Thursday 25 February 1993

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

Ontario Council of Hospital Unions

Helen Fetterly, area vice-president

Helen Henderson Care Centre

Larry Gibson, owner and adminstrator

Providence Continuing Care Centre

Sister Sheila Langton, senior vice-president

Guy Legros, president and chief executive officer

Wayne Westfall, patient

County of Hastings, Homes for the Aged Committee

Lloyd Churchill, chairman

Rob McLaughlin, administrator, Bancroft home the aged

Victorian Order of Nurses

Dr William L. Gekoski, president, Eastern Lake Ontario Branch

June Rickard, executive director, Quinte Branch

Comcare (Canada) Ltd; Para-Med Health Services

Vicki Johnston, area manager, Para-Med

Janet Szczukocki, manager, Comcare

Carla Horsten-Cerisano

Omni Health Care Ltd

Fraser Wilson, vice-president and treasurer

Haliburton, Kawartha, Pine Ridge District Health Unit

Bill Wensley, board member

Dr Alex Hukowich, medical officer of health

Fairhaven Home for Senior Citizens

Dawn Straka, administrator

Specialty Care Inc

Paula C. Jourdain, general manager

Religious Hospitallers of St Joseph Health System

Sister Rosemarie Kugel, president

Association of Roman Catholic Chaplains

Father Ken Stitt, director

Providence Health System

Sister Sheila Brady, representative


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:

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

Johnson, Paul R. (Prince Edward-Lennox-South Hastings/Prince Edward-Lennox-Hastings-Sud ND) for Mr Drainville

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:

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 1032 in Howard Johnson Confederation Place Hotel, Kingston.


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 Acting Chair (Mrs Joan Fawcett): I'd like to begin so that we can keep as close to the schedule as possible, and call the standing committee on social development to order. We are dealing with Bill 101, An Act to amend certain Acts concerning Long Term Care.

I'm Joan Fawcett, acting Chair today for our usual Chair, Charles Beer, who had to go to Toronto for two important meetings. So I welcome everyone and say that we are very happy to be here in Kingston, and I guess I'm extra happy because I am a native of Kingston, having been born and spent my school years here in Kingston, and I'm always happy to get back.


The Acting Chair: I think we will get right under way and call the first presenter from CUPE Local 783 to come forward -- representatives, I guess I should say. If you would mind identifying yourselves for Hansard and then begin your presentation, and then there will be questions afterwards if that is okay with you.

Mrs Helen Fetterly: Good morning. My name is Helen Fetterly and I'm the president of CUPE Local 783 at the Cornwall General Hospital and an area vice-president for the Ontario Council of Hospital Unions, which represents 19,000 hospital workers across Ontario. With me is Sue Capido-Lambert from Kingston CUPE Local 1974.

We thank you for the opportunity to speak here today. We believe the restructuring taking place throughout the health system in the long-term care sector and as represented by Bill 101 has far-reaching consequences for us all.

In less than 20 years, the number of people 65 and older will have grown by 68%. While it is true that today's elderly will be the first to feel the immediate impact of policy decisions made with respect to Bill 101 and the restructuring of long-term care, future generations will also have to live with the consequences long into the next century.

The government has mapped out the route, but the road we're travelling down is taking us into yet another wrong direction. We have tried to respond throughout these many new directions, policy decisions and initiatives with respect to the massive restructuring of our health care system, but with each new twist and turn our concern only mounts.

Bill 101 fails in many of the same ways and for many of the same reasons that the government's long-term care initiative fails. That's because it is part of the bigger context of long-term care. As a result of this, the bill does not really take people into account and, when it does, undermines them by taking away their dignity, their choice and their guarantees to quality of care.

I will be commenting more specifically on the bill later in my presentation, but first I would like to deal with the overall direction of long-term care, of which this bill is a part, and examine some of the serious problems with it.

All parts of our health care system are vitally connected to each other. How can we come up with a comprehensive system that really works in the interests of people if we refuse to see it as just that -- a comprehensive system? How can we entrust reforms in such a critically important sector to a government that does not even see the connection among the different parts of the system? For instance, long-term care is linked with acute care, chronic care, home support community-based services, mental health services etc. It cannot and should not be treated in isolation.

Close acute care hospital beds and services and chronic care beds and community-based home support services become crucial. Close chronic care beds and, again, sufficient home support services and beds in long-term care facilities become urgently required. Touch one part and the other parts are affected.

Insufficiently fund community-based home care services and we know with regrettable certainty that more elderly, not fewer, will present at acute care hospitals. This will put even more strain on hospital workers because of the huge layoffs and cutbacks in beds and services that are already taking place.

We have thought long and hard about why the government has chosen to proceed in this way, examining the parts of the health care system each in isolation from the other. We can only conclude that it is because it makes it harder for the public to see the full impact of the enormous restructuring taking place, and that's because this restructuring is really all about cutbacks -- cutbacks in services, in people and in care levels.

Our health system is being fundamentally and irreparably altered in Ontario and this new system, the one we're working on now, will offer a much lower quality of care with fewer services and far less security to patients and to their families.


I want to briefly point out what's happening in our health care system right now. It's instructive because it reveals the true nature of these so-called reforms. It shows a government that is in the process not of building an improved system of health care but of taking it apart.

Beds, front-line services and people are being slashed from acute care hospitals around the province. In another few months, more than 18 million paid hours will have disappeared from the system. Thousands of jobs have already been lost; thousands more are slated to be as the government continues its financial squeeze on hospitals. Its so-called reform in this sector includes shifting resources from hospitals to community-based agencies to allow for greater home care. In fact, the government has committed itself to transferring $37.6 million annually from the provincial hospital budget to these community agencies. But so far, there has been no equivalent buildup of these. They are not yet in place. We don't think they ever will be. How and where will people get the care they need?

Despite the government's promise to maintain chronic care hospitals at their existing level of service, until the chronic care role study is completed, a number of these hospitals have been forced to close beds and restrict services to seniors and the disabled.

Why is this happening now? Does the government not understand that chronic care hospitals are in fact a vital link in the care for the elderly? They are not, I repeat, not glorified nursing homes. In fact, they provide complex medical care to people who require a variety of approaches which include rehabilitation, specialized nursing care, diagnostics -- that is, intensive, professional care at a subacute level, and often for long periods of time. And they provide that care in a supportive environment.

The whole objective of a chronic care hospital's approach is to help patients return to their homes, if possible, where they can receive necessary community-based support services.

But there will always be a need for institutional care. People who become medically ill and unstable cannot be cared for properly either in their homes or in nursing homes and homes for the aged. Furthermore, the Council of Chronic Care Hospitals reports that these hospitals all carry long waiting lists, with many elderly actually waiting in acute care beds. Again, the clearly urgent questions that must be addressed are: Where will these people go? What will happen to them?

A fundamental link in all the restructuring taking place is the supposedly beefed-up role of community agencies providing increased home care services. But where are these services? What exactly has been put in place in the community-based sector to care for those now being displaced from acute and chronic care hospitals? The Senior Citizens' Consumer Alliance For Long-Term Care Reform notes that the government's hospital funding strategy will result in 3,000 to 5,000 acute care bed closures, and since seniors occupy 50% of the acute care beds, these closures will force tens of thousands of seniors to seek care from these community-based home care agencies.

So what's happening in the sector? We can't get any answers. Yet the government is proceeding to massively restructure long-term care on the basis that these agencies can and somehow will pick up the slack. Most people would agree that the idea of allowing people to remain in their homes, in their communities, if they wish to, and receive the kind of care they need, is an attractive one. Most people would agree that providing these options and choices are positive, but that's not what's happening in this shift to community agencies. This shift is really about transferring resources to the community sector so that the underpaid, and in many cases inadequately trained, home care workers would provide services at a lower cost than in an institutional sector. That is, it's a cost- and quality-cutting measure. And more than that, choice and options are actually going to be reduced, not expanded, because the pressure is going to be on to provide care at home.

In view of the bed closures and cutbacks in acute and chronic care hospitals and waiting lists for beds in long-term care facilities, we are all going to be prevailed on to provide home care, like it or not.

The plan to move care back into the home will really hit women the hardest because we are still the primary care givers. This policy will, in fact, result in far more pressure being placed on women to either withdraw from the workforce entirely or carry a triple burden of responsibility.

It's difficult to listen to government rhetoric about its commitment to equality for women when it is initiating policies that have the effect of pushing us back into another century. Women are already vastly underpaid for their labour as it is. Now we are being pressured into filling in the cracks and holes of government policy, and manipulated into doing it for no pay at all.

This is wrong. It is regressive and it is an attack on all the hard-fought gains we have made over the years.

We seriously question whether the 600 to 700 community agencies can be efficiently organized to deliver good quality home care.

We see far more logic in expanding the role of hospitals and non-profit homes in the provision of community-based health care. Why expand the fragmented network of community agencies when hospitals and homes for the aged have a proven record and already employ a large pool of qualified health care workers? We have pumped billions of dollars into our institutions. It is far more constructive and efficient to expand their role into the provision of community-based services.

Although the consultation paper on long-term care devoted a full section to management of the system, virtually no mention was made of physician management of health care and, alternatively, ways to manage physicians. Like the Senior Citizens' Consumer Alliance For Long-Term Care Reform, we are astonished by the government's failure to examine the role of doctors in the referral to and provision of long-term care services. I want to spend a bit of time on this issue and on other money matters because in a very real way money, or lack of it, is very much at the root of all the restructuring decisions taking place.

Government policy and initiatives are being constructed out of fear. It's as if they looked at the population figures, saw the surging numbers of elderly coming up from the baby boom generation and responded prematurely, unnecessarily and irresponsibly, cutting services, budgets and people. We are absolutely incredulous at this response.

The government has at its disposal a vast army of bureaucrats, advisers and consultants who, had they taken the time, could have identified the huge area of financial waste in the system: billions of dollars that could have been, and still can be, redeployed to guarantee Ontario citizens a viable and quality health care system. We therefore observe that it is probably not the people power and expertise that is lacking, but the political will to take on certain sections of the establishment.

A huge portion of the OHIP budget, 76.1% in 1990-91, is spent maintaining physicians in the style to which they have become accustomed. Under the current system, most doctors are paid on a fee-for-service model. This system encourages unnecessary medical interventions because it rewards physicians each time a diagnostic test or clinical treatment is prescribed.

The fee-for-service system has led to a condition sometimes described as "revolving door" medicine. Since doctors depend on seeing a high volume of patients to maintain their incomes, the system in essence encourages doctors to overbook and, even worse, overprescribe. We believe this fee-for-service approach to health care is at the heart of our system's current financial woes and must be re-examined.

Payments to physicians, other practitioners and commercial labs under OHIP have almost quadrupled in the past 10 years to $4.7 billion in 1990-91. Clearly, this end of the system is out of control. We believe it is imperative the government look seriously at reducing costs associated with physicians.

We recommend the replacement of fee-for-service by salaries wherever possible; the establishment of clinical practice guidelines, including the more appropriate use of therapeutic drugs, testing and treatments; an overall reduction in the number of practising physicians while ensuring the equitable distribution of doctors in all areas of the province; and greater reliance on non-physician human resources in both acute and long-term care.

We will not be able to truly reform any aspect of our health care system if we refuse to look seriously at the costs associated with physicians because it is specifically in this area that huge savings can be realized, and yet, as I mentioned earlier, neither Strategies for Change nor Redirection of Long-Term Care consultation papers dealt with these issues.

In addition, public hospital expenditures could be brought into line with the delivery of quality health care if moves towards democratization were implemented. We made these points in our submission to Mr Paul Wessenger's public hearings on the Public Hospitals Act.

Millions and millions of dollars could be saved annually by reducing waste and inappropriate utilization in the $1-billion Ontario drug benefit program. The government's own program of drugs for seniors is one of the most serious causes of ill health among older people.

Finally, the rapid expansion and growth of for-profit service providers and commercial operators in health care must be immediately curtailed and reversed.


We are extremely concerned about the growth of the private sector in home care. In 1978-79, the number of hours provided to Ontario residents was 82% non-profit, 18% commercial; in 1988, the ratios shifted to 62% non-profit and 38% commercial. At a CUPE health care conference, the Health minister at the time, Frances Lankin, stated that the ratio is now closer to 50-50.

How can we contain costs when health care dollars are fleeing the system in the form of profit? How in the world can this approach be justified, especially when money is tight?

Where does this leave us? First of all, it means that long-term care reform and the overall restructuring of a health care system is really being financed off the backs of laid-off hospital workers, underpaid community service workers, women and the elderly. It further means that there can never be enough money to deliver a sufficient quality of care in any part of the system because it will always be strapped for cash. We are already seeing the regrettable, predictable results of this type of approach.

As I mentioned earlier, as part of the long-term care reform, the government has committed itself to transferring $37.6 million annually from the provincial hospital budgets, ostensibly for community services. This is absolutely appalling, especially when combined with the recent transfer payment allotment to hospitals that fell far short of the mark.

The concrete result of this type of approach means that more hospital workers will be laid off, more front-line services will be cut, less quality health care will be available for consumers and more and more strains will be placed on all parts of the system. It also inevitably means that the government will increasingly look to consumers themselves to help finance reforms. Again, we are already witnessing this.

As a result of the funding announcement which directly relates to long-term care facilities, the government is imposing a fee hike for many residents of nursing homes and homes for the aged. It is estimated that $150 million of the $200 million that will be infused into long-term care facilities will be raised from these increased user fees.

This is not the way to finance a long-term care system. It is our observation that user fees inevitably act as a barrier to accessing health care and are increasingly relied upon by the government to make up shortfalls in revenue.

Moreover, to support this long-term care restructuring, significant dollars will transfer from the non-profit to the for-profit sector as the government moves to equalize funding for all long-term care facilities.

The Ministry of Health announcements have assured the for-profit nursing homes industry that funding for homes for the aged and nursing homes will be equalized this year. This will likely result in less money for municipal homes for the aged.

Since the province is not planning to significantly increase its overall budget for long-term care facilities, this announcement implies that some money going to homes for the aged will go instead to nursing homes. We need to see more non-profit beds in the system, not less. We want to see a more viable, publicly owned, not-for-profit, long-term care system. We believe this is in the best interests of the people of the province.

Serious problems with the underfunding of the entire health care system are also mirrored in Bill 101.

In recent years, the financial contribution by the provincial government for long-term care facilities has not kept pace with the increasing demand. As I mentioned earlier, because of the demographics and because of the severe cutbacks in acute and chronic care hospitals, we will need to see more money infused into long-term care.

But Bill 101 does not include any adequate funding commitment from the province, and worse still, as I mentioned, it shifts dollars from the non-profit sector to the for-profit commercial sector.

The province must make a commitment to provide reliable and adequate funding to the non-profit sector of long-term care facilities.

In theory at least, there is something positive to be said about the role of placement coordinators in bringing some order to the system. However, in the reality of declining institutional care and the completely inadequate supply of non-profit beds in the system, there is a real risk that placement coordinators will become nothing more than enforcement officers, restricting access to long-term care facilities because beds are available in insufficient numbers.

The government must address the fundamental inefficiencies in the system and must ensure that more non-profit beds are opened up for people who need and want them.

The appeal process outlined in the bill is completely inadequate as a dispute resolution mechanism. It's not one that's going to be either effective or fair to an elderly person who isn't happy with their placement or, probably more to the point, lack of it.

People are often not happy in the facilities they find themselves in. They want to get out of a bad situation fast and they don't want to wait a month or more and, in the end, if all else fails, have to take on the government bureaucracy in court. We think the process outlined is an inappropriate use of government power, wielded against a single citizen.

That heavy-handedness is also apparent in that it allows one single member of an appeal board to constitute a quorum.

We hope these sections of the bill will be thoroughly redrafted and that it will be done in the context of more non-profit beds being opened up. It must also spell out that a consumer's choice of where she or he may want to live, in what kind of facility, must at all times be taken into account in their placement.

If the government is really serious about ensuring that standards in facilities are adequate and that residents are receiving the proper levels of care, then it must also incorporate whistle-blowing protection into the bill.

It is the residents and the bargaining unit employees who can monitor a service agreement better than anyone else. We believe they must be legally protected from any owner reprisals, and further that they accompany the all-too-infrequent inspection tours.

It is clear the ministry is not up to policing infractions. We have seen ample evidence of this again and again over the years. It is the resident and employees who have the greatest stake in well-run nursing homes and homes for the aged.

In conclusion, as I have outlined, there are too many questions still to be answered. Too many wrong initiatives and decisions have been hastily made and too little real consultation has taken place with respect to this incredibly important redirection of long-term care.

As it stands now, the system being put in place cannot and will not meet the needs of today's and tomorrow's elderly. On the contrary, it does a disservice to us all and seriously compromises a quality of care that we are all entitled to receive.

We sincerely hope the provincial government and the Health minister come to their senses, because unless and until they do, the entire system of health care delivery in Ontario will be placed at risk by foolhardy and wrong-headed policies that harm rather than help people in need of care.

The decision is obviously the government's to make. We hope it will rethink its direction not only with respect to long-term care but also to acute and chronic care. We must slow down, take another look, reverse many of the decisions already made and engage in real dialogue in order to come up with a reasonable long-term care redirection that truly meets the needs of the people of the province.

The Acting Chair: I thank you very much for your very comprehensive brief. You have touched on a lot of areas and before I start the questioning, I'll welcome the member for -- is it Prince Edward-Lennox-South Hastings? Did I get that right?

Mr Paul R. Johnson (Prince Edward-Lennox-South Hastings): Yes, you did.

Mr Stephen Owens (Scarborough Centre): That's a mouthful.

The Acting Chair: Mr Johnson, welcome to the committee. I'll begin the questioning with Mr Owens.

Mr Owens: In my former life as vice-president and subsequently president of CUPE Local 2001 at Toronto General Hospital, I'm acutely aware of the issues you've outlined with respect to hospitals and spending and other issues that have taken place under the former government.

I guess in terms of your comments on page 15 of your brief with respect to whistle-blowing, one of the things I've been concerned about is that for the week that I've been involved in these hearings, we've heard from a lot of providers. We've not heard from a lot of consumers. We've heard from very, very few groups like CUPE in terms of the current situation, and I think that from my view as an MPP in the riding of Scarborough Centre I can tell you that the current system is not working.


There is little choice for people. We're involved in situations where a constituent calls me up and tells me that she's just received a letter from a nursing home where her husband is residing indicating that he's going to be tossed out a week before Christmas because they can't afford to pay the bill, but my understanding is that we don't do those kinds of things. So, after a lot of negotiations, the individual is still there, but it doesn't address the issues that were raised by the nursing home.

So my question to you and to the Ontario Council of Hospital Unions is, we need that whistle-blowing protection and I agree. What kinds of suggestions would you make around amendments to this particular piece of legislation to ensure that workers from all levels of long-term care are protected if they come to my office or call the Ministry of Health or Ministry of Community and Social Services?

Mrs Fetterly: First of all, I'd like to deal with the issue of the whistle-blowing for the residents. It would be one of our ideas to set up some type of in-house committees, that the residents would have actually a president of a council and/or some kind of system or mechanism in place that they could go directly to their MPP and discuss these issues, because what's happening now, as you said earlier, there's no mechanism in place.

We've had a number of our people across the province who have their mom, their dad in these institutions being told they're having to get out within two or three weeks, a short period of time, and there's no place to put them, and if they challenge the system or do anything in a progressive way to do something, they are treated differently prior to leaving. Many times they have such a fear that they may not get into one of the other institutions that they tend not to do anything. The mechanisms -- I think we would have to sit down and really think about how we could do this, how we could protect them, but I think first of all there would have to be some kind of council system or committee set up from within that sector to try to start to deal with some of those issues.

Mr Owens: The member for Oriole has talked a lot about accreditation processes as a way of ensuring quality care, and the buzzphrase that's being bandied about is "total quality management." In your view, coming from the health care sector and in my view, coming from the health care sector, I have a different view of how accreditation works in real life. Can you maybe share some of your experiences around accreditation in terms of the kind of protections that, in reality, you may or may not offer to residents?

Mrs Fetterly: Accreditations, coming from the hospital sector as a hospital worker, to us it's a farce. We see a lot of times, before the accreditation is taking place, out come the paint brushes, out comes the little bit of window-polishing etc and it's not worth the paper it's written on.

The second part of your question was --

Mr Owens: Was in terms of resident and staff protection and ensuring that residents are receiving optimal programming, that their interests with respect to health and safety are acknowledged. In terms of the staff -- again I've only been on this committee for a week so I haven't had a lot of opportunity to hear other presentations, but health care workers themselves have some concern that the kind of work that one undertakes in the health care field, whether it's in an acute care setting or a long-term care setting, is very heavy. There's a lot of heavy lifting and other issues that are related directly to the health care context.

So in terms of those kinds of issues in terms of the protection not only of the residents but also of the care givers, how do you view accreditation as assisting the residents and, again, staff in the current context and perhaps in the future if we were to take a look at that kind of process?

Mrs Fetterly: The current accreditation system is lacking a lot of avenues with regard to the health and safety of the workers. With regard to the workload, the workloads are far greater in not only just acute care but in the long-term care settings and the homes for the aged and municipal homes. They are put under a tremendous workload.

They have, a lot of times, residents that are in the system because the active care hospital wants to get the bed empty. On many occasions, the records are sometimes "tampered with" in an indirect way. These residents get into these institutions and our workers, the front-line workers, are subject, on many occasions, to very aggressive patients and there are a lot of injuries.

The accreditation that is currently taking place doesn't lend a hand to any of those issues to help our people out there, let alone the residents of the institutions.

The Acting Chair: Thank you very much. I'll have to move on, being mindful of the time. Ms Caplan.

Mrs Elinor Caplan (Oriole): As the Chair said, the brief is very comprehensive and you've touched on a number of areas. There are a number of things that I disagree with and I think it's fair if I put some of that on the record, and some that I think we do come to a meeting of the minds on. I'd like to share some of that with you today as well.

The principle that I've always functioned on, on behalf of the public interest and the taxpayers, is that what's really important is value for money and that the objective should be, who can provide the very best quality care at the best price? I think that's in the public interest and the taxpayers' interest, as opposed to an arbitrary decision as to who the management should be. So I disagree with you, because I think balance between the commercial sector and the public sector is a better public interest model.

We've heard a lot of discussion about choice and flexibility and models for ensuring improvement in quality of care. There's a lot of new management techniques. I'm not going to go into that today, but I share your concern that this piece of legislation, being just one small piece, is moving ahead without the long-term care policy framework that has been promised for some time, that it's moving ahead without the chronic-care role study being complete, that there's no definition for a long-term care facility in this legislation or in any other, so we don't even know what we're ultimately going to be seeing at the other end. We heard in Ottawa from the Ontario Hospital Association about a number of redevelopment projects that are moving forward in the absence of the big picture, the comprehensive approach.

While I share your concerns for how that's all going to come together and fit together, I think that it is very important that the long-term care system be developed, because in my experience as a former minister, I know that we don't have in place a system now and that there's a lot of people -- and that's what this is really about: caring for people -- who are not getting the services that they need in an expeditious manner, not receiving appropriate care. A lot of that has to do with the fact that we don't have any kind of network in place to be able to respond appropriately. So this is just one step, but I would like to ask you some questions, if I have a couple of minutes, on the issue of alternative payment.

You spent quite a bit of your time suggesting that the fee-for-service system should be changed. There are a number of alternative payment models. Health service organizations are one, comprehensive health organizations are another, alternative payment for clinical teaching units in teaching hospitals and faculties of medicine is another, development of CHCs -- community health centres -- as well as alternative models of salary and payment within the health system. It's my understanding, anyway -- perhaps you could fill me in -- that pretty much all of those initiatives which were under way have pretty much -- there's been a freeze on the shift to health service organizations, no substantial shift to community health centres. While there's been talk about CHOs, none is up and functioning.

Are you aware of any alternative payment plans that you've seen in this region? I know that Queen's University was negotiating an alternative payment plan for its clinical teaching unit in the teaching hospitals. Have you heard anything about that?

Mrs Fetterly: No. No, I'm not aware.


Mrs Caplan: We see a rate of growth for money for doctors under OHIP going at 4% at the same as hospitals are getting 1% and, as a result of increases in money for doctors, almost $500 million in the last couple of years, that's the rate of growth for OHIP. If you were giving advice to the government as far as setting its priorities and you had to make some choices because governing is about difficult choices, given the fact that you've seen them raising the rate of growth in OHIP, money for doctors at 4%, money to hospitals at 1%, nurses are losing their jobs because of that, what advice would you give them about where they should put available money or how to reallocate it as a part of the use of alternative payment? Should alternative payment plans be negotiated with the hospitals individually, in your view? How would you suggest that they do that?

Mrs Fetterly: I don't think we need alternative payment plans, my point being the overspending in the system. You talk about the drug benefits, you talk about the wages of the doctors; those are the things that have to be addressed. There have been many studies made throughout the province as to how percentages of seniors, 11%, 10%, come into hospital because of overprescribing. There are many, many areas in my brief that we could touch on, that talk about these issues that are real dollars.

Mrs Caplan: What you're proposing is just put all doctors on salary?

The Acting Chair: I'll have to end it there, I'm sorry.

Mrs Fetterly: Not necessarily. I said some of the doctors on salary were applicable.

The Acting Chair: I thank you very much. I wish we could go on, but we must try to keep fairly close to the schedule and I thank you very much for coming this morning and presenting those points.


The Acting Chair: If the Helen Henderson Care Centre representative could come forward at this time. Welcome to the committee, and if you would take your seat and identify yourself for Hansard, and then begin with your presentation.

Mr Larry Gibson: Thank you very much. My name is Larry Gibson and I'm an owner and administrator of a small nursing home here in the city of Kingston. I also represent my family. We have another facility in Gananoque, which is not a large one necessarily either. It's a 93-bed nursing home and a 40-bed retirement home, so it gives you very close to what homes for the aged are today with the two levels of care and a continuum of care. The facility here in Kingston is a 42-bed nursing home and a 70-bed retirement home. They're all designed economy to scale.

In the initial stage when we started business -- it's a family, as I say. It started in 1965, so we've been in the business for 28 years now. So we feel that we have a good feel for where we've come from and where we are today, as a family, and I can tell you that it's been a struggle right from the very beginning of day one in 1965, just because, as you know, in 1965 there were no rules and regulations for nursing homes and that the extended care act came out in 1972. So at that point in time, you were dealing with your local municipalities and of course they were different throughout the province.

Our facilities, as they started in the area, were to try to keep the seniors living in their area and not having to move. At that point in time, we had our homes for the aged in the area but they were in Kingston and Brockville, so anyone in between would have to leave their locale and that's why we have our one home in Gananoque. The facility here in Kingston was when there were two small nursing homes that were 19 and 23 beds and were not going to meet the rules and regulations in the province of Ontario as we progressed to today.

The owners at that time came to the family and asked if we would be interested in proceeding with buying their licences, as this seems to be the current way today. We bought the 42 beds and, of course, that's not a feasible size of a facility to give the care you would like to and also the amenities that would go along with living in a facility, so we added a retirement home as well, and tried to put some of the amenities that we felt that people, as seniors, would like, more of a home aspect rather than the institutional end. That's sort of how we've grown to where we are today.

Our facilities are accredited. Our facility in Gananoque has had five three-year awards. I guess we were one of the initial ones back in 1978 to receive a three-year award and we favour that system very much. Our background again is health. My mother was a registered nurse and it was her dream to do more like convalescent care, but that has never really come into this province, where someone would be in hospital and not have to have the services after surgery, where it could be a little lighter in the environment. As I say, I think Belleville at one time with Dr Potter had a system similar to that, but it's never really taken off, so we ended up going into the nursing home end of it and it's sort of where we're at today.

We're strong believers in Bill 101, as with the Ontario Nursing Home Association. I think some of what I'm going to be saying is very much what some of you have already heard over and over. I'm a strong supporter of the association. My dad was president of the nursing home association in 1972 when extended care came in. So it just gives you a little bit of a picture of where the family comes from and our background.

It seems like a lot of Bill 101 is whether we're for-profit or not-for-profit and this is sort of where this has all come about, the long-term care reform, and I believe that there is a balance between both, as was said a few minutes ago. It keeps everyone on track and it allows everyone an affordable lifestyle for their needs.

I guess what's happened over the years, though, in 1972 when the extended care act was passed, homes for the aged and nursing homes were very much at the same rates with very little difference. But as you well know today, they are vastly different in how they've separated over the years just because there are different ministry responsibilities, one with the Ministry of Community and Social Services and the other with Health.

I think we all know that for the private sector it has been a struggle. Hopefully, those days will sort of end with the system as it comes aboard, so we support it very much. The seniors of Ontario deserve to have the same services, and the expectations should be the same in both, again in the institutions. I think only by going under this one umbrella, as we have today, we'll give them that right that is owing and deserving to them.

After all, they are our background for all of us who are here today in the room and there shouldn't be this discrimination as there appears to be, though, as you know, with the lawsuit that went on three years ago, it didn't come out as discrimination but it came out and said that the system was unfair and inequitable and that the government at the time should look at it and make it fair for all seniors of Ontario. I gather that's where we all are today.

Our facility, I can tell you, and why we're really promoting and looking forward to Bill 101 and the fair funding is that with the small facility we have with 42 beds and the 70-bed retirement home, my average rate for 1991 was $66 a day. When you take the extended care portion and then you average what our retirement home rates are, $55 and $58 a day depending on your size of room, that gave me a $112,000 loss in 1991. We're just now doing our books for 1992. As you know, Form 7 we'll be giving to the Ministry of Health very shortly, and I hazard a guess what our losses are going to be again.

Very similarly, what is happening is that the residential side carries the extended care portion, and the levels-of-care hopefully will change that. That same system of charging to the residential to carry the extended care happens in our homes for the aged as well. I know one of our own homes for the aged in the area here, a few years ago, went from $61 a day to $88 a day for the residential rates, and that was to carry the losses on the extended care portion.

This also is not just the profit side, but there are non-profit nursing homes as well in this province. We know that the Grove in Arnprior and Sherwood Park Manor in the Brockville area have had losses as well, so that the inequities of funding are for-profit and non-profit within the nursing home sector. It's something that is common to all of us who are in this area.

It's the homes for the aged that have been fortunate enough to have the other system, and also to have the backup of the municipalities that, if they do have losses, the city of Kingston for this area here would support Rideaucrest when they have a loss. We have none of those sort of backups. Again, this is why we support Bill 101. Hopefully, it will make the system equal and fair for everyone again.


I guess what it also comes down to with this industry too is that we've had standards, we've had regulations, we've had inspections and we've had accreditation all along. This has very much kept the private sector in line to the needs of seniors and also with the Ministry of Health standards. The other sector has not had the same regulations and implementation. I sort of fear that's a part that the public sector worries a little bit about. What we've all had to go through all these years, they will have to go through the same sort of situation. It is very difficult living under these rules, but they have given us a very good service. I think the private sector has done very well.

It's like anything, though, whether it's private or public, there are going to be good and bad. I'm quite sure there are many of the public sector facilities I would not want to live in, and I know most of them, having been in the business for 25 years now. I pretty well know every institution within the province and you know there are 500 and some. There are places where you would like to and there are places where you would not like to. Hopefully again, what's fair for all would create a good environment and a safe environment for all seniors in the province.

I think with Bill 101 there are some concerns, though, in that the systems are changing again in the lines that we are going from an insured service to a contractual service, and that again will split where we're going to go because not all institutions or facilities will have the same. There again you are not giving the seniors of Ontario that choice of having a similar or same system. It's going to be different again.

I think in Bill 101, from what we hear anyhow, there is something that we're going to have within the facility that is affordable. We have to determine what services we're going to give all institutions and the expectation of the dollars has to go with that system as well. You cannot have a Cadillac system with Volkswagen dollars to go with it. There has to be a balance.

Another concern that we have, I believe, is that in Kingston and this area by the way, we are very much the strong supporters of a placement coordination service. We were one of the first. Kingston seems to be having a lot of the pilot projects. Home care was first here in the Kingston area. I sat on committees again with placement coordination and they support this area as well.

But it would appear that there may be a lack of choice with the way this system is going. Right now people do have choice and it works out very well with the present system that we have with placement coordination, so we're hopefully not wanting to have another bureaucracy where it would make it difficult to flow as we do in this area.

There's also no appeal for this as well. If institutions decide that they feel they can't cope with an applicant, and the placement coordination says they must, then you are going to have this particular problem where there is no appeal and you have to do it. There's no appeal, again, for families who maybe don't want to go to a particular facility, and we feel that the appeal system is very important as well.

Another area is that the compliance management program with the Ministry of Health is an excellent program. It's something that has evolved over years. We had an adversarial approach with implementing the Nursing Homes Act in the beginning, and it has taken all these years since 1972 to change it to the way we are today, where there's an excellent working relationship between -- the lack of words, you hate calling people inspectors. They're more advisers, and they do come in and inspect, but it depends on how you want to use the words.

To inspect can be intimidating and I can tell you, in the beginning of the years, in our businesses when the word "inspector" was coming to the facility, people were on their toes. Everybody was very fearful of these individuals and wasn't relaxed, at home and comfortable when someone came into the facility, whereas today, it's a whole different approach.

The compliance operator comes in, it's very warm and friendly. Yes, she may find some things that are wrong, but that's what we're here for and it's done on a very cordial basis, and it's usually done with a shaking of hands rather than anger and hate and those sorts of things that went on in the past. So the system has changed and we'd hate to see it go back and regress to 20 years in the past.

I think the biggest thing we all have to do in this particular system is we all have to be accountable for our actions and accountable for the dollars that we were spending of the taxpayers. It's what's happening with the Ministry of Health at this point in time. It would appear that we have an open end and an insurance that goes on and on and on for ever and it can't. We cannot afford all of the things that we all like to think. There has to be some accountability, and I think that goes with our own facilities as well.

In order to save funds in the last few years with our two particular facilities, we went from an incontinency program that was disposable. We were also beginning to consider it was environmentally unsafe and trying to protect the future, but it was also more of a dollars-and-cents. We went with a reusable system. I can tell you, just within a 42-bed facility and a 93-bed facility, we saved $61,000 by changing.

I know public institutions within the province that are still using a disposal system and are much larger than our 42 and 93. So you can just see that there is a lot of waste. I think we all have to look at all programs and see where we can trim back and cut back.

There has been a study done recently with human resources in the Kitchener area where there was a comparison of registered staff within the homes for the aged and the nursing homes, and when you do see the results of these, it is on a two-to-one ratio. You're wondering why, if the nursing homes can operate the way they are today and give a very good service, then why are we spending more money in the public sector and not doing any better or any less?

I guess in conclusion what I would like to do, as you all have a copy here, is thank you for these few moments this morning. Again, my main concern is that the services of long-term care in the province of Ontario be the same for all recipients regardless of the long-term care facility they may reside in.

The Acting Chair: Thank you very much for your presentation. Now, if you would accept questions, I'd begin with Mrs Caplan.

Mrs Caplan: There are a number of amendments that the committee has discussed that I'd like to ask you about. So it will be a series of short questions. Do you think an amendment that would allow facilities the right to refuse, on the basis that they could not provide appropriate care, would be a good one, and also a further amendment that would allow for a right of the placement coordination or the client to appeal that decision would be a valuable amendment in this legislation?

Mr Gibson: I think it would be very valuable. I can tell you in the small facility that we have today, I've had applicants who would come to us, and one of our main concerns would be safety of the resident where he would weigh 350 or 400 pounds. If I don't have the mechanisms to deal with or cope with this sort of need of a person, then I should be able to have the right to be able to say that I can't look after any one of this nature other than -- again, what comes out of this levels-of-care is it allows you the funding to have the tools to do the job.

I mean, you can do anything if you have the funding to do this, but I also think that the families have the right to do it if it's a choice and a facility they like. They should be able, one or the other, to justify maybe why they can't and then come to an equitable reason.


Mrs Caplan: There was one exemption that was discussed in Ottawa last night with the placement coordination people, and that was that there would be an exception or an exemption for emergency situations to that overall concept within the legislation. Do you think a facility, which might not see a long-term placement as appropriate, might be able to cope in an emergency situation?

Mr Gibson: Again, each incident will be an individual situation and I think they have to rule on an individuality basis. I think that given that it was short term, then one can see the light at the end of the tunnel sort of thing and you cope with -- we all have to cope today. I see that being very optional and again it's individual. I think most people are willing to cooperate and work together. It's when we get things in legislation that don't allow us, the sort of adversary approach, then it will break down all your working relationships.

Mrs Caplan: We've also been talking about a new model that would remove the 20-year-old, 1960s style enforcement that's in the bill as it exists today. What I've been suggesting, and Mr Owens referred to it earlier, would be a combination of an accreditation model on the basis of both management and outcome. You know accreditation has changed considerably in the last few years.

Coupled with a requirement under the act to have a residents' council as part of the accreditation, and a total quality management program mandating financial disclosure, all of which is in the Nursing Homes Act now, but then to add to that a similar provision that exists in the Public Hospitals Act now, where the minister has concern about quality of patient care progressive steps could be taken which ultimately would result in trusteeship. It's also permitted in the Nursing Home Act as it exists today. You would have that plus a more positive, continuous improvement model which would continue the existing compliance mode.

The big stick of trusteeship is a very heavy stick that's used very lightly because it is the ultimate, but it would remove, in my view, the financial penalty which would only -- I think financial penalties are hurting the clients in those homes. What's your view on that kind of a model for ensuring quality improvement where you have a problem?

Mr Gibson: Again, it's the working relationship and the legislation is going to allow some appeal in the system. I guess everyone gets worried about getting locked in to a sort of situation and you're put in a corner. If there's a tool to not be locked in a corner, I think everyone can go along with it and I think the accreditation process will work very well. It's just that things won't work out if there isn't a means to back out of a situation or to justify a situation as well sort of thing.

An accreditation process works very well, contrary to what I've heard. It's a process I believe in -- obviously having five three-year awards -- and it is on an ongoing basis. Accreditation is not something that is here today or tomorrow. Again, it depends on the facility.

I didn't realize there would be so many of us here, so I didn't bring enough brochures of the facility, but for those of you who have a copy of it, that is something that has taken us a year and a half to do. The rose on the back of it, you'll see, is out of the garden; the hand is a resident. It depends on the facility you're going to be in and what type of home and how it's managed. It's the caring of the individuals. That whole brochure will tell you a lot, if you look very closely at it; the time it has taken. It starts with the administrator with a family. That particular family had five members in our home. Then it just rolls with the volunteers and there's a whole story in that. Again, it's what you're fortunate to live in and then the philosophies of the facility, and to work with a system that you do the best you can, sort of thing.

Mr Cameron Jackson (Burlington South): Larry, thank you for your brief. I want to explore the concept of the difference in your operations, the nursing home versus the retirement, and how you have the flexibility to make up your losses in one given area. I think you used the word "subsidy." This is not too unfamiliar to some members of the committee, but I wonder how you see the new legislation correcting that, or will you be able to -- are you protected, or is there still that ongoing expectation that you will be able to continue to have the one side subsidize the other side?

Mr Gibson: I guess what we're hoping will come out of the new legislation and equitable funding is that my nursing home portion would not continue to have losses, that the losses will stop, and then the return on the entire investment. The facility you're looking at is $5 million. It's a lot of money. It's a lot of money for a small family and it has to have a certain return on investment. It has to have a contingency plan for the future, because the building is going to age. It's just nine years old now. With what we're losing, we're regressing with what we have today with the system, because my nursing home eats up $112,000 of the profit or the contingency that you possibly would have. We would hope that would end.

Our rates: I guess we would not maybe have as many losses if I decided that -- at $58 a day, I'm one of the lowest retirement homes in the area but I also have more services. Most of our public institutions here in this city, in comparison, are $68 a day for a room, and it's a shared washroom. You come to ours at $58 a day and you have a four-piece suite that goes in the room.

It's a variance, again, as to how you have your losses, but then we know that the government is considering the retirement home industry maybe under the Ministry of Housing. There are people who have increased their rates drastically. But when we started nine years ago I was at $32 a day and today I'm at $58 a day, so in almost ten years I haven't quite doubled. But I can't just go tomorrow and be the same as a home for the aged in the area and go another $10 a day, because we're already hearing from the representative before where they are objecting to the $10 a day that's going to come out with extended care or the level-of-care increase.

It's an area that's really difficult, how to manage a facility and not be gouging the public, what is affordable to the public and give them the services they need. I guess we're hoping that this Bill 101 will make sure that we don't have any more losses and we have a return on our investment.

The other facility in Gananoque has 93 beds. Our profit there was $35,000. Now, for a 93-bed nursing home, and you can multiple the equation at $50,000 or $60,000 a bed today, that's not a very good return on your investment and you wouldn't do it.

Some of you may know that we have a new facility in the Northbrook area that is opening April 1. We, as a family, were looking at that because we're Kingston, we have a lot of pride in our facilities and we give very good care. We want to do it in the Northbrook area but the dollars and cents are not there, and I don't know how that facility is going to work, even under the new funding, with the cost of a building that is costing today with these rates. It just won't work. So something that is nine years old or 15 years old, as with our facility, I can see it working, but not in today's.

Ms Jenny Carter (Peterborough): Thank you for your presentation. I'm sure the standard of care is very high in your facilities, but you did say that there are some facilities where you would not want to live and there were some where you would. You also suggest that the power of inspectors should not be increased.

We have various things in place or that are going to be in place to take care of this. For example, we talked about accreditation and we've heard differing opinions on that. Residents' councils: We discussed those that were presented to this group, and a lot of homes have them and they work very well, but you can't mandate those. You can't put them in legislation, so some places may not have them. We have the Advocacy Act coming in which is going to allow residents to phone a number and get help if they feel they are not being properly treated, and of course there will be a residents' plan of care.

But given that the residents must be central, does this cover the situation, or are we still going to see some facilities which are not up to standard so that we need more machinery in place to deal with this?


Mr Gibson: I don't think we need any more machinery than we have today. The Nursing Homes Act is very sufficient. I think a lot of it is the implementation of the inspection area, the compliance end of it. Personally, I do not know why you can walk into a facility today and you can smell urine. Both our facilities are carpeted -- you can well appreciate that carpet has not been changed in 15 years -- and there are no odours. I do not understand when someone from the inspection branch, compliance, goes to a facility and there are odours.

I don't know. I guess it's just if the compliance officers can all think and tick the same and follow and implement the regulations as they should be, and if people comply to the recommendations at the ministry and that's all taken with sincerity. I don't know in our own industry why some facilities are that way, but there again, it's no different than the public sector either. You can go to homes in this area within a 60-mile radius and smell urine, and I don't know why.

I don't know how to answer your question. What we have is enough. You don't need anything more. It's how to make it work and I don't know those answers, because you can go -- urine is a good one that we all know. That seems to be the big bugaboo and that seems to be where your nose tells you something when you walk in, where you're at with that facility, and why I don't know.

Ms Carter: So there's still something that needs to be done, but you couldn't suggest anything.

Mr Gibson: I don't know. I'm not in the inspection branch. Mr Quirt is sitting there. If he could go around himself and visit all the facilities, the whole 500 and some of them in the province, he'd probably do it himself, but you can't do that; you have to rely on other individuals.

It's the same within my own institution. There are things that happen that I don't like, and it's very difficult to stop some things sometimes because I can't be there all the time. I try. I have residents' councils. I had them before they were legislated, because I believe the residents have a right to have input within the facility, and they do every month. They meet on the second Tuesday. They tell me what they like and what they don't like. I answer it and I try to make it the best possible for them. I just wish all facilities possibly would work that way, but they don't.

The Acting Chair: Thank you very much. We appreciate you coming this morning and making your presentation.

Mr Gibson: Thank you for having me.


The Acting Chair: The next group before us is Providence Continuing Care Centre, if those representatives could come forward and make themselves comfortable. I believe we have a copy of your brief, and identify yourselves, please, for Hansard. Help yourself to that good old Kingston water.

Sister Sheila Langton: Good morning, Madam Chairman, members of the committee, ladies and gentlemen. My name is Sister Sheila Langton. I am a Sister of Providence of St Vincent de Paul and senior vice-president of Providence Continuing Care Centre. Our presentation this morning, as you might imagine, is going to be a group presentation. Mr Guy Legros, our president and CEO, and Mr Wayne Westfall, a consumer of our services, will be speaking later.

We are pleased to have the opportunity to participate in the consultations on the proposed legislation associated with long-term care reform and redirection.

Let me give you some brief background information on our centre.

Providence Manor is a charitable home for the aged with 223 beds, of which 179 are classified as extended care and 44 are residential. Founded in 1861, the House of Providence was home to the Sisters who sheltered destitute elderly persons and orphans, cared for the sick in their homes and visited prisons.

In 1970, this home for the aged was renamed Providence Manor, and by 1991 a major building and renovation project was completed, allowing it to become a most functional gerontological centre.

In Kingston, the Sisters of Providence sponsor a 248-bed facility, St Mary's of the Lake Hospital, which has become a geriatric and rehabilitation centre of excellence for both inpatients and outpatients.

To maintain their tradition as leaders in continuing care, the Sisters of Providence and the governing boards formed the Providence Continuing Care Centre in 1991 to achieve a closer relationship in governance and management between Providence Manor and St Mary's of the Lake Hospital and to enhance quality of care. At the same time, each long-term care facility retained its own mission and identity.

Quality care is provided through a complete range of specialized services available at Providence Manor and St Mary's of the Lake Hospital. The psychosocial, spiritual as well as clinical and physical needs of patients and residents are equally emphasized.

At the outset of our presentation, we would like to commend the government for its perseverance in redirecting our long-term care system. The transition to level-of-care funding is both sensible and long overdue. We support the government's initiative to address the inequities in resource allocation and accountability proposed in Bill 101. The public must be assured of continuous quality improvement and adherence to standard-based practice in the long-term care reform.

To influence the quality of care offered in the area of long-term care, the governing board and administration of Providence Continuing Care Centre would like to address the following areas noted in the proposed legislation: (1) coordinated access to facility services, (2) enhanced accountability in long-term care facilities, and (3) level-of-care funding for long-term care facilities.

Mr Legros will deliver this part of our presentation.

Mr Guy Legros: Coordinated access to facility services: As we understand it, admissions to each home will be made by a specific placement coordinator who will be charged with the responsibility of determining the eligibility of each applicant based on criteria which meet the level-of-care funding guidelines, will determine priority for admission to facilities and manage waiting lists.

The rights of individuals to choose preferred accommodation with their spouse or based on the ethnic population or religious affiliation of the home must be considered with other determining criteria. Bed accessibility cannot be the only driving force for placement; otherwise, people with stated preferences will be placed in available beds regardless of their choice. Failure to give due consideration to preference upfront will absolutely deny a quality of life that would otherwise be enjoyed.

In the proposed legislation, individual homes are also unable to exercise their freedom of choice with limited grounds for refusing a placement and no guaranteed appeal process. The rights of organizations are just as important as the right of choice guaranteed to individuals.

At the present time, we in the Kingston region enjoy an excellent working relationship with the local placement coordination service. We attribute this largely to the leadership style of the present management.

Providence Continuing Care Centre does support the placement coordinator concept. We recommend a continuing cooperative approach, assessing and matching facility resources with residents' needs using appropriate approval or review processes. Thus lifestyle choices which are crucial to human dignity and individuality would be maintained.


Enhanced accountability in long-term care facilities: Bill 101 contains amendments which are designed to improve quality of care for the resident. It clearly distinguishes between what will and will not be allowed, with serious sanctions applied to deter non-compliance.

We support efforts to establish effective accountability mechanisms in long-term care facilities. However, we have concerns with the degree of external control that is being suggested in the legislation. We do not believe that excessive external rules and control will guarantee quality. There is an inherent difference between accountability and inspection.

The governing board of Providence Continuing Care Centre is composed of community representatives, serving without remuneration, who provide vision and direction to the organization to meet the changing needs of residents and their families and assure excellence. In addition, our governing board operates by institutional goals and objectives and ensures that services are delivered efficiently and economically.

At our centre, the governing board and administration have established a total quality management program, of which one goal is the creation of an empowered and enabled workforce with decision-making authority over day-to-day processes. In this way our health care professionals become more efficient and high expectations and standards are achieved through an evolutionary process from within.

We are concerned that the proposed legislation will not allow the governing board the flexibility to both meet changing needs and assure quality of care. We ask this committee to consider further amendments to retain autonomous governance structures with the flexibility to manage performance and change and to recognize the ultimate accountability of the board for the quality of care in each organization.

Presently, the area office of the long-term care division oversees our adherence to quality standards. Ministry personnel meet frequently with us and they are in touch with our consumers in the local community. When this is working very well, we question the need to change.

The concept of an external inspector should be rarely used and only in the most extreme circumstances, when it is clear to all that no other approach will suffice. We recommend that this portion of the legislation be accordingly revised.

Level-of-care funding for long-term care facilities: The amendments will establish the new level-of-care funding scheme. Service agreements will contractually articulate the services and programs which will be provided by each long-term care facility.

We suggest that this service agreement include a commitment to the funding level in order to fulfil the requirements of each service agreement. It is essential to equate care needs with funding. Bill 101 is silent regarding the government's goal to achieve needs-based funding.

In conclusion, we support the need for redirection in long-term care. This government's commitment to providing safe, efficient and effective health care is admirable. We ask that caution be observed in drafting legislation. Let us preserve all of the good aspects of our health care delivery system and continue to promote leadership and vision. We look forward to further participation and comment on the details of this proposed legislation.

At this point I would like to introduce to you Mr Wayne Westfall, who is a client in the attendant care outreach program sponsored by Providence Manor. I'd like to introduce to you Mr Wayne Westfall.

Mr Wayne Westfall: Thanks, Guy. I'd like to thank the committee for your interest in long-term care issues, and I'd also like to thank Sister Sheila and Guy for asking me to speak here.

I was injured climbing a mountain in 1979 and I've been a C5-6 quadriplegic since then, so I've had almost 14 years of personal experience with disability, and I've been a consumer of services in the community since 1980. I've seen a lot of changes since then, a lot of positive changes, and I hope Bill 101 will continue to further that process.

My professional background: I graduated from Toronto with a Master of Social Work in 1984 and worked both in the community and in institutions before my injury. I have worked in both since my injury as a social worker. Now I am a part-time teacher at St Lawrence College and at a local minimum-security institution. As well, I'm an aspiring artist, but we all know that you can't live on that aspect.

Mr Drummond White (Durham Centre): Keep your day job.

Mr Westfall: My day job, yes.

I'm speaking today as a receiver of services and also as a representative of sorts for those people like myself who live in a community but are unable to speak for themselves.

I just want to preface my remarks with a couple of comments. The converging realities of increasing health care costs, decreasing money available and an increasing number of people needing services is really forcing difficult changes. We're all very aware of that. In the past couple of years it's been extremely severe, and I don't see how that's going to change.

In my own opinion, in order for us to effectively meet what is a crisis and is going to get worse in terms of health care, it's essential that we encourage and we demand consumer responsibility for their own health in the community. I think in order to do that we have to provide structures for people like myself to live in the community and to live decently. That's why I'm here today, to talk to that. My comments -- I never get the chance to speak to your standing committees, so some of it may relate to Bill 101 and others are just going to relate to my own agenda, which I could fit in there somewhere if I needed to.

First of all, I want to talk about direct funding, which is the issue directly related to Bill 101. I think direct funding is a good idea, and there are certainly some people with disabilities who will take advantage of it. By and large, though, I don't think it's going to be used by very many of us because it's too complex. If, in addition to my life as it is now -- working, organizing my life -- I had to structure wages and benefit packages into my attendant care, I wouldn't work: it would just be too complex. And I believe that's the case for most people like myself.

However, my situation -- and I'll talk about it in more detail later -- provides a maximum flexibility which allows me, basically, to hire my own attendants and to leave the paperwork to another organization that is better suited for that function.

The big advantage, though, of direct funding, where the money goes right to the client, is that it offers portability, and at present there is no portability of services, of funding. If I leave the services in Kingston and I move out of this catchment area, the money stays behind with the outreach program. Basically, that means I don't move, because there's a waiting list everywhere; I'd be years trying to get somewhere else. So my opportunities to move are extremely limited, the same as anybody trying to move to this place. It's impossible with the current structure the way it is.


I think that does a number of things. Besides limiting my movement around the province, my opportunities, it taxes specialized services in the community such as access, transportation, because people have to come to Kingston for rehab services; they can't go back to their local communities. Transportation services get taxed, accessible housing becomes taxed. Also, employment possibilities: All of these things are really limited. Because basically, what we do is we ghettoize people with disabilities. Kingston ends up with a whole bunch of people, and the rest of Frontenac county has almost nobody, because this is where you have to live in order to get the services you need.

I think another result of that is we end up stereotyping people with disabilities, partly because we just put too many of us in one area, the same as any ghetto occurs when too many people who are a minority live in an area; there's an inevitable opinion that forms in people's minds about individuals. That's a fact of our reality, and that occurs in Kingston also.

Now, the purpose of the outreach program, which I get services from, as I see it, is to maximize the independence of consumers like myself to live in the community and to do this at a minimum cost to the taxpayer. I'll give you an example. In my case, it costs the government about $300 a week to keep me in the community. For that, I hire about six to eight people at any given time around my payroll to provide the services I need. This program -- it didn't start till, I think it was 1985.

Before that, since I was a social worker and to get out of hospital in 1980 there was no program basically, I wrote up my own program. I funded it through voc rehab, which I knew funded employment opportunities then. So I said: "I've got to get a job but I need an attendant to get me to the job. Can you fund me?" It was flexible, and they funded me. That's how I stayed on the program for about four years, until the outreach program came into existence, and none of us had to play these games any more.

But I've been working since 1981. I pay taxes, I live in my own house, I don't live in subsidized housing. I pay for all of my drugs because there's no drug program which thinks I'm a safe enough bet to live long enough to warrant their expenditure. I was on Blue Cross. I went off it for a while and tried to get back on, and they said, "Sorry, we don't want you any more." I also pay for all my medical supplies. The only thing that ADP, the assistive devices program, covers me for is a wheelchair, and that's once every five years. Everything else, and that's about $2,000 a year, comes out of my own money.

None of that would be possible if there weren't a community support program such as outreach. Basically I'd be living in an institution. The institution I'd be living in in this community, because of the level of care I need, would be St Mary's hospital, and the cost there -- the figure I was given -- would be about $6,900 a month, to keep me at St Mary's in one of their beds.

So figure it out: I cost about $15,000 a year to live in the community and do the things I do versus almost $7,000 a month to live at St Mary's. Within three months at St Mary's, you've already paid for me to live in the community for a year. So in terms of outreach and whether it's cost-effective or not, I have absolutely no question that it is.

A bit more about the outreach: The program here, we have a budget of about $800,000. It serves 58 people and it employs 75 staff, some full-time and some part-time. Again, you can do a little mathematics: 58 people, $800,000, that's about $14,000 a year to keep us in the community -- not very much money -- as opposed to that same budget, $800,000, a dozen of us at St Mary's and we've eaten it all up. So I think there's a huge benefit in having structures like the outreach program available.

Kaye Faust, who's a coordinator of the program, tells me that a half to three quarters of the people on the program would require institutional care of some sort, that we would not be able to live in the community if we did not get attendant care. Maybe not all St Mary's, but we'd all have to live in structures, in institutions.

Another thing is that it's great job creation. I employ a lot of people. Most of the people I employ are minorities themselves. Some of them have mental disabilities, some of them are immigrants, some of them are students, a lot of them are either unemployed long-term or they're newly unemployed. So a lot of these people have their own difficulties which prevent them from working in the larger workforce.

The way the program is structured is that Providence Manor -- this is one of those rare cases where a community program is run out of the institution and actually works -- has two coordinators. They basically take in applicants who want to work on the program. But then, people on the program have any number of levels of responsibility, so somebody like me -- I phone up Kaye, she gives me names, I contact the people or they contact me, I interview them, I select them, I train them, I schedule them and I hire them, if necessary, and I leave the paperwork with the outreach program. They do all the CPP and the UI benefits and all that stuff. If I didn't want that responsibility or I wasn't able to take that responsibility, then the coordinators of the program would take that. That can operate at any level in there.

The Acting Chair: Excuse me. I really don't want to break in, because personal experiences are so beneficial to this committee, but I know there are people who will want to ask questions. I've already had several hands up. If you could just summarize, because we are coming to the end of the allotted time and we have to begin again right sharp at 1:30. I hate to do this to you, because it's very valuable, what you are providing this committee.

Mr Westfall: I'll tell you why I think the outreach program works. First of all, it is run out of an institution that does care for people, but mostly the advisory committee is made up of professionals and two consumers -- I'm one of them. It's a non-hierarchical committee where everybody has equal input -- I don't have to call the doctor "doctor." There are two first-class coordinators who really care about the people on the program. They know us all individually and they know how to respond to our situations individually.

We bend the rules to fit the clients on the program rather than the reverse. That is inevitable; you have to do that in order for anything like this to work. No amount of regulation is going to ensure that all my needs are met, and met on a humane basis.

The wages are good, from $11 to $13 an hour, which is what a person providing the same work at Providence Manor would make. That gives me reliable attendants with continuity and consistency. I wouldn't get that through a private agency. You would pay them more to pay their workers less to come and work for me. People quit on $7 an hour; they'll stay for $11 or $12 an hour.

Every two weeks, I'm given a certain block of hours and I schedule those hours to do what I need when I need with the person: one hour today, if I need it, and seven hours tomorrow, if I need it. As long as I stay within my limit, it's there. So huge flexibility.

My scenario, if I had a choice, would be that when somebody moves into the community or they're in the community and they need a level of service, we calculate -- whoever "we" are -- how many hours this person needs. We give them a dollar figure based on that number of hours and then allow them to do what they want with that money, to hire who they want and to hire those services through who they want.

That way I can move out of the community if I wish, I can hire an individual if I wish, I can get my services through an organization if I wish and I think in that way it ensures good quality and it also ensures competitive quality. If I don't like what Providence Manor does, I'll go somewhere else and I'll be the judge of where I go and what quality is.

In terms of accountability, I think there are lots of ways for checking that, but when we give people money for mother's allowance, disability pensions, unemployment insurance, Canada pension, who checks that for accountability? That isn't checked, so I don't see that that should be a major stumbling block in this case either.


My suggestion is that we keep the service agencies small. Kingston at some point is going into an integrated homemaker program, so attendant care services are going to be available on a broader basis. My fear is it's going to move into one organization, probably the local health unit, which is going to have another level of bureaucracy servicing huge numbers of people, and that we're not going to be able to respond to the individual situations on a quick basis and meet the needs which -- somebody follow me around for an hour, for two hours and see the kinds of needs I have. They're very individual. They can't be met under a bunch of rules. If it gets into one organization servicing hundreds of people, that's what's going to happen.

If you want to increase options and you want to do that with a high quality of care, then I think we need to have smaller organizations working within the same community and giving consumers like myself opportunity, choice and responsibility. I have a lot more to say, but that's enough.

The Acting Chair: Thank you very, very much. I'll move directly to Mr Jackson.

Mr Jackson: Wayne, thank you for the insights to the program and to your personal experience. They're helpful. I was rather shocked, years ago, when I learned about the relationship between workers' compensation and direct funding arrangements. Could you clear up for me -- are you liable for the workers' comp? Does it flow from you as the employer in this program or does it flow to the program generally?

Mr Westfall: Since the program has run out of Providence Manor, it is liable for the workers' comp.

Mr Jackson: So this goes on Providence Manor's WCB rating.

Mr Westfall: Whereas if it was direct funding, then I'd have to do something about that myself.

Mr Jackson: Yes, under direct funding it's my understanding that you would. That was the point you were underscoring about the excessive amount of paperwork and the filings. I have constituents who have gone through a nightmare with workers' comp, where what the government pays for the service is almost being lapped by what the WCB charges. It's incredibly --

Mr Westfall: The way the program is structured now, for me it's ideal, because I do everything. I have total independence in my life in terms of my attendant care, but I don't have to do any of the paperwork.

Mr Jackson: I understand that, and most of us who have the opportunity to work with the differently abled community and our constituents have had -- it's hard to understand that we might have a glimpse of the experience, but some of us have had the opportunity to do that. It was this accountability shift which you touched on that I wanted to explore a little more deeply. Perhaps the representatives of Providence Manor may wish to comment about this issue of liability, and then I'll pass to the next questioner in the interests of time.

Mr Legros: I'm not sure I can address that. I think the staff, as outlined by Wayne, are funded by the Ministry of Community and Social Services, but they are part of our payroll and the liability coverage etc is covered and we have insurance, and also the workers' compensation package etc.

I think one comment I should perhaps add is that staff are not professionals per se; they're not social workers or therapists or whatever, but they are our staff and live our mission.

Mr Jackson: Thank you.

Mr Paul Wessenger (Simcoe Centre): Thank you very much for both your presentations. I feel that we needed really enough time for each of you individually, because we've got two points of view here which I very much appreciate, and particularly yours, Wayne, with respect to your personal perspective.

First of all just dealing with some of the concerns about consumer choice and inspection, I'd just like to assure you that the place of coordinating an agency will continue in this area as it now basically does and the consumer choice is very much an essential part of that and will continue to be part of that, and we're certainly looking at seeing there are some assurances we can give in a visual way, because that's certainly the intention.

With respect to the inspection process, I'd just like to also confirm that the same people who are doing the inspection will continue -- the advisers will continue in that role, and there are no plans at all that would in any way change the process. It's just going to be a merging of the two divisions, the nursing home and the home for the aged.

I'd like to just ask one question of Wayne with respect to this delivery of service. You indicated you had a preference for a multiplicity of service delivery as distinct from one organization delivering it. Would that mean that in a sense, as we move -- I don't know whether you're familiar with moving towards the multiservice agency concept -- I would think you would probably be in favour of a more devolved model of multiservice agency where the agencies have an overriding devolved model where they work in a cooperate, integrated manner, but still preserving their individuality.

Mr Westfall: Well, I realize there's duplication of services and a lot of that duplication isn't necessary. I've been around a long time on both sides of the fence, so I've seen it and I know some of the complexities. But there are situations where duplication of service is useful. I think there are going to be a lot more people who are not as disabled as me but with all levels of disability living in the community and going to need help.

So in Kingston we're going to have hundreds of people needing services. To me, having a variety of agencies running that is fair enough, because I think what happens with institutions is that when they get too big, they lose that humanity. They have to. You can't serve a thousand people -- the coordinator can't know everybody. If they service a hundred people, they can. So to me, the best way is to keep it small, which I don't think is inefficient either, because the kinds of things that keep me in the community can be dealt with if a person knows me personally. If they don't, I may have to go to a hospital. What if I go there for a week? The amount of money that costs -- a few of those can easily pay for a coordinator's salary for a smaller program. Do you understand what I'm saying?

Mr Wessenger: Yes, I do. Thank you very much.

Mr Randy R. Hope (Chatham-Kent): I just have a quick question. I'm going to go fishing here because I notice that in your presentation you talked about levels of funding, and I wanted to bring in the perspective of the copayment or user fee -- I'll use the terminology; it's been used in the committee.

What do you see as that, and I'm wondering -- just for your views on the fee structure for residents, because you live in a rural area. I'm sure there are people who still want to live in their home. A spouse might want to live in the home, but because of circumstances, somebody has to move to the residence, and I'm just wondering your viewpoint on that.

Mr Legros: Well, I think that the fee structure as it exists has been working. I think there are proposed changes, for instance, that we would be looking at income versus assets and so on, to arrive at the amount monthly that would be paid by the resident, and whether he or she can afford to pay etc. I guess what I might say is that we do leave $112 per month as a comfort allowance to each resident, and obviously, the $112 per month is eroding for a variety of reasons, I guess not just inflation etc, but with the current changes to the Ontario Drug Benefit Act, for instance, many items that were previously absorbed by the ministry, the government, for the over-65s now must be paid by the resident, and the only source of funds they have is from that $112, and that's a new problem that exists. I think that the user-pay philosophy is not a popular one because people, if they can, will let the state pay as much as the state will absorb and they'll do whatever they can to keep it down. This is not true for everyone, but a lot of people would take that approach. I'm not sure if I'm answering your question.


Mr Hope: Like I said, I was just going fishing for your comments about the copayment aspect and looking at the individual, and I know you deal with individuals.

Mr Legros: The biggest problem with copayment as it exists now, for instance, in the hospital sector is the fact that it doesn't start until after 60 days. I think that's something that needs to be looked at. I think that several governments have looked at that, but there's been no change. I think that that should be changed because if you get in a taxicab the meter starts right away. So because we are under tremendous financial constraints, we need to look at that as a feature.

The Acting Chair: Ms O'Neill, I'll go to you, and then if there is time at the end, we'll go back over here.

Mrs Yvonne O'Neill (Ottawa-Rideau): Thank you, Sister Sheila and Mr Legros. I think you brought forward to us many of your concerns about the placement, governance, needs-based funding and the enforcement mechanisms and the sanctions that accompany those. I just have one question for you and one for Wayne. Do you ever have to or do you accept people on emergency call now for placement? How does that work in Kingston with the coordination placement?

Sister Langton: As we said, we feel that we have such a tremendous working relationship with the placement coordination service that indeed it is handled according to our mission. We look at individual cases. Yes, we do have a waiting list, but there are times when people cannot wait. It has been our tradition in Kingston -- we've been here since 1861, remember, and we've served the needs as we saw them and we have luckily been able to continue that with placement coordination because of the flexibility at the top. If that approach could continue, then we'd be very happy. But yes, we do handle emergencies.

Mrs O'Neill: Mr Wessenger has been saying that he's going to beef that section up some way, or at least ask the minister to, so I hope we can, because you're not the only person who has some concerns about that area of the bill.

Wayne, it has been very helpful for you to give us your perspective. I think some of the best witnessing we have has been from residents' councils and from people like yourself. You told us a lot about the way you manage your life and it certainly seems to be going quite well.

You did, however, express some caution at the very beginning of your remarks about the direct funding that is going to be very much part of this bill. Would you say a little bit more about why you have cautions about that and how you think, either for good or bad, this is going to be played out for the disabled community?

Mr Westfall: If the direct funding is only going to be open for individuals who want to hire the services, I don't think many people are going to use it because of the complexity of all the other things. If I, for instance, got direct funding, I'd just turn around and hire Providence Manor so I wouldn't have to do all that stuff. I have enough in my life without being an employer with the paperwork as well.

Mrs O'Neill: You're the first person who's brought that perspective to us so it's rather interesting that you would state that. I think there will be some difficulties that maybe are unforeseen at the moment.

Mr Westfall: I think that should be an option that's available for people. I know some people with disabilities who are very keen on it, which is great, but I think most of us, we just have enough other things to do that --

Mrs O'Neill: Perhaps we can put something into an amendment that would attend to that.

Mr Westfall: My point really is, when I say, "Give me the dollars and then let me hire who I want," would in my case be, "Give me the dollars and let me hire an agency that is going to do all that paperwork." But I still have the opportunity of saying to the agency whether or not I like the kinds of services I'm getting through them, and if I don't like those services, I could take my dollars, move them somewhere else, to get the kinds of services that I feel I need.

Mr Wessenger: Could I just perhaps clarify that direct funding is an option, not a requirement.

Mr Jackson: Not even a reality yet, let alone an option. It's not even in distinct language in the bill that it's going to happen.

The Acting Chair: Keeping in mind that it's one hour and we have to be back here.

Mrs O'Neill: Could we just have -- since Mr Wessenger did throw that statement out, is there also the second caveat then that a situation like Wayne expresses regarding hiring an agency would be acceptable or does it have to go directly to the individual?

Mr Wessenger: The model has not been developed, but to me it would make sense that one would have the option of going to whatever organization or person who meets whatever the qualifications are to obtain the services.

Mrs O'Neill: Well, you'll be quoted.

The Acting Chair: As I said before, keeping in mind that we do have one hour and then we'll be right back here at 1:30 sharp, and I say that directly -- briefly.

Mr White: Thank you. Wayne, I was very impressed with your statement, with your testimony. The issue I wanted to pick up on, because of the briefness I'm being pressed into, was in regard to the committee that you referred to, and I'm thinking in terms of the instruction really necessary for the placement coordination services, for the direction of services to people who are physically challenged or the elderly.

We've heard a lot about people who are going to be hard to place. We've heard a lot about medical needs etc, and I'm wondering from your standpoint whether you don't think that it's important to have a voice that speaks for the individuals, for the families, from a professional standpoint, from a psychosocial standpoint, a voice that speaks to their living circumstances.

Mr Westfall: Yes. You're talking about the advisory committee for the outreach program, and on that we do have the requisite number of professionals, in terms of physicians, occupational therapy, nursing, administrators, and there are two consumers and also the coordinators of the program who know the individuals. They know them all personally. They're right in their homes. So they really do know these people and I think we cover all of that ground, and that's the total --

Mr White: You do. Actually, I was thinking also of the placement coordination services with their advisory committee. Do you not think that there should be a voice there, such as you have on your advisory committee, for a psychosocial voice, for a social worker or someone else who could speak to the family and the needs of that particular person from a psychosocial perspective?

Mr Westfall: You mean in terms of placement coordination from institutions into the community and vice versa?

Mr White: Yes.

Mr Westfall: I think we have to involve people who have the situation themselves as much as possible in all of these processes. To me, it's the only way to go.

Mr White: Absolutely. Thank you very much.

The Acting Chair: Thank you very much. I thank you for coming and for bringing your perspective and hope that all of these things that you have heard people say will assure you that we will get some amendments to this bill and maybe we can really work towards the continuum of care that we want, and you can provide the good service that you have since 18 --

Sister Langton: Sixty-one.

The Acting Chair: Eighteen sixty-one, and I remember it when it was the House of Providence very well. Thank you very much for coming. Thanks everyone, and we will resume at 1:30 sharp.

The committee recessed at 1230.


The committee resumed at 1334.

The Acting Chair: If I could have people take their seats, please, and the committee members please come to their places. We do have a full afternoon agenda here, and I'd like to be able to have as many questions as possible. Ms Carter, are the other members of your party available? Here's one, okay.

Good afternoon, ladies and gentlemen, and welcome to the standing committee on social development, dealing with Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Acting Chair: I would ask the County of Hastings, Homes for the Aged Committee representative to come forward. I'm Joan Fawcett, the acting Chair this afternoon for our usual Chair, Charles Beer. Welcome gentlemen, and if you would identify yourselves for Hansard, and then begin your presentation.

Mr Lloyd Churchill: Thank you, Madam Chairman. I'm Lloyd Churchill, homes committee chairman for Hastings county, I'm also a member of county council. With me is Rob McLaughlin, our homes administrator in our Bancroft home.

I thank you for the opportunity to able to appear before you today. Rob is here as my counsel because I'm sure that Rob, in his very competent position as administrator of our home, is a lot more adept at answering the questions that may be posed than I myself. Yet, I think that I have had a learning experience today, looking at it as not one involved with social programs or with the administration and carrying out of those programs, but more or less with an independent businessman's view of how operations work.

Probably I'm in an fortunate or unfortunate position, whichever way you want to look at it. I have a great interest in senior citizens, what's happening to our homes. I've been on the committee for four years, the last couple of years chairing that committee. I think that we have two good homes that are well run, well administered. But as an outsider, I look at what is happening in our long-term care, the government programs which are being looked at, and I applaud the government for the direction in which it is going and what it is looking at.

I also have grave reservations. I have worked as an independent businessman for 20-odd years and have been in a position for 14 years in corporate business and 20-odd years of my own business, and I have been in the position, good or bad, to make decisions when they had to be made and get on with running a business. I think if I had taken the time to make some of those decisions that I see the government having to take to make decisions, I would have been wiped out by my competition years ago. This is no slight on the members of this panel, because I realize that you represent different parties, and certainly the implications of what we're looking at today were not all imposed by the party of the day.

Sometimes I very much question the time that we have our homes administrators spending on budgets and preparing budgets in the field of uncertainty in which they work. Once again, private business could not operate that way. I see ourselves operating and preparing 1993 budgets when, at the same time, we don't have approval for 1992 budgets. I don't think we can recapture those expenditures from 1992. They're gone. They're spent. Thank you for giving me the prerogative of doing that; it isn't in my submission, but I'm usually known as saying what I think. My wife says that's not always good.

But I think probably all of us, and certainly the members of our government today, see the writing on the wall. I think sometimes we fail to see that the writing on the wall is addressed to us. I also think the government is trying to put the train back on the track. Perhaps they've got it back on the track with the direction in which they're moving, but I question which way the rails run.

With those opening, probably uncalled-for, remarks, but my customary remarks, I see total frustration in having to deal with the ministry with which we are dealing in our homes, when we are still wondering and asking and looking for questions, which I ask my administrators. "What is the direction?" I've been asking you for two years, "What is the direction in which we're going?" And they're still unknown questions today what that direction is going to be.

So hopefully with the submissions that you hear, with your travelling around the province at this time, having these hearings -- and I'm sure that they must get very boring for some of you members, because what you hear and what I've heard today is pretty well the same line, the same content in all the directives, that the same questions are being asked.

The Acting Chair: Usually there's something a little different.

Mr Churchill: Yes, that's right. Hopefully, there will be in ours, Madam.

Mr Owens: It's already started.

Mr Churchill: I also appreciate the fact that the three people who are here today I found very informative. I almost see myself as an outsider as a provider of care. I don't become involved in those things. You people who are involved and certainly our administration in carrying out those programs are some very dedicated people. I think we have some very dedicated people carrying out the mandate of the health services department of the government in a very confused and unsure position of where they are and where they're going. I find it must be total frustration for those people having to try to cope and carry out those policies.


Getting back, I do appreciate the fact that we can come here today --

The Acting Chair: Don't apologize for your remarks, sir, because if we are going to make this system better it never hurts to start with the truth, and we need to hear that.

Mr Churchill: Thank you and I appreciate that. So I guess the truth would be, hopefully after today and the completion of your committees and the hearings that you're holding across the province, somewhere in the not-too-distant future we can see something but words and some action. To my thinking and the way I've looked at it a number of years, I have heard lots of words but little action.

The Acting Chair: Point well taken.

Mr Churchill: By the way, I have him here as my solicitor to answer any questions that you may put his way, and he carries the brunt of the load. I said he should be giving this deliberation rather than I. Thank you for your indulgence.

I wish to thank this committee for the opportunity to express the following comments, questions and concerns that Hastings county has with respect to Bill 101:

With respect to social services improvements or changes under Bill 101, our homes board of management finds itself in agreement with many of the objectives of the present government. At the same time, we would stress retention of the more positive aspects of the present system which have served our community well. Of course, changing times advocate policy renewal. However, it is our concern that new policy, built on past experience, would remain flexible enough to satisfy the concerns of those for whom it was originally implemented.

As background information, Hastings county has for many years attempted to be responsive to the needs of our aging population. In 1951 Hastings Manor was opened to replace the outdated House of Refuge. Subsequently, expansion to the original facility was undertaken. As a result of this expansion, additional beds provided were for residents in need of considerable hands-on nursing care.

In 1984-86 we renovated Hastings Manor to upgrade the accommodation and service to the residents. In 1967 the county of Hastings constructed a second home for the aged in the town of Bancroft. Its purpose was to facilitate the elderly who were in need of residential, nursing and medical care.

Hastings Manor has a licensed capacity for 256 beds, of which 198 beds are allocated as extended care and the balance of 58 beds as residential care. At Hastings Centennial Manor, the licensed capacity is 104 beds, of which 66 beds are allocated extended care and the balance of 38 beds as residential care.

When the previous government announced its intention to introduce a new redirection for long-term care, we knew that it would have a significant impact on the services and levels of care that we would be expected to provide. However, if homes for the aged are to admit fewer residents who need minimal nursing assistance, what facilities and services would be available in the community for them, and how will these community services be funded?

It is approximately two years since the redirection of long-term care was announced, and we still have very little detail on the whole process. We do know that residents of our facilities were classified last September 1992 as to the level of care they required. We know that we will be expected to meet specific standards in all aspects of the facilities' operations. We know that the funding formula will change. We know that we will be expected to sign a service contract requiring us to meet certain standards in return for funding. We know that we will have compliance officers inspect our facilities. However, no detail has yet been provided on any of these items.

We, as a municipal government, agree that the principles of the provincial government regarding redirection of long-term care are needed. It is indeed time to address the misinformation and confusion that exists, not only from the general public but service providers and community service agencies.

All levels of government must deal with increased costs in the delivery of services, and all share the concern of how to pay for these same services. Provision of health care services to our aging population is a high priority to all of us. We are receptive to the government's efforts to improve service to the elderly and its stated intent to assist in the costs related to nursing services, programs and facility operations.

Hastings county does have some concerns with Bill 101 as it is now proposed, and a few are the following examples:

Admission process: Under Bill 101, all admissions will be processed through a placement coordinator. This placement coordinator will determine eligibility for admission and priority of admission. The facilities we own and operate will only be able to admit applicants deemed appropriate by the placement coordinator. At present, the admission process, as legislated, can be a lengthy process and does need revision.

Currently, the medical documentation required from the physician takes an average of three to four weeks to obtain. In addition, it usually takes one to two weeks to arrange an appointment that is convenient with the applicant and/or family to complete the required forms.

While we see merit in the gathering of information by a central agency, it remains to be seen if the medical documentation required can be obtained from the physicians in a shorter time frame by a placement coordinator. If we are aware that the applicant is in hospital, the discharge planners are very helpful in having the medical documentation completed in a shorter time frame. It must be emphasized that not all the applicants are in hospital and we do not see how the placement coordinator will be more effective than we are in obtaining the required documentation for applicants in the community.

How will information be obtained from applicants in the community? We trust that any changes to the collection of data for admission criteria do not encourage duplication of service or costs.

Right of choice by applicants for admission to a facility: The vast majority of admissions at both of our facilities chose these locations through personal or family choice. Needless to say, both our homes enjoy a good reputation within their respective communities. Virtually all of our applicants have lived their lives within Hastings county and relate to our facilities through family, friends and familiar surroundings. We would not want to see this changed.

Over the years, their tax dollars have helped support our homes, and from this they have developed a sense of ownership in their homes for the aged.

It is not an unusual occurrence that some applications are completed in advance and we are requested by the applicant that it be kept on file until he or she is ready for admission. These are usually the frail elderly who are competent but wish to remain in their own homes as long as possible. We would wish for this possibility to continue.

Our residential beds are always full. For those applicants who freely choose to be admitted, they should have the right to choose a facility they know. Will these people have this right of choice through the placement coordinator? It is very important that this be known at this time, especially when our two homes are some distance apart in location.

Funding: Under our current funding subsidy the Ministry of Community and Social Services, after revenue by residents, cofunds the facility for 70% of expenditures up to the provincially established cap. The municipality's share of expenditures equates to 30% of the cost after all revenue and 100% of all expenditures exceeding the cap. We are advised by the ministry that if our nursing and medical documentation supports the level of care delivered, the province will totally fund that service. We are advised that programs for residents will be fully funded.

We are advised that a set fee of approximately $37 per day will be established for the residents to pay for accommodation costs. This fee would be for those residents who are not in receipt of the guaranteed income supplement. Residents who do not receive GIS would be charged on a sliding scare and the province will fund the difference.

This funding method does not take into account the assets a person may have while having their accommodation charges subsidized. This does not seem equitable and could possibly result in an additional burden on the taxpayer.

All of our future admissions will be at the discretion of the placement coordinator. Those admissions will be only those in need of the ever-increasing levels of care.

In recent years the financial contribution by the provincial government for long-term care facilities has not kept pace with the increasing demand. Do we have any assurance that the funding under Bill 101 will keep pace with the increased service requirements?

We are presently setting our county budget for 1993. Our home administrators have been advised by ministry officials to prepare their budgets, as they have in prior years, and that no facility will receive less funding than in 1992. Hopefully, given that we are still waiting for ministry approval for our 1992 budget, it is not indicative of the level of competency with which future process will be carried out. Is this a signal that there will be a decline in future provincial support for long-term care? Perhaps an amending formula is needed to link the commitment to quality with provincial funding.

There are many questions to be answered with regard to funding and we anxiously await ministry input or seminars on this topic.


Accountability: Hastings County, as the owner of two non-profit homes for the aged, understands and accepts its responsibility to provide for the services needed by seniors. Our homes for the aged committee are elected members of county council and therefore have close ties to the communities our homes serve. This committee meets regularly, with the homes' administrators in attendance. Our administrators report to the committee on topics such as exceptions in day-to-day operations, expenditures not anticipated and recommendations to improve or enhance our services.

In our opinion, accountability to the community exists now. Perhaps in the large urban centres, the close ties to the community through the elected officials and the homes' administrators is less evident than in our more rural locale.

Quality assurance: We agree that there must be some method of measurement of the service being provided by all long-term institutions. It is our understanding that standards are being developed for all aspects of the operation of the facilities. When we have these standards shared with us, we trust that any comments or recommendations will be heard and given consideration.

A point of concern for our board is the possibility that Bill 101 incorrectly assumes that the provincial inspection process of facilities will automatically increase the quality of service.

We must utilize caution in creating a further bureaucratic hierarchy. At the local level, would we not be distancing ourselves even further from the voices of those to whom we are responsible? If we, the owners, are accountable to the government by means of the service contract for funding required, does it not follow then that, as owners, we will ensure that our non-profit facilities meet these standards?

With the principle of accountability accepted by Hastings county, we question in the strongest terms the need for compliance officers. We see the introduction of these compliance officers as an added level of bureaucracy which is not needed for non-profit facilities. Surely, the tax dollars needed for the inspection process proposed could be better used in funding of direct care and services to seniors.

In conclusion, I would like to again emphasize Hastings county's position, which is that we agree with the stated principles of the provincial government with regard to redirection of long-term care. It is our hope that with the best of intentions, the provincial government does not discount the positive aspects of the current system. The right of our seniors to choose for themselves to remain in their homes must be acknowledged. When this is no longer a viable situation, they must also be allowed to select a long-term care facility they know and are comfortable with.

As the owners and operators of non-profit long-term care facilities, we will continue to provide quality services and commit to provide excellence in service delivery. We do wish to stress that cost related to the introduction of compliance officers for non-profit facilities must be identified as part of the overall costs of redirection.

We do have concerns for the adequacy of the proposed funding for facilities and community services. However, we must wait until the actual funding process is announced before judgement can be made. We fully expect an opportunity for consultation.

Again, I thank this committee for the opportunity to put forth the views of Hastings county regarding Bill 101.

The Acting Chair: Thank you for coming before this committee to give us your views. I'll begin the questioning with Mrs O'Neill.

Mrs O'Neill: Thank you very much. I'm glad your brief ended with the request or expectation almost that we would have further consultation on issues such as funding, which is really very, very nebulous in Bill 101. Many people have brought that to us, particularly with what seems to be a much more centralized system. The placement coordinator's role in that and the level of care sometimes seems to be laid on the facilities rather than part of the facility's program.

Mr Churchill: I have faith in your government that it will do it.

Mrs O'Neill: I'm not a member of the government, but I am a member of the Legislature.

Mr Churchill: Is there a difference?

Mrs O'Neill: Sometimes.

Mr Owens: Yvonne had her chance.

Mrs O'Neill: Maybe not fully. The bureaucracy and the buildup of bureaucracy that seems to be part of Bill 101 also seems to be part of your caution. I think it needs to be noted as well.

There's one part of your brief that is somewhat different -- a couple of parts -- but I just wanted to have you go back to page 6. There are two things I'd like you to expand on a little bit. You're the first one who has at least brought to our attention -- maybe the only one who's been honest enough -- that you have applications in advance from people who are not yet ready to move and that these are now honoured by your home. Could you say a little bit more about how that fits in with a waiting list that would be normally considered, having a component of care need.

Mr Churchill: We do have applications on hand at all times in both of our homes. Our board, of which I am a part, the board of management of those homes, usually relies on the competence of our administrators to bring those applications forward. Quite often, you'll have people residential in our village, in our communities, who think somewhere down the road they may possibly enter our home. So they have everything prepared and hopefully can move forward when that time comes. It's usually been the practice that when those applications are probably brought on stream, the administrators bring it to our attention, and they give their evaluation of that process or of that applicant, where he stands in regard to the criteria of family being able to look after him, what his independence is and how bad his needs are.

Mrs O'Neill: Would you do that on an annual basis when you do those?

Mr Churchill: Monthly. We have a monthly list and that's discussed at every monthly board meeting.

Mrs O'Neill: That's very interesting. As I say, you're the first one, I think, who's brought that forward, and it certainly ties in very closely with the community-based care aspect of this bill.

Mr Churchill: I think it's very different, if I may call you Yvonne. The fact is our homes are in smaller areas where we are more conversant with the people and the applicants who are requiring to come into our homes. Most of the time, we know them on a name-to-name basis.

Mrs O'Neill: Which I think is something we have to note. Could you say a little bit on your other concern regarding, if we want to call it as it was this morning, the user fee now being somewhat based on income and not considering assets. You are a business person and I think I'd like to hear you say a little bit more about that part of your brief.

Mr Churchill: I think we have to acknowledge that in this society in which we live today, there's no free lunch, and everybody is entitled to pay their way or should be entitled or expected or requested or feel it important that they pay their way.

If we go into this capping process which the government is alluding to, I believe there are many residents who will end up in our homes who do have some ability to pay, and this will change from home to home. For instance, in the two homes we have now that we administer in Belleville and Bancroft, there is a different level of ability of those people to pay. It's brought about I think by the little bit more affluent families we are serving in the Belleville area compared to the less affluent families we are serving in the north area.

We think, as a board, if that person has the ability to pay, then he or she should pay more than those who do not have the ability to pay. I believe by putting a cap on that, you're putting everybody on the same level. Inadvertently, that is going to be picked up by the taxpayer. In all due respect, we are sometimes paying, as taxpayers, for something which that patient or resident could afford to pay themselves and probably would quite gladly do so in some cases. Not everybody is out there looking for a freebie.

Mrs O'Neill: You and others have brought that to our attention. I think it's something we should really look at.


Mr Noble Villeneuve (S-D-G & East Grenville): Thank you for a very succinct brief. Rural Ontario shoots from the shoulder, and sir, you shoot from the shoulder. That's kind of nice to hear. It's also nice to hear your comments that, more so in rural Ontario possibly than in urban Ontario, would people be willing to pay their fair share. You'll notice it in many instances, and I think you've touched on it to a degree.

The mix of residents in your two homes: Would they be 50% from your more or less urban areas and 50% from strictly rural, or what's the breakdown?

Mr Churchill: There are two distinct parties we are dealing with altogether. Pretty well, our home in Bancroft is rural, probably 95% to 100% rural. In Belleville, it's probably just the reverse: It's a city population we're dealing with; a few of them coming from close proximity to the city, but mostly Belleville, Trenton, in that catchment area.

One thing I may say is that I also sat seven years as vice-president of Ontario Housing for Hastings, Prince Edward, Belleville and different areas; Trenton, before it had its own. I found in that area too that we had people who were willing to pay. We always think people are out there for a free ride. There are a lot of people who aren't out there for a free ride. Most of the people in here today don't want a free ride. I found, from my experience in that sector, that a lot of people are willing to pay, quite willing to pay, to get into that atmosphere of living that those homes provided for them: an atmosphere of community with people of their own age and limitations, and also their own expectations. Yes, I think we have people out there who would be willing to pay a higher share to be in those homes.

Mr Villeneuve: You want more autonomy, then, I gather, on the caps; you may be looking after residents who are heavier care than in some areas, and you would like to see some flexibility on those caps. Could you comment just a bit on that?

Mr Churchill: I would like to see that flexibility. Yes, we're looking at different levels of care. We're even looking at different levels of care in, let's say, our home in Bancroft compared to Belleville. It is a tendency, we have found anyway, for our residents in the rural area to keep their loved ones in their homes for a longer time than those who are in the more affluent society.

Mr Villeneuve: And you would have Meals on Wheels and services.

Mr Churchill: We do have, yes.

Mr Villeneuve: One final question: inspections. You touched on it. Yesterday in Ottawa we were told by the regional municipality of Ottawa-Carleton that it was going to be increasing bureaucracy, with Bill 101, at the expense of beds. I hope that's not the case, but inspections, yes. Coming from rural southeastern Ontario, we've had some nightmares with certain homes for the aged which were not up to scratch, and thank goodness for people who cared; hopefully, the situation was corrected.

But the inspection system leaves a great deal to be desired. I'll cite you an example. In the riding I represent, not too long ago, warm fresh cheese curds were considered, by the so-called inspectors, to be bad for your health. I spoke to the Minister of Health, I spoke to the Minister of Agriculture and Food, and they agreed that was all wrong, but it was out of their hands. Sometimes the bureaucracy gets going and it's very difficult to control once they have their hands on the so-called levers of power.

I'm looking for a little more guidance from people like yourself as to what that inspection service should be. To me, that's a very important aspect of Bill 101.

Mr Churchill: Probably Rob will comment after me; he is more qualified to comment on that. In the private business world, in terms of health and food regulations and stuff -- I've always been in the food industry, one end of it or another, and what I have seen is not a uniform enforcing of policy right across the province. In fact, different inspectors come in from Health and the different food departments, and there isn't the same level of verification done by those people. I don't know where it breaks down. I know they're all operating from the same mandate put out by the ministry which they represent, but they close their eyes to one situation in one locale and try to enforce it in another locale.

I have found over the years that sometimes, if you tell these guys to bugger off and give them a hard time, they quite often do; not always. The governments haven't changed this procedure, I've found, in 20 or 30 years of doing that. I usually try and work with them, because, number one, I've been a firm believer -- in fact, my established business that I have had for 20 years, for a number of years was never inspected by Health or Agriculture and Food. I went to Health and said, "I want my premises inspected." I would like to know that I am running a good, clean operation, within the guidelines set out. Somewhere, I feel, the process breaks down in the uniformity of what it was intended to be. I can't answer that for you.

Mr Rob McLaughlin: I'd like to thank Mr Churchill for placing that tremendous weight on my shoulders at the beginning of having to answer questions and then very adeptly removing that weight from me.

Mr Villeneuve, I couldn't agree with you more. There are some dangers in self-policing, if we can use that as opposed to inspections. "Inspections" is a bad term; "self-policing" probably is too. There are some dangers in that.

Over the course of the years, there have been horror stories in long-term care, no question. I think those horror stories have been dealt with, in whatever fashion. There are mechanisms currently in place under two different pieces of legislation to deal with that.

I see some kind of marriage taking place there, yes, that will work. Hopefully, it will not be -- as Mr Gibson alluded to this morning -- the old regime of the inspection branch, where one was under the thumb and you walked in total fear of these people. I see whatever structure is formulated as being a collaborative effort on behalf of us, the providers, and the people who are doing the "inspection" or standards enforcement; holding hands and coming to a successful conclusion that's going to benefit the people we serve. If we can achieve that, it will be wonderful.

Mr Villeneuve: It will be in the regulations. Of course, that's out of the hands of the politicians, and sometimes those regulations make us pretty nervous. Thank you very much.

Mr McLaughlin: But being a civil servant, sir, who does normally set those, I have to trust them.

Mr Churchill: Hopefully, I think we'll be getting more in line doing that. At my own grocery operations, I've always told my staff: "Don't expect the customer to buy anything that your mother wouldn't buy. Make sure it's first-class." I think too that if we, as care givers in all the facilities we have, would bear that in mind, regardless of whatever bureaucracy level we may be at -- don't institutionalize it so much that you take the human kindness out of it. Also, don't expect to put people into an institution that you would not live in yourself.

Ms Carter: Thank you for your presentation. I'd like to raise the question of placement coordination, which you raise in your brief. If there's a problem with Bill 101, I think it's partly that it leaves a lot out, and, as you just mentioned, some of that will be made up in the regulations. But there tends to be an assumption that this new placement coordination will not allow choice, and I want to say that that is not the case, that it's very much intended that the consumer's choice will be the main consideration in where a person is going to go. We've had a lot of presentations from homes with ethnic or religious or whatever different backgrounds who were afraid they would not get the consumers who corresponded to their specialty. From what I understand, that will not be the case.

We have in fact heard from placement coordinators in our hearings -- we had a lady in Ottawa last night -- and it seems to work very well. We've also had presenters who say that there is already placement coordination in their areas and that they're very happy indeed with it. We have asked some of these coordinators whether they see their function changing as Bill 101 comes into force, and they don't see any reason why that would be the case. So I think that although concerns over this are very legitimate, as far as I can see, that is going to work well.

We have the VON following you, and we heard from some VON presenters in other areas who are involved in this function, and --

Mr Churchill: I think it has a function, Jenny, to carry out. In different homes or institutions or whatever care facility you have -- in our present situation, the one I can speak conversantly about, which I am connected with, I think we see that job being done. I don't have any great misgivings about that coordinator. I think that in all aspects of the life we're living today, there's some kind of coordinator somewhere pushing the button saying when we do and don't. The only thing is that I also see the coordinator as a person who knows which side his or her bread is buttered on. Sometimes their actions and the responsibilities they carry out can be influenced one way or another. I suppose that's a wrong statement to make when I, as the reeve of my village, also get calls that say, "Can you quicken up the process? My father wants to get in there," or something. I guess the same pressures are put on the municipal politicians that the coordinator would have.

Ms Carter: Well, as a member of provincial parliament --

Mr Churchill: And you certainly deal with that all the time. I want to see you before I go. I have a couple of things I want to talk to you about.

Mr Villeneuve: You came to the right place.

The Acting Chair: I want to thank you for coming before this committee. You have brought to our attention something new, so we thank you for that. We wish you good luck.

Mr Churchill: I thank you and I wish you well.



The Acting Chair: Would the representatives of the Victorian Order of Nurses, Eastern Lake Ontario branch, please come forward? Oh, with several other branches, I guess. Would you identify yourself, please, sir?

Dr William L. Gekoski: Thank you for the opportunity to make this presentation. My name is Bill Gekoski. I'm the president of the board of directors of the Eastern Lake Ontario branch of the Victorian Order of Nurses. I'm here today, however, representing not only my own branch but four other branches in southeastern Ontario. If you look on page 2 of the briefing paper we've presented, I'd like to introduce my colleagues from the other branches. Perhaps they would be in a better position than I to answer some of the questions you may have.

The Acting Chair: They're most welcome to come to the table.

Dr Gekoski: We've got our group all here. From my own branch, in addition to me, we have our executive director, Ivan Ip; from the Quinte branch, Mary Lou Workman, president of the board of directors, and June Rickard, executive director of the branch; from Brockville, Leeds and Grenville branch, Judy Roth, president, Kathy Robertson, vice-president, and Joan Bennett, executive director; from the Lanark branch, Gary Rice, the president, is unable to be here, but Karen Thorington, the executive director, is here; and from Peterborough, Victoria and Haliburton branch, Dawn Straka, the president, is here, and Lyn Linton, the executive director, is unable to be here.

The Acting Chair: Welcome to you all. I see a few familiar faces.

Dr Gekoski: I'd like to begin with a brief statement of background information about the VON and then proceed to our position on Bill 101.

The VON was established in 1897 as a non-profit, charitable organization to provide professional and caring nursing services in the community. Initially comprised of only six branches, one of the original ones being located here in Kingston, the VON now has 73 branches across our country. The 33 branches in Ontario provide services available to over 90% of the residents of this province.

Although best known for our visiting nursing services, our various branches offer a total of over 45 different programs, ranging from Meals on Wheels to adult day programs to homemaking to placement coordination service, to a wide variety of specialized nursing services such as cycler dialysis, enterostomal therapy, intravenous therapy and so on.

New programs are generally developed locally, provincial and national standards are developed, and then new programs are made available to our other branches. VON branches are very much locally based, with active volunteer boards that spend countless hours engaged in trying to establish community needs and develop programs to meet these, often in partnership with other community organizations or with government.

I'd like to begin our comments regarding Bill 101 with some general statements and then proceed to focus on some specific points. The overarching position of the VON on the issue of long-term care reform to which Bill 101 is intimately related is that consumers requiring long-term care services to promote their health and wellbeing should have a choice of needed services delivered in their preferred location by their preferred provider within available resources.

Basic to this position is the need to deal with provision of facility-based and community-based services in an integrated manner. From this standpoint, although the VON finds much that it can support in Bill 101, we also find much that is lacking. Because VON sees the shortcomings of Bill 101 as substantial, we urge the government to postpone acting on this bill until after the release of the long-term care reform policy document, which -- I say this perhaps with tongue in cheek -- we are led to believe is imminent.

Let us develop our position more fully. We see the changes incorporated in Bill 101 as incremental and not sufficiently comprehensive to appropriately empower the consumer. The bill provides for a number of improvements in service and service delivery which VON applauds, allowing for direct funding grants for the physically challenged, beginning the process of standardization of legislation for long-term care facilities, ensuring consumer access to key information regarding facility services, care and accommodation, ensuring a consumer's knowledge of his or her own care plan and allowing for an appeal process regarding eligibility for service.

However, to fully develop these incremental improvements, the bill should, at minimum, specify similar requirements for chronic care beds and should provide a requirement for residents' councils in all long-term care facilities.

That the government is prepared to proceed with Bill 101 before the long-term care reform policy paper is even released suggests that, despite protestation to the contrary, it remains more interested in institutional care than in developing health promotion and community care options and integrating them with institutional care so as to generate a comprehensive approach to long-term care. Given that the resources allocated to the institutional sector dramatically outweigh those allocated to the community sector, the government's insistence in proceeding with Bill 101 independently of the policy framework for long-term care reform clearly results in the reinforcing of the institutional bias.

I'd like to make some remarks about fiscal accountability. In addition to our concern that the timing of the tabling of Bill 101 implies a continuing emphasis on the institutional care sector, the VON is also seriously concerned that one of the results of the provisions of Bill 101 is the promotion of an approach to fiscal accountability that emphasizes control of resource utilization in the absence of any attempt to measure resource outcome.

Examples in the legislation include, one, controlling the number and type of beds, as well as the associated costs, rather than evaluating the benefit of the facility versus the other care options from a systemic and a consumer perspective. A second example involves promoting a regulatory control model rather than a quality management model. A third example involves failing to consider alternate quality control models such as accreditation. A fourth example involves failing to promote comparability by requiring standardization of data collection with the facility system and across the health care system for evaluation purposes.

If I may turn to planning, the VON is concerned that, by moving ahead on legislation related to facilities independent of the long-term care reform policy framework and prior to local DHC planning input, the government is not following its own direction to develop a strategic, policy-based approach, which is grounded in widespread consultation, to the health care system. Bill 101 allows the government to designate the number of beds, to require certain types and capacities 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.

It is for these reasons that the VON urges that the legislation be deferred until the long-term care reform policy framework is released and debated and the DHCs' planning for long-term care can occur and be referenced with respect to the designation of numbers and types of facility beds.

Resource allocation: Bill 101 appears to ensure the continuation of centralized funding of extended care beds, as there seems to be no reference to chronic care beds and to the separate funding of these beds. The VON strongly urges that the government move away from a policy of centralized, fragmented funding to a policy of district funding authorities which receive a long-term care envelope to be deployed so as to support community-based, in-home services and facility service provision. It is our view that only when such a comprehensive district envelope funding approach is developed will we achieve a significant redirection in long-term care from institutional care to community-based care, and only then will we see the development of flexible, cost-effective services reflecting community need and priorities.

The VON recognizes that the current funding model of per diem funding is a disincentive to caring for residents with complex needs and intensive resource requirements. At a time when the government is considering the need for flexible funding and flexible service delivery models, we argue that it should consider the possibility of multiple funding options for long-term care facility beds.


We submit that the development of comprehensive multiservice agencies by the VON and by other community agencies funded by capitation may significantly reduce the bed requirements by providing more comprehensive and potentially more cost-effective options in the home. Before facility services are expanded, other community-based services should be considered. By having a locally administered funding envelope, greater flexibility can be achieved.

In addition, utilization of community-based services, such as speciality nursing consultation teams, delivered in facilities should be considered as part of the funding option. For example, a VON -- or other service provider, for that matter -- infusion therapy team could provide such services in long-term care facilities where such procedures are not required frequently enough to justify the cost of providing this higher level of care on an in-house basis and where the alternative is transfer of residents to a bed designated at a higher and therefore more costly level of care.

The VON also supports the need for a provincial role in long-term care facility planning to ensure the development of provincial standards and requirements for care programs and for assessing community planning decisions.

Placement coordination: The VON is also concerned about how the changes embodied in Bill 101 will affect placement coordination services. Although none of the five branches present here today administer a placement coordination service, this service is administered by eight of our branches elsewhere in the province. We are concerned that, under the provisions of Bill 101, the placement coordinator will have virtually unilateral decision-making power as to placement, where clients may only appeal after the fact.

Given that consumer choice is a key element of VON's position regarding long-term care reform, we find the provisions of Bill 101 regarding placement coordination to be unsatisfactory. We believe it is essential that this service reside in a multiservice environment and not in a long-term care facility, where even the appearance of objectivity and of freedom from possible conflict of interest will be difficult to achieve. The VON urges the government to consider placement coordination in the larger context of the long-term care reform policy framework.

Devolution: We in the VON are committed to the principles of continuity of care, consumer choice and seamless access to services within the available resources. We feel that these objective are most likely to be attained in a context where funding envelopes are provided to district planning authorities and where the planning authority is responsible for all long-term care, facility and community based.

The reason that we are so strongly committed to such an approach is that we believe in the grass-roots approach that communities, when provided with the relevant information, are in the best position to determine their own needs and achieve their objectives within the available resources. If one looks at the history of the VON, our position is easily explicable. This is essentially how we have operated so successfully over the years. We have always counted on local volunteer boards to assess community needs, develop programs to meet these needs and find ways to fund these programs. The local approach has worked for us and has resulted in VON branches each of which has a somewhat different set of programs developed to meet unmet community needs and has resulted in a very large and varied set of programs when the province as a whole is considered.

Let's look at VON's local variability. Each of the five branches represented here today has developed new and innovative programs to meet the needs of its community. My own branch, Eastern Lake Ontario, developed, in partnership with the local Alzheimer society and the Ministry of Community and Social Services, the Kingston community Alzheimer respite and enrichment program, known as the CARE program, to provide respite to care givers of Alzheimer victims and to provide stimulation and enrichment to the victim himself. Established through a vast expenditure of volunteer hours, the program has been extremely successful in meeting important needs. It has also served as a model for similar CARE programs in our Quinte branch, Simcoe branch, elsewhere in this province and in at least one out-of-province branch.

In the Quinte Branch, health maintenance clinics have been established to foster health promotion and to bring services out into the community to individuals who might not otherwise access such services. The Lanark branch, in participation with the Almonte General Hospital, has developed a diabetic education program, another more specific form of a health maintenance and promotion service.

In the Brockville, Leeds and Grenville branch, a very successful home support program has been developed that provides, via a single phone call, access to a whole set of services which assist people in remaining in their own homes: Meals on Wheels, volunteer visiting, home maintenance assistance, income tax assistance, medical transportation, telephone reassurance and other services as well.

In the Peterborough, Victoria and Haliburton branch, an incontinence management program has been developed to help people cope with one of the major problems that often makes it difficult for people to remain in their own homes. The Peterborough branch is also currently involved in developing a very exciting supportive housing program that, among other things, would house the VON branch office directly in the supportive housing facility.

This is just a very small sampling of how, and how effectively, local branches of the VON have operated to assess what is needed in their communities and to do what needs to be done to meet these needs. We have no doubt that a devolved approach to funding will facilitate development by the VON, and by other agencies and organizations, of those services that communities need and can afford. Each community is different, has different needs and has its own set of existing agencies and services. To not capitalize on the richness, diversity and commitment at the local level would seem foolish.

Let me end by noting that the government is talking about creating multiservice agencies. Each VON branch already is a multiservice agency. Let VON branches and other multiservice agencies, existing ones and newly formed ones, continue to work together at the local level by creating district funding envelopes and by combining in these envelopes funds for community based and facility services. We are convinced that such an approach will allow for each community to make whatever tradeoffs it deems best in order to achieve high quality services, continuity of care, consumer choice and seamless access to services within the resources available.

On behalf of the five branches of the VON in southeastern Ontario, thank you for letting us address the committee. Profiles of each of the five branches are included with this brief. These profiles suggest to you the activities, volume, character and so on of each branch, as well as providing you with some idea of the breadth and depth of talent and commitment of those individuals who work as volunteers on our local boards of directors. Representatives of all five branches are, as I said, here and available to answer any questions you may have about our position on Bill 101 or any of the programs or activities of the specific branches.

The Acting Chair: Thank you very much. We have had several of the branches appear before us.

Dr Gekoski: Yes, I realize that.

The Acting Chair: But it is really good to have you here. I'll begin the questioning with Mr Villeneuve.

Mr Villeneuve: Dr Gekoski, thank you very much for outlining what you've done. I think the VON and many other organizations, similar care providers, do it in a very quiet and a very efficient way. In your second to last paragraph you say, "Let VON branches and other multiservice agencies continue to work together." Do you see some interference, directly or indirectly, in Bill 101?

Dr Gekoski: No, in all fairness, not directly in Bill 101, but of course we're still so uncertain about the details of the long-term care reform policy framework and the discussion as to whether there will be a single comprehensive multiservice agency or an umbrella with subgroups and so on. We don't know, but of course we are in favour ultimately of a position that allows the groups that already are doing it to continue doing it and that does not try to reinvent the wheel and overbureaucratize the system.

Mr Villeneuve: I know your areas cover large portions of rural eastern Ontario as well as whatever urban areas are in eastern Ontario.

Dr Gekoski: Yes, we do.

Mr Villeneuve: Fiscal accountability, and I see you've put that kind of as number 1, is of great concern; as we know, governments at all levels have not got that many dollars. In the four items that you put in there, you touch on controlling the number and types of beds as well as associated costs.

Regarding autonomy, we would certainly like to see the autonomy stay with the local organizations that know best, without any shadow of a doubt. But where you say in your number 2, "promoting a regulatory control model rather than a quality management model" is of great concern to me. Quality should be number 1; caring people looking after people who need care is what it's all about.

The bureaucracy will be taking over. We were told, as I mentioned to the previous people that made a presentation, that Ottawa-Carleton foresees bureaucracy taking over the money that maybe could be used for beds. Do you see some of that here? You've itemized this, so maybe you could refine that a little bit.

Dr Gekoski: Surely. I guess our concern in part is that we think that quality management is essential and that obviously the government has to be assured that all facilities and all community based organizations have a mechanism for quality management. That doesn't mean the mechanism has to come down from the top and be the same everywhere. I think that's the concern some of our people have, that it's simply going to be dictated down from the top and not be flexible to the kinds of different situations that exist in different localities and in different institutions.


After all, I think the assumption is that the majority of institutions and community organizations are already doing a good job. Sure, there are some that aren't and we have to look after that as a society, but the notion of a single quality control mechanism across the whole province doesn't seem to us to be reasonable.

Mr Villeneuve: It boils down to autonomy and you covered it well by saying the local people know what the needs are and they find ways of funding them.

Dr Gekoski: That's right.

Mr Villeneuve: Let's try and leave as much of that in place as we can.

Dr Gekoski: Exactly. I gave you the example in Brockville of the home support program. That kind of a program isn't needed in Kingston. The Senior Citizens Council in Kingston has done a wonderful job with that set of needs. Every community is different, and certainly the legislation has to allow for individual differences across communities.

Mr Villeneuve: You've made your point well, doctor. Thank you.

Mr White: Thank you, Dr Gekoski. I wanted to pick up on a couple of points: first, in terms of the placement coordination services. As you're probably aware, in many of the areas where they're in existence in the province they are either informed, directed or directly involved with the VON, and the VON is very clearly the leading agency throughout our province in placement coordination services.

Where you make reference to the facility base, frankly, you read the legislation -- it looks as if somehow that placement coordination service is directly sited in that institution, but in fact it's a community-based service, the services we have presently. Of course, those services will be the ones that will undoubtedly be funded.

Would you be in favour of having that mechanism, that community-based information, that multiservice or multidisciplinary committee that informs the PCS, included in the regulations so it's really clear that's the direction of the province?

Dr Gekoski: If I understand the question correctly, and this is not an area I personally have a lot of experience with, because in our own area we don't have the placement coordination service, I would think it needs to be covered in both the legislation in front of us today as well as in the legislation that will follow from the long-term care reform policy statement. We believe it should stay in the community and not be based in the facilities. Maybe we've misread the legislation there, but that was our sense.

Let me just ask if -- June Rickard, the executive director from the Quinte branch, I think she's perhaps better informed than I am on this particular issue. June?

Mrs June Rickard: I think the comment --

Mr White: You have to sit closer to the microphone.

The Acting Chair: Just come up to the desk and identify yourself.

Mrs Rickard: I'm June Rickard. I'm executive director of the Quinte branch, based in Trenton. I think our comment in the paper arose from our desire to see that objectivity maintained. Most of the placement coordination services, as you just indicated, are presently community based and we're very concerned that they remain there.

Mr White: Absolutely.

Mrs Rickard: I see this as being a key role -- and if we can avoid the conflict of interest that would arise if in fact they moved into the facility, whether it be hospital, nursing home or whatever.

Mr White: Sure, and you'd be in favour of that direction being in the regulation.

The Acting Chair: Excuse me, Mr White. Would you permit the parliamentary assistant to just clarify that. He's asked to --

Mr White: I'm wondering if I could pose my next question before that clarification.

The Acting Chair: All right, if you can do it quickly, because we are close to the time.

Mr White: Absolutely. The issue you bring up about the institutional side being addressed first -- I'm wondering, in terms of the next long-term care legislation, there are presently barriers to interaction with the institutional facilities. You bring up the issue of providing services to institutions that are not capable of providing in-house. So you'd also be in favour with that next piece of legislation of ensuring that those services are available to people wherever they are in the community, including in an institution.

Dr Gekoski: Yes, and within each community let the relevant facilities and organizations work out best how to do it, rather than trying to work out a formula in Toronto that then would be applied across the province.

Mr White: Thank you.

Mr Wessenger: If I just might clarify, existing placement coordination agencies will continue to perform that function, and in the long-term, of course, there's the whole planning process under the district health councils, which will deal with such questions as the nature of all these service agencies and so forth. I assume that, as you say, as we have this flexibility and difference throughout the province as different communities have different needs, I'm sure local district health councils will come up with differences as well, in their recommendations.

Dr Gekoski: Our plea, though, is that the facility based and the community based be dealt with in the same envelope. That's our bottom line in terms of --

Mr Wessenger: I can assure you, the placement coordination aspect -- it obviously has to explore both the community based and the facility based and it has to deal with both. I think it's even in our legislation now in the fact that it requires it explore the community-based options.

Dr Gekoski: Thank you for that clarification. I appreciate that.

Mrs Caplan: I think one of the problems we've seen with this legislation is that so much of it is left to regulation, which avoids the opportunity for participation and scrutiny. Once the legislation is in place, the process for establishing regulation is internal to government and often is even lacking in the kind of opportunity for discussion and consultation that -- other than legislative committee hearing takes.

So we've heard from a number of deputants the concern they have that there's not enough explicit in the legislation that will clarify what's going to happen by regulation. We are encouraging the government to consider some amendments and put into the legislation some of those things the parliamentary assistant has assured us will be dealt with by regulation.

I want to thank you. Your brief is very comprehensive. We have heard from a number of VON organizations across the province. We're very aware of the good work that is done, but one of the debates we've been having at this committee has been -- and Mr Villeneuve referred to it as well -- the concept of the regulatory model versus the quality management model and the outmoded, outdated, big-stick inspection input, or after-the-fact attempt at quality control rather than a -- I'm not sure that "newfangled" was the word Mr Owens used earlier --

Mr Owens: No.

Mrs Caplan: Well, it was something like that.

Mr Owens: That's clearly your word.

Mrs Caplan: No. The word I have been using is --

The Acting Chair: I know there's going to be a question here for the presenter.

Mrs Caplan: That's right -- a more modern approach to outcome measure, which would include an appropriate place for accreditation.

I'd like you to take a few minutes and tell us why you believe it's a better way and how this legislation could be changed to bring about a more quality-management-focused approach and an outcome, results-oriented, positive accountability model. Really, I'm asking you to help convince the government that is the right way to go.

Dr Gekoski: Right, okay. I appreciate the intent of your question and I'll try to make my response brief because it's a big question. Especially as a researcher in gerontology, I don't usually answer questions like this in two minutes, but I think there are some comments I can make that are brief.

The Acting Chair: Please give it your old college try.


Dr Gekoski: Right. I think it is important to allow quality management frameworks to develop in specific settings, and not to impose one from the top. At the same time -- and this is in our brief -- obviously the provincial government has the ultimate responsibility for quality, so there has to be some mechanism to make sure that a quality management approach is undertaken in each district, in each facility and for each community-based organization.

The forms quality management can take could be very different. I appreciate the concerns that have been raised this morning regarding inspection and the kind of climate that can create. Perhaps one solution is to have some kind of an "inspection" -- and I use that word in quotes advisedly -- of a local level through a part of the DHC rather than doing it from far away, but it would still --

Mrs Caplan: Peer review?

Dr Gekoski: Peer review -- that's fine. We're used to that in the academic world and I think it works very well. There still have to be, of course, provincial guidelines, though, as a bottom line, to guarantee that there are in place appropriate quality management techniques.

Mrs Caplan: Would you be comfortable --

The Acting Chair: No, I'm sorry, I just have to go on. I do thank you very much. I hate to be the heavy. I know there are many things we could discuss, but we're getting a little behind.

Dr Gekoski: No, I appreciate that. We all learn from each other's presentations. Thank you.

The Acting Chair: Thank you very much.


The Acting Chair: Would the next group, Para-Med Health Services, from Kingston, please come forward and make yourselves comfortable at the table.

Glad to have you here this afternoon before us. Would you please identify yourselves for Hansard record and then make your presentation.

Ms Vicki Johnston: I'm Vicki Johnston. I'm the area manager for Para-Med Health Services in Kingston.

Ms Janet Szczukocki: I'm Janet Szczukocki, the manager for Comcare (Canada) Ltd in Kingston.

Ms Johnston: Thank you for the opportunity to participate in these presentations regarding Bill 101 today. Janet and I are members of the Ontario Home Health Care Providers' Association, which represents most of the private home care agencies in Ontario.

Karen Gill, who is the manager of All-Care Health Services, can't be with us today. However, we represent the three Kingston private agencies and we work closely together and share a common commitment for training and education as the key to quality service provision to our clients.

Although Bill 101 principally deals with health care in facilities, it will help determine many long-term care direction initiatives. It appears that this bill is the only legislation required to implement long-term care redirection. From the private agency perspective we are participating, as this may be our only opportunity to speak in favour of private sector participation.

We have closely followed the government's long-term care redirection. The central thrust in the redirection is to help people stay in their homes longer through expanded community-based health care rather than to be cared for in a health care facility. We strongly support such a direction where community care is an appropriate choice. Our experience has shown us how people benefit from care at home for as long as possible. This thrust is confirmed in the draft legislation of Bill 101. Bill 101 would ensure equitable access to long-term care facilities through placement coordination only after all options for community care have been exhausted.

This direction is based on the premise that there will be more care available in the community, but there are as yet no plans or funding in place to expand community-based care to the extent that would be necessary to make home care available as a true alternative to facility care. In fact, we think the committee should take note that while government has declared its aim to expand community-based care, the Minister of Health has considered severely limiting -- virtually eliminating -- private agencies who provide about 45% of home care services.

If the government wanted to enforce a public sector preference by directing all new business to public sector agencies, no legislation or regulation would be needed to force our members out of publicly funded home care; it could be done simply by not giving us any more business. Of course, this could force many of our member companies into failure and bankruptcy.

It is extremely important to note that in Kingston alone our agencies provide service to approximately 1,000 clients. We employ approximately 700 health and support service workers in this community; that is, Kingston. Almost all of them are women. Many are visible minorities and about half of our employees work part-time in order to take advantage of flexible schedules to fit their families' needs. In Kingston and other areas, most of management are women, and in some cases entrepreneurial women are owners.

The impact of forcing private agencies into failure should be clear. It would result in job loss at a time of high unemployment, job loss for those who can least afford it. Although some of the private agency workers will find jobs with public agencies, there will be jobs lost and considerable job disruption.

There will be loss of choice for consumers. Having a choice between different types of service providers is important. It is just as important as having a choice in physician or hospital care.

There will be a loss of flexibility. Private agencies have developed in response to the need for 24-hour service, seven days a week. They have developed in response to the need for service provision in geographically isolated areas and the need for no minimum limit on service. Finally, private agencies have developed in response to the need for specialized service.

In Kingston, private agencies provide specialized service in IV therapy, ventilator care and head injury. There is evidence that deprivatization will result in a rigid bureaucratic system. In Manitoba, the provincial government is moving away from a totally public system because it has become inflexible and too costly.

Forcing private sector agencies into closure will mean increased cost to taxpayers, since the deficits of public sector agencies have historically been covered by the provincial government. It is important to recognize that government home care programs purchase home support services from both the private and public sectors for the same cost. The cost of purchasing other services from the private sector is often less than purchasing from the public sector. When private sector agencies provide exactly the same services with comparable quality to the public sector without deficit financing, it can only equal efficiency.

We believe that ownership of agencies should not be the criterion for selection of those who will provide service in the future. We believe that accountability for service -- a combination of quality, cost and availability -- should be the criterion for service delivery. We support the development of province-wide standards and accreditation procedures for all agencies participating in an integrated long-term care system.

With regard to standards, there is another section of Bill 101 on which we wish to comment. An amendment would allow the Ministry of Community and Social Services to provide payments directly to disabled persons who wish to self-manage their funding and attendant services. We recognize the change is aimed at assisting adults with disabilities to realize their ambition to live as independently as possible, and we applaud that ambition. The disabled person self-managing his or her own care should, however, receive care which meets provincial standards, and the province should know that its money is being used effectively. Workers who provide that care should be protected against loss of benefits like workers' compensation, unemployment insurance and Canada pension. Workers should continue to receive ongoing professional training as if they were working for public or private agencies. Clients like ventilator-dependent quadriplegics should know their care givers have the most up-to-date training possible. We urge the committee to recommend that the framework for self-managed care include safeguards for both clients and workers.

We have consulted as many people as possible involved in policy development to try to understand why the government would want to limit our participation in publicly funded home care. A recent letter from Premier Bob Rae to our field staff confirmed this direction. The Premier said, "Nothing that we heard during the consultation indicated that we should change this direction" -- that is, a continued preference for not-for-profit services. He continues, "We are now looking at how not-for-profit services can be put into place." Yet clients, particularly home care programs, have publicly expressed their support and desire for a pluralistic system. They have provided evidence to the Minister of Health of why a future long-term care system will require a balance of public and private sector agencies.


In conclusion, we urge the standing committee and the provincial government to look at Bill 101 in the total context of long-term care redirection. You must consider how implementation of Bill 101 will affect other aspects of long-term care redirection, specifically home care. We strongly recommend that a balanced system between public and private home care providers continue to exist for the benefit of the client.

The Acting Chair: Thank you very much for your presentation. It is the government's turn to go first. Mr White.

Mr White: Thank you very much for your presentation. I think you've articulated some very strong concerns. You are also aware, though, that this piece of legislation deals primarily with the institutional care and with the many homes and facilities that have been operated under different pieces of legislation from time gone past. In fact, privately owned nursing homes for the most part are very supportive of the legislation because it puts them on a much more equal footing with the not-for-profit services. In this regard, in this perspective, the issue of not-for-profit and for-profit is brought together in this legislation. Are you afraid that with the placement coordination services being operated by non-profit services, that might affect your nursing services?

Ms Johnston: No, not at all. In fact, in Kingston we already have a system where we have a placement coordination service that's operated out of home care. I don't see that that will implicate us in any way. I guess our reason for commenting at this time is simply, again, because the legislation does not have a lot of clear direction. I think I heard Elinor Caplan mention that it's not very explicit. And we don't want to miss the opportunity to comment on the fact that we feel there should be a balanced system in the community and that there are implications in terms of community care. It seems a bit disjointed, I guess. If you are going to look at facility care and changes in facility care, it's hard to imagine how you can do that without looking at community care as well.

Mr White: How has your business gone in Kingston? I know that in many areas of the province, private nursing services have really done exceptionally well in the last 5 to 10 years. What has your experience been like here in Kingston?

Ms Johnston: We have been in Kingston for 13 years and certainly we have seen some changes over the years. I think in Kingston the private sector would probably have about 45% of the share of public funding through home care, and certainly we have experienced growth.

Mr White: So you've experienced continual growth over the last number of years.

Ms Johnston: Yes, and that, I think, is because we have been responsive to the needs in the community, as other agencies have as well.

Mrs O'Neill: I don't think you should say with any hesitation that you've experienced growth. I think that it speaks for itself that you must be providing the service, that you must be providing it in the way the community wishes it, and in a cost-effective manner, or your business wouldn't be growing. That's what I have difficulty with. We have had a lot of people in your same circumstance present to us. Last night the group in Ottawa said that members of the government were suggesting they were shooting at shadows. I tend to have my thoughts more in your court. I don't think you're shooting at shadows.

Can you tell me how you were notified, or was it just through that Premier's letter, that there is a preference for non-profit that seems to be taking a new profile?

Ms Johnston: I think that when we read Frances Lankin's announcement, there is clearly a statement in the announcement that indicates that there will be a continued preference for not-for-profit. In fact, in one of the announcement copies that we have, it says they will only utilize not-for-profit in their long-term care redirection. We became alarmed at those types of statements and started to write letters to the Premier and since that time have received that kind of letter back from him.

Mrs O'Neill: Have you noticed any changes in your dealings with the municipalities in this area regarding the picking up of new clients, or is everything just about the same in this area?

Ms Szczukocki: I find that it's basically the same. We haven't experienced a lot of change. We have had support in this community from our home care director, who has expressed the feeling that they are very happy with the choice they have because each service provider is able to provide their own unique services that maybe one other one doesn't. We're always keen on developing new services, and they are happy with that choice.

Mrs O'Neill: I am glad to hear that, because that's not the case in every municipality. I'm glad you brought forward to us the fears that you have regarding the hampering of flexibility, the costing fears you have of a new system. And I'm glad you brought forward the attendant care component of Bill 101, which arises, of course, from the direct funding. All of those things, I think, we have heard from other people. They've taken a new profile. I think in clause-by-clause we'll have to look at them.

Mr Villeneuve: Thank you very much, ladies, for your presentations. I've also had in my riding serious concerns expressed by the private sector care and service givers, and I think justifiably founded, as you've expressed in your brief.

You, I understand, are very close to 50% of the care and service givers of the Kingston area here. Would you be able to comment as to whether the so-called non-profit -- and that has a connotation to it that is not quite right and I compliment you for not using it in your brief except for quoting the Premier. I think we've got to get that straight.

In most instances, would the work that you're getting be the average, run-of-the-mill type service, or is it heavier service that seems to be sent in your direction with anticipation that you would provide that service, again, for no more and maybe less cost?

Ms Johnston: I think certainly there's a mix. We would definitely have our share of average, or whatever you would call it: older clients who may require general types of home support work and that sort of thing. But we also get much more difficult or complex cases. Also, say, in terms of head injury and different programs like that, where we would provide additional training and pick up the costs for that training, it's not uncommon for public sector to receive additional funding for their training. We tend to end up providing that sort of training and picking up the cost for that, as well as spending additional time, in the head injury program again, meeting with various occupational therapists and different other people involved in the program. Those types of costs are picked up by our company.

Mr Villeneuve: I think the clientele, the public out there, wants to have a choice. You people are providing service around the clock where in many instances the so-called not-for-profit, again using a cliché from the government, seems to have a little trouble getting people to work on those weekends when you people are called upon. Can you maybe comment on that one?

Ms Johnston: I think that they do, actually. I think in our community we're seeing an expanded role for VON and other not-for-profit agencies to meet that demand and to be more flexible, and I would say that we've seen a response to that need.

Mr Villeneuve: So it's been reasonably fair to this point. You're simply expressing your concerns and wanting them to be on the record. I thank you for that.

The Acting Chair: Thank you very much for coming forward this afternoon. We appreciate your taking the time to appear before us because we take into consideration everyone's concerns, and we thank you for coming.

Ms Johnston: Thank you.



The Acting Chair: The next person on the list is Ms Carla Horsten-Cerisano. Welcome to the committee this afternoon. You may begin.

Ms Carla Horsten-Cerisano: I am -- or was -- a mother of two handicapped boys afflicted with muscular dystrophy, Duchenne.

Last November, Frances Lankin, in her statement of November 26, stated:

"Finally, our fifth goal is to make direct payments to adults with disabilities so that they can purchase and manage their own services. This goal addresses the central importance to consumers of maximizing dignity, independence and control over their own lives."

It has come to my attention just recently that a pilot program is already established in Ottawa where terminally ill cancer patients have received up to $10,000 to manage their own services and that it is working very well.

The government advocates the central importance of independence for the handicapped adult but puts restrictions on its use as to from whom services can be purchased. Care giving services cannot be purchased from a parent or other relatives.

For 15 years I have cared for my two handicapped sons at home, watched over them and helped them manage their terminal illness, muscular dystrophy. As a single parent working full-time, I found it extremely hard financially to be able to give my sons the care and attention they needed and still need and the quality of life they deserve.

When we read that this bill will give the handicapped person freedom to purchase services, we were relieved that there was finally a chance for me to maybe give up my full-time job and care for both of them at home full-time. For the past year my son Christopher was completely bedridden and on oxygen, while Dino is wheelchair-bound and bedridden 24 hours, day and night. We found over the years that home care was not willing to give Christopher, and later Dino, the care and comfort they needed and only I, as a mother and care giver, was aware of this. It would have been a tremendous relief to be able financially to buy the services they both needed from different sources in the community.

Here are but a few samples of what we had to endure: When Christopher came out of the hospital and needed oxygen daily to help him with his breathing, he needed a hospital bed, which we received through home care for a few months. But one day I received a phone call that this service would be discontinued and we had to buy our own hospital beds, both for Dino and Christopher, at a cost of $1,900 of our own money.

Physiotherapy is crucial for a young person and for a young adult with muscular dystrophy to keep legs, arms and hips straight and the head flexible. We can only get one visit per week from home care. So many times I asked for at least two visits per week but was refused. I was told to do the passive exercises myself with Christopher and Dino, which I now do. I was told years ago by one of the physios, when Christopher was still straight, "It's no use doing exercises on Christopher because he'll never get better," and for years that service was discontinued. As a result, he could not straighten out his arms and legs and had excruciating pain in his back.

We asked home care to arrange proper seating at Kingston General Hospital for Christopher's wheelchair because he had pain and discomfort when sitting upright in his electric wheelchair. He was refused access to the seating clinic at KGH. We were told to go back to the person who had done the original seating in our home. Christopher refused because it was not done right in the first place, and this person operated out of St Mary's of the Lake Hospital.

As Christopher's health deteriorated and he begged me to quit my job and stay home with him, I tried every possible avenue to stay home. I tried to obtain mother's allowance, I tried welfare, I tried unemployment insurance, but I always stood before closed doors. I asked Attendant Outreach to send someone out in the evening or at night -- I am a night desk clerk at a hotel -- but not enough hours were available and the women do not work after 11 pm, I was told. I tried the Red Cross for help and was told they do not provide babysitters for nine hours at a time through home care but that we could purchase their services and pay the full rate per hour, which is more than I earn per hour.

Meanwhile Christopher asked more and more for me to stay home with him. It was agonizing for me to leave him and Dino every evening to go to work. He offered me his whole pension cheque, which I could not bring myself to take. I had to keep on working, hoping against all odds for him to be all right for the time I could not spend with him. I depended wholly on my son Ricardo's help in the evening to be with his brothers.

Christopher chose not to be placed on life support, a ventilator. Christopher died last December, at home, at the age of 25, when I was at work, and for the rest of my life I'll live with the pain and regret not to have had the chance to spend more time with him and to be with him when he needed me most.

Next month my son Dino, 18 years, has to have his back operation done in Ottawa, the Luque procedure, which can't be done here in Kingston. Already I feel the financial strain to provide the best possible care for him. He decided to give his own blood for his operation because of the AIDS scare. This can only be done in Ottawa at the Red Cross head office, so once a week for five weeks we have to make this trip to Ottawa and then we have to rent a van two times to transport his electric wheelchair to Ottawa for changes to be made there after the operation. All this will set me back at least $500, and I only earn a little more than minimum wage.

I've been told that it will not be possible for the handicapped person to buy the care services from his family, as family would misuse the funds. I cannot understand how the government can come to this conclusion. I urge the government not to restrict but to let us parents provide long-term care at home for our family members.

I mentioned before that a pilot project is already under way in Ottawa. I ask respectfully for this program to be extended to all families who are willing and able to provide long-term care at home at a fraction of the cost compared to what it would cost placing him in a long-term facility.

The Acting Chair: Thank you very much for coming here. I know this has been difficult for you, and I hope that you will agree to answer questions of the committee.

Ms Horsten-Cerisano: Yes.

The Acting Chair: I'll begin with Ms Caplan.

Mrs Caplan: It's so important for us on the committee to hear from families and from people who both require the care and are trying to keep loved ones at home. I think many of us have had different experiences, usually with our parents or in-laws and sometimes with children, in seeking out care and services. I think it's been important for the committee to hear from you the struggles you've had in trying to find appropriate care for your sons.

This particular piece of legislation deals primarily with institutions, with the one exception, and that is the option for direct funding, and I honestly don't know whether that direct funding as proposed here would solve your problems. I think you've been very, very articulate. I don't have any particular questions to ask you, except that obviously you're concerned that the direct funding would not serve to solve the problems your son has experienced.

Ms Horsten-Cerisano: Well, I think it would, because then I could stay home and look after Dino now full-time instead of going out to work full-time.

Mrs Caplan: So you believe that, as proposed, the option in this bill that would allow for direct funding would help your son to buy the services in the community?

Ms Horsten-Cerisano: Yes, definitely. He could look at different companies.

Mrs Caplan: I'm glad you've explained that. We've heard from many people who've said that they think it will help. Right now it can be provided by order in council, and my question is, do you have anybody you're working with at Community and Social Services to try and help until this legislation comes into place?


Ms Horsten-Cerisano: I approached them once and they said there's no money available for that kind of thing, just lately, four weeks ago, just before Christopher died, and after that too. They don't give much information out, in Kingston anyway.

Mrs Caplan: Let me ask the parliamentary assistant if there's any advice he could give to this family. I know the parliamentary assistant for Comsoc is here.

Ms Horsten-Cerisano: It's not just my family. There's many. There are about five families in Kingston with children with muscular dystrophy.

The Acting Chair: Mr Hope, would you have anything to say on that?

Mr Hope: Because we're dealing with a particular case, it's very hard for me. I read this before your presentation. I took one of the staff and we went outside to have a conversation and I am looking for detailed information about what went on around this. I don't have any specific answers for you.

We're hoping the changes in the act will provide that, but I still question, the same as what Elinor just questioned, why wasn't somebody pursuing an order in council for direct services and the services to be there? There's a lot of unanswered questions that I have, and I can only assure you that we'll look into what you've brought here in this paper and we'll investigate what all has happened around this case in particular. That will be strictly between yourselves and us, the conversation. That's not really for public information. That's between the client, yourself as an acting partner of the client, and the government, to make sure what happened around this particular case.

There's just a lot of unanswered questions I had, and I've already stood up and tried to get some of them answered, but as soon as I get more answers about the specifics of this, I'll definitely make sure we get in contact with you.

Ms Horsten-Cerisano: Will you keep in contact with us?

Mr Hope: Yes. I have your phone number. Everything on the bottom is appropriate?

Ms Horsten-Cerisano: Yes. Now, these services: Does that include purchase of equipment, or is it just for services?

Mr Hope: That's why I need to take a whole investigation and look at what all has been done around this particular case, talk to the case manager who's been dealing with it and find out particulars about what all's going on. There's a lot of unanswered questions here that I have in my head. The order in council is one that's really an unanswered question.

Mrs Caplan: It may be possible, but you'll have to work with them and find out.

The Acting Chair: Mr Villeneuve.

Mr Villeneuve: My questions will be brief, simply to thank you, Ms Cerisano, for being here. I'm sure it was not easy. We are subject as politicians to all sorts of legislation and regulation, but try as we may, there are always people like you with a situation that is quite unique, and the order in council is the route. However, many people are not aware of this, and that's where you get the runaround from the bureaucracy, which you quite obviously got for a long time. I suppose they could have but they didn't feel it was their particular job to bring it to the minister for an order-in-council decision. We cannot accommodate everyone in regulation and legislation. There are always cases like yours which get missed. That's why you have then to deal on a one-to-one basis with your particular problem, and hopefully common sense prevails. In your case, common sense looks like you should be at home with some support from government assistance to look after your own children. That's common sense.

The Acting Chair: Excuse me. Mr Owens, did you have anything to say on this?

Mr Owens: Absolutely. As I read your story and listened to you, it reminded me of a situation I dealt with in my own riding and am continuing to deal with, with a mother, again a single mom, dealing with two severely disabled kids. There is a process, if I can be helpful to Mr Hope in this issue. There is an agreement called a special services at home agreement which will provide up to $10,000 a year. We don't need to go through the order-in-council process, which can be quite arduous. I can again be helpful to Mr Hope that the process does work. Hopefully, we'll get in touch with the local member in this area and get this process under way immediately for you.

What you can do is to negotiate the number of hours with respect to nursing care versus home care, based on assessments. It doesn't immediately answer your question with respect to having yourself which, in the best of all worlds, would be the good thing to do because kids need their moms. You're right; you know your kids and the kinds of things they need to have done for them in order to make them not only comfortable but to have a good quality of life. If Mr Hope needs any assistance with this, I'll certainly be willing to help him with that. Thank you for your presentation.

Ms Horsten-Cerisano: Thank you.

The Acting Chair: Thank you very much, Mr Owens. That's very useful. I noticed that there was a hand up in the audience. While I cannot accommodate your speaking, maybe you can speak with the parliamentary assistant afterwards. Thank you.


The Acting Chair: Would the next presenter, Omni Health Care Ltd, please come forward and take your place at the table. I ask you to identify yourself and then make your presentation. Welcome to the committee.

Mr Fraser Wilson: My name is Fraser Wilson from Omni Health Care. We represent eight nursing homes in the province of Ontario. Our head office is based in Peterborough. We have four nursing homes in Peterborough and surrounding area. We have a home in Napanee, one in Cornwall, another in Almonte, which is close to Ottawa, and we have an eighth facility in Aurora.

I'd like to take this opportunity to thank you, the members, for hearing our concerns. We are here to endorse the presentation prepared by our association, the Ontario Nursing Home Association. I have listened to most of the comments you have heard today and I'm going to take a rather more informal approach to this. I don't want to reiterate everything that has been said today. I agree with a lot of what has been said, and I will make specific comments to some of the areas I would like to bring to your attention.

In principle, we support Bill 101. Basically, as alluded to by several presenters today, we have much difficulty with the fact that, to this date, we do not have a contractual agreement. We don't know what the expectation is of long-term care facilities in order to accommodate level of care through the province of Ontario in every long-term care facility, as opposed to nursing homes specifically.

We're also concerned with the fact that there has been no specific announcement as to the funding that is proposed for long-term care. Not knowing what the contractual agreements are going to be, not knowing what the funding is going to be, we feel that we are dealing with uncertainties and very global concepts, the concepts of which we can agree with for the most part.

I would also like to endorse the comment that was made by the home for the aged earlier. We would like the opportunity to be able to respond to the funding model when it's formalized, and also comment on the contractual agreements that we will ultimately have to abide by.

Specifically, with the contractual agreements: As stated previously, the contractual agreements are moving away from the insured services. It moves away from the universality of health care. Basically, we're not opposed to that, under the assumption that all long-term care facilities will be working within the same contractual agreement.

Basically, what has happened over the past is that nursing homes, through legislation, regulations and compliance management, have had to adhere to certain standards instead of regulations, as to those of homes for the aged. To worsen that situation, there has been a very significant difference in the funding between the two long-term care facilities.

We are very supportive of the fact that there is going to be equitable funding between all long-term care facilities. It has been very necessary through the years, and I think it can only better the care that will be forwarded to residents or the recipients of that care.

As far as the enhanced accountability is concerned, we don't know what is within these contractual agreements. We are certainly not opposed to bettering the care; we're not opposed to giving more nursing services, but where we have a large problem is that there's nothing in Bill 101 that makes the government accountable for supporting those increased levels of care with appropriate funding. There needs to be an accountability.

The last three years are a good example in that all long-term care facilities, including nursing homes, have had to operate at levels that are less than inflation. We've been underfunded. We've been asked to continue the level of care that we've had in the past, and it is becoming increasingly more difficult to adhere to those levels of care.

In the event that the funding is not matched, we would suggest that Bill 101 provide some sort of flexibility that would allow us to prioritize the care to be provided to the residents at the end of the day. Whether it be a reduction in staffing, which is much the same as hospitals have right now, if the funding is not there, we have to have flexibility in order to control our costs.

There have been several comments made today in regard to the enforcement of these contracts. From what I can hear from the members, I don't see a lot of support for the sanctions that are proposed in the bill. I have heard comments to a trusteeship. Quite frankly, nursing homes have been operating for some time under compliance management, which is an established set of rules, regulations, standards under which we have to comply. We are inspected by a compliance officer whose job is basically to ensure that we are complying with the set standards. In the event that we do not comply, then the opportunity is extended to the facility to rectify the situation or at least give the rationale behind the situation.


It is our position that the system that is in place with nursing homes right now works very well, and it is not militant in nature. I think pursuing sanctions would be detrimental to resident care at the end of the day. If funding is withheld from a facility, it's those remaining residents who are in the long-term care facilities who are going to be hurt by such sanctions. I don't believe there is any need to further increase the powers of the compliance officers. I really do believe that compliance management, as it is in place right now in nursing homes, is a very adequate system of resolving disputes.

There has been much controversy over the placement coordination agencies. I believe one of the main concerns that has stemmed from that is the fact that the bill, as it stands right now, does not provide us with any specific details as to what their purpose will be. I think that's why you're finding so many of the respondents here making comment to it.

We are of the opinion that there are placement coordination agencies in place in a lot of communities at the present time. The parliamentary assistant has referred, on several occasions, to the one that is in place in Kingston. It is our understanding, from the proposed bill, that there will be another level of bureaucracy that would either replace or supersede the one in place. We would strongly suggest that the one that is in place be utilized. It has already been established that there has been a lot of money, especially in the Peterborough area, invested in computer systems etc, and to be quite frank with you, the system really is working quite adequately in the Peterborough area.

In the event that the agency is going to outline to potential residents of long-term care facilities its direction as to which facility it would be, there have been many comments today about the notion of the right of choice. We would endorse that, and from what I can hear in this committee, it is well endorsed by the committee that there should be the right of choice.

Also, there has to be the ability for the facility to appeal a placement that is suggested by the agency, the reason being that if we have a resident who we certainly do not feel is capable, we can safely care for that person. The example that was cited earlier is if you had a 350- to 400-pound resident and you don't have the capacity to care for that person. There's a potential danger if he or she goes into your facility and you don't have the appropriate equipment. We ought to be able to have an appeal mechanism to stop the placement and perhaps suggest an alternative placement.

The one comment that there have not been very many comments on today is the fact that nursing homes already participate in the care plans. Everybody was assessing long-term care, homes for the aged, charitable homes for the aged, nursing homes were all classified last year. We would hope that in long-term care reform there is not going to be too much emphasis on the paper process. There is already too much onus on the paper process. If it's not documented, the care isn't provided. Unfortunately, there is a severe price to pay for paperwork. That is a reduction in care. I would seriously suggest that moves be taken to try and limit the paperwork and enhance or try and maximize the hands-on care that is extended to the recipients of the care.

I'd just like to sum up, then, that we are in support of Bill 101, as is our association. We have made brief comments on proposed changes of where we have problems with it. We would ask that you act expeditiously in getting the contractual agreements formalized so that they can be reviewed by the participants and we have some sort of indication of what the proposed funding is going to be for long-term care reform.

I would like to thank you for the opportunity and would welcome any questions.

The Acting Chair: I thank you very much for coming this afternoon. I do detect, now and then, a lovely little brogue that comes through.

Mr Fraser Wilson: There is a brogue.

The Acting Chair: It's nice to hear. I'll begin the questioning with Mr Villeneuve.

Mr Villeneuve: Mr Wilson, thank you for your presentation. I gather that three words would summarize why you're here: funding, compliance and placements, not necessarily in that order. You're the chief financial officer of eight of Omni's health care nursing homes. Why are the so-called non-profit nursing homes receiving more funding from the government? Can you explain that, as the chief financial officer?

Mr Fraser Wilson: I believe that it has happened over time. The major discrepancy between the two facilities is the fact that homes for the aged are able to get a top-up from the municipality. As one of my predecessors alluded to, they get 30% of their funding from the municipality. In the event that there are any expenditures over the 100% cap, that is also picked up by the municipality.

Both those top-ups are not extended to nursing homes. Basically, right now we are operating at a level of $77 per resident per day. Homes for the aged are operating anywhere from $110 through $118 per resident per day. Not included in that figure: Homes for the aged are not accountable for mortgages. The municipality picks up that cost. They are not accountable for municipal taxes, business and realty, they do not pay provincial sales tax and they get a 50% rebate on the goods and services tax, all of which we do not get. Those are all in addition to the $118. That disparity is what caused Justice Holland to say that the situation has to be resolved. It has to be resolved quickly and there has to be some equity in the system for all long-term care facilities.


Mr Villeneuve: How many nursing home residents would you have in your eight facilities?

Mr Fraser Wilson: We represent 654 residents.

Mr Villeneuve: You touched three times here on compliance and sanctions. Could you elaborate on that a little bit? Because Bill 101 will be addressing that very directly.

Mr Fraser Wilson: Sanctions, as I understand the proposal, would have an inspector or a compliance officer come into the facility. In the event that they find any non-compliance, they have the ability to literally stop your funding. If the funding stops, it puts the facility in a very awkward position in that it has a need to continue to get the revenues. In the event that the revenues are not forwarded by the ministry, then we would be forced into a predicament where we might have to cut costs. In order to cut costs, that is going to reflect directly on the residents.

Mr Villeneuve: Inspections are done regularly at the nursing homes, I gather. Could you explain what's happening now on-site in your eight nursing homes?

Mr Fraser Wilson: On an annualized basis every nursing home in Ontario is inspected. We call it an annual re-license. At that annual re-license they check our performance relative to compliance management, the standards established for nursing homes that we have to comply with. On the exit of that inspection they will either say that we are totally compliant or we are non-compliant. In the event that we are non-compliant, we have to propose our corrective action. That corrective action is then reviewed by the ministry and is seen as being acceptable or unacceptable. If it's unacceptable, we are given the opportunity to give a second corrective action. We'll go through that process a couple of times. Then it gets under enforcement, and that's where some of the more senior bureaucrats in the ministry are involved and take far more aggressive action.

Mr Villeneuve: Have you found it reasonable?

Mr Fraser Wilson: Absolutely.

Ms Carter: As the member for Peterborough, I'd especially like to welcome you to the hearings.

Mr Fraser Wilson: Thank you.

Ms Carter: You seem to imply that for-profit homes are going to be disadvantaged. I am a little surprised at that because it seems to me that this legislation is compensating for what was in fact a disadvantage in the past, that many homes had residents whose real level of care was not being funded, whereas now, through the three different categories of funding -- the residential cost, the levels-of-care funding and the programming money, which I gather will be on a per capita basis -- it seems to me that all facilities will now be funded equally, the only difference being that if they have more high-level-of-care patients they will get more for that reason. Could you comment on that?

Mr Fraser Wilson: I don't believe I did allude that we would be disadvantaged. I cautioned that our past experience has been that where we are asked to perform at a specific level the funds have not been met by government. If the eventuality comes about that they hold true to their promise or their obligation and are accountable, then I certainly would not be disadvantaged, depending on how the dollars are distributed between the three categories you just alluded to. But that we don't know yet.

Ms Carter: Of course, there is a ceiling to the amount of money that the government has available, but on the other hand this is a larger sum than has previously been available, and although priority is going to be for heavy-care patients, there will not be extra people in that category because of the legislation, so I can't see that anybody's going to be worse off.

Mr Fraser Wilson: Until such time as we know where the dollars are going to go, in the nursing and personal care aspect of the funding model we estimate the cost for nursing homes as $46 per resident per day for providing nursing and personal care services. If this new funding model comes out and allocates $35 per resident per day, then we are absolutely going to be disadvantaged. It will have a direct impact on the number of staff we can have on hand. To say that we're going to be disadvantaged -- we can't comment until such time as we know what the funding model is going to be.

Ms Carter: Maybe we need some clarification. I don't know whether I can do this.

The Acting Chair: The parliamentary assistant has been asked to speak. Maybe this is his chance.

Ms Carter: The $35 will be what the residents pay; it will not be the total funding.

Mr Fraser Wilson: That was just an example.

Mr Wessenger: I wanted to make a few comments. I just want to reiterate what Ms Carter has indicated. The fact is that this legislation has priority with the government, because of our recognition of the inequitable funding for nursing homes and many homes for the aged. As you may know, in 1992 we did provide two sets of bridge funding in addition to the economic increase to nursing homes to respond to the difficulties. The whole level-of-funding approach is to create the equality and to provide those services. I know everyone is waiting to see what the end result is going to be, but there is going to be $206 million to distribute to the homes for the aged and nursing homes, which is bound to have some impact on improving services in those areas.

Mr Fraser Wilson: Just to comment on the point you made about the funds we received in 1992. Albeit we received funding, it equated to 2%. It is no secret that going through labour negotiations, which accounts for anywhere from 65% to 75% of our revenues, the average increase was in excess of 5%, so 2% didn't begin to look at it. That's where we're very apprehensive about the commitment from the government in the future. We need to know that they are going to recognize our costs.

Nursing homes are probably the only private sector in our economy that has to publicly disclose a financial operations statement that indicates exactly where our dollars have been spent. Those are submitted to the Ministry of Health and, to be quite frank with you, have not been given due consideration in the past. That has led us to be very apprehensive. We would like something in the proposed legislation that would actually deal with that, make sure there's an obligation on them to look at the costs of operating a nursing home, staffing a nursing home.

Mrs Caplan: This particular piece of legislation, I believe, really turns the clock back from the compliance model which is in place right now at the ministry to an outmoded, outdated inspection model that does not improve quality of care or quality of life to the residents of the facilities. The existing Nursing Homes Act has not been amended to reflect the change. The change in the new compliance plan has been the result of policy decisions. There is an opportunity in this legislation to update as opposed to turn the clock back. The language and tone of this bill, which really replaces it with an adversarial model, are ones that I think we have a chance to look at changing.

Over the last few days of these hearings, I've been exploring some different alternatives. One that we've been talking a little bit about would require a residents' council, which this legislation does not require but which the Nursing Homes Act does require for nursing homes. Have you had good experience with residents' councils in your home? Do you find them active? Do they make a difference?

Mr Fraser Wilson: For the most part, very active. On occasion, depending on your resident population, you may have trouble filling the capacity, but for the most part it's very insightful as to how they view their living environment.


Mrs Caplan: Do most of your homes have total quality management processes?

Mr Fraser Wilson: We have quality assurance. Quality management is a new concept that's being introduced by accreditation. We are pursuing that avenue, but we most certainly have quality assurance in place.

Mrs Caplan: You're quite correct that the term "quality management" is new and that it is part of the accreditation process. Do all of your homes participate in accreditation?

Mr Fraser Wilson: Yes, every one of our facilities has a three-year accreditation status.

Mrs Caplan: Would you be comfortable if you had a model which replaced the inspection model and allowed for a compliance management approach where, rather than inspectors, you had compliance officers, if accreditation on both management and outcome were mandatory as opposed to voluntary, as it is now?

Mr Fraser Wilson: If we look at compliance management, it has spun off from accreditation.

Mrs Caplan: That's right.

Mr Fraser Wilson: Accreditation has actually established criteria, standards etc throughout Canada. I believe compliance management has actually adopted a lot of the philosophical goals, standards etc. To be quite honest with you, we already abide by that kind of standard and find it a very good model. It's very reflective of the ability of care and how you might equate yourself to another long-term care facility. We find it a very effective tool.

Mrs Caplan: The other thing that accreditation does is the concept of peer review, where the assessors and the surveyors are there to come in on an ongoing basis. Are you comfortable with that concept of peer review as one of improving quality?

Mr Fraser Wilson: I'm not quite familiar with peer review, to be quite honest with you.

Mrs Caplan: That's where assessors come from the same kind of facility. They come in to help and to assess what you're doing.

Mr Fraser Wilson: To put it in the context of Ontario, as opposed to accreditation, which brings somebody from Alberta or someone out from the east, where they have completely different funding circumstances and different levels of care -- it's hard to equate to them sometimes -- I think it certainly would not be detrimental to have it internal to Ontario, especially where everybody is having to abide by the same legislation, be it homes for the aged, charitable homes or nursing homes.

Mrs Caplan: One last, short question?

The Acting Chair: All right, a last one.

Mrs Caplan: Would you support an amendment that allowed for a right to refuse on the basis that the long-term care facility could not provide appropriate care, provided that there was a right of appeal by either the placement coordination service or the client?

Mr Fraser Wilson: I think it's necessary.

Mrs Caplan: Do you think there should be an exemption from that right of refusal in emergency situations, for the short term?

Mr Fraser Wilson: Ultimately we're going to have to work with it somehow. As long as it's short-term and the efforts are being made by the placement coordination agency, the Ministry of Health and the actual facility, I don't -- it has to happen; somebody has to accommodate the resident. They can't be abandoned.

The Acting Chair: Thank you very much for coming before us this afternoon. We appreciate your time.


The Acting Chair: And now the familiar Haliburton, Kawartha, Pine Ridge District Health Unit -- familiar to me, at least, and possibly too to Ms Carter. Welcome, gentlemen, old friend Mr Wensley and new man on the block, Dr Hukowich. I'll ask you to identify yourselves and make your presentation at this time. Welcome to the committee.

Mr Bill Wensley: Thank you, Madam Chair. We're grateful for this opportunity. I'm Bill Wensley, a member of the board of the Haliburton, Kawartha, Pine Ridge District Health Unit. With me is my colleague, Dr Alex Hukowich, who is our fairly recently appointed medical officer of health.

I would just like to take this opportunity to explain briefly who we are and what we've been doing. I believe you have copies of our presentation. I think perhaps I will read most of it. It shouldn't take too long.

The Haliburton, Kawartha, Pine Ridge District Health Unit is one of 43 health units, regional and municipal health departments established and operating under the Health Protection and Promotion Act. For almost 20 years we have been responsible for the ongoing administration of the provincial home care program in the counties of Haliburton, Victoria and Northumberland. Over the years, as the mandate of the home care program has grown from solely acute services to include the chronic home care program, the integrated homemaker program and the school health support services program, the board of health has been charged with the responsibility of its administration.

The term "administration" is perhaps an unfortunate one. It does not do justice in describing the health unit's role in ensuring the availability of the various component services. Our involvement has made these programs more than a legislative description, but a tangible and real service enabling people to receive appropriate care and continue living in their own homes. The health unit therefore provides not only an administrative support structure to ensure that budgets are drafted and bills are paid, but provides the case managers and coordinators to assess the needs of the clients, arrange the required services and monitor the client's situation.

We recognize that while some do not accept this brokerage model, the existence of independent case managers very much parallels the independence foreseen for the placement coordinators and is central to a balanced system that is responsive to clients' needs but neither solely client- nor provider-driven.

Although not all home care programs are provided through health units, the board feels strongly that where this has been the situation, health units have fulfilled their obligations in the operations of the programs and should continue to play a central and key role as any legitimate problems in the system are addressed by building on existing strengths. I believe this is one of our fundamental underlying philosophies to this whole issue.

We do support the government's five stated major policy goals of equitable and needs-based funding; strengthened accountability; consistent facility payment; single point of access; and, flexibility to allow direct payment for self-managed care for the disabled. We support these.

The board has in the past supported the underlying principles related to long-term care reform and we have only raised concerns where government plans for the translation of those principles into structures and organizations have been unstated, unclear or felt to be inefficient, duplicative or without evidence that they would indeed accomplish the stated intent. As an example, we opposed the establishment of the 40 new service coordinating agencies, as proposed in the October 1991 government redirection discussion paper.

At this committee's initial briefing by the then Minister of Health, the Honourable Frances Lankin stated that Bill 101 was, "the beginning of a reform process that will result in a major restructuring of long-term care and support services for elderly persons, adults with physical disabilities and people who need health services at home."

The minister also recognized that this bill does not address many of the vital issues relating to what the long-term care system will look like at the completion of the reform process or at any intermediate steps in this process. We would have preferred that the government's intent was as clearly enunciated as its underlying principles so that this bill, any subsequent legislation or any organizational changes could be reviewed in the context of a specific blueprint or road-map. Only in this way could there be informed discussion as to whether both legislative and non-legislative proposals for change could indeed produce an agreed upon desired end. This is one of our major concerns.

The board does not feel in a position to comment specifically on the various technical issues raised in this bill. However, we believe the bill creates the pivotal position of placement coordinator in a way that may obviate the main need for any further legislative changes. It is our understanding that not all structural elements require a legislative framework. While hospitals, health units and long-term care facilities do have empowering legislation, health councils have been set up without recourse to legislation.

If placement coordinators can be either persons or entities, will there necessarily be any requirement for further legislative amendments or new legislation to resolve the remaining issues, or can the government simply designate Ministry of Health employees, existing organizations or create new organizations to serve this function without the necessity of further discussion or debate in the Legislature?


The board is concerned that what is presented as merely a beginning to the reform process could become the end of any required legislative change. We would like the assurance that there will be further opportunities to discuss future steps in the reform process from the perspective of how they will meet the underlying principles of reform.

I now come to our main recommendation. We believe that the key role of placement coordinators should not be enshrined in legislation until such time as the government has spelled out the model or models which can be used for the governance and coordination of long-term care, as we believe these are equally crucial steps in the reform process. To that end, we support the minister's intent of calling a further conference on long-term care once the government's special adviser's report is released. We also support the role that district health councils can play in local planning and implementation of long-term care services.

If the long-term care reform process is to eventually lead to an improved system rather than simply a different system, it is important that proposals at various steps of the process be examined within the framework of the desired outcome. None of us can judge the value of any particular path in this journey, unless we know the desired destination.

We thank you for this opportunity to express our views in a general way on this bill.

The Acting Chair: Thank you very much and I'm glad that you have left time for questioning. I believe the government side is first in the questioners. Do I have someone who would like to pose a question? None? Then, Ms O'Neill.

Mrs O'Neill: As we've said before, every brief has a different perspective, and I'm not sure we've had a health unit before us to this point.

I want you to tell us a little bit more about how the district health council is working with this piece of legislation, because we understood that the minister in December said, "Let's get busy out there in the field". Can you update us on where you are in Kingston at the district health council level with this piece of legislation?


Mrs O'Neill: I'm sorry, Peterborough.

Dr Alex Hukowich: Haliburton, Kawartha, Pine Ridge, which are the three counties that surround Peterborough --

Mrs O'Neill: Thank you, help me.

Dr Hukowich: -- although the health council for that area does include the four counties, and so includes Peterborough. The health council, as opposed to the health unit, has set up a number of committees and those committees, I believe, are still working on trying to develop some kind of model that may be appropriate locally.

Mrs O'Neill: And would you be part of that?

Dr Hukowich: The health unit has been part of some of those committees, yes.

Mrs O'Neill: You seem to be expressing very strong cautions regarding the placement coordinator, I think maybe the strongest we've heard, particularly in suggesting that we remove the clause from the bill totally until the models have been determined. We've heard all kinds of fears, I think is the best word to use regarding the placement coordination. I think you've worded it so well when you say that we don't know whether it's a person or an agency, and we've been told various things, particularly by the parliamentary assistant, throughout the hearings, but the bill itself does not say very much. Particularly in areas where there have not been firmly embodied boards and placement coordination agencies, there are certainly a lot more concerns. Do you want to say a little bit about what you would find as necessary in the model, how complete it would have to be, or some of the guidelines?

In London, we actually had a group present to us a model or set of guidelines it felt should be right in the legislation. I think we know, but maybe you could emphasize a little more why you are so cautious, and then what you think are the necessary ingredients for your ease in accepting the role.

Dr Hukowich: I think the reason for the caution is because -- again, we may be in error -- certainly our understanding is that you don't necessarily have to put everything into legislation. I think the district health councils are an example. They're provided no kind of legislative mandate yet they're there and they do their work. So the concern is that you can also develop, without any further recourse to legislation, a variety of policy decisions, a variety of models, some of which may be appropriate, others may not be, without any further opportunity for discussion in terms of whether they will meet the stated intent of producing an improved system.

In terms of what we would like to see in those models, I don't think the board is committed to any particular model. What we'd like to see is what's being planned or what the range of options may be as they're developed locally, so that we would know that they're going to meet the intent of the legislation in meeting those underlying goals.

Without the government coming forward, we're left with a variety of previous statements that have been made in previous documents setting up new agencies, which we feel is clearly inappropriate, would be a waste of effort, would be a waste of money at a time when the funds should be put into actual service provision rather than developing new agencies. We'd like to know the plans in terms of those other areas first, so that they can form the context for these placement coordinators, whether they be persons or whether they be agencies.

Mrs O'Neill: As I say, I think you have expressed very clearly what many other people have brought forward as well, and I hope that the government is hearing, because there is a giant leap of faith into a whole body of regulations which we would not have any access to or any ability to comment on, nor you, and that certainly would be part of our concerns as we go into amendments. I think that our party wants to tighten that up or give much more direction to what the role of the placement coordinator would be, who or what agency, and guidelines that would surround it. We've come to that conclusion as we've travelled across the province.

So you've brought it and highlighted it, and I think there must be other things in the bill that are also of concern to you but you've decided to highlight that one, and I'm very pleased you have.

The Acting Chair: I believe the parliamentary assistant, Mr Wessenger, would like to comment.

Mr Wessenger: Yes. I gather you don't have placement coordination in your area now?

Dr Hukowich: I'm not certain of that. As I say, I'm relatively new there. I've come from an area where in fact we did have placement coordination, as operated by the health unit, along with the home care program and the various other programs. I'm not certain as to what the exact situation is in Haliburton.

Mr Wessenger: Perhaps I should give some indication. As you know, about half the province is now presently covered by placement coordination, and I must say that every place we've been to where they've had placement coordination we've heard very strong support for the service.

Basically, once the legislation is passed, existing placement coordination agencies will continue to fulfil that function. There is an intention to extend placement coordination across the province to areas that don't have it, but there was a definite statement made that there would not be a new bureaucracy created.

Under the former process, something called SCAs were proposed, which was an independent separate function, but that is not the case. The intention is to attach placement coordination, where it doesn't exist, to existing agencies rather than to create a new structure. The eventual process is to go through the creation of what they call the multiservice agency through the district health councils' planning process under the long-term care subcommittee. In fact, the whole planning process for the long-term care is to be through this long-term care subcommittee of the district health council, which is to be broadened to have broader consumer input, as well as provider input and so forth.

So that's sort of the perspective. That's what I was somewhat concerned about why you would be concerned about having placement coordinators put in legislation, because, quite frankly, I don't see how we could achieve the models of having those with the greatest need being given the highest priority for placement without having placement coordinators in place, as well as we couldn't provide the consumer choice to bring all those facilities to the consumer, which is a very important element of the process.


Mr Wensley: I would just like to emphasize that we don't disagree with the idea or the concept of placement coordinators. We just don't feel it's necessary to put it in legislation. We're not convinced that's necessary.

Dr Hukowich: At least until the remainder of the information is available as to how they're going to work and how it's going to be governed.

The Acting Chair: I'd like to thank you very much for coming before the committee. I wish we had more time, because I know there are other questions, but we must move on.

Mrs Caplan: Chair, could I just make one small statement? The long-term care reform policy document framework: We've had a commitment from the parliamentary assistant that that should be available in March. Also in March should be the chronic care rules study from them. Given the legislative process, I'm asking if it will give you comfort having that before this is passed?

Dr Hukowich: I think if we can have all of that and everyone can look at that and debate whatever comes out in that document, then yes.

The Acting Chair: Thank you very much.


The Acting Chair: Fairhaven Home for Senior Citizens, welcome to the committee. Would you kindly identify yourself, please.

Mrs Dawn Straka: I'm Dawn Straka. I'm the administrator at Fairhaven Home in Peterborough. I do apologize. A committee management member was supposed to come along with me, as was an advisory committee member. One got busy today advising and the other got busy doing political things, so I'm here alone.

Mrs Caplan: Political things?

Mr Villeneuve: We're not used to that.

Mrs Straka: You're not used to it, okay.

At the beginning I'd just like to say a few words about Fairhaven. We are a joint city-county-municipal home for the aged. We're situated in Peterborough but serve the whole of the county of Peterborough. We have 132 residential care beds, and approximately two thirds of those residents have extended care approvals, but we can't honour them because we don't have the extended care beds to put them in. As well, we have 121 extended care residents.

I did, on my handout, show the actual costs for 1992. I thought this might be helpful, that the actual residential care cost last year was $59.28; extended care, $117.03, and when you average them out, divided by the number of resident care days, it comes out to be $89.41.

The new directions in the long-term care sector of Ontario's health and social services system certainly received strong endorsement by the home prior to and during the discussions and consultation, and certainly many of the principles of the redirection reform were endorsed strongly in those I've listed.

What I'm attempting to do today is not address everything that the other -- I know our association and my colleagues in other homes have come and talked about a number of issues. What I've done is picked out a few issues that may be of less importance but certainly might help clarify some of the thinking regarding the institutional sector.

The first issue is governance. Municipal homes for the aged, as I'm sure most of you know, are governed by political appointees. In my particular case, they're all municipal or county politicians. Many homes advocate a change in this practice and certainly I know I would welcome a broader mix of board members with a wide variety of expertise.

All new initiatives in the past four years in Fairhaven Home have used a community advisory committee with representations of residents, families, concerned citizens and professional experts. Examples of such advisory committees are a pastoral care committee or our special care and our fund-raising committees. We certainly strongly appreciate the value of the advice, and we advocate this practice continuing.

Talking about governance, certainly some of us have sat in Toronto the last couple of days at a large meeting with members of the government looking at Bill 101 and what the meaning is going to be for us. I think one issue that we're all still questioning, and that I realize will be addressed down the road in 1994 and 1995, is the role of municipalities. Another issue related to this is the importance, certainly, that education is going to have for all of us and particularly, I would assume, for the private sector, for the directors and owners, and in our sector for the municipal representatives, to learn more about what is expected of us in the near future.

Related to the issue of governance is accountability, and certainly we believe municipal homes are and have been accountable. We are accountable not only to our municipal representatives and city and county bureaucracy but to the political government through our long-term care area office, as well as, obviously, to the community through our residents, our families, auditors, accreditors. As a public institution, we've been -- I was going to say "subjected"; that's not quite the right word -- but we've had a twice-annual public inspection panel come through our home. This is a panel of jurors who have a couple of weeks off, and they do come and visit all public institutions, so we've experienced that.

"Quality services" is a term that our home has coined for what most people are calling total quality management. There are other terms for a similar concept. Though our program is still in its infancy, everyone from the committee of management to the line staff and residents will be involved. One strategy that we are using is a suggestion with formal feedback to suggestions. Any suggestion that comes through to us, we put the response up for everybody to read and share it with everybody in the home. We've also been trying brown bag lunches around the clock with staff, and this is just so that we get information feeding up and down through the channels.

You questioned the gentleman from Omni regarding residents' councils. Certainly our residents council is active, but with the level of client or resident that we're now getting, it's often very difficult. They're just beyond being capable of active participation. But we certainly do have meetings on a very regular basis.

The other thought that certainly we will be having is a family council. We've done a lot of family support work in the home, but I believe in the future having a family and significant-other council is important.

Having a new set of standards dedicated to long-term facilities is certainly most welcome. For our sector, a revision of the very outdated Ministry of Community and Social Services administration manual is very welcome. We certainly are pleased that we're getting new standards. At the same time, we caution against the possibility of putting more emphasis on the process of meeting defined standards than on actually improving the quality of the programs and services. I can cite some examples. Certain facilities might have beautiful policy and procedure manuals, but if they don't apply, then they are of no use. So that's just a caution.


The policing approach: There's some indication that certainly for the municipal and charitable homes there will be more inspection than we've had in the past, and we caution against the policing approach because we believe it inhibits professionalism and certainly takes power away from boards and staff.

I thought a word on volunteers might be useful. They certainly play an important role in our facility, from the board and committee participation to resident programming, entertainment, to special projects like Canada 125 celebrations and outreach programs like Meals on Wheels. We have hundreds of volunteers in our home every week. They're recruited locally and come to the home with a desire to do a specific program and service. They don't come just because they want to be near seniors or whatever. They want to do something very specific. Volunteers not only input into the running of our facility, but they are another strong link between the facility and the community.

Respite or short-term facility care of persons who normally live in their own homes needs to be addressed in administrative policy and procedure, which hopefully will clarify the ministry's expectations. This is something we've been waiting for for a number of years.

On March 8 of this year, my home will open a second special care unit, with 17 long-term beds and six short-term beds. I probably should just quickly review what special care is. This is a unit dedicated to persons with cognitive impairment, and at the end of the unit there is a locked door that one must know how to key to get in and out of.

This unit will occupy redeveloped residential care space. I think this is something that homes that were predominantly residential care originally -- the space is no longer appropriate so what we've done is, on our own, with very little ministry financial support, taken the space, redeveloped it, and we will use it for this care.

The long-term care area office has given us approval for the long-term part of this proposal but not the six shorter-term beds, and I certainly urge this committee to try to address short-term care, because it is a need, definitely.

We did a survey back in November in the planning of this facility and there were 59 people in the Peterborough area who were needing to get into that 23-bed unit at that time.

Pre-admission assessment: In the last year the ministries of Health and Community and Social Services, as you know well, and all long-term facilities invested a tremendous amount of effort into comprehensive resident assessment and documentation. The new draft standards resulting from redirection have proposed utilization of a request-for-admission form which is not consistent in format and terminology with a classification tool. That was the tool that we all used in the fall.

Other consistent forms exist, and certainly we're advocating the one that our PC has developed, which is the Peterborough assessment for continuing care coordination. It is an excellent form and it is consistent with classification. My suggestion is, it certainly makes it a lot easier and more objective when terminology is the same. So please, if that can happen, that would be great.

In conclusion then, on behalf of our residents, families, board staff and volunteers, I've raised some issues. Although these are not as high-profile as funding, inspection, centralized sanctions, control and placement coordination, attention to these issues I've raised will also make a difference for persons requiring long-term care in facilities like mine. Thank you for this opportunity, and if there are any questions, I'd be happy to try to answer them.

The Acting Chair: Thank you very much for coming. I believe there is time for one question per caucus. We'll start with Ms O'Neill.

Mrs O'Neill: Two things you mentioned have not been very much part of our discussions. I would like to have you say a little more about them, because you seem to indicate that there are needs and that the approvals haven't been coming. Before I begin to do that, you pricked my curiosity with your brown-bag lunches around the clock with staff. I don't know what that is; it sounds interesting.

Mrs Straka: Basically, as senior staff within the home, we come in and sit down and talk to the staff who are on duty about any issue they're concerned about. They're very concerned about funding, for example. They hear, "We get so much," or that the ministry in the future is only going to be giving $37, or I think it's up to $38.25 now; that's what I heard yesterday, I believe. It's to try to clarify this for them. As well with the residents: We wander around the home and try to sit with them and listen to what their concerns are.

Mrs O'Neill: That sounds like a very good initiative. If I may go back to the two parts of your brief -- they're actually on the last page. You're talking about respite. I'd like you to talk a little bit about who really needs that, how important it is in your community of Peterborough, and then the six short-term beds that you say are so high-profile in need in your community and yet have not received approval. I think it's important that we hear.

Mrs Straka: Who are these people? These are people with cognitive impairment, probably Alzheimer's, but as you well know, one cannot really definitively diagnose Alzheimer's until the time of autopsy. But they're people who are confused, whose needs have really outlived the community services; they may require constant supervision, and whose families may be burnt out. You may have noticed that I am on the board of the VON. I certainly wear the two hats. That's my volunteer board; this is my professionally paid. Anyhow, they're people who used to go to the VON day care centre, but that no longer is enough to meet their needs, so they come in.

Mrs O'Neill: So the short-term?

Mrs Straka: That's the overall. The short-term side is people whose families need a break. I know the legislation is looking towards giving people 30-day stays in institutions like ours, up to three times a year, but it's to get the approval from the local office to proceed with this.

Mrs O'Neill: Thank you for highlighting those special needs for us.

Mr Villeneuve: Thank you very much for your presentation, shedding light on some of the areas that maybe haven't been touched on quite so much. Volunteerism is very important in your operation. Would you have a waiting list?

Mrs Straka: We work through the Peterborough continuing care coordination service. They maintain the waiting list for us. For example, in the last few weeks, we've had to hold back on admitting residential care residents to let our population drop down so we can admit these new special-care people. We've seen lists there. You could have up to 50 or 60. How they divide them is according to their level of need. They may be residential. They also list them according to where the person is, whether they're in hospital or another facility, whether they're at home on their own.

Mr Villeneuve: That's my next question: Is it domiciliary homes, rest homes, or are people basically coming in from their home or that of someone of their family? Would you have a breakdown?

Mrs Straka: Yes, I have a sense of where people are coming from into my institution. I'd say about a third of them are coming from other facilities; probably most of that one third is from hospital directly. A crisis has happened in home, and they need to be institutionalized quickly. In Ontario we've developed a number of rest homes and retirement homes which have, in many cases, lovely facilities but not a great deal of supportive staffing to go along with it. It's these people who are now coming or wanting to come to homes for the aged, and I'm sure nursing homes as well.


Mr Villeneuve: So that would indicate why your high percentage of extended care requirements; it's a little higher than normal.

Mrs Straka: We're one of the institutions in the province that has a lower ratio of extended care to residential care residents. Many of the homes for the aged are as high as 80%, 90% extended care. That has depended upon many factors in the past.

Mr Wessenger: Thank you very much for your presentation. I'm pleased to see that you've anticipated the legislation with respect to the respite care plans.

Mrs Straka: Yes, we've tried to learn what's coming.

Mr Wessenger: I really appreciate that; I think you're doing a great job in that area. I'd just like to assure you, though, with respect to your comments concerning the inspection process, that under the present inspection process or compliance or program adviser system, the same people are going to be doing the same thing they always have done and be carrying out the same policies. I just wanted to assure you of that.

Ms Carter: I wanted to say something on the same point. Welcome to the hearings. Of course, I know Fairhaven home very well. What I know particularly about Fairhaven is how open to the community it is; it is a community facility. Municipal politicians take a great interest in it and, as you said, there's a large number of volunteers and there's a lot of coming and going. Fairhaven is very open to the community. Even if you wanted to get away with anything, you couldn't, because there is all this coming and going, and it's so much part of the community.

When you say you don't want intensified inspection because it inhibits professionalism and power to boards and staff and so on, that may very well be true of Fairhaven, which doesn't need that, but I think you were here this morning when I --

Mrs Straka: No, I was not here this morning. Sorry, Jenny.

Ms Carter: There was one gentleman here who agreed that although most homes are very well run, there are some he personally would not want to live in. In other words, there are problems in some facilities. I just wondered whether you would agree that we do need some kind of system in place other than the more general safeguards that maybe apply in Fairhaven.

Mrs Straka: Over the years, we've had a fairly good relationship with the local Comsoc office, now the long-term care area office. I believe they're very aware of the standards of care within our facilities. I'm personally not upset about having an inspector or compliance officer come into the home; I just don't want to spend tons and tons of time preparing for this and taking it away from the other duties or tasks that would ultimately maybe benefit our residents to a greater degree.

The Acting Chair: Thank you very much. I really appreciate you coming to the committee. I wish you well.

Mrs Straka: Thank you.


The Acting Chair: Would the representatives of Specialty Care Inc please come forward.

Ms Paula C. Jourdain: Good afternoon. I'm Paula Jourdain; I'm general manager with Specialty Care. This is Mary Gorham, who was the administrator of Franklin Lake Manor, an old facility that's since been replaced and is now operating as Trillium Ridge, which has been open since May in Kingston.

Specialty Care is a family-owned corporation. We own four homes across the province, nursing homes and retirement homes. We've just built, as I mentioned, Trillium Ridge in Kingston, which has been open for six months. It's a combination facility: 90 nursing home beds and 44 units of retirement home. I really want to address the committee based on our experience here in Kingston. I know you've been inundated with nursing home presentations this morning, so I won't go through the full report -- that is, the common things we've been hearing from other people -- but try to highlight our experience as it relates here to Kingston.

First of all, we're looking forward enormously to seeing long-term care reform come into place. Since 1972, we've seen the differential in funding between nursing homes and homes for the aged increase dramatically, to the point where municipal homes for the aged are now receiving close to 40% more than nursing homes. The situation has just become unbearable, and we look forward to having the funding system equalized so that we have the opportunity to provide the same level of care that the homes for the aged have been able to provide.

We also look forward to an equalization in the inspection process, as was just talked about. We've certainly had a great deal of experience with the inspection-compliance program, and we've seen it evolve from the days of the "police" model to a more consultative report. I know that the government's own Woods Gordon study that was commissioned in the late 1970s, I believe, or early 1980s --

Mrs Caplan: It was 1986.

Ms Jourdain: -- thank you; 1986 -- supported the fact that a consultative model was preferred to a police model.

I certainly know, as a board member of the nursing home association, that nursing homes across the province are committed to providing quality care. We've been operating with such small margins and in such deficit positions that problems have arisen, and I think that that is always the case. Once the funding is equalized, I think you'll find that services across the board will improve and problems will decrease.

As a matter of fact, the nursing home association is just preparing a report on accreditation. As you may know, the nursing home association has been strongly in favour of accreditation, and at the present time over 95% of our members are accredited. We would hope that the accreditation system, which is a national system, could be a beginning to a self-monitoring peer review. Where now the Ministry of Health has the compliance management section, plus what's called the enforcement section for sort of problem homes or new homes, perhaps over time the compliance section could be reduced in its need, in that only if there are certain particular problems, then you could go to enforcement; if you were new or if there were certain problem identified. Hopefully, we could move through accreditation and through other systems to self-monitoring. The legislation seems to be based more on the old inspection system, and we'd like to see that some thought be given to growth in the self-monitoring area.

Another of the key points we wanted to address was the whole role of placement coordination. In Kingston in particular, I think, we have an excellent placement coordination system that's already working, and working very well. We'd certainly like to see that existing program with the home care system. I know it'll be different in different communities, but here we'd hope that would be the program that would be identified to carry on and that no new level -- I heard you talking a little bit earlier -- of bureaucracy be created. I think we all know there's not enough funds around to create more bureaucrats.

I think it's fundamental that we do have a key access point for seniors, whether it be for home care or whether it be for institutional placement or short-term placement. However, I don't think it's necessary for us to have one agency provide all the services. I know there's been some move to coordinate all of the home care stuff. Obviously, in the institutional, it wouldn't be all one provider. But as long as there's a good access point, that people know where to go, it does allow the community to develop different alternatives that meet the needs of different ethnic groups or different preferences in terms of delivery service. I certainly would hope that in terms of the home care that the for-profit and the public could still coincide to allow diversity in services.

The other thing we would like is to make sure that choice is still allowed for the consumer. There seems to be an appeal mechanism built in for the consumer with regard to the decision as to whether they're eligible for placement or not, but there doesn't seem to be an appeal mechanism built in for the actual placement that's recommended.

At the same time, there doesn't seem to be any ability for a home to decide who it will accept and will not accept. I can understand that there's a concern that homes may take all the "light-care" people, and obviously that's not the intent. But I think a home should have the ability to define its mission and to say which kind of clients it would like to take. Trillium Ridge, as I said, is a joint facility. I know Ernie Lightman came out with some recommendations suggesting that combined facilities were not advisable. I would like to strongly, strongly emphasize that we have found that combined facilities are just so appreciated by the community.

We have a number of family members in our Keswick home -- not in Kingston as of yet -- where you might have two people come into the retirement home and then, as one person requires more care, he or she may move to the nursing home. Having a combined facility, you're under the same roof, you have the same management, you have the same staff, the couple can still enjoy their meals together. It just provides an awful lot of services and it means that people don't have to move two and three times. I just fundamentally disagree with Mr Lightman in that particular regard.


I guess it comes up here. In terms of Trillium Ridge, in our nursing home side, we do give preference to our retirement home residents. Some people say this is favouritism, but we feel that it's a community. We've accepted people into this community, and by giving them preference, we're guaranteeing them a safe haven. They come into a retirement home which is a little bit nicer. There's more carpeting. It's private pay. People are paying a little bit higher. They want to have extra services and they get them. They get larger rooms. Maybe they'll get two rooms. The residents in the retirement homes are more active, so you have more bridge clubs and euchre clubs which you don't have in the nursing homes. It's a way to move into a communal setting at a time when you can accept it and you can enjoy it, so that when you do go to a nursing home, it's not a huge shift.

We found that families have really appreciated that, and I would like that to be considered. I would think that is a mandate nursing homes should be allowed to define for themselves, as well as things like, obviously, the ethnic homes, the Chinese homes, the Ukrainian homes, whatever. I think that's a lot more clear-cut. Certainly this could be subject to abuses, but with some guidelines of placement coordination service, I think homes should be allowed to set their mandate which would be approved as part of your service agreement.

Sanctions: Again, in the legislation it sounds like there's a huge hammering. I can appreciate that the government wants to have some controls. It's just that when you read them in black and white, it sounds pretty onerous and it sounds like you can put us out of business in a day. I would just caution that they sound pretty strict and would like to see some sort of recognition that these would be last-resort activities.

I think you've heard all the other things before from a nursing home association or from the other members, so I'd just like to open it for questions now if anybody has anything.

The Acting Chair: Thank you very much for your presentation. We'll begin with Mr Villeneuve.

Mr Villeneuve: Thank you for your presentation. You just touched on compliance. Have you had any problems meeting the requirements? The nursing home's been there for 15 years?

Ms Jourdain: We've operated nursing homes for 15 years; Franklin Lake, yes.

Mr Villeneuve: Any problem in that area?

Ms Jourdain: We've had some problems but not major problems. I think we went through a hard time in the early 1980s when there was this sort of -- they called themselves, "We're here to police you." That was used, and there was a "let's see if we can find some problems" attitude. I think in the last three years the approach has been much more consultative and we don't have problems now. I think that works much better. I think the compliance advisers -- I'm still calling them inspectors; I'm showing my age and my disability to change -- often do provide assistance. There's good and there's bad, as within every pot, but quite truthfully, if there's a problem inspector, you can get it resolved at head office. But no, it's not a problem.

Mr Villeneuve: You have, of course, your groups of residents who belong to the residents' association. Is that working reasonably well and is there involvement by the families?

Ms Jourdain: Yes. We have regular family meetings. In one particular home, we've started a residents' advisory council or family advisory council, and we've had several family meetings at Trillium Ridge, although we haven't formed a council as yet.

Mr Villeneuve: Informally, that is resolving the problems to your satisfaction, the satisfaction of the residents and the families, and you say don't bring us into it.

Ms Jourdain: Actually, as you increase the copayment and people have a greater say in what they're purchasing, I think you're going to find them becoming more vocal and saying, "I'm paying for this; this is what I expect". Yes, I think that's very true.

Mr Owens: Just a quick question to the parliamentary assistant. The presenters have raised again the issue around an appeal mechanism for homes and residences. My question is, if we were entertaining an amendment like that -- for instance, we currently have an appeal mechanism in place for potential residents. What would happen if an acute care institution was wanting to devolve a patient into the system, but an appeal has been filed by the resident or by the potential receiver? What protections would the ministry be entertaining in terms of the user fees that are available to the hospitals now? Once a discharge date is set and if the patient isn't out by such and such a date, what kinds of things would the ministry be looking at to ensure that the patient's rights were protected?

Mr Wessenger: I think you raise an interesting problem with respect to what you do with the patient in those circumstances under the new legislation. Right now, of course, there's no real remedy except on a cooperative basis, but even under the new legislation, although a placement coordinator could select a facility on an emergency basis to send the resident to -- because the highest priority will be given to the cases that fall into the emergency category -- if the home, on the grounds that will be under the regulations, takes the position, "We refuse this client because we do not have the services for this client," then that obviously creates an unresolved situation. At the present time, there's really no quick resolution to that other than to find another facility.

Mr Owens: Not to put you and the minister on the spot, but in terms of thinking the appeal process through, it's a concern that I've developed over the last week in terms of wanting to keep the patients' and potential residents' civil rights whole, so that they're not being penalized on one end while actuating rights on the other end. I certainly hope some thought would be put into that.

Mr Wessenger: I think the obligation of the placement coordinator would be to find a place quickly if he or she could under those circumstances. If one institution refused, you'd have to go to another facility, hopefully one that would accept. That would be the way it would have to work in practice. You couldn't really wait on an appeal. I think it's essential there be a quick way of trying to resolve matters before they go to an appeal. I think it's very important that you have some sort of dispute resolution process, some local way of dealing with it. Hopefully that would deal with most of the cases very quickly and not necessitate going to the appeal board.

Mrs Caplan: We've been exploring different models for ensuring continuous quality improvement and the new quality management concepts. Over the course of the last few days, we've talked about mandatory accreditation as opposed to voluntary, or as part of the contract that could be developed, that it would require accreditation, a quality management program, residents' councils, client surveys, peer review. It could be flexible and negotiated as part of the contract.

One of the thoughts I've just had, actually from talking with the previous presenter, was that since I believe the policy framework will look at devolution to regional boards for long-term care -- that's what was originally intended and I'm assuming that's the direction this government intends to go -- do you see a role for that kind of assurance back to that local body rather than to the ministry for the positive role of education, peer review within the district and that sort of thing, to help nursing homes, to help all long-term care facilities improve the quality of care, and reserve for the ministry only the opportunity to intervene when it has a real concern that patient care is in jeopardy, as it can in the Public Hospitals Act? To devolve the responsibility to the multipurpose regional body --


Ms Jourdain: Yes, I would agree with that. I think that's why the legislation, the way it's proposed, with all this stuff about quality assurance, which of course is an outdated term as it is -- I think if we go in with the belief that everyone wants to provide good service, that's a fundamental thing. We're going in; we want to provide good service.

If there's a bad service that's provided, whether because of poor management, lack of funds, staffing problems, labour problems or whatever, then I think, yes, keep your enforcement section downtown, but let's look at something, whether it be accreditation, whether it be through a combination of the two associations. The homes for the aged and the nursing homes are starting to communicate a little bit more closely and we see we will have to communicate even more.

Certainly, the Ontario Nursing Home Association has a set of standards for all our staff -- for housekeeping staff, for laundry staff, for our maintenance staff, for our kitchen staff. These are standards we've shared with the homes for the aged, and we would be willing to continue to ensure that we do have ongoing training and services which would be coordinated.

The local level is where it's going to happen. I think that's the other thing that's very confusing at this point, what is the planning role? Are the district health councils going to be it? Who's going to plan all this stuff? It's got to be coordinated. Your placement coordinator has to coordinate your institutional with your community and how is that going to work because the institutional is all from head office and the community stuff is all from DHCs or other social service bodies.

So it would sure help if you'd just draw up the map and draw some pies and say, "Yes, these are the pies." Are they going to be the 14 regions or are they going to be the DHC regions or are they going to be the municipal regions? We'd sure like one set of boundaries and one planning body to go to at a local level. That would help.

Mrs Caplan: I don't know whether you've heard, but our party and our leader have often said that one size should not fit all and that local communities are best at solving problems. What was mentioned to me by a previous presenter was that perhaps on the local level, boards of health or health units with a lot of expertise in food management and quality outcome controls -- they have all kinds of new terminology today -- could be a source and a resource for assisting in this kind of a quality management program if it was a locally driven initiative. So it just occurred to me that maybe this legislation really is going in the wrong direction by trying to centrally control all those functions --

Ms Jourdain: That's the old model.

Mrs Caplan: -- and should be more forward-looking to consider the idea of devolution of the -- I'll use the term "quality management" or "continuous quality improvement values," because it is a culture change. We want to believe that everybody can do better

Ms Jourdain: You've got the two areas that are broken up here, because you've got the move to the 14 area offices, and your service agreements are going to be written with the local offices, yet your monitoring is coming from head office. So, yes, it's a good concept.

The Acting Chair: Thank you very much. Mr Wessenger has a short question that has not been asked before.

Mr Wessenger: I was very interested in this combined model of a retirement home and nursing home.

Ms Jourdain: Oh, great, we think they're fabulous.

Mr Wessenger: Are they separate? Is there any physical separation?

Ms Jourdain: Specialty Care happens to have two. In Keswick, we have a one-storey facility; one half is retirement home and one half is nursing home. In Kingston, our facility's a two-storey facility joined by an elevator.

Mr Wessenger: So the residents in the retirement home and the nursing home residents share any common social activities and so forth?

Ms Jourdain: Yes, to a certain level. The retirement home residents, when they come in, don't want to do that because they don't want to associate with the sick people and they don't want to know about that side of it. But as more and more retirement home people leave, say one spouse goes to the other side or a friend who is next door goes to the other side, then they'll go over and visit the other person and vice versa. So when you have bingo or church services or all the various activities, you'll find that they go back and forth. We do keep some activities separate just because there are generally two levels of clientele because of levels of care needs, but a lot of them are mixed.

Mr Wessenger: That leads into my second question. Do you see it basically as a retirement home, a low level of care or no care at all, and the nursing side having a high level of care, or are there several people living there where it could be interchangeable despite the level of care they require?

Ms Jourdain: I think there are always people in the retirement home who definitely would be eligible for the nursing home and are waiting for placement.

Mr Wessenger: Are there people in the nursing home who could change over?

Ms Jourdain: No, I don't think so. There might be a very small percentage. I think when you change the copayment, that'll totally change, because there are some people who cannot afford a retirement home who do go straight into the nursing home. The number is very small actually.

I think when the copayment issue is changed -- and by the way, I'm very strongly in favour of that because I remember coming in when I actually used to work for the Ministry of Community and Social Services in my first life as a social worker and I used to fund services for the mentally retarded as a program supervisor. I went next door to the guy who was next to me, he used to fund homes for the aged, and I said, "Well, how do you get someone into a home for the aged?" I didn't even know about nursing homes then, of course. He said, "Well, you just get this little paper signed by the doctor." I said, "And who funds it?" He said, "The government funds it." I said, "What if the person pays?" He said, "Oh, well, whatever they get in the government cheque, they get to keep $100 and that goes, and the rest is all paid by the government." I said, "What if the guy's really rich?" He said, "Well, it doesn't matter." I said, "This is fundamentally sort of wrong." This is 20 years ago.

But then I went on and did my own work with my own people and forgot about it until I got back into nursing homes. So I think it's great. Let people pay if they've got the money. I think the sliding scale you've got, while it has some problems, is certainly easy to assess. I don't know what you do with the guy who has no income but has a zillion dollars in assets. I guess that's a perennial problem. But it's an improvement.

Mr Wessenger: Could I just follow up with one more thing about your combination home?

Ms Jourdain: Yes.

Mr Wessenger: Do you feel it's a good idea to have this combination?

Ms Jourdain: Absolutely.

Mr Wessenger: I mean besides for financial reasons, because we heard from another presenter earlier today that, because he had a small nursing home, in order to make it financially viable, he had to make it combination.

Ms Jourdain: Absolutely.

Mr Wessenger: So you think from a social and a financial basis, it's good?

Ms Jourdain: Oh, absolutely; from the resident's perspective and from the family's perspective. Actually, that's why our retirement home fills up faster than other retirement homes in the same community, because families really like to know they've got that. It helps the families and it also helps spouses and it helps friends. We just had an instance where we had to move a resident because there was water damage because of the storm. I shouldn't be telling you this, because we don't have any problems in our homes, but we had to move a resident in the retirement home. We just had to move him from one room to a larger room, a double room, for the same price. They're really shaken up, so can you imagine if you have to move not just down the hall to a nicer, bigger, better room but to a whole new building, to a nursing home. This way, at least when you're moving someone, you're moving them within the environment they know and with friends they know. I can't see the rationale for not supporting them, I really can't.

Mr Wessenger: Fine, thank you very much.

Ms Jourdain: Okay?

The Acting Chair: Thank you very much for coming before the committee.

Ms Jourdain: Thank you.



The Acting Chair: And now the Religious Hospitallers of St Joseph Health System. Sister Rosemarie, welcome to the committee. We appreciate your coming, and if you would identify yourself again for Hansard please and then begin your presentation.

Sister Rosemarie Kugel: My name is Sister Rosemarie Kugel. I'm president of the Religious Hospitallers of St Joseph Health System. The Religious Hospitallers of St Joseph Health System is comprised of health facilities located in Ontario, New Brunswick, Illinois, Wisconsin and the Dominican Republic. In Ontario, we operate Hotel Dieu Hospital, Kingston. It's a teaching facility affiliated with Queen's University. We also operate a community hospital in St Catharines and health centres in both Cornwall and Windsor.

In both Cornwall and Windsor, in order to improve patient and resident care, we have integrated governance, management and, to some extent, the programs of our acute care facilities with our homes for the aged. The linkages have existed for many years, but recently we have had them formalized. Through this integration, we hope to achieve both improved services and improved economic performance.

In considering amendment to Bill 101, we support the concept of placement coordination. However, our experience with placement coordination has varied. In both Cornwall and Windsor, we operate homes for the aged totalling approximately 400 beds. In each of these communities, there are strong linguistic, cultural and religious affiliations. We hope that the placement coordinators would be required to respect these realities as well as the person's right to choose. In addition, we hope that the placement coordinators would also take into consideration the service agreements as well as the funding levels determined for these facilities. We feel it would be appropriate to include these criteria in the legislation so that all coordinators are guided by the same criteria.

We also feel that the amendment is not clear regarding the rights of a provider. If a placement coordinator makes a placement which is inconsistent with the facility's mission, its service agreement or its funding level, a means of appeal should be available for both the user and the provider. This should be included in the act.

I stated earlier that we have worked hard to improve the quality of care which we provide by the integration of our homes for the aged with our acute care facilities. In some areas where we operate health care facilities, efforts are being made to develop a single entry system for access to residential care, extended care and acute care.

In Ontario, some of our acute care facilities are developing quick response teams to deal with appropriate access. Geriatric assessment programs deal with access to geriatric, acute and chronic care as well as placement coordination to address access to residential care. In Ontario, we also operate an apartment facility for the elderly which is accessible to self-pay tenants, partially subsidized tenants and, in some instances, handicapped tenants. We have developed these corporate linkages to assist in providing ready access from residential care through to acute care. We know that this benefits the users.

It appears that Bill 101 addresses the coordination of access in only one part of the health care delivery spectrum. The need to coordinate health care across the spectrum in an integrated fashion still remains outstanding. So we believe this requires some consideration.

Regarding standards, quality and inspection, our health care centres in Ontario are fully accredited facilities and have received the highest accreditation award. We believe that these results flow from the commitment that the boards, management, staff and physicians have to the mission statement of the facility, which stresses, among other things, the Christian values of: (1) respecting the dignity of the person; (2) providing quality holistic care; and (3) being responsible stewards of the human and financial resources of the facility.

Over the years, our challenge has been to call many people to join us in striving to carry out our mission of serving the poor, the sick and the needy. At times, we are overwhelmed with the public's response and support to the care given in our health care facilities. They have been very positive.

We are concerned about the tone of Bill 101. Rather than calling upon us to develop an acceptable mission statement and to perform in accordance with our mission, Bill 101 proposes the punitive loss of inspection and retribution which is an authoritarian rather than the collaborative approach held up as a model by this government.

Voluntary accreditation has been a successful tool in assessing the quality of care in acute and chronic care facilities. We suggest that it be implemented in residential care as well. The Public Hospitals Act gives the Ministry of Health the authority, where there is an abuse, to appoint investigators, inspectors and supervisors who may take steps deemed necessary to improve the quality of the management and administration of the hospital as well as the care and treatment of patients. We suggest a similar approach in Bill 101.

Earlier in this submission, I referred to the linguistic, cultural and religious realities that exist in our facilities. We try to respond to these concerns in our mission statement and the manner in which we operate our facilities. In recent years, a number of ethical issues have arisen. In each of our facilities, we have established ethics and values committees to help us respond to these fundamental concerns.

Bill 101 does not deal directly with governance issues. We understand that we may be hearing more in this area a little later. When governance is addressed, we hope that it will be enabling rather than directory, which will permit us to continue to respond to the needs of those we serve by dealing openly with the serious ethical issues which are now surfacing.

Relative to funding, we have been involved in providing residential care in Cornwall and Windsor for nearly 50 years. We have participated in the accreditation process for these facilities and have addressed ways and means of improving the quality of care we provide to our residents as well as improvements in management and administration. Our greatest concern has been inadequate funding. Perhaps the proposed service agreements and the new funding levels will assist in stabilizing the funding issues. We hope so, because the present financial situation cannot continue or we will soon find many of our long-term care facilities unable to continue to serve those in need.

We thank you for the opportunity to present our submissions. We recognize and endorse the reform of long-term care. We desire and wish to collaborate with government in ensuring that those in need have access to our facilities and that the care they receive is appropriate and cost-effective. Lastly, we hope that the Ministry of Community and Social Services will recognize that access and quality care can only be provided when the facilities are adequately funded. Thank you.

The Acting Chair: I thank you very much for coming before the committee. You bring back memories, because I remember when I was a student going to high school here in Kingston I did do some work at the Hotel Dieu Hospital; you provided a summer job for a student who needed it. Now, Mr Hope, do you have something or Mr Owens?

Mr Owens: Mr Hope is the parliamentary assistant, so I'll defer to Mr Hope.


Mr Hope: I got in here a little late so I was reading up and getting caught up on it. One of the areas I want to touch on because it seems to be a high emphasis on the inspection process -- I heard those individuals who are being accredited through the accreditation and I believe it's about 50% of the nursing homes and the homes for the aged that are accredited and 50% that are not.

But I've heard through the presentations people are saying consistency of all three different -- you know, and then when it comes to inspection there seems to be a little bit of non-consistency. My biggest fear is around -- I'm hearing in your presentation you're talking around the Public Hospitals Act, where the minister would have the authority to appoint an investigator and an inspector. So I'm taking that to be that it has to be the will of the individual to file a complaint.

Sister Kugel: Not necessarily. That can be from family. A request can come through that there is abuse. Staff can present it. That is not necessarily the way.

Mr Hope: But we're looking forward for the general public to come forward other than working on a proactive approach and trying to go in and do, because those were accredited, and those who have good standards and everything else -- I'm sure the inspectors would be better off to deal with those who are not complying. I've had one problem in my own area where the owner just walked away from it and I talked to the workers of staying on and making sure that we could get a placement coordination in place.

I'm really concerned. I was going through some of the history books looking at health and safety issues. I believe it was the Tory government that brought in the legislation, and everybody was concerned about the inspector title that was there. They were saying, "Well, why should we need inspectors when people can speak?" Then once the system was in, those who have a good working relationship with inspectors continue to have that. I don't think they come down with a hammer or the militancy.

I understand what you're saying. You've got a good record. I know about your facility in Windsor. I'm just saying in order for consistency, we just can't say, "Those good ones that have accreditation don't need inspectors and those bad ones that are not accredited need inspectors." I'm wondering about consistency across the board. I've been hearing that quite a bit.

Sister Kugel: I believe that, as I had mentioned, I think accreditation -- and it's strongly recommended that it would be across the board. I believe the speaker before me kind of insinuated or made the comment that it's a little against professionalism. If you're always waiting for the possibility of an inspector to come in, that's not the manner in which you'd like to function.

If you would be carrying through on an accreditation process on a regular basis and you're following standards, it's very easy to gauge your whole operation, and that goes through all levels. Also, you have your quality assurance committees in all your facilities now. Certainly that's reported to your board. Your board requires that it receives the reports. I think it takes a little bit away from your independence or the whole sense of accountability of your board for your facility and for the operation of it. So I still believe that accreditation would be better.

Mrs Caplan: I'm very familiar with your facilities. Nice to see you, Sister. I think we should clarify something. I've been advocating over the last couple of days exactly the model that you've proposed and I want to put on the record that we've never discussed this, your presentation, before, and the fact that your ideas are very similar to what I've been suggesting is coincidence. Is that correct?

Sister Kugel: That's right, because I've never heard you. I wasn't here.

Mrs Caplan: I just thought we should put that on the record. There was no collusion in the development of your presentation for the committee.

Sister Kugel: None whatsoever.

Mrs Caplan: I agree very much with your proposal and I believe that it is forward-looking and outcome-oriented and positive and will result in improvement rather than the big-stick approach. I also have had, as you know, opportunities to see how the Public Hospitals Act process works and it does work, because it is a very big stick that you don't want to use unless out of a concern for the jeopardy of individuals.

For Mr Hope and anyone else who's interested, anybody can trigger that concern, and the minister can send in an investigator under the act, but usually you don't even have to send an investigator under the act. You can contact and say, "Do we have to use the act or can we send someone in to investigate without the act?" So the process of that act has worked extremely well.

Mr Hope referred to the occupational health and safety, and I would point out to him that the whole concept of the adversarial labour management inspector attitude is just outdated, outmoded and what we're looking at is new. You may want to comment on that further, but you've really called for a statement of principles.

We've also been talking here about an amendment that would include in the legislation a statement of the guiding principles, which would be multicultural, linguistic, religious, social and so forth. Would you like to see that in the legislation?

Sister Kugel: I believe it would be a good idea, but I think when we were making our statement that this would be taken into consideration by that placement coordinator very much, and I think that's why we were stating it, whether it really needs to be in there. It would be a good idea.

Mrs Caplan: The suggestion for an amendment would be more of a statement of principles that would guide the placement coordination --

Sister Kugel: That's right.

Mrs Caplan: -- and also the long-term care facilities as they work together to provide better care. That was the concept of a statement of principles, to guide the legislation. Is there anything further you want to say --

The Acting Chair: This is the last question.

Mrs Caplan: -- on the proposed model and why a positive approach is better for the people you're trying to care for, and perhaps the role of the staff, how it's changed?

Sister Kugel: I'm sorry, I'm not quite --

Mrs Caplan: In providing improved care, how you get your staff involved in your process.

Sister Kugel: The staff would be very much involved with your quality assurance programs, and that is ongoing. They get the reports back, and any deficiencies would be brought back to each of your departments.

Mrs Caplan: There's a lot of monitoring.

Sister Kugel: It's monitored, yes, and then the board receives a report and if there hasn't been improvement, it's taken back. So at all levels it's monitored. The monitoring is carried out within your facility, not heavy-handed. When it has to be, then we would agree with that, but to put it in a regulation for everyone who is really doing very fine work -- and I think most of our homes are and your long-term facilities are. Collaboration's the name of the game, and not the heavy hand today, I would say.

Mrs Caplan: Thank you, Sister.

Mr Villeneuve: Thank you, Sister. I must tell you, I'm quite familiar with St Joseph's Villa in Cornwall. Sister Kane, on many occasions when she was there, told me about the funding problems. I guess it hasn't changed a great deal.

Sister Kugel: It hasn't.

Mr Villeneuve: Is it still the situation where your patients are much older and much more care-demanding than all other facilities? I can only speak of Cornwall, because that's the one I'm familiar with.

Sister Kugel: I believe when they come in, they're residents. At this point there would be 50 residential, 100 extended care. When they first come in, they're residents, but their level of care changes and your funding does not accommodate that. That base does not change. So this is where the problem is from day one. It's just continued, because there has not been the reform.

Mr Villeneuve: The other one then -- we're not going to solve it with this particular committee -- but the moral and ethical issues that you touch upon I think must be borne in mind by this committee, by the minister and by those who will be administering Bill 101, because we know what's before the courts now and it's going to get much more complicated. It's great that you brought it to our attention. Thank you very much.

Sister Kugel: There will be -- and this is where we are initiating -- our ethics and values audit committee, and that will be audited too. But certainly we have policies that we will have to develop. As you know, the whole idea of euthanasia is being brought forth, nutrition, hydration. I think all of these issues need to be considered, so they will be dealt with within our committees.

The Acting Chair: Thank you very much, Sister, for coming before us and giving us your views and, I would say, good advice.

Sister Kugel: Thank you.



The Acting Chair: Now the Association of Roman Catholic Chaplains, Father Stitt. Welcome to the committee.

Father Ken Stitt: Thank you very much.

The Acting Chair: If you would identify yourself for Hansard, please, and then present your report.

Father Stitt: My name is Ken Stitt. I'm the director of the Association of Roman Catholic Chaplains for this area, referred to as ARCC. I understand, I just discovered, you don't have a copy of my brief. I assure you it's just that -- it's very brief -- and ask you to bear with me for a few moments.

The Association of Roman Catholic Chaplains came into being in this archdiocese of Kingston in 1977 to provide pastoral workers, mostly lay workers and chaplains, with an educational program designed to promote specialized pastoral care to our seniors residing in nursing homes in this area, long-term care facilities and hospitals, both the chronic and acute care hospitals. Being parish-based -- and we think that's the secret of our organization -- the association strives to reconnect, where possible, our senior population with their respective faith family. In this manner in this training program, we believe we are indeed empowering the laity to be actively responsible for health care at the local level, meaning the parish or the congregation.

Our association sets standards of education whereby all graduates are certified to provide top-quality, we believe, pastoral care. Having a Roman Catholic basis, our membership includes pastoral workers from the Anglican Diocese of Ontario and also the United Church of Canada in this Bay of Quinte Conference.

The archdiocese of Kingston, our area, stretches along Lake Ontario and the Bay of Quinte from Trenton on the west to Chesterville on the east and goes north to include Carleton Place and Marmora. In a recent study to find out how many beds we had in the area, we discovered we have a total of over 3,700 long-term care beds occupied by seniors within the archdiocese. Understandably, we administer to more than this number, because our approach is not just archdiocesan but rather ecumenical and holistic.

We are well aware of and recognize the unique aspects of culture -- someone mentioned culture before -- family support and spiritual values -- Sister mentioned spiritual values -- of seniors with whom we work. In the past, we understand from experience that admission to long-term care facilities did respect the aforementioned cultural milieu of the person's ethnic traditions, family involvement, family locale. In the process of placement in the past, we understand, some degree of choice was indeed exercised by the patient, the resident or the family.

While the proposed amendments to Bill 101 goes a long way in supporting the uniqueness of the senior population, we do have some reservations about the role of the placement coordinator. That came up before. In our society, the right of choice has been fundamental to the human dignity of the individual. We of ARCC fear that this basic human right of choice might be eroded if the individual is not given choice in placement.

In reading the proposed legislation, the placement coordinator could possibly and most likely will control -- a funny word, "control" -- placement to one or more facilities. This placement coordinator may receive a request from an individual or family to be placed in a specific home or placement because of its locale, its religious or cultural affiliation or its ethnic complexion.

We are concerned as to how much weight the applicant's choice will have under the proposed new system of the role of the placement coordinator, so we ask respectfully that the committee and the government proceed with great care in this sensitive area of placement.

I thank the committee for the opportunity to be part of these proceedings. Thank you. It was short.

The Acting Chair: Thank you, Father. We begin the questioning with Ms O'Neill.

Mrs O'Neill: Father, thank you for coming. I've just had a very personal experience of my dad's death last month. In the hospital -- actually, they call it a health facility -- in a large Ontario city, there is a pastoral team of 32. It was an outstanding experience. I would suggest that the pastoral care was every bit as much of importance to myself and likely to my father as the medical care that we received in his last few days.

I really liked your little -- I think it was almost an aside when you said, "Funny word, `control.'" I think any of us who have brought up a family or have experienced any kinds of personal relationships know that is a very strange word when we talk about individuals. I think you're highlighting from a very poignant perspective the right of choice and the jeopardy that many feel the right of choice is in with Bill 101.

We have suggested, and maybe you heard us earlier this afternoon, setting some guidelines or statements of principles in the bill regarding the role of the placement coordinator because we think it's so fundamental.

I think communities, and yours is one, where placement coordination has gone on quite successfully -- levels of trust have been built over perhaps 20 years in some communities -- people are still feeling fairly comfortable. But with one individual, and it could be one individual according to the legislation, or an agency where there has never been this experience, or certainly in the territories that are not as organized as many of our urban areas, I think there's a great deal of fear.

You bring it, as I say, from an area of work that you've taken upon yourself where you feel that you need the flexibility, you need the guarantees that the people you have worked with over the years have been able to receive in this community and you want those maintained, if I can paraphrase what you've been saying.

I thank you for coming. I think you are the only pastoral care worker who has come, or chaplain, as the term used to be used more frequently. We've had a lot of people talk about your work and present it as part of their brief, and we've had people talk about pastoral care committees, but I think you're the first one who's come in person to present from your perspective your daily work over the last 20 years, so thank you so much.

Father Stitt: Thank you.

Mr Villeneuve: Father, thank you very much for coming. I have the privilege of representing the far-easternmost section of the Kingston diocese and it's nice that you're on record here with placements being of major concern; 3,700 beds, I believe I heard you mention. Surely, with that kind of accommodation, local autonomy is most important. We've had it brought to the attention of the committee time and again, and I think you simply reinforced the fact, that local people with input from the people of the area can do it so much better than a hierarchy or a bureaucracy or controllers, as I guess you've used. So I don't have a question for you, Father, other than to say thank you for emphasizing that to the committee, to the minister.

Father Stitt: Thank you, Mr Villeneuve.

Mr White: Thank you, Reverend Father. I agree wholeheartedly with Mr Villeneuve's comments about the importance of the placement coordination and the services being operated locally. The funding of course for those local services has to come from the province. That, I believe, is the very stated intent and has been made several times by the parliamentary assistant, that the existing placement coordination services, the existing services, are the ones that will be doing these services, but they will be coordinated and informed by a local committee from some of the facilities you mentioned, from some of the local services.

What I would want to ask of you would be whether you feel that the importance of the spiritual and social needs of the elderly should be there as directing those committees, as directing that placement coordination in the regulations.

Father Stitt: Do I feel they should be?

Mr White: Yes.


Father Stitt: Yes. Unofficially, we are meeting with people from both dioceses and with the local United Church and the district health council, just informally, on this very issue, how we can share and be part of what's going on.

So often I find in long-term care facilities that the resident has been removed from their faith group and they're just at sea, and I've seen wonderful things happen when they have been reconnected with the faith group, great things.

Mr White: I'm wondering also if I could ask you about how your services work. You've mentioned the involvement of the United Church and the Anglican Church. My own experience was that my family were Presbyterians. Not unlike Ms O'Neill, the pastoral care that was offered to my family on the demise of my father was every bit as important as the medical care. How do you interrelate with other faiths?

Father Stitt: I'm delighted you asked me that.

Mr White: I thought you might be.

Father Stitt: I think about seven years ago I was approached. The university was looking for some funding for pastoral training and we were looking for a program, and so there was a happy marriage. What happened is we have developed a program. There are two programs going on. There's one for professionally highly paid pastoral workers. Our program here in this diocese consists of 200 hours and we train people to work in a volunteer capacity. Of all the churches, we seem to be about the only trained program around for pastoral workers.

The only people who have joined us so far is the Anglican diocese and individual members from the Bay of Quinte Conference of the United Church. We're going to run three programs for three years and so we hope to attract -- we have new programs starting on April 16 and it will be a multifaith group, we hope.

Mr White: So you even involve the canny Scots, you hope.

Father Stitt: Yes.

Mr White: Thank you.

Father Stitt: Thank you for asking.

The Acting Chair: Thank you, Father, for coming and providing us with this information. As Ms O'Neill said, you are the first, so you are unique, and I thank you for being here this afternoon.

Father Stitt: Thank you very much.


The Acting Chair: The last presentation this afternoon, Providence Health System. Sister Sheila Brady, welcome to the committee. Perhaps you would identify yourself for Hansard, please, and give us your presentation.

Sister Sheila Brady: Thank you very much, Madam Chair. We were falsely called Providence Help System, and maybe it wasn't so false. They do call on us for help quite often.

My name is Sister Sheila Brady, a Sister of Providence of St Vincent de Paul. I am representing our Providence Health System in Ontario. Our congregation sponsors eight homes and hospitals across Canada from Ontario to British Columbia, with extensive experience and commitment to long-term care.

Here in Kingston we founded and continue to sponsor Providence Continuing Care Centre, which is comprised of St Mary's of the Lake Hospital and Providence Manor, a charitable home for the aged. In 1861, our founding sisters gave refuge and compassionate care to the elderly, poor and sick in Kingston and area. Our financial resources were nil and our sisters were obliged to go begging at that time, and now we come begging to the government.

A long and excellent tradition in caring for the elderly has continued, and from this base we believe we have much to offer your committee as you seek to amend legislation regarding long-term care in homes for the aged and nursing homes in Ontario.

Providence Health System supports this government's initiative in redirecting our long-term care system. Reform is needed and we laud your courage to do so. It has been a frustrating time for us as well, struggling with the inequities in resource allocation to Providence Manor and erosion of our equity through deficit funding, while maintaining high standards of care. We continue to address the needs of our residents holistically in collaboration with them. However, we feel there are serious potential implications to Bill 101 with its amendments of various statutes dealing with long-term care.

We view Bill 101 as regressive in some areas, providing a tighter reign on homes whose standards are unacceptable, yet at the same time punishing those homes that strive for excellence in resident care. We question whether this proposed legislation balances the protection of the frail elderly while ensuring cost-effectiveness in the system.

We encourage the government to build on the strengths already in place and not attempt to homogenize homes with central control in inspectors' hands.

Providence Health System would like to address the following implications noted in the proposed legislation: First, governance issues; second, quality care issues; and third, residents' right of choice.

Governance issues: The strength of our home for the aged, Providence Manor here in Kingston, lies in its governance by a volunteer board and a high calibre of administrative staff. These board members and leaders are committed to ensuring safe, compassionate care in the spirit of our founders within the limits of scarce resources. They have been and are now accountable to our residents and their families, to the Kingston community, to the Sisters of Providence of St Vincent de Paul and to the Ministry of Community and Social Services.

We recommend that you build on governance autonomy, authority, accountability and flexibility to meet the ever-changing needs of our elderly and disabled residents and day clients.

The Sisters of Providence and our governing board of Providence Continuing Care Centre have been leaders in continuing care in Kingston. As stewards of a denominational home, we are vigilant in ensuring that legislation respects our tradition and mission in long-term care, just as we respect you and your role to address the inequities in the health system with dwindling resources.

Quality care issues: Bill 101 promotes quality assurance, and with good reason. The leadership team at Providence Manor is instituting a total quality management program which embraces far more than just quality assurance to meet high standards and expectations in resident care. The principles of this program empower our employees to make decisions at the lowest possible level and motivate them to strive for excellence in quality care.

We urge you to balance costly outside inspections with strong total quality management principles which our voluntary board accepts as a major responsibility to ensure high standards of care.

Freedom of choice: We have collaborated and cooperated with the staff and placement coordination service in Kingston for many years, both at Providence Manor and St Mary's of the Lake Hospital. Again, we urge you to build on that strength. Bill 101 addresses eligibility of residents based on levels-of-care funding guidelines. We trust the coordinators will also take into consideration placement based on spousal or family approximation, on their preferred culture and on the religious affiliation of the home.

We agree in the fundamental concept of appropriate access and utilization of scarce resources, but the rights of individual residents and their families must be respected as well.

In the legislation, an appeal process is to be initiated to determine ineligibility of resident placement. However, individual homes are denied an appeal process, and we urge you to review this.

In conclusion, I wish to thank you for the opportunity to express our concerns here in Kingston. We would request that this committee be attentive to our concerns and address them.

The Acting Chair: Thank you very much for coming forward. If we could, we'll begin the questioning with Mr Villeneuve.


Mr Villeneuve: Sister Brady, thank you. Again, the placement seems to be a major concern. I think you've articulated well the fact that indeed homes should also have in place a mechanism whereby they could appeal and I'm just wondering -- I'm subbing on this committee. I've not been a member of it at all and I'm privileged to be able to. I'm learning here as well. Would the parliamentary assistant want to comment on that, if indeed that's being considered? When we look at religious orders operating, certainly there is a situation here that --

Mr Wessenger: I can only explain what's in the legislation right now in the sense that the consumer choice aspect is very much a part of the process in which the placement coordination works. It's a basic principle. Certainly we're looking at ways to see if we can make that clearer by having some statement of principles or something of that nature in the legislation. So yes, we're looking at that.

At the moment there is a right of refusal of a facility, but other than through the courts, there would be no other appeal process. The only thing I can say is that would be a matter that would be taken under consideration.

Mr Villeneuve: Sister, it sounds positive. It sounds like they're listening.

Sister Brady: It sounds like they are.

Mr Villeneuve: Thank you.

Mr Hope: We always listen.

Ms Carter: Thank you for that very brief and concise report.

First of all, the governance issues: This Bill 101, as you know, is only a partial bill as far as reforming long-term care is concerned. I understand that governance is one of the things that is going to be looked at later. Obviously, it is a matter of great concern but it's not, as such, dealt with in that bill, so we're still looking for whatever information will be on that.

I'd also like to raise the quality-of-care issue. That's one that keeps on coming up. Obviously, we all want the best possible quality of care in all our institutions. I think the point is that a lot of institutions do not need a lot of external monitoring. They have internal mechanisms, but sometimes more than that is needed. When we look at the spectrum of possibilities, the Advocacy Act is going to be coming into force. That will give residents a right of individual appeal other than what they have at the moment. They are going to have personal plans of care which are going to be available to them, so hopefully that will help.

We know there are residents' councils in quite a lot of facilities, and we feel that's a very helpful thing too, although not something you can legislate and enforce, because it has to be spontaneous.

But having said all that, there is still the problem of homes which are not meeting standards. We do know from some of our presenters that those homes still very much exist. I was just wondering if you could comment on what we do about that and whether in fact some form of inspection is not needed.

Sister Brady: I think I mentioned that especially with inspectors coming in, we're just afraid all the homes will be tarred with the same brush and we don't think some of them really need to be.

Ms Carter: I agree with that, but what about the others, and how do we legislate for that?

Sister Brady: When I was in Alberta, and I worked there as well, they had what they called a premier's committee, I believe, that used to come around to the hospitals, the homes all over the province. They didn't come as inspectors; they came as a committee of concerned citizens. That was a very interesting committee. We never looked on them as real inspectors and we knew that our quality was high. We had very few concerns in our facilities. They certainly righted some of the wrongs that were going on in some of the health facilities I know. So that is one area this committee might look at. It's not as threatening as your inspectors. I hate to see us go back to that and put the control in their hands. That committee made recommendations and we made sure we did something about them, but it didn't carry a heavy stick.

Mrs Caplan: Thank you very much, Sister, for an excellent presentation. It's been a long day. I think I speak for all members of the committee in that we've had so many excellent presentations here. We've been hearing the same themes but in very different ways and from personal experiences. The themes you've raised are similar. I'd like to be specific and ask you whether or not you would support the following kinds of amendments. Would you support an amendment that made accreditation mandatory rather than voluntary?

Sister Brady: Yes, I would, very much so.

Mrs Caplan: Would you require, either in the contract or just as a requirement of the ministry, that quality management be the approach for continuous improvement within the facility?

Sister Brady: Yes.

Mrs Caplan: I disagree with Ms Carter. The Nursing Homes Act makes residents' councils mandatory. Would you be comfortable with this legislation mandating residents' councils for all long-term care facilities?

Sister Brady: I think you'll run into a problem. We're finding that more and more in our homes are getting very frail, and not that many can serve on residents' councils.

Mrs Caplan: What about the concept of resident or family councils so you could have the family involved?

Sister Brady: Family; that would be fine. Yes. We use ours very much. We really listen to them and they have a lot to say about their care.

Mrs Caplan: Again, comfortable with financial disclosures?

Sister Brady: Yes.

Mrs Caplan: Would you be comfortable with an amendment that allowed or gave the right to long-term care facilities to refuse an admission on the basis that they didn't think they could provide appropriate care, but allowed for an appeal of that right and an exception in emergency situations?

Sister Brady: That sounds reasonable, yes.

Mrs Caplan: Also, I'm assuming that you'd like that statement of principles we talked about.

Sister Brady: Yes, very much so.

Mrs Caplan: The other is an amendment on the amount of time that we've been talking about. This is the question I have for you. How long do you think it's reasonable to give for an appeal process?

Sister Brady: I haven't had any experience in that, so I really can't answer that.

Mrs Caplan: Okay, thanks very much. The only other thing we'd asked for was a definition of "long-term care facility." It's absent from this legislation. I wonder whether you think it's important or whether a long-term care facility knows it's a long-term care facility and you don't need to try to define it.

Sister Brady: I think they know.

Mrs Caplan: They know?

Sister Brady: Yes, I hope so.

Mrs Caplan: Thanks.

The Acting Chair: Thank you very much, Sister, for coming today. I wish, at this time, to thank all of the presenters who have taken the time to come before us. It really does help us, especially those who have had to travel. I know some of those people have left and I should have thanked them as they left, but we really do appreciate your efforts in getting here and we certainly do appreciate the kind hospitality shown to us here in Kingston.

Mr Hope: I think I recognize the dedicated three who have been sitting there since early this morning.

The Acting Chair: I guess so. You win the medal of longevity, or something like that. Also, thank you to the committee members, who have been fairly congenial today. I really want to congratulate you all.

Mr Hope: It's Elinor. She keeps trying to provoke me.

The Acting Chair: Let's not start. Certainly, thanks to our clerk, who looked after us so well this week, our legislative research person, all our ministry staff who have accompanied us and also our Hansard people. Thank you very much for an enjoyable week.

Mrs O'Neill: Madam Chairman, before we adjourn, could you give us, now that this series of hearings has come to an end, when we meet next as a committee? I think that decision's been made, hasn't it?

The Acting Chair: I believe it is March 8 at 10 am, Queen's Park, probably in committee room 1 or 2.

Mrs O'Neill: It's for hearings, is it?

The Acting Chair: Yes, the Toronto hearings.

Mr Hope: One of the things we've discussed as a subcommittee is that the total week of March 8 will be public hearings, and then the Tuesday, which will be March 23, we'll move into clause-by-clause.

Mr Wessenger: No. May I just clarify that?

Mr Hope: No, you're not going to.

Mr Wessenger: On the 22nd and 23rd --

Mr Hope: The 22nd is a Monday. We're going to exclude the Monday because some people will just be returning from March break. So we've now moved to the Tuesday and the Wednesday, March 23 and March 24, two days for the clause-by-clause. That's the intent. It sounds very good. There'll be clarification of that on March 8, but the week of March 8 will be totally public hearings.

The Acting Chair: Thank you very much, Mr Hope, for that information. The committee stands adjourned until March 8 at 10 o'clock.

The committee adjourned at 1741.