other programs, I think, in the west have basically lost most of the visiting nursing. It doesn't mean that VON won't be in Regina; it just won't have visiting nursing. There will be other programs that they will have to develop.

Mrs Fawcett: What would they be doing then?

Ms Courville: They could be doing a lot of things. I know in Prince Albert they are into occupational health in the north. Moose Jaw is doing things with education of health care aides and people working in the home, like homemakers, doing education programs there. I think that some of the other areas that they may be developing may still be out there, and Regina would be doing some of those things as well.

Mrs Fawcett: But I think we would agree that if we want this long-term care to work here in Ontario, you are a very integral part of that, making it work.

Ms Courville: Certainly, and I think that VON certainly has changed significantly over the 95 years that it has been in existence, and I know that -- and I know Charlie mentioned this before -- we will be changing in the future, and that's part of what we're ready to do.

Mrs Fawcett: Just briefly, I'd like also to mention I was glad to hear you refer to the native population, because we haven't heard too much about that. I know we are awaiting a study from the advisory --

Ms Raymond: We were just saying --

Mrs Fawcett: You don't have to touch it.

Ms Raymond: We were just saying today that one of the problems, of course, is the time that a nurse has to spend with a client. Jean was saying that we have one patient on the island, three hours, plus the fact that they've got to go over a bridge, pay a toll, which we do not get reimbursed for, and come back. So we're thinking now of asking for a reimbursement on tolls, but we'll leave that out of this.

But what I wanted to get back to is your comment about, did we see a crisis? I don't think we see a crisis. I don't think that's the way we work. I think we see there are problems and I think we see there are solutions, and I think what we have to say is, let's get the problems out and let's work on the solutions and let's stop all this pussyfooting around, passing the buck here, there, elsewhere.

I can say this because I'm coming from years and years, and I won't be here, probably, to see what finally ends up. Oh yes, I will. I'm going to live to 105, I might warn you.

So I don't think we have a crisis, but I certainly think we have some problems that have to be looked at and dealt with. I don't think VON has all the answers but I think it has some large hunks that it can put in there and hopefully do the job.


Mrs Fawcett: Sounds to me like that ad, "Just do it," is what you're suggesting. thank you.

The Chair: We want to be careful about tolls. That could lead us down all kinds of funny roads.

Ms Raymond: Oh, I know.

Mr White: I want to commend you for your presentation. You do it with a little bit of humour and a real strong sense, I have, of your service in your community and your pride in what you have done. I want to say you're right, we should be going further. When you say it's expediency, political pressures and funding problems and all those other kinds of things, you're probably right too.

Ms Raymond: Unfortunately.

Mr White: There's only so much you can accomplish at one time, and I think we've done a tremendous amount with this bill. There is obviously, and has been, a stated commitment to go further in the very direction you're prodding us in and that you'll be on the leading edge of.

I just want to state very clearly that all of the VON presentations that we've heard -- all 14?

Ms Courville: Only 14?

Ms Raymond: Well, there are 33 branches. You've got some more to come.

Mr White: I think there's probably more tomorrow as well. Every community we've been in we've heard two or three at least. They've all been not only excellent, and many along the same lines, the same themes, but also they all had those little unique twists that it wasn't like, "Oh gee, another VON presentation." It's like, "Hey, I'm looking forward to it, even though I've heard some of it before." I want to commend you and say, yes, you're right. You know, we're not going as far as we would like to, but we will be.

The Chair: Thank you again very much for coming, and if we were giving out awards for longevity in terms of being here all day, I think --

Ms Raymond: We're going to stay till the end.

The Chair: Very good. Thank you all for coming and being with us tonight. I'm sorry, was there anything else? Please.

Ms Heidi Jaeggin: As director of the eastern counties PCS, I would like to just bring something to your attention concerning placement of natives on Akwesasne, in our area, that's currently happening.

The current home for the elderly that serves that population is in Snye, Quebec. As you may be aware, the reserve cuts three jurisdictions; two provincial jurisdictions, Ontario and Quebec. It also cuts into New York state, and it has the US federal government involved and also the Canadian federal government involved.

The home for the elderly is in Snye, which is on the Quebec side, and the residents, whether they be Ontario residents or Quebec residents, access acute care predominantly in Cornwall if they're Canadian citizens. If they're American citizens they access acute care in Massena or in Malone, New York.

I understand there is a nursing home being built on Cornwall Island to serve the Ontario residents, which will certainly be an advantage, but right now the problem we're having is that, because of the violence on the reserve, the natives are not wanting placement in their own home for the elderly and we're having to look at resources not only in New York state but also in Cornwall and within eastern counties long-term care facilities.

We also have individuals on the reserve currently who, for example, are on respirators and total care whom we cannot place in either respite or chronic care and we are now having to access, certainly, Élisabeth Bruyère centres for these individuals, and they're natives. I realize that there's no native representation and it's becoming a real difficulty around Akwesasne, specifically because of cigarette smuggling, and there is now a large number of incidents of violence on the St Lawrence River.

The Chair: Perhaps one of the things I might do, as Chair of the committee and through Hansard, is to send along what you have just related to us to both the Minister of Health and the minister responsible for native affairs. We know and mention has been made of a paper that is coming out with respect to natives, and I think to get that kind of input -- they may well have received it through other channels, but I think having given it, and, as you noted, we have not had native representation here today, you describe a very practical, day-to-day problem which clearly needs to be dealt with, and I would undertake to do that.

Ms Jaeggin: I think to access our services to the home for the elderly we have to go through customs, we have to go into New York State and back into Quebec. So there are serious logistic problems with border-crossing.

The Chair: Okay. Thank you for that information and, again, thank you all very much for coming.

Ms Jaeggin: Thank you.


The Chair: I would now like to call on the representatives from the Arbor Living Centers, if they would good enough to come forward. We have received a copy of your presentation. Please make yourself comfortable, and perhaps you'd be good enough just to introduce yourself and proceed with your presentation.

Mr J. Michael Bausch: Thank you, Mr Chairman. I trust it's been a long day and I trust I won't keep you too long this evening.

The Chair: We're still very bright and cheery.

Mr Bausch: You're better than I am.

My name is Michael Bausch and I'm the president of Arbor Living Centers, which is a management company responsible for the provision of care and services to over 2,700 seniors in 17 nursing and 16 retirement homes throughout southern Ontario. Our client base includes both for-profit and not-for-profit providers of long-term care. Most of these facilities are in smaller communities, 10 of which are in eastern Ontario. Our comments on Bill 101 will be confined to our interpretation of its impact on nursing homes, although our experience in retirement homes also heavily influences our thinking.

I'd like to begin by applauding the current initiatives of the government of Ontario, for we believe the bill represents the first legitimate attempt to bring more equity in funding and regulation to all extended care providers through the province. It certainly has been a long time coming, but it's warmly received.

In addition to attempting to level the playing field, this bill proposes to fund all residents of all extended care facilities on the basis of demonstrated need without reference to the particular long-term care facility chosen by individual residents and their families. In your travels across the province, I'm confident that you've heard often of the historic inequity in funding levels among different types of providers and there's no need to belabour it further.

In addition, the bill proposes to apply universal standards of regulation to all types of long-term care providers, utilizing a common set of rules and inspection procedures. Once again, in enhancing consumer choice, it has long made good sense to ensure that all providers be held accountable according to the same rules, assuring residents and families that basic minimum standards are maintained wherever extended care is being delivered. In our opinion, this feature of the bill should be applauded by provider and consumer alike.

However, as you might suspect, we do have some concerns. These concerns largely include provisions which we believe could potentially limit consumer choice, could create additional inequities while removing historic ones and in general create a wide range of new problems. I'd like to concentrate on five elements, what I've labelled the contract, the placement coordinator, penalties and processes, quality assurance and resident councils.

It's our understanding that extended care has historically been an insured service in the province under the auspices of OHIP and that Bill 101 proposes replacing this insured service through contractual service agreements between government and providers. This is an extremely significant departure from historic commitments to universal and accessible health care in the province.

While at first glance contractual agreements appear to represent an efficient replacement for cumbersome regulations, the fundamental underlying assumption in any contract is that all parties accept certain responsibilities and failure to discharge agreed-upon responsibilities results in breach. Contractual breach leads inevitably to remedies available to the non-offending party vis-à-vis the party in breach. We can see little of these fundamental elements of contract in the bill. The responsibilities appear to largely incumbent upon the provider, with little responsibility in evidence upon government.


More specifically, the bill eliminates all government responsibility to fund providers equally to ensure that the same level of services to all residents throughout the province is made possible. It would appear possible for government to treat different providers in different ways, funding some programs in some facilities while not providing these programs in others. We would suggest that the ultimate losers in this scenario are residents, those who are in effect being denied equal access to programs.

Additionally, there would appear to be no attendant responsibility defined in the bill for the government to fund requirements of extended care residents as determined by their assessed needs. The proposed resident classification system will be used to allocate available funds for nursing and personal care. Quality-of-life programs and accommodation will be funded using another, currently unidentified approach.

The resident classification system should enable government to develop a case mix system, which is a means of comparing one extended care facility to another and to determine how available funds will be distributed among all facilities. There is no guarantee that available funds, however, will match assessed resident needs, and, more importantly, no ability for facilities to react to inadequate funding levels is set out in the bill. To return to the contractual analogy, the ability to determine remedies in case of breach of contract on the part of government is denied and it would appear that the contractual service agreements are not intended to be contracts at all, as all remedies are reserved for only one party to the contract, government.

Not only are contractual service agreements provided for, but also individualized care plans for each resident and a notice in writing to each resident describing services to be provided under the service agreement is specified. A further requirement is that the care outlined in individual care plans must be provided. Should government funding be inadequate, however, no flexibility is envisioned. One can only speculate as to the accuracy and detail of care plans, considering that there is assurance of financial resources sufficient to meet the needs of all residents.

The proposed legislation also seems to focus on process, as evidenced by paper trails. While no doubt facilitating the proposed inspection process, this represents a step backward from modern approaches to resident satisfaction. Instead, we would submit, the focus should be on outcomes as matched against resident needs as identified in care plans, for a rigid insistence on paper trails is translated into facility staff devoting increasing amounts of time to documentation rather than to direct resident care.

We would submit that the nature of the contractual arrangement envisioned in the bill is further compromised by the provision of immunity for all acts done in good faith by placement coordinators and inspectors while no such similar protection is provided for facility staff. In the interests of equity alone, similar treatment should be afforded to staff.

Finally, all contracts customarily provide for some form of arbitral process to resolve differences between parties, and in this bill no arbitration or appeal process is identified. Clearly, with government able to alter funding, to change policy and to redefine programming requirements, the contract is too one-sided. Some process enabling facilities to appeal disparities between government funding and government-mandated programming really must be incorporated, for to ignore it is to encourage behaviour adverse to desired outcomes and could ultimately result in extensive and perhaps needless litigation.

To turn to the placement coordinator, throughout the long and arduous consultative process surrounding reform of long-term care delivery, perhaps no item has been more contentious than the role of the placement coordinator or similar functionary under ever-changing titles. There does seem, though, to be general agreement among government providers and consumers that some form of central information agency is required. Far too many anecdotal incidents of vast confusion among residents and family members have been recounted to deny the legitimacy of this need.

However, there has been and continues to be great difference of opinion as to the amount of authority and responsibility which ought best to be vested in this position. We believe there are legitimate concerns that placement coordinators will literally be given the power to control individual lives.

The bill appears to provide for the placement coordinator to determine eligibility for placement in a long-term care facility. How will placement be determined if individual care requirements and preferences have not been determined? We would submit that eligibility for service is distinctly different from determination of requirements. As well, many placement decisions need to be made on evenings and weekends. Will the service be available 24 hours a day, seven days a week? Will substitute decision-makers and responsible parties be identified prior to admission in order to minimize incidents of default in financial obligations and in the establishing of ability to pay? Perhaps most importantly, will the placement coordinator be required to consider applicant preference, be it geographic, ethnic or religious, linguistic or family-driven? These concerns simply aren't addressed in this bill, and they do represent continuing concerns as expressed to us as providers and through many other consumer forums, such as the seniors' alliance. Finally, will placement coordinators assume responsibility for discharge planning and the coordination involved when changed needs dictate movement to a higher level of care more appropriate to the resident?

Once again, to safeguard consumer choice, we believe some means of appeal of placement decisions must be incorporated into the legislation. This process must be timely, it must be accessible and it must be efficient, for typically at time of placement the need is acute. An unnecessarily complex process would not be in the best interests of residents and families.

As well, from a facility perspective, what assurance is there that an individual facility has the ability to meet the needs of the prospective residents? Currently, the facility administrator, the director of resident care and often the medical adviser are all part of carefully determining whether or not an applicant's needs can be met, where he or she is to be situated within the facility and, in cases of shared accommodation, how well the potential resident can be matched with prospective roommates. Health status, care requirements, cultural, religious and language factors are all considered.

We believe that individual facilities must continue to have the right to define their missions and the types of services they are able to deliver. The ability to refuse an individual applicant must be retained when the facility's mission, human and physical resources preclude the ability to meet residents' care needs. Particularly among ethnic and religion-specific extended care facilities, there is great concern about the proposed placement coordinator's ability to undermine their entire reason for being.

The need for an appeal mechanism, then, is equally demonstrated on behalf of individual facilities. Timely and efficient, a process whereby placement decisions may be challenged when the ability to meet the care requirements, both medical and social, of potential residents is compromised simply must be provided for in the legislation.

To turn to penalties and process, it would appear that the bill provides for a series of sanctions that government may use to penalize facilities if they are deemed to be in breach of contract. Without providing any similar penalties for government, these sanctions include reducing or withholding payment, freezing of admissions and suspending or revoking approval to operate. Tremendous power, then, would be placed with government to impose sanctions in an arbitrary and unchecked manner.

We would suggest that some of these strategies would be counterproductive. Particularly with financially driven sanctions, great care must be exercised to ensure that not only would the provider suffer penalties but what the likely impact might be on the rest of the residents. Once again, some means of appeal should be specified in the draft legislation in order to focus the penalty, to ensure that the penalty is applied in a non-arbitrary fashion and that the residents of the facility are not ultimately called upon to bear the burden. We would submit that, once again, the nature of the proposed contractual arrangement is too one-sided.


To those of us who have been involved in long-term care delivery for some time, it would appear that Bill 101 implies a return to an adversarial approach to inspections of extended care facilities. This despite the fact that government-commissioned studies long ago examined the effect of an enforcement or adversarial approach versus a combined consultative and enforcement approach. The Woods Gordon report of 1986 identified poor outcomes from the then adversarial climate between inspectors and providers. It was detrimental to problem-solving. It prevented the Ministry of Health from focusing efforts on the issues of greatest importance to resident health and safety.

The result of that study was a change in approach, resulting in a compliance management program that has proven to be very effective in monitoring resident care services and programs while facilitating problem resolution prior to the situation escalating to serious proportions. It is only after consultative efforts have been exhausted that enforcement has been invoked.

Bill 101 provides for a return to an older and universally rejected system. Inspection powers are clearly designed for worst-case scenarios. Broad powers are specified that would likely result in inconsistent and potentially unfair application of sanctions, and a return to an adversarial approach would likely mean a return to the period of increased litigation between government and providers, an unnecessary waste of valuable resources. The accountability of providers is not at issue; process is. This step backwards has no place in this bill.

Particularly when the impact and role of advocates with the passage of the Advocacy Act is considered, we would question the increased power of inspectors. What are these advocates for? Are they not to help improve communication and problem-solving? Are they not to intervene when residents' rights are being jeopardized? Why then the need for stepped-up inspection powers?

Bill 101 requires that each facility should establish quality assurance programs, and we assume this terminology is interchangeable with other, perhaps more in-vogue management processes such as total quality management. But of key significance is the lack of confidentiality in this clause of the bill. Quality assurance records, of necessity, in order not to subvert the desired process, must remain confidential. These records should be for the use of the facility in improving service levels, for most likely, commentary on staff will be contained therein, and the records accordingly should not be available to inspectors as part of normal routine. We would request that amendments to the draft legislation be made to reflect this.

Finally, residents' councils: We were most surprised to see no reference to residents' councils in Bill 101. The current Nursing Homes Act requires administrators of licensed nursing homes in the province to inform residents of their right to form a council and specifies its powers. No such similar requirement exists in homes for the aged, be they municipal or charitable.

While it is undoubtedly true that this requirement has probably not resulted in all nursing homes having an effective resident council, it most certainly has raised the awareness level of the place and the need for resident councils. Where resident councils do exist, and where nursing homes have assumed the responsibility of encouraging and supporting their formation, resident councils have proved to be an effective liaison between residents and management of the facility, and with the increased role of advocates in long-term care facilities, it would seem that the desirability of councils is strengthened, for advocates could act as a further resource and strength for the efficacy of these organizations. Failure to continue this provision in new legislation would represent a step backwards.

To summarize, while highly desired and long awaited, we believe the bill still falls short. The deletion of extended care as an insured service under OHIP and its replacement with the contractual relationship in the form provided will do little to improve the delivery of long-term care, for we believe too much power is reserved to government and its inspectors without corresponding accountability. Relatively little power, protection and/or choice is reserved for providers and consumers. Remedies for breach of contract by government are non-existent. Far too many issues are left to be defined by regulation and thus avoid legislative scrutiny, and facilities must provide for all resident care needs with absolutely no assurance that funding to support these needs, as defined by care plans, will be provided.

We would therefore strongly urge that Bill 101 be amended to provide for the following nine items:

(1) The government should be held accountable for the maintenance of equitable and consistent services in all long-term care facilities in Ontario.

(2) The legislation must not require facilities to provide all services as defined in care plans unless government assumes responsibilities for funding these services.

(3) Remedies must be provided to facilities in case of contractual breach by government in the provision of funding adequate to meet assessed needs of residents.

(4) Existing resources should be used for the placement coordination function and no new level of bureaucracy should be created for these purposes.

(5) Both applicants and facilities must have access to a timely and efficient appeal mechanism to challenge placement decisions by placement coordinators.

(6) The powers of government inspectors should not be increased and the use of the existing compliance management program should be continued.

(7) Sanctions for non-compliance should be reserved as a last resort and facilities should have the right of appeal of sanctions prior to their imposition.

(8) No member of any inspection staff should have access to personnel records or records dealing with quality review activities, peer review or performance review activities or quality improvement activities.

(9) Facilities must inform residents of their right to form a residents' council with specific powers, and facilities must encourage and facilitate the organization of these residents' councils and their continuation.

On behalf of our residents, our staff and our owners, I thank you very much for your time and for your thoughtful consideration of these issues. I'd be happy to answer any questions you might have.

The Chair: Thank you very much for a very full and clear presentation. We'll begin the questioning with Mr Jackson.

Mr Jackson: Michael, good to see you. Thank you for a well-laid-out brief to the committee with distinct recommendations.

I want to pursue a reference you make. It's been raised twice before, to my knowledge. I want to talk about a situation where a resident goes into arrears. There's nothing in the bill that assists a facility with that fact, yet it's clear that you can't simply discharge an individual, because as I understand it -- I may need some guidance here from Mr Quirt -- the placement coordination agency would be advised that this person is no longer paying. It's been documented and they now have to step in and find another facility where they can afford it. Is that essentially in rough terms how this system's going to work? I'd like to pursue this whole area, because in the absence of those kinds of decisions, what options do these facilities have?

The Chair: Can we put the question through the parliamentary assistant?

Mr Wessenger: Ministry staff can reply to that.

Mr Quirt: First of all, we don't envisage a situation where the resident wouldn't be able to afford the charge, because the charge will be established in direct relation to his or her income, but there are now circumstances where residents, for whatever reason, do not pay the rate that nursing homes or homes for the aged are entitled to receive from the resident.

Under the current situation, the only resource the facility has is to do its best to bring the issue to the attention of the resident, the resident's family or representative, and if that doesn't work, to take the resident to court and sue him for the maintenance arrears. That's a very difficult and uncomfortable procedure for any administrator to proceed with.

The current situation is as I've described it and there is no remedy to that situation in Bill 101. I would make the comment however that each facility is guaranteed a specified amount for accommodation regardless of the ability of the residents to pay either the $26 universally affordable charge or the $38 maximum. So the fact that residents wouldn't be in a position to pay or don't pay the rate they're required to pay is an issue not only for the facility now but for the province, which is obliged to make up the difference between what a resident can't pay and the rate of accommodation that the facility's guaranteed.

Mr Jackson: Could we explore that a little further, because maybe I'm not catching it. I'll just use lay terms, because then I won't confuse myself. You've got a resident in a home. All the workup's been done about their ability to pay and a figure has been agreed upon. The province puts its contribution in and the resident theirs. Now the resident doesn't pay for whatever reason. The home still has to put food on the table, still has to provide the staffing. I'm lost as to at what point the province steps in and says, "Okay, you're not getting paid, facility, so we're going to make up the difference." After they go to court?

Mr Quirt: Under the current system, the province never steps in.


Mr Jackson: I understand the current system. Under the current system, as long as they can find another placement, out they go. But my understanding is that what Bill 101 does is prevents them from making placement decisions. All placement decisions are made by the placement coordination service, and if that's the case, then is that not your interpretation? That's how I read it, that these recalcitrant residents can't be moved without the province's permission.

Mr Quirt: I think your assessment of the current situation is a bit off. It's highly unusual for a nursing home or a home for the aged to discharge somebody simply because they're behind in their payments.

Mr Jackson: I didn't say that. Until they find them another location.

Mr Quirt: No, that doesn't happen usually. They continue to care for the resident and they continue to pursue the issue of the maintenance arrears.

The Chair: I just want to be clear. As I understand what Mr Quirt said, in terms of the new system, there would be an obligation on the province working with the facility to make up that money, if that money wasn't there.

Mr Jackson: On the accommodation portion is what I heard.

Mr Quirt: That's correct.

Mr Jackson: But they're still having to feed and staff to the service level for the other two panels.

Mr Quirt: We would be funding that 100%.

Mr Jackson: 100%?

Mr Quirt: Yes. We would be ensuring that each facility received a certain amount of money for accommodation for each resident, quite independent from an amount that has to be higher than the amount the resident pays for accommodation, higher than the $38.

Mr Jackson: Is that in legislation or will that be in regulation?

Mr Quirt: That will be in regulation, because the figures will be changed annually as funding increases.

Mr Jackson: Okay. I've used up all of my time. I guess I'm trying to suggest there is an example that is not in legislation. Those contractual assurances will occur, but it's now relegated to the regulation portion. Although that's the intention, it may not be the contractual obligation. I'll wait till I see the regulations, but frankly I think that was one of the points you were making.

Mr Bausch: Yes, very much so.

Mr Jackson: I know I've used up my time, Mr Chairman, and thank you, but I wanted to understand that better, because it's the third time it's been raised, the concept of the financial obligations of the province here.

The Chair: I think that was useful to clarify.

Mr Owens: Turning to your section on penalties and process, my question is, first, how do you get recalcitrant homes to comply, and when they don't comply, what sort of penalties would you suggest be imposed in order to get their attention and force them into complying with regulations and other statutes?

Mr Bausch: In the first instance, what we're strongly suggesting is that this bill purports to throw the baby out with the bathwater. After a lot of hard work and extensive study, I think both providers and regulators or representatives of regulators within residential services branch would agree that today's system is much better than the system of five years ago, which is a combined carrot-and-stick approach, and we just don't see that reflected, that newer approach provided for in this bill.

I'm very much concerned that the sanctions provided for or identified in the bill are too much the ultimate, there aren't enough intermediate steps. It's too easy to say that there should be withholding of funds, but that's a very, very drastic step to have to take. Quite frankly, who is harmed by it? The provider clearly will be encouraged to exhibit different behaviour, but in the meantime, who picks up the food bills to make sure that the residents are being fed?

It seems to me somewhat analogous to drafting other laws and the penalties thereunder in a criminal sense. You must be very, very careful that you don't hamstring the regulator in giving him only extreme options to apply. I just don't see evidence in the bill. Perhaps, again, to return to Mr Jackson's comments, in general, in my opinion, there's far too much left to regulation and so it's left the bill open to misinterpretation which perhaps government did not intend, but my position is to try to point out where we have difficulty, not where we really agree with things.

You must have a gradation, in my opinion, of powers available to the regulator so that he can deal with situations as those situations dictate. Financial sanctions may be one of them, but that's pretty extreme, and I think you'd really want to apply that in the last case.

Mr Owens: In terms of the appeal process, what kind of amendments -- I don't recall seeing anything in the nine points that you made -- would you suggest to make the appeal process, in your view, work for both the potential client and the residence itself?

Mr Bausch: I guess it's probably easier to describe it in general terms than to be very specific, but there would have to be some sort of referee system that's virtually a ready response team. What I'm hearing from residents, what I'm hearing from residents' councils and various consumer groups is, human nature being what it is, people don't start into the process until the 11th hour. I probably wouldn't do it with my mom and I don't think you would either. You tend to exhaust all other remedies so that when the time has arrived it really needs to be done.

I would grant you that a very complex system right now would be simplified by this approach, and simplified greatly. But the desire is quite simply to be able to have access to a process where I, as the consumer, say: "I don't like the decision you made, Mr Placement Coordinator, what are my rights? What are my options?" The right to appeal seems to be fundamental in everything that we do in this society, and it's just not shown here. There would have to be a quick and ready response, perhaps through a referee, and if that's not satisfactory, I guess there'd have to be a longer unfolding process if you wanted to get it through. But what I'm hearing from consumers is, "Please make it quick, relatively quick."

I think from a provider's point of view, a similar instance. Two particular groups that we represent -- one is a religiously oriented organization and one is an ethnically oriented organization -- are absolutely terror-struck by the prospect of having to take in a resident who doesn't fit, in their terms, in one case from a religious point of view, in another case from an ethnic point of view.

This bill makes it appear that they would have to yield to the wishes of the placement coordinator, that's their fear, and if that's to be continued, the next step is: "If you're going to foist this on me, surely to goodness I should have some right of appeal. To whom do I appeal?" And again I would submit, although the provider might not be interested in due dispatch because he's trying to refuse to take someone, it's not in his best interests or the consumer's best interests.



Mr Bausch: It may not be that simple. He may have an empty bed which he proposes to fill with someone of his ethnic persuasion, whereas the placement coordinator is saying, "I've got a much more pressing problem and I want to put in so-and-so." That's the concern.

The Chair: I'm going to allow Mr Hope a short supplementary because he's been patient all evening and this will be his last chance.

Mr Hope: I have been very patient all day. The questioning was going on around the penalty aspect -- and you say we have to outline it clearly; if we put step 1, step 2, step 3, step 4 and the final would be cutting off funding -- if we outline that, wouldn't that just encourage the process? The only ones who are going to be penalized are those who are the bad out of the category. The good ones will always try to rectify problems and I believe there'd be a cooperation there to correct the problems. But if we label each of the steps, wouldn't they just say, "Well, I don't need to comply with this, this is step 1, and I can go to step 2 or I could go to step 3 before it eventually affects me." Don't we leave an opportunity for more violations or non-compliance if we were to put the steps specifically?

Mr Bausch: I would have two responses, Mr Hope. I think the view is quite jaundiced, to be candid, because I don't think that's exactly what happens. I guess the analogy would be in the case of murder. If the only penalty is the death penalty, there really is very little option in terms of reforming and making people change their behaviour, and I don't think the analogy is that badly based.

Mr Quirt's branch has had to operate under two different systems and I think he would have to agree that the current system, which provides for a carrot and a stick approach, has been far more effective. The stick still exists, but the carrot determines who needs to be whipped. There's a gradation of steps and it's just worked out very efficiently, at low cost. I suppose one might think in the interests of efficiency you should rush the judgement to the end, but you're going to get there soon enough anyway and a lot of good operators are not going to be unduly damaged by the process.

The Chair: We have to move on now.

Mrs Caplan: I would like to pursue this line because one of the opportunities that this committee has is to present amendments to the government or suggest ideas which hopefully the government will consider and bring forward its own amendments.

If we consider that the purpose of this reform is really to provide better access to care and choice in care to people in need of long-term care services, the question becomes, "How do you design a process which will achieve that result?" Your term "universally rejected system of the big stick," I think is quite correct, financial penalties penalize the residents, whether it's food or care or whatever. We know the huge proportion of the funds go to staffing and service directly.

One of the things we've been talking about here is an amendment that would mandate accreditation which would accredit both management and outcome; a mandate for a total quality management program or a quality management program; mandate a residents' council; and, mandate financial disclosure. That's sort of the mandate of the plan, but there's still not a stick there for the really bad apple which TQM and continuous improvement models say you look at what the result is, you become results oriented, but you still have to have a way of ensuring when you have a really bad situation that you can do something, because ultimately the government has to be responsible.

Are you familiar with the Public Hospitals Act?

Mr Bausch: No.

Mrs Caplan: The Public Hospitals Act has a provision, when the minister has cause for concern about quality of care -- I believe it's section 7 -- whereby the minister can appoint, under that particular act, an inspector. Due process is then built in. Then a second step is the supervisor, and ultimately trusteeship occurs to safeguard patient care. That is the big stick, bad apple approach, but that's not invoked lightly, and what it does is it allows for a process that is very separate from compliance or support or anything else.

If you were to go with an accreditation which by regulation required all of those other good things that bring the values of quality management and continuous improvement on one side, would you be comfortable with a process such as the Public Hospitals Act kind of process for intrusion in a worst-case scenario? It would remove all penalities. What it would say is that if the home, if the facility, is not providing quality of care, ultimately government walks in and takes it over.

Mr Bausch: That's a pretty stiff penalty.

Mrs Caplan: That's a pretty stiff penalty.

Mr Bausch: You said it removes all penalties, it doesn't remove them all. But I happen to agree with you, Ms Caplan. Although I don't know the Public Hospitals Act, I do know the Nursing Homes Act, and what you've described, in my view, has been lifted from the existing Nursing Homes Act, and I think that aspect of the act and the regulations -- and this is the point I'm trying to make to government -- was a very positive change in nursing homes, and I think ministry staff would say that. I know the working relationship between providers and staff has vastly improved over that of five years ago.

Under the Nursing Homes Act, the Minister of Health has the right to invoke powers of trusteeship, and every nursing home provider knows that. But there are so many intermediate steps that can be taken. You don't have to, you can zip to the end, my understanding is, if it's deemed serious enough. If government does that, and it's done it haphazardly or arbitrarily, there are rights of appeal with the nursing homes review board to determine who did what to whom. I would assume there are a vast array of avenues of retribution available to the nursing homes review board.

Those are the good elements of the one act that Bill 101 proposes to amend that I can see as a provider of extended care services and nursing homes, and I would like to see it maintained. I don't think it needs a lot of tinkering.

Mrs Caplan: Last question?

The Chair: Brief.

Mrs Caplan: If you were to go with that kind of model, you could virtually eliminate the inspection and turn that into a compliance-education-supportive role for the ministry.

Mr Bausch: That in fact is the key aspect of the change that I've been referring to several times, that there's a group of people who act as consultative advisers -- that's the carrot -- and then if that doesn't work there are a bunch of enforcement people who come along and do the tough guy routine. That seems to have produced a much better system, in my view at least.

Mrs Caplan: The language of the old act has not been changed. That change has come without changes to the legislation. That's been by policy.

Mr Bausch: That's true. That came through regulation.

Mrs Caplan: So you'd have an opportunity here to write something new.

The Chair: I'm afraid we're going to have to close this off, and I apologize, but again, thank you very much for coming before the committee and for your presentation and answering our questions.

Mr Bausch: Thank you.



The Chair: I'd like now to call on the Ottawa-Carleton Placement Coordination Service, if they would be good enough to come forward. I want to thank you very much for being with us tonight. I must first of all apologize. Because of the vagaries of air travel, I'm afraid I'm going to have to leave. It's not because of anything you're about to say. I would very much have liked to have been here to hear your presentation and I do apologize the way the schedule has gone, but what is it they say, planes wait for no man and no woman? I will certainly read with interest what you have to say and will turn the chair over to Ms Fawcett, who I know will keep this motley crew in line.

Ms Suzanne Smith: There are disadvantages to being last and this is one of them, but I appreciate it.

The Chair: Thank you very much for being here, and if you would just introduce yourself, then please go ahead with your presentation.

Ms Smith: My name is Suzanne Smith. I'm the director of the Ottawa-Carleton Placement Coordination Service. My colleague is Lucy Carrière, the chief coordinator at the agency, and she's here for moral support and to help me with any questions you may have afterwards. I know it's late and you all want to go home, so my brief will be just that, brief.

As the director of the Ottawa PCS, I welcome the opportunity to respond to the amendments in legislation known as Bill 101. The Ottawa-Carleton Placement Coordination Service is an independent agency with a 14-member board of directors. Our board represents the various aspects of our community, both service providers and consumers, profit and non-profit. The Ontario association has also responded to the bill. My response will include comments as an association member and as the director of the Ottawa PCS.

To ensure that the consumer is best served, there must be a centralized, independent, objective, coordinated service available which has the responsibility and authority to assist consumers in obtaining the most suitable placement according to their needs. The amendments will streamline and amalgamate the current system for admission to long-term care facilities.

Placement coordinators would not expect to admit clients to facilities without considering all aspects of placement. This would include discussing with the facility representative any applicant whose needs may not be considered by the facility as appropriate for a current bed vacancy. Facilities should have the right to appeal any decision that contradicts those rights.

The intent to make long-term care equitable to all, particularly those who have been considered less desirable as residents and therefore denied access to the long-term care facilities of their choice, is a positive step.

We have concerns, however, that Bill 101 does not adequately address the needs of these hard-to-serve clients, particularly those who are physically aggressive. Clients are currently rejected because facilities are unable to meet their needs. Long-term care facilities will require additional resources to meet the needs of these clients. It is therefore unrealistic to expect all facilities to meet all needs of all clients. There should be flexibility at the local level to decide which facilities could be designated to serve this population.

Bill 101 will allow adults with physical disabilities to purchase and manage their own services, a move which will support their dignity and independence.

Eligibility criteria must be precise and consistent throughout the province, but with enough scope to accommodate all potential situations. Furthermore, regulations authorizing admission to a long-term care facility must be equally clear. The immunity clause will offer little protection if such regulations are ambiguous.

Regulations regarding screening for infectious diseases such as tuberculosis, salmonella, hepatitis and HIV should be standardized. They should specify what testing is required, when it is to be done and/or repeated and who assumes the cost. Alternatives in case of client refusal should also be specified.

Clarification is needed regarding who and under what circumstances a person can give consent on behalf of the consumer for application or admission to a facility. Regulations should specify how and under whose authority information can be transmitted between long-term care facilities and placement coordinators.

PCS recognizes that an appeal procedure to review a determination of ineligibility is essential to our accountability. We recommend that notice be given not only to the applicant but also to his or her care giver or next of kin.

We support the presence of the placement coordinator at the appeal board as well as the powers assigned to the board. Hearings must be held locally and convened within a specified time in order for this review to be meaningful to a frail population.

We are extremely pleased that short-stay beds for respite care, emergency admission and supportive care are recognized as essential. If equal access is to be maintained, these beds must not be used as a way of securing a back-door admission to a long-term care facility.

We recognize the right of the client to have a choice of a long-term care facility, particularly as it pertains to specific religious, ethnic, geographic and cultural preferences. The Ottawa-Carleton PCS always advocates for client choice. However, it is important to remember that choice is often dependent on bed availability and on circumstances. The current wait list in our region exceeds 1,200 applicants, with another 200 clients being assessed for placement.

Residential care within the long-term care facilities will at times be the most appropriate type of care for some clients. In the proposed system, this option would be limited to clients who can afford it.

With the authority given to the placement coordinator, there will be reliable and accurate data on bed usage and bed requirements throughout the province as well as standardization of the care requirements of consumers admitted to long-term care. In Ottawa-Carleton the PCS works in partnership with the community and all the facilities. This has been made possible through open communication and also because of the composition of our board of directors. We hope that future boards will include the same broad spectrum.

In conclusion, I just wish to say that our PCS affirms a commitment to maintaining and improving our present collaborative working arrangement.

The Acting Chair (Mrs Joan M. Fawcett): Thank you very much, Ms Smith. You did keep your brief very brief and we appreciate that, but we do appreciate you coming, because I think, without exception, every brief has mentioned the placement coordination services as a concern and they would need a clarification. First on the list of questioners is Ms Carter.

Ms Carter: As our Chairman has said, this is a very central and important function of this whole thing and a lot of criticisms of the bill have focused on what they perceive to be the great power that is going to be in the hands of placement coordinators. They fear that this is just going to be uncontrolled, that people won't have choice, that their specific needs will not be met, that people will be forced on institutions that don't want them and so on. You have given us some very specific suggestions as to what you would like to see in the legislation, but how do you counter that broader argument that we've been hearing? Do you think that what seems to be a system that is now working well is suddenly going to become erratic and unfair and overpowerful? Has this been suggested?

Ms Smith: I don't want to sound naïve, but I don't see very big differences in the proposed system. We have always advocated for client choice, but I think we have to remember that choice is limited right now because of bed availability. We do approximately maybe 30 interim placements on a monthly basis. In the past, most of these placements would occur outside the region. We have worked very hard with facilities over the past years to get them to accept interim placements, and this has been very successful, so where we used to make 20, 25 interim placements outside the region, we now have perhaps five or six a month. We feel that it's better for a client to be in a second choice than to be placed 50 miles from his family.

Ms Carter: But earlier this evening, when we were hearing from people connected with a Jewish home, they were saying that if people are placed in what is an inappropriate home because they're at the top of the list, as it were, then to move them is very disruptive, and I'm just wondering what the answer is to that.

Ms Smith: I agree the move is disruptive, but it's also realistic. We have a lot of urgent placements. When you have a long waiting list and a lot of urgent placements, whoever's needs have to be met is the person who is considered.

In the case of ethnic and cultural issues, definitely we would continue to try and place these people in those facilities even if they temporarily have to be placed in another bed, and I think the short-stay beds might meet that need. It talks about a period of two weeks for emergency placements, which gives us some time to work out something else. We would never send a Catholic francophone to a Jewish home for the aged or vice versa, because this just wouldn't make any sense.


Ms Carter: Yet this is the fear that we're getting again and again, that the distinctive nature of these homes is going to be eroded.

Ms Smith: I guess I don't see that happening in Ottawa-Carleton. I really don't.

Mrs Caplan: Every presentation we have heard has mentioned placement coordination services. Where they don't have them in practice, there are concerns and fears, and where they do have them in practice, we've heard consistently across the province that each of those regions had a unique situation because their placement coordination service was working really well and everybody liked it, which suggests perhaps that the fears can be allayed or that it's the fear of the change or the unknown, but I think the fear is real and we shouldn't ignore it.

One of the suggestions would be to have in the legislation a statement of principles that would guide placement coordination services. Actually, there was one service in London that presented to the committee, and it's available in Hansard, the statement of principles that guides it today. Although it is informal, would you be comfortable with a statement of principles in the legislation that would suggest that the sensitivity to multicultural and linguistic and social need was a guide, wherever possible, in meeting appropriate placement?

Ms Smith: Most definitely I would support that, yes; we all would.

Mrs Caplan: That might go some way to allaying the fears, I think, from what we've heard. You're to be congratulated, and the other placement coordination services. I know many of them are relatively new and some have been around for quite a long time, but it's been really a very good example of communities working together to meet the needs of the people they want to care for.

Just to switch very briefly, on page 2 of your brief you referred to, "Hearings must be held locally and convened within a specified time." From your experience, what do you think that time limit should be? We've heard everything from two weeks to 30 days. What do you think is reasonable to be able to provide appeal hearings?

Ms Smith: I would say probably a month. That sounds reasonable.

Mrs Caplan: You don't think that's too long?

Ms Smith: For the hard-to-serve clients, we sometimes have to wait six months now before we can place them, so I think a month is certainly very reasonable.

Mrs Caplan: I think we have a few minutes. We've also heard a suggestion that the facilities have the right to refuse on the basis that they can't provide appropriate care and that there be an appeal of that refusal. That's not in the legislation today. Would you support that right of refusal on the basis that the facility doesn't believe that it can provide appropriate care?

Ms Smith: Definitely, if it's well grounded, but I'd like to say too that one of our fears is that we are going to be told that we have to place people with aggressive behaviour in a certain facility when we know it can't meet their needs.

Mrs Caplan: Would you believe that in that case, there might then be -- I had written it down here so I wouldn't forget. If you had to place somebody in an emergency situation, if the facility had a right to refuse, do you think the legislation might be helpful if it gave emergency powers, extraordinary circumstances that said that notwithstanding the right of a facility to refuse initially, until you could find a more appropriate placement, in an emergency you would ask them to take that patient? Do you think that would work or not?

Ms Smith: I think maybe it could work, but I would also like to say that perhaps additional funding could be made available to these facilities on a temporary basis if they accept to care for this person. Would you like to add to that?

Ms Lucy Carrière: When we talk about appropriate facilities, I would think we would probably have attempted to get that appropriate facility initially and I think these short-term beds would enable us to do that.

Mrs Caplan: As the legislation stands now, there is no right for facilities to refuse. If you were to add the right to refuse in an appeal process, that would add potentially a month, if that was the amount of time. So in an emergency situation, where you really felt that facility could provide the care, do you think then that the placement coordination service should be able to have an exemption from the facility's right to refuse?

Ms Smith: I think some facilities should be designated as specific to meet the needs of certain clients. For example, our chronic care hospitals could develop units to meet the needs of these people on a short-term basis.

Mrs Caplan: Have you participated in the role study that we expect to see in March?

The Acting Chair: I think we'll have to move on to the parliamentary assistant.

Mrs Caplan: That's a good recommendation.

Mr Wessenger: Thank you for presentation. I would just sort of like to explore some of your comments with particular respect to the hard-to-serve clients, as you call them. Right now, do you have certain facilities you have designated under the existing system that you will consider for those difficult-to-serve clients?

Ms Smith: No, we don't. It's very difficult to place any client with a behavioural problem. Usually they end up in acute care hospitals until their behaviour is under control or until they've deteriorated to the point where they no longer pose a placement problem.

Mr Wessenger: Do you think it would be of any assistance with respect to the long-term care facilities if there was some resource like a travelling team of experts to assist facilities in dealing with some of these behavioural problems?

Ms Smith: I think, yes, definitely. It does happen in some areas. I think that would be a good idea.

Mr Wessenger: The other thing I would just like to comment on is your concern about residential care, that at times it would be the most appropriate type of care for some clients and this option would be limited to clients who can afford it. First of all, I would just like to clarify that certainly it isn't just physical care that's going to be taken into account in determining eligibility. There will also be social aspects such as psychological factors that would be involved. But just as an addition to that, do you feel that it would greatly assist if there is much more substantial investment in supportive housing to provide other options?

Ms Smith: Definitely, yes.

The Acting Chair: I thank you for coming this evening and waiting very patiently, because I think, as your brief has been, all the briefs we have had before us here in Ottawa have been very, very helpful to our deliberations and we thank everyone who has been before us.

I would like to remind the committee that the bus will leave at 8 o'clock tomorrow morning sharp, in front.

Ms Smith: Thank you. Thank you for being so alert too at this time.

The Acting Chair: Certainly I would want to say that we have received excellent hospitality here in Ottawa and hopefully we can return some time.

So 8 o'clock tomorrow morning. The committee stands adjourned and will resume in Kingston tomorrow morning.

The committee adjourned at 2108.