Thursday 11 March 1993

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

Sunnycrest Nursing Home

Jean Forrest, administrator

Ontario Dental Association

Dr Aldo Boccia, member, health care committee

Copernicus Lodge

Stan Mamak, board member

AIDS Action Now

Patti Bregman, volunteer

Leisureworld Inc

Herman Grad, president

David Cutler, vice-president, operations

Villa Care Centre

David Jarlette, administrator

Royal Canadian Legion

Dave Gordon, deputy district commander, District G

Jim Margerum, district commander, District G

Dr Joel Sadavoy

Victorian Order of Nurses, Simcoe county branch

Melody Miles, executive director

Victorian Order of Nurses, Waterloo region branch

Elizabeth Allan, executive director

IOOF Senior Citizens Homes Inc

Cindy Trapp, director of finance

Don Mills Foundation for Senior Citizens, Inc

Joseph Bogdan, board member

Bill Krever, president and chief executive officer

Association of Placement Cordination Services of Ontario

Joyce Caygill, president


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

*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:

Carter, Jenny (Peterborough ND) for Mr White

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

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

Malkowski, Gary (York East/-Est ND) for Mr Owens

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

Sullivan, Barbara (Halton Centre L) for Mr Daigeler

Wessenger, Paul (Simcoe Centre ND) for Mrs Mathyssen

Also taking part / Autres participants et participantes:

Czukar, Gail, legal counsel, Ministry of Health

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

Wessenger, Paul, parliamentary assistant to the Minister of Health

Clerk / Greffier: Arnott, Douglas

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

The committee met at 1009 in committee room 1.


Consideration of Bill 101, An Act to amend certain Acts concerning Long Term Care / Loi modifiant certaines lois en ce qui concerne les soins de longue durée.

The Chair (Mr Charles Beer): Good morning, ladies and gentlemen, and welcome to Thursday, March 11. This is the meeting of the standing committee on social development to review Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: Our first witness this morning is from Sunnycrest Nursing Home. We welcome you to the committee. If you would be good enough, first of all, to introduce yourself for Hansard and for the committee members, then please go ahead with your presentation. We'll follow up with some questions.

Mrs Jean Forrest: My name is Jean Forrest. I'm the administrator of Sunnycrest Nursing Home in Whitby, Ontario. I'm glad to have this opportunity to speak to you on behalf of the residents and the staff of the nursing home.

Sunnycrest is a 136-bed facility. It has been owned by the present owners for 25 years. It was originally a large house and we added on to it in 1971 and then again in 1983. At that time, we upgraded all of the facility and added a respite bed. We're a large, modern facility. We're located on three floors, we have no structural deficiencies and we're in compliance with all regulatory bodies.

I joined the staff in 1983 as director of care, and I've been administrator since 1985. I'm a registered nurse. I have a certificate in gerontology and a BA in health services administration. I'm a member of the Durham region placement coordination committee.

The staff of our home were awarded the Ontario Nursing Home Association staff achievement award for the care college in 1987, where our residents attend courses, receive credits and then they're given a certificate. We're respected in the community for the level of care that we give our residents. We were awarded accreditation status in 1984 and we've remained accredited ever since. We received a three-year award in 1986, in 1989 and in 1992. All of our residents are extended care level. Our average age of residents is 85. We have 120 staff. Most of them are organized under CUPE. We have a strong volunteer group and numerous educational and community groups use us for work placement projects. I hope that gives you an overview of where we're coming from.

I'd like to address, in Bill 101, the following areas: the service agreement, placement, inspection process, quality assurance and plans of care.

The service agreement is crucial to the functioning of any home, and for us particularly. Through it, funds will flow, programs will be provided and therefore care will be determined, but we have not yet seen this document. We're expected to move from a system of funding per bed to a system of funding for programs which we will agree in advance to provide, but we're not told what dollars are available to fund these programs. It would appear that we're to state what we are intending to provide to our residents without knowing if we'll be able to pay the staff who will be required to deliver the care.

We recognize that as more and more people elect to stay at home, being cared for by community programs, the person who will need our care will require more levels of care that at this time we don't provide; for example, catheter care and oxygen therapy. This care has not been part of our philosophy, as these care needs can only be met by registered staff. Our present funding does not allow us to increase the number of registered staff. The government has indicated that the homes will provide this level of care, but we have not been assured that adequate funding will be provided to enable us to increase that level.

We are caught in a dilemma. Do we say we will provide this care, trust that funds will be there, or do we face reality and say that because we don't know what funds are available, we're unable to provide the care? Should we state that we cannot provide the care, where does that leave the residents in the community who need long-term beds and we can't meet their needs? It would appear also that if we don't find an agreement, we'll no longer be a nursing home. We must know what funding will be available for each level of care before we can make an informed decision as to what care we are going to provide. These decisions need to be made before we can sign the agreement.

Our strategic plan foresees us being a community resource providing programs to meet the needs of the elderly. We could provide wheels to meals, Meals on Wheels, day programs, podiatry clinics. We could share our physiotherapy and our pastoral care services. We could coordinate staff providing care in the community. We can provide any level of care that we can train our staff to give. Our ability to train will, of course, depend on the funding available.

Bill 101 indicates that placement to long-term-care beds will be controlled by a placement coordinator, but this coordinator has not been identified. It raises concerns for us, as placement is crucial to our ability to provide care. The coordinator has been given the sole power to determine who will be eligible for a long-term care bed.

There is an avenue of appeal open to the family should they disagree with the decision. Mention is made of final appeal to the courts. I wonder who will bear the cost of this. Does this mean that families who couldn't bear the cost would not be able to appeal?

There is no avenue of appeal in this bill for the homes.

We may have very grave concerns with the care needs and the ability of that person who is coming to us to fit into the bed or the area. Persons are not being placed into an empty house; they are being placed into the home of 135 other people. The home must have a voice that this placement is suitable before the placement is made. The needs of those already placed must be taken into account. We must be able to make our voice known.

The fact that a person is deemed eligible and is the one who has top priority is not all that's required to make a suitable placement. Human beings are complex. They cannot be reduced to a few pages on an application form. The home and the placement coordination service must have the freedom to work as professionals, as a team, for the benefit of all residents, those already in the home and the person seeking placement.

The present system that we have in Durham region of placement coordination service works well for us. In this system, the family has a choice of where they would like to be placed. I don't see that choice evident in Bill 101. We stress the need for avenues to be identified where those awaiting placement can have their choice known and honoured.

We are now in a state of crisis. Our residents are growing older. Some of them have lived with us for more than 20 years. The residents we are admitting have remained longer on community supports and require more care, but we have not received funding to address that problem. Our staff are asked to give more and more and to work for less money than other sectors are providing. We are paid $77 daily and the government knows that it takes $120 daily to keep a resident in a municipal home.

Who bears the brunt of that inequity? Our residents do. These are the same ones who paid the same taxes as the people who live in a municipal home. The court case that the Ontario Nursing Home Association brought forward identified that this inequity does exist, but Bill 101 does not appear to identify any strategies to correct this. In fact, it appears to allow that some homes can be funded at different rates than others. Where does that place the vulnerable elderly person who is placed in a home that's not funded to provide the same care as another home?

Our staff are the other ones who are affected by this inequity. They're being asked to do more and more, when funding to address the levels of care is not forthcoming. The Ontario liquor board pays staff more to stock bottles on the shelves than Ontario pays to have its elderly looked after.

Too long have you used the excuse that the private sector should not be funded because it makes a profit. Mechanisms are in place to ensure that funds are directed to specific areas. Financial statements are filed with the government annually. We post them for public viewing. Business taxes are paid to municipalities. GST and PST are paid to the respective levels of government. Buildings are erected and maintained without government investment.

The government has recognized the need to continue to use the private sector in providing care to the elderly. It's the government's responsibility now to ensure that these elderly receive equitable care.

It has taken many years of collaborative effort by the Ministry of Health and nursing homes staff to reach the present level of respect and trust that is exhibited between the residential services branch and the homes. We are not adversaries in providing care to the elderly. Homes and ministry want the same thing: to meet the care needs of all aspects of the resident's life and to provide this care in a safe and comfortable environment.

Why then does this legislation revert to the use of inspectors, when we have already achieved the compliance program? That program was put in after the government's own study by Woods Gordon.


Care givers in the homes are, in the majority, people who desire to serve the elderly. Their jobs are not easy; in fact, they've got very difficult jobs, with many stresses. We have policies and procedures in place the meet the requirements of the Nursing Homes Act, the health and safety act, the food premises act, the fire code, and I could go on and on. Staff are required to adhere to all of these while they deal with the very particular needs of the frail elderly. It's extremely demoralizing to know that an inspector is in the building reviewing the work they're doing.

Please continue to use the compliance system, where staff are able to communicate. Residents are better cared for by staff who feel appreciated rather than the focus of inspections.

Bill 101 refers to such systems as quality assurance.

Nursing home administrators are required to be licensed and to have a certain level of education. Most homes are accredited. All homes are monitored by the compliance management program. Surely these systems will ensure that high-quality management systems are in place. There is no need to identify specific management systems in regulation. Identification of such systems will actually hamper the natural evolution of good management processes. For example, Sunnycrest has had a quality assurance program in place since 1985. This has further evolved through quality management, and at present we have a program of continuous quality improvement.

We believe that the government should set systems in place to identify the care it requires and have systems that monitor whether that care is being given. The management of the facilities should be left to the professionals who are qualified to do it.

As with quality assurance, we find problems with identifying plans of care in legislation. The act specifies that residents will be cared for by registered staff. Registered staff are professionals. They're regulated by the College of Nurses and, as such, they must develop a plan of care for any person they care for. Government really should take a leaf out of its own book and use quality management processes which will empower the professionals to do the job they're qualified to do.

Bill 101 has set out many sanctions that can be used against a home, without identifying any accountability for those who have the power to enforce the sanctions. There's little evidence that the residents have been given any avenues to strengthen their voice.

The tone of this bill infers that homes are adversaries of the resident, when the reality is that nursing home staff, at every level, hold the resident in high esteem and want to give the best care possible. We can only do this when the government recognizes the needs of the elderly and provides equitable levels of funding to enable us to meet those needs.

Thank you for this opportunity to make our concerns known.

The Chair: Thank you very much, Mrs Forrest. You mentioned to me at the beginning that this is your first time before a committee. If everyone who came before a committee for the first time put the work and effort into the presentation that you clearly have made, I think we would be a lot better off. We thank you for your first visit, hopefully not the last. We'll begin questioning with Ms Sullivan.

Mrs Barbara Sullivan (Halton Centre): I too appreciated this brief. It really addresses the pragmatic issues that are facing nursing homes and indeed homes for the aged across the province, because they are working in an atmosphere that is basically one of a lack of knowledge and a lack of information about which to plan. Therefore, my questions are going to be to the parliamentary assistant. I'm going to ask him, first of all, what funding will be available for each care level, and when homes will be informed of that so they can draft their budgets and prepare for the case mix index within their own properties? What funding will be available to enhance the skills of workers in existing homes to perform the services which now will be not only allowed but perhaps mandated in homes, and must all homes provide those services? Ms Forrest has indicated two or three areas of increased service which are not required everywhere. Third, who will cover the cost of the appeal, and will intervenor funding be available? Is that contemplated?

The Chair: We have the parliamentary assistant.

Mr Paul Wessenger (Simcoe Centre): Unfortunately, ministry staff has not heard the questions. I'll address the first question and refer to staff, because the first question involved the funding. As we know, there's the general overall funding of $206 million for the facility sector.

Mrs Sullivan: I think the interest was in the level of funding for each care level as it's identified on the case mix index.

Mr Wessenger: I'll ask ministry staff to indicate that.

Mr Geoff Quirt: Geoff Quirt, acting executive director of the long-term care division. I have to say that for the record at the start of each day.

The Chair: We just want to make sure you know who you are.

Mr Quirt: Some days, I'm not sure.

The funding will be provided through three components in the three-part funding formula. The funding that's available will be the funding currently provided to nursing homes and homes for the aged plus $206 million generated through the redirection of long-term care. That funding will be divided among facilities in the following way:

All facilities will receive a fixed rate for providing accommodation services. That rate is yet to be finalized but will be more than $38 a day, which is what the residents will be requested to pay if able to do so based on their income. There will be a second amount of money that will be a fixed amount of money, provided on a per-client, per-day basis, that will be available for quality of life programming. Because there's no accurate way to measure someone's need for spiritual care, recreation, physiotherapy or occupational therapy, that funding will be provided on a per-client, per-day basis.

Mrs Sullivan: Do you know the level of that funding, Mr Quirt?

Mr Quirt: No, we don't at this point. I'll explain in a moment how we'll arrive at that level of funding. The third category will provide funding based on the nursing and personal care requirements of residents. That funding will vary in accordance with the actual care requirements of people in each facility, and it will be varied by comparing one facility to all other facilities in the province through a system of case mix indices.

Following completion of the estimates process within government, we will confirm how much funding is available in the base budget for nursing homes and homes for the aged, a process that happens each year. We will then calculate the average funding for each individual facility, and we will then take the case mix index for each facility and vary that average upwards, if its care requirements are higher than the average, or downwards, if its care requirements are lower than the average.

It's expected that we'll be meeting with our funding working group towards the end of March to present it with the funding available, how the average is calculated, the average case mix indices for each different category of care in our system and the individual case mix index for each particular facility. It will then be a matter of simply calculating the formula for each facility, and each facility will be able to know exactly what its funding would be in each of the three categories.

We will propose, at that meeting, to representatives of the Nursing Home Association, the homes for the aged association, Concerned Friends, residents' councils and representatives from organized labour, how the funding available might be divided up among those three categories: accommodation, programming and nursing and personal care.

We expect to get feedback and have some dialogue on the distribution of those funds before a final decision is made. We don't want to make an arbitrary decision, without having some discussion with the people affected, on how the overall funds might be divided into those three categories. That's expected to happen towards the end of the month, around April 1, depending on when the estimates process confirms the amount of money available for 1993-94.


Mrs Sullivan: The second question related to what funding would be available to enhance the skills of workers, and whether all homes must enhance their staff to ensure that the additional medical treatments which will be allowed in homes are delivered in each home.

Mr Quirt: Yes. Funding for training will be a legitimate cost in the program component of the budget as well as the nursing and personal care component of the budget. In other words, expenditures related to sending a worker on a course or bringing in an expert for in-service training will be a legitimate expense in spending the money that's allocated to each facility for nursing and personal care or quality-of-life programming.

In addition, as an aside, the government's palliative care policy will fund the training of a staff person from every nursing home and every home for the aged in Ontario in learning more about how to appropriately deliver palliative care in long-term care facilities. That's a separate initiative I thought I'd mention.

There will be a requirement for increased RN coverage in our long-term care facilities. I mentioned before that currently there's no requirement for 24-hour RN coverage in nursing homes. That will be a requirement in the new system.

There will be some latitude for each facility to decide, within the funding provided for nursing and personal care, the most appropriate staff mix to meet the needs of their particular residents. Some facilities may opt to have more RNAs, others may decide that they'd rather have more health care aides, and others may decide that more professional staff would be a more appropriate expenditure from the funding available for nursing and personal care, if there was a requirement that their residents had for a higher-than-usual degree of interventions that required an RN service.

Mrs Sullivan: I think the second part of the question is whether you will require all homes to have skilled workers and the capital facilities that are required sometimes for, by example, oxygen therapy and catheter care, which are in a different situation now under the Nursing Homes Act.

Mr Quirt: We would require that there be RN coverage on a 24-hour basis in all long-term care facilities, and we would require that before oxygen therapy or catheter care were delivered, the facility staff receive the appropriate training and develop the appropriate policies and procedures that their facility would need to ensure that they deliver that in a safe way.

We'd also provide whatever consultative support from our compliance advisers and our nursing consultants that might be necessary for a facility to upgrade its skills. I'd qualify that comment by saying that the RNs who work in our long-term care facilities are professionals; they may need some refresher courses in some cases, but I think they are as up to the job as the nurses who do those services in people's own homes and have been doing that for the last 15 years.

The Chair: Mrs Sullivan, we're going to have to move on.

Mrs Sullivan: The last question was intervenor funding for court appeals, to cover the cost of the appeal.

Ms Gail Czukar: Gail Czukar, legal counsel with the Ministry of Health. Did you say intervenor funding or just funding for appellants and so on for the placement coordination appeal?

Mrs Sullivan: One or the other. Have you considered either?

Ms Czukar: We've considered approaching legal aid about legal aid certificates. In any event, legal clinics would be available to assist people whose incomes are at a level where they can't afford their own legal counsel, as they are now for the current appeal.

The Chair: Mr White.

Mr Drummond White (Durham Centre): Good morning, Jean. How are you?

Mrs Forrest: Fine.

Mr White: I'm very impressed, as you know, with your facility and the quality of care you've offered, the acuity and the knowledge that you have personally and your advice. The first time I was there, of the many times I've been there -- my assistant even offered a course at your facility -- I met with a number of nursing home administrators, yourself included. You all have practical problems, and I think you bring up a lot of those things: Here's the law, but where's the money? I think that's a lot of how you operate. You want to be able to offer the best possible care, but when I met with you and Ivan and a number of other people from this whole area, from Richmond Hill through to Cobourg and Port Perry, one of the main issues you were bringing up was the inequity in funding, that municipal homes for the aged receive more money on a day-to-day basis than nursing homes. Under this bill, if you're a long-term care facility, whatever act regulated you in the past, you would be receiving the same level of funding for care.

Mrs Forrest: That has not been stated.

Mr White: It hasn't. Okay. That's certainly one of the things the nursing home association was very pleased about. I think it's fairly clear in the act that we're bringing together those different pieces of legislation so that there's a fairness and an equity brought about.

Mrs Forrest: I agree. I see steps in that direction, but we have not been told that we will receive the same funding as homes for the aged.

Mr White: On a daily basis.

Mrs Forrest: On a daily basis.

Mr White: I think that's a really practical consideration I think we should deal with.

You're also on the placement coordination committee, locally?

Mrs Forrest: In Durham region, yes.

Mr White: How is that service working?

Mrs Forrest: It works very well for us. I think definitely, rather than create another system, that system could be utilized.

Mr White: That's the system that would be utilized. As you say, rather than creating another system, all you do is fund what we already have to make sure it keeps on going. You have a pretty direct feed into that, being on that committee.

Mrs Forrest: Yes.

Mr White: Okay. So you're satisfied that if the funding went to that placement coordination committee in Durham, those decisions would be reasonably palatable for your facility.

Mrs Forrest: They would be, but we still need a voice to --

Mr White: You'll have that voice. You're actually still on the committee.

Mrs Forrest: Well, yes and no. We need a voice to be able to say that yes, this person seems to be requiring our care and yes, this person is the first person priority, but the room that this person's about to go into has X, Y and Z and that person will not fit in. We have to be able to say no to some people.

Mr White: That's the appeal issue, and I think it's a very valid point.

I want to thank you for coming and for bringing forth those very practical, humane and professional concerns. Could we just get a clarification on that one point Jean's still concerned about, that there would be an inequity of funding on a day-to-day --

Mr Wessenger: I understand it's been made clear on many occasions that the level-of-care funding will be the same for all institutions except for the exception. I think that is what the presenter may be referring to, the fact that some of the high-cost ones will be red-circled. No institution is going to have its funds reduced. In a sense it is not going to be actual equal dollars to all institutions, but everybody's guaranteed that equality with respect to the level-of-care funding.

Mr White: But a facility like hers would not be red-circled. She's at the bottom of the heap.

Mr Wessenger: That's right.

Mrs Forrest: Are you saying, then, that we will be funded to bring our quality-of-care programs, including social workers, physiotherapists, pastoral care people and all the other persons who are now in place in municipal homes in place now?

Mr Wessenger: No, I think that's --

Mrs Forrest: What I see then is inequality.

Mr Wessenger: As I say, there are some homes for the aged that receive more money than they would be entitled to under the levels-of-care funding.

Mrs Forrest: I know what you're saying. What I'm saying is that my residents deserve the same care as residents in a municipal home. They deserve to have the same programs available to them, and that takes money.

Mr Wessenger: I understand. You've made your point.

The Chair: Your point is clear. Again, on behalf of the committee I want to thank you very much for coming down this morning and joining us.



The Chair: If I could next call on the representatives from the Ontario Dental Association, if they would be good enough to come forward.

Mr Cameron Jackson (Burlington South): Mr Chairman, I anecdotally referred to Martha and Mary. Just for the record, that was a campaign done by the ONHA to demonstrate that Martha lived in a nursing home and Mary lived in a home for the aged and that their care needs were the same. It was an interjection, but for the purposes of Hansard, I'd like to clarify. The deputant understood the reference and agreed with it.

The Chair: Thank you.

Welcome to the committee. If you would be good enough to introduce yourselves for Hansard and for the committee members, then please go ahead with your presentation. We have a copy of your brief in front of us.

Dr Aldo Boccia: Thank you. I'm Dr Aldo Boccia, a general dental practitioner in the province of Ontario, and I'd like to thank the Chairman and members of the committee for giving me the opportunity to speak to you about Bill 101. I am also a member of the health care committee of the Ontario Dental Association. With me I have Linda Samek, who is director of professional affairs for our association. She is also serving on the health care committee of the Ontario Dental Association. We are here on behalf of the Ontario Dental Association, which represents more than 5,000 dentists. Our comments today will focus on two key areas: access and funding.

The mission of the Ontario Dental Association is to support its members in the delivery of exemplary oral health services to the residents of Ontario. Unfortunately, there are a number of barriers which restrict our ability to serve the oral health needs of the long-term care population. We trust that new legislation will eliminate these barriers and enhance access to needed dental care for this special population group.

As you know, the current Nursing Homes Act recognizes that dental care should be available to the nursing home resident. Here, the physician attending the resident informs the administrator that the resident is in need of the service of a dentist, and the administrator arranges with the resident to receive services at their own expense.

Despite recognizing that patients may require dental care, there is no corresponding requirement to provide ongoing regular dental care to this patient population. Neither the Charitable Institutions Act nor the Homes for the Aged and Rest Homes Act requires that routine dental care be provided on an ongoing basis. Thus, patients within Ontario's long-term care system have only a theoretical right to needed care on a timely basis.

In June 1992 the then Minister of Community and Social Services, the Honourable Zanana Akande, reported on a redirection of long-term care. According to the minister, a fundamental principle to be contained in the policy framework was a patient's right to fair and equitable access to appropriate services, so that people who use the services can make informed choices.

Today's ad hoc arrangements for the delivery of oral health care to this special patient population are not in keeping with the principle of equitable access outlined by the ministry, and the legislation that we see in front of us does not guarantee that those within the long-term care system will have access to dental care.

We are pleased to see that the plan of care outlined in all three sections of Bill 101 recognizes the need to provide for a continuum of care, but based upon our experience within the long-term care system, we believe there is a need to clarify which services will be available to these patients. In our view, it is not good enough to say that the regulations will address this matter. We ask for your commitment that revisions to current legislation will guarantee access to dental care on a regular basis for this special patient population.

If the facilities referred to in Bill 101 are going to ensure that they assess and provide for the "requirements" of each resident on an ongoing basis, there must be a mechanism in place to work with the dental profession. We stress that we cannot simply leave it to the physician to recognize that dental care is required. The physician is not educated and trained to diagnose and treat the full range of oral health conditions. Thus, the coordination and provision of a plan of care will require consultation with a dentist.

Once again we emphasize that our goal is to eliminate the hurdles that patients must cross to obtain needed dental care within today's long-term care system. Enhanced access to a broad range of oral health services will benefit this at-risk patient population.

We agree with the comments outlined in the consumer report on long-term care reform that there is compelling evidence that poor oral health has a direct impact on the physical and mental health of seniors. The ODA wants to work with all interested parties to ensure that the impact is positive for those with physical disabilities, chronic illness and the elderly within the long-term care system.

Funding remains a major barrier to accessing oral health services for this patient population. Therefore, it was with great pleasure that the ODA read the June 1991 statement from the Ministry of Community and Social Services announcing, "Quality care will be affordable to all, regardless of their financial situation." Even though this announcement reported that money would be added to the budgets of existing nursing homes and homes for the aged to "ensure that the ever-increasing care requirements of residents can be met effectively," there was no corresponding announcement about what care requirements were to be met. Now, nearly two years later, there is still no clear direction about the range of health services that are to be provided for the long-term care patient.

We have stated here that the ODA believes that oral health care should be included among the core programs available through the long-term care delivery system. At the same time, without appropriate funding mechanisms, many of these patients would be forced to delay needed dental care. As a private practitioner, I can tell you that many dentists frequently arrange to ease the financial burden an individual senior may face. None the less, such ad hoc financial arrangements are not an appropriate alternative to a province-wide funding program designed specifically to meet the needs of this special patient population.

Because the elderly comprise a significant portion of those within the long-term care system, we want you to know that the ODA developed a strategy to implement a dental plan for Ontario's elderly. When we shared our proposal with the Ministry of Health in 1987, we noted that we understood that it was "essential that attention be paid to the need to develop a program Ontarians can afford." While we encouraged the ministry to provide dental benefits to all seniors in Ontario, we recognized that financial constraints may not permit the immediate implementation of a universal program. Therefore, we agreed to support, at a minimum, a program that would provide benefits to those confined to institutional settings and seniors receiving guaranteed supplement.

To date, the government has not introduced financial assistance for dental care provided to our seniors or others within the long-term care system. This reform process provides each of us with the opportunity to review the allocation of funds.

Because this new legislation will prescribe maximum amounts to be charged to designated services, the ODA wants to offer our assistance in establishing professional fees for dental care. The ODA has considerable experience in developing and maintaining the dental fee guide and designing dental plans, including cost containment plans. We look forward to the opportunity to explore funding issues with you in more detail.

In summary, we want you to know that our concern about the delivery of oral health services to the elderly, the institutionalized and homebound is long-standing. It is because of our experiences within the current system that we emphasize the need for new legislative initiatives. We are particularly pleased that the Senior Citizens' Consumer Alliance for Long-Term Care Reform recognized that "Oral health care services are an integral component of long-term care and urgently need to be put in place." We could not agree more. The ODA wants to be involved in developing solutions to today's problems.


As a profession committed to the delivery of exemplary oral health services for Ontario residents, the ODA has established a network of subcommittees in each of our 38 component societies. These special patient subcommittees are prepared to work with all stakeholders in their communities in an effort to enhance access to dental care for this population of elderly, disabled and chronically ill patients. Some societies, including the four Toronto societies, have purchased a complete mobile dental unit, which can be utilized by our members on a rotational basis. In short, we are willing and available to provide care within the long-term system in communities right across Ontario.

In our view, those who have contributed so much to society should not be denied access to regular and ongoing dental care. It's important that we work together to develop comprehensive legislation designed to enhance a full range of services on a routine basis.

I thank you again and I will be pleased to entertain any questions you might have.

The Chair: Thank you very much for coming today and sharing those thoughts with us. We'll begin the questioning with Mr Jackson.

Mr Jackson: Thank you very much, Mr Chairman. Aldo, welcome and thank you for your brief. I cast my mind back to the last three provincial elections and I seem to recall a couple of political parties promising geriatric dental plans for Ontario.

Dr Boccia: Yes.

Mr Jackson: We seem not to be any closer to it, but we've never had a better opportunity in the last decade to merge the medical needs of seniors with reform.

Perhaps, Mr Chairman, I might direct my question to the parliamentary assistant and ask where, if at all, the very cogent arguments for geriatric dental programs in long-term care facilities, where those discussions are currently with the government and where the government's planning is within the Ministry of Health in these matters.

Mr Wessenger: I'll ask the ministry staff to indicate if there's any aspect of that involved in this forum.

Mr Quirt: The long-term care facility manual draft requires that, as a standard, oral assessments upon admission by facility medical staff be completed. I know presenters this morning have commented that this may not be the most appropriate practitioner to do that kind of an assessment, and I think that's a very valid perspective. Secondly, it requires that annual dental and denture assessments and preventive dental services be made available to the resident.

Mr Jackson, it doesn't deal with the issue that I think you're raising, which is whether in fact the cost of dental services would continue to be the responsibility of seniors in Ontario. It goes on to say that daily oral care would be identified as a required topic for in-service training, but the long-term care redirection does not propose to provide dental services to seniors on an insured basis. I think that's really the question you're asking.

Mr Jackson: So there are no discussions and no plans at this time to address the dental care needs of institutionalized seniors?

Mr Quirt: Bill 101 and the long-term care division is not proposing to cover all the costs of dental care for seniors in long-term care facilities. I know the minister herself is aware of the recommendations of the Hicks committee and others on the need to look at the issue of the costs associated with dental care for seniors. There are also efforts under way to require public health units to be more involved on a mandatory basis in assessing the dental health of seniors and others. But I'm not aware of any proposal currently to make dental care an insured service or to provide funding for dental care for seniors. If there is one, I have not been aware of it.

Mr Jackson: Okay. You've answered the question twice two different ways, but I got the same answer, "We're not planning any program currently around the cost aspect of dental care for seniors in long-term care facilities."

Mr Quirt: Not that I am aware of.

Mr Jackson: My next question is, when your government increased user fees and indicated that a greater portion of seniors' limited incomes can be contributed towards their accommodation, what, if any, impact analysis has been done which considers that there are other fee-for-service necessary medical -- I'll call them interventions; they are in fact interventions because it's proactive and preventive health care when you're dealing with dental work -- to what extent was your government sensitive to those costs when you are taking a bigger bite of it just to put a roof over their heads?

I recognize fully that what's in the legislation currently is simply a statement which says we encourage dental care and our doors will be open so they can come in and under no circumstances can you bar a dentist and a hygienist from coming into a nursing home. That's essentially all that we're offering seniors in these institutions.

I just want to ask what impact analysis has been done about these costs for seniors that flow from their health, according to this report, as well as their mental health? Was that considered when you came up with the increased user fees?

Mr Quirt: There was no analysis or study of the specific costs related to dental care, so the answer to your question is no, there was not a study specific to dental costs.

Mr Jackson: Do you think it would be fair for the minister to begin analysing that, since a senior citizen has certain supports which flow from his or her ability to enjoy life with dignity and dental care happens to be one of them? It may not be as important as getting three meals a day, but it's certainly up there with all their other medical-type interventions.

Gum disease and all the other degenerative aspects of poor dental care only compound this with additional drug costs, with medical interventions, with modified diets. There's a great list of things when one understands this, and I know, Mr Quirt, you wouldn't be working for the Ministry of Health if you didn't already know that.

Mr Wessenger: I think perhaps we're getting into, if I might respond to Mr Jackson, more political issues here as distinct from ministry issues. I don't want to put Mr Quirt in the position of answering policy questions at the political level. Certainly I'm aware of the Hicks report. I've had some discussions with public health unit people concerning the need for dental services for the senior population, and certainly that is something that I can only say is a matter that is being looked at.

The only thing I'd have to say is, we all have to remember the financial realities we all live in politically and financially at the present time. We live in a world with an expanding ability to meet needs and the lack of financial ability to meet all those needs is always a question of priorities. I think that is something that governments always have to make those difficult decisions as to which priorities they establish. Certainly there's a recognition of the needs but there's a question the ability to meet those needs.

Mr Jackson: I certainly appreciate the parliamentary assistant jumping in on any occasion, but that's limited comfort, to state the reality.

I want to just return to the point that at no point in the last decade has it been more relevant to raise these issues. When we're dealing with restructuring long-term care, we are promising our Ontario citizens quality and access and equity. We knew the fiscal realities we're dealing with. I'm just rather disappointed that the financial impact of medically necessary interventions was not considered when the user fees were increased for seniors. I regret that has occurred by this government.

Dr Boccia: I just want to clarify one point, that dentistry has not been barred according to the act. Yes, conducting treatment as well as public health. Public health hasn't been doing it and the problem that the dentist has is that the facilities do not have sufficient administrative support to accommodate a dentist on an ongoing basis, whether it's the actual administrators or the facilities within the home etc. Dentists are making attempts today, all across Ontario, to enter these homes but with great resistance.

The Chair: Thank you. Mr Owens.


Mr Stephen Owens (Scarborough Centre): I'd like to thank you for your presentation. As usual, you hit a very important nail squarely on the head. It's been my experience through my own dentist, Paul Aquilina, and a dentist who occupies space in the same plaza, Stephen Abrams, that there's a commitment to patients and especially to those who are having income difficulties or to seniors. As a matter of fact, we've nominated Stephen Abrams for the Canada 125 award in our riding.

I don't want to be difficult to the parliamentary assistant but he knows, through working with me on the Advocacy Act, my commitment to these kinds of issues.

I'm looking at page 12 of the draft manual and it talks about the oral and dental care and that, "Arrangements for dental assessment and preventive services, scaling and cleaning annually for residents wanting the service on a fee-for-service basis will be arranged."

My question then is, if a person is not in a position to afford those services -- and dental professionals, in my view, in my experience, have been quite reasonable in my riding. I'm not going to speak for dentists across the province, but there is an attempt to operate on a reduced-fee basis. But at some point, somebody's got to pay for something in this process. I'm wondering whether the ministry is prepared to sit down with the Ontario Dental Association and work out some kind of process that would, in my view, be an excellent addition in terms of the quality of life.

Mr Jackson indicated quite correctly that perhaps dental care is not as important as food, or however it was put. But the problem is that if a person has one of the gum diseases or gums simply retract as part of the aging process, food no longer becomes the issue; it's the ability to ingest the food that becomes the issue.

I guess my question to the parliamentary assistant is, what ability is there at this point for the ministry to sit down with the Ontario Dental Association and its practitioners and work out a process where an effective program can be implemented?

Mr Wessenger: I certainly acknowledge your point to the extent that we do have in our society, as you know, dental programs for children and we don't have those same programs for seniors, which is certainly a gap I would acknowledge exists. Certainly I think we should be working towards -- I agree with you -- working with the dental association.

Mr Owens: My concern about this, quite frankly, is that there appears to be a political war going on between the municipalities and the provincial government on the backs of the poor, the seniors, and at best there is a hodgepodge system with the provision of dental services.

On the Toronto side of Victoria Park Avenue, the city of Toronto provided dental services for welfare recipients, for instance. On the other side of Victoria Park, roughly 50 yards or less in distance, the city of Scarborough did not provide those kinds of services. I think from the approach of the quality of life issues -- and I agree with the intent of this bill and the purpose of this bill -- if we can't provide it within the context of Bill 101, then in terms of companion legislation, this certainly should be looked at in terms of the provision of these kinds of services.

Mr Wessenger: If I just might make a comment on that, though. Perhaps I'm the wrong parliamentary assistant to be making that comment, but certainly the process of the assumption of social assistance, 100% by the province, should ensure that we have a consistent policy with respect to the matter of, for instance, dental care. My concern is, and I would really need ministry advice on this matter, how seniors fit in in that social assistance scheme.

The Chair: Before we resolve all of those issues, I'm afraid I'm going to have to move on to Ms Sullivan or we're going to be in real-time trouble. Ms Sullivan with the last question.

Mrs Sullivan: I think this is an important brief, because these issues have not been before the committee before this point. I'm interested first of all in knowing if the ODA has been involved in the consultations on the draft manual and has participated in the discussion with respect to the draft manual.

Dr Boccia: No, we have not.

Mrs Sullivan: I think that is one of the problems here. I'm going to have to ask for some clarification here, having just seen certain sections of the draft manual last night. If we look at the existing regulations under the Nursing Homes Act, there is one regulation that says, "Where a resident or a physician attending the resident informs the administrator that he or she is in need of the services of a dentist, the administrator shall arrange for the resident to receive that." That's what happens now.

If we look at the draft manuals, the first draft is far more extensive than the second draft. The question is, does the second draft incorporate everything from the first draft or is the second draft going to be what the final form is?

Mr Wessenger: I will ask ministry staff, though I can assure you the second draft is still a draft.

Mr Quirt: I'm quite frankly not aware of the differences between what is said about dental services in the first draft and what's said about them in the second draft. There may well have been an omission. Because I'm not aware of what was in the first and second -- I haven't looked at it recently -- I can't answer your question. If there's a recommendation you have on what might be returned to it, we'd be happy to discuss that with our manual committee when we revisit the manual on March 15.

Mrs Sullivan: What I'm seeing is a difference in that the first draft includes standards, administrative criteria, staffing criteria and service provision criteria. The second draft appears only to cover standards, and I think it's significant that the dentists haven't even been consulted on it.

Mr Quirt: It appears to me there might be something missing if there's that big a difference between the first draft and the second draft. We'd be happy to have a look at it, talk to staff to find out what the intent was in any change and on whose advice it was made, and reply to you specifically on that if you'd like.

Mrs Sullivan: Perhaps we can have a clarification, but --

The Chair: Mrs Sullivan, I'm sorry.

Mrs Sullivan: Am I out of time already?

The Chair: We're in big trouble with time. Could you just put one more question, because I want to allow the witnesses to comment.

Mrs Sullivan: I think it is interesting that there appears to be an improvement in the manual in that, at least in the standard of care, there would at least be an annual oral assessment, including scaling and cleaning. However, that would be done on a fee-for-service basis. I'm interested in your mobile dental units and how you see those services being provided through those dental units. I'm interested in the insurance question as well, but we don't have time to get into that.

Dr Boccia: First of all, we were a little disappointed that we weren't consulted and we are certainly prepared to do so from today on. At any time the ministry would require our assistance, we will be there. We are disappointed that the public health people have not done their job; I am personally. From 1984, they've been complaining of funding and manpower as well and haven't entered many of the homes even within the Toronto boundaries, never mind the rest of Ontario.

With respect to the mobile equipment, Toronto right now has a full dental unit which is being shared by the four component societies, and that's basically a north, south, east and west division of Metro Toronto. We have been working with public health people who will go in and screen the patients initially, because unfortunately, there is a cost for screening as well, consultation, the reporting back to the family etc.

Public health has been handling the situation by simply identifying the patient in need. There is no real screening, no real dental treatment plan or assessment done. They just have a quick look, do some prophylactic care if they can, and then report back to a central body, which I'm involved with, which identifies the patient. We then send the unit into the home, do the initial screening and report back to the administrator, who in turn goes to the family member, if there's a family involved. Then discussions go back and forth, literature etc, with dentists and the family sometimes, to come down with a final treatment plan and costs, and then the dentist is allowed to administer the treatment. The dentists bring in their own assistants, their own materials etc. The unit has been made available through the Academy of Dentistry here in Toronto at a cost of just under $25,000.

The Chair: I know we could go on for some time, but I think, as you can see among all the members who are asking you questions, your points have been heard.

Dr Boccia: Thank you very much.

The Chair: Thank you very much for coming.



The Chair: Perhaps I could then call upon the representative from Copernicus Lodge and just note to committee members, with some chastisement of the Chair himself, that we do have a time problem. If members could just ask one question, it would assist us in getting through the rest of the schedule.

Welcome to the committee this morning. If you would be good enough to introduce yourself, then please go ahead with your presentation.

Mr Stan Mamak: I am Stan Mamak, Copernicus Lodge. Apart from a bit of raw cold today, it's another gorgeous day to be thankful for. I'd say the average person in this room, each one of us, has approximately 4,000 to 5,000 more such days before we begin a descent. Let me read you two descriptions of that descent:

"We do not die wholly at our deaths; we have mouldered away gradually long before. Faculty after faculty, interest after interest, attachment after attachment disappear. We are torn from ourselves while living.

"Growing old is not a gradual decline, but a series of drops, full of sorrow, from one ledge to another below it."

Copernicus Lodge is a non-profit home for the aged under the Charitable Institutions Act. I've been a volunteer there for in excess of 13 years, a member of the executive committee and have headed numerous committees. We are greatly concerned that Bill 101, as it stands now, certainly appears to focus on physical health care needs. What about the other half? What makes life more than just surviving, where a stranger has the potential of being an unmet friend? We have the means to express one's faith, familiar food tastes and smells and a reassuring warmth of long-lived cultural traditions and expressions.

What, to each one of you, do the following words mean: golombki, oplatek, wielkanoc, sto lat, przyjaciel? To seniors among our community, they're laden with emotional resonance. If you're a parent or a grandparent who comes from a proud cultural tradition that has included Copernicus, Chopin, Lech Walesa and Pope John Paul II and you're suddenly designated to be put in a given place by a "placement coordination service" or a placement coordinator, with scant, if any, regard, in our reading of this legislation, for your language, your culture, your psychogeriatric status in terms of fit with other people who are going to be in the home in which you're placed, what does that mean to you?

For many of our parents and grandparents, the descent into old age is probably one of the most terrifying experiences in their lives. This is no time to further traumatize them by placing them in an insensitive environment.

I've attached two letters from families of residents who have stayed with us at Copernicus Lodge to indicate to you the kind of atmosphere provided there and to point out that this was achieved. We have the lowest per diem cost among care institutions of this type in the province.

I've received a report from a seminar held in Burlington on February 10 of this year, Ethical Challenges of Health Care for the Elderly, in which an M. McLean, who is a professor of gerontology at McMaster University, spoke about the rights of ethnic or multicultural people to die in their own community. He referred to the case of a French-speaking woman who died while in the care of an English-speaking doctor and nurse. The woman's daughter was very distraught knowing her mother's final words were not heard or understood due to the language barrier.

A court challenge ensued and the court ruled that individuals have a right to die in an environment familiar to them. Mr McLean feels that the individuals not only have a right to die in their own environment, but they also have a right to live in their own environment. We share that belief.

I'd just like to pose some questions to the committee. Why in Bill 101 are you ignoring the accumulated experience and wisdom of countless groups in Ontario with hands-on experience in long-term care of our parents and grandparents in favour of a theoretical construct or series of constructs? In my view, it is somewhat like saying: "Well, we want to build a new house. Forget about the experience of engineers and architects; we've got a great theory here."

I think we all remember the great intellectual fads. We had the Hall-Dennis report and open-concept schooling. Where has that gone? Into the trash bin of history. Here we're talking about a new intellectual fad, in our view: one-stop shopping. In my view, we're talking one-stop disaster.

I challenge any member of this committee to point out where in Bill 101 as it stands provision is made for religious, cultural or psychogeriatric sensitivity in the placement of our parents, our grandparents and, in the near future, ourselves. Why is the proposed system throwing out things that are working well? In other words, don't fix a sound wheel. We have homes, we believe, that work well and I believe that a home such as ours is imbued with respect for the individual, with a degree of caring and contentment and, yes, love.

Why in the legislation as it's written now on second reading is there virtually no mention in regard to linguistic, religious and cultural factors? We believe that not only the application materials but the legislation itself must be amended to reflect these critical components. These are not frivolous extras.

Why is there no possible appeal, as I understand it, of a placement coordinator's decision to place the person? As I understand the legislation, there is an appeal in regard to whether you're eligible for long-term care, but unless I have missed something in the legislation, I'm not aware of any appeal as of right to an individual in regard to the placement that is made of that individual. Think of it: Suddenly, somebody tells you where you're likely to spend a good portion of the rest of your life, if not the rest of your life, and you have no chance to appeal that decision.


Why are the contributions and the commitment of community groups and volunteers effectively being ignored and neglected by this bill? Why are they in effect being told to get lost? In sum, when virtually all of the groups in the province that have been involved in long-term care of multicultural elderly agree that this bill will jeopardize services for thousands of seniors of multicultural background, why is this bill being proceeded with in this form?

Let me put it to you a different way. This bill would be wonderful legislation as it stands if (1) you wanted to commit psychological violence to our seniors by placing them in an alien and insensitive environment in many instances; (2) if you wanted to warehouse parents and grandparents according to relative degrees of physical infirmity; (3) if you wanted to take the caring out of long-term care; (4) if you wanted to create even more obstacles to access to long-term care for multicultural parents and grandparents; and (5) if you want to guillotine existing community involvement and financial contribution.

I've included a quotation at the end of the very brief brief there, a paraphrase of a German proverb, "An old person loved is winter with flowers." As it stands, in our experienced opinion this bill will not facilitate winter with flowers for our parents, grandparents and, in a not-so-distant future, ourselves. We believe it's a papier mâché of the real thing. We urge an uncommon exercise of your judgement, wisdom and compassion, for in the end the bell tolls for each of us as we age.

The Chair: Thank you very much, both for your oral presentation and for the brief that you've submitted and, I just note for Hansard, along with some letters you've attached. We'll begin the questions with Mr Wessenger.

Mr Wessenger: Thank you for your presentation. I'd just like to make clear to you that it's never been the intention to not be sensitive to cultural, linguistic and religious aspects. It's also, perhaps because of a misunderstanding, been that legally people have to consent to where they're placed. What we have done and announced yesterday, in order to clarify the situation, is that we would be bringing an amendment which would require the placement coordinator to take into account the preferences of the applicant, particularly with reference to the aspects of cultural, ethnic, linguistic and religious matters.

That's going to be an amendment in the legislation to make clear, because there was never any intention not to take any of this into account. In order to clarify the uncertainties that evidently have been created out there, that amendment will be placed. It will also be made clear in the legislation that the individual must consent to his placement. That was a legal right there, but we're putting it in there just to clarify, and also the right of the institution to refuse where it doesn't have the physical facilities or the trained staff appropriate for the placement.

Also, I might just refer to your other aspect. You did raise the question in your written brief with respect to placement coordination services. There's certainly no intention to have only placement coordinating services, particularly in the Metropolitan area, in English only. Obviously, in order to work in that type of culture and the linguistic situation we have to have those services available in other languages.

Mr Mamak: Are you giving a commitment that you will have them available?

Mr Wessenger: I think it's fair to say that we can certainly give a commitment in the Metropolitan area. Whether you can provide it, I don't know. I might ask Mr Quirt to comment on how we provide it outside the areas where you have a diversity.

Mr Quirt: Certainly the placement coordination services would be available in both languages in those designated areas across the province where the service would be available in French as well as in English. In Metro Toronto, there would need to be a number of different capacities to speak the language of a number of different potential candidates for our long-term care facilities.

That would be a requirement the government would make of the agency that was selected to be the placement coordination agency, that it had the capacity to respond to the needs of the residents of the area effectively in whatever language necessary. There may well be arrangements where a member of your staff or a member of the staff of other charitable homes for the aged would be called upon on a contractual basis or something to assist the placement coordination agency in that way.

Mrs Yvonne O'Neill (Ottawa-Rideau): Thank you, Mr Mamak. I think you presented your points -- others have presented them truly, but you presented them with a great deal of poignance and reality. I can see why you are having so much difficulty because, as you can see, your question has been ours: Is that a commitment?

Each time someone like yourself comes forward, we are told that there are amendments and it has actually been read into the record, although we haven't seen it in writing. We see the service manual changing some as it's progressing now at draft 2. We know there are a lot of regulations that are going to come, but all of this is being done with a great deal of request for a leap of faith, and I'm not sure that we have enough to go on, even after six weeks of hearings, or that we feel your concerns are going to be addressed the way we hope they will be.

The appeal process is where I'd like to place my question. We have had lots of discussion about that. Could you put a little bit more into your fears about the appeal process from your perspective?

Mr Mamak: Are you talking about the appeal process in terms of whether you are eligible for long-term care?

Mrs O'Neill: No, the second part of your statement.

Mr Mamak: In terms of the placement, I mean, I'm not completely reassured by the comment that you can refuse a placement. That potentially could be empty if the person says, "Well, sure, you're entitled to refuse a placement, but if you do, sayonara."

Mrs O'Neill: This is a general fear, you know, about how long and what kind of personal preference guarantees do we have in this legislation? At the moment, we don't feel they're there.

Mr Mamak: I concur with that. I feel not only that they're not there but the legislation embodies the values, and if you don't have those values but talk about putting them in regulations, talk about putting them in manuals, they can be manipulated so easily, they can be omitted so easily and without public notice, without public discussion. We want them in the legislation, period.

Mrs O'Neill: Which is your only guarantee in the courts.

Mr Mamak: Exactly.

The Chair: I'm sorry. We have to move on. Mr Jackson.

Mr Jackson: I wanted to thank you for your references to eastern European culture generally as well. My grandmother has the privilege in the province of Manitoba to reside in a facility similar to Copernicus Lodge, and I simply wish to thank you for committing these concerns to paper and in the presentation on an ongoing basis. I think that's important. Even though we've had the assurances from the parliamentary assistant, it's abundantly clear that it does not guarantee the ethnicity of a certain facility; it only indicates that it'll be considered.

I also want to thank you for your old German proverb, which I think is quite beautiful.

The Chair: Thank you very much, Mr Mamak, for coming before the committee today and making your presentation.



The Chair: If I could next ask for the representative from AIDS Action Now, welcome to the committee. If you could just introduce yourself, then please go ahead.

Ms Patti Bregman: I'm Patti Bregman and, just to make the record clear, because I was here a couple of weeks ago on behalf of another group, I'm here as a volunteer with AIDS Action Now. I sit on their provincial issues committee. Part of my interest in AIDS Action Now is because of the long history it has had in working within the community to create and develop community-based services and programs.

Unfortunately I got snowed in in Peterborough yesterday, so we don't have a written brief for you this morning, but basically AIDS Action Now is a participant in the coalition on the long-term care and disability issues. However, there are specific issues which are significant to the AIDS-HIV community that have not been addressed in long-term care.

AIDS Action Now has been very active, as I'm sure most of you know, within the government and outside the government, sitting on committees like the Ontario committee for AIDS and HIV. Long-term care unfortunately did not deal with these issues, and I think the context we're placing it in is that we're seeing a rapidly increasing number of treatments. We're unfortunately also seeing a rapidly increasing number of cases diagnosed, with the most rapid growth being outside of Metro Toronto, and that is part of the issue we need to address. We're also seeing a more educated group of people coming up and learning more. We're seeing doctors who've learned to work with clients.

Unfortunately, what we're not seeing is the corresponding growth in the kinds of home care and support services that are going to be needed to ensure that people who are HIV-positive or have AIDS can really live in the community and participate, pay taxes and continue working as long as possible. To some extent what we see is that unless the government addresses the issues of long-term care and community-based services for people with HIV and AIDS now, we will see a major crisis in terms of the cost this will bring. We'll have more and more people in acute care hospitals as opposed to being able to live in the community.

We have another problem, which I think can't be addressed by this committee but has to be recognized in looking at the specific issues of HIV and AIDS, and that is the limited expertise of professionals. We need to look at making sure both more professionals become educated and more supports are provided, but I think in terms of regional funding issues, we have to recognize that many people will gravitate to larger centres, because that's where the treatment is.

We do have a concern that if we're on a regionally funded base system, areas like Metro Toronto or London or Ottawa, where we'll see the cases going, are going to lose out, and we'll have some problems in allocating funding. People from rural areas will be moving into the city. We need to make sure that whatever funding allocation system is set up accounts for the kind of movement that will occur until we can get the specialized services and housing and other supports into the community.

The first recommendation we want to make, I think, is that the provincial government make a clear commitment that the needs and interests of people living with AIDS and HIV will be integrated into the ongoing reform of long-term care. People with HIV and AIDS must be included in the process of developing these services.

As I said, we have a very long history of working quite effectively, and I think right now, as a result of pressure from AIDS Action Now, the Wellesley Hospital is developing a standards-of-care manual for physicians and health care professionals treating people with HIV and AIDS. This is being done as part of a joint community-professional endeavour, and that's the type of involvement we see.

It's not simply sitting on a committee. There needs to be input and control on an ongoing basis, and I think the community has demonstrated the expertise and the willingness to put resources in. AIDS Action Now does not get government funding. It does not have paid staff. These are people who really care about what's happening and have a very strong commitment. So we need to see that type of commitment from the government.

I think in terms of the barriers that we see, there are two. One is the lack of services. The other is waiting lists. As people are living longer and can use more and more community-based settings, things like supportive housing, waiting lists become a major barrier. People don't have time. While it's long-term care in the sense that people with disabilities have it, it's long-term care that has to be delivered immediately, and the consequences, we know, of not delivering appropriate care immediately mean death comes quicker or you lose your capacity much faster. We don't have time to deal with waiting lists and we're going to have to look at ways of either allocating specific services or waiting lists or somehow recognizing the urgency of the situation and making sure resources are going there.

The other area we wanted to address in terms of home care is that while there are some home care agencies that have done quite a good job and are providing IVservices in the home, there need to be an increased number of services available, but we also need to get rid of the dividing line between medical and social services. I think you've heard about this from the other disability groups.

What happens is you get caught between programs. One program will provide a little piece of this, another program provides another piece and another program provides a third piece. If those programs either have eligibility criteria that exclude you from one and to live in the community you need all three or you're not funded to receive all three, it's not going to help. You won't be able to stay in the community.

I think one area in which this is clearly evident, and I think you've seen comments about it recently, is in drug funding. While drug funding is not part of long-term care, if people don't have access to drugs or access to nurses who can do IV therapy at home, they are forced into the hospital, and it won't matter what other services are being provided. So we need to see a breaking down of the barriers between the different kinds of services so that we don't create gaps that people will fall through and then not have access to services.

I think one of our recommendations is that you start to look at funding, a pilot program working with the AIDS-HIV community and with the existing service providers to see what we can come up with along the lines of the integrated homemaker program in East York. Let's not only look at developing pilot programs that use existing service agency supports but let's look at how we can involve the existing volunteer supports, of which there are many in that community, and integrate them. We're not talking about putting in large amounts of money. What we're trying to do is to take a look at the system and find more effective ways to use money that's in the system. There may be small amounts needed, but we're not suggesting the government should suddenly place huge amounts of money into home care.

What we want to see are pilot projects working with the community that guarantee the long-term funding it needs to sustain service agencies that will put some time into it, but to really use what's in the community.

One particular gap that's been growing as the number of women who are infected grows is the need for supports for mothers, which is not simply respite care but respite care where crèches are provided or day care is provided for children. Women's needs have generally not been addressed in the area of AIDS and HIV, and there's a growing concern about that.

But I think it's particularly important in the area of community-based services, community care, home care going in or even supported housing that we recognize there are going to be single mothers who are HIV positive who may live eight to 10 years who should not be deprived of the right to live with their children simply because they have an infection. We need to make sure that we're providing that type of respite service and counselling available for the families all the way along.

There will be, similarly, mothers with children who are HIV positive. They need services, but it's a different type of service. We're very concerned about the growing number of single mothers who are HIV positive and who have very few family supports. We're not dealing with a population where the grandparents say, "Come home and live with us." We're dealing with a population that has, as a rule, very strong community supports. There are people in the community who will help, but we don't see it in terms of the service providers. They are there.

In terms of Bill 101, and I think this is where our interests converge, it is to make sure that direct funding can also be used for this type of service; in other words, not simply attendant care services but to make direct funding available to help people who are living in the community who may be falling through cracks or may need additional services so they don't have to give up jobs.

One of the real concerns right now in the community is that people are being forced to stop working and go on welfare in order to receive certain benefits. I think everybody would like that to stop. People would like to be able to keep working. So we need to look at direct funding as that type of subsidy that could be available for very specific kinds of cases.

The second area which I think we need to address a bit is the area of supported housing and accommodation, because again we run into the problem, and it's really a double discrimination where people with HIV are discriminated against. We know that there are people who are uncomfortable. You go into a nursing home and they say, "We can't deal with that kind of client." We have hospitals that say, "We can't deal with that." That can't last.

Firstly, we need good community housing. In other words, we need housing in which people can remain even if they need a certain level, and one of our suggestions is that we look into using existing housing. Look at the housing where people live. In many cases, you'll have communities already established. You'll have a number of people who are HIV positive living within a geographic area. Let's look at how we can work with the community to use that housing and provide outreach services into that housing. Rather than dislocating people from existing supports, let's look at bringing the supports in, and I think that's something that could easily be done in Metro Toronto as part of a pilot project.

What we'd like to recommend is that we fund these projects and that they're based on existing consumer-initiated projects and coordinated models with the community. We don't want to go out and develop new models. We're not looking, as I said, for huge amounts of money, but let's start looking at funding projects that keep people in their homes. Even if they need additional levels, let's bring the service in. Let's set up small supported living units within existing housing rather than trying to go out and build new housing or dislocate people.


We need to deal with the next level of housing. There is almost nothing in the province, with the exception of places like Casey House, which is hospice and palliative care. We need to look at some of the innovative programs that are developed, for example, in England that will provide the next level where people really can't live independently. This is going to become an increasing problem because of HIV dementia; and it's become more and more recognized that as people live longer with AIDS and HIV we'll see more and more cases of dementia.

We have a great deal of concern about what's happening now. ARCH has already received calls about two cases in which people were committed to psychiatric facilities, not because they had a mental illness that could be dealt with but because they were outside of Metro and they said there was nowhere else for them to go. Families say, "They can live with us." Nursing homes won't take them, retirement homes won't take them, so let's put them in a mental institution.

Unfortunately, the boards of review said, "Yes, we agree there's no other option." So I think we really need to start addressing this, and it will have to be addressed creatively, and, I think, depending on the location, with different kinds of options. In some communities, it may be possible to take a floor in an existing facility and set up some special services that are available.

I think part of it is educating the public. Once people understand that you can put people with HIV in settings with everybody else, a lot of that fear will dissipate. We're doing it in public hospitals, but we have to recognize that there are going to be specific services that are quite unique. We are not suggesting that you set up around the province different types of housing specifically for AIDS and HIV people, but I do think we need to look at this and we need to look at it in the context of Bill 101 and make sure that there's no discrimination permitted against people who are HIV positive and that one of the requirements is that the facilities are really going to have to acknowledge that they are going to have take people who are HIV positive unless the government's prepared to come up with some other alternative.

So I think essentially, as I know you're pressed for time and there may be questions, that really what we're trying to say is that we understand fiscal limitations, we understand sexual limitations, what we haven't yet seen is anybody addressing the specific problems of the AIDS-HIV community. We think it's a community that's shown a phenomenal amount of strength in developing some really innovative programs. In some respects things like the senior day care programs are replicated in the HIV community. I think it would be really beneficial to specifically focus some of the reform on this and also use it as a learning experience. I think we can look at the programs that have been developed, and it's one of the areas in which I think consumers have truly developed a partnership with professionals. What we see are doctors who have responded to people with HIV learning more. They set standards. They work with the doctors. They work with the community. People go in and advocate. We need to look at that and learn for the rest of long-term care reform.

But I guess our final message is to really make sure that we're addressing it directly, that sufficient funding is allocated and we don't fall through the holes again.

The Chair: Thank you very much. I don't think the snowstorm in Peterborough affected at all the presentation, and we really appreciate your coming in. Of course, as you know, that is in Hansard, so we've got it. In going to questions -- and I agreed to do this, but we do have a time constraint -- if members could focus their questions and keep them brief, and we'll begin with Ms Fawcett.

Mrs Joan M. Fawcett (Northumberland): Thank you for coming, because I think this is a topic that we haven't heard that much about and yet we are going to. There is going to be a crisis out there, and it is a different kind of care. These people are young, for the most part, and that presents a problem in its own. The time is so short and there are many questions, but you have certainly given us a tremendous amount of your knowledge.

Ms Bergman: As I said, we'll be glad to come talk to people individually on an ongoing basis.

Mrs Fawcett: That's good. Maybe I would address the parliamentary assistant and ask: Is there contemplation by this government of putting the palliative care under the long-term care bill, 101? Do you feel there is a place for it? Is it going to be incorporated?

Mr Wessenger: Certainly, it's very much a part of the whole process, the palliative care. But I will ask perhaps ministry staff to just indicate what specifically, briefly, with respect to the AIDS-related --

Mrs Fawcett: Maybe if there's anything there now, and if there is contemplation of something further.

Mr Quirt: With respect to palliative care, there will be funding made available to train about 1,000 community service workers in palliative care. There will be funding to train physicians specifically in palliative care. There will be support for about 30 to 35 volunteer palliative care programs across the province in need of support. There will be the development of 14 regional pain and symptom control teams that will no doubt improve the delivery of palliative care for all clients, including those living with HIV and AIDS.

With respect to long-term care redirection, I know some planning has gone on in Metropolitan Toronto and elsewhere about how supportive housing programs, for example, might be developed for those people needing a structured environment, a supervised environment, particularly for those people who are suffering from a degree of dementia as a result of HIV and AIDS. The changes to the in-home services program will allow us to do a better job of supporting clients with AIDS as well. More of that discussion needs to happen and more planning needs to happen locally at the district health council level to make sure that this population's needs are considered in the overall long-term care planning.

Mrs Fawcett: Hopefully, you'll get a pilot project.

Ms Bregman: Can I just make one quick comment on that?

The Chair: Yes.

Ms Bregman: This is our concern with regional planning, however: In many communities, people are still unwilling to identify themselves as being HIV positive. We're very concerned that if you leave it solely to DHCs and there is no policy coming from the ministry, we will not be seeing the development of sufficient programs around the province. So I really urge you to go beyond just leaving it in the hands of the DHCs, because that will not serve the rest of the province.

Mr Owens: I'd like to thank you, Ms Bregman, on behalf of your group, for an excellent presentation. I think that you make a good point in terms of long-term care having different contexts for different people, and you've provided another context for us to take a look at today.

I think that I'd like to meet with you to discuss some of the issues, especially your supported housing issues. I'm currently conducting a task force with respect to the use of cooperatives. In terms of looking at community-directed services and client-directed services, I think that you may have an excellent fit.

You're absolutely right: In my experience with the AIDS Committee of Toronto in a previous life as a volunteer, the community has clearly pulled together and has driven the agenda, in my view, quite successfully on behalf of the client group contained within the community.

I like your suggestions around the standardization of programs and access points. There's nothing more disheartening than to find out that you qualified for one and a half points in one funding program only to be disqualified in another.

In terms of the issue with respect to women again, the alarming rise in the incidence of HIV infection among women is not yet addressed. I think that it further perpetuates the discrimination that women currently face within all aspects of society, and this yet another issue that needs to be dealt with in terms of how we support the equal partners within the society. So I'd like to meet with you to discuss these issues.

Ms Bregman: Sure. In fact, if I can, I'll meet with you wearing both hats, because I'm working on the supportive housing issue for the disabled community as well. I wear a lot of hats.

The Chair: I have a feeling that you may find, as a result of this, that whatever hat is on, there will be a number of meetings. I am sorry, but I think you can appreciate that you've raised a good number of issues, and clearly ones that have to be addressed, and that a number of people will be following up where more time would be available. So thank you again very much for joining us today.

Ms Bregman: You're welcome.



The Chair: Could I then call on the representatives from Leisureworld. Would they be good enough to come forward. Gentlemen, thank you. I know you've been sitting there for a while and I apologize for running a bit late, but we welcome you to the committee. Would you be good enough to introduce yourselves and then please go ahead with your presentation. We have a copy of your submission.

Mr Herman Grad: Herman Grad, Leisureworld.

Mr David Cutler: David Cutler. I'll be doing this part of the presentation. I'm the vice-president of Leisureworld operations, a chain of nursing homes.

Leisureworld finds itself in a unique position in that we operate under the definition of a for-profit home. In reality, today all our homes are non-profit due to the lack of appropriate funding in the past and now in the future by the delays we're encountering in the passage of this bill.

We believe the seniors of Ontario deserve more consistency in standards and funding of care delivery. We support and applaud the efforts of this committee to facilitate the implementation of long-term care reform and we encourage you to move forward with this bill.

I realize time is limited, so I'll give you a synopsis of our written submission and will then address any questions you might have.

While there are many sections in the proposed legislation that are positive, our concerns pertain to the wording of portions of Bill 101 and certain omissions.

First, there are many unanswered questions raised by the way the bill is written. We are concerned about a wide range of problems that could be created by the approach taken. While we see an intention to be more equitable, some amendments continue to discriminate against residents of nursing homes. We recommend that the government be held accountable to maintain equitable and consistent services in all long-term care facilities throughout Ontario.

We're apprehensive about the movement away from extended care to a contractual agreement model. It disturbs us that there will no longer be a universal, accessible approach to health care in these facilities as the extended care program will no longer be an insured service under OHIP in Ontario.

There's no specific language outlining the content of what a service agreement will entail. In fact, to date, not even a draft of what a service agreement might contain is available for any of us to review. Equally unsettling is that again there's no accountability placed on the government to provide funds to meet the service agreement.

The development of the case mix index, which scores one facility's care level relative to another, by no means guarantees that funding will be sufficient to ensure the assessed needs of the residents are met. The bill holds facilities accountable for providing all residents' needs without ensuring that funding will be provided to make this possible.

Next, the legislation states that the care outlined in a resident's care plan must be provided. The problem is, there's no flexibility should the resources not be available to provide the services outlined in the care plan. In fact, this legislation may seriously discourage accurate and detailed plans of care due to lack of resources stemming from lack of funding. To make matters worse, because there's not enough money in the system to meet all residents' assessed needs -- that's what this whole study was about -- as identified in the care plans, facilities will automatically be in breach of their contracts.

We recommend that the legislation not require facilities to provide all services as defined in the care plan unless the government assumes the responsibility of funding these services.

There are no details of how the placement coordinator will function. I heard earlier the parliamentary assistant's comments on the amendments to be made. We suggest that the duties be outlined in the legislation and that this position be given the responsibility to determine eligibility for placement, to identify a substitute decision-maker for the applicant, to determine the applicant's ability to make the copayment, to identify a responsible party in the event that there's default of the applicant's payment, to take consideration of the applicant's choice with respect to ethnic, linguistic, geographic and religious preferences, for discharge planning and coordination involvement when a resident needs to be moved to another location and, further, to provide services seven days a week, 24 hours a day, because these residents might require movement on weekends at all hours.

We would also suggest that existing resources be used for their function and that no new level of bureaucracy be created for this purpose.

Eligibility determination should be a combination of physical, medical and social requirements. Facilities must have the right to define their missions and the type of services they are able to deliver. Both applicants and facilities must be able to refuse a placement based on the client's preference and the home's ability to meet the resident care needs.

Both applicants and facilities must have a timely and efficient appeals mechanism with respect to placement.

The immunity clause that protects placement coordinators and inspectors, as now determined to be used, for acts done in good faith must be expanded to include facility staff as well.

With regard to the sanctions, we wonder if the bill is not creating a potential nightmare for a resident and his family. In many cases, sanctions such as freezing admissions and withholding payments will in fact jeopardize the provision of care to residents still in the facility. Sanctions should only be implemented as a final resort and facilities must have the right to appeal the sanctions implemented.

We are extremely disappointed to see the reintroduction of the word "inspector." Past experience has shown that the inspector model created an adversarial climate that was not in the best interests of quality care. It failed dismally. All long-term care facilities, regardless of their profit designation, must be reviewed under the same set of standards and criteria.

We strongly support the continuation of the current compliance management program which stresses consultation rather than confrontation.

We question why the powers of the inspectors need to be increased. The recently passed Bill 74, the Advocacy Act, negates this need, as advocates will help to communicate and assist residents with unresolved issues and problems. That is the purpose of Bill 74. Let it do its job.

While we support the concept of quality assurance programs, the term itself is outdated. In the past two to three years, for instance, our company has grown from a basic quality assurance program to a more refined total quality management program. We suggest a more generic term such as "quality management" be used.

In addition, we do not support inspectors being given powers that allow them to review and possibly use our total quality management information for their own purposes. I respectfully submit that allowance of this will cause a facility to develop an ambiguous approach to self-evaluation and the whole philosophy of total quality management will become meaningless. Very seldom does government legislation encourage growth, also, for us to monitor our quality of service without bureaucratic intervention.

Consistent with the above concern is our aversion to the inspectors having any rights to personnel records, peer reviews or performance reviews. This can only be seen as a total invasion of staff privacy and serves to meet no rational goal. We wonder what confidentiality issues would be breached.

The bill has given far too much power to the government and inspectors without the corresponding accountability. Consumers and facilities, however, have been given very little power, protection or choice. The bill leaves too many issues to be defined by regulations. We haven't even seen the regulations as yet.

We are grateful for the opportunity to address you, but we are really only addressing you on the bill we have seen. We don't know what the regulations say, so how can we do a complete presentation?

In summary, I'd like to stress that this bill should provide reasonable and equitable guidelines for all long-term care facilities. Don't reintroduce policing by inspectors. Keep the consultative approach using the compliance management program.

There are many talented and dedicated people in both the for-profit and not-for-profit sectors. Bring them together under one act that addresses everyone by the same standards, criteria and funding model.


The Chair: Thank you very much for the presentation you've made orally and also the document you have given me. I just note for the record that you have summarized it and that there are more arguments made in your paper. I appreciate the way you did that. Also, I just want to indicate that a lot of these points have been made by your colleagues as well, so I think what you have done is support some of those particular positions. We'll begin the questioning with Mr Wilson.

Mr Jim Wilson (Simcoe West): Thank you for your presentation. I think it was concise and to the point. As the Chair said, a number of the points have been raised, but our experience with these committees is that repetition is a good thing to drive the point home; for instance, the very fact that there's no obligation for the government to actually live up to its part of a service agreement or to actually fund you so that you can fulfil the plans of care, and many other points with regard to inspection, the placement coordination system and the powers of placement coordinators.

These points have been made for weeks now and the government just hasn't come forward with its amendments at all yet. You'll get lipservice from the parliamentary assistant and from members opposite indicating that they're quite willing to, in some areas, make some changes. We've not seen those.

You did mention a point, though, that I did not ask before, and that is that you recommend that the placement coordinators should identify the substitute decision-maker and the person if it's not the same person responsible for financial obligations of one of your residents. What happens now when a resident goes into default of payment? Do you take a normal small business approach to that or do you just sort of carry on?

Mr Cutler: Invariably, it involves us in having to write off the money, even if there is a contract signed by a substitute. We try to collect the money, but you just can't draw blood from a stone, so to speak. It's very difficult.

Mr Grad: In 20 years we have never litigated with a resident and we're not prepared to do that. In many cases, relatives simply won't pay and we just have to write the money off.

Mr Jim Wilson: That's interesting. It's useful to hear how you handle that, because I think the impression left out there of nursing home operators by some people in the communities is a picture of you people as the big bad wolves who don't treat your residents fairly and that sort of thing. But in terms of default of payment, you take a very humane approach to it and a commonsense approach. It would be helpful, though, I gather, if the application form clearly spelled out someone else who might have that obligation on behalf of the resident.

With regard to access to records, your points made in that section of your brief, I'm having déjà vu all over again, as I'm sure members of the Liberal Party are. We went through this with the Advocacy Act. The government has back in this legislation all the stuff we tried to take out of the Advocacy Act. We were somewhat successful in ensuring that some of these internal management tools were not used inappropriately against institutions.

Do you want to just take a minute to explain to the committee the importance? I think you very honestly said to the committee that if inspectors have access to quality review activities, peer review, performance review activities or quality improvement activities, the records pertaining to those activities, it could very well force you to write in code or have a not-as-effective quality management system in place as you should.

Mr Grad: We have a contradiction at the moment in that our union agreements -- we deal with several unions -- don't allow us to provide those confidential records to anyone and yet the government inspectors would be able to come in and look at private and confidential personnel records. It would create many problems for us if that were to continue.

Mr Jim Wilson: Has that been discussed with your unions? Are they aware of this?

Mr Grad: Unions are not prepared to discuss too many things these days and they're not prepared to back off any agreement or give in in any way, specifically with respect to this issue.

The Chair: Mr Wilson, I'm afraid we're going to have to move on. Mr Wessenger.

Mr Wessenger: Thank you very much for your presentation. I think I have met with you on previous occasions and am certainly aware of your facilities and your concerns.

First of all, I'd just like to just make some clarifications. You've mentioned the insurance model, and I'd just like to suggest to you that, first of all, the insurance model of course is not a requirement under the Canada Health Act for this type of care. Secondly, the homes for the aged have operated on a non-insurance model and seem to have done quite well under that system. Thirdly, I think certainly by moving to a contract model it provides the flexibility of allowing the provision of open beds for respite care and emergency care which I think does have an added advantage to the system.

With respect to some of your comments, I think I can provide some clarification. First of all, on the question of the compliance system, I'd just like to assure you that this system will continue in effect. Second, with respect to your comments concerning quality improvement programs, the only thing I can do is to assure you that we're looking very carefully at that with respect to the information question. With respect to generic terms, I think we certainly agree with you in principle. We'd prefer to have generic language rather than buzzword language with respect to the question of quality programs.

With that, I'd just like to thank you for your presentation. We certainly hope that we all see this legislation in effect quickly.

Mrs Sullivan: Once again, I appreciate this brief. We will have amendments that respond to many of the issues you have raised that we'll be putting on the table.

I want to clarify, because this has come before us again this morning from the ministry and the parliamentary assistant, the issue of how there will in fact be continuing equivalency between the commercial homes and the homes for the aged which are not commercial. We certainly understand that where there are voluntary services and fund-raising activities and so on, there can be enhancements in the quality-of-life areas, and that will be more likely in the non-profit homes.

The second issue is the pay equity issue, which is a very serious one in terms of levels of staff compensation. I want to ask the parliamentary assistant if the government is reconsidering its position, given that the principle of this bill is level-of-care funding with respect to pay equity funding for the private sector.

The other question I want to ask the parliamentary assistant is, there has been a clear promise of open beds for respite and emergency care, when in fact there are waiting lists in virtually every community across Ontario. Where are those open beds going to come from?

The Chair: The parliamentary assistant with those two questions, and then I'm afraid we're going to have to move on.

Mr Wessenger: I think, first, the pay equity question is still a matter up for discussion and consideration. There has been no policy established on that as of yet.

With respect to the matter of the respite beds, I'll ask ministry staff to comment.

Mr Quirt: You're quite right that if beds are left open for respite purposes, then a permanent resident is not going to be living in that bed. We feel, however, that by providing respite services in facilities, that bed used to allow family care givers to have a break by admitting their family member for either an emergency situation or for a planned respite vacation will allow many more people to be able to maintain their family members at home, which would be their preference at that point, and it would be one available to support family care givers in doing that.

We feel it's a good investment to provide respite care in facilities, recognizing that if two facility beds are left open for respite purposes, then there are two fewer permanent residents in the facility.


Mrs Sullivan: That's the difficulty I'm having. I think it's wonderful and in fact a very positive initiative to have respite care beds available in the facilities. Once again, however, we are looking at an aging population. We are looking at people who are on waiting lists with more severe physical and mental problems that must be dealt with when they're admitted to the home. There has been a freeze on new beds.

Where are those respite care beds going to come from? You're basically adding to the waiting list in making that promise. To open the beds up, you will have to wait for someone to die in a nursing home or in a home for the aged. That's how they will be opened up, and therefore somebody else who has the need for that space will not be able to have the facility-based care he or she requires.


Mrs Sullivan: Parliamentary assistant, this is a policy question. I'm not attacking the ministry people. Please let it be shown.

The Chair: Just very briefly, please, parliamentary assistant.

Mr Wessenger: I certainly acknowledge the point you're making. What you're saying is that if you provide these beds, you are diminishing from the stock of permanent beds. However, I think there's certainly an assumption made that we have an overall appropriate number of beds in the province of Ontario. We have a maldistribution of those beds, and I think that is recognized.

I don't want to go back to staff on this particular question, but I'm wondering if we're going to take that into account in the setting up of respite beds. For instance, I'm just thinking of my own regional area. We have a surplus of beds in part of the area and we have a shortage of beds in another part. It would make more sense in the respite bed situation to try to open up the beds in the areas where you have the surplus rather than the areas where you have the shortage. I'll have to ask staff if they can comment on it. The issue is raised --

The Chair: I think the issue's on the table at this point.

Mr Wessenger: It's an interesting issue.

The Chair: I regret, but we still have one more witness and I really must urge us to move on. Gentlemen, I want to thank you very much for coming again. I think you can see you've raised a number of issues which the committee will be dealing with.

Mr Cutler: Thank you.


The Chair: If I could then call on the representative from the Villa Care Centre, please. Thank you for coming before the committee and also for waiting for your turn at the table. If you'd be good enough to introduce yourself, then please go ahead with your presentation.

Mr David Jarlette: My name is David Jarlette. I'm the administrator of the Villa Care Centre in Midland. It's a 109-bed nursing home. I come to you not as an institution. I've come here to speak on behalf of our residents, because it's our residents that will be affected by changes to Bill 101.

There may be many groups that are trying to derail long-term care reform. I'm not one of those people. I think what I'm going to be bringing up is just some concerns with portions of Bill 101 and its omissions. We want to see the bill passed as quickly as possible and we're in great support of it.

I think a little bit of history dealing with residents in nursing homes is that we haven't been adequately funded in comparison to other institutions, such as the municipally run homes for the aged, and that has resulted in our residents not having the ability to receive the same level of services for our residents as residents in other types of institutions, whether they be charitable homes, municipal homes or nursing homes.

In 1989, for people who are not aware, there was a lawsuit put against the provincial government on the grounds of discrimination and inequitable treatment of residents in nursing homes compared to those in municipally run homes for the aged. The court found no discrimination, but it did urge the government to move on and deal with the inequities.

This issue is still in the court systems and is awaiting hearing at the Supreme Court of Canada, so it's been a long-term concern with respect to funding and our ability to provide quality services to our residents for quite a number of years. We are pleased with the government's attempt to develop the same set of rules and more equitable treatment for all long-term care facilities and we strongly endorse that.

We see that there is no government accountability to maintain equitable and consistent services to meet resident needs across all of Ontario, and we've seen in the bill that there's an ability to fund different institutions for different programs. I think we need to look at the fairness, no matter whether a resident is in a charitable or not-for-profit or for-profit or home for the aged. It's the resident who suffers, and I think there has to be consideration given specifically to the residents when you're really looking at equity for them.

We're concerned with the role of the placement coordinator, the lack of choice of applicants, the lack of appeal for the applicants and the lack of appeal for the facility, because it can be quite difficult when we're looking at our waiting lists, a resident coming in. An example of that may be that resident who might be quite aggressive and noisy. We have a four-bed ward where four residents are staying in that room. Placing a resident who could be aggressive and quite noisy in that room could be very disruptive to the quality of the life of other residents in that room. As a facility, we have to ensure the rights and the quality of life for the residents who are currently in our facility, as well as ensuring that when we bring a resident in, we're providing him or her with good quality care, and we can meet that too.

We are concerned that the bill sets up a more adversarial approach to inspections. From being in the long-term care field for many years, at one time we had an inspection system. It was quite adversarial. A lot of times things just didn't get done because of that approach. The approach of compliance, working together, does work. Things do get resolved and the quality of life of the residents does improve under that type of system.

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

I feel that we must go forward with the bill. Our residents have waited a long time for it and we must end the discrimination based on the type of facility a resident is in. As a facility, we're quite prepared to work with the government, work in partnership and hopefully ensure that the process of reform works well for the residents of the facilities. Thank you.

The Chair: Thank you very much, and thank you for coming down from Midland this morning to be with us. We'll begin the questioning with Miss Carter.


Ms Jenny Carter (Peterborough): Thank you. Now you did state that, like many others, you had great concern with the unfairness of the funding system as it was previously, and of course that has been addressed in Bill 101. Also, we have the three envelopes that are going to cover -- of course people are going to contribute to their accommodation, but that is going to be funded equally across the board -- we're going to have the envelopes for things like spiritual needs and so on and we're going to have the care and the medical side also funded separately.

Now, given this bill, do you feel there's anything in the funding system, as suggested, which is not fair, or does it solve that problem?

Mr Jarlette: I don't think the bill is addressing that. I believe it addresses that funding can be available for approved programs. I think maybe an example I could give you would be our physical facilities, the actual building, its design. Our facility was built in 1976. The type of residents we admitted in 1976 required quite considerably less care than they do today.

Problems with that? Examples are dining room space -- when people are in wheelchairs in dining rooms, they take up a lot more space than residents who could previously walk down to the dining room and sit in a chair; just moving people on elevators. As an example, you can only put four wheelchairs in an elevator to transport or assist residents down to a dining room in a multi-floor facility, but a lot more residents could be in an elevator if they're walking.

These sorts of changes, with the types of residents we have, if we don't have the appropriate capital funding to build, renovate and keep our facilities up to snuff, that affects the quality of life of the residents. So if government gives special grants or capital improvement grants to, let's say, the not-for-profit sector, not-for-profit residents are going to be receiving the benefits of a much nicer physical facility than residents in a nursing home. I don't think that's necessarily fair.

Ms Carter: It was my understanding that residents who had a high level of care need would not be assigned to homes that were not physically capable of handling them.

Mr Jarlette: I think what's happening now is that traditionally the extended care program was from 1.5 hours of care up to, I believe, about 2.5. We're finding in our facility in Midland that approximately 40% to 50% of the residents really have a chronic care level. That's far and above what we were initially designed, funded or staffed to accommodate.

Ms Carter: So you are feeling pressure at this time?

Mr Jarlette: We are feeling quite pressured, yes.

The Chair: Thank you. Mrs O'Neill.

Mrs O'Neill: I'm glad you have been able to present your case, because it seems the general consensus about Bill 101 as it was presented initially was that this is level-of-care funding, this is what we've been waiting for for ever; it's here now. You're suggesting -- and others, but maybe you have been more explicit -- on the capital side, there are absolutely no mentions of capital or a commitment of capital, whether it be for increased care needs or whether it be for updating of present facilities. I presume that is your concern, at least one of your concerns. I'd like you to say a little bit more about that because, as I say, you seem to be the group, particularly the nursing homes, that this bill should have satisfied.

Mr Jarlette: The facility that I operate is in compliance with the Nursing Homes Act. I am not running into a problem of non-compliance and having to rebuild. I guess the point I am trying to make is that I think the types of residents that we're going to be caring for in the future are going to be requiring a lot more care. I think in future the facilities are going to have to be adapted, renovated and changed to meet those different care needs for those residents.

Mrs O'Neill: Do you feel there is any mention in the bill about capital?

Mr Jarlette: There is no mention, to my understanding, of capital in the bill.

Mrs O'Neill: And that's one of your concerns.

Mr Jarlette: We are quite concerned about that, because if we don't have the capital funding

Mr Jarlette: And we are quite concerned about that because if we don't have the capital funding, eventually we won't be in business because of the fact that we won't be able to keep our facilities up to acceptable standards in the long run.

Mrs O'Neill: Thank you.

The Chair: Thank you again very much for coming before the committee and expressing your concerns this morning.

The committee stands adjourned until 2 o'clock this afternoon.

The committee recessed at 1226.


The committee resumed at 1408.

The Chair: Good afternoon, ladies and gentlemen. The standing committee on social development is meeting to examine Bill 101, An Act to amend certain Acts concerning Long Term Care. Just very briefly, before we begin the afternoon's proceedings, I would like to call on Alison Drummond to make a note about a document that she's given us.

Ms Alison Drummond: This morning, everybody got a memo from research looking like this. Could you tear out the witness sheet from your summary of submissions that you received on Tuesday afternoon and replace it with this? What happened was our computer went down at the office and I didn't realize that the witnesses from Ottawa and Kingston are all in the brief but they're not in the list of witnesses. So those codes can be a little obscure without this to let you know who's who.

The Chair: Never trust those computers.


The Chair: Our first representatives today are from the Royal Canadian Legion, Kingston branch. We want to welcome you to the committee. Would you be good enough just to introduce yourselves, and then please go ahead with your presentation. We have received a copy as well.

Mr Dave Gordon: My name is Dave Gordon. I'm the deputy district commander of the Royal Canadian Legion, District G. To my right is Jim Margerum, who is a district commander, and I believe presented a brief to you in Ottawa when you were there.

The Chair: Welcome to you both.

Mr Gordon: Thank you. As a part of the Royal Canadian Legion, our prime responsibility is to ensure that veterans and their dependants receive the care and assistance they are entitled to. We must make sure that we monitor the policies, programs and delivery systems which will meet their needs and that we recommend and/or lobby on their behalf to implement necessary corrective measures.

As a part of our mandate, we also play a prominent role in our communities to ensure our seniors, youth and disadvantaged are assisted and protected. The legion's involvement and support we have provided and will continue to deliver to eastern Ontario is a matter of record.

Our problems with Bill 101 and long-term care:

(1) We agree with and express the same concerns as our colleagues' briefs previously presented to this committee regarding: (a) the admission standards regarding eligibility, new provincial standards vis-à-vis veterans' health care regulations; (b) removal of extended/long-term care, level II designation and conversion to chronic care beds; (c) the failure of the province to fulfil the responsibilities of keeping veterans' designated beds in service which were transferred from Veterans Affairs Canada, ie, 45 chronic care beds in Sunnybrook, Toronto; (d) not putting into service the beds being closed at the psychiatric institute in London -- approximately 160 -- where they are badly needed in northern Ontario in particular, and other areas in Ontario; (e) the new coordinated placement service requirement to ensure veterans' priorities are recognized and respected, as guaranteed by federal legislation.

(2) In eastern Ontario we are extremely concerned that the new long-term care redirection has a serious void. With the designation of chronic care beds and the urgent direction of the province to put extended care level residents or patients back into the community, we see a lack of facilities and programs and support systems. Sufficient housing and accommodations do not exist to provide for the semi-independent domiciliary or sheltered needs of seniors and other disadvantaged. We recently opened a 44-unit seniors' housing complex in Kingston called Legion Villa in an attempt to help these people live in dignity and comfort. There is a need for more supportive semi-independent accommodation.

(3) Once again we express our colleagues' dismay that veterans' priority beds and veterans' rights, transferred from the federal government and paid for, are not even mentioned or indicated in Bill 101. For that matter, nor are the veterans.

In conclusion, while we have criticized objectively, we're working actively with the province and others to resolve and develop the infrastructure and facilities needed in eastern and, indeed, all of Ontario, to look after the needs of seniors, veterans and the less fortunate.

Mr Chairman, I thank you for allowing our presentation of this brief this afternoon and we'll be happy to respond to any questions.

The Chair: Thank you very much. We'll move right to questions.

Mrs Sullivan: This is an interesting presentation. As a matter of fact, my colleagues and I were discussing the legion presentation which was made in Ottawa at lunch today. I want to ask the ministry and the parliamentary assistant to the minister two questions, just so we can further our own understanding of this entire situation and see where potential amendments are.

Can you advise us where and how the veterans' health care regulations vary from provincial standards with respect to eligibility for admission to long-term care placements? Secondly, what is the intention of the province in terms of its dealings with veterans' rights accommodation, where there is a contractual agreement with the federal government in relationship to those beds?

Mr Wessenger: I will answer part of the question first and then refer it to ministry staff for the balance.

First of all, as you may know, Bill 101 does not relate to any of the priority beds that now exist, because they all exist in chronic care hospitals and this bill does not deal with chronic care hospitals, so the priority will still remain in that aspect. The issue has been raised with respect to the question of what is going to happen in the future with respect to the Perley Hospital. There is a transfer agreement that has been entered into between the federal government and the provincial government with respect to those priority beds. I have read the provisions of that agreement and in my opinion that agreement provides that the matter of placement in the priority beds in the long-term care facility, if it becomes such a facility, will still continue through the federal process.

Of course, a judge might find an interpretation other than mine, but that is my interpretation upon reading the agreement. It's certainly the intention of the ministry to respect that priority. The minister will be writing a letter to confirm that aspect. Also, the minister has certainly expressed a willingness to meet with the legion in order to discuss the matter further to help clarify the situation.

Mr Jim Margerum: If I could comment on that, Perley and Rideau Veterans' is not a hospital any more; it's called a health centre. It has not been designated as a hospital. The beds under chronic care are in long-term care. In the old designation there was level 1 to level 4, level 4 being the heaviest care requirement. Those beds that were to go originally into the Perley and Rideau Veterans' Health Centre were 175 long-term care, which were up to level 2, and 75 heavy care, which were level 3 and level 4. In the process of developing the long-term care bill, 101, that designation was removed and they're all called chronic care beds. They're not called as you suggest.

The veterans' health care regulations very specifically stated the type of requirement for eligibility to get into those beds. The new agreement specifically states -- and I say "specifically states"; we've had it checked legally -- that the new provincial long-term care admission standards yet to be enacted in place are the admission requirements. I suggest that they overrule veterans' health care regulations. The problem we have with it is that if the federal government is transferring the responsibility along with the dollars to provide the facility, its requirement should transfer with it.

Mr Wessenger: I'm going to have ministry staff comment on that because we certainly have a disagreement with that interpretation. I'll ask ministry staff to further elaborate.

Mr Quirt: Just to clarify the status of the Perley Hospital currently, it is now a chronic hospital and will continue to be a chronic hospital until the new Perley and Rideau Veterans' Health Centre is opened. When that new centre is opened, it will be funded as a long-term care facility and will no longer be a hospital when that new facility is open.

The transfer agreement that was signed between Veterans Affairs, the province of Ontario and Perley Hospital, in our opinion, maintains priority access for veterans for 250 of those new beds. I know that there are two clauses on the same page and I can understand why you have a different impression.

Mr Margerum: There are five clauses.

Mr Quirt: It's the intention of the Minister of Health to write to Veterans Affairs to reconfirm her understanding of the agreement, and her understanding is that priority access will be continued for those 250 beds following construction of the new long-term care facility. I would note as well that any veteran being admitted to that new facility would have the opportunity to receive whatever service at whatever level he needed in that new setting.

Mr Margerum: I would suggest, with all respect, that the original draft agreement which was provided to us by Veterans Affairs Canada included admission standards that related to the existing facilities being the Rideau vets' home and the Perley Hospital. That was in here. There were no grandfather clause requirements, nothing pertaining to new provisions to be developed by the province.

When the final contract or transfer agreement came out, there were five clauses specifically relating to admission. Our argument is very straightforward: If what we are concerned about is not the case, why are the clauses in the agreement? They shouldn't be in there. The language in this was sufficient to cover.

I read it again for the record: "The admission process at the Perley-Rideau Veterans' Health Centre" -- and that is a new facility -- "(a) In accordance with the provincial redirection of long-term care, the admission process to the Perley-Rideau Veterans' Health Centre will be coordinated through the services coordinating agency. The role of this organization, the admission committee of the Perley Rideau vets' centre and the practice and procedures of the admission process shall be established in accordance with long-term care reform policies and guidelines which may be in place from time to time."

That is exactly the clause that bothers us, and in here the clause is an all-including clause that states specifically all the facilities.


Mr Quirt: I don't have the document in front of me, but I think on the same page there's a reference back to the continued priority access for veterans to those 250 beds. My understanding is that Veterans Affairs Canada feels it does have priority access to those beds or it wouldn't be interested in paying for a big part of the facility; and as I mentioned earlier, the Minister of Health is under the impression and certainly signed the agreement in the spirit of maintaining priority access for veterans and is willing to write to reconfirm that position.

The minister is also interested in meeting with representatives from the legion to talk about this issue and the issue of priority access generally to chronic hospitals as well.

Mr Gordon: When?

Mr Margerum: We've tried for a year and a half, sir, and we were unable to get that meeting with the minister.

Mr Quirt: Mr Wessenger discussed the matter with the minister --

Mr Wessenger: A few days ago, yes.

Mr Quirt: -- two days ago and she indicated her willingness to meet with you, and I suspect her office will be in contact with you.

Mr Margerum: I go back again to reinforce the argument on the clause on page 14 of the transfer agreement, which is clause 33(b) 1. "The admission committee at the Rideau vets' home, which reviews all applications for admissions and establishes the appropriate type of care and health services required...the department shall be represented on the admission committee by the director or his delegate." Those are existing facilities.

Now, clause 2: "The admission committee at the Perley-Rideau Veterans' Health Centre" -- this is the new one -- "which will function in accordance with the long-term care redirection and provincial enactments." It does not say Veterans Affairs Canada health care regulations. It does not say it. The words are missing. We can only assume that what's in there is what would go by in a court of law or in a dispute.

The Chair: I'm going to continue with questions. You have a commitment that there will be a meeting with the minister where hopefully that can be resolved. Mr Wilson.

Mr Jim Wilson: Commanders, like you, I and my party aren't satisfied that a meeting with the minister or an exchange of letters between the provincial minister and the federal government will have any weight at all in law should this come down to a court case.

I think you need protection for priority placement for veterans and protection of the current federal-provincial agreements, and I wrote legion command when this was first raised some four or five weeks ago to express the fact that we have drafted amendments to try and give you that protection.

I also want to say that as Health critic, one of the first things I did was to visit Perley Hospital and to review the plans for the Perley-Rideau Veterans' Health Centre, the new health centre, so I'm very much aware of it.

This is a contentious issue, and because the government tells us that its intentions are good, I want to ask the parliamentary assistant, why won't you put your intentions in writing in this legislation? Why don't we write a clause into this legislation that says nothing in this act is to contravene any of the current federal-provincial agreements established to give priority access and placement to Canada's veterans? Why can't we do that and just make it absolutely clear, and clear for the courts? Even if you think it's redundant, put it in the act.

Mr Wessenger: We feel that it's clear in the agreement that the rights are protected, and to make an amendment purely to reiterate what's under a legally binding agreement would not particularly make sense. I will ask legal counsel. They may wish to comment further on this. I shouldn't be playing lawyer as well as politician.

Ms Czukar: I'm Gail Czukar, legal counsel with the Ministry of Health. I don't know that it would necessarily make it perfectly clear if we had something in our legislation. You would then have a conflict between provincial legislation, federal legislation and regulations and a federal-provincial agreement which is binding on the ministers. So I don't know that this will solve the problem. I think there are different legal opinions, as there were when the transfer agreement was negotiated, and it is something that has to be looked at.

The legion obviously has obtained legal advice that gives it an interpretation, we have an interpretation, and the federal government, which participated in the agreement, has an interpretation. I think the meeting that's been committed to is probably the best forum for trying to work out where the best legal protection can be obtained. It's not clear to me that changing our legislation would be the best place to do that.

Mr Jim Wilson: Except that I'm a legislator; playing a shell game is not acceptable to me nor to the members of this committee. I want this issue resolved. You've known, Mr Wessenger, for quite some time that this issue was out there. It was brought up weeks ago in the hearings. You're only now getting around to having your minister meet with these people. It's bad enough that we have to do everything else in this legislation in a void; now you're telling us that another serious issue affecting Canada's veterans has to be done in a void and that we have to have some sort of faith that you're going to correct this in the long run.

I don't think that's good enough, and I don't think you should be asking the Legislature, which will be sitting in a few weeks, to deal with this legislation, to pass this, when there's an issue like this outstanding. So I think you'd better get your act together in the next seven days and bring us amendments forward next Tuesday to clear this up.

Mr Wessenger: Mr Wilson, I suggest that we do have our act together, and I suggest that legally binding agreements protect rights as well as legislation.

Mr Jim Wilson: Look, what you're saying is --

The Chair: Order, please.

Mr Wessenger: You're not a lawyer, Mr Wilson. I'll go on record as a lawyer saying that in my opinion the agreement gives protection to the legion. I may disagree with the legion's lawyer, but that's something to be worked out. If clarification is needed, an amending agreement or something of that nature just to clarify, I'm sure that can be worked out. I think it's clear that the intention is not to in any way detract from the priority beds, and certainly we're prepared to look at the best way of ensuring that, but we feel that they're protected now. There may be some additional things that can be looked at to be done. Obviously, the matter shouldn't be played politics with; we should look at it to see the best way to protect the interests of the legion.

Mr Jim Wilson: I'm not. If I were a legionnaire, I would be insulted by the treatment this government has given. Okay, I'm not a lawyer, but they've had legal advice. These are intelligent people. They've had to come before the committee many times now to drive this point home. I'm just not satisfied, and I'm going on record to indicate that I'm not satisfied with the government's response to this issue.

The Chair: I think at this point the issues are clearly on the table, and there's a difference of opinion which hopefully will be resolved before the legislation is enacted. I think at this point we have probably set that out sufficiently. I'd like to just provide the opportunity to either of our two witnesses, if there is any final point you would like to make, and then I'm afraid we'll have to move on.

Mr Margerum: I have one other point concerning it. If in fact there's no problem, as it's alluded to, if we have no problem, I begin to wonder, when I see the eligibility and admission standards put out by the Ministry of Health, I believe. One of the clauses in the introduction says it is proposed that persons currently on waiting lists for residential care will be required to meet the new eligibility criteria in order to be eligible for facility-based care. I make the point that veterans are on eligibility lists, and it does not say, "veterans excepted." It does not say that.

I make it very clear, as I go through the information, that I don't pretend to be a lawyer. I am not a lawyer; I'm a concerned citizen who's worried like hell about the treatment veterans are getting. When I see language like this, entire agreement clauses that specifically state that the minister is sending us a letter saying, "We agree with you; we'll look after it," that isn't worth a tinker's dam. What the clause says is that anything that is not written in this agreement is not binding. I am not a lawyer. I will not debate as a lawyer because I don't have the capability, but I'll state very clearly that this transfer agreement and Bill 101 do not recognize veterans' rights or veterans' priorities.


The Chair: I think we recognize those points you have made, and made very cogently, not only here but in Ottawa. I think there has been a commitment made today, which we have all heard, that there is going to be a meeting with the minister. I think it's fair to say that the members assembled will be following up to make sure that the meeting takes place and that these issues will be dealt with at that time and, we hope, resolved.

Mrs O'Neill: Mr Chairman, we don't have a copy of the agreement. It's come up twice to this committee. Some members of the committee do have it. I really feel we should --

The Chair: Copies were distributed, I thought, in Ottawa --

Mrs O'Neill: No, we have not had it. I would be very conscious of it if we did.

The Chair: Oh, I'm sorry. Each caucus has a copy. We can make other copies. There's no problem.

Mrs O'Neill: I think it would be helpful. This has been a very high-profile item with this committee. We all should have access to that --

The Chair: We'll make sure each member has one, and we will, I'm sure, see that there will be a meeting with the minister.

Mr Margerum: There are two agreements. There's the signed agreement and there's the draft agreement. That has to be compared, to understand where we're coming from.

Mrs O'Neill: We'd like to have both of those, sir, please.

The Chair: Thank you very much for coming. Just to reiterate, I think the arguments both in terms of the testimony in Ottawa and here today have placed all of those issues very clearly in the public record, which is what this committee hearing is, and we wish you the very best in your discussions with the minister, which I would assume will happen soon. Thank you, and a safe trip back to Kingston.

Mr Larry O'Connor (Durham-York): Mr Chair, while the next people are coming to the table, I'd like to say something. This last discussion we just had shows there is a problem. The legion does have a concern. I just wanted to make a point that I'm sure Mr Wilson raised, that these people have a concern. The minister, through Mr Wessenger, has said she's agreed to meet with them. Perhaps he could take the message to the minister that they meet before we get into clause-by-clause, if it's possible for that to happen. I think basically what Mr Wilson and the people from the legion are saying is that they've got a problem and it's not going to do us much good if it comes after the clause-by-clause. If Mr Wessenger can take that back to the minister, I think there will be a little bit more comfort around this room.

The Chair: Thank you.


The Chair: Just before recognizing the member, I would call on Dr Joel Sadavoy from the University of Toronto faculty of medicine, division of geriatric psychiatry, to come forward. Dr Sadavoy, welcome to the committee. Before we go too far down the road with the legal profession, I think we'll stay with the medical profession. We want to welcome you to the committee. Perhaps you might at the outset again identify yourself and your functions at the University of Toronto, and then please go ahead with your presentation and with the slides or whatever you're going to be showing us.

Dr Joel Sadavoy: First of all, thank you for the opportunity of addressing you. I am the head of the division of geriatric psychiatry at the University of Toronto, and I have other duties at local hospitals in the field. I am also the president of the Canadian Academy of Geriatric Psychiatry, which is a national group, and I am a member of the interfaculty group in geriatric psychiatry, which represents the five Ontario medical schools and their geriatric psychiatry services.

Wearing all of those hats, I come to present this view of the psychiatric aspects of long-term care reform. In doing so, I want to first acknowledge the fact that there is an advisory committee in geriatric psychiatry which has been developed. It began primarily as a discussion between the representatives of provincial hospitals and the ministry. That's largely where the discussion is occurring at the moment. I wanted to broaden the view of geriatric psychiatry and long-term care so that it could be incorporated, where appropriate, into the deliberations of this committee.

I will have to be somewhat of a magician, I think, to present slides. We don't have a projector.

The Chair: I apologize. I gather a machine at some point arrived and then disappeared, although it may have returned. If that indeed is the machine, perhaps we could have a brief recess to get it set up. "Is that the machine?" said the Chairman, hopefully.

Clerk of the Committee (Mr Douglas Arnott): Yes.

The Chair: It is. We will recess for a minute or two and get set up.

The committee recessed at 1436 and resumed at 1442.

The Chair: The committee will come back into session, and by the magic of modern technology, we seem to have got the system working, so please continue.

Dr Sadavoy: Thank you very much. This brief is presented to demonstrate the need for Bill 101 to deal specifically with the mental health needs of the elderly, the prime consumers of long-term care services. Within this group are the special needs of minority and ethnocultural elderly. The presentation is divided into two components: background data on psychiatric problems of the elderly as they relate to long-term care, and specific recommendations arising out of these data.

The management of mental health issues in long-term care is best viewed as occurring on a continuum, beginning in the community and running through the acute care system, especially the general hospitals, to the long-term care facilities; that is nursing, charitable and municipal homes. Psychiatric disorders are a central factor in service delivery at each level of the system.

At present, approximately 95% of those over the age of 65 continue to live in the community. In the United States, 90% of those over 75 and 80% of those over 80 reside in the community. As with many global statistics, however, these figures do not identify the level of illness and service needs of this population.

Formal psychiatric services are underutilized by community-dwelling elderly, and the majority of care is provided by non-psychiatric practitioners: 80% of the elderly with a psychiatric diagnosis are treated by non-psychiatric medical practitioners. Equally important is the finding that only 5% of elderly patients with psychiatric disorders who are seen by those practitioners are referred to a psychiatrist, and these tend to be only the most severely ill.

On first sight, it may seem encouraging to you, and cost-effective for general medical practitioners, to treat elderly patients, and to a degree this is true. However, there are important problems associated with this pattern of care, in particular, the well-documented, inappropriate use of medications and underdiagnosis of psychiatric problems, with attendant failure to find and treat reversible psychiatric disorders.

The scope of this issue is revealed when we look at the nature of the psychiatric problems that must be addressed in the community. Many of these problems are hidden and only come to the attention of psychiatrists or other health care providers when a crisis occurs. This is especially true of ethnocultural elderly that we'll deal with in a few minutes.

Within the community, therefore, there is a large pool of elderly patients often unrecognized who present a wide variety of disorders. Of special concern are the dementias -- that is, failure of brain function due to organic illness -- which occur particularly in those over the age of 80. In looking at these figures, it is important to be aware that for every demented patient living at home, there are care givers who must be involved and who come under considerable strain.

Depressive disorders affect over 15% of the geriatric population. They are especially important to identify because they are reversible and treatable in many situations. Anxiety disorders are also common, and in this group of special concern is the almost 5% of the population made up almost entirely of women who are phobic and quietly living lives of isolation and fear. Eleven per cent of the geriatric population has some form of psychosis -- that is, loss of touch with reality -- and based on our current knowledge, about 2% of this group suffers with alcohol or drug abuse problems.

Thirty-five per cent of all patients admitted to general hospitals are over 65. These patients stay 30% longer than younger patients, and based on current data, 40% to 50% of them, almost half, develop some kind of psychiatric disturbance. These figures are, I have to tell you, based on US studies. I think they are probably comparable in Canada, but we don't have specific data for this country that I know of.

The majority of the problems of patients in general hospitals are dementia, as I mentioned before, delirium -- that is an acute agitation which is usually secondary to a medical disorder and is often reversible and treatable -- and significant depressive illness. Data from several studies indicate that psychiatric disorders in these settings of general hospitals tend to be markedly underdiagnosed. It is probable, for example, that two thirds of depressed patients in these hospitals are neither recognized nor referred for psychiatric assessment. So what is the relevance to long-term care?

Since the general hospital is often the last stop before a patient is placed in an institution, staff in these hospitals who deal with geriatric patients are especially concerned with the interface between the acute care sector and the long-term care sector. Often, patients who are transferred from acute to long-term care have become unable to manage at home, even with support, because of a psychiatric disorder. Consequently, rational decisions regarding placement of patients of the general hospital to the long-term care sector require a formal interface with general hospital discharge teams which are able to address psychiatric as well as medical and social needs.

Chronic settings: The staff of chronic care institutions rank behaviour disorders as the most pressing problems with which they must cope.

Based on US studies -- and we have some confirmation from Canadian studies -- up to 94% of residents in nursing homes have been reported to have a formal psychiatric diagnosis. Half to three quarters of these have dementia -- that is, the progressive, permanent loss of intellectual functioning that I mentioned before -- and many of these patients also have psychotic or depressive disorders. Of those who are newly admitted to an institution, one in five is delusional. They've lost touch with reality and they're often quite paranoid, suspicious.

Two thirds of residents in nursing homes have at least one behaviourial disturbance, and half of these residents are given psychotropic medications; that is, medications for psychiatric disorders or behaviour disturbance. This latter statistic is disturbing when we recognize that the reasons for prescribing drugs to these elderly often are poorly defined. A psychiatrist is rarely consulted or available, and follow-up by a physician is often poor.

The data are confirmed by a recent study by David Conn and his group, who surveyed Ontario nursing homes to determine the need for psychiatric services as perceived by senior nursing home personnel. In particular, the medical directors and the directors of nursing were surveyed.

About 600 of 1,148 nursing homes responded. Over 50% of these homes had no psychiatric service available and, equally important, almost 90% had fewer than five hours a month of psychiatric service, so that almost all the nursing homes in Ontario are virtually unserved by psychiatric specialists. I'm not talking about geriatric psychiatrists; I'm talking about any psychiatrist.


As we saw earlier, up to 94% of residents in nursing homes have been shown to have a psychiatric disorder, but interestingly, when this group was studied -- the medical directors and nursing directors -- they estimated a prevalence of approximately 30%. This is a marked underestimate when compared to the data that we have from actual studies.

One of the most telling pieces of data from this study, which is confirmed by clinical experience, is that the most challenging and frequent problem the staff of nursing homes face is that of aggression, followed by wandering and depression.

I'd like to move on now and talk about some data with regard to ethnocultural issues and the elderly. This information derives from the preliminary report of the cross-cultural geriatric psychiatry subcommittee of the division of geriatric psychiatry at the University of Toronto. The data are enclosed in the appendix to this report which you should have in hand.

In surveying all the data available, it is evident that ethnocultural groups do not seek out psychiatric services until a crisis arises. Consequently, this group is disproportionately represented in emergency and crisis services in hospitals and elsewhere.

When the ethnic origin and language of care givers do not match those of clients, there is a decline in the outcome of care. This leads to an increased risk of psychiatric institutionalization. Again, these data come primarily from US studies.

Ethnocultural groups show a different pattern of psychiatric disorder and therefore must be dealt with in a different way sometimes than their white or non-ethnic counterparts. In particular, psychiatric morbidity, the amount of psychiatric disorder, appears to be higher. For example, Chinese elderly women have a much higher suicide rate then their English-speaking peers. For those over 85, the rate, according to one study, is 10 times that of white counterparts.

Other mental health issues derive from loss of status, isolation, alienation from the dominant culture, discriminatory legislation, racism and mistrust of mainstream health care especially for mental health problems.

With regard to psychiatric care, the 1988 Canadian task force on mental health issues affecting immigrants and refugees found that there has been insufficient effort to make general community programs for the elderly accessible to ethnocultural groups.

The problems are further demonstrated by census data, the Ontario 1991 census. Those over 65 make up approximately 11% of the population. Of these, about 24% are non-English or French-speaking.

The 1986 Ontario census showed that of the elderly population 13% were Italian, 10% Chinese, 7% Portuguese, 4% South Asian and 3% Latin, Central or South American. One of the problems of presenting on this topic is that inevitably there will be groups that may be left out. That is certainly not the intention here, but these are the data that we have at our disposal.

While the data on ethnospecific mental health problems of the elderly are very limited, a variety of problems has been identified to this point by our group. In particular, there is an absence of ethnospecific geriatric mental health clinics available. There is a failure of programs in the long-term care system to take special cognizance of the needs of this population. Staff are essentially untrained in dealing with ethnospecific problems and there are few resources for language interpretation to assist geriatric mental health care teams.

We have a number of recommendations to suggest. With regard to the ethnospecific issues, our group recommends that ethnic and cultural factors be central considerations in the development of routine care plans, extraordinary care plans, training of placement coordinators, criteria for establishing quality assurance programs and the development of in-service training programs. We will be able to make more specific recommendations as our study continues.

With regard to general mental health recommendations, it is recommended that routine care and all plans of care for the elderly include mental health issues along with the physical, social and environmental. Routine care, as defined in the act, should require specific management of emotional and behavioural disorders. This is most important, since these disorders in facilities are often missed or ignored in long-term care facilities until a crisis arises.

Care plans for extraordinary care should specifically designate psychiatric needs. In this regard, we would suggest that it is most important that the availability of or requirement for funding for extraordinary care of psychiatric disorders be specified at the outset of the reform process. Just in that regard, one of the problems that institutions have is that they do not have the resources to access mental health care consultation and so, in part because of that, those resources are not made available and are not sought by the institutions themselves.

We suggest that one criterion for granting institutional licences should be the capacity of institutions to provide psychiatric care for disorders of mental health. In particular, we recommend that institutions be required to ensure the availability of regular psychiatric consultation and treatment. Institutional licensing criteria should also include a requirement for staff training in psychiatric disorders, adequate staffing patterns to handle disturbed, aggressive, wandering or otherwise impaired individuals, as well as appropriate physical facilities such as closed, safe environments and observational facilities. We make that recommendation recognizing the limitations that exist in many institutions.

The effective function of the placement coordinators is central to the success of long-term care reform. Placement coordinators will be most effective if they are trained and knowledgeable in the types of psychiatric disorders most prevalent in the elderly, if they are trained in knowledge of the mental health care needs of the applicants they will encounter who have various types of psychiatric problems and if they have available to them psychiatric consultation on a formally designated basis. In other words, it will not be enough to establish a principle that this should happen. Some kind of system must be put into place to ensure that facilities are readily available to placement coordinators to obtain the kind of consultation that they need.

In determining eligibility for admission to an institution, disorders of mental health should not be a cause for refusal. This currently is the situation in many institutions. However, for the most difficult problems it may be prudent to identify and designate specific facilities which are able to provide the extraordinary psychiatric care necessary in some cases.

Not all institutions are able to deal with the most difficult of the psychiatric problems they will be presented with. The argument may be put forward that such patients should be in primary psychiatric facilities. Unfortunately, the reality is often more difficult to implement. The Ontario hospitals may be one resource to make use of in that regard, but whatever we do, I think that nursing home facilities and chronic care facilities are going to end up having to deal with psychiatric disorders, and serious ones.

In determining the adequacy of quality assurance programs, all such programs should include evaluation of the diagnosis and management of psychiatric disorders together with the efficacy of consultation and treatment resources of these disorders. The level of care needed by a resident of a facility will be influenced strongly by the presence of psychiatric problems. The act will be strengthened if psychiatric and emotional disorders are indicated as special factors in determining level of care.

Moreover, service is improved by the special designation of beds for psychiatric disorders with in-service training for the staff of such units. It is recognized that not all institutions will have the capacity or willingness to provide these facilities. Consequently, certain institutions in each region may be developed to manage psychiatric problems.

Finally, I re-emphasize that in-service training should specifically include training in the management of disorders of mental health.

Those are the data and recommendations we have to present. Thank you.


The Chair: Thank you very much for that presentation, for the recommendations and the detail in it. It's very helpful. I think I'm safe in saying that is the first presentation I believe we've had from the psychiatric perspective and we're very grateful for it. We'll get right to questions, beginning with Mr Wilson.

Mr Jim Wilson: I'll just add to what Mr Beer has said. We very much appreciate your bringing your expertise and knowledge to the committee's attention.

I have a couple of questions. It seems to me you make an excellent recommendation in terms of the fact that the psychological status -- I don't know what the non-layman's term is -- of an individual should be taken into consideration when determining levels of care. I'm not even sure, though, who's doing the pre-admission assessments in this legislation. It seems to me that's where you're most appropriate with regard to that point.

I'm going to refer this open-ended question to the parliamentary assistant, because I think that will be dealt with in regulation. Maybe we can get a ruling here now on how pre-admission assessments are to be done and whether psychological factors are taken into consideration with a qualified psychiatrist.

Mr Wessenger: I'll ask ministry staff to respond to the question of how it's going to work on the assessment and placement coordination, because I think that's really the question. Is that true?

Mr Jim Wilson: Yes.

Mr Quirt: The preadmission assessment to determine whether a person's long-term care needs should be best met in a facility would be done by the placement coordination service initially, would involve a multiservice agency eventually and would involve the attending physician of the individual in question. Should that multidisciplinary assessment indicate that there would be the need for a psychiatric assessment or review of the client's mental health status, then the physician could refer that client to a psychiatrist for an assessment or whatever treatment might be necessary.

Once the person was admitted to the long-term care facility -- you mentioned levels-of-care funding. The resident classification system does take into account the nursing and personal care resources that a client might need as a result of the behaviour he exhibits. That's something that doesn't factor into eligibility for extended care now very much. Someone can score quite highly in the resident classification system on the basis of behaviour alone, given that it has a significant impact on the staff time required to appropriately care for that resident.

Mr Jim Wilson: I gather what the witness has been saying, though, is that even with the new system, unless there is a requirement for the placement coordinator to actually consult a psychiatrist and be given the resources to be able to do that -- I guess that leads to the question, in the current situation, is it that the institutions don't have the resources or the staff don't have the training and knowledge? The referral rate for psychiatric consultation is abysmally low, and unless there's some sort of requirement in the assessment and in the regulations to include psychiatrists as part of the assessment team, I don't see us really solving the problem.

Dr Sadavoy: First of all, I think the sophistication around psychiatric disorders varies widely from place to place but, in general, I would say that it is low unless there are dramatic symptoms that the patient presents.

The question of whether a psychiatrist per se has to be involved is another issue. I think it's probably unrealistic to think that psychiatric manpower will be sufficient to provide a psychiatrist at each level, including the placement coordination level, but there are other ways of constructing the screening instrument; for example, to look for the more subtle signs of disorder which can have a profound impact on the way an individual copes and adapts to an institution as well as on the nature of the treatment that has to be put into place.

One of the concerns we have is that, to my knowledge, specific attention has not yet been paid to the need for an instrument to screen in this way. I may be mistaken about that.

Mr Quirt: There is a screening assessment instrument under development that has been under development for at least two years now and has been tested with people in the home care program and, I believe, with people who are working in placement coordination. I can't recall whether there's a specific reference to referral for psychiatric assessment in that instrument, but there's certainly an interest in the clients' mental health state and the fact that they may be depressed or the fact that they may have a cognitive impairment.

Certainly the intention would be to try to determine whether the behaviour the client was exhibiting was as a result of a psychiatric illness or as a result of inappropriately prescribed medication. The intent of the assessment is to take a multidisciplinary and holistic approach to measuring the service requirements of the particular individual. We can certainly check to see if that instrument would prompt the question as to whether or not psychiatric assessment would be appropriate to that particular client in determining how best to meet her needs.

Dr Sadavoy: It might be helpful in that regard for two things to happen. First of all, you may want to have that instrument reviewed by geriatric psychiatrists in consultation.

Secondly, merely identifying the problems or having an instrument is not the end point, of course. There is a necessity, I think, for the placement coordination function to have attached to it a formal liaison with a backup service that can provide the expert consultation should something arise out of the screening instrument.

Mr Gary Malkowski (York East): That was very comprehensive and well presented from a psychiatric perspective for geriatrics and for people with disabilities. I'm curious to know, though, before the development of Bill 101, were there any studies to show if there were any geriatric or psychiatric experiences where they actually experienced discrimination trying to get into long-term care facilities because of the need for a lot of care and the requirements that would entail?

Dr Sadavoy: Indeed there are numerous clinical instances in which institutions bar the door if someone does not conform to their particular standards of behaviour. In other words: Are they going to require a lot of care, are there indications of aggression and, in particular, do they suffer from Alzheimer's disease? If one writes that down on an application form in the current system, it is often the case that institutions will refuse admission.

Mr Malkowski: Just to follows up on that point: This legislation, Bill 101, do you believe this will actually then end up helping some of those senior citizens with psychiatric problems get into long-term care facilities? Do you think this will actually help those people? Will it improve a bad situation or, in your view, do you think this might make it worse?

Dr Sadavoy: I don't think it'll make it worse, but I think it will improve it only if we are able to provide the kinds of services necessary to deal with these problems in a more effective way within the institutional sector of care.

Mr Malkowski: My very last point then, if I may. Some of the ethnocultural groups you mentioned: Do you feel specific admission criteria are needed for eligibility for some of those people? Would you like to see added perhaps a psychosocial criterion? Would that help for some of those groups to see if that would be more a success rate to get some of those people in, to get the resources those people need?

Dr Sadavoy: I think there's a lot we don't understand about the referral pattern in other communities. We don't know, for example, the prejudices that may exist within the communities towards the traditional health care system and there may be an avoidance within communities -- we're pretty sure there is an avoidance of traditional health care for a variety of reasons.

I think, rather than setting specific criteria for admission for various subgroups of elderly, we are probably going to be more successful if we increase the sensitivity of the system to the kinds of problems individuals in these communities may have so we can identify when they are in trouble and find them and offer help. Additionally, these problems probably are not going to be resolved if we impose something from the top, from the dominant culture, if you will.


I think the development of programming for these communities will be most effective if it happens from within the community itself. That's the goal of our current work, which is to try to determine, first of all, what the problems are of the elderly within those groups, what the services are that currently exist and what the service requirements may be for the future. Once we have that information we'll be able to make specific recommendations, some of which may address the question that you pose.

Mrs Sullivan: I'm interested in this discussion. We have certainly learned, before committee and in other instances, from homes themselves of the increasing psychiatric difficulties with patients, largely because of the increasing age of residents who are entering homes, residents who, 40 years ago, may not have survived long enough to have the symptoms that are evident today and are in fact living to express them, frequently with violence. And there are issues associated with, by example, the questions of security of the nursing staff, questions related to ongoing skills of the nursing staff, in that staff tend to have been trained in other aspects of geriatric care rather than in psychiatric geriatric nursing.

I was glancing through the manual and I don't see, either in the description of the home and the services which are provided to residents or in the standards for admission and medical care, any reference to psychiatric care. The closest thing I can find is that the medical director and the attending physician have an opportunity to refer to physicians with specialist knowledge. I guess that would be the input for the psychiatrist.

Earlier today we spoke about homes which could not meet certain needs because of physical limitations. In my view, because of physical limitations there are certain reasons to not admit certain psychiatric patients to certain homes. If, by example, a home does not have the ability to provide a secure facility, certain Alzheimer patients ought not to be in that facility.

We asked earlier if the province was going to assist with money in terms of upgrades. There's going to be more demand for medical care provided in the nursing homes. Is there going to be assistance, if the province is going to say that the psychiatric patient who is aggressive or who is a wanderer must be admitted to any home, that the home will have the appropriate facilities to deal with that patient, who is both a patient and a resident, and that ongoing psychiatric care will be made available apart from the medical model? This is a mental health model.

What I'm asking is, is every home going to be required to accept all patients no matter what level of psychiatric illness and, if so, is the province going to come up with the capital dollars that will be necessary (a) to upgrade skills and (b) to upgrade facilities?

Mr Wessenger: I think it's fair to say that the whole concept of this reform and the whole concept of placement coordination is that applicants will be placed where the services are appropriate. Obviously some services do not have either the physical facilities or trained staff to accept all applicants. I think it would be fair to say no, not every facility is going to have to accept every type of applicant, for the simple reason that you have to look at the ability of that facility to service the needs of that applicant. I think that's the first thing to say.

Also, I might just add that we're awaiting of course the chronic hospital report. There may be a particular role that the chronic hospitals may also play in this whole question. I don't know whether ministry staff wish to add anything to what I've said, but I think I've pretty well covered the question.

Mrs Sullivan: It's unfortunate that we don't have that report in front of us now so that we could deal with these issues in their totality. Will the ministry then, in further developments to the manual, consider the question of psychiatric assessment and ongoing psychiatric care as part of the development of standards?

Mr Wessenger: I certainly will ask ministry staff to take that into consideration. Ministry staff might like to make some comments on that.

Mr Quirt: The reference that you pointed out was the accurate reference in terms of the option and requirement for the attending physician to make whatever appropriate referral for specialized assessment or care. It would be the attending physician who would refer the client to a psychiatrist if a psychiatric assessment or psychiatric treatment were necessary.

The program manual will deal with issues related to nursing care with respect to providing a secure environment and appropriate programming for people with cognitive impairments. As has been pointed out, that's a growing percentage of the clients in our facilities.

With respect to capital funding, which was your other question, currently the government has a capital funding program for the homes for the aged program. The bill before you contains a provision to allow for the development of a capital funding program for not-for-profit nursing homes.

Mrs Sullivan: And the commercial sector?

Mr Quirt: The capital funding program is under review currently with a view to targeting the capital resources to those facilities most in need of upgrading. In virtually all the capital projects we've been involved with, we've encouraged or required the development of a secure area within the facility appropriately designed to meet the needs of people with cognitive impairments.

The Chair: I'm afraid we're going to have to bring this to an end, but I want to allow you a final word, Dr Sadavoy.

Dr Sadavoy: Thank you very much. Very quickly, there are two issues. First, homes often don't have the option of deciding whom they're going to admit because these problems grow within the institution as often as they are admitted to the institution. There has to be provision for dealing with them, regardless of whether patients are admitted initially or not.

Second, the regulation as written, the option to refer, has functioned in a very inadequate way. When we recognize the scope of the problem we're dealing with, it is perhaps the dominant issue within a nursing home beyond the physical problems. I would urge the committee to consider altering that regulation so that there be more specific attention paid to these problems and remedies stipulated. Thank you.

The Chair: Again, on behalf of the committee, thank you very much for coming. I think you've raised a whole series of issues in a very specific and particular way that may have been bouncing around a bit in our heads, but you've really focused those. We thank you very much for coming this afternoon.



The Chair: I would now call on the Victorian Order of Nurses, Simcoe county branch presenters, if they would be good enough to come forward. I know we have some Simcoe representatives around the table. I watch them swell with pride. Yesterday it was York region. Today it's Simcoe county. Who knows about tomorrow.

We want to welcome you to the committee. If you'd be good enough to introduce yourself, then please go ahead with your presentation.

Ms Melody Miles: Mr Chairman and members of the standing committee on social development, my name is Melody Miles and I'm the executive director of the VON, Simcoe county branch. I am pleased to have the opportunity to appear before you this afternoon to comment on the proposed amendments specific to Bill 101, An Act to amend certain Acts concerning Long Term Care, and to address long-term care policy issues in general.

As you are likely aware, the VON is a national, not-for-profit voluntary health care organization that addresses the health needs of people across Canada through services provided by nurses, other health professionals, home support service workers and volunteers. As a major provider of nursing and other services in the home and community, the VON believes that individuals have primary responsibility for their own health; that the value and dignity of human life is respected; that access to comprehensive, compassionate, family and community-centred health and support services is the right of all individuals; that volunteers make a valuable contribution by extending and complementing the services provided by health professionals and home support workers; and finally, that community health services of assured quality are essential.

Since June 1990, VON has been involved in ongoing dialogue with the government specific to proposals for reform of the long-term care system. On a personal note, I find being afforded the opportunity to participate first hand in the consultation process to be most encouraging.

With regard to the geographic and demographic profile of Simcoe county, the Simcoe country branch of VON, which this year, incidentally, celebrated its 70th anniversary, services the largest and most centrally located county in Ontario. Geographically, Simcoe county is bordered by Georgian Bay to the north, the counties of Grey and Dufferin and Peel region on the west, York region on the south and the counties of Durham and Victoria and Muskoka region on the east. Several of its larger centres, including Orillia, Collingwood and Bradford, are situated on its boundaries and thus have service linkages which often are outside of Simcoe county. Simcoe county, split almost evenly between rural and urban populations, is a very decentralized community consisting of 35 municipalities and two Indian reserves, Christian Island and Rama.

Standing at a population of 288,705, Simcoe county is one of the highest growth areas in the province. The number of people aged 65 years and over is increasing at the greatest rate, with the subpopulation of those 75 and over experiencing growth of 25% between 1981 and 1986. It is projected that the population over 65 years of age will increase from 30,735 in 1986 to 40,000 in 1996 for a growth rate of 30%.

Specific to ethnicity, 60% of the residents of Simcoe county declare a single ethnic origin: 71% British, 8% French and 20% other ethnic origins. Simcoe county is a designated area for French-language services due primarily to the French settlements in the north planning area of Penetanguishene and Tiny and the francophone population at CFB Borden in Essa township. The native population is strongly represented in Christian Island and Rama and the Portuguese population prominently represented in Bradford.

With respect to VON services, the VON, Simcoe county branch, provides a variety of services throughout the county, both in-home and in long-term care facilities. The breadth of service offerings include visiting nursing, palliative care, enterostomal therapy, IV therapy, foot care clinics, adult day away and Alzheimer respite and enrichment programs. Estimated cumulative service stats for the 1992-93 fiscal year are expected to exceed 136,000 client contacts or visits.

VON, Simcoe county, employs a multidisciplinary staff: registered nurses; registered nursing assistants; home support or respite care works, who would be health care aides or homemakers; and a recreational therapist. Each care provider works to assess client or community needs and each develops his or her plan of care in partnership with the client.

VON is moving to an expanded role for registered nurses in both primary and secondary care. Nurses have a key role in long-term care both in facilities and in the community. The nurse focuses on individual and family response to illness and disability in long-term care, and plays a key role in health promotion and disease prevention. Nurses are well equipped to respond to the diversified needs of the long-term care client. Across the province registered nursing assistants are assuming an expanded role with less complex stable cases still involving skilled nursing intervention, and home support workers are providing personal care under the supervision of a health professional.

As a key stakeholder in community health and long-term care service delivery, as a trusted and credible client advocate and as an organization governed by a voluntary board representative of the Simcoe county catchment area, VON is in a position to ascertain the health care service needs of and hear concerns expressed by the members of the community it serves.

It is from this perspective that I address the following issues specific to the proposed amendment to Bill 101. The seven issues will be: vision, planning, funding or cost containment, quality management, allocation of resources, respite services and, finally, placement coordinators and coordination.

With respect to the vision of Bill 101, Bill 101 is an incremental improvement in empowering the consumer in that it does allow for direct funding grants to the physically challenged. It starts to standardize legislation for long-term care facilities. It ensures consumer access to key information regarding facility services, care accommodation and consumer knowledge of the plan of care. Finally, it allows for an appeal process regarding eligibility for service.

VON most certainly supports these incremental improvements and strongly recommends (1) that these changes be expanded to include similar requirements for chronic care beds or facilities and requirements for residents' councils in all long-term care facilities; (2) that consumers have a choice of whether to receive needed services in a facility or community setting within an envelope of available resources; and (3) that the importance of and provision for service sensitive to cultural, linguistic and racial equity be factored therein.

With respect to planning, it's imperative that planning responsibilities -- provincial, regional and local -- be clearly defined. Provincial responsibilities could include the definition of core programs that would be available across the province such as foot care, emergency respite services, health education and supportive counselling for care givers; and the definition of a quality management framework including standards, outcomes and reporting requirements.

Regional responsibilities could include specialized service planning such as specialized rehabilitation resources. Local planning could include the continuum of care from health promotion through rehabilitation to chronic level care in the home, community or facility. VON believes that the decision-making authority should be close to all the people. This philosophy is supported by the provincial government and notably by Simcoe county DHC. VON supports the lead role for local planning being assigned to the expanded DHC. This is in fact a reality in my county.

Services to our seniors and disabled require discussion as well. We must be mindful of the importance of provision of a continuum of long-term care services. Some individuals may require only short-term care in a nursing home or chronic care facility, and with appropriate intervention may be able to return to home-based care with supportive services. Both the consumer and the service provider have the responsibility of ensuring that appropriate planning is done to achieve essentially a seamless service delivery.

While VON recognizes the complexity of the long-term care system, we believe that moving ahead with implementation of certain areas before the entire policy framework is debated may further fragment the system. The government, in moving ahead on Bill 101, has sent a clear message that it is still more interested in institutional care rather than developing health promotion and community care options.

With respect to item 3, funding/cost containment, today in Ontario the resources allocated to institutional care -- that is, chronic beds, extended care beds and residential beds -- far exceed the resources allocated to community and in-home services.

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


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

Although it is recognized that cost-effective service provision is essential, hence the move to the regionalization of specialty services, the geographic realities and uniqueness of each area must be considered. This might involve such innovative delivery concepts as travelling or mobile units, a concept currently under consideration at VON Simcoe due to the county's large rural population.

With respect to quality management, which is item 4, one cannot speak of service delivery without stressing the importance of government assurance as to outcome and quality of same. Standards which would likely be developed at the provincial level would serve to promote a high level of accountability. Development and implementation of standards should be encouraged in conjunction with consumers, government, professionals and agencies involved in the delivery of the service.

VON branches across Canada fully endorse and, I am proud to say, actively take a quality management approach to care. This approach promotes consumer choice and empowerment through client or customer involvement in the evaluative process of programs and services that are provided to and for them.

Bill 101 appears to promote a control or regulatory model rather than that of quality management. Inspection, in fact, has been shown to promote a lack of trust in quality care from both the provider and the consumer perspective. Empowering consumers in a quality management approach strives to ensure that the right services are provided at the right time in the right place by the right provider. VON strongly recommends that the government consider the concepts of quality improvement to ensure high service standard and consumer satisfaction.

With respect to the allocation of resources, at a time when the government is considering the need for flexible funding and service delivery models -- for example, capitation or the multiservice agencies etc -- the government would be well advised to consider the possibility of multiple funding options for long-term care facility beds. VON does agree in principle that the current funding model of per diem funding is a disincentive to caring for residents with complex needs and intensive resource requirements.

VON suggests that the development of comprehensive multiservice agencies by VON and other community agencies funded by capitation may significantly reduce the bed requirements by providing more comprehensive and potentially cost-effective options in the home.

Furthermore, prior to expanding facility services, other community-based options, such as the utilization of community-based services and facilities, should be considered; that is, active nursing skills and specialty consultation teams, should be considered as part of the funding options. A VON nurse trained in infusion therapy, for example, could provide such services to long-term care facilities that do not have frequent enough requirements for infusion to make the in-house team cost-effective.

With respect to respite services, it is acknowledged that family care givers form an integral component in the continuum of service providers. Up to 90% of the care and support received by long-term clients who live at home is given by family and friends. In order for individuals to be secure receiving community-based services, there is a need to ensure the availability of needed services, on an ongoing basis, through committed and ongoing funding. That is to say that people who receive long-term care must be able to count on the ongoing availability of the core services, such as community support services, health and personal care and respite services. The services must continue to be available to individuals and families irrespective of their degree of illness and disability. Otherwise, individuals and families will opt for the perceived security of a facility-based service.

While Bill 101 does include a provision for short-stay accommodation, it fails to recognize the community-based respite service option. VON Simcoe county currently provides an Alzheimer respite and enrichment program which stresses care giver support, counselling and education.

With respect to item 7, placement coordination, VON supports the concept of expanding placement coordination and in fact currently administers eight placement coordinators province-wide. As this is recognized as a service need in Simcoe county, VON is considering making application to administer same.

Serving consumers through a centralized, independent and objective placement service will assist to ensure equal and equitable access to both information and placement. VON is pleased to acknowledge that the regulations allow for an appeal process regarding eligibility for service.

Once again, the concern centres around the lack of consumer control over location of sources in the expanded role of placement coordination. We recommend compelling the coordinators to ascertain and provide the consumer's choice of service location.

In conclusion, VON wishes to emphasize our continued interest in and support for long-term care reform and to acknowledge and formally thank the government for utilizing the consultation process so consistently. VON looks forward to working with our partners, consumers, service coordinating agencies and government in planning and implementing an enhanced health care system which will provide a quality continuum of care within available, albeit scarce, resources. Thank you once again for providing me the opportunity to speak on behalf of VON Simcoe County, and I will at this time be pleased to answer any questions that the panel may have.

The Chair: Thank you very much for your submission. As you are aware, I think, and as we've noted, we've had many submissions from the VON.

Ms Miles: I am aware of that.

The Chair: The one thing I know I can say without fear of contradiction is that they have all been very thorough and of a high quality, and we're very glad that you were able to be with us today. Because of some time problems, we're only going to be able to have two questions, and I think, in fairness, those will go to the Simcoe county representatives. We'll begin with Mr Wessenger.

Mr Wessenger: Thank you very much for your presentation. As usual, the presentations of the VON are very thoughtful and comprehensive, and I certainly appreciate them.

First of all, I'd just like to make a comment on your reference to respite care in the community. I'd like to assure you that it is a preference to provide respite care within the community, and it's really to provide both options. The reason it isn't in this bill, of course, is because this is not relating to the community care aspect of the long-term care policy but is relating only to the institutional aspect.

I have one short question. You indicate that you're concerned about the disincentive for community care or the incentive for more intensive care in facilities, and I'm wondering if you have any more specific suggestions on how you might provide incentives with respect to the community care aspect; as you say, to encourage people, if they are able, to move back into the community.

Ms Miles: I think it's connected very strongly to ensuring that there's community support, and that obviously is the focus that VON would always take.

Mr Wessenger: So to ensure that those services are available in the community is really the incentive you're looking for.

Ms Miles: That's right. Absolutely.

Mr Jim Wilson: From Simcoe Centre to Simcoe West. Thank you, Chair, for exercising your well-learned control of this committee and allowing Simcoe county reps this opportunity, although I'd be happy to share Ms Miles's expertise with any member of the committee who might have a question.

Ms Miles, thank you for coming down today and sharing your experience with us and driving home the points that are important concerns on behalf of the VON. I want to give you an opportunity, though, to give the lay of the land, as it were, to members of the committee who are not from Simcoe county. You mention on page 7 of your brief that the government is moving ahead on Bill 101, and it's been interpreted that perhaps that's sending a message that it's more concerned with institutional care than community-based services. What I gather from those comments is that really it's a question of priorities, that if the government was serious about community-based care -- we've already seen a downsizing of hospitals, we've seen a downsizing of that type of institutional care, but we haven't seen the dollars shift to the community-based care. What's the lay of the land in Simcoe county? Are you able to keep up with the demand in terms of providing in-home services?

Ms Miles: To this point in time, we have been able to do that. Where we have experienced some difficulty is that as the demands increase in terms of acuity of care, so do the educational requirements of the staff within the branch. So it is really at that end. It's not so much the inability to provide the service; it is providing the opportunity to have all of our professional staff trained to the degree that they're able to at least satisfy the acuity measure.

Mr Jim Wilson: To your knowledge, has there been movement on behalf of the government to ensure that you'll have the training dollars available to your staff?


Ms Miles: We have not seen it from a funding perspective, no.

Mr Jim Wilson: Finally, you talk about the fact that respite care should go hand in hand with short-stay accommodation. Do you want to take a moment to explain that? Because you're right, the bill doesn't speak to a lot of things, and one of them is respite care. Do you want to give us a feel for why that's so important?

Ms Miles: Certainly from our perspective, the success of our Alzheimer respite and enrichment program has been such that the coordinators of the program are of the opinion that there would be a number of persons within the facility structure who could in fact be serviced very well in the home. Because the support to the care giver is just not readily available, the decision has been made by the care giver that placement really ought to be in an institution.

Mr Jim Wilson: So it's perhaps an unnecessary placement.

Ms Miles: In our opinion, certainly at times, yes. It's really based on a care giver's decision more than the actual client's decision.

Mr Jim Wilson: Correct me if I'm wrong. I'm quite aware that in many parts of the county we really don't have any respite care. There are waiting lists, and when you do get it, it's for such a short duration that it really isn't sufficient.

Ms Miles: The criterion we utilize in our particular program is that there need be at least a three- to four-hour requirement for our service before we would be going in. I feel definitely very strongly that there is a need for respite and care giver relief on the one- to two-hour basis, not necessarily for extended periods of time.

Mr Jim Wilson: Thank you very much.

The Chair: Thank you very much again for coming before the committee. We appreciate it.

Ms Miles: Thank you, Mr Chairman.


The Chair: Moving from Simcoe county to Waterloo, I would now call the Victorian Order of Nurses from the region of Waterloo. May I also welcome you to the committee.

Before asking you to introduce yourself and begin your presentation, I want to indicate that before you complete your presentation, I'm probably going to have to leave. I just want you to know it's not because of anything you are about to say.

Mr O'Connor: I hope it's nothing we said.

The Chair: No, nothing you said either.

Mrs Elizabeth Allan: I can assure you mine is much shorter. I think you've heard most of it. I don't recognize anyone from Waterloo county here. Is that right?

The Chair: But there's a presence in the room, I'm sure, from Waterloo.

Mr Jim Wilson: Elizabeth Witmer.

Mrs Allan: Good afternoon. It is my pleasure to address the standing committee on social justice. I am Elizabeth Allan. I am the executive director for the Waterloo region Victorian Order of Nurses. I understand you are well-acquainted with VON by now on this committee.

The Chair: Happily so.

Mrs Allan: Good. Most of you end up in the case load at some point in time, so pay close attention.

As you know, we are a not-for-profit voluntary organization. There are 73 branches across Canada, of which in Ontario there are 33 branches. The Waterloo population that the branch serves is about 375,000 people. That takes in numerous small towns and communities in the county. We've been in operation from 1907, and one branch after another amalgamated until eventually they formed, in the 1960s, the Waterloo county. We're located at 5 Manitou Drive in Kitchener, which is about the centre of the county.

Currently, we have a staff of 134 people, consisting of registered nurses, registered nursing assistants, a chartered accountant and clerical workers. In 1992-93, the branch delivered 111,000 home visits. We offer two main programs, visiting nursing and foot care, and within the visiting nursing program we have several qualified specialized nurses.

So the specialties are: palliative care -- there is a team that delivers palliative care to the home for dying patients, and 15% of our case load are palliative, dying in their homes, mostly of diseases like cancer; we have a diabetic care specialty; we have 22 foot care clinics in the community; we have an enterostomal therapy clinic nurse; and we have intravenous infusion therapy. Recently, we had a businessman who was too antsy to stay in hospital, and he had his IV with his computer at home and managed beautifully. I would predict that is the future, that many people who are on long-term antibiotics, for a month or whatever, will certainly receive them through an intravenous by the nurse at home and manage beautifully with their work.

The VON board is composed of 13 volunteers from the Waterloo region. Each of the members brings some very specific skills to the board. Some of these board members also sit on other boards in the county. The board's responsibilities include financial, strategic planning and policy development. Since Waterloo VON is a major health provider in our community, it is from this perspective that I bring you these comments on the proposed Bill 101.

The areas of concern in the bill that I will outline include continued fragmentation of the health care system, limited empowerment of the consumer, quality versus inspection control, funding and community agencies.

Continued fragmentation of the system: The current legislation stands alone. It does not envision a totally integrated system of reform. As the bill is currently written, it fragments the long-term care section into sectors dealing with nursing homes and homes for the aged while ignoring the community sector.

The picture presented at this time is not one of a total, redirected, integrated system. The legislation is dealing with some of the parts, and admittedly very important parts. But the largest area, and the place where most of the clients are and should remain, is the community, and this has been omitted, the community part has been omitted. The consumer does not want to deal with parts, and that's what's been the problem. The consumer, when upset or ill, does not understand how to work within the system or to work the system. What he wants is a seamless organization of care where he can move from one sector to another easily without repeating the same data -- that's the tombstone data -- and without fear of the unknown. Therefore, the comprehensive multiservice coordinating body is essential for the public to access long-term care. We think it's a good idea.

Recommendation 1: That the legislation be reworked to include the entirety of the long-term care sector and that all segments of long-term care be integrated.

Limited power for the consumer: The bill has tried to empower the consumer. It allows for direct funding grants to the physically challenged; it ensures consumer access to key information regarding facility services, accommodation and knowledge of their care plan; and it allows for an appeal process regarding eligibility for service.

These changes are good. However, they need to be expanded to include a requirement for a residents' council in all long-term care facilities. I saw it in only one aspect of the bill, but it needs to be throughout, for all long-term care facilities. The consumer also needs to be given the choice of the location and the choice of what facility to enter, rather than this being the sole decision of a placement coordinator. I think other speakers have alluded to that.

Recommendation 2: That all consumers have a choice of whether to receive the needed services in a facility or community setting within the envelope of available resources.

Quality versus inspection control: History has demonstrated that control through inspection does not achieve the desired outcome but in fact can produce deviant behaviour due to fear or uncertainty. Therefore, recommendation 3 is that the homes use quality management improvement concepts in order to ensure the highest standards of care for the consumer.

The next issue is funding. The level of payment based on consumer acuity is not an incentive to promote wellness -- I repeat, is not an incentive. This system begs the answers to the following questions: Who will monitor the needs of the consumer versus the needs of the nursing home? After all, the home is in business and plans to stay in business. That's its objective. The second question is, what qualifications will the professional who decides the important issue of acuity have, and how does one ensure that wellness is the motivator and the priority for the funding purposes?

So recommendation 4 is that a funding formula be developed that will focus on the consumer's needs and care required, rather than only on acuity.


Community agencies: The community needs have been overlooked in the development of the proposed legislation in terms of the individual needs of the consumer. One of the roles of community agencies and homes is to educate and inform the consumer regarding options available to them in their community; for example, foot care clinics.

VON plays a pivotal role in the delivery of health services in the community and in continually educating the client. Therefore, the integration of community services with nursing homes and homes for the aged is critical in order to ensure the highest level of care provision to the consumer and to promote a seamless system.

Recommendation 5 is: The proposed legislation must include a linkage of community agencies with the long-term sector to ensure continuous service provision to the consumers.

I thank the committee for this opportunity to speak. I'm glad to see you didn't have to leave, Mr Beer, and I'll be pleased to answer any of your questions.

The Chair: Thank you very much, both for the presentation and the specific recommendations. We'll move to questioning with Ms O'Neill.

Mrs O'Neill: Thank you very much for coming. It is true that we've had many contacts with the VON across the province. I'd just like to mention to you that it's interesting when you talk about quality versus inspection control, because our last presenter in Kingston began his remarks by saying, "Control, that's a funny word," and I think it is, especially when we're talking about care.

The VON in the Waterloo area, I see from your brief, does not do the placement coordination work for the area.

Mrs Allan: No, we don't. The placement coordination is a separate service and my understanding is that eventually it will come under home care if this bill continues. We don't do it, but we do assessments for them.

Mrs O'Neill: So you're asking a very important question that others have asked: What qualifications and what kind of format will the placement coordination take?

Mrs Allan: It's a lot of power for one person. As I listened to the physician who spoke before me, he clearly said the amount of education required for this person. It's essential that the person be very highly educated. I would not suggest that is the case today and I would say that is a concern.

Mrs O'Neill: Because we've been told over and over through the hearings, by both the parliamentary assistant and ministry staff, that the successful placement coordination agencies that are in existence will somehow be grandfathered or will take up this position. You would like something more in the legislation than that?

Mrs Allan: Yes.

Mrs O'Neill: Could you suggest how you feel your concerns could be allayed in the legislation?

Mrs Allan: I don't think it should be one person. I think that gives tremendous power to one person. That's the way that I read the legislation, that it is one person. It sounds like it's one person per home or one person per institution.

Mrs O'Neill: That's one interpretation. The legislation can be interpreted in many ways, in my opinion.

Mrs Allan: Do you interpret it that it's more than one?

Mrs O'Neill: It could be. A placement coordinator could have many facilities under his guidance.

Mrs Allan: By one person?

Mrs O'Neill: It could be one; it could be a group; it could be an agency.

Mrs Allan: I see an agency, but I see one person. That's far too much power. I see that it doesn't give the client the choice. I don't understand the legislation. Does that mean if you lived in Waterloo county and that placement coordinator or group said, "No, you don't belong in these, but we have to put you over to London," is that a possibility? What happens to the family? What happens to the people who have to visit and care for that person?

Mrs O'Neill: We haven't been able to get a definition of what the community would be either. Both of those things are concerns. I'm glad you brought them forward again and I think that the more repetitive that particular concern becomes -- the concerns also about your community health component in this bill being lacking. We've been told the bill will be replaced by another piece of legislation that will include the community component. That is also something where we have to take a leap of faith. I'm glad you also brought up the residents' councils, because again, I feel they should be in all parts of the legislation, not just one, as you do.

Mrs Allan: Exactly. The way the bill is written now, the client has to go and say to someone, "I would like to know what my care is." Most clients will not do that. Most clients are reticent to do that, but if there was a council of their own peers, they would quickly say, "I'm not satisfied, and how do I find this out?"

You have to realize the level of education in that generation. Some of them are very timid and they just won't ask. They might sense that something's wrong but they just won't ask it. I suppose that's where they really need an advocate and the advocate would be this council.

Mrs O'Neill: Thank you for bringing your concerns forward.

Mrs Allan: Thank you. I enjoyed meeting the committee and addressing you.

The Acting Chair (Mrs Joan M. Fawcett): You're not finished yet.

Mrs Allan: Oh, I'm sorry. I'm trying to rush you.

The Acting Chair: Mr Wilson is next, please.

Mr Jim Wilson: I'll just ask you a very quick question. You talk on page 3 about the importance of the comprehensive multiservice coordinating body. You also mention prior to that that we're doing a lot of this legislation sort of in a void. We don't have the full picture of what long-term care really is going to look like in the end.

Given that, I'd be very interested to know, in 30 words or less, if you can do it, what you think the multiservice coordinating agency's going to look like and if all the partners will be in there. Because it's a term that gets thrown around. Everybody's supportive of it but nobody can tell me what it is exactly. They've all got little different views of it, and I really would like to challenge the government to give us the full picture on what it is.

Mr White: In 30 words or less.

Mr Randy R. Hope (Chatham-Kent): Give her a little bit longer time. Most people can't even answer the questions.

Mr Jim Wilson: Be fair; this is a fair question.

The Acting Chair: Order, please. Could I have the witness answer the question?

Mrs Allan: What do I see it looking like? It's going to be very large and quite unwieldy. If the board has all the players or a number of the players on it from the various community agencies, it's going to have difficulty, I would say, managing, but I understand the goal is to save money.

Some communities have a lot of this in place already. Waterloo is one community that has many of these factors in place, but a northern community that wouldn't, it will be difficult, and I really don't know how they would do it. I can see what would happen in Waterloo county. It would come to the region. It seems logical.

Mr Jim Wilson: I appreciate your comments because in answering the question, a difficult question at that, you do highlight some of the problems and some of the things going through our minds as legislators in putting this together, because we're also at a pivotal point, I think, in the province with DHCs.

Mrs Allan: Yes, that's right, you are. What do we do with them?

Mr Jim Wilson: And looking at what policy direction the government's going to take with the DHCs in the future.

Mrs Allan: Exactly.

Mr O'Connor: I guess that little discussion that was started there, we really don't know, I guess, at this point in time, because if we take a look at each community, it's all going to look a little bit different. Because if you take a look at, perhaps, a district health council that might be focused around southern Ontario and compare that to one that perhaps represents more of a rural area, it's going to look different.

So of course the comprehensive multiservice coordinating body is going to look different in every area, and of course when that does happen, then some of the people we're going to go see are the VON, because we're going to take its expertise.

You started off by commenting that everybody's going to see, perhaps, a VON at one time or another during their lifetime.

Mrs Allan: I would think so.

Mr O'Connor: I know that when my son was born I certainly welcomed the visit that we had by the VON to help us with my son and the care, and as new parents it's always warming to know that you've got a little bit of support in the community. So it was certainly well appreciated, and he's six years old and he's fine.

The question that I'd like to ask, and I guess we heard a little bit of it from the VON presentation before you, is around the residents' council. We've heard different opinions around the residents' council and perhaps you could expand on it and on its effectiveness -- should there be some room for community involvement in that and who from the community, perhaps, should be involved, because I think that's all part of the picture and maybe you'd like to expand.


Mrs Allan: I think that in the community we've been kind of left over to the side. Institutions have been here and long-term care facilities here, and it's just very recently that they've started to include the community. District health councils have started to say, "Let's look at their budgets and invite the community in."

What happens in the institutions greatly affects the community. If you dump and close a bunch of beds in the hospitals, where do you think they're going? They're going out into the community. I do think that the resident councils are necessary in all these facilities, and I do think that they should be made up of consumers and providers. So include the community people as representatives.

I think the VON and other agencies have a lot to contribute, and I think there'll be a lot of education about what's out in the community. Rarely do these people come back to the community. Once you get access into a nursing home, I think I read something recently that less than 3% ever get back to the community. It's not even considered. It should be considered. How do you consider that? It's by education, by putting these people on committees to work with them. Does that help?

Mr O'Connor: You certainly really drove the point home on page 4 when you talked about whether or not the payment is an incentive to promote wellness.

Mrs Allan: Well, is it?

Mr O'Connor: You certainly did drive your point home at that point. I guess it's something that maybe can be looked at if you do have a committee that's going to represent the community as well.

Mrs Allan: That's right; exactly.

Mr O'Connor: Thank you very much for your presentation.

Mrs Allan: Thank you. Anyone else?

The Acting Chair: Just one more. The parliamentary assistant has a clarification.

Mr Wessenger: I'd just like to clarify this whole question of consumer choice again, because it seems to be misunderstood with respect to placement coordination. The role of placement coordination is to enhance consumer choice by providing all the options to the consumer, those in the community and those in facilities. That includes supportive housing options, home care and all the various facilities. Then the consumer will make the choice as to those options.

Mrs Allan: So are you saying that the way the bill is written it won't be the placement coordinator who'll make the choice, that the consumer will? He'll just lay it out?

Mr Wessenger: The consumer will make the choice, yes.

Mrs Allan: Okay. I appreciate that. I'll take that one back. Anything else?

The Acting Chair: Thank you very much for your presentation and for being here.

Mrs Allan: Thank you. I enjoyed it.


The Acting Chair: The next group is the IOOF Senior Citizen Homes Inc. Would the representative please come forward. I believe we have your presentation in front of us, so if you would identify yourself and begin, please.

Mrs Cindy Trapp: Good afternoon, Madam Chair, members of provincial Parliament, ladies and gentlemen. My name is Cindy Trapp, and I'm the director of finance at the IOOF Senior Citizen Homes. I'd also like to identify some supporters that I have brought with me today, and I'll have them just raise their hands. I have Mrs Marg Roane, who's past president of the Rebekah assembly, a volunteer and a past service provider at our home; Mrs Bea Hall, a resident and long-standing Rebekah; Mrs Pat Athron, a tenant in our seniors' apartments, volunteer and Rebekah; Mrs Irene Adams, a Rebekah, a volunteer and past employee of the home; and Miss Florence Robertson, a resident and nurse by profession. Thank you for the opportunity to speak this afternoon.

Since 1897, the Odd Fellows and Rebekahs of Ontario, a fraternal organization founded on the great principles of serving our fellow man, have sponsored and operated non-profit support services and housing for children, the elderly, the destitute and disadvantaged of this province. The fraternity created a charitable non-profit corporation known as the IOOF Senior Citizen Homes Inc to hold and operate its new and expanded operations in Barrie, Ontario, which includes a 154-bed home for the aged, 20 units of seniors' independent living apartments and a new 80-unit seniors' supportive housing development due for completion in the fall of this year.

Of the fraternity's 28,000 provincial membership, the majority are seniors who have an imminent stake in the future of long-term care and community-based services. The IOOF is very supportive of the government's initiative to restructure the long-term care and community support service system to benefit our current and future elderly.

On behalf of the fraternity, its members and clients, we would like to comment on aspects of Bill 101, impending regulations and guidelines as they specifically relate to the Charitable Institutions Act. We have serious concerns about our ability to provide a sensitive service to our clients while maintaining our unique identity and autonomy.

We believe that the charitable homes for the aged represent the unique and diverse mosaic of Ontario's society. Through our fraternal sponsorship over the past century, we have willingly provided a range of services and supports that have immeasurably benefited our membership and society, as well as greatly reducing the financial impact on the province's social system.

For some 25 years or more, charitable homes and government have enjoyed a partnership of support, respect and trust to the mutual benefit of our elderly consumers, government and sponsoring groups. However, the flavour of Bill 101 does not recognize or respect the important role played by charitable homes in the attainment of the high standards of care enjoyed by our elderly residents. Bill 101 brings into being an adversarial and punitive system which does not support or communicate the mutual working relationships that have brought non-profit, long-term care to the accepted standards of today.

On the subject of admission eligibility criteria, we are seriously concerned about the increase in the power and authority of the PCSs to the extent that their decisions relating to client assessment and admission may infringe on the legislative accountability and/or the traditional moral responsibilities that facility boards hold on behalf of their sponsoring memberships. Boards must be allowed to govern and define the mission of their organizations.

One of the primary principles of the redirection was to recognize the consumer's right to choice and self-determination. The amending legislation does not communicate this very important right of the consumer, but instead has left the process, if any, to be defined by regulation. To date, the admission criteria appear to be inflexible and do not ensure admission for reasons of social, religious, fraternal, cultural and/or spousal relationships.

Although the rights of religious, cultural and/or ethnic groups may be recognized, we are concerned that the right of our membership to choose the IOOF's facility will be overlooked. Just as each ethnic group enjoys a unique and special cultural lifestyle, so do the members of our fraternity. As a matter of fact, the lives of many of our elderly members have revolved solely around the fraternity, its traditions, services and social affiliations. We are seriously concerned that the rights of our members living within our provincial jurisdiction will not be taken seriously by the placement coordinators and thus will be ignored.

Therefore, just as the rights of choice for religious and ethnic consumers have been specifically recognized and protected, we respectfully request that our fraternal members be given the same recognition within the regulations and guidelines to choose our facility regardless of provincial or regional boundaries. Requests for transfer from fraternal, ethnic and religious consumers to like facilities should be given priority standing under category 2 and not last standing in category 3 as presently suggested. This will be of particular importance to charitable non-profit facilities with fraternal, religious and ethnic affiliations.

The future willingness of these organizations, as well as ours, to raise funds in support of long-term health care will depend directly on their ability to provide services to the sponsoring memberships. We are quite sure that the province would not wish to inherit these institutions along with the increased costs associated with lost donation revenues.

With respect to subsection 9.5(6), this subsection gives the appearance that the facility has no involvement in the decision to admit a client and that grounds for refusal will be few under legislation.

Just as it is important to protect the right to choice by the consumer, each institution must also maintain its inherent right to choose an appropriate client who best suits its unique fraternal, religious and/or ethnic status, physical environment, human resources, skills and socio-case mix.

The draft guidelines would lead us to believe that many new types of care services will be added to the homes for the aged which have historically been provided in acute, rehabilitative and/or chronic care facilities. These might include catheterization, tube-feeding, intravenous medications and therapies such as speech, occupational and physio. Charitable homes for the aged must be given the freedom to choose the extent of services to be provided within their facilities and must not be penalized through legislation for their chosen direction.


Many charitable non-profit organizations have successfully operated campus-based facilities which include a continuum of services. The continuum of care service should not be interrupted, nor the right of the consumer, having met the eligibility requirements, to be given priority status for admission to the campus institution when a bed is available.

On the subject of the appeals process, we applaud the government for recognizing the need for an appeal process as a means through which consumers can seek an impartial hearing regarding an adverse decision for admission. However, we are distressed in that the legislation does not go far enough. Facilities must be provided with a similar appeal process under legislation to allow an impartial forum in which they may address concerns arising from compliance issues, levels of care assessment, admission criteria, subsidy funding, service issues and other like concerns that would adversely affect their day-to-day operations.

With respect to clause 9.8(2)(a), we suggest that clause 9.8(2)(a) be amended to include "an advocate and/or an agent acting on behalf of the applicant." If the current trend for seniors' long-term care continues, it would not be unusual to have an applicant in his or her late 80s or 90s. Applicants seeking a decision by the appeal board may not have the ability to represent themselves adequately and/or appropriately under the act.

Subsection 9.8(3) allows for a single-person adjudicator to preside at such appeals. We believe strongly that if a sensitive, just decision is to be reached, the quorum of the board should be a minimum of three persons, each from a different discipline, thus ensuring an interdisciplinary approach to the board's rulings.

Quality assurance should be a process through which all the partners in care strive for improvement and excellence. However, we are concerned that defined quality assurance issues will become non-negotiable and inflexible through the inspection process. A quality of care incentive approach would be far more palatable than a regressive quality assurance system which is only used as an enhanced enforcement mechanism. If quality assurance is to be legislated, then the legislation and/or regulations must ensure that the issues identified through the process are positive, supportive, negotiable and not punitive.

With respect to posting of information, section 9.15, we agree that certain information should be available to our residents' families and the public relating to service agreements, legislation, regulations and other such information. However, we do not support the premise that this information must be posted in the main entrance of our facilities. Homes for the aged have long strived to become less institutional in nature and more residential in appearance. Posting of such information in libraries or having such information available at the business office would better suit our residential environment.

Although the financial information regarding our operations is public, we suggest that the posting of such information may directly result in the unionization of many non-union charitable facilities and also provide an open opportunity for this information to be used by unions to negotiate contracts that are comparable to those in the municipal sector of south-central Ontario.

Unless the province is willing to provide the increased subsidies to allow for such settlements, we strongly suggest that financial information not be publicly posted. Our corporation supports fair wages and benefits for all staff in long-term care, but we do not agree with the unusually high wages and benefits being paid in the municipal sector at the expense of the public purse, which will soon impact on the quality of care to be provided.

Not surprisingly, the dramatic change in admission age has been a direct consequence of increased community services and an inability of our system of support services to keep pace with the growing elderly population. As a result, the institutional sector will continue to overtax facilities' human and financial resources. We believe it will be impossible for the youth of today to fund, through the tax system, the social services of our society within 20 years.

We believe that equitable user fees must be established, based on income testing and asset availability for all non-health-related services provided in institutions. The government should not restrict the potential income to be derived from this approach by arbitrarily setting limits on the number of persons who should pay the full preferred accommodation rate. It would be irresponsible to promote a discriminatory fee structure for similar accommodations when faced with shrinking tax resources and burgeoning provincial debt. When a consumer has the ability to pay for non-health-related services, they should not be provided at society's expense.

Quality of care must not be sacrificed as a tradeoff for cost containment and ease of administration. All costs related to health care must be recognized. We strongly recommend that the funding system incorporate specific quality incentives to institutions; for example, on an institution attaining accreditation.

Financial incentives should be created to increase post-acute-care discharge to facilities to decrease free hospitalization and inappropriate stays and to encourage long-term care facility participation. We believe that such incentives would strongly influence agency behaviour and better serve to improve quality of care, access and overall cost containment within the health care system.

The case mix reimbursement system must recognize a labour index where wages and benefits cannot be adjusted downwards. The funding formula must be sensitive to the labour rates of the current collective agreements and increased costs associated with imposed settlements under arbitration.

Staffing levels and ratio guidelines must be developed that focus on outcomes of care and not processes of care. Serious attention should be given to avoiding mandated staffing levels that would restrict facilities from being creative and flexible with fluctuating availability of human resources.

We strongly believe that it is vital for the case mix classification and reimbursement system to be rebased and reweighted annually for the first three years and then every five years thereafter. This approach will be mandatory if we are to better understand the transition to the new system and to respond to changes in the future.

We also believe that the administration should consider letting additional funding dollars flow in 1993 and amend subsidy formulas later. Our concern is that if facilities don't receive additional moneys this year, it has the same effect as a mandatory reduction in services immediately as staffing levels will have to be reduced.

In conclusion, we are on the precipice of a new generation of issues where service delivery to the elderly and the physically and developmentally handicapped require innovative solutions to meet the challenges of heightened public expectations and service needs in a climate of shrinking financial resources.

It is this combination of factors that has created our current chaotic situation for unprecedented demands on our social service and health care system. We are now presented with a window of opportunity to create services that adapt to the multifarious and dynamic environment in which we live. In so doing, we must not lose sight of our primary objectives by obfuscating the issues with increasingly complex solutions and systems.

On behalf of our board of directors, residents and staff, we wish to thank the committee for this opportunity of addressing you here today. I'll be glad to answer any questions.

The Acting Chair: Thank you very much. We appreciate your coming before the committee today and also appreciate the members of your group coming as well. We'll begin the questioning right now with Mr Wilson.

Mr Jim Wilson: Ms Trapp, I want to thank you. Although it's late in our committee hearings, you're one of the few presenters who's talked so much about finances and the ever-increasing burden that our social services are placing on the taxpayers of Ontario. So often governments don't want to talk about that in the open, and they sure don't want to talk about it at committees, because it's politically sensitive stuff. Maybe it's because you're a director of finance that you've given us, I think, a very balanced approach. You've hit a number of issues head on, which politicians don't like to do.

As you talk about in your conclusion, government response to these ideas has been to make everything seem far more difficult than it really is and to try and always respond -- and all governments are guilty of this -- to citizens by saying, "Well, that's such a complex matter, I don't think we can really discuss it fully today."

Having said that, I want to go back to the bigger question, because it's been raised a lot when it comes to charitable homes for the aged, and that is that I think opposition members, through amendments, and the government, through its own amendments, can do some things with Bill 101 to protect and in fact recognize the cultural and spiritual needs of residents, and maybe a few others, maybe linguistic and --

Mrs Trapp: And fraternal is our point.


Mr Jim Wilson: Yes. Yours is fraternal; others, it's the same idea. The fund-raisers at Baycrest have worked long and hard, and when they have a family member who needs to get into Baycrest -- I don't blame them -- they want the family member to get into Baycrest. They've worked hard to raise money and sit on the board of governors and that sort of thing. I think it's human nature and I don't blame anyone for it. I'm just not sure how we can do it, unless we put a provision in the bill that says that the sponsors of the home have a priority access.

We've just spent the afternoon talking about veterans' affairs and the worry of the Canadian Legion that, even though they've got some agreements in place with the federal government and the provincial government, there's a dispute going on whether or not their priority access will even be secured with the passage of this legislation.

So I guess what I'm going to ask you to try to get a feel for things is, what would be the frequency of others outside of the fraternity actually applying to your home? That would give us an indication of the need for protection.

Mrs Trapp: There's no doubt that the majority of the residents who live in our home are still from the community which we operate in. I would suggest that 10% to 15% of the residents in our home may also be from our area but may be from outside of our locale and a member of the fraternity.

Mr Jim Wilson: I see. Do you have a waiting list at the home?

Mrs Trapp: We have a waiting list of close to 300 people.

Mr Jim Wilson: And of the 300 the vast majority would be fraternity members?

Mrs Trapp: No. I would say that 10% to 15% would be fraternity members.

Mr Jim Wilson: Is that right? That gives us an indication of what the problem is.

Mrs Trapp: I think we've also addressed that in terms of what category they would be in too. We're moving it up to a category 2 rather than a category 3 in terms of --

Mr Jim Wilson: Except that the eligibility criteria are very medically based and don't really take that into account, other than I think we are going to do something in terms -- I hope anyway -- of ensuring that consumer choice is given a higher rating than it currently is, and perhaps that will go a long way.

Mrs Trapp: The people I've brought with me today could speak to that because that is definitely their preference, if they are a member of that fraternity, to have that choice recognized.

Mr Jim Wilson: Sure. I understand that and to a great extent I agree with that.

Mr Wessenger: Thank you very much for your presentation. I'm certainly very familiar with the IOOF home and also with the Rebekahs and Odd Fellows because as in the past, as you --

Mrs Trapp: Everybody noticed the friendly face across the room.

Mr Wessenger: I certainly appreciate the leadership that you've taken, particularly for your latest venture, the supportive housing project, because that does provide a great addition to the community in providing for that choice.

For instance, the spousal situation I think can be very much accommodated by your having the supportive housing unit there along with the long-term care facility. It gives a choice for spouses, which I think is commendable and something we need more of in these types of new facilities. I would also like to welcome the residents here from the IOOF home.

I just have a couple of comments. First of all, you mentioned the whole question of consumer choice. Yesterday we did announce that we're going to bring an amendment forward to the bill that will require the placement coordinator to recognize the preferences of the applicant, particularly those relating to cultural, linguistic, ethnic and spiritual aspects.

Mrs Trapp: So fraternal will be included in that?

Mr Wessenger: I think cultural would include that aspect.

Mrs Trapp: I'll be encouraged to take that back.

Mr Wessenger: Cultural is a pretty broad concept and I think it would include that.

Secondly, you make a reference with respect to the limits on those who pay the full preferred accommodation rate. I'd just like to indicate that those limits are under review at the moment.

The other thing you mentioned was the review of the case-mix classification. You asked it to be done annually for the first three years. I'd like to assure you of the intention that it be done annually, period, not just for the first three years, because we certainly want to make sure that the funding keeps in line with the --


Mr Wessenger: Staff wants to clarify.

Mr Quirt: I'd just like to clarify that the resident classification exercise to determine care requirements in each facility would be done annually. But I think what you're referring to in your brief is a provider activity study to make sure that the seven categories appropriately reflect the differences in actual service consumption. For example, does a client who scores as a G really require 5.3 times this much funding for nursing and personal care as a client who scores as an A, or should it be seven times as much or four times as much?

We will be doing that review this fall and we will be doing it at regular intervals. We'll be doing it at least every five years. But we want to see how the results come out this fall to see how far off they are from the assumptions in the instrument now. If they're way off, then perhaps we'll have to do it again next year to make sure that we keep more current. But it is our intention to do that on a regular basis to make sure that it's a fair measurement of the actual care requirements of residents.

Mrs Trapp: Thank you very much for that clarification.

Mrs O'Neill: I really thank you for this brief, and I guess I would ask you, rather than the parliamentary assistant, whether you think the term "cultural" includes fraternal.

Mrs Trapp: I question that. We think that is a unique definition, and so I hope that, yes, it would be included in cultural. But by us bringing that point up, it hasn't been clear to us that it recognizes fraternal as well.

Mrs O'Neill: Maybe we should consider very strongly adding it.

Mrs Trapp: That would be our recommendation of a specific definition.

Mrs O'Neill: You brought forward several things, and I concur with my colleague about the financial highlights. Not many presenters have talked about the pressures of the collective agreements that are in existence right now that are still going to be in existence, and the only cut then that could be made is service in many cases.

Mrs Trapp: That's correct.

Mrs O'Neill: I think you've also highlighted the financial incentives that should be built into the system to have people move forward when their care is to be less intense or less heavy, as we call it, and I think that's another very good point.

The one I wanted to ask you the question about is where you really began, because we haven't had too many people suggest it to us. I have had an opportunity to ask one other group. You feel that the IOOF's ability to govern or the governance structure is somehow going to be threatened, that the mission statement is not necessarily going to be possible to meet. Would you like to say a little bit more about why you feel that way about Bill 101?

Mrs Trapp: Our concern is that if the placement coordination service agency has the authority to say who is coming into our home, we feel that we want to have some authority over the levels of service that we provide and how we provide that service; that forms part of what our board does and the role that it performs. So, for example, for the types of therapies -- occupational, physical, social -- we will have to have the staffing levels appropriate to meet those levels of care. If the dollars aren't there funding-wise for us to hire the additional staff to provide those services, we feel that we should have control over what our organization offers in terms of the facilities, both residential and nursing.

Mrs O'Neill: I think this is one of the big difficulties with organizations and facilities such as yours: They feel their strengths and the traditions that have been built will somehow not be recognized, built upon and used.

Mrs Trapp: That's correct.

Mrs O'Neill: I hope somehow we can get some wording into the bill that will guarantee that your mission and your decision-making is protected.

Mrs Trapp: That's exactly what we're looking for. We're proud of the facility that we run. I think our residents would confirm that it is a home, and we hope to be able to continue in that vein.

The Acting Chair: Thank you very much for coming before the committee. We appreciate your time.

Mrs Trapp: Thank you very much for the opportunity.



The Acting Chair: Now if the representatives of the Don Mills Foundation for Senior Citizens, Inc, would come forward, please. Welcome to the committee. Take a seat there, please. We have a copy of your brief, so if you would like to introduce yourselves and proceed.

Mr Joseph Bogdan: Thank you, Madam Chair. My name is Joseph Bogdan. I'm a member of the board of directors of the Don Mills Foundation for Senior Citizens, Inc. I would just like to briefly introduce you to our foundation.

We are a not-for-profit community organization composed of volunteers and professional staff. We are committed to all aspects of care for seniors in the community and we offer a broad range of services and a commitment to a continuum of care.

The Don Mills Foundation was formed in 1969. We opened a 136-bed home for the aged in that year. Then in 1976 we opened Taylor Place, a senior adult centre which today serves an annual membership of approximately 1,100 people and, in addition, provides services to 800 seniors in the community through home support services, a frail elderly day program and an Alzheimer's day program.

The foundation is, I think, to use a cliché now, proactive rather than reactive. We have been in the forefront of a number of programs for seniors even before they were allocated for government funding. We basically have that as our mandate through our board and staff at this time.

I would like to introduce to you Bill Krever, who is our CEO. I would like Bill to take you briefly through our presentation.

Mr Bill Krever: Again, let me just restate that it's a pleasure to be before the committee this afternoon to talk about Bill 101. We certainly appreciate this opportunity.

There are really four areas that I'd like to briefly touch on about Bill 101 that we're concerned about, but before I do that, I just want to state that one of the differences about the Don Mills Foundation is that not only do we represent a long-term care facility or home for the aged, but we also have many other elements of the long-term care system, including home support services, community services and an elderly persons' centre. I think that's a little different perspective that we're coming from today.

In terms of the four areas I wanted to briefly touch on, the first is access to long-term care facilities, the second is the funding formula, the third is incentives and motivation for local governance and the fourth is conditions of admissions.

In terms of access to long-term care facilities, certainly the concept of centralized or single-point access is a key component of long-term care reform, and it's a principle that's strongly supported by the Don Mills Foundation.

The placement coordination model, as proposed in Bill 101, however, fails to recognize the strong role of multiservice agencies. Certainly that has changed somewhat over the last couple of months with the introduction of the comprehensive multiservice agencies, but we're still not quite aware of exactly the definition of those agencies. That is one of our strengths in the Don Mills community.

Just to give you an example, many of the admissions to Thompson House home for the aged come through our network of community support services. In these cases, applicants are already linked with a case manager or a placement coordinator through our agency and the admission process, and the related emotional stress for applicants and their family members is minimized. With the proposed new placement coordination system, the admission process could become more stressful for the applicant, not to mention more expensive and unnecessary for the long-term care system.

Also, with the growing demand for long-term care facilities and the current waiting lists for facilities, it's important to maximize all of the existing long-term care beds, and the effect of an efficient processing of new admissions is an important business component of any successful long-term care facility. The addition of a placement coordination service could be counterproductive in terms of maximizing the use of all existing beds. Certainly the foundation is committed to maximizing the use of all our programs and services along with, at the same time, respecting and enhancing the dignity and independence of the seniors we serve.

In terms of the funding formula, again the principle of level-of-care funding is strongly supported by the Don Mills Foundation and is a major improvement to the long-term care system as we see it. However, the lack of funding for all areas of the system and for levels of care is eroding the quality of long-term care and is drastically reducing the innovative and creative nature of most non-profit service providers. Further, the concept of level-of-care funding does not work unless the established funding for care is adequate compared to the actual cost of providing care. As we have experienced with the existing funding arrangement for residential and extended-care beds, and also in the community for home support services and Alzheimer programs, the theoretical funding formulas are not effective if the key and controlling factor is an annual provincial funding allocation process.

Also, the proposed resident copayment scheme is a major concern for the foundation and represents a dramatic loss of income from resident rents. The concept of income-only testing rather than the current income and asset testing will cost the long-term care facilities and the province millions of dollars. This is at a time when funds are drastically needed in all areas of the long-term care sector and any removal of funds from the system will put extra pressure on government funding.

Also, the proposed funding formula restricts the ability of long-term care facilities to establish special resident services based on fee-for-service, and also the provision of private rooms is restricted and the rents that facilities can charge for private rooms.

In terms of incentives and motivation for local governance, the foundation has been a leader in the field of long-term care services for more than 25 years, and it's through the efforts of a community-based, voluntary board of directors that we've implemented a wide range of vital services.

Bill 101 greatly increases the amount of government involvement through inspections and a sanctioning process. Unfortunately, this involvement does not necessarily correspond to an increase in quality of service and merely serves as a disincentive for existing governing bodies.

Also, quality management or quality assurance is an important planning and monitoring process within the long-term care sector, and this type of approach has been implemented by many non-profit homes for the aged in Ontario on a voluntary basis. As well, a number of homes for the aged have received accreditation through the Canadian Council on Health Facilities Accreditation, and many other homes for the aged have adopted the principles of accreditation on a voluntary basis. This commitment to quality management demonstrates the integrity and professionalism of the not-for-profit sector. The best approach, we feel, to quality management is through commitment and ownership on behalf of the governing body and not through provincial regulations.

Finally, in terms of conditions of admissions, Thompson House home for the aged currently serves 136 residents. We've estimated that about 90% of our residents would meet the proposed admission criteria. The remaining 10% of our residents would not likely be approved for admission under the new structure. It must be stressed that these residents have chosen Thompson House as their home and have made an important decision to move into a long-term care facility. It is apparent that while they do not meet the proposed criteria, these residents require the services of Thompson House and are not capable of or willing to live independently in the community. While we recognize that current residents will not be affected by the proposed admission criteria, we also realize that future applicants who do not meet the criteria will ultimately be denied admission to a long-term care facility.

I think one of the positive aspects of the current funding structure of residential and extended-care beds has led to the development of a mixture of residents ranging from those individuals who need very little nursing care and are very active and mobile to those individuals who require heavy nursing care and have severe physical or cognitive limitations. This mixture has added somewhat to the atmosphere of many long-term care facilities and has created, we feel, a more positive image of aging and has developed a certain peer support component among residents. With the new admission criteria, some of this resident mix will be lost.

In conclusion, again we would like to stress that the foundation is very supportive of many of the principles contained in the long-term care reform. Through our 25 years of experience in providing services in all areas of the long-term care spectrum, we do recognize the need to develop a more integrated and responsive system.

One of the key elements that has enabled the foundation to be successful over the past 25 years is the fact that we do represent all major areas of the long-term care spectrum. We recommend to the standing committee that all elements of the long-term-care spectrum be considered within Bill 101, and not only the narrow spectrum that deals with homes for the aged.

Again, we'd like to thank the committee for the opportunity to appear this afternoon, and we'd be glad to answer any questions.


The Acting Chair: Thank you very much for your presentation.

Mr Wessenger: I'd just like to ask you one question. You indicate that there'll be a great deal of revenue lost as a result of not having an asset test with respect to copayment provisions. Do you have any range of estimates of how much of the revenue you feel would be lost to homes for the aged in Ontario? Any percentage indications on that?

Mr Krever: Certainly we haven't done that type of analysis for our own facility, because we understand that any revenue that's lost now will be picked up by the ministry in terms of the funding formula. Just to give you an example, on an individual basis, I believe the daily rate now for residential care is about $52 a day, in that area. That will go down to, I think, $36 or $38 a day, so per day that will be the loss. I have heard estimates for the province -- and I don't know the extent of the reality of this -- that in the area of $20 million could be lost through this.

Mr Wessenger: I'll ask ministry staff to clarify on that issue.

Mr Quirt: The figure you just mentioned is quite close to the real figure. It's approximately $20 million that residential care residents pay now that they will not have to pay under the new income-tested copayment.

Mrs Sullivan: Then could I just ask the parliamentary assistant why the government has indicated it will no longer include the asset test, when in fact that $20 million could be used elsewhere in the system rather than basically to supplement people who do have resources? These are 20 million taxpayer dollars.

Mr Wessenger: Certainly it's been a policy decision that unfairness is created in requiring asset contribution. The case in particular of the spouse in the matrimonial home is one where you would not want to look at an asset situation, or perhaps an asset which is non-liquid, which would again create a great difficulty, and also to respect the dignity -- we've certainly heard from consumer groups that very much advocated that assets not be included in the obligation to make copayments.

Mrs Sullivan: I think it's a remarkable public policy decision.

Mr Hope: Are you for it?

Mrs Sullivan: No. I'm very interested in the discussion you have about your own residents, where you indicate that about 10% of your residents would not meet the criterion included in the manual for admission. How many of your residents would have preplanned their stays in your facility?

Mr Krever: I would think most would have. We have a centralized process somewhat similar to what will be done with the placement coordination system. I would say most of the admissions now go through about a three- to four-month period of admission, so it is planned. There are probably 10% or 20% that are emergency-type admissions either coming from hospitals or through sudden illness, but most would be planned, and most also are planned through our home support services. We may have members of Taylor Place who have planned five years ahead that when the time comes, they would like Thompson House to be the long-term care facility they live in.

Mrs Sullivan: If and when this bill passes and the placement coordination system is put into place, would you indicate your interest in serving as a placement coordinator?

Mr Krever: Certainly that would be something we would be interested in. We are already doing those functions now. We have those resources on staff. Until we see the final definition of the comprehensive multiservice organization, it's hard to know whether we would fit that, but I would think that along those lines, we would see ourselves fitting into that model.

Part of our concern is that homes for the aged have been doing the admissions already and have the resources and the staff now to do all of the admissions, and with Bill 101 we're going to have to hire staff province-wide to do all of that work again. We're almost duplicating those resources, so that is a concern.

Mrs Sullivan: Have you had any indication that the ministry views placement coordination from the providers as a conflict of interest?

Mr Krever: Not really, to any extent. We haven't been that involved in those discussions. Personally, we haven't seen it as a conflict of interest in our role, I think because we are multiservice and part of our placement service is also to look at other facilities, so that if Thompson House is not the appropriate facility, our placement coordinators would work with other facilities.

Mr Jim Wilson: Thank you for your presentation. Since you are the second-last presentation, I want to make a comment on something you touched upon in your presentation; that's with regard once again to the government's policy decision to simply do an income test and ignore assets. You should know and be aware that this was the government that used to talk about corporate welfare bums, I recall, having to run a campaign against them two and a half years ago.

I just want to show you the inconsistency in their logic. CUPE earlier this week talked about nursing home operators getting rich on the depreciation of their assets. Now this government that hates depreciation of assets and write-offs thereto is ignoring them altogether. Frankly, I think they just don't understand. It's sad, is about all I can say. I don't know why any government in this day and age would want to forfeit $20-million worth of revenue, when all indications to this committee have been that it's badly needed out there. I'm sure the Treasurer would have had something to say about that.

The Acting Chair: I know there's a question coming soon.

Mr Jim Wilson: Well, it's free speech.

I just have one quick question with regard to social admissions, because we are in the process of drafting amendments on whether we should include that in the admission criteria and allow for social admissions. You mentioned in your brief that about 10% might be social admissions. You see that as a positive, I gather, in terms of giving you a mix. Does the proposed funding formula give you an incentive to keep social admissions?

Mr Krever: Not really. When we look at admissions, we look at each individual admission through the placement coordination service, so it's based on the need of the applicant. We do look first at community alternatives, but what we find is that there are some people who need a long-term care facility even though they don't need all of the nursing services. So for us that really isn't a concern.

Also, with level-of-care funding obviously there would be an incentive if you were trying to keep a staff complement to match a higher level of care. That's never been a concern for the foundation.

I think more of a concern for us is that Thompson House is really a community for the residents, that is the community they live in, and I think having a mixture of residents is helpful. Also, it certainly affects the appearance of the home. In Thompson House, the second floor, which is our main floor, is basically the residential area; it's free of nursing stations at this point and it's a very different environment. I think it's a very positive look when you first come into Thompson House. With this reform, we would have to look at renovating that area, putting in nursing stations, doing many modifications, and of course we would also look to the government for capital funding to do that.

More importantly, for people coming in from the community to look at Thompson House for the first time, it would give a very different impression of the facility if all you're seeing is heavy levels of care. I think even for the applicants themselves it would give a different impression. I think the perception of many applicants as to their own level of care is often very different from the reality, and I think to be confronted with that in all areas of the home would be a negative perception.

The Acting Chair: Thank you very much gentlemen for your presentation. We appreciate it, and certainly you've added a unique insight into your facilities.



The Acting Chair: Next, and the last presenter of the hearings, is the Association of Placement Coordination Services. Is it safe to say we've left the best to the last?

Mrs Joyce Caygill: Oh, that's a wonderful thought.

The Acting Chair: We welcome you to the committee. Would you identify yourself and then make your presentation, please.

Mrs Caygill: Thanks very much. I'm Joyce Caygill. I'm president of the Association of Placement Coordination Services of Ontario and I'm also the director of the placement coordination service in Hamilton-Wentworth.

I know you're all tired, or at least if you're not, you should be, so I'm not going to keep you very long, but I do hope that if you have questions, you'll pose them to me.

The full text of our association response is contained in the February 11, 1993, document, with which I believe you have already been supplied. Today, I just handed out some notes that I'm going to speak to now.

You'll note in that official response that our major emphases are upon our support for the streamlining of the current pieces of legislation and reducing the fragmentation in service delivery which results from so many disparate acts and regulations. But we strongly support the intent of the provincial government to provide equitable care to those who require it and to be as judicious in the use of the tax base as possible.

We support the plan to provide those disabled adults who wish to purchase their own services with funding to do so. However, we regret the continued omission of special reference to those with cognitive impairments and those whose care needs make them difficult to place.

We support the concept of an appeal procedure. In fact, in our 1990 response to the Strategies for Change document, we said, "An appeal procedure should be fundamental to the development of any program." In our response to the Redirection of Long-Term Care document of 1992, we said, "It is necessary to have a decision review or appeal committee responsible to consider the overall service of the SCA." At that time we were expecting the home care and the PCS programs to be merged in a service coordinating agency. So now I guess you could call it CMSA.

In our 1993 response to Bill 101 we say, "APCSO members recognize that a consumer appeal procedure to review determination of eligibility is essential."

I agreed with the earlier comment when the lady from the IOOF said that individuals should be able to be represented in any appeal by their family members, because it's our experience that a great many of these people who might be appealing are not able to do it on their own behalf. So really, they must have either a family, a friend or somebody representing their interests. Perhaps when the advocacy bill comes in, that would be an appropriate road for an advocate. I don't know.

Similarly, we have been ardent supporters of the concept of choice, both for the prospective resident and for the care provider agency. In 1990 we said, "There should be profound respect for the autonomy and independence of the individual and equal respect for the dignity and decision-making capacity within the family unit." In 1992, we quoted our mission statement, and the second item in our mission statement is that we "recognize the individual right to freedom of choice and quality of life." Further in that document we stated, "We expect that clients and care givers will not only be involved in the decision-making, but that they will assume some of the responsibility for developing service plans." In other words, they're integrally involved in everything that involves that individual.

We believe very strongly, and we've written on this many times, that it's important that persons be treated with compassion. Those who apply for placement and back out at the last minute should not be penalized because they're cautious or because they're slow to make decisions. They must be allowed to make decisions in their own way and in their own time.

Similarly, those who accept a placement in order to wait for their first choice must continue to have their waiting periods honoured. In other words, if they accept placement somewhere to wait, they must not go to the bottom of the list for their chosen facility. PCS has always been careful that this doesn't happen, and by the way, you know, I suppose, there are 23 PCSs in the province of Ontario, and the one in Hamilton has been in operation for 23 years next month.

Incidentally, as to the waiting lists, in those 23 years, I have been going and taking the waiting lists from the institutions at their request and returning to them those people who truly are waiting. We have never found that more than 10% of those who are on the waiting list are actually waiting for placement, because people put their names on in case; they put their names on even though they're inappropriate for that facility; they put their name on at perhaps 16 facilities; they may be dead; they may be placed; they may have changed their minds; they may have left the community. Never once have I taken 300 names from a home and given them back more than 30.

I've emphasized the focus upon choices because I've heard that this is a subject of much concern in long-term care facilities, and the reason I quoted from documents we have produced is so that you know I'm not responding to the comments alone, but that I am giving you our philosophy. Those who have been involved with the PCS over the years know that our credo is choice for the consumer and choice for the receiving facility. We can't do it any other way.

I agree that this isn't mentioned in Bill 101, but our understanding of the legislation is that it is an enabling document only. It's the regulations and the guidelines which accompany it that will spell out the ways in which we can operate, as will the policy and procedures manual for placement coordination. I have spent the entire day with the design team looking at those things, and I can assure you that there isn't one of them who isn't absolutely clear on these particular issues around choice and recognition of the needs of the receiving facility and the uniqueness of the facility. I've said that in the next paragraph.

It's obvious that in some locations choice is based upon availability of facilities and beds, but that in no way prevents consumers and providers from making choices within that context. If the only thing you have in your region is a nursing home and a home for the aged, then at least people can choose between two options, if that's all there is, but they must be able to make a choice.

Certainly, APCSO wouldn't want those facilities which are ethnic- or religion-specific to see their cultures being eroded. We support their concerns, and I supported the two speakers who I heard prior to me. We react appropriately in our present dealings with them and with consumers and we hope to continue to respect them in the future under Bill 101. I would like to suggest to you that we might have a little civil disobedience here, because if you didn't include that, we would do it anyway, whether you wanted us to or not, because that's the way we feel.

I've attached to your little brief here a copy of a recommendation letter which is in standard use in PCS Hamilton, and I'll tell you how it came about. I went to my support staff and they were typing all these letters. I said, "Just give me the top one, will you?" and I whited out the name on it.

As you will see at the back there, it just so happens that it relates very clearly to choice. It says, "We have reviewed this assessment and suggest `Type 2' level of care" -- type 2, by the way, refers to the Ministry of Health patient care classification by type of care, which was produced in 1975, which we're still using -- "specifically, that which is found in a nursing home that will accommodate an O2 concentrator and a dialysis regime such as," and we mention three that will accept both the concentrator and a dialysis regime. "Please have the client/family visit the suggested facilities and advise us of their preference. We suggest the client/family maintain contact with the facility of their choice. A copy of the assessment will be forwarded to the chosen facility/ies upon recept of a signed consent form." Then we advise the home care case manager to discuss the nursing home monthly copayments with the family.

You'll see that the printed questions on the bottom there are for the health professional to fill in. In other words, the case manager would go out and say to the client, "What do you think about this suggestion?" say to the family, "What do you think about this suggestion?" and "What does the care provider think about this question?" Then we ask also that they contact us immediately if there's disagreement.

If you look at the other pages, you'll see that there are two sheets there that are what we call consent forms. In Hamilton-Wentworth, we have to deal with a lot of people whose first language is not English and whose level of education may not be high, so we try not to do things in legalese; we try to make it very simple. So we're saying: "We've suggested nursing home placement. Let us know which ones you prefer." Further down, we ask them what kind of accommodation they like and we ask them to complete it and return. We've made it quite clear that we can't release any information until they've given us this consent, and we've also made it quite clear that we are dependent upon their choice.


Because it's so confusing for people when you have a lot of facilities in a place as large as Hamilton, we've separated the nursing homes and the homes for the aged, because you simply can't expect people to know the difference between the two. We've certainly explained it to them, but then they forget. In the future, I think we can be able to combine all of those into one list, but they still would have their own choice -- at least I hope so. They will if we have anything to do with it. I think you can see from this that the copies of consent to release information clearly identify the PCS approach to choices.

I haven't cluttered you with a lot of other information because I think those are the major ones, but I'd be delighted to answer questions if anyone has any.

The Acting Chair: Thank you very much for your presentation and your slight confession beforehand, in case something --

Mrs Caygill: Yes, I'm sorry about that. I hope nobody holds it against me.

The Acting Chair: Definitely not. The first questioner is Ms O'Neill.

Mrs O'Neill: This is very interesting, because we haven't seen these forms before. I'd like to go to the form.

Mrs Caygill: That's only Hamilton's; everybody has a different one.

Mrs O'Neill: Okay. I'd like to go to the form, if I may. You have suggested that you try to simplify it as best as possible, and you've got the copayment rates there. Would people know what they meant if they got this? Would you have explained before how this could be dealt with? I mean, some of this could be quite frightening.

Mrs Caygill: I draw your attention to the person to whom it's addressed. It says, "To: Case Manager, home care program," so this would not be given to the individual. If it has to go to the individual directly, they have a personal letter that says, "We've reviewed the assessment and we think that your mother would be able to manage very well in such-and-such a place." In other words, it's couched in much better language. This is for the home care case manager to go out and say, "We've talked to PCS and this is what it thinks." So this is advice to the home care manager.

Mrs O'Neill: Having cleared me up on that -- and I guess I am tired --

Mrs Caygill: I think it's logical that you would ask that question.

Mrs O'Neill: Where do you see the appeal process -- and I presume there may be one in Hamilton; I don't know -- as it's built into 101, coming on stream with this kind of a system, which you seem to have worked out over a period of years?

Mrs Caygill: I think that I have to be honest and say that as we do now, we're determining eligibility based on the extended care benefit form, because what we would be doing is saying: "I can see that you would like your mother to go into a nursing home, but quite frankly, she won't meet the eligibility criteria. I think you've got to look at some alternatives." Over the years there have been one or two people who have said, "I still want her in a chronic hospital," or whatever it might be. So we have developed an appeal procedure and what we did, because of course we were just acting locally, was convene a committee of providers of care, both medical and nursing, in those long-term care facilities, presented the case and asked for their opinion. Their opinion was binding as far as we were concerned.

I see a similar type of thing, but with different representation, of course, on it. But I see that if an individual says, "Look, I'm not satisfied with it," if it was my staff, I would expect them to come to me and say, "I'm being challenged on this one," and I would review it and I would either reverse the decision if I felt there was a legitimate reason, or if I upheld my worker's decision, then I would expect that I would be the first one to have to notify whichever committee that we do have some disagreement here.

I think the important thing is that it doesn't become a shouting match of them versus us; it has to be recognized that this is the individual's right to do this. Nobody is perfect, and I think that we clearly need some kind of an appeal procedure. I expect also that it would be available to the long-term care facility to appeal for some reason and I would like it, because in the times that we have convened the appeal committee in the past, it has always been me who has convened it, because I wanted a person in an institution, usually a chronic hospital, and the chronic hospital was saying, "No, we can't provide the care," and I've been saying, "Look, somebody's got to look after this individual."

So I see the appeal as having a much wider approach, shall we say, or scope, than just the client. I agree with the previous speaker, who said there should be an appeal for the facilities.

Mrs O'Neill: Have you brought that forward in your discussions with the officials you mentioned earlier?

Mrs Caygill: We talked about that at length today.

Mrs O'Neill: How do you feel that's going?

Mrs Caygill: I feel that, from the perspective of the people who are employed to be doing the design, they feel very comfortable with this. In fact, we didn't seem to have any disagreement on that at all. Obviously it will depend upon you, the people who make the major decisions, as to whether their work and their outlines will be accepted. But I think that if you were to speak with them now, you would see that they would agree with many of the things, from the PCS perspective, that have been discussed by people coming here.

One thing I wouldn't agree with is the delay. I was listening to the gentleman who said placement coordination will slow things down. What we found is that it doesn't slow it down. What it does is enables -- for instance, you get someone who comes in and says, "I think my mother should be in a nursing home," and once you start to investigate, you find that's totally inappropriate. So, immediately, you're offering them a plethora of services from which they may choose, and sometimes, if they go directly to the institution, they wait for nine months, their turn comes up and when they get there, the home says, "Oh, my God, we can't look after you," and they've waited all that time in sort of anxiety.

The other fascinating thing that you'll find in the literature is that, if you make information available to people and they know there are options and they know there is some safety net out there, they're not really as demanding of the service, and funnily enough, they use less. The more they know about what's available, the less service they use. We have 4,500 applications a year for admission to a long-term care facility in Hamilton. We've never placed more than 100 to 1,000 in the 23 years we've been in business.

Mrs O'Neill: And you're just facilities; you don't guide people to other community care?

Mrs Caygill: Sure we do. That's the first move because, you see, some people already have the services of the hospital; they have the discharge planner or the social worker in the hospital. Some are on the home care program, so they have their help. Some of them have been applying, we'll say, to a home for the aged, and they have been redirected to a PCS because the home for the aged wants to make sure this is an appropriate location. So the first thing we're doing is to look to see what's available for them out there, because the majority of people are going to stay at home.

This gentleman spoke about social admissions. I was sort of twitchy with that because I thought, "What do you mean by `social'?" For instance, if you live alone and you're terrified of things that go bump in the night, that's not a social admission; you really need that because your anxiety level is such that you're not functioning normally. I think you have to recognize that because people then begin to have bizarre feelings and they'll start feeling that, "Somebody's in my apartment; they keep coming in; they steal my mail," because their hearing is off. I think there was somebody here whose hearing is poor; mine is. I hear things. I can even hear what sound like voices in the distance, but they're not there and the elderly people are the same.

Mrs O'Neill: Thank you very much.

Mr Jim Wilson: Mrs Caygill, I very much appreciate your attitude with respect to consumer choice and I'm very pleased to hear your determination in that regard. Is the Health Services Appeal Board the appropriate board to be making the appeal? It's been suggested to us that perhaps we should be setting up a long-term care board.

Mrs Caygill: Let me tell you what I said earlier today. You know, once you make things so formal and so cut and dried, it becomes a very adversarial situation. Frequently, you can deal with things by negotiation. If, for instance, a person is not satisfied, he really doesn't want to wait a month, six weeks or two months until some decision is made. Let's be realistic. You can't convene appeals swiftly all over a province. You can't do them within 24 hours.


I'd like to see a situation where, if there appears to be an impasse, and this definitely is a problem, why couldn't we go to the area managers to begin with? They don't have a vested interest but they might be able to arbitrate appropriately for us and then, if it seems a reasonable thing to do, that might be the route to go, to go further than that.

I feel we haven't really accepted the concept of the area manager and what they can do and what we could use them for fully. If we're going to decentralize, let's put them in that position of being able to look at the community. They know what's going on there. Similarly, if you have a disagreement -- I was asked this. Supposing a PCS says to somebody: "Why won't you take Mr X? I can't see any reason why you wouldn't take him. You just don't like him for some reason," and there's an impasse there, then I think the area manager would be the one to arbitrate on that and say, "Look, PCS, you're being unreasonable in expecting them to take him," or, "Long-term care facility X, you really are being unreasonable in not taking him." I think that way you've kept it in the community and you've had them respond to the community needs rather than having a legal stepwise progression.

Mr Jim Wilson: I appreciate your comments and I just want to tell you that I don't think any members of the committee have suggested anything negative about the placement coordination services that are in place, in fact. I think we all are aware in our own areas of the waiting lists and the inaccuracy of those waiting lists for many of our facilities and the need for coordination. Some of us come from areas where placement coordination services don't exist, so it is going to be new for our areas.

Mrs Caygill: Please don't misunderstand me. This is not misrepresentation on the part of the facilities; they have no other way of knowing. They have no way of knowing whether what they've got is accurate or not, so it's not their fault.

Mr Jim Wilson: Yes, and I think all sectors, the charitable, the municipal and the nursing home sectors that I've talked to, agree that many years ago they should have, on a volunteer basis, gotten better coordinated. Given that they haven't, I think there's a real role to be played for placement coordination.

Mr O'Connor: A lot of the questions I was going to ask, of course, have been answered and you certainly have presented it quite well. Before I became a member of the Legislature I used to build cars in Oshawa and on occasion, when the pension rep was on vacation or whatever, I advised people on what their pension benefits were and advised them as to the dollars and cents. Of course, like a placement coordinator, you take all the information and I certainly wouldn't be a person to go and tell somebody, "Well, it's time you retired." I mean, it's a very personal decision, just like the placement coordination and choice. It's something they've got to decide for themselves.

Through the course of the hearings, we have heard from countless people saying: "We think there needs to be an appeal process. There's got to be choice and choice has got to be paramount." It's one thing that we have heard and I think, as we finish the hearings right now and go into clause-by-clause, you're fitting into the committee hearing process because you've spelled out and maybe addressed some of the concerns we've got. In your form you've shown us, it seems a little bit vague, but I guess there's a lot of the discussion that does take place in the placement perhaps that we don't hear about. Maybe you could just expand a little bit about some of that process.

Mrs Caygill: Are you talking about the last page?

Mr O'Connor: Yes.

Mrs Caygill: What's happened, you see -- that's a home care case manager. Home care case managers and PCS coordinators live in each other's pockets. For instance, in ours we have an intercom directly with the home care because we're all in the same building under the same administration. Usually what happens is that the case manager will identify there's a real crisis situation coming up and, I've got to tell you, some of them are incredibly bizarre unless you're actually in the business. So they'll come in -- and whatever I quote is something that's really happened over the years. A case manager will come in and say to one of my coordinators: "Look, I've got this case. He's going to put a knife in her back. We've got to move one of them quickly, okay?" That's the start of it. We get the material in very quickly. My coordinator is talking to the case manager. They're working backwards and forwards: how they can do this; how they can quickly get the consent; how they can get the information from the physician; how we can deal with the institution. We might do that all in one day, because we can't allow this to go on because we might have a major catastrophe.

So this little thing is really a confirmation of what's gone on and it's really for the file. These things are filled in so that we know, yes, the family agreed; no, the client didn't; what did we do about it if the client didn't agree.

That's what that is. Most of it is done backwards and forwards. Most of it is done by telephone, because we have to work quickly. There would be a lot of negotiation perhaps with that family member who was at risk, a lot of discussion with him or her, and that's just one example.

Mr O'Connor: So the process we've heard about -- we've heard it called bureaucratic -- I think really is a very personal process that does allow the consumer as much choice as possible. You don't offer a bureaucratic process. I think you've reassured us of that.

Mrs Caygill: It can't be bureaucratic. I certainly wouldn't work in it and I certainly wouldn't have been here as long as I have, which is 18 years in this particular one. If you could meet the coordinators and the directors, you'd find they all think the same way.

Mr O'Connor: Thank you very much.

Mrs Caygill: By the way, Madam Chair, may I just say one thing? I would like you all, when you are making your decision, to realize that not all old people are in institutions. I don't know the number, but there's a very surprising percentage of people who are over 100 who are living alone. In the placement coordination service grouping, we have one lady who's 110 and she lives alone in her own house. I think you have to recognize that's happening more and more. So when you're talking about elderly persons, please don't look at them all together. I'm getting up there and I don't want to be classed as one of those who needs help yet.

The Acting Chair: Thank you very, very much for your presentation. You did bring something unique to us and I thank you for that.

Mrs Sullivan: I have some questions which I'd like to put to the ministry and to the parliamentary assistant before we leave. First of all, what is the position of the manual vis-à-vis the regulations?

Mr Jim Wilson: That's a very good question.

Mr Wessenger: I will ask ministry staff to indicate.

Mr Quirt: The expectations of the government will be laid out in three places -- in the bill before you, in regulations that will be drafted within the powers of the bill, and third, in more specific standards for service delivery and guidelines. In other words, good advice on how to deliver services in a long-term care facility will be included in the program manual.

The program manual will contain those practice-related things that need to be updated on an ongoing basis. There will be provincial expectations laid out in standards, but they'll change as the practice in the long-term care field changes. As we've mentioned earlier to the committee, we have a commitment from both provider associations and consumer groups to meet on a regular basis on a standing committee to review that manual so that if page 68 is confusing or if there's a better way to do things than is recommended on page 68, we'll tear that one out and mail everybody a new page.

There are three different levels of provincial expectation: those in the bill before you; regulations affecting things like the funding formula, resident payments; and third, a program manual that details standards of practice and provides guidelines and advice to facilities on how to do the best job possible.

Mrs Sullivan: Which piece of information then, the manual, the regulation or the legislation, or which in combination, will be used as a judgement with respect to the withdrawal of funding or reduction of funding from a facility if the facility is seen not to be in compliance? All three? One?

Mr Quirt: Possibly all three, possibly one of those three. But I remind you that through the compliance management program, every effort will be made to assist the facility to improve service so that sanctions would be used only as a last resort. The specific withdrawal of funding is most likely to be a contravention of the service agreement or a contravention of the regulations or the act that would seriously affect the safety and welfare of the residents in the facility.

Also, funding would be reduced, of course, if facilities didn't spend the money they were approved to spend in the provision of quality of life programs or nursing and personal care. For example, if they were approved to spend $2 million on nursing and personal care and only spent $1.5 million, that's all the money the province would provide.


Mrs Sullivan: If there is not agreement between the facilities and the ministry with respect to the content of the manual -- I'll give you an example. In the nutrition section of the second draft, by example, it appears that whoever has written this assumes that all long-term care patients will be able to eat in a restaurant facility or circumstance, at a table in a communal environment. That is not what happens in most nursing homes. Every person who is there cannot function that way. Then what?

Mr Quirt: In that particular instance it's widely recognized by ministry staff that there are some clients who cannot eat in a congregate setting. It's also expected practice in long-term care facilities, and certainly the expectation of practitioners in every home for the aged and nursing home in Ontario, that every resident should be given that opportunity to be up and sitting normally to eat in a congregate setting with other people if it's at all possible. Most DONs take pride in the fact that every one of their residents is up and able to interact with other people. They're not at all happy if residents deteriorate to the point where it's no longer possible. They clearly recognize that there are some residents who will require to be fed in their own bed or their own room.

Mrs Sullivan: Or to feed residents who can't swallow.

Mr Quirt: That's correct. But as is the case within the industry, the emphasis is on maintaining the optimal level of functioning of all residents in the facility. That's certainly the objective.

Mrs Sullivan: I understand what the objective is, but what I'm saying is, if the manual does not reflect reality and homes are, as a result, in non-compliance --

Mr Quirt: I would be very surprised if the manual in its current state -- and I haven't read the dietary section recently -- made it a requirement that all residents would be fed in a congregate setting.

Mrs Sullivan: It comes very close to that.

Mr Quirt: I think it would certainly establish a standard that all residents would have their meals in the most normal and independent manner possible and that all residents who required assistance in eating would be provided with that assistance and would require that all residents who required a special therapeutic diet would get it and standards to that effect. If in fact the program manual contains something silly and unachievable, I think we'd hear about that very quickly through the committee I mentioned and would make the necessary adjustment to it.

Mrs Sullivan: I use that one as an example, but just in terms of implementation.

The next question is, could you review with us again, as you did yesterday, the question of bridge financing? If this legislation does not pass quickly and is not proclaimed quickly, where are our homes left in terms of financing for 1993?

Mr Quirt: The government has provided two bridge funding initiatives for nursing homes and charitable homes for the aged. The first one provided funding effective September 1, 1991, and provided an additional amount of funding April 1 -- I'm sorry; I'm off by one year, I believe -- September 1990 to April 1, 1991. The facilities were required -- I think I might be off by a year again.

Mrs Sullivan: Yes, you are.

Mr Quirt: I'm going to have to get that chart.

There have been two bridge funding initiatives. The first one required all nursing homes to come to a particular level of staffing in that they were at various levels, anywhere from two hours of nursing and personal care per day per resident to some facilities providing over three. The bridge funding initiative was provided on the expectation that all nursing homes would achieve, in two equal increments, 2.25 hours of nursing and personal care per day. The second bridge funding initiative provided, coincidentally, an equivalent amount of money, another $1.32 per day, and there was no additional expectation of staffing in that second bridge funding initiative.

Those bridge funding initiatives were designed to allow facilities to respond to the serious financial situations they were in up until January 1, 1993, which was, as you well know, our first target date for the implementation of levels-of-care funding. The legislative schedule, the policy development schedule, did not let us meet that January 1, 1993, date, and no decision has been taken, as I think Mr Wessenger indicated yesterday, on either an economic adjustment or an additional bridge funding initiative for facilities. As has been mentioned previously, we would hope to introduce levels-of-care funding as soon as possible after the Legislature would approve passage of Bill 101.

Mrs O'Neill: Could we have a date for the clause-by-clause, Madam Chair?

The Acting Chair: I was just about to tell you that, Ms O'Neill. This brings to a close the hearings on Bill 101, An act to amend certain Acts concerning Long Term Care. We will reconvene March 23 for clause-by-clause, but the clerk will be in touch with everyone should that date change or to confirm. The committee stands adjourned.

The committee adjourned at 1726.