Tuesday 23 August 1994

Long-Term Care Act, 1994, Bill 173, Mrs Grier / Loi de 1994 sur les soins de longue durée,

projet de loi 173, Mme Grier

Canadian Red Cross Society, Ontario division, Sault Ste Marie branch

Shelley McEachern, chair, homemaker services committee

Sue Irvine, member, Timmins and district homemaker services committee

Ontario March of Dimes, Sault Ste Marie regional office

Valerie Scarfone, independent living manager

Sault Ste Marie General and Plummer Memorial public hospitals

Manu Malkani, president and chief executive officer

Johanne Messier-Mann, manager, long-term services, palliative care and psychogeriatrics

Laurie Walton, director, ambulatory and community services

Victorian Order of Nurses, Algoma and Sudbury branches

Sharon Baiden, executive director, Sudbury branch

Cheryl Sullivan, assistant executive director, Algoma branch

Charlene Brown, nurse manager, Espanola suboffice

Algoma District Health Council

Jim Dalgliesh, chair, long-term care committee

Susan Van Atte, health care planner, long-term care committee

Porcupine Health Unit

Dr John MacIntyre, acting medical officer of health

Joan Cameron, director, home care program

Regional Municipality of Sudbury, health and social services committee

Jim Griffin, member, health and social services committee

Mark Mieto, director, health and social services, Sudbury region

Algoma Health Unit

Gail Russell, administrator, Algoma home care program

Dr Allan Northan, medical officer of health, Algoma

Alzheimer Society of Sault Ste Marie and Algoma District

Brenda Lailey, chapter administrator

Maria Bell, member and care giver

Ontario Community Support Association, areas 11 and 12

Angele Poitras, representative

Russel DeCou, representative


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

*Acting Chair / Présidente suppléante: McGuinty, Dalton (Ottawa South/-Sud L)

Vice-Chair / Vice-Président: Eddy, Ron (Brant-Haldimand L)

Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

Hope, Randy R. (Chatham-Kent ND)

*Martin, Tony (Sault Ste Marie ND)

*O'Connor, Larry (Durham-York ND)

*O'Neill, Yvonne (Ottawa-Rideau L)

Owens, Stephen (Scarborough Centre ND)

*Rizzo, Tony (Oakwood ND)

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

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Haslam, Karen (Perth ND) for Ms Carter

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

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

Sullivan, Barbara (Halton Centre L) for Mr Eddy

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Also taking part / Autres participants et participantes:

Ministry of Health:

Czukar, Gail, legal counsel, long-term care legislation

Quirt, Geoff, acting executive director, long-term care division

Wessenger, Paul, parliamentary assistant to the minister

Clerk / Greffier: Arnott, Doug

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

The committee met at 0931 in the Holiday Inn, Sault Ste Marie.


Consideration of Bill 173, An Act respecting Long-Term Care / Projet de loi 173, Loi concernant les soins de longue durée.


The Chair (Mr Charles Beer): Good morning, ladies and gentlemen. The standing committee on social development is in session. We're delighted to be here in Sault Ste Marie for our hearings today. We have a very full schedule, so without further ado I would invite the representatives from the Canadian Red Cross Society, Sault Ste Marie branch, to come forward and make their presentation. As you come forward, we have a copy of the submission and welcome you to the committee. If you'd be good enough just to introduce yourselves for members of the committee, then go ahead.

Ms Shelley McEachern: Good morning. My name is Shelley McEachern and I'm with the Canadian Red Cross Society as a volunteer.

Ms Sue Irvine: Good morning. My name is Sue Irvine and I'm also with the Red Cross Society. I'm from Timmins. This morning Shelley and I will be speaking on behalf of northeastern Ontario.

I'm a Red Cross volunteer from Timmins and I am a registered nurse by profession. Presently, I work in the education department in our local hospital. I have been involved with the Red Cross since the early 1980s. Initially, I became involved with the Red Cross through teaching in home support level II and level III programs. It is through this experience that I became aware of the valuable contributions that the Red Cross provides in my community. I presently sit as a member of the local Timmins and district Red Cross homemaker committee, and I also serve as the northeastern homemaker representative on the provincial homemaker committee. Having lived and worked all my life in northeastern Ontario, I would like today to share with you what the Red Cross means to the people of northeastern Ontario.

Northeastern Ontario is a vast geographical area. Most of the communities are isolated from each other, far from urban centres, difficult, and sometimes impossible, to access in the winter. Transportation is often very limited and can also be very expensive.

Red Cross has been providing in-home services in this region for nearly four decades. Homemaker and home support services are provided by four main branches: Sudbury, North Bay, Timmins and Sault Ste Marie. From these main branches, Red Cross provides services to areas such as White River, Dubreuilville, Wawa, Elliot Lake, Blind River, Thessalon, Smooth Rock Falls, Cochrane, Kapuskasing, Hearst, Iroquois Falls, Matheson, Hornepayne and their surrounding areas. In all of these communities, except for Sudbury and North Bay, Red Cross is the only provider of homemaker services. Other services that the Red Cross provides include Meals on Wheels, Wheels to Meals, adult day care, Alzheimer respite, home maintenance, transportation, home health care equipment services, friendly visiting, telephone assurance, and fun and fitness programs.

As community needs have been identified, Red Cross has historically expanded their services. Our ability to readily respond to meet local community needs and to provide high-quality service has reinforced our reputation as a credible service provider. Within northeastern Ontario there has been a lot of collaboration and cooperation between service providers. Duplication of services has been kept to a minimum. A good example of this collaboration is the Alzheimer respite and home support program for the elderly in Sault Ste Marie. These programs could have been spun off, creating new organizations, but instead it was decided to build on the existing Red Cross service.

The development of suboffices has enabled Red Cross to provide a cost-effective and efficient way of delivering services in this area while maintaining provincial standards. Administrative functions are supported from the main branch office while service delivery and supervisory functions are delivered in the suboffices. This enables us to maintain a local presence in these communities. In these areas we hire local people, we are able to be more responsive to community needs and we are able to mobilize local volunteer support. However, Red Cross has made a commitment to provide services in these areas.

Each month in northeastern Ontario, Red Cross provides almost 50,000 hours of homemaking service to over 2,500 clients, utilizing over 500 staff. Hundreds of volunteers are involved in providing other home support services. For example, last year in Timmins over 100 volunteers provided 8,000 meals to 122 clients, and 800 volunteer hours were needed to handle over 32,000 calls to the telephone assurance program in Timmins.

I would like to take this opportunity to highlight a few examples of the Red Cross responding to community needs with the assistance of our vast network of dedicated volunteers and staff. The following two examples demonstrate the excellent reputation and support the Red Cross enjoys in the community it serves.

The first one: A local Red Cross transportation program in a small community 50 kilometres from Sudbury is a fine example of Red Cross voluntarism in action. Red Cross has been providing transportation services to this community for the past five years. Volunteers and staff are from this community, including the mayor, who is the chairperson of the Red Cross transportation committee. During the five years volunteers have driven the equivalent of six times around the world. More than half the volunteer drivers are seniors.

One particular driver -- in fact, she has driven the most kilometres -- serves on the local Red Cross transportation committee. Every year she makes a hand-hooked rug to be raffled off for fund-raising to help this program and then also helps with the sale of the tickets. This volunteer was also a client of the service a few years ago. I wonder if she will continue to be such a good volunteer for an MSA 50 kilometres away.

This particular volunteer is also a member of a seniors' club. She became involved with the Red Cross due to the Red Cross linkage with the seniors' club. A local mining company had donated a building to the seniors' club and the club, in turn, offered free office space for the Red Cross.

The main branch office in Sudbury provides administrative support to this program. Red Cross, Ontario division, supports this initiative through the development of provincial programs for recruitment, orientation and training of volunteers and volunteer recognition programs. It also provides support to the volunteers, helping them to provide a high-quality, standardized service.

The second example: Five years ago, Red Cross started a gardening program in Timmins. A gentleman who was a Rotarian and former market gardener had an innovative idea that would allow him to garden despite his infirmities. He created what is now known as the tire garden. By piling discarded truck tires and filling them with earth, he was able to create garden plots that were elevated. He wanted to share his garden with other seniors. Having received Meals on Wheels from the Red Cross, he approached the local branch to ask if seniors could visit his farm and help him tend his tire garden.

Beginning in late spring, volunteers bring seniors to the garden twice a week. During their visit, volunteers assist the seniors in gardening activities and prepare a picnic lunch. The local food stores donate the refreshments. The Rotary Club has donated the picnic tables, barbecues and lawn chairs. They have installed portable toilets and also donate all of the seeds yearly.

The program has been so successful that last year it expanded to other northern Ontario communities through funds made available from the government. This year it looks like we are headed for a bumper crop.

We would now like to share with you two examples of how the Red Cross homemaking services can make a difference in the lives of their clients as well.

The first one is a female client in her late twenties. She's a quadriplegic resulting from a motor vehicle accident. At the time of her accident she had three small children under the age of five. Her husband, who works in the lumbering industry, is away 12 hours per day. She lives in a remote area 20 kilometres from the small northern town in which one of our suboffices is located. She has been a client since 1985.

Red Cross provides services 12 hours a day, five days a week. The Red Cross homemaker provides child care, household management and personal care to this client. Road and weather conditions are an ongoing challenge to providing services to this family because of her location. Our service has allowed this family to continue to function.

The second example is the Red Cross providing services to an AIDS victim who is terminally ill. He was one of our first AIDS clients in 1988. At that time he told us that we were all learning about AIDS and he didn't know what he would do or how he would get through each day without his homemaker. She was with him till the day of his death. His wish to die at home was made possible because of this Red Cross homemaker.


Although we support the principles underlying the reform and the purposes as outlined in Bill 173, we are not able to support the creation of multiservice agencies, or MSAs, as described in the act. We are concerned that the proposed model appears to discard a system with proven strengths, replacing it with complex and highly bureaucratic organizational structures, this despite input that has demonstrated such monopolistic organizations do not work. Rather, they lead to a two-tiered system.

In the northeast, organizations like VON, home care program and the Red Cross have a long history of collaborative relations. These organizations provide excellent services. We should be building on this proven expertise and not discarding it.

We are very concerned that clients are unaware of the impact that this legislation will have on agencies that have been providing services to them over the past several decades. The results of regular surveys of client satisfaction conducted by the Red Cross indicate a high level of satisfaction with our service. If the legislation is to be proclaimed without amendment, the Red Cross and many similar agencies will be forced out of business. If this is to be the case, the government has an obligation to inform the public.

Our quality service comes from the partnership between our volunteers and staff who are committed to our vision, to our mission and to our fundamental principles. We feel the legislation will have a very damaging impact on our volunteers' role within the Red Cross. We are a volunteer-based organization. Our wide range of programs and services provides volunteers with diverse backgrounds and interests a variety of meaningful opportunities to participate in the work of the society.

The legislation, as it is currently drafted, precludes the Red Cross, its regions, branches or programs from becoming an MSA or providing services as part of an MSA. The Red Cross is committed to meeting the needs of the vulnerable members of our communities, building on the range of services that we have developed over the last 75 years.

The Ontario division of The Canadian Red Cross Society is not a distinct organization but is a part of a national incorporated entity, the Canadian Red Cross Society, which in turn is part of the International Red Cross and Red Crescent Movement. The Red Cross has a long history of effective and efficient services throughout the world.

The legislation requires that each MSA be incorporated under Ontario legislation. Each MSA must have its own board of governors selected in accordance with the act. These requirements are incompatible with the fundamental principles and corporate structure of the Canadian Red Cross Society.

In summary, Bill 173 specifically excludes the Red Cross from providing in-home services to the residents of Ontario. It would be a tragedy if our present system was dismantled and replaced by a large bureaucracy. Can the government afford to disregard 75 years of credible, accountable and fiscally responsible services?

Thank you. Shelley McEachern will now comment on specific aspects of the bill.

Ms McEachern: My name is Shelley McEachern. I'm a volunteer with The Canadian Red Cross Society. In particular, I'm chair of the Sault Ste Marie homemaker committee. I became involved with the Red Cross as a result of my keen interest in community health care and, in particular, the health care of the elderly.

I am a nurse by profession and currently the director of care of a long-term care facility. As a result of my work experience, I have encountered several individuals who because of the Red Cross were able to postpone institutionalization. This specific experience, combined with the good work and reputation the Red Cross maintains in this community, led me to the society when I choose to volunteer my time and talents.

I am also the president of the Alzheimer Association of Ontario. Originally, my involvement with the Red Cross was through the development of a respite program for people afflicted with Alzheimer disease. I continue to be a liaison between the Red Cross and the local Alzheimer society. Our local Alzheimer society supported training homemakers to a level that would support in-home respite service. The Alzheimer society's commitment to training is ongoing. The training has given homemakers the competence to provide service to clients with Alzheimer disease. With the competence has come the confidence to work with this challenging population.

We welcome the opportunity to comment on Bill 173. There are several issues of particular interest or concern to us that we will specifically address in this submission.

The Red Cross specifically recommends that three sections of the legislation be amended. We believe that these amendments would in no way adversely affect the purposes of the act; rather, they would enhance flexibility and allow the existing strengths of the system to be augmented.

Part II, section 2, paragraphs 3 to 4: This section designates the community services which are to be provided by the MSAs. The bill describes four categories for these services and specifically delineates the specific services that fall under each category. The bill describes community support services, homemaking services, personal support services and professional services.

The basic premise underlying the breakdown appears to be to separate personal care, or "hands-on" care, of the person versus non-personal care and services. We have two concerns with this aspect of the legislation.

The division between homemaking and personal support services is inconsistent with current practice and emerging future trends. It has taken concentrated effort over the past few years to erase the misapprehension that homemakers are nothing but cleaning ladies, subservient to the other members of the health care team.

The homemaker has begun to achieve genuine recognition as a valued member of the health care team. The wording of the legislation significantly devalues the role of the homemaker and may lead to a reversal of the growing appreciation of the homemaker as an integral member of the health care team.

The separation of personal care versus non-personal care and services appears to be impractical and may create serious difficulties for the management of service delivery. The delineation of services between the two categories is inconsistent with the way the services are usually delivered into the client's home. Many functions routinely provided by the homemakers cross the boundaries between what the legislation classifies as "homemaker" and that called "personal support."

We are also very concerned that the uncertainty arising from the reform has created significant anxiety among our staff. One of our highest priorities is to look after the interests of the over 6,000 individuals, mostly women, whom we employ.


Recommendation: The Red Cross recommends that the legislation be reworded to eliminate the specific reference to, and categorization of, community services; that the regulations to the act be used to define those services to be provided by an MSA; and that the act and the regulations respect interrelationships between services.

Part VI, section 13: This section stipulates that an MSA may not spend more than 20% of its budget to purchase community services. The Red Cross recognizes that the government has committed to moving away from the brokerage system. In our opinion, the problem with the current delivery system is not brokerage but lack of coordination and poor access. We feel that in many situations brokerage can be an efficient system for service delivery.

Presently, many services are provided effectively and efficiently by a number of established agencies. These agencies have long histories of service to their communities. They are often supported and governed by volunteers who are part of that community. Stable relationships have been developed between provider agencies, care givers and the individuals they serve. Rather than replacing the existing system, efforts should be made to improve coordination and enhance efficiencies. One example would be to contract with a provider agency for blocks of service rather than the less efficient client-by-client contracting that now occurs.

In most communities, services are provided by several provider agencies. Each agency must retain a critical volume of service to remain economically viable. The volume of services must be adequate to support the operation if the agency is to stay in business. Also, the volume must be adequate to allow the development and maintenance of an infrastructure that supports quality and risk management. Where MSAs are declared, and as they move towards assuming 80% of a given service, the critical volume necessary for the alternative provider to exist will be lost. The MSA will then be forced to assume responsibility for providing service before it is ready. Alternatively, clients will be placed on waiting lists. The Red Cross is very concerned that clients may face waiting lists, a decline in quality of service, or limited or no choice. Those who wish to purchase services outside the MSA will be unable to do so if there are no alternative providers in the community.

In may remote and sparsely populated communities, like northeast Ontario, the Red Cross is the sole agency willing to provide service. Our corporate structure and fundamental principles preclude us from providing services within the proposed MSA structure. We are concerned that if the MSAs are imposed in these areas, the declining volume of service allocated to us, in combination with increasing deficits due to the high costs associated with travel, will ultimately force us out of business. This will leave many clients without service. Where the local MSA plans to assume responsibility for directly providing the necessary services to these clients, accommodation will have to be made to offset the deficit inherent in servicing these areas of the province.

Recommendation: The Red Cross recommends that the legislation be reworded to remove limits on the amount of service that an MSA may purchase and that the legislation enable each community to choose the best service delivery model or models and optimum mix of provider agencies to meet the needs of its residents.

Part VI, section 15: This section says that MSAs have just four years to comply with all the provisions of the legislation. Under the tight structures of this draft legislation, communities will not have the flexibility to identify and implement the models of service delivery that best suit their needs.

Recommendation: The Red Cross recommends that the legislation be reworded to eliminate the requirement for MSAs to comply with the provisions of the act within four years after being designated as MSAs and that the legislation enable each community to develop and implement the model for community-based long-term care that best meets its unique needs and its culture.

The enormity of the impact of this legislation has not been fully explained to the consumer. Government speaks of expanding services to underserviced areas, yet there will be no additional resources made available. Red Cross has been working collaboratively with other service providers to maximize the use of available resources. In northeastern Ontario, duplication of service providers is not an issue. The legislation must permit agencies such as the Red Cross to continue to provide excellent and necessary services to the residents of the province. Thank you.

The Chair: Thank you very much for a very full brief. I want to permit a question from each caucus, but I would ask for just one question and if you could keep it brief, because of our time constraints.

Mr Tony Martin (Sault Ste Marie): Thank you. I wanted to first say welcome to all of my colleagues from Queen's Park to my home town. There's a song, I think, that goes like that. It's nice that we were able to come up and hear from the folks in Sault Ste Marie and area. I'm looking forward to hearing from everybody today so that I can be better educated on this issue and understand what the concerns are.

I want to thank the Red Cross for coming forward. Certainly there's no doubt but that you do tremendous work. The services that you provide across the north are certainly a major part of what actually, before I started this process, I thought was your work, which is in the area of blood supply. Every time there's a major crisis in the world, the Red Cross is always there. I'm assuming you're not saying today that if you lose some of your ground in this whole process, the Red Cross is going to disappear. It's been around for a long time. I'm sure it'll be around for quite a time to come.

You know that the reason for this reform, which has been called for by people for over 10 years now, is to provide equity of service and access across the province, particularly in the areas that you spoke of today, the smaller, remote areas that need the same supports that the larger centres need and that we want to in fact build on the good things that you and other people have been doing in this area.

Actually, you had said in your last paragraph that there wouldn't be any more money. We have increased the funding to long-term care by 54% in the last couple of years, and there is a plan to increase it even more, so that those services can be provided. We certainly are also looking at a great degree of local control and direction.


My question to you is, first of all, do you belong to the Ontario Community Support Association? I think you do. We had somebody present yesterday who was an active participant in that organization. Are you aware of the call that they made for an MSA? Are you involved in the local planning consultation process in Sault Ste Marie and area?

Ms McEachern: Yes, we are a member and we are involved in the local planning process that is ongoing. There are a number of community agencies currently meeting to discuss the development of the MSA within our area and Red Cross has, through its staff and volunteers, participated in that process. The Red Cross homemaker committee in the Sault has discussed that issue over the summer and are willing to speak with any of the other agencies in the development of these MSAs.

Mrs Barbara Sullivan (Halton Centre): I'd just like to correct the record. The community support association has not supported the MSA. In fact, the Red Cross comprises 50% of that organization and they're certainly not in favour of the MSA model as proposed.

I want to indicate to you that our party will be putting amendments forward with respect to the 20% limit and the transition time, but I also want to ask the ministry some questions with respect to your brief.

You've indicated how the Red Cross has adapted its infrastructure to meet the needs of distance and geography of the north and to reach people in remote areas, and you have spoken with respect to the deficits that are associated on the operating side of your budgets with ensuring that services are provided in those remote areas.

I would be very interested in knowing how the ministry will take into account, since it's going to put you out of business in homemaking and home care services, the costs of what in your organization are deficits, of covering those remote areas, which clearly in your organization are made up through other fund-raising vehicles and other parts of your budget.

How will the ministry and what steps has the ministry taken to ensure that those deficits are covered and that the full budget costs that are held by the Red Cross are in fact met through the MSA? What guarantees will you put into place?

Mr Paul Wessenger (Simcoe Centre): If I might just comment on that, I think it's fair to say it's anticipated, with the MSA, that you're going to have administrative savings with respect to the functions. So you're going to have a more efficient delivery of service, and we do not anticipate you would have deficits occur under the MSA situation.

I'm not aware, I must admit, of the extent to which there are deficits in the home care program here. It would be interesting to have that information, and maybe we could have the Red Cross indicate, in its various branches, what deficits it has in running its home care programs. That might be of assistance to the committee.

The Chair: Is there any comment you want to make on that at this time?

Ms McEachern: No, other than to say that I'm sure that information is available and that we'll forward it to the committee.

Mr Cameron Jackson (Burlington South): I appreciate receiving your brief. I was here when we were doing Bill 101 and it was unique to the presentations in northern Ontario that they sort of gave us little insights into the extended world of support services. They used the occasion of Bill 101 to talk about the future of Bill 173, and I appreciate that because that added to my education.

Now I find myself, a year and a bit later, back here in northern Ontario and I see an absolute shift on the part of the government in terms of the model. Your concerns which you expressed a year and a bit ago are now coming forward, but they're coming forward in a more desperate fashion.

My question to you is: Given that you thought you were working with a brokerage model, which was the genesis of how services were developed in the north -- you're now into an assimilation, a monopoly model, which is going to, by your own words, wipe out your agency -- would you, for the record, indicate support if the Conservative Party were to put in an amendment that allows for the brokerage model to be maintained in northern Ontario because of the unique nature of the service which is already established that we don't wish to dismantle; and secondly, that it respects the absolute unique challenges of distance and access, which you've been doing a superb job of? I frankly don't trust government to do a better job than what you've been doing.

Would you support an amendment which, although it differentiates between southern and northern Ontario, it's clear that this legislation was drafted in Toronto, made in Toronto and it's a Toronto-centred solution for a problem the north doesn't have?

Ms McEachern: Well, your comments are certainly appropriate. That's exactly our feeling, so yes, I think we would support that sort of a motion.

Mr Jackson: Thank you very much.

The Chair: Thank you for coming before the committee this morning.

Mr Martin: Mr Chair, may I, while they're in transit, make --

The Chair: Let me just call the next witness and then I'll recognize you, Mr Martin.

Mr Martin: Okay.

The Chair: Thank you. The Ontario March of Dimes, Sault Ste Marie branch, if the representative would come forward.

Mr Martin: I'd just like to, on a point of privilege, clear the record here. Mrs Sullivan had said that the OCSA did not in fact support MSAs. There was a woman who came before us yesterday and I have her presentation here, and very clearly in here the OCSA is saying that it supports MSA models and indeed alternate MSA models across the province in this exercise. I just want to make sure that the record is correct and that my comments are not refuted in any way.


The Chair: Order, please, order.

Mr Martin: I'm just asking the opposition to read the briefs, Mr Chair.

The Chair: That's fine. The point has been made. We are here this morning to listen to the witnesses and we'll go ahead with that.


The Chair: Welcome to the committee. Every now and then members get a little itchy. I want to welcome you to the committee. If you'd be good enough to introduce yourself; we have a copy of your submission in front of us. Welcome.

Ms Valerie Scarfone: My name is Valerie Scarfone and I'm the independent living manager for the Ontario March of Dimes in Sault Ste Marie. I'll try to summarize our brief.

The Ontario March of Dimes commends the government of Ontario for its efforts to reform long-term care services in this province and to implement the multiservice agency concept.

Ontario March of Dimes has a vital interest in the reform process. The mission statement in our organization is "to assist adults with physical disabilities to lead meaningful and dignified lives." We accomplish our mission through the provision of a variety of programs and services. Our largest program is the attendant services program, which provides assistance with activities of daily living to enable adults with physical disabilities to live in their own homes.

Locally, the Ontario March of Dimes operates a support service living unit program for 12 individuals in Sault Ste Marie. This program provides 10,504 hours of service annually to 12 individuals, with a budget of $451,320. Three outreach attendant care programs operate throughout the district of Algoma. Together, these programs provide a combined total of 17,069 hours of service each year to 55 individuals, with a budget of $545,183.

Both the outreach attendant services programs and the support service living units have extensive waiting lists in this community and in the district. Waiting lists are for both people wanting an increase in the current level of service they receive and for initial service. In the district there are approximately 40 people waiting for attendant services.

For the majority of individuals receiving outreach attendant service, there is a desperate need for respite services for their family members. The availability of respite services is essential to enable people with disabilities to remain in their own homes. Currently, in the Algoma district there are no in-home respite services for our consumers, adults with physical disabilities, and for their families.

In the many public consultations on long-term care reform held over the last few years, the Ontario March of Dimes has encouraged its consumers, volunteers and staff members to express their ideas about this reform. This paper summarizes the position of Ontario March of Dimes on long-term care.

Ontario March of Dimes believes that the key principle of long-term care reform should be guaranteed access to essential long-term care services required by persons with physical disabilities and older people to live independently in the community. Long-term care reform must also retain choice for consumers in accessing services. Ontario March of Dimes strongly recommends that consumers maintain the option of accessing attendant services directly or through the multiservice agency. Competition in service provision will ensure that consumers benefit from increased quality through a greater service accountability and thus can truly act as consumers, choosing the service provider that best meets their needs.

Consumers with disabilities have clearly stated that they do not wish to have a medically oriented service philosophy in making important decisions in their lives. They believe that this philosophy will only perpetuate the notion of disability as illness and serve to promote dependency rather than independence. The non-medical, consumer-directed nature of attendant services should therefore be protected, while ensuring choice with respect to where and by whom the service is provided.

Service provision and assessment:

Prior to the shift of funding from institutions to community-based services, Ontario March of Dimes urges that there be equitable local resources developed across Ontario to ensure that essential services such as homemaking, visiting nursing and attendant services are available in all parts of the province. Ontario March of Dimes believes that assessment and service provision should be separate to avoid potential conflicts of interest.

The multiservice agency staff should be trained to assess consumers in the broad context of their total wellbeing and independence and not just their medical needs. Consumers with disabilities should have input in establishing service and administrative standards for community support services to ensure that they meet their needs and not just those of seniors. As well, the boards of multiservice agencies should have a strong component of participation from consumers with disabilities.


We oppose user fees for long-term care services. Many of these services are essential to allowing persons with disabilities to maintain independence.

Ontario March of Dimes supports the broad range of services provided by long-term care. However, the ministries of Health and Community and Social Services have made reference to the fact that personal support and professional services would be "generic" in nature. The concept of generic services should be carefully considered to avoid opting for the least expensive option rather than the best quality and most appropriate service. Certain groups have developed specialized skills for servicing client groups while fostering integration. These skills, along with the options they represent, should not be sacrificed in the pursuit of a generic service provider.

Life skills training:

In addition to the need for greater expansion and accessibility to community support services, there is a very real need for funding for life skills training programs for those moving to supportive housing projects from chronic care or nursing home settings. Life skills training not only helps individuals to achieve successful independent living but also reduced costs as consumers lessen their dependency on attendant care services. This is especially true for Sault Ste Marie. When we're looking at people for our support service living units, we often refer them to either Sudbury or Toronto for life skills as there's no formal program here.

Appeal process:

There should be a simple and expedient process in place for consumers and agencies to appeal decisions of the multiservice agencies. Services should continue while a decision is being appealed.

Funding of long-term care:

(1) Core services: Ontario March of Dimes believes that long-term care reform should proceed in the context of protecting Canada's universal health care system, restructuring services for greater effectiveness and efficiency and shifting to a model of wellness and prevention.

We strongly recommend that funding also be provided for assistive devices and home modifications which allow individuals to continue living in their own homes.

Governments should ensure that consumers are not denied benefit of coverage for items such as incontinence supplies by virtue of their leaving the home care nursing case load to receive services from an attendant services program.

(2) Support services: We are concerned that the possible transfer of funding for outreach attendant services to the multiservice agencies could jeopardize the smaller outreach programs. Many of these programs offer services which are unique and respond to consumer need in innovative ways. We believe the province should continue to directly fund the support service living units and the outreach attendant services programs. A common problem experienced by consumers of support services is rigidity of provision. Due to funding restrictions, many service providers limit the availability of attendant care on weekends or nights. This restriction severely limits opportunities for people to live independently.

We recommend that the government provide funding for agencies to provide extended service and make it mandatory for all service providers to make this available. Extended service should also be offered in the workplace, school and recreational settings to ensure that persons with disabilities are not restricted from pursuing opportunities in these areas.

As well, volunteerism as an integral part of attendant services programs requires a financial commitment on the part of the government. While volunteers should not replace staff, they can serve to enhance programs and contribute to extending independence and fostering integration.

(3) Direct funding: Ontario March of Dimes believes that direct funding to consumers with disabilities for attendant services should be a central option within the reformed long-term care system. The concept of direct funding would give consumers with disabilities confidence, experience in handling finances and managing people and help them to achieve greater independence by controlling decisions that affect their lives.

Supportive housing:

As the long-term care reform process promotes community-based care in the home, the basic underlying assumption is that the recipient of support services has a home.

Ontario March of Dimes believes that supportive housing should be encouraged in the widest possible range of housing types and locations. Our 13 years of experience in operating support service living units demonstrates that the support service living unit is a successful model which merits expansion.

We therefore strongly recommend that the Ministry of Housing and municipalities collaborate to provide accessible affordable housing units in the province and to encourage non-profit organizations to sponsor the support service living unit projects.

In conclusion, the Ontario March of Dimes encourages the Ontario government to enact Bill 173 in order to proceed with long-term care reform.

However, we believe that the points raised in this paper should be carefully considered prior to implementing the reformed system. Further consultation with consumers, service providers and community organizations is essential in order to develop an effective and efficient long-term care system in Ontario. We are committed to working with the government to ensure that the reformed long-term care system respects the autonomy of persons with disabilities in choosing services which most appropriately meet their needs.

Mrs Barbara Sullivan: Thank you for your brief. I'm interested in two questions that you have raised. The first one is with respect to the life skills training. I am wondering if the ministry could respond by indicating if life skills training is included under the personal support services in the mandatory basket. That would be subsection 2(6), paragraph 4, "Training a person to carry out or assist with any of the activities referred to in paragraphs 1 and 2," which would include "routine personal activities of living."

The other question, also of the ministry, is: What steps will be taken with respect to funding the outreach attendant services and the support service living units as a result of long-term care reform? How will that fold into the MSA?

The Chair: The parliamentary assistant.

Mr Wessenger: I'm going to refer part of that question to the ministry. Perhaps I'll just indicate that the SSLUs will continue to be funded outside of the MSA model and I understand, with respect to the attendant care, it's going to be a consumer decision with respect to how those services are delivered. The rest of the questions I'll refer to Mr Quirt.

Mr Geoff Quirt: As the parliamentary assistant has indicated, consumers of attendant care outreach services in each community will have the option of having their attendant care outreach program funded separately, as it is now, by the province directly, or, if they choose, they could opt to receive their services from the multiservice agency.

With respect to life skills training, yes, that is the kind of thing that section of the bill refers to. In addition to that, with the support service living unit program, it's quite possible for us to include, in the funding that goes to the SSLU, funding to support training activities if that's a necessary part of providing the support needed to assist someone in transition from a chronic hospital to an even more independent lifestyle than a support service living unit.

Presumably, if clients here have to go elsewhere for that, it would be worthwhile to explore with the DHCs whether they would recommend to the minister that a proposal for that type of training be funded.

Mr Jim Wilson (Simcoe West): Thank you, Ms Scarfone, for your presentation. I was just wondering if you had any further points to make about the MSA model that's proposed, envisioned in this actual piece of legislation. Do you have any concerns about the fact that 80% of the services will now be delivered by one agency? That is the twist that we've encountered along the road of long-term care reform. We've gone past one-stop shopping and one-stop access and one phone number to an actual monopolistic model. Has the Ontario March of Dimes addressed that? Because, of course, the government will simply take your sentences in this brief, as it did with the Ontario Community Support Association, and say, "Well, March of Dimes is fully supportive of the MSA model," so here's an opportunity to express any concerns you might have.

Ms Scarfone: The concern we have is that we believe that persons with disabilities should have the option of accessing attendant services outside of the multiservice agency.

Mr Jim Wilson: As long as there's that flexibility, you're fine with it.

Ms Scarfone: That's right.

Mr Jim Wilson: Okay.

Mr Martin: My question was answered. The answer was given. I again want to thank you for the tremendous work that the March of Dimes is doing in this community and continues to do. We don't get a chance often enough to do that publicly. Of course, this legislation is designed to build on that good work and to bring some coordination and cooperation to the picture.


Certainly, your reference to consumer rights and things being driven by consumers, which I know is a guiding principle of how you folks operate, is also built in here. There is an appeal process and there's in fact a bill of rights that comes with this that will ensure that people have every opportunity to contest and to give input. The coordinating committee itself will be locally driven, elected by local people, and will have a high component of consumer presence there.

Given that the supportive housing piece is outside of this, just how much of what you do then will be affected by this new MSA piece that's beginning to roll out, and are you part of the local process that's pulling all of this together?

Ms Scarfone: Half of our attendant services program is outreach services, so half of our programs in this area would be affected by the multiservice agency. As far as my involvement in the planning process, I serve on the district health council long-term care committee, so I'm quite involved in the planning.


The Chair: I then call on the representatives from the Sault Ste Marie General Hospital. Would you be good enough to come forward. We have received a copy of your brief, and once you're settled, if you would be good enough just to introduce yourselves and then please go ahead.

Perhaps I might just indicate to committee members as you're getting ready, the witnesses after this presentation will be from the Victorian Order of Nurses and then the final witness for this morning will be from the Algoma District Health Council, so there's a change from what is on your program.

Mr Manu Malkani: Thank you for the opportunity to appear before your committee today. My name is Manu Malkani and I'm the president and CEO of the two hospitals in Sault Ste Marie: the Sault Ste Marie General Hospital and the Plummer Memorial Public Hospital. With me are Mrs Laurie Walton, who is the director of our ambulatory and community services at the two hospitals combined, and Mrs Johanne Messier-Mann, the manager of our long-term services, palliative care and psychogeriatrics.

Again, all three of us represent both hospitals together. Laurie and Johanne will be making the bulk of our presentation today. I would like to take a few minutes simply to give you some background information about the organizations which we represent.

Both of our hospitals in Sault Ste Marie have a very long history of serving this community. The general hospital was founded 98 years ago by the Grey Sisters of the Immaculate Conception and the Plummer Memorial Public Hospital was founded 77 years ago.

Since the early 1980s, both of our hospitals have been engaged in a program of rationalization of services. In the early part of the 1980s, most of our efforts were focused on the rationalization of clinical programs, programs such as mental health, oncology, obstetrics, those kinds of programs. But more recently, in the last 18 months, we have come together even more closely in a very innovative partnership which provides for joint or shared governance of our two hospitals along with a single or common management and medical staff.

All of this has been driven by the initiative of our volunteer boards of directors, whose goal has been to eliminate all unnecessary duplication in our services while yet maintaining the history and tradition and independence of each organization. Our partnership we believe is the first such relationship between a Catholic and a public hospital, certainly in Ontario and perhaps even in the country, and we are very proud of what we have achieved by working together voluntarily with our staff, with our unions, with the representatives in our community, all for the good of the community.

I will not detail for you what these accomplishments are, although Mr Tony Martin on your committee is intimately familiar with all of these and in fact has been a very strong supporter of our efforts. I just want to make the point, because I think it's very key to the rest of our presentation, that all of this that we have achieved between our hospitals, while we have cooperation by way of innovative arrangements to deal with common problems, has been a result of the effort of volunteers working together within a framework of enabling legislation. I don't think any of this could have happened if we were working within a very tight prescribed kind of environment.

I'm going to stop with that and I will call on Johanne Messier-Mann to pick it up from here.

Mrs Johanne Messier-Mann: Our presentation will be brief and will be limited to the following three areas of concern: These centre around the mandate of the multiservice agency; secondly, the use of the term "community-based" in the legislation; and thirdly, the functions of district health councils.

The mandate of multiservice agencies: The Sault Ste Marie General Hospital and Plummer Memorial Public Hospital support the objective of reform in the long-term care system. What we cannot support is the method by which the proposed legislation seeks to achieve this reform. The proposed legislation must focus clearly on the problem which it seems to fix.

The problem with long-term care now is access. We are not aware of any claims that the services, once accessed, are of poor quality.

The problem of access can quite easily be fixed by creating a central agency in each community to coordinate access to the host of non-institutionally based long-term care services. Such a coordinating service has been in existence in Sault Ste Marie and in many other communities for accessing institutionally based long-term care services and has worked quite well. Of course, I'm talking about our local placement coordination service.

Instead of such a simple and focused approach to solving a well-defined problem, the legislation seeks to alter other key features of our present long-term care delivery system, features which are not problems and indeed have served the communities very well. In so doing, we fear that the proposed legislation will create new problems such as:

-- First of all, replace the rich heritage and traditions of individual provider agencies and organizations by a large impersonal and bureaucratic organization;

-- Significantly dilute, if not eliminate, the commitment and participation of volunteers in the running of these organizations as well as the provision of services;

-- Lose the fund-raising effort of volunteers, with the result that the system will require increased tax dollars or the system will have to manage with less dollars.

We recommend that the scope of the MSAs be limited to coordinating access to non-institutionally based long-term care service and not include the actual delivery, provision or evaluation of services.

I will now pass to Mrs Laurie Walton.


Mrs Laurie Walton: I'd like to carry on and talk about the use of the term "community-based" in the legislation.

The legislation uses the terms "community-based" and "institutional" in a mutually exclusive way. The fact is, many hospitals in Ontario, and our two local hospitals, have provided a host of services outside of institutions, services such as primary care, supportive care, counselling and so on. We like to believe that our hospital and other institutions are as much a part of the community as are those agencies which provide services in the home.

Surely the purpose of legislation is not to set up boundaries within an established continuum of care. The negativity that exists in the very first statement of the purpose of the act, "To ensure that a wide range of community services are available to people in their own homes and in other community settings so that alternatives to institutional care exist," reinforces the current fragmentation of access to services. We would recommend that "community-based services" be replaced by "non-institutionally-based services."

Our last point of concern has to do with the functions of the district health councils. Bill 173 enshrines DHCs in legislation and attempts to clarify their functions. However, we feel the redefined functions are not sufficiently clear concerning planning versus management. We would recommend, therefore, that the role of DHCs be clarified as being one of planning and advisory. Any change in this should be subject to a separate process of public debate and consultation.

Thank you for your attention, and we'd be pleased now to answer any questions.

Mr Jim Wilson: Thank you for a very good brief. As Health critic for the Ontario PC Party, I just want to tell you that there's nothing you've said that I or my caucus colleagues would have any disagreement with whatsoever.

I think you make an excellent point with respect to the terminology "community-based" versus "institutional services" or "institutional care" or whatever language, because as hospitals restructure, of course, you've been increasingly expanding the mandate and expanding the services into the community. We see that throughout the province, and you're to be congratulated for that. We will keep that in mind. That's a new suggestion to this committee and we'll certainly keep it under advisement with respect to amendments.

Very few presenters, as we've travelled the province, have talked about the new mandate or the new definition enshrining district health councils in legislation for the first time. I'm wondering if you could expand on your final comment here with respect to planning versus management by DHCs. What fears do you have? Because I am in full agreement that we don't really know what the management function is going to be and there could be some very scary things happening in this province with respect to the powers of the DHCs in the future.

Mrs Walton: That is our concern, that it is vague and it is sweeping. In particular, one of the functions, and I'll just quote, is "to perform any other duties assigned" to them by the minister. We have all of that tagged on -- at least, we used to, in the good old days, have that tagged on to our job descriptions, and it meant all kinds of add-ons at any point in time in our careers. But surely the legislation should be a little more restrictive versus broad. This is quite vague, and I'll agree with you, there are some risks to it.

Mr Jim Wilson: In this area of the province, what has the general discussion been or has there been a consensus reached about what the role of DHCs should be? I refer to, for instance, the southwestern region of the province, where there's a move on for a regional government with respect to DHCs. What's the feeling here in the north?

Mr Malkani: We've enjoyed I believe a fairly healthy relationship with the DHC, with our DHC over here. For our DHC, as all the other DHCs so far, their role has largely been planning, sort of district-wide planning, and an advisory role to the Minister of Health. Certainly our DHC has not gotten involved with the micromanagement of hospitals or other organizations. I can speak on behalf of our hospitals that that hasn't happened.

Our fear is what is likely to happen in the future if the terms of reference of the DHCs change. We see a certain ambiguity in the legislation. We may be putting two and two together and getting five, but we're not sure about that, and it is a caution that we want to leave with the committee that the role needs to be clarified rather than made blurred, and the clarification we would recommend ought to be in the direction of a planning and advisory role rather than one of management.

Mr Jim Wilson: Mr Chairman, I think we still have a bit of time. Could I just ask, with respect to the function of the MSAs, and I think you make a very good point on page 6 of your brief, in the public consultations that took place in the north during the long-term care reform process, was there an outcry from the people here that the MSA, in addition to coordinating services, should also be delivering the services? Because the government claims that is the case throughout the province and that's why this legislation has them delivering 80% of the services.

Mrs Walton: Initially, in the beginning stages of consultation, we were at the tables. We had lots of good discussion. I don't believe we understood the full implementation scheme, and I think that's where it is now unfolding and we have some questions regarding that. The total dismantling or destruction of community-based services as they exist right now is, again, very risky, particularly when we have no indication as to whether there will be the dollars or the total cost to do it. Certainly, when we look at the reform as it currently is unfolding in relation to long-term care facilities, we do have some distinct concerns regarding the cost and the implementation and the outcomes in relation to that reform.

Mr Martin: Again, I want to commend the hospital for the good work that it does in the areas it's involved in, and certainly the comment you make in your brief about access being the question here and not necessarily the quality of care, where it can be accessed. I think we have to recognize too that as our population ages, that whole question becomes even more acute and of greater concern. How do we deliver the kinds of services that are going to be required and how do we coordinate that so that we get the most mileage for every dollar that we put in and reduce duplication?

I wanted to say how, for example, the hospitals were an excellent example of that in this community. The coming together of the two hospitals was not something that was laid down from up above; it was a locally grown solution that we all participated in. It brought with it, though, some high degree of anxiety and fear, and in the end I think it's rolling out to be something that the community has wanted for about 10 or more years and is beginning to see the fruits of.

Certainly it's the intention of the government in this legislation to allow local areas to decide for themselves what the MSA will look like, who it will include and how it will deliver services, all those kinds of things. And yes, that's pretty risky business, but I think, given the experience of the hospital restructuring that happened here and the fruits of that, it's worth it, don't you think?

Mrs Walton: If I could just add one other point, it was risky and it was something that the community wanted and it was necessary, and because of those reasons and because it was a community risk-taking for a community need, yes, we participated. Change at any point in time is very difficult, but I think you're hearing from a large majority of communities that they really don't want to take this risk within their community. Communities are being asked to solve the problem that's being imposed upon them.

Mr Martin: Actually, we're not hearing from large groups of communities that this is not something they want. Everybody wants the system reformed; they want improvements in the service. What we're hearing from are groups that are going to be directly affected, such as the groups that came into my office when the hospital restructuring was happening and who had some concerns because they were going to be directly affected. They were concerned about their jobs and where they fit in and all of that kind of thing, and it comes with this kind of a process.

So I would suggest to you that this community is involved in this process. There is a coordinating function happening, there are people meeting. As a matter of fact, there will be a group coming later who will talk a bit about the meetings that have been held. There have been a lot of people participating, and I think there is an indication that this community wants to be part of this change, wants to be able to take advantage of the new moneys that will flow to this. We've put $850 million of new money in already and there's more coming.

Are you participating in that local planning process? Are you on that committee? Is your group on that committee?

Mrs Walton: I sit on the long-term care committee at district health council.

Mr Malkani: If I can just add to what Laurie said, and again using the restructuring of our hospital as an example, as you know, there is a model framework put forward by the Ministry of Health as to how communities should approach the restructuring exercise. Our approach in Sault Ste Marie was quite different from that. As you know as well, it has taken a lot of effort, and with a lot of help from you, to get the ministry to recognize that even though our approach may have been different from the model prescribed, the results are at least as good as, if not better than, what has been achieved in other communities.


That really is the fundamental premise that we're putting forward: Leave room, in whatever we do, for locally made solutions. The problems may be common but we have a "made in Sault Ste Marie" solution over here, and we think it's best for us. It may not be best for Chatham or somebody else. Similarly, with long-term reform as well, we agree with the objectives but we feel the framework being prescribed in the legislation is a bit overly prescriptive and might dampen some of the initiative at the local community level.

Mr Dalton McGuinty (Ottawa South): Thank you very much for a very good presentation. I think you have clearly articulated for us the essence of the problem, one of access, and the difficulties associated with the government's response to that problem.

If the hearings have emphasized anything for us, it's that there is a tremendous concern about what is going to happen to all of our volunteers working throughout the province in long-term care. I don't have any numbers on this but I would guess that at least 25% of the work that is presently being performed within the umbrella of long-term care is being done by volunteers. It may be much higher. I think on page 6 you've quite aptly highlighted some of the concerns connected with that.

I think you either have to be terribly naïve or wilfully blind, that volunteers who do work for individual organizations now are somehow going to transfer that loyalty to essentially a government agency. Human nature dictates that we are loyal to organizations because they have heritages, they have traditions, they have logos, they have mottos, they have uniforms, they have special missions. You contrast that with government today, and politicians and political institutions: We are suspect, we are treated with scepticism. That may not be right, that may not be healthy, but that happens to be the God's truth, as I see it.

The other problem with government is we're so concerned with political correctness that everything has to come out a shade of grey and we're dishing up pablum. But people need distinctive features. That's what attracts them to the various volunteer organizations. I just have some very great concerns about what's going to happen to those volunteers, and I think it's simply unreasonable to expect that they will work for a multiservice agency. Would you care to comment?

Mrs Walton: I think you're absolutely correct, and my understanding of the brief that was put forward by the Catholic Health Association says it all in relation to volunteers. It's our tradition and our understanding that a lot of people are tied into the heritage and not necessarily the service. The people who come daily to the local hospitals -- and they come twice a day; these people come around lunchtime to help feed patients and come back around suppertime to again look after their relatives' needs -- it's a tradition that they keep up for years and years. They do it because they have a close connection and they believe in the work we're doing and they're very grateful for having that service provided for their relative. So even at the direct care level we have volunteers who are coming because they believe in the organization and the values of that organization. Then at board level we have all kinds of volunteers, and even at DHC level you have all kinds of volunteers who are doing a lot of the work.

Mr Malkani: When we talk about the effect this might have on the volunteer effort, admittedly to some extent we are crystal-balling, we are anticipating what may happen. I don't think that any changes are going to happen in a black-and-white fashion overnight, but I think there is a risk that over a period of time, as the perception gets reinforced that long-term care is now a government responsibility provided at taxpayers' expense and so on -- rightly or wrongly, I think the model will foster that perception, and that will then begin to erode the extent of volunteerism.

Mr Wessenger: Thank you very much for your presentation. What would be certainly very enlightening to myself and I'm sure other members of the committee is if you would elaborate somewhat on your innovative partnership. Particularly, I'd like to know how you model your governance, the question of how the board works to make decisions, for instance, to give to management, and the extent to which you have your administration functions integrated in the new system. Lastly, I don't know whether you're in a position yet to indicate perhaps the level of efficiencies you've achieved in the sense of savings in the administrative functions that could go into service provision.

Mr Malkani: The model as we described it in our presentation is one which allows the two hospitals to carry on as separate corporations with two separate boards of directors, but at the governance level there is a new mechanism built in. Again, depending on whether you want me to get into details of that mechanism, let me just say for the time being that that mechanism binds both boards to a common approach on certain very key issues. The bylaws of the hospitals have been rewritten and approved by the Ministry of Health to allow that to happen.

The general hospital is a Catholic hospital, owned and operated by the Grey Sisters. The Plummer hospital is a public hospital. This arrangement came about through the recognition by the boards that although there were some differences between us, the similarities were greater than the differences and we needed to find a way to get the best of both worlds.

So we preserved the independence, we preserved the traditions, as we say, and the culture of each, yet we've come together through a binding mechanism. Neither board can "wiggle out," I guess is a crude term for it, of this commitment. We are bound to a common cause on a number of important things: decisions such as programs, who will do what, decisions about the budgets, decisions about hiring and firing the CEO. Those kinds of questions are pretty fundamental issues and all are bound to a common approach through that new joint mechanism.

Now, keep in mind that the boards don't cost any money; the boards are volunteers. So the fact that we have two boards, the academic question is, aren't we still duplicating things? Yes, we are, but to me that cup is half full rather than half empty, because we have twice as many community agents with their fingerprints on what's happening, rather than with a single board.

The expenses, the costs, are at the management level, at the operating level. Twelve months ago we had two CEOs and two VPs of finance and two directors of housekeeping and two of everything else. Today we have one of each and we are on our way to having a single laundry, a single kitchen, a single emergency department. What we have achieved in the last 12 months has been a direct saving in our expenses, in our management and overhead and infrastructure costs, of approximately $2 million on a budget of $87 million. Those are cold, hard numbers. That is money that would otherwise have to be found elsewhere.

That's a thumbnail sketch of what we've done and how.

Mr Wessenger: That's very interesting. I appreciate that.

The Chair: Thank you all very much for coming before the committee this morning.


The Chair: If I could then call on our next presenters, from the Algoma and Sudbury branches of the Victorian Order of Nurses. Welcome to the committee this morning. We appreciate you coming together and also presenting a joint brief. If you'd be good enough just to introduce yourselves. We do have a copy of your submission before us.

Ms Sharon Baiden: Good morning. On behalf of the Victorian Order of Nurses, Algoma branch and Sudbury branch, we are pleased to come before the Ontario Legislature's committee on social development. Bonjour. Nous allons lire cette présentation en anglais, mais si vous voulez, ce texte sera disponible en français.

My name is Sharon Baiden, executive director of the VON, Sudbury branch. With me this morning are Cheryl Sullivan, assistant executive director, VON Algoma, and Charlene Brown, the nurse manager with the VON Espanola suboffice. Together we wish to share with you a joint perspective from the area served by our branches.


VON welcomes the opportunity to come before your committee today to comment on Bill 173, An Act respecting Long-Term Care. Our presentation will specifically respond to the approval and regulation of agencies for the delivery of a wide range of community services, the designation of approved agencies as multiservice agencies, the bill of rights for persons receiving community services, and the various statutes dealing with long-term care.

At the outset, we wish to commend the government for demonstrating ongoing commitment to involving stakeholders, volunteers, consumers, service providers and others across the province in health care reform. Again today you have shown your willingness to consult with the people through your visit to the Algoma district and your invitation to VON to come before you.

Ms Cheryl Sullivan: I'd just like to give you a bit of background. The Victorian Order of Nurses is a national charitable organization dedicated to providing health and related services to communities across Canada. As a major provider of nursing and other services in the home and community, VON believes that individuals have primary responsibility for their own health. The maintenance of health directly and positively affects the quality of their lives.

VON believes that the value and the dignity of human life is respected. Individuals have the right to accept or refuse health care, to obtain information about their health and health care, and to participate with health professionals in making decisions about and plans for the provision of their care. Individuals and families are supported so as to enable them to live and to meet death in comfort and with dignity. VON believes that access to comprehensive, compassionate, family- and community-centred health care is the right of all individuals regardless of their ability to pay.

Health care providers collaborate to develop, implement and evaluate services which respond to the expressed needs of individuals, families and communities in keeping with the principles of primary health care. Volunteers make a valuable contribution by extending and complementing the services provided by health professionals. At the local and provincial and national levels, volunteers help to identify the needs, formulate policy, plan and promote, support and provide community health services. Community health services of assured quality are essential. VON has a responsibility to expand knowledge through ongoing research, program evaluation and education.

VON believes health is a resource for everyday living, an essential dimension to the quality of life. Health gives people the ability to make choices, to gain satisfaction from living and to manage and change their surroundings. As a non-profit registered charity, the VON works collaboratively to assess needs and to assist individuals in the planning and development of services to meet their needs. Charitable services are developed and delivered based on identified needs.

Fund-raising is an essential part of our charitable services. Fund-raised dollars are often used to develop demonstration pilot projects which prove the value of specific services. Such services may go on to become core services, part of the universal health system. Other charitable services will complement and enhance core services.

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

Volunteers are essential to VON's ability to achieve our mission. Trained volunteers are critical to supporting professional providers and family members in an environment where high-quality, cost-effective services are necessary. Both VON Sudbury and VON Algoma offer services delivered by volunteers.

VON employs a range of professional, para-professional and support staff in the delivery of community-based services.

Over the years, VON has kept up to date with technological advances and has continually developed a diversified service base. We work to ensure a multidisciplinary team approach to assess needs and to develop care plans in partnership with consumers. VON recognizes the need for consumer involvement in care and has encouraged mutual participation of family and other providers in the planning of care around identified needs.

Family and other care giver involvement is vital to all aspects of service provision. Through teaching and support, members of the team have developed skills to manage the elderly or chronically disabled. Our staff, volunteers and board members "care for life through respect, participation, responsiveness and courage." These are VON Canada core values. Practices are guided by the VON Canada mission, goals and objectives to ensure the maintenance of professional and administration standards.

VON Algoma and VON Sudbury cover a vast geographic area. Our branches have worked closely with the community to identify needs for services and to develop programs to meet these needs based on geographic and demographic considerations. Most recently, the Minister of Health appointed VON Algoma and VON Sudbury as joint sponsors for the establishment of a regional pain and symptom control community resource team. This program will serve all communities within the entire region.

Ms Baiden: Our primary service has been in-home visiting nursing, with an ever-expanding role as needs of consumers have changed and the focus to community-based health care has increased. VON has noted a shift in complexity of needs to include high-level assessment and speciality skills in such areas as palliative care, chronic debilitating illness, infusion therapy and pain management in both acute and long-term care conditions. The evolution of such services has provided an appropriate alternative to hospitalization and/or long-term care facility placement.

VON services are provided to all age groups, with the majority of consumers being the age of 65 and older. Maintenance of health and restoration to optimal levels of functioning through teaching, wellness promotion and supportive care are the aims of VON programs.

VON services are provided within a continuum of a quality management philosophy which incorporates a cost-effective approach to service provision. Within this framework, services are provided at the right time, in the right place and by the right provider. The approach is a consumer-focused process which centres around achieving outcomes that consumers feel meet their individual needs. Consumer choice is promoted, and participation in decision-making through involvement in care planning and goal setting forms the foundation of the service plan.

Ms Cheryl Sullivan: The programs presently offered by each branch include: in Algoma, visiting nursing, enterostomal therapy, shift nursing, palliative care specialty nursing, pain and symptom management, hospice volunteer visiting, placement coordination service, foot care, diabetic educator services and intravenous therapy; in Sudbury, visiting nursing, early postpartum discharge, palliative care, pain and symptom management, shift nursing, diabetic educator resource, foot care, adult day care, placement coordination service for Sudbury and Manitoulin, home support program in Espanola, insurance company assessments and hospice volunteer visiting in Espanola.

Our future directions include new and expanded community-based programs to meet the challenges of promoting a healthier and more independent population. VON looks to the future as an integral partner in the reformed long-term care system to ensure consumer focus and participation, simplified access, an improved community-based service system, accountability to all areas, and planning through district health councils.

Since June 1990, VON has carefully considered the government's proposals for reform of the long-term care system. Through the changes in government and the ongoing review of the long-term care system, VON has been involved in discussion and response to the proposed changes, including a formal submission on Bill 101, An Act to amend certain Acts concerning Long-Term Care.


Bill 173, purposes of the act: VON supports the purposes of the act. As an organization with a history of providing community-based, long-term care and support services for elderly persons, adults with physical disabilities and persons who require services at home, VON welcomes the creation of a new legislative framework for planning, managing and delivering community services. Over the years, VON services have expanded to provide a comprehensive range of services at home and in the community.

VON strongly endorses equitable access to community services through the consistent application of eligibility criteria. Flexibility in the model will be essential in ensuring the needs of each community are met. Innovation in service delivery is necessary to recognize unique consumer needs.

Efficient management of human, financial and other resources will be a critical success indicator. Resource utilization should be based on sound research and contain measurable outcomes, as determined by local communities in their development and evaluation of MSAs.

Given that communities will develop a model that best suits their needs, the potential exists for lack of standardization around services and programs throughout the province. We believe that it is crucial that in a flexible system of service delivery, a standardized approach to evaluation of the identified outcomes be developed to determine the effectiveness of any given model.

Measurement against a baseline criterion will allow for maintenance of local autonomy and the availability of core services on a province-wide basis, while ensuring key standards are met. Measurement and evaluation of services against standards and outcomes are an integral part of VON's business practice and are essential in quality management. Quality must be achieved in a cost-effective and efficient manner ensuring continuous improvement.

Ms Brown: Interpretation: The definitions as described in the act serve as useful clarification in a number of areas. Both consumer and provider involvement are essential in the development of the MSA. VON is founded on local community boards to achieve planning, monitoring, accountability and delivery of services, in partnership with communities, clients, staff and other providers.

The bill of rights: VON recognizes and respects the rights of persons receiving community services, as described in the act. These elements are incorporated in VON's philosophy of service. An essential component of the bill of rights should be consumer choice surrounding service type, location or provider of services. At present, consumer choice is not clearly identified as being assured in the act.

Funding of services and approvals: VON supports the government's commitment to controlling health care expenditure. In managing resources, funds must be allocated according to strategic priorities, as determined by local communities. Caution is advised when considering the cost of the new system.

The MSA structure is a new concept with associated costs not known. Careful planning is necessary to ensure the goals of reform are achieved, while ensuring the rate of health care expenditure is controlled. Proven efficiencies must be noted in order to operate within limited resources. Where models do not demonstrate the ability to achieve the stated objectives of long-term care reform, a mechanism should be in place to mandate alternative service delivery models.

Providing services at home and in the community is a priority and is consistent with the government's strategic direction. VON notes, however, with concern that the legislation gives no guarantee of adequate funding for services to meet consumer needs. Consideration should also be given to assess consumer needs, demands and expectation and to balance service delivery on a funded or fee-for-service basis.

In consideration of MSAs, the number of standalone agencies needs clear analysis. In many areas of the north, small communities are looking for autonomy in the direction of their health and social services system. Some feel that separate MSAs for each community is the way to achieve this goal.

Movement in this direction could be the catalyst for the creation of a number of new agencies with layers of support and administrative functions that could significantly increase the cost of service provision. VON strongly urges consideration of satellite sites with a core of centralized support and administrative functions in conjunction with balanced representation at the board level in considering MSA services for areas with wide geographic dispersity.

Ms Baiden: I'd now like to speak to multiservice agencies as described in the act. Wherever possible, the existing strengths of agencies, services, and programs should be recognized and incorporated into MSA design. VON does not support dismantling the entire system, but rather suggests that weaknesses in the present methods of service delivery be identified and measures to improve such areas be developed. This will enable communities to move through the developmental phase of a multiservice agency with increased efficiency both from time and cost perspectives.

The VON proposes that an appropriate beginning to a multiservice agency be the formation of a federation of long-term care health and social service community agencies committed to working together towards the stated objectives of long-term care reform. This coalition would include the establishment of an advisory committee that meets the recommended composition of the board of directors as described in the act and provides the connection between agencies and their respective boards of directors in an advisory capacity rather than in a governing role.

The composition of MSA boards as defined in the act demonstrate a broad range of criteria that would most appropriately ensure balanced representation. MSA boards should include providers of health and social service agencies who have expertise in direct service delivery and other members of the community to whom the MSA is accountable. Included in membership to the advisory committee in an ex officio capacity would be representation from the long-term care division and district health council to provide information and advice throughout the development to a fully integrated model.

During this transitional development phase, local boards would retain governance and accountability to consumers and the community. Such a model would ensure effectiveness in terms of cost, service, and quality through well-developed management information systems using common data standards province-wide, allowing for evaluation, monitoring and measurement on quality management indicators.

In evolving such a model, VON recommends the development of a system-wide record and documentation scheme. This would promote the sharing and exchange of information on a timely basis and with minimal repetition and disruption to the consumer. Simplified entry, a long-identified priority for consumers, should ensure access to services in a timely, unencumbered manner.

We believe this will be achieved through an integrated service delivery model featuring one-stop access to the core basket of services by telephone or in person, referral of clients to an appropriate service type, staff or volunteer provider, allowing consumer choice. Health and social service agencies have the expertise and experience in serving and meeting consumer needs. Consumers view much of health care coordination and delivery of services to be governmental and bureaucratic. Involvement of existing community agencies avoids the creation of another level of government sponsoring the MSA.

To ensure that consumers have a smooth transition through services, linkages with member agencies must be developed in the area of information systems. Rapid transfer of information and referral data is essential to timely access to services. Many agencies have fully integrated use of technology in their management of existing case loads. Again, present structure should be evaluated and built upon to avoid duplication and/or rework.

Volunteer involvement and participation in multiservice agencies is critical. Many have already indicated that they are not interested in volunteering for the government, hence further rationale to support a partnership model of community agencies where volunteer involvement is extensive at present. Given the already stated value of volunteers and the need for fund-raised dollars, the legislation should clearly state the preference for a not-for-profit registered charity as the sponsoring agency.

During the transitional planning period, the partnership of agencies will work towards the mutual identification of a sponsoring agency meeting these criteria which will ultimately become the fully integrated MSA model.


Ms Cheryl Sullivan: With regard to the rules governing the approved agencies, as stated in the act, the rules outline protection for consumers of services and ensure involvement by consumers in the development of their plan of service. Protection of consumers should also ensure that there are no waiting lists for core services from the MSA. With capped budgets and no alternative service available for consumers, MSAs may be prone to waiting lists. Placing consumers on waiting lists for core services could put consumers at risk and potentially increase their rate and frequency of admission to hospitals and/or long-term care facilities.

VON supports an assessment process that could be initiated by a client request for services, such as Meals on Wheels or home support. Further, with respect to eligibility determination, VON supports the need for an eligibility test.

VON is, however, very sensitive to consumers' common complaint that the present system is rife with unnecessary and/or duplication of assessment. The act would seem to continue this bureaucratic rigidity. VON proposes a less obtrusive system of self-reporting and eligibility, and self-application for services when this is possible. The development of a common assessment tool would assist in alleviating this problem.

In general, VON is concerned about the direction of the legislation regarding compulsory needs assessment by MSA staff for eligibility for all services. Assessment and service planning, as described in the act, should be utilized for more complex cases and clinical skills. Centralized telephone intake utilizing a risk screening tool could allow for separation of clients into those needs which require no further formal assessment or service plan. Others could be referred for more in-depth assessment. As previously proposed, electronic databases within the MSA on line with providers would aid in preventing duplication of information and assessment.

Rules governing service providers: VON fully supports the consumer's right of complete access to personal records, as indicated in the act. For approximately three years, VON records have been in the consumer's home. This has given consumers the right to document information on their record and to contribute to their own care plan. VON believes that the information in the record belongs to the consumer. Consumers further have the right to a copy of the record on request. The original belongs to the agency. In a multiservice agency, there should be one common record for the consumer with all providers of care having the responsibility of utilizing and contributing to a common record integrating consumer involvement and input.

With VON records being located in consumers' homes, we have recognized the need to protect individuals from accessing certain information and, thus, we support the process as outlined in the act for dealing with sensitive information.

Appeals: A process for appeals is a critical component to ensure that consumers have an avenue of recourse whenever there is a disagreement around the service being provided, denied or withdrawn. Again, this ensures consumers' rights regarding services. We strongly emphasize and support the need for timely appointment of dates for hearings.

Revocation and takeover powers: Revocation or suspension of approval of an agency is supported as another mechanism to ensure protection to consumers and compliance to standards.

Other issues and concerns: Given the diversity of Ontario in terms of geography and present service availability, the legislation needs to recognize unique challenges and dimensions to service delivery. The focus should be on ensuring core services are available and protected, avoiding bureaucratizing the MSA and allowing communities flexibility to design the MSA appropriate to meet their needs.

If the model for an MSA -- multiservice agency -- that evolves is one that includes the merger of existing agencies, VON urges the government to consider the needs for all employees in terms of fair and equitable opportunity for employment in the MSA. Such protection should be afforded to staff regardless of affiliation with unions. Employees represented by a bargaining agent have been afforded protection through the successor rights under the Labour Relations Act. Similar protection should be afforded to non-union workers affected by mergers in an MSA. VON recommends that the legislation be amended to contain a clear statement to this effect in order to provide for equal opportunity for all employees accessing jobs in the MSA.

In the event mergers result in severance of workers and other outstanding liabilities, such as with property, the government should provide funding to offset these costs. Presently, not-for-profit agencies, which deliver a vast majority of community-based services, do not have the resources to pay severance. In VON, surplus moneys have been returned to government or reinvested in the community to enhance service delivery.

The government has recognized that many charitable organizations are supported through donations and other sources of funding, such as United Way. In order to ensure the much-needed contributions to the charitable organizations, the MSA must be a charitable agency.

VON strongly believes in building on the existing skills and experience already in the community. Such a system is characterized by highly regarded health and community support agencies, volunteer commitment to and identification with these agencies, and the charitable, non-profit service offered in addition to government-funded services. The challenge is to achieve redirection goals building on the solid foundation of today.

In listening to consumers, communities, health and social service providers and health planners, VON has concluded that there is strong support for the redirection goals of easier access to comprehensive and expanded services in the home and community.

Ms Baiden: I would now like to conclude our remarks. Our presentation today has attempted to highlight the changes needed for a sustaining system for community-based health and social services. As noted throughout our brief, the legislation addresses several areas for change in reforming the long-term care system.

To summarize, VON suggests the following areas be considered for revision in the act, as presently stated, including the following: Greater flexibility in the model for consumer access to services; development of provincial standards for delivery, monitoring and evaluation of core services; assurance of consumer choice; mandated alternative MSA models if objectives of long-term care reform are not achieved; guarantee of adequate funding to meet consumer needs.

We propose the consideration of transitional planning MSA model consisting of a coalition of existing health and social service agencies as an interim step in determining a final MSA model; a stated preference for a not-for-profit, registered charitable agency as the sponsor for a fully integrated MSA; mechanisms to ensure no waiting lists to core services; client-initiated assessment to allow for self-referral/self-reporting for services when possible and as appropriate; mandate to ensure the development of a common assessment tool and client record between agency service providers; protection of workers regardless of affiliation to bargaining units in the event of agency merger; in the event of agency mergers, stated protection in the act for severance and other liabilities.

VON is a respected, cohesive organization in which all members of board, staff and volunteers are committed to realizing the vision of health care for the province of Ontario. VON believes that the valuable skills, experience and innovation all community-based agencies, that for so many years have made significant contributions to communities, should be recognized, respected and further promoted.

Change must be well planned and integrate the strengths of the current system. The guiding principles of long-term care reform parallel VON's core values and fundamental philosophy. VON is committed to providing leadership through the transformation of our health and social service system.


Mr Gary Malkowski (York East): Thank you very much for your very comprehensive presentation that raised both concerns and suggestions.

One of the comments that I have heard from a variety of organizations is the issue or concern that's been raised about volunteerism, as well as talking about a guarantee in terms of at least a minimum of service being provided, that there be standards. I'd like to hear your comments just in terms of volunteer issues. Do you see that the legislation should include some sort of coordination in terms of volunteers so that there is a way that we can make sure that the volunteer is recognized for the work they've done, but also that we can somehow make sure they're maintained in the system? As well, how do you see both the coordination of volunteerism, as well as the issue of fund-raising?

The second point is just the issue of the guarantee of services. Do you feel that within the legislation those services that are listed do in fact guarantee a minimum of services across the province? Would you see any concerns in that? Maybe you could make some comments on that.

Ms Baiden: I'll respond to your first comments and questions around volunteers. I think you've mentioned some very key words, that being recognition.

One of the very significant areas that we find in VON is the very significant contribution that volunteers have made to a number of the services and programs that we offer from a governance standpoint as well from a direct service standpoint, and with that there has been significant need to recognize the valued contributions. What we're hearing from many of our volunteers is that by some of the proposals that are being suggested through the establishment of a multiservice agency, the very critical role and function of the volunteer is being lost.

From the point of view of fund-raising as well -- you had a question about fund-raising -- again, many of the volunteers are committed to the philosophy of VON by way of its charitable work and feel very committed to giving of their time to fund-raise and invest their time for dollars that are ultimately going to come back into their own communities.

You've also asked about the need to have a clear identification of the necessity to coordinate volunteers. VON has developed a number of programs whereby volunteer coordination has been a very integral part of the success of the volunteer work. Some of our VON branches have up to 100 volunteers, and so the point you raised around the need for coordination of volunteers is very valid and our hope is that the legislation would clearly recognize the work of the volunteer and as well have some stipulation that there would need to be resource to coordinate the work of volunteers.

I think the second question that you asked was around core services, and I'd need clarification on that question, if you don't mind.

Mr Malkowski: The legislation right now does reflect a guarantee of a minimum of services throughout the province, of core services, but you talked about, for example, making sure that waiting lists didn't come into existence because of the MSA being in place. Do you think, the way you read the legislation right now, that in fact a guarantee of services is entrenched in the act?

Ms Baiden: I think, in reading the legislation, it's not clear as to whether or not core services will be guaranteed in every community and the extent to which those services will be available. In some of the programs that we've seen kicked off in the community over the last few years, the services very quickly are identified as essential services, consumers seek to access those services, and it seems to be no time before they're full and we then see waiting lists.

I can speak, for example, to a home support program that we run in a small rural community, and it's a community that is budgeted, based on limited and capped hours. We do see the establishment of waiting lists and that's been necessary in order to manage to available resources, but we would like to see some type of assuredness that waiting lists for this kind of service would be alleviated, and not only through the assurance that the core service be there but the assurance that there's resource there to support the core services as well.

Mr Malkowski: Just on a point of clarification, Mr Chair, can I ask counsel to clarify the issue of minimum services being provided throughout the province. Could you just clarify that?

Ms Gail Czukar: The act requires that each MSA provide or ensure the provision of the mandatory basket of services, and that is the way the act guarantees there will be a minimum level of service in each community where there is an MSA, because they're required to provide those services.

In terms of standards and so on, there is the power to make regulations regarding standards of service delivery and so on, which I believe the presenters have addressed as well, and those will be put in place and there are currently program manuals circulating to that effect and so on.

Mr Malkowski: Thank you for sharing your feedback with us.

Mrs Barbara Sullivan: Thank you for a brief which really shows that you've gone from A to Z in this bill and considered the issues that your organization will face. I do want to point out, though, apropos of the last interchange, that in fact waiting lists are guaranteed. The services may be there but not in adequate numbers to ensure that they're provided in a timely fashion. What is guaranteed to the person is that they are put on a waiting list.

But I wanted to go to something that's really a core part of your brief. Your brief indicates, in fact, that the VON is supportive of a federated model and not of a monopolistic model. The federated model that you see would retain the spirit and the special mission, the expertise and a fairly extensive amount of the infrastructure of existing agencies; that would be integrated through a coordinating body. We could call it an MSA, but that would be the coordination. That model is precluded under this legislation. That model cannot take place under this legislation.

So what that leads us to is a number of labour adjustment issues including severances, including benefits interruption, including questions of wage parity, including pension plan changes, and the questions of worker protection which, in fact, you've raised in your brief.

The ministry committed the other day in our hearings that the government would pay for severances for people from your agency, by example, who were made redundant as a result of the new MSA. It seems to me that it's kind of foolish for the government to be putting money into paying severances to people who work in an existing agency, who are providing services which meet the needs of the community. The government might have to take over capital assets or purchase capital assets from organizations like the VON and so on, instead of putting that funding into incremental services that are required to meet the needs of the community or into ensuring that the coordination of existing services, as you've recommended in the federated model, is in fact put into place.

I'd like to ask you two questions. First of all, do you think it makes sense for the government to be putting money into labour adjustment questions when service needs are still very much in existence? Secondly, do the people who now work for the VON in Algoma, in the Sault, in Sudbury, in Manitoulin really want to work for another organization that really is a government agency, no matter how you cut it?

Ms Baiden: I really appreciate some of the comments that you've made. One of the things that I'd like to clarify was in some of your initial comments around the MSA being a federated model. The proposal that we've suggested today is to establish a federation or a coalition of agencies very much as a transitional approach to developing a fully integrated MSA. In doing so, part of the hope would be planning around -- in the event, the agencies that participate in that kind of model, through its evolution and streamlining some of the processes and getting a better handle on admissions etc, may find ultimately that is the way to go and that it works well. It's just that we have a system that needs a lot of improvement. Once those agencies start working together, it may become clear that it would be helpful to amalgamate some agencies or to ultimately have one sponsoring agency.

So to be clear, we're not proposing a federated model at the end, but rather a transitional kind of model.

Mrs Barbara Sullivan: But could I point out to you that you have no option for a federated model. Even if that meets the needs best in your community, there is no option under this legislation for a federated model ever to be put into place. You must go to the monopolistic model after four years of the transition period.

Ms Baiden: I guess then, just to respond to that, our hope is that there will be some flexibility on that whole question -- I know right now the legislation is clearly precluding a federated model -- by way of our proposal to have the legislation give consideration to this as a potential model. I think right now because we're talking about a model that hasn't been tested in terms of efficiency across the province, so that we would look to this to really be a means of bringing the key players to a common table to talk about and debate some of the problems and to ultimately improve the system by way of some of those key areas.


Specifically, you've asked some questions around the government's commitment to funding liability, particularly around severance. In VON, some of the other liabilities that we have identified are things such as our occupancy where many of us are committed to long-term leases, but through the transitional planning period, there would be the opportunity to be planning for the transition of staff, if that's the way it goes, such that the liabilities in terms of severance would be minimized in that staff would be transferred, but some of the very key concerns we have are around the liability that would be posed in the event of jobs being eliminated.

Mr Jackson: Sharon, how many employees are currently with VON Sudbury?

Ms Baiden: Just over 200.

Mr Jackson: And the work you do, have you any estimate of the amount of displacement that could be created if you don't win in a lottery of services from your MSA?

Ms Baiden: In terms of displacement, I would see that the services that we provide are essential -- we're meeting a need -- so under the MSA model, our view is that many of the services that are provided by our staff will continue to be provided by our staff, and we would certainly advocate that our existing staff continue to be the providers of service. Is that what you're getting at in terms of displacement?

Mr Jackson: Well, no. Virtually every group except for you have said there will be large displacement because of the 80-20 factor. If they consume all of your services, you might violate the 20% rule, so the chances of you surviving that lottery are between zero and nil. I'm just simply asking if you as an administrator have taken a step back and looked at what life might be like a year or two years from now in terms of not your workers but your agency. Those workers are going to be doing most of the work, there's no question about that, but I assume you're unionized? You're not unionized? What are you?

Ms Baiden: We're both.

Mr Jackson: You're both?

Ms Baiden: We have registered nurses represented by the Ontario Nurses' Association, and our registered practical nurses in the Sudbury branch are not represented by a bargaining agent, but in the Algoma branch our PNs are represented by the Practical Nurses' Federation, and in Espanola none of the nurses are represented by a bargaining agent.

Mr Jackson: So there could be a breakout at various ways depending upon the MSA's attitude towards hiring from a unionized base and a non-unionized base.

Virtually every group in the north is informed of huge displacements of staff. Some of them may get their jobs, but they won't be working for that agency, and I just wondered what position that puts your agency in.

Some are indicating that 90% of their activities are contained within this legislation; therefore they'll cease to exist. Some are saying a good 60% of their activities when -- some of the Catholic service agencies that are tied to facilities, their adjustment is in a different framework, but VON is not associated with a given facility. A long-term care facility is a standalone, community-based support service, so you're 100% affected by this legislation would be my awareness of VONs in some of the presentations around the province.

Have you not given any thought to what would happen to your agency? Your parent association has pretty well concluded some things and shared it with this committee.

Ms Baiden: Thanks for the clarification. In terms of displacement, probably 95% of the services that VON is presently providing are services that would fall within that core basket of MSA services, so in terms of displacement, there would be the potential for our workers being displaced to another employer, that being the sponsoring agency, the MSA. I guess, as we have indicated during our presentation, we don't feel fully committed to the notion of dismantling the existing system and having agencies such as VON, Red Cross etc, collapse under the MSA and being absorbed or consumed by the MSA. So taking the extreme that that happens, the majority of our workers would be displaced.

Mr Jackson: Finally, there is a proposal before the minister which is receiving some favourable response with respect to an MSA in Wawa. Have any of you been familiar with or participated in development of that model, and to what extent has that -- and I haven't seen that plan. We've requested a copy of it and we'll receive it soon, but until I see a copy, I need to rely on some feedback in terms of how VON participated in the development of that model and the comfort level of VON with respect to the ultimate model and how it's been presented in the shape and form in which it's now before the government.

Ms Cheryl Sullivan: In terms of the development of the model, we are aware that it has been developed. We have been allowed to sit on certain committees, mainly in a listening capacity. It's my understanding that there's a real possibility that the VON, as it is now known and working in Wawa, would not exist.

The Chair: We will have to move on. The parliamentary assistant had a last comment and then we'll go on to our last witness.

Mr Wessenger: I'd just like to thank you, first of all, for providing us with an excellent brief and also an individual perspective, which is something we don't get that often. It really is appreciated. Just to clarify a couple of points: First of all, with respect to the question of involving waiting lists, as you know, there'll be eligibility criteria provided for who gets the services and also criteria for prioritizing need. Hopefully management will minimize or eliminate waiting lists. The other thing, just a clarification to indicate that the MSAs of course, as you know, are not government agencies but non-profit. I think most of your recommendation are just excellent.

Mr Jackson: On a point of order, Mr Chairman: I understand the process for this committee is a process of Q and A and presentation of questions and answers. At the point the deputants indicated that they had not seen the Wawa model, to have this sort of spoon-fed pap about how wonderful this bill is going to be --

The Chair: Mr Jackson --

Mr Jackson: -- in my view, Mr Chairman, that's not appropriate.

Mr O'Connor: Where's the point of order?

The Chair: Mr Jackson, that's not a point of order.

Mr Jackson: It's absolutely inappropriate.

The Chair: Mr Jackson, I'm sorry.

Mr Jackson: If you want to make this into a political forum as to what this bill is or isn't going to do --

The Chair: Mr Jackson, you're out of order.

Mr Jackson: -- it's simply a process to ask questions.

The Chair: No, Mr Jackson, that is not appropriate. Each member is free to ask a question or express his or her views on what has been said and each person will take what they wish from that.

May I thank the three of you for coming here before the committee and again for the brief that you presented. We appreciate it.


The Chair: I then call on our last witness for this morning, the representatives from the Algoma District Health Council. We welcome you to the committee this morning.

Mr Jim Dalgliesh: First of all, let me just introduce the people with me. Gil Contant is a provider member from Elliot Lake on the long-term care committee of the district health council. Valerie Scarfone is a provider member from Sault Ste Marie on the committee. Susan Van Atte is the health care planner for the committee. My name is Jim Dalgliesh and I am the chairman of the long-term care committee of the district health council.

Just to start off, we didn't come prepared today -- we got asked this morning if we could speak and we're quite happy to do that, rather than speak to the legislation which we hadn't anticipated speaking to, although certainly we can comment, I guess, to questions and answers after our brief presentation to give you an update of what our committee has done to date throughout the region and possibly to end on the challenges that we see facing the committee, if that's agreeable.

I will turn it over to Susan, our long-term care planner, to give you an update of our activities today.


Ms Susan Van Atte: The long-term care committee in the district of Algoma first met in February of this year. The committee has 24 members, a cross-section of consumers, providers and others from across the district, also representing a number of cultural and ethnic groups on that committee.

Some of the activities: As you know, there is a lot of information surrounding long-term care and one of the biggest tasks that we had to do was educate the committee and also the public in terms of what the policies and guidelines were.

One of our first activities concerned supportive housing consultations, and in conjunction with the long-term care division, which I should add has supported us in the planning process, we held a number of meetings in Hornepayne, White River, Wawa, Sault Ste Marie and Thessalon around that particular policy paper. We also used those meetings as an opportunity to provide education on long-term care in general.

We struck a number of subcommittees to assist the long-term care committee, and one of those was a supportive housing committee, which has sent out a call for proposals with a deadline of the end of September for new moneys that came our way in Algoma.

We recognized very early in the process that we are such a large district, and it was very difficult to conduct a planning process with one long-term care committee. We felt we needed to have advisory committees from different localities across Algoma and so we have long-term care advisory committees in central Algoma, Hornepayne and east Algoma.

We have struck a multi-year-plan subcommittee which has just begun to meet and is challenged with bringing together all of the information that we need to make informed decisions around the needs and priorities in Algoma.

We recognized early on in the process that communication was key to the success of the planning process in Algoma, and we have a communications subcommittee. We publish a monthly newsletter, and that is what we've circulated to you this morning. The newsletter appears monthly following our long-term care committee meetings, and it's distributed to key agencies and to individuals across the district to bring them up to date as to what we're doing. It's also published in French and in large print for those individuals who are visually impaired.

The committees: perhaps the majority of their activity has been around the multiservice agency development. We set out in early May and June to hold community meetings to inform residents of the communities across Algoma what the multiservice agency development was all about. We asked for their input as to what they felt would be the successful outcomes for an MSA, and also we began to have some dialogue around possible options for our district.

The meetings we held were in Hornepayne, Sault Ste Marie, central Algoma, Blind River and Elliot Lake. People were nominated from those meetings, along with key providers, volunteers and consumers, to come to what we called a pre-design multiservice agency workshop in the middle of June, and at that point we identified in more detail some of the successful outcomes that we needed for Algoma.

We also asked for input at those meetings regarding our planning process, and suggested a process that we would follow and asked for input and whether or not people agreed with the process that we had laid out, and we have since amended that based on the input that we received.

Regarding the multiservice agency, we sent out a call for ideas with a deadline of September 30 for more specific input around models, and we're awaiting responses, and those responses, in addition to meeting with providers and the meetings that we already have, will form the basis of a discussion paper which will go out for community consultation and have specific recommendations from the district health council.

There have been dollars made available for transitional stages in the multiservice agency development, and to date, we know that there appears to be interest from some of the providers in Sault Ste Marie and the providers in east Algoma to apply for some of these transitional dollars.

Now I'll turn it over to Jim, who is going to highlight some of the challenges faced by the Algoma District Health Council.

Mr Dalgliesh: The challenges that we foresee obviously include the geography of the Algoma district. It's quite large. The distance from the main population base of Sault Ste Marie is significant for meetings and for people to get in. Many of the individuals living in the district live in remote rural areas, which causes some issues on delivery of services and so forth. There's a lack of professionals in the remote areas. Many of them are based in Sault Ste Marie, which, once again, causes issues to get those services delivered close to home, and to attract professionals and retain them is another ongoing issue for this area.

Hornepayne, which is part of our district, is almost seven hours away from the Sault and receives services from Algoma, Cochrane and Thunder Bay, depending on the services being provided, and that has some unique challenges as well, to plan for that.

We are struggling right now with the providers wanting to move ahead with the transitional stages of MSA. We're very happy to see that they are moving forward in different regions in the district, working with other local providers in that area to put some ideas forward, but at this point the long-term care committee has not decided how many MSAs there shall be for community consultation, and therefore it's sort of difficult to provide advice and comment, as the local providers meet and get input from their local consumers.

That will be an issue we'll be grappling with, I think, in the next two to three months, as proposals start surfacing and as we, as a long-term care committee, start grappling with the economics of one MSA, two MSAs or three, recognizing at least the assumption that I think some of us make: The more MSAs there are, presumably the more administrative costs that will be incurred. That's an assumption at the present time. I think it's fairly valid, but time till tell. We're grappling with how to capture those costs as we're projecting our views on the administrative costs versus the individuals who might be managing or running those organizations in the future.

As I've heard just recently, there is the challenge of human resource changes, which is also very difficult for the providers to deal with and for all of us to deal with, the difficulties of keeping the communication channels open and dealing with people in other communities. The providers in the outlying areas, from Sault Ste Marie -- and they're not small, by any means -- feel that they have as much voice as some of the major providers in Sault Ste Marie. That's an ongoing issue for any service being provided in this region. We have a concentration of population in the Sault and also Elliot Lake, and somewhat in Blind River, but not as much, and we have to take that into account as well.

Our major task is a fairly heavy workload, we think, that is being asked of district health councils. It's certainly challenging. It's a real challenge for the volunteers who are receiving services or have family members receiving them, to educate and keep them informed and for us to get their valuable input, but it's a lot of reading for them and a lot of knowledge to obtain in a very short time, to ensure that their participation is valuable and worthwhile. We've had some comments from some of our consumers, as we sometimes slip into jargon, using health terms and so forth and then try and bring ourselves back to that.

Then, of course, the issue: Can we meet the time lines imposed by the Ministry of Health? That's always an ongoing issue for us.

Mr Chairman, those are the challenges that we see at the present time and we on the panel would be quite happy to try and answer any questions.


Mrs Barbara Sullivan: Thank you for the summary of the activities of the DHC with respect to reform of long-term care. I'm also particularly pleased that you've outlined the barriers or the difficulties in coming together with a plan. I think your underlining the effects of remote areas, of the geography and distance, of the economic issues and of the human resources issues are extremely important for us to understand this entire scenario.

I'm interested in the time lines you've talked about, particularly with respect to the MSA task force that you've undertaken. I understand from your scenario that you will be looking for a discussion paper for circulation some time late in the fall after the September 30 call for ideas. Subsequent to that, how long do you think it will take for the Algoma DHC to come forward with a recommendation with respect to MSAs and the appropriate mechanism, and then how long after that are you projecting that the MSAs would be up and running?

The reason I ask this question is that it's very clear that the government's intention is to go to the Legislature for third reading of Bill 173 this autumn, and the model you came up with, the model the community prefers, may in fact be precluded by the legislation that goes ahead.

Ms Van Atte: We originally felt that we would have some decisions, firm recommendations, possibly by the late spring, around the specific models that we could then submit to the Ministry of Health for approval. We really didn't anticipate that we would have a board in place until probably the end of 1995.

Mrs Barbara Sullivan: You have talked about the distance between your communities and the small areas which have to be incorporated into your design. If it's the view that a federated model, by example, of service delivery is in fact the most amenable to your community, what choice will you have then at the DHC latterly?

Mr Dalgliesh: Maybe I could comment on that and then maybe if someone else wants to comment. I think what's likely to happen, from my talking to different people and understanding of where I think some communities may be coming from, there's likely to be a request from the providers and possibly the communities for more than one MSA in the Algoma district.

One of the things we're looking at doing is trying to speculate, and that's all it is, on what the administrative costs are for one MSA versus more than one, and that seems to be one of the thrusts of the proposed legislation right now, to try and redirect money from administrative costs to direct service provision. I think it's likely to be that we'll have a debate on our long-term care committee as to how many there shall be. I'm hoping to focus the dialogue in that regard and come up with possibly some creative model that will meet the needs of everybody, but keeping the long-term administrative costs to what is intended; I guess to a lower minimum dollar amount than what is currently being spent.

Mrs Barbara Sullivan: In my own community we have a lot of pressure for more than one MSA and a second MSA would be located, by example, 20 minutes from the physical location of the first. You're dealing with quite, quite different scenarios. Hornepayne, I understand, has just contracted with the new primary care doctor for the next two years, seven hours away. How are you going to deal with that situation without incremental costs if there is more than one MSA?

Mr Dalgliesh: That's something we'll have to explore, obviously. I think there will be a push for more than one MSA and we'll have to see if that makes sense or not and come to a consensus as part of our process. I think the other issue that you've raised is the fact -- I have a sense, from the major providers anyway, in this community, there's a growing consensus to go to the federated model I think, which you indicated previously and which I'm aware of, that the legislation doesn't allow. We're certainly going to have some dialogue over that. I think it was wise to have access to transitional models. I guess where the real push comes is, at what point do you get out of a transitional phase, which right now is a maximum of four years, and get down to one larger agency?

At the present time, from my perspective as chair of the long-term care committee, we would be looking for some kind of commitment on proposals to tell us how that is going to take place, before approving requests for transitional models. I've had dialogue with some of the major providers in the community already in that regard. I think without that, you don't get some of the gains, as anticipated in the legislation right now, personally.

Mr Jim Wilson: Thank you, members of the district health council, for your presentation, it was most informative. I also appreciate the updates in terms of the newsletters that you've provided us with. I note in the first one that's provided, chronologically anyway, April 1994, there's a comment about how MSAs will be governed and it says that, "MSAs will be non-profit, incorporated agencies, operating at arm's length from the provincial government."

I'm just wondering if, after you've now seen and studied Bill 173, you still feel that MSAs are truly operating at arm's length, given that MSAs exist strictly at the pleasure of the Minister of Health and the government of the day. Their bylaws need approval, the makeup of the board's prescribed, services that are to be delivered need ministerial approval, the fees are prescribed too and how they can be collected. There's an 80-20 rule imposed. Eligibility criteria will be prescribed by the government, various notices that have to be provided to consumers are prescribed, recordkeeping and reporting are prescribed. In addition, there are 42 other regulatory powers. Now that you've seen the bill and studied it, do you still think these things are operating at arm's length, because this is the most bizarre arm's-length relationship I've ever seen?

Mr Dalgliesh: I guess I'll comment. I wouldn't disagree with the thrust of your comments, but I would frankly see that some other sectors of the health care industry, such as other aspects of long-term care, I don't think are that much different at the present time than MSA development. I think there are a lot of rules and regulations in health, in a lot of cases for very good reasons, I guess. If you're working in the environment you certainly may feel at times there are overprescriptive rules and regulations, but I don't see that much significantly different, as far as the control mechanisms for MSAs, as some other aspects of some other health services being provided. I'm just speaking personally now.

Mr Jim Wilson: Except that when we started in to long-term care reform and the consultations over the last couple of years, the sales job by the government I think left the impression that these would be far more arm's length, more autonomous and greater flexibility in local communities. Most of the presenters to date have indicated that there's not a great deal of flexibility.


Mr Dalgliesh: As I just reiterate, I don't think there's much flexibility in some other sectors of the long-term care either, from what I see.

Mr Martin: I want, as well as the others, to thank you for coming today and thank you for all of the work you've obviously done up to this point. I know it's a tremendous amount of time and energy and when, as you have stated, you consider the distance you folks travel to get to meetings and things like that, it certainly is impressive. And all of it, for the most part, volunteer. That's an interesting piece of this whole puzzle as well and I'll get to that in a minute.

I also want to thank you, Jim, for your letter suggesting that this committee come into the north. I don't specifically say Sault Ste Marie but I thought, since you invited, we try and get the group here. It's good that you came and we can hear from you, so thanks for that.

I wanted to follow up a bit on Jim's line of questioning, because I think it's important that this whole question of local planning, local control, local autonomy -- certainly Sault Ste Marie is not known to be a community that kind of rolls over and plays dead. I think over the years we've proven that we have a mind of our own and we're willing to stand up for what we believe in.

Certainly the group you've put together here that's in this pamphlet representing the area -- I recognize most of the people here and they are very highly motivated, self-driven and are going to make sure that we get something here that's going to be helpful to the region.

I wanted to ask you, re the legislation, we've been criticized as we've gone around the province for being too prescriptive; we've been criticized for not being prescriptive enough. Maybe that's good in that we hope to land somewhere probably in the middle, because I think it's important that we put a framework in place that will be helpful, as opposed to full of holes. I'd like you to comment on that.

With your experience so far of this process, do you think you're being allowed to make decisions that will in fact give us the best possible return for our investment in this area? The question of volunteers: Obviously, so far, this whole operation has been driven primarily by volunteers, the district health council is volunteer, your group is volunteer, and you talked initially about consumer volunteers on the group.

Do you think you'll be able to maintain that momentum once we get into the real, nitty-gritty MSA and down the line a ways?

Mr Dalgliesh: I think the volunteers certainly -- and we have some concerns about them as well. Keep in mind our volunteers tend to be -- some of them anyway -- not the healthiest individuals, and we've already had discussions after sitting for -- we typically have three-hour meetings, although we've had the one-day, all-day session. The one-day session was certainly a burden for some of them to stay tuned and so forth, so we have to be a little careful in that regard and we're trying to keep that in mind.

I think the volunteers can only go so far. We certainly want their input. As they receive services, they can tell us where the problems are and so forth and we can try and address that. I think some of the principles or major principles that the legislation is aimed at does this. I would indicate from my knowledge -- because I was on a long-term care committee, the old one, probably seven or eight years ago -- some of those principles, like one-stop shopping, have not been changed that much from back then under different parties in charge type of thing.

I think there's a clear consensus that some of those principles are very desirable to work towards. I think it's very difficult for the providers -- although I think the transitional process has given us some impetus to get together. My perception of providers locally and across the district along with the consumers is that we already have good relationships in place, people work closely together. I think this is quite frankly forcing people to work that much closer together, to contemplate such things as one chart, one assessment and so forth.

I think, all in all, it's certainly difficult to argue against the goals that are intended, but we've already had some consumers drop off our committee and subcommittees just because of the time commitment and their ability to travel because, as Susan has indicated, we have -- at least, Susan has and some others -- across the district and that's quite challenging for people to make the time. As a matter of fact, in the audience today, there's a good representation of the members of the long-term care committee. There must be at least half here in the audience, which I think once again indicates very good interest in your proceedings and in moving forward with the legislation.

Mr Martin: I just want to focus for a minute on this question of the interim and then the long-term MSA and the federated model that was proposed. You were here -- maybe you weren't -- when the hospitals came in and presented that they had found -- any of us who live in this community know that over the last 10 or 15 years there's been a big question about how we can amalgamate the hospitals. I think there were some who were convinced that it could never happen, but it did. A model was put together that seemed to fit the needs and the concerns of the people involved.

Is there any way in your mind, given the creativity and energy and intelligence that's on your committee, that we'll be able to find some way of incorporating, if not a federated model, at least something that will capture the essence of what's there already? This legislation is about building on what's already out there that's good. Is there any room there that you can see that would allow for some more creative model that might fit?

Mr Dalgliesh: I think the federated model, frankly, only gets you part of the way there, and having worked in one of the local hospitals for quite some time and having been through a number of the rationalization discussions, merging, amalgamation and so forth, I sort of think I have some insight into the pros and cons.

One of the things we've openly discussed, that I have raised with at least one or two providers, is right now I think the legislation covers unionized workers; they're basically protected. I think the VON, as I've read their brief previously, makes a very valid point: Why aren't the non-union people provided for as well? I think one of the sticking points, frankly, on moving from the federated model to a new entity, I would suspect, is the concern, and I think rightfully so, of the loss of jobs and careers of different individuals. I've raised it with a couple of people. What if locally we decided that we would guarantee there would not be loss of jobs, but we would do it over a period of time? This creates its own problems, quite frankly, in doing that, but that's one of the great fears. Of course, another fear is that different organizations that have long histories lose those ties as well.

Similar to the hospitals, at some point if you're going to move forward, you have to bite the bullet, so to say, and make some decisions.

The Chair: Thank you very much. I'm sorry, we're out of time, but on behalf of the committee I want to thank you for coming. It's been very useful, I think, to hear what you have been doing as a planning group and, as was mentioned before, we thank you for the newsletters that you have left with us.

In adjourning, if I could just remind committee members that we start again at 1:30. I also need to advise you that you must check out of your rooms here before we come back. So if you could just remember to do that, they'll look after the bags.

The committee recessed from 1209 to 1333.


The Chair: Good afternoon, ladies and gentlemen. I'll call the meeting of the standing committee on social development back into session. We continue our hearings in Sault Ste Marie. Our first witnesses for this afternoon are representing the Porcupine board of health and the Porcupine home care program, if I could invite them to come forward and begin their presentation. As you come forward, we're just getting a copy of your submission passed around, if you'd also be good enough to introduce yourselves for Hansard and members of the committee. Welcome.

Dr John MacIntyre: Thank you very much, Mr Chairman. My name's John MacIntyre. I'm the acting medical officer of health for the Porcupine Health Unit.

Ms Joan Cameron: I'm Joan Cameron. I'm the director of the home care program for the Porcupine health care unit.

Dr MacIntyre: Mr Chairman, we thank your committee for giving us an opportunity to meet with you today. The text of our presentation is in front of you and I'll essentially be following what we've prepared for you in writing.

We are here today representing the Porcupine Health Unit as a community-based provider organization, but we also wish to speak for the organization as a member of the community in the district of Cochrane. The health unit has been in existence for 50 years, with 24 years' experience in the development and delivery of in-home services.

The Porcupine home care program serves a population of approximately 94,000, with a central office based in Timmins and a network of eight suboffices located in major community centres across the district.

Our home care program includes placement coordination services as well as the delivery of acute care, chronic care, integrated homemaking and school health programs. Crucial to the quality and comprehensiveness of service provision in Cochrane district has been the close working partnership established among related health and social service agencies. We now maintain service contract agreements with 20 independent agencies and coordinate activities through functional relationships with several other volunteer groups and provider organizations in the community.

Notwithstanding the record of achievements to date, substantive reform in the delivery of community-based care is essential if our society is to be prepared for the future. Economic and social realities demand it. The question is not whether change is required, but what changes are necessary and what would be the best and most opportune way to proceed.

There is a risk, however, that in undue haste to change the system we overlook or even discard lessons from what has already been accomplished. In-home services in the Cochrane district have grown from inception in 1968 to a broadly based and highly adaptable service structure operating on an annual budget of $7.4 million. On a provincial scale, health units have overseen the critical early stages of program introduction and later years of expansion and innovation in 32 of 39 home care programs which now operate in the province.

All this was accomplished under a simple legislative mandate, "Every board of health shall superintend, provide or ensure the provision of...home care services that are insured services under the Health Insurance Act, including services to the acutely ill and the chronically ill." That's one sentence, and our working copy of Bill 173 runs to 53 pages.

If Bill 173 is indeed the answer, then we ask, what is the question and where is the evidence that such extensive and complex legislation is required to further the purposes of long-term care reform? We believe that much more can be gained without such an excessive degree of legislative intrusion.

It is almost as if the authors of Bill 173 are intent on re-creating the system from bottom up. Would it not instead be reasonable first to evaluate current standards in community service delivery and use this as a point of reference for choosing preferred strategies of improvement? If health units that currently manage home care programs are not to be that benchmark, then what standard of performance will replace them?

Section 11(3) of the proposed act relegates our health unit, along with all others in the province, to least-favoured status as an agency of last resort. We have been left only to guess at the reasons for this bias. Does the evidence available repudiate so completely the results in home care achieved under the direction of boards of health? It seems almost embarrassingly obvious that all across Ontario where home care programs exist, either alone or in conjunction with public health programs, multiservice integration of long-term care is already quite advanced.

In the press, in position papers and in public statements, generalizations abound. There's been a regular stream of criticism against poor quality of service, lack of coordination, barriers to access, inequity and administrative waste. The massive rollout of long-term care redirection has induced a wave of discontent, fear, anxiety and unreasonably high consumer expectations. A consulting group reports that administrative costs for certain programs around the province range up to 40% of total budget, and a cloud of suspicion hangs over all of us. There remains a pervasive sense of management incompetence, waste, duplication and provider ineptness on a scale that warrants radical and rapid restructuring of long-term care delivery.

If this truly represents the benchmark of performance, we agree that sweeping legislation is urgently needed. If otherwise, however, we would urge more patience and a more deliberate approach in evaluating and implementing options for long-term care reform at the local level.

The proposed act, quite correctly, builds on several goals and principles which are central to reform. Part I specifies that the main purposes for the legislation are to ensure that community services are available as a substitute for institutional care, to improve quality of community services, to respect individual autonomy, to simplify and improve access, to promote efficiency and equity, and to encourage community involvement.


The fundamental purpose of this act, of course, is not simply to declare the virtue of reform principles and goals. Rather, the act interprets reform principles by setting out a particular form, or the parameters to define the form, in which they are to be applied. Our community has barely begun to address the implications of different models of delivery for long-term care. It is premature, therefore, for the government to present draft legislation and expect to receive well-informed advice. We agree and re-emphasize that community involvement is the only guarantee of successful reform, but informed community involvement is just as crucial, if not more so, during the formative stages of health reform law as it will be after new legislation comes into effect.

To this point in time, our community has no framework for the evaluation of service outcomes as a test of different multiservice integration models, we have no standard measure of relative costs or method for understanding the relative advantages of various administrative structures, nor have we evolved a basic agreement among ourselves on the role and mechanism for ongoing community consultation, yet Bill 173 deals with all these issues and would lay the foundation for many years to come. We are told by the Ministry of Health, however, that the MSA concept will work, but is this assurance good enough in itself? Is it not at the very heart of community involvement that we as a community must believe it will work?

Before local communities can properly advise the province on a suitable legislative framework, one that will sustain the goals of reform well into the future, there are three aspects in particular of Bill 173 which require more time for discussion at the district level: One concerns the scope and practical effect of multiservice agency autonomy relative to the degree of central ministry control; a second pertains to the accountability of approved agencies for equitable resource allocation on behalf of the whole community, which has to be balanced against obligations to individual consumers; and the third concerns the concept of continuity of care in community-based services. Unfortunately, to date our community has not had the opportunity to hold thorough or well-considered debate in these areas.

Regarding local agency autonomy, it is instructive to compare Bill 173 with the mandate that has been vested in boards of health under the Health Protection and Promotion Act. Boards of health retain a wide margin of discretion in the design and delivery of mandatory health programs and services. Service standards from the ministry are issued in the form of guidelines, allowing choices to be made which adapt to local priorities, social characteristics and resource capacity. Relatively speaking, the concept of administrative control and accountability proposed in Bill 173 creates an immeasurable and worrisome potential for management by regulation.

We believe that local communities, through the agency of district health councils, must be engaged more fully on the issues of distribution of authority before a law is struck. Needless to say, whatever principles of governance are written into long-term care legislation, these will establish a precedent for accountability relationships in all other sectors of community-based care, including public health.

With the exercise of local autonomy there emerges a fundamental economic conflict between private and public welfare. Directly associated with this dilemma is the problem of defining a list of mandatory insured services. Obligations to the individual consumer cannot be open-ended. The law must constrain individual rights to maintain costs within affordable limits and ensure equity of access for the community as a whole. Granting legal sanction for waiting lists, as is done in Bill 173, is not the answer.

The complexities entailed in achieving equity of service, access and affordable coverage cannot be micro-managed through central regulation. Our community, however, is not yet ready to assume such responsibilities, nor are we sufficiently well informed to make recommendations on an appropriate devolution of powers to local approved agencies.

Moving slower with the passage of long-term care legislation will not mean that needed improvements in the system will suffer unacceptable delay. One needs merely to consider the intensity at which progress is now being maintained. For instance:

-- The Ontario Home Care Programs Association and the in-home services branch of the Ministry of Health are presently revising regulations, policy and procedure to provide more flexibility in the mix of services and extended hours for service, which together will result in better use of resources.

-- A patient management information system and ACCPAC accounting system have been installed across the province, promoting greater utilization and fiscal accountability.

-- Consumer representation has been expanded on various municipal planning committees, advisory boards and management boards.

-- The Porcupine public health and home care programs are collaborating in the development of a health information centre and referral service that will be run by senior citizen volunteers.

-- The long-term care planning committee for Kapuskasing and neighbouring communities has submitted a proposal for a 1-800 service to be operated by the Porcupine public health and home care office.

If the province truly believes that local communities have both the resolve and the ability to make wise decisions, then the results demonstrated thus far should persuade us that reform does not require immediate legislation. The essential conditions for change at the present time require a clearer mandate from the provincial government in support of the district health council role as a leader in local planning and negotiation.

Bill 173 introduces an amendment to the Ministry of Health Act which is supplementary in nature to the provisions for long-term care delivery. In fact, the relative importance should be reversed. Workable answers to the tough questions of social program delivery will be found where local communities hold themselves accountable for honest debate and dialogue. A reinforced mandate for DHCs should state that health councils have a primary accountability to the interests of their own community and that their role as advisers to the minister should be to advocate for the local perspective. Stable and steady progress in health system reform requires this expression of confidence in the local capacity for self-directed change.

In conclusion, we offer the following recommendations.

First, based upon the considerations previously presented, we maintain that Bill 173 is premature. It is therefore recommended that third reading of Bill 173 be delayed until specific regulations, program guidelines, policies, procedures and user-fee structure have been drafted and presented for consultation at the district level.

Second, given that the principle of community involvement depends upon having legitimate responsibility and a commensurate level of local authority in planning, development and implementation of health reform, it is recommended that the Ministry of Health Act be amended to mandate district health councils as planning and negotiating authorities within their geographic jurisdictions; to empower DHCs with fiscal responsibility to plan, develop and implement programs such as MSAs; and to provide adequate means with which DHCs may fulfil this expanded mandate.

Third, grounded in the knowledge that progress in long-term care must and can continue unabated without waiting on new legislation, it is recommended that service providers in each community place a priority on simplifying access to services by providing a one-stop information and referral system as soon as possible and that government commit the necessary funds to put this strategy into place.

Fourth, given the prevalence of misinformation, misunderstanding and confusion which now surrounds the purpose and promise of multiservice agencies, it is recommended that prior to establishing a provincial mandate for MSAs, a measured approach be taken for the development of pilot projects which can be properly evaluated.

Fifth, and we call this our recommendation of last resort, in the absence of reasonable justification to the contrary, we recommend that section 11(3) be deleted.


Mr Jim Wilson: Thank you for a submission that's full of common sense. I'm coming to the same conclusion that you're submitting today, and that is that the government really should take a break from these hearings and come back with a redrafted bill, because a number of the concerns we've heard throughout the province would require substantial redrafting and, in fact, reintroduction of a new piece of legislation.

I appreciate your comments with respect to asking the government at this time to take a step back from this process and allow local planning and local initiative to continue, because it really has started in a number of areas in the province, in most of the province. There are some areas, like my own in Simcoe county, where it's a bit of a dog's breakfast and I'm not sure how the government's going to get all the parties together. I think that mainly comes from morale being pretty bad there, and people don't like having a gun to their heads when asked to come together and cooperate on a so-called volunteer basis among agencies.

You call recommendation number 5 your recommendation of last resort. I think it's a good recommendation because I'm not sure why the government has a bias against boards of health, or municipalities in this case, other than they've made utterings that the construction of boards of health is not leaving room right now for consumers and that sort of thing. We do tend to forget, I think, that a number of people who are on boards of health are human beings and they're also consumers.

But would it be your contention there -- because I think the government sees this legislation as a cornerstone in their health care policy and I'm Health critic for my party and I've been hearing about it for a long time. They're going to move ahead with some form of legislation. I suspect it'll be substantially what you see before you now. Perhaps we could help you with an amendment by deleting 11(3) -- that's your suggestion -- or, if the government wouldn't agree on that, should we not just try another approach and say that perhaps boards of health, before they can be designated are opened up to greater consumer participation? Help me out here because the government doesn't very often accept amendments, in the four years I've been Health critic anyway.

Dr MacIntyre: The concern about boards of health and their representativeness, the nature of their governance model, is certainly a concern that I have, but not solely in relation to long-term care. I think there may be an inherent contradiction here, if I may call it that, in that public health is very much a community-based service. If it's deemed, for whatever reason, that the governing structure that's now represented by the board of health model is inappropriate to community-based long-term care services, then does that not automatically make it invalid as a sufficient governance model for public health?

Mr Jim Wilson: Don't tempt the government.

Dr MacIntyre: Okay, let me take this one step further.

Mr Jim Wilson: They're getting rid of a lot of other agencies, so don't give them any good reasons.

Dr MacIntyre: I don't know whether it's a matter of getting rid of it. I don't fear that public health is somehow going to slip beneath the surface of the water and disappear for ever. Yet I think it's only fair that community-based services be considered as a unit. This is, again, an extension of this governance model, a distinction that's being made between a governance model for long-term care and what perhaps might be approved for public health. Is that not inherently a fragmentation of community-based care?

In all my practice, we are finding intersection. Certainly in the Porcupine Health Unit we have intersection between those. I mean, public health is very active in immunization. Every fall we launch a major campaign on behalf of the elderly in our community to make sure that they're all adequately protected against influenza. Is that not a critical component of clinical care, to maintain the independence of individuals at home?

I agree, I would not argue against the change, but there are two things here. Let's be consistent about the nature of the governance model that's appropriate across community-based care. Second, let's not make artificial distinctions between long-term care as a community-based service and public health as some separate community-based service.

Mr Malkowski: Thank you for your presentation. I was listening to your recommendations and I think all of them deserve consideration, but talking about number 2, saying where the district health councils become more financially accountable, and number 4, talking about pilot projects, I'd like to ask a question. When you think DHCs are ready to make recommendations, in terms of having an agency, perhaps there is a district health council that has worked with the agencies and is ready to go ahead with the establishment of their MSA. Do you think that they should have the opportunity to do that? We allow them to go ahead and yet we still go ahead with the consultations and with the legislation, so that would be a kind of pilot project.

Dr MacIntyre: If that means concurrent movement on, say, two tracks, if I understand the question correctly --

Mr Malkowski: Yes, that's right.

Dr MacIntyre: -- I would think that from the standpoint of maintaining purposeful community involvement, one track should be ahead of the other track. What I'm trying to state here is that the sequence is important. I'm not speaking from a provincial standpoint but from our own experience in the community. I really believe that this legislation is well ahead of us, well ahead of our ability to comprehend the implications to our future development. Quite apart from the DHC role, whether it's going to be more fiscally responsible or otherwise, I do believe that as a community under the guidance of the DHC, we do need a good bit of time just to digest what's already before us. If it's all right, Joan might have something to add to that.

Ms Cameron: I believe at the present time, and I speak for the northern district of Cochrane, its services are well established, based upon an infrastructure that has grown over a 24-year period. Much of our service delivery restriction is based upon our inability to recruit and retain professionals in the north. This continues to be a constant problem, but we do try to provide equitable access for all who require care to the resources we have.

The infrastructure is based upon a series of suboffices that report through to the Timmins central office, but each office is autonomous in its own ability to interact with the formally contracted service providers within that community, as well as functionally with other service providers. We've indicated in our presentation today that we do have 20 formal contracts with other service providers. Representatives of these agencies meet frequently in case conferences, in supervisory meetings and over the phone at night, because most of our area is already on call, providing service 24 hours a day, seven days a week. We've leapt ahead of the legislation, so to speak, responding to the needs of the district in the north and the various communities.

We try to provide care that is sensitive culturally, religiously and linguistically as well as care that meets the individual, minority and personal differences of people. We try to match care givers with these needs.

Most recently, we have become involved in launching a new area of service. I'll be opening up an office with full service on Moose Factory Island in the middle of September and yesterday received an invitation from the chiefs on the James Bay coast to meet with them in Attawapiskat, Kashechewan and Fort Albany in the middle of October.

I only emphasize the success of the program based with the Porcupine public health program to date because I do think we have provided a very good level of care and the majority of our clients and families indeed speak very positively of the services that we provide.

Mr Malkowski: Just a point, if I could ask the parliamentary assistant: The DHCs, if they make a recommendation for ministry approval, would they continue on then, even though the legislation is still in process? How would that work?

Mr Wessenger: I'll make a preliminary answer and then I'll let ministry staff follow up, but it appears to me that to establish an MSA, you actually have to have the legislative framework in effect before one can be established. You can certainly plan for one ahead of time, and that's what we're trying to do. I'll just ask if Mr Quirt can add anything further to that.

Mr Quirt: Clearly, you would have to have the pass before the ministry could designate an agency as a multiservice agency. In the interim, prior to the passage of the legislation, there are other things that could happen, and there are a number of agencies and groups of agencies that are applying for proposal development grants to develop the process through which consensus is reached on how to integrate their service delivery.

Certainly that activity can happen and a number of service improvements can happen in the meantime. One example was your suggestion that a 1-800 number be established so that agencies cooperatively provide improved access, even though there may be 20 or more agencies involved. That's an example of the kind of service improvement that can take place in the interim and lead towards further collaboration and integration of services.


The Chair: Dr MacIntyre, did you wish to just make a comment?

Dr MacIntyre: Very quickly, DHCs perhaps are an example. DHCs, as agencies, have been recognized for many, many years and there's no legislative statute, provision, per se outside of regulation. So I don't know why MSAs, as a construction for long-term care delivery, could not exist in the absence of Bill 173.

The Chair: Thank you. I'm afraid we're going to have to move on to our final question.

Mrs Yvonne O'Neill (Ottawa-Rideau): Dr MacIntyre, I doubt you saw my second reading speech, but many of the same questions were asked by me that have been asked by you today. I feel you've been very pointed in stating that we cannot be open-ended when we're offering services, and I unfortunately think that this bill does give that impression, that all that has been bad will be cured. I'm glad that you've talked about the things that are good and that they are much more evident than maybe some people have suggested. I'm also very glad that you talked about the reforms in progress and that your associate Ms Cameron has brought it even further along in her remarks.

I have a two-pronged question for you. Although your brief is very specific in many ways, you didn't talk at all about the four-year interim transition the minister announced more recently and how you feel about that, and then I'm quite fascinated to see that you've taken that giant leap with the district health council to include even financial responsibility and then the accountability that would accompany that. I just wouldn't have expected that to come out of this particular brief, so maybe you can suggest why you did that and whether you think the community you represent is along with you on that suggestion for DHCs, because you're certainly the first ones that have been as specific in that recommendation.

Dr MacIntyre: I'd be pleased to respond. So far as the DHC role is concerned, I'm convinced beyond any doubt that it represents an entity whose job it should be to bring people together, but around goals and towards the purpose of steering the community in a certain direction. I don't mean in the sense of they're going to exercise choice on behalf, but that's why I use the word "negotiation." DHCs are always associated with this role of planning, but you can plan and plan and plan, and plans go nowhere. But if you plan by process of involving the local community -- and those community members, those community players are stakeholders, and they know that the exercise is one that's going to govern their activities and the benefits of their local community -- then I don't think planning is going to be so idle, be such a wandering or meandering effect or phenomenon.

That's why I think it's not only in relation to long-term care, nor is it a short-term view. The issue is that reform is not a one-off affair. We're into a period of turmoil that is not going to be over whether Bill 173 is passed or not. The next stage is going to be upon us, and we might find that having constructed or defined a certain continuum of care, a certain mix of services that we now categorize as the essential or the mandatory insured group of services, that mandatory coverage, it's no longer adequate and we have to establish new links.

I really think we need to focus our attention, concentrate all our effort, on coming together around some very hard economic issues, and to do that means putting a table for members to gather around but having leadership at that table for the sake of ongoing planning and negotiation. And when that activity really comes home to roost is when you've got the dollars in front of you, and that's why I'm relating it to this whole business about open-endedness.

This is what got us into trouble over medical care. Why? Because we don't have the economic view. We've defined community welfare as the sum of individual welfare, and that's essentially where I see this bill going; that is, it's a consumers' rights bill. It opens the opportunity, or at least it creates an entitlement, for people to ask for services. But I don't find here anywhere that the collective accountability to the community resource, the total resource, is recognized. How are you going to account for that?

As far as the transition period is concerned, my short answer to that is, for your transition period is fine, but going where? What's the outcome of that? I'd like to have a sense that your transition period is going to be the opportunity that we need to get our heads around the issues at stake from our community perspective, and I'm not satisfied that that won't be pre-empted if this legislation is passed at this point.

The Chair: I'm sorry to interject. I'm afraid we're out of time and if we're to keep to the schedule we'll have to draw this to a close. But may I on behalf of the committee thank you both for coming here this afternoon and for your presentation.


The Chair: I call on the representatives from the health and social services committee, regional municipality of Sudbury, if they would please come forward. Welcome to the committee.

Mr Jim Griffin: Good afternoon. My name is Jim Griffin. I'm a regional councillor from Sudbury. I'm here in my capacity as a member of the health and social services committee, and sitting next to me is Mark Mieto. Mark is the director of health and social services with our region.

I'd like to thank you for coming to northern Ontario. I guess we're all blessed with this warm weather that you see here today in Sault Ste Marie. We've had it all summer, by the way, up here in the north; no rain.

With the shortness of time, we do want to get into the meat of this, though, and express to you our concerns regarding the proposed MSA structure. On behalf of our committee at the region, I'd like to thank you for allowing us the opportunity to voice our opinion.

I want to stress that the MSA concept as a whole, at least from our viewpoint, is a sound one. I'm sure, in fact I know, that all of you sitting here today as politicians have listened to many accounts from constituents attempting to access the current system who unfortunately can only speak of confusion and some frustration.

I want to point out too that since at least 1987, we've been following this. We've been involved in it. We're not here just in passing today to comment on some legislation that is going to take place. We've been working with it. We've been working with the seniors. We have a seniors' advisory council. We as a community are at this point in time ahead of the legislation, I think.

With that in mind, I think we can all agree that this endeavour is a long-awaited, important one. It's our hope that it will be carried out thoughtfully by government and, just as importantly, will be examined and constructively commented on by the opposition.

With that in mind, we would now like to outline six major concerns that we have with the proposed bill.


First of all, we'd like to see the legislation allow communities to determine who will play this planning role. Clause 1(g) of the proposed bill clearly states that the purpose of the act is "to encourage local community involvement in planning, coordinating, integrating, managing and delivering community services." Now, it sounds great, but if you examine this closely, the legislation reveals that this purpose is not set in stone. For example, the Minister of Health recently announced that the job of planning MSAs will be given to the DHCs. We feel that if you enshrine in legislation the role of planning for the DHCs, the district health councils, then other groups or organizations may be left out of this important process.

In Sudbury, for example, at this point in time, our seniors' advisory council has historically been involved with such endeavours. Our written submission explains all of this, but I can't help but footnote on a personal level how down-to-earth, how immediately involved this seniors advisory council is, without any direction from DHC or government, but certainly through the regional municipality of Sudbury it has become a huge impact in our community with down-to-earth suggestions, a hands-on approach and really feels at this point in time it may well be left out of the planning if it goes to DHCs. That's an example of a group that feels that way.

We consulted in our community. I must admit there's no evidence that our community was consulted. I know the MSA, the structure, is going to be given to the DHCs and this is community involvement, but we haven't had any consultation up to this point with this hearing here today in this whole regard, and I just want to point that out.

Secondly, we'd like the legislation to allow communities to determine their own model of implementation. In a similar fashion, we consulted in our community to determine the type of implementation model for MSAs. The consensus was that a brokerage model should be adopted, rather than the proposed total integrated model. If communities are to play the role in coordinating and managing MSAs, why shouldn't they be allowed to determine how to do it?

Our child care system is a classic example of how a brokerage model can work, and with your permission, I'd like to pass it over to Mark just to explain briefly how we se the brokerage model working in our child care area in Sudbury.

Mr Mark Mieto: Approximately two or three years ago, we had a number of families in the community express concern about the problems they had in accessing our day care system. We had about 20 day care providers within our community, so theoretically some of the families are on one or two or could be on up to 20 different waiting lists within a community because of the 20 different agencies providing services. There were 20 sets of priorities, they had slightly different intake systems, and trying to move around from one day care system to another to be closer to work or whatever was very difficult. We recognized that as a concern within the community and we got the providers together and we started to work on it, again without any legislation and without any structure, but we did go forward as a community and we came forward with this brokerage model.

What we now have is three people working for the regional municipality of Sudbury who provide a central intake. They do all the assessments. They coordinate all the services and put you on to the waiting list of the most appropriate child care centre. That manages a system for 700 subsidized child care spaces, and you can appreciate there's a lot of in and out in the system, so it manages a fairly complex process for the community.

Also, the prioritization, the intake and all of that has been worked out with a community planning body which provides for the providers, the consumer advocates and others to be involved, and we've received a lot of valuable input from that group in terms of setting the priorities and the allocation mechanisms involved in this process.

It just illustrates that there are other models that can work in a community in a social services or a human services setting, and I guess what we're saying is it also allows for a decentralized delivery, meaning that the 20 day care agencies are still intact, many of them run by volunteers, and allows them to be fully participating in their agencies and their organizations. Again, that certainly reflects, from our perspective, the model, that brokerage model, would go a long way to meeting the original objectives of this legislation.

Mr Griffin: We're not saying that's the only model. It's an example of a model that is brokerage in nature which could be used, and certainly all we're asking is that the flexibility be placed in the legislation to allow that type of dimension.

Thirdly, we'd like you to reconsider the four-year deadline. MSA restructuring, I don't have tell you that, is going to be a complex, time-consuming process, and while some communities may be able to reorganize in two years, others may take an awful lot longer. As you are aware, regional differences exist within the province. The degree of services differs vastly within the province. For example, from north to south, you're all well aware of, I think, the problems we face in Sudbury and in northern Ontario with delivery of health care services. Possibly, Mark, you could speak just to the degree of services.

Mr Mieto: Again, just to maybe give an example of that, I'm aware of certain service delivery agencies in Metro Toronto where there's an executive director, a finance person, perhaps one or two professionals in program administration and the delivery agencies. I can think of similar agencies in Sudbury where the executive director is the sole person who answers the telephone, coordinates the services and, if no volunteer shows up, they will jump in their car and go provide the service. That's the same agency. So there are differentials when you talk about one program in an urban setting versus something in a rural setting. You can't use a blanket approach to these kinds of settings. You have to understand the realities within communities.

Mr Griffin: And we'd like to see that reality reflected somehow within the legislation.

Fourthly, we'd ask that we eliminate the 20% limit on services purchased. I'm aware of a number of presentations at your public hearings in Toronto, and this point apparently came up a number of times.

If the services are being delivered efficiently, then why phase them out and allow government to deliver them all? Many problems may arise, in our opinion, if the MSA becomes this huge manager and deliverer of important services. We find the 20% rule arbitrary. There's an inherent conflict of interest here that we can see.

We understand that all of these agencies have administrative costs. They have administrators, financial advisers. They may well run to duplication. But it's very important that before the legislation comes into place, you weigh the cost of losing the potential loss of volunteer help against the apparent cost of these administrative features in the different small agencies, or member agencies.

There could be a perception, as we see it; the groups may perceive that the MSA is running everything, and if the MSA is doing it, then why volunteer? Like in Sudbury, the Meals on Wheels is really one person delivering thousands of meals with several volunteers, hundreds of volunteers. There's literally little or no overhead or administrative cost to that. But would those volunteers remain there if the MSA, a government agency, perceived as a government agency, was taking over the administration of Meals on Wheels?

In the north I think in particular -- and I say that without a knowledge of the south -- we feel that there's a potential there for all of these volunteers to dissipate, to lose their interest because they feel government's going to do it.

The local community should be able to determine this ratio themselves. If it's 20, if it's 80, if it's 60, like, who cares? What's the difference? You're taking an enormous risk by assuming that the thousands of volunteers will continue to work and continue to function if the MSA does it. Therefore, eliminate the 20% rule.


Fifthly, we'd ask you to consider adopting AMO's position on governance. I'm sure you're all very likely aware of AMO's views re the MSA. If not, we've refreshed your memory by outlining their position on governance in our written submission to you, with all due respect.

The most important point, as we see it, that AMO's trying to make, which we fully endorse, is the following: Municipalities are a level of government with a proven commitment to providing long-term care services. As such, we feel that municipal governments should be provided with the right of first refusal to govern local MSAs and to determine which model is appropriate for their community.

Sixthly, we'd like you to consider the consequences of appeal board decisions. As it stands in the legislation, the appeal board is very powerful, so powerful that enshrined in legislation is a clause which makes their decisions irrevocable. Well, this finality clause, as we see it, could have serious ramifications on delivering long-term health care in local communities.

Mark, we have an example, and it's only one example and a very simple one, but I think it illustrates clearly the potential damage that could be inflicted if this appeal board process is not thought out carefully.

Mr Mieto: I was just going to explain that in our community we dealt with a discharge from one of the chronic care facilities and the family was very interested in having that person within their own home and the person required very extensive 24-hour services. When we were looking at it from our integrated homemakers program, it would have absorbed almost 60% of our budget for one individual, which had historically been involved through a history of a process in developing some criteria for it.

Ultimately, the area office was able to make special arrangements for that case, but in essence, if the appeal board has a final determination over an MSA board, a potential example that one could see, a scenario -- and this is assuming that there will be limited funds given to an MSA structure at some point -- is that if an appeal hearing were held, perhaps on four or five different persons who required new services in a community, and no appropriate funding were given to that MSA, that MSA board could have been working on an expansion to, let's say, a Meals on Wheels service where volunteers were trained, arrangements were made and individuals were ready for the service. As an MSA board, you're out there saying,"Yes, we're going to launch this service," and meanwhile you just receive an appeal board hearing that orders you to pay out, let's say, $400,000 or $500,000. Where is your credibility as an MSA structure to be truly involved in planning and delivering services?

Somehow, someone has to work out that either for one year after this board makes a ruling, funds are provided, so that the financial flexibility and the planning capabilities are not eroded by this special appeal board -- some provision has to be made for that, because otherwise the MSA structures will not have credibility at the local level.

Mr Griffin: You can imagine the feeling locally if decisions are made and through the back door all the decisions that are recognizable as being made by the MSA and the community suddenly are changed and reversed and the community knows that. They'll know it the next day.

Let me conclude by saying that as members of the Legislature, you have an arduous yet important task ahead of you. The creation of such an MSA structure has been long awaited. From our viewpoint at the regional municipality of Sudbury, please proceed. We believe in the basics of all this. There must be some vehicle by which this whole process can evolve. There must be some starting point, some central focus. If adopted, this system obviously is going to affect thousands of Ontarians. It's hoped that all the suggestions and comments you hear throughout the public hearings will be considered as you enter into the clause-by-clause deliberations.

On behalf of the region of Sudbury's health and social services committee, we would like to thank you all very much for your attentiveness and for the opportunity to express our views here today. At this time, if time permits, Mark and I would be more than happy to answer any questions you may have.

Mr Larry O'Connor (Durham-York): I appreciate you coming from Sudbury. I spent a lot of time in my youth north of there in Capreol and consequently in the flats near Garson picking a few blueberries in my time with my nine brothers and sisters. It was a good pastime. It also got us out of the hair of my mum and dad, I guess.

There has been a lot of work gone on as far as health care delivery for home care and what not in Sudbury. I'm sure you're all proud of the integrated homemaking program, over $1 million committed there that's been annualized, $15 million now into home care, I think, this year's budget -- incredible. The district health council has an allocation for supportive housing of half a million dollars I believe it is. So there's a lot happening there.

Earlier we heard from people representing, again, parts of the large rural north, and I represent rural parts of two large regional municipalities down in southern Ontario. Durham-York's the riding, so a little bit of Durham and a little bit of York, but the rural parts. I wondered, with consumer representation and what not, how then you could see the cooperation. I guess you probably have it with your senior advisory committee. How do they work, given so large an area, with some of the decisions you've come to us with, some of the suggestions you've come to us with, because my understanding is that the seniors' advisory council does work with the long-term care area office and has been working with the long-term care committee with the DHC and there has been some cooperation there.

I just wonder, because you seem to point a different view and pose it a little different way, maybe some of the rural parts, which was pointed out earlier as a concern, not being reflective of some of the decisions. How do we make sure consumers in those parts are fully represented in the care that they need and we want to make sure they have for their future as we proceed with this redirection?

Mr Griffin: I don't know if I have answers in terms of distribution by population or just number of users. It's a difficult question and I see what you're going to be faced with when you try to do that. We're all consumers, and I guess we tire of having segments of society represent because they're a minority or because they're a segment, and yet we all are or will be consumers of this whole process.

Mr O'Connor: I can't consider myself a consumer of long-term care services right now, in all honesty, and very few of my local municipal representatives are in fact really seniors so they could consider themselves as consumers. But your advisory committee that you mentioned: Is that representative of the whole area or is it based in Sudbury? How broad is that?

Mr Griffin: It's representative of the whole area. You're familiar with the Sudbury area. The chairperson was from Walden and there are members from Capreol and all of the different small municipalities. They have meetings both in Sudbury and in outside municipalities. So they are representative, and I think it's on a voluntary basis. There's no commitment on that advisory council, as I recall, Mark, for two to be from this area, one from here, is there? It's basically representative.

Mr Mieto: It's geographic but primarily the structure was set up to represent the almost 80 seniors' organizations and there are about 16 or 20 members who represent those other organizations within a community. Its sole focus and its board of directors is strictly consumers, although there is a special advisory committee of service providers to provide that professional expertise to the consumers who would be on the advisory council.


Mr McGuinty: Gentlemen, thank you very much for your presentation. I particularly enjoyed learning about the way in which you dealt with your regional day care and developed a regional day care program. I think it serves as a very good example for us in terms of the kind of approach that we might bring to the problems connected with the delivery of long-term care service in the province.

I don't really think I have a question so much as a comment to which you may wish to respond.

The Chair: None the less, a brief comment.

Mr McGuinty: None the less, a very brief comment, Mr Chair. The government seems to conceptualize -- let me put it this way: I think one of the strengths on which we should be capitalizing, one of the strengths we should be harnessing, is the way in which long-term care in this province has continued to evolve and to adapt to meet changing needs. I see that as a strength.

Now, there is undoubtedly something there that's missing which government can supplement, and I think that's by resolving the accessibility problem. But I don't think you kill the damn animal which has served us so well by adapting to a changing environment and replace it with something that is perfectly static. My concern is if we come up with the MSA model, and that's to be the be-all and the end-all, what do we do if it doesn't work? We've eliminated its ability to continue to evolve and adapt.

Mr Griffin: That's exactly why we say that the example we used is only an example. It may not work in Chapleau, Ontario, or it may work in Chapleau, Ontario. That's why the flexibility has to be within the legislation. If it's working, why fix it? That flexibility has to be built in. That's a good point, and I build on that. That's exactly where we're coming from.

The Chair: I regret that time flies by in these hearings, and I'm afraid we are going to have to move on. We do appreciate very much the regional municipality coming before the committee. It is always good to see you.


The Chair: I then invite the representatives from the Algoma Health Unit, if they could come forward, please.

Mrs Barbara Sullivan: Mr Chairman, as they're coming forward, I wonder if I could request that the ministry -- perhaps not at this time, because we are pressed for time -- brief the committee on how it envisages aboriginal concerns, including those that are associated with geography, encompassed by the MSAs, particularly those combining the spiritual, the health and the cultural needs of a remote geographic area with the purchase of specialized services such as speech-language pathology and so on, which are included as mandatory services, or even the trainer funding. I think that we would all appreciate that kind of a briefing.

The Chair: We will work that out. I'll discuss that with the parliamentary assistant.

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

Ms Gail Russell: My name is Gail Russell. I'm administrator of the Algoma home care program.

Dr Allan Northan: My name is Allan Northan. I'm the medical officer of health for the Algoma district.

You may have a copy of my presentation. I'm just going to go through it as it's laid out, and you can follow it with me. I started off by saying that long-term care reform is meant to address the following, and there are five items there.

The first one is one-stop access. I would perhaps like to look at that more as improved access, because one-stop access gives what some people have said is a sort of feeling of unreality, that something's there that won't be there. I don't think it'll always be easy in something as complex as long-term care to just pick up the phone and have everything solved at once. So if it's made to seem that simple, I think that's an impossibility. But I think improved access should certainly be stated as a goal of long-term care reform.

The second one is improved community-based services. I really think the services that we have in our community are basically excellent, and I'm talking from experience working in Sudbury and also here in Algoma, that the services are excellent. I think what we're probably trying to say is improved coordination, and I think there probably is some improvement in coordination that could occur.

The third thing that long-term care reform is meant to address is a consumer-focused system. I guess I'd have to ask: What has the system been focused on, if it hasn't been consumers, for all these years? I think we have done a good job for the consumer. One of the things that has paralysed us, or caused us problems, in home care are the rules and inflexibility that were built into the system; not something that was designed locally, but was a provincial entity. I think that is something that's easy to address.

The fourth thing was improved, consistent accountability. I think the accountability has been as good as the services that I've talked about, and again, it may be the coordination of those accountable that we're talking about.

The fifth one is local community-controlled planning through the district health council. I think, in my mind, that's a little bit, again, painting a picture that's not completely true, because it's not, as it's gone so far, local community-controlled planning, because there's been a large amount of central planning and central control. The broad plan has come centrally from the province, and the district health councils have been asked to facilitate that plan and to work out the details of that plan. But, as some speakers have said, there hasn't been that flexibility to design the local system of choice; it's within the parameters, the plan that the government set out.

What needs to be done to achieve the above goals, those five things that we're addressing? There are really three things to look at that are on the table right now. There are MSAs throughout Ontario, which is what is being proposed in the legislation. I would suggest another alternative is a pilot MSA to look at this more closely in a more experimental way. The third one is more flexibility in existing agencies plus collaboration among agencies, or what people are starting to talk about now is the federated model of all the services working together in a more closely aligned collaboration.

I guess you could have a fourth one and say change nothing, but I think we all agree that there is room for change, and change for the better.

I'll look at those three choices one by one. First is the MSA. Would an MSA achieve the goals set out better than either what's in place right now or some of the other alternatives? I don't think it would. Would an MSA be less expensive than the present system or a federated model? No. If you consider the cost considerations, one thing is that you'd probably be looking at new offices, especially if we're talking about multiple MSAs to replace the approximately 40 home care programs and associated services in the province.

You'd have a lot of new offices to begin with. Former offices, for example, would not have common compatible computer systems; you'd get into that kind of issue. There'd certainly be serious staff issues. Remuneration to the highest pay levels would be one thing that you would have to deal with as you put all these component agencies together, and that could cause a lot of chaos and inequities throughout the province. Union contracts would be expected to go to the highest benefit levels and so on. I think the first few years of this kind of solution could result in much attention to process and less to program delivery. In my mind, I'd be worried that we might not get what we wanted.

I guess another question is, is a monopoly of services the answer? I don't think so. I always believe that incentive is important, and I think this system does challenge the whole incentive issue.

Is there presently an agency in place that is suited to take on the MSA role? I mention this one particularly because -- and Dr MacIntyre had the same concern -- Bill 173, for some reason, states that health units would be looked at only in terms of a last resort; all other possibilities would have to be looked at before health units were chosen to be an MSA. So if we had to have MSAs, if they are necessary, I want to refute that part of the legislation.

Health units would be a logical first place to consider. First of all, the infrastructures are in place with health units, and some health units right now are actually close to the MSA that's envisioned. Health units have case management, they have the health professionals, such as the physios, the OTs, the speech-language pathologists, social workers, dieticians, and some health units have their own nursing services.

In particular, in terms of nursing services in the north, Sudbury has its own nursing services in Chapleau and Manitoulin Island, so it's already doing that itself. Here in Algoma we have our own nursing services in Elliot Lake. The purchase-of-service nursing services have not chosen to take on the areas that we have, because they're in the remote, hard-to-staff areas. But the health unit, because it was accountable and responsible for the service, has had to provide the nursing services.


There is expertise, and I can use our health unit in particular as an example, already in place in the health unit. First of all, there are 20 years of expertise of the staff involved. There's management experience. Myself, as medical officer, I've had six years with the long-term care area, and I have a background in rehabilitation medicine as well. Our business administrator was the former home care administrator. She is now in charge of the health unit's business administration, is a nurse by background, but also has a CMA and an MBA and is well-qualified.

Our home care administrator, beside me, Gail Russell, is very competent and runs the program at present. One of her assistants is a former VON executive director, who ran the VON in our community. So we have a wealth of experience in the agency. Also, the agency is strong in terms of prevention, promotion and evaluation. In terms of service delivery, we're moving to extend our hours further and heading towards the 24-hour-coverage concept in time.

I'll come to the governance issue, which has been raised. I'm sure, since I'm one of the later speakers, you've heard a lot of these arguments before and things will be contested both ways. But I think in terms of governance, our board members for health units are quite capable of being a board. First of all, many board members are elected officials, and they're elected by and for the people. These elected officials are ones anybody can go after in terms of concerns, complaints and so on and have much more leverage because those people are elected. Anything that they put in the press, in editorials and so on, has a lot more leverage on a board member who depends on being re-elected than on somebody who's appointed to the board.

The other thing about board members is, I'm sure if boards of health were surveyed, I strongly suspect the majority of the members of all 42 boards of health in Ontario would have experienced significant personal exposure to long-term care situations, even if they didn't have the services themselves. I'm sure almost all of us have either elderly family members or others in our family who have received home care services, and we know very well what the problems are and can be.

The second choice was the MSA pilot. The reason I look at the pilot is, as I said, I think the MSA concept for all of Ontario is quite a megaproject, and a pilot of the MSA concept would make sense, to me at least. If the pilot turned out to be a Titanic, then at least the province wouldn't have a whole fleet of them. I think that analogy is important, because you're going to be in an awful mess if this whole thing blows up in our face and our whole system is sinking. That's probably too dramatic. No matter what we do, it's too good right now to make changes and sink it, but we could bring it back a few steps, and that would not be useful in a time of economic restraint with all the needs that are out there.

In terms of the third choice, the federated model is being talked about now in terms of what Dr MacIntyre was asked about in terms of that interim delivery model. The federated model is supposed to be a collaboration of component services of the proposed MSA. I think that the agencies are willing to work together right now. My feeling is that perhaps the lever of all this intimidation of forming MSAs and so on has made a lot of agencies that in the past did not talk to each other, as they should have, much more ready to discuss issues that are in common, and that is the consumer.

A coordinated system of agency service delivery would be paramount. I think physical collocation of agencies would, where feasible, improve communication by virtue of easy accessibility of agency staff.

The other thing about a federated model is that the messy amalgamation of employees with varying labour contract backgrounds would be avoided. I think that one is going to be an enormous headache if the MSA ever goes ahead. I just can't see how all the varying backgrounds of labour contracts are just going to come together, and I don't know if anybody has even looked at that. I'd be very interested to know what people have thought about that, because that will be messy.

Morale of staff resides in part with agency heritage, and a federation would not wipe out agency heritage.

On page 18 of the question and answer section on Bill 173 that the Ministry of Health put out in June 1994, the following is quoted:

"Under the new legislation, there will be no requirement that services must be provided only on a visitation basis or in hourly allotments. This will make it possible for care providers to tailor their care provision to fit the consumer's needs rather than adhering to rigid, inflexible program rules. This increased flexibility will make it possible also to provide essential respite for family care providers when they really need it."

I think that above change is the crux that needs to happen. I've felt for the years I've been involved with home care and long-term care that the inflexibility of rules has hampered our ability to deliver services to the consumer. That one statement within the legislation is key. If the whole legislation falls, I hope that part does not fall, because that's critical, that there be the flexibility of service delivery.

That basically is my presentation. In summary, I've basically said that the MSA is not the proven way to go. If we need MSAs, health units I think really should be considered very seriously because of their wealth of experience in that area. If the MSA model is the way the government wants to go, I think a pilot should be seriously considered before we embark on the whole thing. I've talked about governance, and I'm not going to rehash that. My feeling is that perhaps at this time it would be recommended that a federated model provincially would be my way of going, and at the same time, if it's felt necessary, a pilot MSA could be started to see how that works out.

Mr Jim Wilson: Thank you for your presentation. The federated model has been discussed by a number of presenters to this committee. I don't think we've ever asked the government why in essence it has rejected that model, so I'll place that question to the parliamentary assistant at this time.

Mr Wessenger: Perhaps the first thing I should say is that a federated model under the legislation is permitted during the transition period. But at the end of the four-year period, after the MSA is designated, of course, it has to evolve into a completely integrated model.

I think if we look at the definition of a federated model, a federated model still would involve each of the agencies continuing with its own administrative structure. As a result of that, you would not have the cost savings that could be effected by common administration. I think this morning we had an interesting presentation from the two hospitals in this area. We had evidence that $2 million in savings resulted from the coordination of management and administration. It's certainly very much a policy of this government to encourage more cost-effective delivery.

I think the other aspect that I might indicate is the whole question of the inefficiencies with respect to the different agencies delivering different services. It's certainly the evidence before us by one of the multiservice agencies that existed, I believe, in the county of Victoria that they felt it was much quicker decision-making and a better, more streamlined process having a single agency rather than having the non-communication between the various agencies.

A third aspect is the whole question of accountability. I think it's very much a principal part of this legislation that we have a board that is community-based and is responsible to the community. How do you achieve that in a federated model, particularly if some of the models in the federation aren't bodies that have local governance?


Mr Jim Wilson: I suspected that I would hear parts of that answer from the parliamentary assistant, but if you're so sure that your new MSA bureaucracy is going to save money, why can't you provide this committee with one iota of evidence to that effect? You've not told us what the current, mostly volunteer structures out there now, the current agencies, what that's costing. So we don't know what the benchmark is right now. You haven't told us what the cost of new MSAs is going to be.

In fact, all of the evidence to this committee suggests that we're heading into a new large government bureaucracy much like mistakes that have been made in the past 20 years by governments when we've amalgamated municipalities ad hoc throughout the province or amalgamated school boards or whatever. Now we're doing it in health care. If you're so sure, why can't you provide any evidence to this committee so that we're not doing this without some actual fact?

Secondly, with respect to accountability, and maybe the witnesses want to comment on this, you've just been told by two boards of health which have elected officials on their boards already that you've got direct accountability. The example given by the witness here about the leverage that consumers have on elected officials is far more than they're going to have on anonymous bureaucrats in the MSA. So I don't see the basis at all, Mr Wessenger, in fact for the approach you're taking. The witnesses may want to add something.

Dr Northan: About the cost especially, where you're using a hospital analogy, I think it's a bit dangerous to externalize one experience to another. Hospitals are two like entities, where they've got multiples of, say, director of nursing, director of this, director of that. What we're talking about are unlike services coming together, where expertise will still be needed to run these various areas; like homemaking will be run by somebody and still will need to be and so on. So you're bringing a lot of unlike things together that will still need to be run by people who understand the running of these components. So I'm not so sure that you're going to see the kind of savings you might have seen in a hospital merger, for one comment.

Mr Wessenger: Could I just comment?

The Chair: Briefly, please.

Mr Wessenger: This is more in general terms, but certainly part of the parameters of the local planning community is to look at the cost-effectiveness of the new structure. That's one of the criteria that they are to use when they're recommending a structure, to ensure that there will be this cost-effectiveness and these cost savings. So I would assume that if the long-term care committee came to the conclusion that there was no cost-effectiveness in the new structure, then it wouldn't recommend a new structure.

I think the other thing we should remember, that perhaps is a misapprehension here, in a sense, is that with this legislation, when you're talking about pilot projects, it's not anticipated you're going to have MSAs established at the same time in every community across Ontario. It's obviously going to take a period of time to evolve, and it should be remembered that the four-year transition period starts from the time an MSA is designated. For instance, you may have an MSA designated, shall we say, in this community next year. On the other hand, in another community it might be two or three or four years down the road before you'd have an MSA designated. So I think we should remember that, that the legislation contemplates that type of approach.

Dr Northan: I'd still like to see a pilot project prove your point. I don't think it's proven that an MSA will be as cost saving as you suggest, and I think a pilot is a wise way to go. I don't see the rush.

Mr Martin: I just want to thank you for coming forward and for your very thoughtful presentation today, and to say to you that certainly the experiences that you have had, the delivery of service that the health unit in Algoma reflects, are some of the good things that we want to build on in this new model. That's why we're bringing people like yourselves together on these coordinating committees and boards, especially the one that presented before lunch.

I recognize the fact that you sent me a letter a few weeks ago, very pointed in terms of why you were not being considered to be an MSA if in fact one agency was chosen. I wanted the ministry people to perhaps respond to that question so that I don't have to relay that to you. You'll get it from the horse's mouth today as opposed to through me, although I suppose politically you're looking for a commitment from me to maybe some further action on that.

Dr Northan: Just an explanation.

The Chair: Which horse's mouth were you intending?

Mr Martin: In line with that question, I found it interesting that on the one hand you were saying that MSAs probably wouldn't work, because they would just be too big and unwieldy and the efficiencies wouldn't accrue that we're expecting, and on the other hand, though, you're saying that you in fact do operate now very much as an MSA; that you deliver a host of services across the region and that if we were going to consider an agency in this area to deliver it, you'd probably be the most logical one to pick.

I suggest to you that the VON could make the same argument and the Red Cross could probably make an argument very similar, and that in fact is the reason why we're trying to pull together the groups so that we might in this area move away finally -- the term was used this morning "bite the bullet" around the question of who's going to deliver the service, how it's going to be delivered in a consistent, equitable fashion across the province and Algoma, so that in fact we are focused on the consumer as opposed to our own organizations and their continuance into the future.

But I'd like to ask the ministry, if it would, for me and for Dr Northan here, why it is they were put at the bottom of the list in terms of being considered for an MSA.

Mr Wessenger: Okay, perhaps I will give the answer, and I'll give Mr Quirt an opportunity to elaborate, because I may not cover the whole aspect. I think there are two problems with respect to a board of health. I think first it's a governance model in the sense that, how do you ensure in the governance model that you have consumer representatives and also have that input of health providers and social service providers which you want in an MSA? So that's one of the problems.

If I might just add a personal observation here -- I think I'd have to say it's personal, because I don't want to tie the ministry with this observation -- I think certainly in my discussions with many medical officers of health, a lot of them have some concern about the present governance model in the sense that the body that's providing the majority of money is not accountable. In other words, the provincial government provides the majority of money for boards of health, yet the control of them is vested in the municipality. So it's a problem with respect to the whole disentanglement aspect, and that's, I know, related to boards of health.

The third aspect of concern is, would a government body, a board of health, have the same ability to bring in volunteers? I think that's something we should ask the boards of health, because I'd like to know whether they in fact feel they could successfully incorporate the volunteer programs.

Of course the last aspect is, seeing that they're not a charitable corporation, although there might be deductibility for the donations, how successful would they be at raising donations from the private sector?

The Chair: I'm going to ask Dr Northan if he'd like to comment on that. We are tight for time, and I'm afraid we'll then have to move on.

Dr Northan: Okay. I guess as far as taking care of volunteers, I don't see that as a problem. If one agency can do it, so can another. In fact, we have a volunteer coordination system within our health unit, and we get a lot of good work out of volunteers from the community. So we already do that.

As far as being a charitable organization, our health unit isn't, but I understand that Porcupine Health Unit is, so health units have done that before too. So it's not something that's impossible to do; they've done it. Most health units haven't done it, because of the complexities involved. But if you've got the reason to do it, enough merit out of going through the agony of becoming a charitable organization, then, sure, we're quite equipped to do it if we had to.

I guess I say, though, I've been terribly concerned over the whole governance issue, because I don't see this as key to the service delivery. I think no matter who you've got on the board, you have intelligent, committed people, and I think we're all touched by long-term care issues. I think elected officials have other reasons, just being elected, for being good board members. But if you get consumers who have their own specific experience with long-term care, are they necessarily going to be good for the system when they bring their one or two particular concerns about long-term care with them to the board?

Board members are not supposed to be focused on certain issues; they're supposed to look globally at the whole picture. I think that's a quality that you'll want with people. I've seen some board members who have consumer issues who get very focused on things that are very key to their own lives, and that's something that board members have to try to avoid. I think good board members will avoid their own personal stake in it and look at the broad picture.


The Chair: Thank you, and for a final short, sharp question, Ms Sullivan.

Mrs Barbara Sullivan: We know and we have spoken at some length with respect to the lack of feasibility studies both on cost benefits, cost-effectiveness, service improvements, outcomes measurement that could be achieved through an MSA as envisaged through this bill. The government has so far rejected a pilot project. I'm going to ask government officials now if they will consider a pilot project to ensure that those measurements are taken. Indeed, one community can be used as a basis for observations about the cost-effectiveness and feasibility of the MSA model that's being put forward.

Mr Wessenger: It's certainly not anticipated there would be what we call pilot projects, but as I indicated earlier, we foresee MSAs developing at different rates across the province, and obviously there'll be assessments from the early developments and they'll influence the later developments.

Dr Northan: Could I make one comment here just about the whole administrative issue and the cost related to this pilot? One of the things you said is that amalgamating will save money because two hospitals are amalgamated into one.

One of the problems with the MSA concept, I know in our district, is that we've got a district-wide system of running our home care services now through district agencies. At least, a lot of our services are run that way. With the MSA concept, at least this district is looking at maybe four, five, six possible MSA sites. If that happens, if it comes out that way, I don't know how it's going to work out if it comes about.

Say we get six MSAs in this district where we had single-district systems. That administrative saving that you're talking about isn't obviously there in my mind. I agree with the last comment, that a pilot would have to look at this and look at the scope and the size of this thing and how much administration per capita and so on. If we end up with six or seven MSAs in this district and right through the province, and instead of having, say, 40 systems we've got 500, to me we're going to be into a cost overrun.

The Chair: Thank you. Again, I regret as Chair I have to play the heavy and bring this discussion to a close, but we do want to thank you for your presentation and answering our questions today.


The Chair: I invite the representatives from the Alzheimer Society of Sault Ste Marie and Algoma District. I believe members have a copy of your submission. We want to welcome you to the committee this afternoon.

Ms Brenda Lailey: My name is Brenda Lailey. I am the chapter administrator for the Alzheimer Society of Sault Ste Marie and Algoma District.

Ms Maria Bell: My name is Maria Bell. I am a member of the Alzheimer association and a care giver of an Alzheimer patient.

Ms Lailey: As administrator, I'm pleased to be able to attend to today's hearings on behalf of persons with Alzheimer disease who are often unable to speak for themselves. Maria, a family care giver and a member of the society, will speak later.

We're here today to discuss with you some important factors and concerns that we have as family care givers, volunteers and staff members of the Alzheimer society. In brief, we would like to highlight some important information concerning Alzheimer disease, discuss some principles of long-term care reform in conjunction with care for persons with Alzheimer disease and make suggestions for how the principles of Bill 173 can be implemented to effect positive change for persons with Alzheimer disease and their care givers. As well, Maria would like to share with you her personal story.

Alzheimer disease is progressive, degenerative and exacting in its effect upon the person. It turns formerly self-reliant human beings into dependents without dignity, humanity and memory. Care givers, who are usually family members, must cope with emotional, financial and physical stress, often without respite in a gruelling 36-hour day.

The recently completed Canadian Study of Health and Aging reveals that 8% of Canadians aged 65 or over suffer from dementia. Of these individuals 5.1%, or almost two thirds of all dementias, have been identified as having Alzheimer disease. The study further reveals that 26% of persons aged 85 or over suffer from Alzheimer disease, and in Ontario more Alzheimer persons currently reside in institutions than in the community.

It is anticipated that the number of cases of Alzheimer disease in Canada will double by the year 2021. Recent figures released in the United States indicate that Alzheimer disease is the third most costly disease. The costs for providing care for Alzheimer persons are exceeded only by those associated with cancer and heart disease.

At present, there is no known cause or cure for this disease that robs the mind of a lifetime of skills and memories. There is also no effective treatment to alter its progress. Following diagnosis, Alzheimer disease can progress for a period of from two to 15 years. During that time, the Alzheimer person will depend more and more on a variety of care givers, both family and professional.

Because of the progressive nature of the disease and the potential for many years of care, it is essential that adequate community support systems be put in place to meet these needs. Without access to readily available and adequate respite services, there is concern that the Alzheimer person may require premature institutionalization. In addition, the burden of care required to maintain an Alzheimer person at home often takes a heavy toll on the primary family care giver. Without adequate support, the care giver's health deteriorates and the ultimate result is two persons requiring long-term care.

Our comments around one-stop access: The Alzheimer society supports the multiservice agency concept with its focus on a one-stop shop, the availability of basic services across Ontario and local design of programs to meet local needs. We are concerned that in meeting the admirable goal of consolidation and integration of programs, the needs of both family care givers and people with Alzheimer disease may be lost among the competing interests of other consumer groups. This will, we fear, be compounded by both cost containment and misconceptions about suitable services to the extent that our constituents will be put at risk.

It has been our experience that family care givers of Alzheimer persons are often reluctant to reach out for assistance. Inevitably, it takes a crisis or breakdown in the care giver's health to precipitate the search for assistance.

The Alzheimer society treats these families as a priority, offering a quick and personal response to their plight. This is achieved through education and awareness about the disease, care giver support groups, referrals for respite homemaking, the wandering person registry, the volunteer companion program, as well as in-home activity therapist services and the Alzheimer day away program where appropriate. It is our hope that should future assessment and referral of dementia persons be conducted by the staff of the MSA, these front-line workers must be sensitive to the emotional needs of care givers and also be able to respond quickly.

We further recommend that sufficient funds should be made available in all MSAs whereby personal reassessments of the condition of people with progressive neurological diseases are done on at least a twice-yearly basis and service plans are adapted to meet the changed circumstances.

Likewise, when an Alzheimer family approaches the MSA for assistance, it is recommended that the assessment staff refer that family to the Alzheimer society for specific information about the disease and additional support as a part of the overall care plan for the individual. We further recommend that a formal referral process be put in place, including the necessary client assessment information, so that the individual needs of the Alzheimer person and his or her family care givers can be identified and addressed without delay.


We are indeed please that both homemaking services and adult day programs have been identified as core services in the proposed legislation. Both of these services provide respite for the family care giver as well as an opportunity for a trained individual to involve the Alzheimer person in meaningful activities which focus on his or her persisting strengths rather than on the deficits resulting from the progression of the disease.

It should also be recognized that respite care is essential for care givers of Alzheimer persons. At the present time, the Alzheimer Society of Sault Ste Marie, in conjunction with the Canadian Red Cross Society, administers a budget of $60,000 for the provision of respite care for Alzheimer families throughout the district of Algoma. With the inception of the multiservice agency concept, it is vitally important for Alzheimer care givers to be able to continue to access this source of additional respite care.

Concern exists for those families attempting to maintain an Alzheimer person at home who do not qualify for respite homemaking or who are already receiving the maximum 60 hours of homemaking currently available through the home care program.

For families requiring night-time supervision of a person at risk for wandering, the 60-hour maximum provides for a mere seven night shifts per month with next to no hours left over for daytime relief. Because of the intensity of care required for an Alzheimer person, how will these care givers be able to access sufficient respite services in order to avoid premature institutionalization because the family is unable to cope with what is so often referred to as a 36-hour day?

At the present time, the Alzheimer respite homemaking program provides respite care to 23 families in the district of Algoma, and 17 of these families also receive homemaking services through the home care program. If these individuals continue to require the same level of care until March 31, 1995, ie, the end of the current fiscal year, there is a projected deficit of approximately $7,000. As a result, we will be unable to meet the present demand, and service for those already registered will have to be reduced. As well, any new requests for respite assistance will have to go on a waiting list. To illustrate the current demand, during the months of June, July and the first three weeks of August of this year, 22 new families have approached the Alzheimer society for information and assistance. We anticipate that this trend will continue because of the greying of the population.

The board of directors of the multiservice agency will have a responsibility to ensure that the dollars allocated to their funding envelope are spent wisely. If large numbers of individuals requiring long-term care are Alzheimer persons, then we would submit that the planning should reflect this need.

Further, because of the long-term progressive nature of Alzheimer disease and the specific deficits it causes, the Alzheimer society continues to see difficulties in meeting the needs of people with Alzheimer disease through generic community-based services. Indeed, the association finds that placing people with Alzheimer disease in integrated adult day programs can be simply another form of institutionalization.

It is the society's belief that the specialized Alzheimer day program currently offered in conjunction with the F.J. Davey Home is of vital importance and should be continued. Through specific activities, the program maximizes the remaining skills of persons with Alzheimer disease and related dementias, thereby prolonging residence in the community.

The Alzheimer society commends the government for the development of a system which includes the recognition of both people with Alzheimer disease and family care givers as separate consumers of long-term care services. Since an individual suffering from Alzheimer disease or a related dementia is seldom the one who requests service and is often not capable of making his or her own decisions, it is imperative that the primary care giver be afforded the opportunity to participate in the preparation of a suitable care plan, regardless of whether a legal authority exists.

The legislation requires that the composition of the board of directors for a multiservice agency "include consumers and other members of the community to reflect the diversity of the population served." Recognizing that to this date no consumer group of people with Alzheimer disease exists from which representatives may be drawn for appointment to long-term care planning or service delivery bodies, but that care givers of people with Alzheimer disease are themselves consumers of different long-term care services and maybe substitute decision-makers who have been chosen by people with the disease, we strongly recommend that MSA boards include people who have been directly affected by the disease.

The legislation also provides an opportunity for "consumers receiving community services" to "appeal certain decisions made by an approved agency providing services under the act," and that such "appeals will be heard by the Health Services Appeal Board." Concern exists regarding the length of time required to permit such an appeal process to take place. It is our recommendation that a local appeal process be established for review of any service delivery decision with which a consumer is dissatisfied.

It is our position that one-stop access to information and referral will be a positive step forward for individuals seeking assistance with the care of an Alzheimer person. It is our hope that the expertise and support currently provided by the Alzheimer society will continue to be an integral part of the care plan for all dementia persons and their care givers.

Ms Bell: I would like to thank you for allowing me to speak on Bill 173, addressing the concerns that I have as a consumer and a member of the Alzheimer society. My concerns are similar to those in my situation who cannot speak for themselves or who do not have the makeup to do so. It is for these two reasons that I feel one-stop shopping is a great idea.

My mother and I did not spend a lot of time together before the onset of this disease, and therefore making the decision to seek help for her, when my father was not able to even see the problem, was very difficult for me. Because I lived in the part of town that directed me past the Alzheimer office every day and because I knew them from my work, which is taking donations at a funeral home, I identified them as a source of help for my situation. After almost a year of contemplation, I finally went in to get some information.

I was fortunate that these two avenues were available to me. To most others they are not, therefore I feel it is important that the public be educated about the help they can receive. The Alzheimer society was a haven for me and for many others, regardless of our situation. I feel that they are a necessary association to be a part of the total health care plan.

My father is 78 years old and has worked hard all his life. Unfortunately, homemaking was not one of his strong points. The Alzheimer society recognized his need for help and was there to give counsel to those with a more clinical outlook who had assessed him as lazy because he could not keep house and look after my mother as well as he appeared to be able to. The Alzheimer society recognized his cultural upbringing and his inability to change and learn a foreign skill at 78 years old. By utilizing the Red Cross respite homemaking service and the Alzheimer day away program and by showing concern and help to a man willing to change what he could, they were able to keep my mother in her home more comfortably, and with an improved outlook, for two years.

The support group gave my father the release he needed and the understanding that there were others like him. For those who have more natural homemaking tendencies the times are longer, and the wives of men with Alzheimer seem to be able to do even more. This appears to me to be a saving to the long-term care, since maintaining someone in an institution costs considerably more. For this reason, I believe that respite care is essential.

The Alzheimer day away program maintained my mother's skills as long as they could and there was a marked change in her state of mind when she went there. Now in the nursing home, my mother has teamed up with one other lady from the day away program and they seem to have a communication all their own. They are reasonably happy, and this helps those who are caring for them at the nursing home now.

With the Alzheimer day away program and the Red Cross respite homemaking in place, assessment of my mother's condition was easy and the flow of help was quick. With Alzheimer disease, the need for quick response is essential to the safety of the patient and society itself. The need for specialized help is real and the Alzheimer society should remain able to work for these special people.

Ms Lailey: I'd just like to close and ask that the following recommendations be considered in order to effect positive change for persons with Alzheimer disease and their care givers:

-- Easy access to information, and referral to appropriate services;

-- Personal reassessments on at least a twice-yearly basis;

-- Quick response to requests for respite care;

-- Education about Alzheimer disease be available for all care givers;

-- Adequate levels of respite homemaking be available to meet the special needs of family care givers;

-- Allocation of money from the funding envelope to reflect the number of individuals with Alzheimer disease or some other dementia;

-- Inclusion of persons directly affected by Alzheimer disease, and a representative of the Alzheimer society, on the board of directors of the multiservice agency;

-- Establishment of a local appeal process;

-- Involvement of the local chapter of the Alzheimer society as a part of the total care plan;

-- Continuation of the specialized Alzheimer day away program.

In order to respect the time limit set for today's presentations to the committee, our brief has focused primarily on the needs of Alzheimer persons and their family care givers, our greatest concern. However, this in no way diminishes our further concerns regarding the implementation of Bill 173 and the multiservice agency.

We recognize the potential impact on the role of the society, its board of directors and volunteers as well as on our ability to fund-raise in the community. These issues continue to be discussed at length as we attempt to chart our course through these challenging times.

On behalf of persons living and coping with Alzheimer disease, the Alzheimer society board, volunteers and staff, we would like to thank you for this opportunity to share our observations, concerns and recommendations regarding the effective provision of services to Alzheimer persons through the implementation of the multiservice agency.


The Chair: Thank you very much for your submission and also for the appendix with the recommendations. We have time for a question from each caucus.

Mrs Karen Haslam (Perth): Sorry, Mr Chair, I was handing him one of the questions I want him to throw in when he's talking.

The Chair: If he can weave that all into one nice, big question, that would be appreciated by the Chair.

Mr Martin: I just want to, first, thank you for coming forward. It's probably the closest we've come yet to hearing from a consumer group, I think.

Mr O'Connor: We have heard from a few.

Mr Martin: Anyway, it's good to hear from somebody who is directly in contact with and representing a group of people that actually is a very specialized group in this whole area.

I want to say thanks for all the work that you've done and to assure you that this initiative of the government is to try and build on the good work that you do and include the volunteers and the efforts and the donations, the goodwill that you've generated in the community up to this point.

I wanted to ask the parliamentary assistant and perhaps the ministry officials if they would help me share with you more concisely what's in this bill for groups such as yours specifically because it is a specialized area. I think it's addressed but I'd like them to tell you. Perhaps you might want a contact on that.

Also, my colleague here wanted to know, if I might, while I'm at it, throw this in: You suggested that a local appeal process be established for review of any service delivery decision with which a consumer is dissatisfied. She's asking how and who you mean there.

The Chair: Perhaps we could begin with the last question first and then we'll come back.

Mr Martin: Okay, yes.

Ms Lailey: I've read the act, by the way, and my intimation from it is that the appeal process would happen at some larger level, an appeal board. I read into it that it would happen in Toronto or somewhere.

For Alzheimer families that's impossible. They have to be able to say and articulate their needs. In Maria's example, when her father came forward and needed homemaking assistance, he was not assessed as qualifying for the level of assistance that he needed, so they had an avenue open to them to come to the Alzheimer society and access our little pot, as it were.

I think that in this larger picture there has to be a process locally, whether it is a volunteer group, an adjunct to the MSA, a committee here or the board of directors, some kind of an appeal process that people can go to.

The Chair: The parliamentary assistant on the first issue.

Mr Wessenger: I'm going to refer the matter to Mr Quirt particularly for how your society would relate under the bill. But I also understand your concerns about a local appeal process. I would assume that would be part of the planning process to ensure that there is an informal appeal process that could deal with problems, because I agree; in the appeal process, the end result is a very complex and difficult one.

Mr Quirt: The first comment I'd make is that the bill allows for a more flexible approach to meeting the needs of clients in their own homes and does specifically reference support to care givers and respite care in that context. As you well know better than we do, respite for care givers can be provided in a number of ways, whether it's a volunteer, a homemaker, a professional or perhaps a short stay for the person being cared for in a long-term care facility. We hope that all throughout the system respite care will be a bona fide, legitimate reason for providing service. That's been a problem up till now.

With the home care program we had to define somebody as a patient, and whether in fact the family was trying desperately to cope, to maintain that person at home, was often beside the point. So, by having respite front and centre and support to care givers front and centre we are letting our service providers do what they've wanted to do all along, and that's being more supportive to families like the ones you represent which, by the way, provide, according to Statistics Canada, about 90% of the long-term care in Canada. The publicly funded programs account for about 10% of the long-term care support activity that's done for citizens in the country.

I'd mention a second point with respect to day care programs that are specific to long-term care facility settings. It's been recommended by a number of presenters to the committee that we consider exempting those facility-based programs from the limitations that may be inherent if, for example, the purchase of those services were to go over the 20% limit in the bill. That's certainly something I know our minister would be very interested in getting your viewpoint on and discussing and looking at alternatives there.

The third point I'd make very briefly is that I know that in some communities there are some highly specialized services that your organization provides, and part of the rationale for allowing the 20% purchase limit in three areas was to make sure that those specialized and hard-to-duplicate services could be available through that mechanism. It wouldn't surprise me if that would be the approach that many district health councils would take in their planning.

One further point on the appeal process: There is an appeal process now, but I think your point is well taken that there are all kinds of other steps that need to be gone through, dealing with the agency administration, the agency board and government officials, prior to the client exercising the right to go before the appeal board. An earlier presenter from municipalities talked about the home care program. Well, right now that appeal board could make a ruling binding on that municipal government and its operation of the home care program. It doesn't happen very often because of what you've suggested, that people sensibly get together and try to find resolutions before it gets to that point.

The Chair: Would you like to make just any brief comment on that? Then we need to move on to the next questioner.

Ms Lailey: No, I don't think so.

Mrs Barbara Sullivan: Thank you very much. I think that many of the issues you've raised are ones that have been of some concern to our caucus over the past while. We have heard from one other Alzheimer organization as well as doctors in the public service who have been concerned with the illnesses associated with dementia, including schizophrenia and Alzheimer. We are now working on wording in our caucus to take forward, to include in professional services under the bill a notation that there ought to be services required for persons with dementia. I think that just adding that surround in the bill may be of some help.

I also wanted to respond with respect to your raising the issue of the appeal process. It seems to me that now a person who has Alzheimer or any other long-term illness that's a mental illness is in a particularly difficult situation with respect to appeals. I think, by example, of the monumental legislative surround that is either in place now or coming into place in a very short period of time with the Advocacy Act, the Consent to Treatment Act, the Substitute Decisions Act, the appeal process with respect to long-term care facility entrance, now another appeal process here, and frankly it doesn't make sense.


A lot of these things are being put into place simply because there is a viewpoint that there isn't a trust, a trusting relationship that exists between a care giver and a patient or a client. I think that, frankly, is a frightening commentary on our society. But, as well, I think we have to come to terms with reality, that when people want to or feel the need to have a decision altered, there has to be a simple and reasonable process as close to home as possible to ensure that will happen. We will be working also on recommendations not just for a vague idea that an MSA might put in its own rules, but for actually something that's included in the legislation, because now the appeal process that's included in the legislation is to the Health Services Appeal Board.

I wanted to ask the ministry if all of the services that you've outlined on page 5 of your brief, including the wandering person registry -- some of them we know are included, but the wandering person registry, the volunteer companion program, the in-home activity therapist and the day-away program -- are in fact included in the basket of services using other words.

Mr Quirt: I think it's fair to say they're included using other words. The wandering person registry, for example, or the care giver support groups are often funded as a home support program now and it would be included under the community services heading in the bill.

The in-home activity therapist could arguably, I suppose, be considered as a community support or a professional service, depending on the type of therapist that's involved. If it's an occupational therapist or a physiotherapist, that's certainly included as a core service. The day-away program, day care programs are mentioned specifically, and using homemakers for the purposes of respite and care giver support is definitely included.

Mr Jim Wilson: Thank you for your presentation. I found it interesting. Following on Ms Sullivan's question, because I wrote the same or probably similar notation to what she probably made on her page 5, and that is, it seems to me that a number of the services that you're either hoping to deliver -- I'm just a little unclear. You talk on page 6 about the $60,000 budget that, in conjunction with the Canadian Red Cross, you're co-administrating?

Ms Lailey: Yes, it's rather unique. The dollars are funded through the Ministry of Community and Social Services, the long-term care division. The dollars go to the Red Cross and they administer them. One of our staff works with the administrator of the Red Cross program and we are the referral point. None of the programs that are mentioned here receive any funding at all. Our chapter is totally self-supporting through donations and fundraising. So the dollars that serve that homemaking program go directly to Red Cross for service.

Mr Jim Wilson: That's good to know, because I had written down that unless there was an exemption from the 20% rule, you're toast.

Ms Lailey: I'm not sure it's clear at this point whether that $60,000 -- and that's the $60,000 question. Will it get put into the big pot or will it be left for access by our kind of person?

Mr Jim Wilson: Well, let's ask that because it's key or else you're out of business, for that part anyway.

The Chair: The $60,000 question then goes to Mr Wessenger.

Mr Wessenger: I'll refer it to Mr Quirt.

Mr Quirt: If in fact what's happening now, and I'm going to have to speculate a bit, is that the home care program, when wishing to provide homemaker services, is particularly sensitive to a family situation with Alzheimer, the Red Cross collaborates with your organization and you make sure that the homemaker is sensitive and trained to meet the needs of that client.

Ms Lailey: That's correct. It helps the Red Cross homemakers that go into Alzheimer homes and make every effort.

Mr Quirt: Yes. I don't see why that type of an arrangement couldn't exist either for the homemakers that are employed by the MSA, or continue to exist, if it was appropriate, to be purchased on a specific basis for those clients. It would only take a $300,000 homemaking budget, and I'm sure the homemaking budget for both home care programs is about 10 times that, to allow your funding to flow within that 20% rule.

Ms Lailey: Well, we would continue the education piece. I think our concern is the dollars for specific respite care for Alzheimer persons. I don't see where that --

Mr Quirt: I think most people would conclude that it will be easier for the folks in the system now to respond to the homemaker needs of families caring for people with Alzheimer under the new system than it is currently.

Mr Jim Wilson: If you don't have an exemption of 20%, if you're doing the training component and there is a dollar value attached to that and you fall under the 20% rule, you'll have a constant battle, I would think, with the MSA to make sure that you can continue to do that training outside of the MSA because large government bureaucracies, the way this thing's set up, want to do as much in-house as possible. I fear for the --


The Chair: Order, please. It's getting late in the afternoon.

Interjection: No, no. It's a good point, though.

The Chair: I realize it's a good point but all I wanted to say was we are running a bit late and tomorrow morning we are meeting with your counterparts, the Ontario association. Perhaps we'd have an opportunity to continue some of this discussion, but I just regret that we need to move on to our final presentation for today.

Mr Jim Wilson: Can I ask you a question while you're changing presenters, then?

The Chair: On behalf of the members of the committee, thank you for coming before us this afternoon.

I'll just call the next witness and then, Mr Wilson, turn the floor back to you. Representatives from the Ontario Community Support Association, areas 11 and 12, if they would be good enough to come forward.

Mr Jim Wilson: Just a quick question, if Mr Quirt could expand on his comment in response to the previous presenters. When he talked about that the minister may contemplate or be amenable to an exemption from the 20% rule of some facility-based services, that's the first time we've heard that, is it not?

Mrs Barbara Sullivan: No. Point of order, Mr Chairman: Yesterday there was a commitment to an amendment that would ensure that the facility-based adult day programs were exempted from the 20%. There was a firm commitment. I made that note as well and I was surprised to hear today that the worm has turned and now the response is that the minister may consider an exemption.

The Chair: Was this the reference on the questioning yesterday in Hansard?

Mrs Barbara Sullivan: Yes.

Mr Jim Wilson: That's my point. It's a tough one to nail down. So what is the answer?

The Chair: Well, we can also get the --

Mr Jim Wilson: I'm still waiting for the breakdown on the $850 million. I mean, how many days, Mr Chairman, do you expect us to wait for answers?

The Chair: Briefly then, Mr Wessenger, do you have a comment? I think the other thing we can do is --


The Chair: Order, please.

Mr Wessenger: I think Mr Quirt's position is that he's prepared to recommend the situation. I think that's what he's on record as and, obviously, until the matter comes before the minister no final decision can be made.



The Chair: Welcome, our final presenters for today. I want to welcome you. The members are getting a little antsy here, but I can assure you that they're going to --


The Chair: That's right. It's going to be an interesting flight back down south, I suppose. But we welcome you both to the committee, and if you'd be good enough to introduce yourselves to members of the committee for Hansard, then please proceed with your presentation.

Ms Angele Poitras: Good afternoon. My name is Angele Poitras. I'm the director of Meals on Wheels in Sudbury and I'm a member of the Ontario Community Support Association. I'm here representing areas 11 and 12 today.

Beside me is Russel DeCou, assistant to the director of Meals on Wheels, and he will be available to answer questions as well in the second half of this presentation.

The presentation will begin with a brief overview of what OCSA is and that will be followed by areas of legislation that OCSA endorses and the key areas of concern. Given the time constraints, I hope that you all have received the OCSA response regarding Bill 173. If you have not received that, please inform Mr DeCou and he will make sure that you receive it very shortly.

The Chair: We have copies of that document.

Ms Poitras: Wonderful, Mr Chair. I'm hoping to talk just for 15 minutes, and then 15 minutes for questions and answers or anything else that may occur in the last 15 minutes.

The Ontario Community Support Association is an organization of direct providers of community-based services. The primary purpose is to support, promote and represent the interest of community-based, non-for-profit health and social service agencies across Ontario.

OCSA was created on April 1, 1992, through an amalgamation of three provincial organizations, being Meals on Wheels of Ontario, the Ontario Association of Visiting Homemaking Services and the Ontario Home Support Association. All have long recognized a common interest in supporting community service and all have a long tradition of service in the community program. In fact, 1993 marked the 30th anniversary of Meals on Wheels of Ontario, and 1996 will mark the 25th anniversary of the Sudbury Meals on Wheels program.

OCSA is governed by a board of directors consisting of 25 community leaders. We all have representation from francophone and native communities. All are volunteers. The 300 member agencies across the province service 600,000 clients, have 10,000 dedicated staff and an army of over 45,000 active, hands-on volunteers who work diligently to provide this necessary wide range of services. Many of the volunteers in these programs are seniors themselves.

In 1993 these volunteers donated 1.2 million hours of service. In Sudbury alone, Meals on Wheels program utilizes 300 volunteers to delivery over 30,000 meals yearly to over 400 people. In the Nipissing-Timiskaming area, which is area 11, over 700 volunteers service over 4,000 people.

I'm sure you're aware of the programs that are contained within OCSA, and I'll name just a few: Meals on Wheels, Alzheimer day programs, client intervention and assistance, seniors' day programs, and the list goes on.

OCSA is subdivided into 15 areas. I'm here today to represent areas 11 and 12, which comprise the following: Cochrane, Muskoka, Nipissing, Parry Sound, Timiskaming, Algoma-Manitoulin and Sudbury. One of the great strengths of a provincial organization like the Ontario Community Support Association is the direct, concerted voice that we provide.

The membership supports several aspects of Bill 173, one of them being the purposes of the act. OCSA strongly supports the objectives contained in the purposes of the act. It is a key component of this legislation. In a written submission of which you have been given copies, we have suggested minor revisions.

The bill of rights: We are committed to a service delivery mechanism that is driven by individual consumer needs which responds to the requirements of natural communities and their cultural diversity and that will support the development of equity of service across the province. In areas 11 and 12 we believe this bill of rights to be of utmost importance as the large geographical we cover and the cultural diversity of our client base will be recognized and treated in an equitable manner.

OCSA recognizes and endorses the client's bill of rights as outlined in the legislation. The necessity of the client being informed is an essential component to providing client-centred services.

As some northern communities in areas 11 and 12 do not have all the services required within an MSA, we are concerned over the appeal process and strongly recommend and support the implementation of two types of appeals.

OCSA recommends that there must continue to be options beyond an appeal mechanism for those clients on waiting lists. Without a second appeal, appeals will be very costly, time-consuming and very confusing for the client.

Rules governing approved agencies: OCSA supports alternative MSA models which endorse the principles outlined in the purposes of the act and which are a result of the community planning process. The act must ensure that services are planned, delivered and evaluated from an integrated health and social service perspective. We believe in a long-term care system that stresses the importance of maintaining and promoting health, wellness and early intervention in addressing client needs and that provides flexible service along the continuum of care.

OCSA applauds the government for including the provision of the proposed changes to the Public Vehicles Act.

Now we're past the glory and we're on to a few areas of concern that OCSA would like to address. These are based on input from member agencies.

The six areas that are covered are (a) areas not covered in the legislation; (b) the regulations; (c) volunteerism in the reformed long-term care system; (d) multiservice agencies; (e) categories of service; and (f) definitions. The areas I will concentrate on today are the areas that aren't covered in the legislation, in particular the protection of workers, the role of volunteers and the 20-80 split.

In the document Partnerships in Long-Term Care: Guidelines for the Establishment of Multi-Service Agencies, released in September 1993, messages regarding the perceived preferential treatment of unionized employees in the new MSA became apparent. Subsequently in Bill 173 there were no references regarding the protection of not-for-profit, community-based employees as a result of implementation of long-term care reform.

Long-term care reform acknowledges the need for experienced, trained staff for the provision of services, yet the proposed process for the development of multiservice agencies along with social contract reductions and constrained finances all currently have or will potentially have a negative impact on employment in the broader socio-healthcare sector.

Also, a forgotten group of employees are those who work through brokerage agencies, and they should have their experience recognized in this process. The community support sector consists of 10,000 employees who are experienced and trained in the care and delivery of services. These staff have worked for years for low wages and minimal benefits, their only benefit being their client. They have a strong commitment and loyalty to providing quality services. Unionized employees in the broader socio-healthcare sector are demanding priority employment in the community sector. Our sector is predominantly non-unionized and thus less able to voice concerns.

OCSA recommends that client continuity and respect of the relationship between existing employees and consumers of service should be paramount. Consequently, employee transfers to new agencies should be seamless with no break in employment or client service.

All employees of not-for-profit community support service agencies should be guaranteed comparable positions in the new service delivery structures without loss of seniority. Otherwise, in all community support sector hiring, displaced employees from not-for-profit community support agencies should be given priority over other socio-healthcare sector employees.

To reiterate the concerns of Mark Mieto earlier from the region of Sudbury, I will speak only for areas 11 and 12. I think that the actual job titles must be really looked at. Job titles are not truly indicative of the job descriptions that people are performing. As mentioned previously, an executive director in an agency may be answering the telephone and taking client applications and delivering meals in that sort of instance where there aren't a lot of staff. There aren't personnel managers, there are no finance managers.

To give further credence to that, just last week I had to go pick up a burnt meal and discuss it with the client and then bring it to the food source, and I am listed as an executive director of a Meals on Wheels agency. So I think we have to seriously look at what actual job duties are within a particular job description.

With the job description being looked at, there is a possibility that once job descriptions are looked at, not just job titles, it may require two people to perform one job, and will this really be truly cost-effective with the new system?

The staff that are currently managing and doing the day-to-day operations of these agencies are trained and they're willing to undergo more training. They have relationships with clients, community contacts, and are dedicated to their clients and their mother agencies, and they deserve to be a top priority.

Pages 35 to 41 deal with the general regulations, and it is a view that Bill 173 has taken an overly prescriptive approach to the provision of community-based services. OCSA is concerned that 42 regulations have yet to be produced. Much is unknown at this time, yet the areas to be covered appear to be quite prescriptive. It is very difficult to present a response to the legislation in the absence of the detailed information which will be in the regulations.

OCSA recommends that OCSA must be actively involved in producing and approving the regulations to be developed for Bill 173. Furthermore, OCSA recommends that extreme caution needs to be applied in setting retroactive dates of application.

The next issue I'd like to address is volunteerism in the reform long-term care system. It is an essential component in the delivery of community-based services. Many could not function without it. The volunteer base must be recognized as being deeply rooted in the community and potentially fragile. In addition to their work in direct service provision, they also raise a significant amount of dollars that allow programs to continue.


There is a lack of detailed planning regarding volunteers in the long-term care. Historically, volunteers have always been the backbone of community support, and they must be recognized and the issue addressed. OCSA recommends the following: that there be recognition of the role of volunteers in the body of the legislation, and that volunteer management in regulation number 11 should be expanded to require MSAs to develop and implement a plan for the recruitment, training, scheduling, supervision, retention, recognition and expense reimbursement of volunteers. The lack of mention in the bill regarding volunteers and the government's viewpoint that the volunteer will continue on in much the same way as before are perhaps an oversight.

Participation in discussions with persons who are volunteers has strongly suggested that your average volunteer will not volunteer for a large bureaucratic organization. Their loyalty is to individual agencies, staff and clients. Volunteer management must be mentioned and given adequate dollars, especially initially when the volunteer base of Ontario will need to be re-educated regarding the redirection of long-term care.


Ms Poitras: Sorry.

The Chair: We're awake.

Ms Poitras: Is he awake too now?


Ms Poitras: Is he? He's leaving? Well, it's 10 to 4. I had to do something to make sure you're all paying attention.

With regard to the volunteerism issue, we have also have to look at the board of directors that is currently in place, the wealth of information they bring with them, contacts. Often you have lawyers or accountants who bring expertise without cost to agencies. Will they be prepared to do this for an MSA or will these services now have to be purchased?

On the multiservice agencies, the only thing I'm going to say about pages 12 and 13 is that it is essential that there be sufficient flexibility to allow communities to develop an MSA system to meet local needs. I think from the presentations I've seen this afternoon that's come out as a very, very strong point. If you've seen the OCSA response to Bill 173, you've read the recommendations, and it's very similar. Everyone is looking for community input.

The other thing I would like to address is the limits on services purchased regarding the 80-20. It is assumed that the client who has financial resources and prefers to purchase services from a not-for-profit or profit agency will not be restricted. Will there be flexibility allowed over the 20%? What if a client lives in an area where the only available services have to be purchased? There are a number of agencies, some of which are Meals on Wheels, which do not receive any government funding. What will be the impact of this policy on those agencies?

A single provider -- for example, a homemaker agency -- may provide services that fall within at least two of the service categories. Therefore, it may be very difficult to allocate costs. Will moneys be allocated from the funding envelope to ensure that needed services are developed within the MSA? Will this cause duplication and force other agencies to either (a) become part of an MSA or (b) dissolve because MSA cannot purchase their services?

The 20-80 split of services: Where are these figures arrived at? Are they arrived at by looking at the agencies that will be legislated into being an MSA, and the government has said, "Oh, we will only have to purchase 20% out of the MSA"?

In conclusion, I would like to state that OCSA applauds the leadership demonstrated by the provincial government through the development of Bill 173. It establishes a key building block in the foundation of the new long-term care system. We appreciate the commitment to building partnerships with the community to effectively plan and implement meaningful change.

I thank you for this opportunity to bring forth our concerns and I now leave the floor open to questions and answers.

The Chair: Again, I ask members to be brief in their questions as we do have a bit of a problem with time. We'll start with Mr Malkowski.

Mr Malkowski: Thank you for your presentation. From time to time I volunteer for East York Meals on Wheels. I find that a very valuable service, and I encourage other members to participate in their local Meals on Wheels because I think it's a good experience.

The people at the East York Meals on Wheels spoke to me similarly on points that you mentioned when they talked about the concerns of their non-union members and about other concerns that they heard. A point that they made: They thought perhaps if there was an amendment to the legislation which included a coordinator, a mandated position of coordinator of volunteer services for each MSA, so that they would be responsible for doing recruitment and outreach and training of the volunteers. I would be interested in your comments, if you thought that was a worthwhile idea.

Ms Poitras: Excuse me. Is there one manager of volunteer services for each MSA?

Mr Malkowski: Yes.

Ms Poitras: I will speak on behalf of what I know, Meals on Wheels, and we'll use that as a basis. We have a volunteer base of almost 400, so if you take just Meals on Wheels -- we're not talking VON, Red Cross, Alzheimer's, anybody else who may be part of the MSA -- I have trouble in thinking that one person could manage, recruit and train enough volunteers to man every single agency.

Mr Malkowski: Then perhaps do you have any suggestions or other ideas that might help the MSA with this?

Ms Poitras: I think traditionally the position of volunteer management has always been kind of: "Well, if we have the money, we'll hire them. If not, we'll get a volunteer to recruit some more." I think we have to recognize that volunteer managers are true professionals and that the service they provide for the agency is invaluable. They have interpersonal skills that are just unsurpassable, to get these people to do what's needed to be done. So I think that each particular program or department or agency within an MSA must retain its own volunteer manager.

Could I just ask for a clarification from the policy person to reply to that?

Mr Quirt: The presenters were quite right that a great number of our home support agencies have volunteer coordinators, and in effect our funding goes to help coordinate volunteer effort in many home support organizations. So MSAs would be free to have either one large volunteer recruitment training and support department or to have volunteer recruitment people specific to each program, whichever they felt was the best way to do it. But clearly the recruitment and training and support of volunteers is going to be a very necessary, ongoing skill, and that's why it's important that the people who are good at it now continue to do that job.

Mrs Barbara Sullivan: We see the Ontario association recommendations, and I was a little disappointed that you moved so quickly over your reactions to the multiservice agency, because indeed we had a little dispute this morning with respect to what the position of your association was.

I indicated that it was my understanding, from presentations that have been made to the committee, that in fact you had made very strong recommendations with respect to the MSA. Indeed, I have the Ontario recommendations and they suggest, in part, that functional integration of information could be achieved through electronic communication systems, by combining physical locations for smaller community support agencies to achieve economy of finances and volunteers, and that functional integration, of course, would respect the need for increased coordination of access.

Indeed, what you suggest is that "if functional integration is pursued, top priority must be given to ensuring that there is an effective computerized information network in place" etc. You also believe, and I just want to say this for the record and you state quite clearly, that "MSAs must not be allowed to develop into large bureaucratic organizations," which is a very grave concern to all of us. You also believe that there must be consistent standards throughout the province.

I also want to note: "One-stop or single-access does not necessarily mean that all services and care providers have to be assembled under one roof and that consumers have only one point of contact in the community." It may, for example, be achieved by a functional integration of information, referral, assessment case management, service delivery and follow-up in multiple locations.

Recommendations that you have made through your Ontario body, through the presentation which was made from I think districts 13 and 14 yesterday -- and yours today, indicate that indeed your association is not 100% committed to the model which is included in Bill 173, and I want the record firmly corrected.


The Chair: Do you want to comment on that?

Ms Poitras: I appreciate Ms Sullivan's disappointment that I skipped over that. Unfortunately, I wasn't here to actually see what went on this morning, but I figured somebody would bring it up during the Q and A period.

I do have in front of me the policy resolution that was passed by the general membership in May 1994 by OCSA. Their position clearly states: "We believe that community development principles and processes should be applied at the local level in order to develop the appropriate community multiservice delivery mechanisms. Therefore, be it resolved that OCSA support the reform of the long-term care systems provided the following policies are adhered to."

Mr Russel DeCou: And then it goes into the recommendations.

The Chair: And what you have read, just so we understand, is in the submission.

Ms Poitras: Yes. Like Ms Sullivan has stated, there are concerns. We approve a system that's going to provide better client service, going to be more cost-effective, provide training, adequate staffing dollars, adequate volunteer dollars, but we do have serious concerns that need to be addressed, and that's why seven representative OCSAs will be meeting and talking to your committee.

Mr Jim Wilson: I think in the list of concerns that you did mention today and mentioned in the past, one which is key to this bill is the 80-20 rule, and you mentioned your concerns about that again today. I have a very simple question. Not wanting to be provocative as a Health critic, and doing my job as such, I'll simply ask you, and it's come up consistently in the OCSA briefs and I must admit it's a point that needs a bit of explanation for me: You said today you asked the government to exercise extreme caution in establishing retroactive dates. It's in the list, one of the recommendations.

Ms Poitras: Recommendations of OCSA in their response?

Mr Jim Wilson: Yes.

Ms Poitras: What is it that you --

Mr Jim Wilson: The first four or five times I heard it, I didn't quite know what it meant. What does it mean? I know there are some retroactive dates in terms of an MSA taking on its role. There's a one-day overlap or something.

Ms Poitras: I think it all has to go along with the former presentations that you've had today, just extreme caution in everything: the go-ahead dates, that sort of thing. OCSA just wants to make a stand that they would like things to be clearly thought out before things actually go ahead, and have ramifications of retroactive dates fully been thought out? That's my understanding.

Mr Jim Wilson: Is it referring to a clause in the bill, Mr Quirt, do you think, or the parliamentary assistant?

Mr Wessenger: I'm advised that there is a power in the bill with respect to making retroactive regulations, or regulations retroactive. I'm also advised it would be exercised with due caution because it generally relates to the question of funding issues, to recognize the fact that moneys have been advanced in the past. So that's the purpose of the regulation, as I understand it.

The Chair: Thank you for coming before the committee this afternoon. Before adjourning our meeting here, I think it only appropriate to ask Mr Martin if he wishes to make a few brief closing remarks.

Mr Martin: Can I finish the discussion with Ms Sullivan?

The Chair: Oh, no. I would prefer we did some nice things about Sault Ste Marie and the district of Algoma so that we can leave in a cheery mood.

Mr Martin: I just want to thank the committee and all who are involved for coming to the Sault and hearing us out here. I think today as well, to the folks who have been here, the committee has heard a very full and fair representation of the level of concern and interest, and actually enthusiasm, about this whole process, and I think it will only but be helpful. So just thank you to everybody. It gives a face to the democratic process that we often so much talk about and yet don't always see, so thanks very much.

The Chair: Thank you, Mr Martin. To the committee members, the bus for the airport will be at the front of the hotel in about 25 minutes, at 4:30, so if people could make sure they are there and we'll go out to the airport. I would remind everyone that we begin our hearings again tomorrow morning in Toronto at 9:30 and then later in the afternoon go on to London, where we will be meeting tomorrow evening.

With that, the committee then stands adjourned until tomorrow morning at 9:30 at Queen's Park.

The committee adjourned at 1606.