Monday 12 September 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

Lise Nolet

Victorian Order of Nurses, Eastern Counties, Pembroke, Ottawa-Carleton and South Renfrew branches

Beth McDonald, executive director, Ottawa-Carleton branch

Charles Armstrong, president, Ottawa-Carleton branch

Joan Booth, president, South Renfrew branch

Ottawa-Carleton Community Health Centres

Martha Smith, manager, seniors program, South-East Ottawa Community Services

Karen Stotsky, executive director, Centretown Community Health Centre

David Hole, executive director, South-East Ottawa Community Services

Peggy Feltmate, executive director, Community Resource Centre of Goulbourn, Kanata and West Carleton

Community Support Coalition of Ottawa-Carleton

Ginette Rashleigh, manager, home support program, Gloucester Centre for Community Resources

Carol Halstead, administrator, home support program, township of Osgoode

St Patrick's Home of Ottawa

Maureen Goodspeed, board chair

Bradson Home Health Care

Allayne Evans, vice-president

Margaret Simons, home support worker


Isabel Leach, coordinator, Dr L.U. McCluskey Centre

Eileen Sicoli, coordinator, pastoral care

Service d'entraide communautaire pour les aînées et les aînés francophones

Denise Chevrier, vice-présidente

Pierre Périard, directeur général

Union of Ontario Indians

Dr Alan Roy, health director

Vernon Roote, deputy grand chief, Anishinabek Nation

Regional Municipality of Ottawa-Carleton

Peter Clark, chair

Garry Armstrong, commissioner, homes for the aged

Betty Margeson

Ottawa-Carleton Regional District Health Council

Jacqueline Neatby, long-term care committee

Avril Gunter, chair, multiservice agency working group

Council on Aging for Ottawa-Carleton

Sylvia Goldblatt, president

Jean Shaw, chair, long-term care task force

County of Renfrew

Alvin Stone, warden

Andrew Dickson, reeve and member, welfare and homes for the aged management committee

Michael Johnson, chief administrative officer and treasurer

Ontario Hospital Association / Association des hôpitaux de l'Ontario

Laurent Isabelle, chair-elect/président élu ou désigné

Dan Drown, senior consultant, chronic care, mental health and rehabilitation division

Michel Bilodeau, president, Council of Chronic Hospitals of Ontario

continued overleaf

Continued from overleaf

Sisters of Charity of Ottawa Health Service

Michel Bilodeau, president

Ottawa West Seniors Recreation Advisory Committee

Tom Sparling, manager, recreation and volunteer services, Beacon Hill Lodge.

Karen Colby, recreationalist, Central Park Lodge

Lindsay Webber, recreation therapist, geriatric psychiatry department, Royal Ottawa hospital

Ontario Home Care Case Managers' Association, eastern region

Judi Burke, membership secretary

Susan McGurn, regional representative

Canadian Red Cross Society, Ontario division, Ottawa-Carleton branch / Société canadienne de la Croix-Rouge,

division de l'Ontario, section d'Ottawa-Carleton

Jane Levoy, manager, homemaker service, Renfrew North

Madeleine Germain-Kennedy, client, homemaker service

Senior Citizens' Consumer Alliance for Long-Term Care Reform, Ottawa branch

Bert Hanmer, representative

Ontario Community Support Association, area 10

Janet Snyder, executive director, King's Daughters Dinner Wagon

Ann Hargest, member, Visiting Homemakers Association of Ottawa-Carleton

Health Care Unions of Ottawa-Carleton

Betty Sommers, chair

Charlene Avon, national staff representative, Canadian Union of Public Employees

Addiction Research Foundation

Christine Bois, program director

Centre de santé communautaire de l'Estrie

Roland Beaulieu, directeur général


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

*McGuinty, Dalton (Ottawa South/-Sud L)

*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:

Gigantes, Evelyn, (Ottawa Centre ND) for Mr Rizzo

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

Sterling, Norman W. (Carleton PC) for Mrs Cunningham

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

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

Wessenger, Paul, parliamentary assistant to the minister

Clerk / Greffier: Arnott, Doug

Staff / Personnel: Boucher, Joanne, research officer, Legislative Research Service

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


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): We have a very full schedule today here in Ottawa going through until later this evening, so we'll begin this morning's presentations. I invite Lise Nolet to come forward, please. Good morning and welcome to the committee. We have received a copy of your presentation, so when you're ready, please go ahead. We have 20 minutes.

Mme Lise Nolet : Merci. Bonjour, mesdames et messieurs. Good morning, ladies and gentlemen. Je me nomme Lise Nolet. Je vous adresse la parole aujourd'hui non à titre de professionnelle des soins de la santé mais à titre d'une citoyenne intéressée au domaine, puis aussi à titre de la plus jeune membre du Conseil consultatif de l'Ontario sur la condition féminine.

Ma présentation est suite à une consultation avec quelques-unes de mes collègues au Conseil consultatif, et puis aussi d'intérêt personnel, puisque j'ai une soeur qui est atteinte d'une maladie assez grave et qui sans doute, ou probablement, devra avoir recours à vos services, peut-être plus tôt qu'on l'aimerait. J'ai aussi remarqué que c'est souvent une question d'implication ou d'intérêt spécifique pour les femmes, les soins de santé de longue durée. J'ai de même remarqué ceci en lisant votre politique. La majorité des ministres du cabinet qui étaient impliquées étaient des ministres femmes. Donc, c'est ça qui est la présentation d'aujourd'hui.

In principle, one cannot dispute being in favour of the proposed community-based long-term care model, because it establishes a long-awaited empowering quality care. The empowerment of communities and clients is an interesting aspect of this bill, and this I find is a very positive aspect.

There are some other positive points that I would like to point out to you from Bill 173: the fact that it strengthens viable alternatives to existing rigid health care regulatory systems; the fact that it wants to improve service quality at local levels through a flexible regulatory framework; the fact, as I have mentioned earlier, that it empowers communities and clients in their capacity as decision-makers and providers of services and also as consumers of health care services. It will facilitate an equitable access to services by various interest groups and regions and it will guarantee an appropriate accountability by decentralized health care administrators.

However, as with other proposed programs, some flaws do exist and some questions remain unanswered. This is why I have decided to come forth today and do a presentation. My questions and the points that I want to raise to your attention today are of specific interest to women in Ontario.

In their diverse roles in society, women take part in long-term health care with their hearts and sometimes their lives. Clients are often women, who necessarily have different needs than men. The reason why women are often clients is because of their longer life expectancy and the fact that women make up the large majority of the family members who are caught in the middle between their work, their children, their ill partners, their ill and elderly parents and their ill children. Therefore, Bill 173 may raise some concerns for those women who work in and/or consume long-term health care services, such women as retired women caring for aging parents, disabled or ill partners, disabled or ill children:

-- Local responsibilities delegated to municipalities may mean a lack of consistency among program delivery methods depending on the local district health council's priorities, therefore moulding the services according to the degrees of awareness of the region to women's special needs, as well as various regional practices in human resources management.

-- Northern Ontario women and other rural regions in Ontario may be disadvantaged in the budget allocation model. Such reasons are for the travel costs, the isolation and the lack of qualified health care professionals to serve those designated areas.

-- Some criteria may differ from region to region in organizing the waiting lists for services, again based on varying levels of women's needs awareness among regions.

-- Special assistance in 24-hour care will be needed by disabled women who have children.

-- Cutbacks to hospital jobs, which represent decent wages, good benefits and permanence: These will be replaced by community-based jobs, which will probably be for the most part contract-based jobs, depending on patient load, with little or no benefits or security. It should be noted that most of those health care professional jobs are held by women.

To approach the above issues, an appropriate understanding of real-life problems is needed to respond to women's concerns. The reform of long-term health care legislation is particular in its span of impact. It will indeed affect the weakest members of our society -- that is, the chronically ill and the elders -- and will transfer their future into the hands of the communities in which they are part.

The various actors involved in this reform are in major part women. The roles, needs and benefits of women in Bill 173 are diverse but can be classified in various categories according to the functions women can play in the long-term health care system as clients, as taxpayers, as agency administrators and as health care workers. In each case a particular concern emerges, and history tells us that women's concerns, while being sometimes very different from men's agenda, are often obscured in such reforms due to the lack of awareness for women's special needs and roles in the health care system. One needs to admit that each region in Ontario differs in its degree of understanding and willingness to support women's special needs and roles and benefits in health care.

The decentralization of long-term care services may increase this segmentation of women's needs understanding. A major implication of this is that each agency and district council is free to interpret what women really need and what their role can be in providing long-term health care services. Moreover, the guarantees of proportional representation of women on administrative boards and in decision-making are virtually left to each agency and council, which increases the risk of lower awareness of women's needs and roles.

Because of their important involvement in the health care system, and because of their particular needs and constraints when becoming dependent on long-term health care, women do have a dramatically different agenda than men. The reform should in effect take this fact into consideration, since it may detrimentally affect the lives of quite more women than men, and this to quite different extents.

I understand that legislation, when passed, must be flexible enough to evolve with time passing by and avoid making references to the changing conditions of specific groups in society. Nevertheless, it should be possible to recognize seemingly stable patterns of gender relations behaviour in Ontario's regions and of the structure of female lives and work in the health care system.

The issues raised above are still at the stage of questions. It would require a certain amount of clarifications from professionals to guarantee that the responses to those concerns are positive for all women. I nevertheless attempt to point out a couple of such issues in detail here which make reference to specific sections of Bill 173; for example, when I discussed the waiting list issue earlier.

Bill 173 deals with the waiting list issue in subsection 21(2) by stating that the person in need of services will be placed on a waiting list if the service is not immediately available to him or her. But my question to you is how this list will be prioritized. Will this waiting list be based on a first-come, first-served basis of application, or will there be needs assessment to prioritize who is in greater need of these services?

For example, if a needs assessment is not conducted, a young mother with two young children who is disabled with multiple sclerosis may be in great need of care for her children and for herself to keep going on a daily basis, but if she has been put on the waiting list later than someone who is not as severely handicapped or in as great need as she is, they may have services before her. That is why I feel that needs assessment should be conducted in order to prioritize waiting lists.

Another scenario: I am wondering if chronically ill or elderly people on a waiting list will be disadvantaged if they have informal care givers at home taking care of them. We should note that these informal care givers are often women who have to care for them. They are in great need of support also, and I'm wondering if these people will be disadvantaged.

On another issue, subsection 2(7) of Bill 173 deals with the professionals. It enumerates all the professionals that will be dealing with this new health care system -- well, they have always been dealing with the health care system. These are all professions that are traditionally occupied by women. The caring and helping professions, as they are known, are not the highest paying professions, especially for female workers, and now if they become decentralized, they may even be less secure, with less benefits.

In conclusion, this evaluation of Bill 173 could continue for hours. In my quality of ordinary citizen, I may not afford this procedure. However, it is this Legislature's responsibility to recognize the special roles, needs and benefits of women in long-term health care reform.

We have pointed out earlier that the decentralization and empowerment of the system in providing these services will generate new possibilities for better administration of health care. But our statement of women's concerns and their particular perspective in the health care system should provide this committee with sufficient material for further analysis. I commend this Legislature to come up with clear statements and guarantees of women's particular needs, roles and benefits of Bill 173.

Mrs Barbara Sullivan (Halton Centre): Welcome to the committee. You're the first person who has come before the committee to specifically identify the particular concerns of women. I think that in one area, with respect to the waiting list, you've identified a problem that's a singular one with this legislation. The only guarantee, in fact, in this entire legislation about long-term care is that one will be put on a waiting list.

We know that in other circumstances, whether it's hospitals or waiting for services in other areas that are non-institutional, there are various methods of determining what kind of priority there would be. Sometimes it's geography, sometimes it's acuity, sometimes there is an examination of what the health and social needs are, and sometimes the waiting list is completely determined by service availability.

My deep concern with this legislation is that because the only guarantee is that there will be a waiting list, and secondly, there is no guarantee that funding will flow to the MSAs to provide the services, in fact the waiting list will be controlled by the fact that services simply aren't available in a community, and many of those agencies that have been providing those services will simply be put out of business. I wonder if you'd comment on that. Have you considered, I guess, the issue that in fact the rationing will be done because the services won't be available?

Ms Nolet: Yes, but I was just wondering how the waiting list procedure will be conducted, if it will be on a first-come, first-served basis or if there will be needs assessment conducted to ensure that the people who are in great need of the service will be getting that service before other people who maybe are -- well, we can't say that anyone is not in need of a service, but with the needs assessment, we can measure and identify special-needs people who are maybe in more urgent need. That is the point I wanted to make.

Mrs Sullivan: I understand that, and I think it's a very good one. The difficulty is that there's no criterion for establishing those waiting lists. The criterion is just that the waiting list be established. Thank you for making this point.

The Chair: Thank you very much. I regret that since there are a number of presentations today, we're limited with question time, but we appreciate your coming before the committee this morning.


Mr Larry O'Connor (Durham-York): Can I make a point? We received today also some information by ministry officials on governance. In light of the information -- it's really quite useful and practical -- I wonder if we could have the clerk make additional copies so that we can pass one on to the people who make the presentations as they leave, because it does answer some very practical questions for these people.

The Chair: I think we can arrange that.


The Chair: I call the Victorian Order of Nurses: Eastern Counties, Ottawa-Carleton, Pembroke and south Renfrew Branches. I would just note to committee members that as we have done on a number of occasions with the VON, they have come together to make a joint presentation, which is the reason for there being more time. Depending on how that time goes, I will work in one or more questions.

Ladies and gentlemen, welcome to the committee.

Ms Beth McDonald: Good morning. On behalf of the Victorian Order of Nurses, Eastern Counties, Pembroke, Ottawa-Carleton and south Renfrew branches, we're pleased to come before the Ontario Legislature's standing committee on social development to share with you a joint perspective from the areas served by our branches. The members of VON representing the branches are Charles Armstrong, president, VON Ottawa-Carleton branch; Joan Booth, president of VON, south Renfrew branch; and Beth McDonald, executive director, VON, Ottawa-Carleton branch.

At the outset, we commend the government for demonstrating ongoing commitment to involving stakeholders -- volunteers, consumers, service providers and others from across the province -- in this process of health care reform. Again today, you have shown your willingness to consult with the people through your visit to this region and your invitation to the VON to present before you.

Our paper, which has been circulated to you, gives a brief overview of who we are, followed by areas of the legislation VON endorses as well as our key areas of concern and recommended revisions to Bill 173.

For the purposes of this presentation, highlights of our brief will be presented. We will hear first from Joan Booth, president of south Renfrew branch.

Mrs Joan Booth: Thank you for the opportunity to present to you. As a volunteer, I wish to begin by addressing the planning document, A New Way to Plan, Manage and Deliver Services and Community Support.

On page 4 of the partnerships document we read, "Ontario has a number of excellent long-term care and support programs that provide a wide array of services."

To take over everything which you acknowledge to be excellent because there are a few flaws and limitations would be one of the most paternalistic approaches possible. Surely a more mature and democratic approach would be to offer help and constructive guidance. Democracy is more about growth, independence and ultimately interdependence than about control, power and takeover. In the 19th century, Abraham Lincoln summed it up in the words, "As I will not be a slave, I will not be a master."

Another quote from the document: "Neighbourhood and other groups have made significant contributions to supporting members of their communities by developing community support services, with volunteers in many instances playing an essential role in the provision of these services."

Here, may I add, volunteers have played an essential role in the initiation of many of the services too. As a volunteer, I helped build, deliver and fund-raise for many of the support services and programs available today. Like many others, I volunteered because it's a way of life. Volunteering is giving from the heart, just one of life's responses to life's knocks, opportunities and experiences. In an age of designer labels, it seems only what is bought or paid for has value or respect and anything given freely has no worth and is even suspect.

Another quote from the document: "The MSA plan must include an employee transition plan outlining: volunteer responsibilities and recruitment and retention strategies...."

This plan to actively recruit, train and retain volunteers is a misuse of the term "volunteer." Volunteering grew one person at a time. Now these persons are perceived as a group. Such collective nouns when referring to individuals suggest someone seeks to manage and control. In this context, volunteers as employees, unpaid workers, might more aptly describe the intent. However, since workers have benefits, remunerations, rights and protection, it would be equally incorrect to use that term.

Another quote from the document: "Volunteers will be needed.... Fund-raising, promotional and public education activities, so ably carried out by many volunteers now, will continue to be essential in the MSA."

Thousands, perhaps millions of hours of unpaid work will certainly be needed, along with hundreds of private vehicles, to make the government big MSAs work and to fill the gaps which will be created by the dissolution of agencies, early hospital discharges and an aging population. Throughout the reform process, it does not appear that quality of service is being challenged, rather the affordability of agency boards.

Another quote from the document: "Board members are volunteers. In most agencies, board meetings and related activities require much time and energy."

Have board members complained? No. They are volunteers, free to resign if they find the commitment too onerous. How the amalgamation of agency boards into one big MSA and the setting up of new administrative bureaucracies will be more cost-effective is very unclear.

Another quote from the document: "With the amalgamation of boards, some board members may want to participate in other areas of interest, such as direct client service, or projects which support the service operations."

Many board members already do this in their communities in a variety of ways. The plan to dissolve agency boards at the time that boards have evolved to boards of governance developing a team approach to the service delivery by the agencies seems very negative.

Another quote from the document: "Communities can ensure some services do not lose their individual identities as they become part of a larger MSA organization, especially if this individuality is important to consumers. Through the use of such identifiers as a service name, logo or service location, these once separate service providers whose boards have amalgamated within the MSA can retain their individuality."


How is this possible? A logo or name are as much an integral part of an agency being a corporation as is its board. Perhaps more disturbing is the implied deception that the agency is still in existence.

The big MSA is about amalgamation of service providers; dissolution of agency boards; deployment of employees, paid and unpaid; a monopoly of hiring, planning, service delivery, monitoring, budgeting, funding and evaluating: about control and takeover. Is that what a consumer expected?

As a person needing one of the services, the greatest concern is clause 21(2) of Bill 173, "If a community service outlined in a person's plan of service is not immediately available, the approved agency shall place the person on the waiting list for that service and shall advise the person when the service becomes available."

A great deal of time has been spent on improving access to the basket of services, which is commendable, but will there be adequate funds to fill the basket, replenish the basket, pay for the new costly administration of big MSAs, remunerate all the employees who will be needed in the community on an equitable basis, for example, for transportation, including the additional persons who will be needed with hospital bed closures, facility beds limited and more persons scattered in the community? Even employees labelled volunteers will have to get to where they have to go. With no cost analysis, the improved access could translate into access to waiting lists. The anxiety, confusion and now disillusionment are becoming as contagious as fear, hardly a recipe for health and wellness.

District health councils are making a gallant effort to comply with ministry direction in order to qualify for one-time funding in November. They are planning as if the MSA of clause 11(1) of Bill 173 had already been mandated, not for a bill still to be debated and not yet law.

Our recommendations: Produce legislation which will concentrate on access; streamline information and referral, eligibility and assessment by developing generic forms; increase use of technology for information management and exchange of data; plan for a continuum of care; make it possible for agencies to work more collaboratively by bringing together approved member agencies in a federation, conglomerate, consortium or even association, like a good United Way has an association of member agencies to reduce duplication and fragmentation; and please, handle our tax dollars with the same care and accountability as the United Way agencies handle our donated dollars.

We have to pay our taxes and put the money in your hands. We have no choice. But we do have a choice whether or not we give to help our communities. Please respect the ways in which we choose to give and leave volunteering in our hands.

As partners in long-term care, we are requesting a renewed way to plan, manage and deliver services with community support. Preserve what is valuable, fixing only what needs fixing, so the legislation may become truly an act respecting long-term care.

Mr Charles Armstrong: As we approached this topic, I tried to reassure myself -- and continue to do so -- as I made my notes that we were not approaching this -- I was not approaching this and VON in the province of Ontario was not approaching this -- as an emotional question. There's no doubt that when the concepts were first dealt with in policy papers, it was a very emotional time as we dwelt on our past and questioned where our future would be. I know as a branch we've gone beyond that and I hope our comments and our paper today really deal with a thoughtful, professional approach to long-term care in Ontario. That's the approach I believe we are taking.

As I made my notes, I said this is probably more a political process than an emotional one, and I somehow felt if we could remove the emotion in the politics, we could all go home and get the job done. There's no doubt that if we fail at this, the emotion on the streets will be quite real, as health care is one of the most fundamental services that the province does provide. As an accountant, I think we're always looking at the downside, and that's a real concern.

VON, among the branches that are here today, without question -- there's no uncertainty -- accepts the objectives of long-term care and the reform: the coordinated approach, the consumers, the ease of access and being in the community. Albeit they're rather vague and imprecise, they are worthy objectives to work towards, and I'll explain that further.

Ontario should be proud of what we do have. We do have very strong community health care and long-term care. It's probably the success of what we have that's bringing us together at this time in that we are concerned about costs, and it's the success of what we have that's part of that problem.

If I look at our community and look at the players in this community, and I'm sure in many of the communities, we have strong players. We have knowledgeable professionals within the DHC, within the home care program, within the community groups. I have no doubt that within those groups there is the knowledge, the history, the experience, the professional training to work towards and solve some of the things that we're trying to solve here in the consumer-friendly and ease of access.

My concern, and this is probably quite personal, is that over the last period of time we've moved from one policy statement -- we had a range of colours -- and one policy paper to another, sat at board tables and tried to interpret what was being addressed, what did this mean, where are we going. We always say, "Well, there's not sufficient detail; there's not enough information to really know how to interpret this." And all of a sudden, we've jumped from those policy papers to proposed law.

As we sit in the community, we're very concerned as a branch. There's not sufficient costing, there's not sufficient detail and analysis to have the confidence that we really know what we're doing. My concern is that we haven't done the costing, we're not sure what this is going to cost to do, and yet we are comparing those costs to what we're trying to achieve, what we're trying to save.

Once we unravel what we have, I'm not sure we can put it back together that quickly. The Canadian Broadcasting Corp, some people within the corporation, decided that the news should change from 10 to 9 -- and I'm sure that wasn't broadly accepted within the corporation -- turned out to be wrong, and it's not that hard finally to change the news back to 10 o'clock. This won't be that easy to put back if we go too far.

In thinking of what is happening in many provinces, in fact in many countries, there is definitely a move to privatization and to break up into smaller component parts, and perhaps that's exactly what the province is doing, but from the community's point of view, we're doing the opposite. We have the potential to go from free-standing groups to an amalgamated concept. If you read all the management books these days, the whole new theme, and we change the themes on a monthly basis, I think, but the focus now is on team playing. All the new books are on teams and objectives and hit squads and all that kind of thing, and I'm not sure that this is moving in the right direction there.

As I sit and try and say, "What are we trying to achieve?" I believe cost-effectiveness is one of the objectives, apart from the consumer focus, which means we are going to have to have, and I believe there's a belief that we're going to have, fewer employees. They'll probably be middle-management-type people, which is happening all across the country in all kinds of industries. I believe there's a belief that we're going to reduce the overhead costs, and I'm sure there's a belief we're going to try to quantify the amount of product or reduce the amount of product that's available to be consumed.


We haven't seen those costs. I have no idea what the financial targets are. If we knew that, if you knew that, then the next question would be, is there another way we could save those costs or achieve those savings, and are they even meaningful targets? There's definitely going to be a cost to put this together, and I don't know what that cost is compared to the savings.

One cost that is not talked about enough -- we're certainly talking about it -- is the cost to close community groups. We've got commitments, we've got equipment and most of all we've got people. If there's job loss through this transition, there are certain laws that have to be upheld and people need to be paid, and there's going to be a major cost if there's a major downsizing in personnel.

Thinking about an MSA in the community, I think you see it as a community group with volunteers. At least at this stage, the community sees it as an imposed arm of the province with a bureaucratic flavour to it. I'm convinced that the MSA will be more bureaucratic, with more management people than most of the community groups. I look at our branch in Ottawa. It's a $12-million-plus operation, and if we took out our staff who were involved with front-line people, we'd probably have two or three management people. The MSA will not be like that, I guarantee you.

I'm perhaps embarrassed to make the next point, but I have confidence that if you compare our salary costs to what your salary costs are going to be, there's going to be a gap and I think our staff will be happy because they're going to get increased salaries. So that's a plus from that point of view.

If you compare the dedication of our salaried staff in a voluntary organization with a history and a sense of team play and a purpose with a municipally run or a broader organization, I'm not sure the same dedication, the same donated time will be there. It's just a concern.

I guess the last comment in that theme is, who's on the street Friday night at 5 o'clock? Whom do you phone if you need help? It's the community groups in most cases. You don't try to phone a department of health after 5 o'clock.

On the financial side, I can assure the committee that within the branches, our branch in particular, we would donate, we would contribute to the program, your program, on an annual basis $50,000 to $200,000 or $300,000 in terms of training, education; funds we don't receive as part of our fee structure, money that we raise to train staff as the mix of clients we receive changes. As we get pressured to reduce our fees, with a heavy investment in computerization, retraining, those are real dollars multiplied across all the community groups. I guess I'm predicting those dollars will not be there.

Our goal: Regardless of what happens, we will continue on. VON will exist. We will be fund-raising for our own self and carrying on. I'm concerned that that drying up of funds is real, and huge dollars.

I guess our recommendation is, remain as flexible as you can. Nobody has a model in mind that they have confidence in. I've talked to countless people within the Ministry of Health, within the colleges and the universities and various agencies. Everyone has their own theory. Everyone believes they have a model that works, and "What's wrong with the other person's model?"

If we're not really sure, then I suggest we take a medical approach or a scientific approach: When you're not sure you just don't go and do it. You start small, you experiment, you test, you do a prototype in part of the province. The downside -- it's too big. Many of the professionals are saying, "We're looking at the community health care and long-term care," which is a small part of the total health care scene. I'm sure that's next and it makes sense to do this part before we look at the whole thing.

The province's role I believe is to set the goals, objectives, the policy, the direction, which is being done. The province should be providing encouragement and support, which it's doing. That support also has to be financial support. The province needs to monitor, follow up, make sure that this policy gets implemented. But I really believe that until we know what we're doing we should go slow, we should let the professionals in the health care field tackle this thing, probably on a project-type basis, and above all, if we could go ahead without the emotion and without the politics, I think the consumer in Ontario would be the best served.

Ms McDonald: Having heard those comments, VON recommends the following areas be considered for revision in the act:

Greater flexibility in the model for consumer access to services. 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 mandatory services are accessible and protected, avoiding the bureaucratizing of the multiservice agency and ensuring the communities' flexibility to design the MSA appropriate to their needs. The development of provincial standards for delivery, monitoring and evaluation of those mandatory services, assuring consumer choice, guaranteeing adequate funding to meet consumer needs and the ability to mandate alternate MSA delivery models if objectives of long-term care reform are not achieved will ensure the purposes of the act while allowing the needed flexibility.

Protection of workers, regardless of affiliation to bargaining units, in the event of agency mergers. If the model for an MSA 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 bargaining agents 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 a multiservice agency. 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.

Stated protection in the act for severances and other liabilities. In the event mergers result in severance of workers and other outstanding liabilities, such as with property or dissolution of corporations, 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 the government or reinvested in the community to enhance service delivery.

Stated preference for a not-for-profit registered charitable organization as a sponsor for the fully integrated MSA. The government has recognized that many charitable organizations are supported through donations and other sources of funding, such as United Way. Tax receipts are provided to donors and are an incentive to the donor. In order to ensure that much-needed contributions to charitable organizations continue, the MSA must be a charitable agency.

Building on existing skills and experiences. VON strongly believes in building on the existing skills and experiences already in the community. Such system is characterized by highly regarded health and community support agencies, volunteer commitment to and identification with these agencies and the charitable not-for-profit service offered, in addition to government-funded services.

The challenge is to achieve redirection goals building on the solid foundation in place today. VON proposes consideration of transitional planning for the MSA model consisting of a coalition of existing health and social service agencies. 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.


VON is a respected cohesive organization in which all members of the 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 of all community-based agencies that for 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 service system. The guiding principles of long-term care parallel VON's core values and fundamental philosophy. VON is committed to providing leadership through the transformation of our health and social services system.

Mr Chairman, this concludes our formal presentation.

The Chair: Thank you again for coming together in a joint presentation, which gives us a little bit more time for questions, and we'll begin with Mr Wilson.

Mr Jim Wilson (Simcoe West): Thank you for your presentation. It was very comprehensive and in fact covered a number of concerns that we've also expressed in our PC caucus in terms of the approach that this bill is taking to the principles. I want to ask you about that. In group after group, when we were holding public meetings for a couple of weeks, we heard many concerns, and I think the bottom line is, should we be supporting this legislation? We all know the principles. We have great concerns, though, as to what this government has done with the principles of long-term care.

Somewhere along the line in those rainbow-coloured documents we went from one-stop shopping or access, which I thought -- as Health critic for a number of years I followed it and participated in many of those public consultations -- in the legislature was going to be a fairly simple model, one phone number in an area. I didn't think we were going to have this sort of monopoly MSA, as Ms Booth has correctly pointed out. I didn't hear a great outcry from the people of Ontario that they wanted MSAs to not only coordinate the services but also to have a monopoly on delivery of services.

I have two questions. One is, is it worth it, given this legislation and given that as legislators we have a very clear yes/no decision to make to this legislation? Secondly, I do want to know: Given what the bill actually does, aside from the principles of long-term care which are stated in all kinds of wonderful documents, will the people of eastern Ontario benefit in any way? My belief is that much of the money that's to go to long-term care will not be going to front-line services but will simply be spent in the next few years setting up this monopoly.

Do you want to tackle those? We're getting down to the wire here and we have to start to make some very serious decisions on how much opposition we want to put forward to this bill.

Ms McDonald: I think you've heard from us the areas where we have some concerns and you've certainly re-articulated those. The principles of the bill, the purposes and the goals, I think are sound. How it has moved over the past four years from improving access through information and referral to this now potentially very large, expensive bureaucratic system is very difficult to understand, and obviously we're suggesting that it not be supported.

Mr Jim Wilson: That's very clear. Thank you. Mr Armstrong, I think, wants to say something.

Mr Armstrong: Yes. There's no one involved in health care that would not suggest there are ways to improve, to cut back on costs. I think all the players know there are savings to be achieved and there definitely is duplication of management functions, if you look at the community, and an MSA in some form of concept will deal with that.

It can be dealt with. If that's an objective that we need to solve, personally I believe it can be solved in a much easier and less dramatic way, a way with less potential downside than the coming together in some huge conglomeration. We can't do it without knowing more about it and that's the biggest fear. That's the message, I think.

Mr Jim Wilson: I think you're right on the pilot projects, and that would be the commonsense way to approach this, I would think.

Ms Jenny Carter (Peterborough): I'm just looking at the question of governance here. You talk about a bureaucracy, that somehow we're establishing a bureaucracy by bringing these different organizations together. I have in front of me a document that is discussing this question of governance of multiservice agencies. They'll be governed by independent community-based boards of non-profit corporations which will be elected and will hire their own staff. It's not the ministry's intention to appoint these boards, nor to hire the staff of the MSAs.

Also, we have provisions that at least one third of the members of the boards be consumers and that there should also be providers represented on those boards. There is a suggested definition of "consumer" here, which is "someone with physical disabilities, someone who is or has received long-term care services, family members of someone receiving LTC services, family care givers and parents of children who receive or have received school health support services."

This doesn't sound to me like a bureaucracy, so I just wonder what your comments on that might be.

Mr Armstrong: Certainly my comment is that I don't think the board is going to be bureaucratic. I'm not sure I can see it evolving in the traditional community sense off the bat, but it's not the board that's going to be bureaucratic; it's the structure itself which is going to have numerous employees and numerous activities. Reading the law, as soon as we start drafting law, it gets bureaucratic in who gets access and what are the tests.

Ms Carter: But it seems to me that by simplifying it we're making it less bureaucratic. There are going to be fewer people employed at that level of management and more people in the front lines actually providing services to the consumer.

Ms McDonald: Our position is that with the present systems that involve community agencies as providers, in fact we are very streamlined presently. Part of our concern relates also then to the cost and the lack of costing. We don't know what the expected outcomes are. We hear cost-effectiveness. How do you measure that? What services are going to be mandatory? What are not? The question was raised earlier by Ms Sullivan, how do we deal with waiting lists? People are not on waiting lists, by and large, these days. What happens to the basket of services, as Mrs Booth asked? What's in the basket? We don't know that yet, and until that kind of information is available, we don't believe that good planning and implementation can be done and achieve a goal or the goals of improved health care, which I think is what we all want.


The Chair: We could go on for the rest of the morning, I'm sure, with questions, but we thank you very much for coming before the committee with your presentation today.


The Chair: I then call upon the representatives of the Ottawa-Carleton Community Health Centres. Welcome to the committee. I should probably add that I noticed one of your members has been very helpful in answering the telephone that's been ringing at the back and delivering messages to the front. What will happen now that you're up here I'm not quite sure. We want to thank you all for coming this morning. We have a copy of your presentation. If you'd be good enough to introduce yourselves, please go ahead.

Ms Martha Smith: I'd like to say good morning to the members of the standing committee and thank you to the audience behind us for coming. We're here to represent the network of community health centres in Ottawa-Carleton. With me are David Hole, the executive director of South-East Ottawa Community Services; Karen Stotsky, the executive director of Centretown Community Health Centre; and Peggy Feltmate, the executive director of the Community Resource Centre of Goulbourn, Kanata and West Carleton. My name is Martha Smith. I'm a program manager of senior services and I'm also from South-East Ottawa Community Services.

We're here to represent the network of community health centres which right now numbers seven in the Ottawa-Carleton area. We're serving a number of communities -- Sandy Hill, Centretown, Somerset West, southeast Ottawa, Pinecrest-Queensway, Carlington, Goulbourn, Kanata and West Carleton. Currently, we number about 350 staff jointly and administer $18 million in community and public funds. In the past year we've had 800 volunteers, approximately, who have been offering about 55,000 hours of volunteer service.

We are multiservice centres made up of multidisciplinary teams of professional staff working in two areas: social services and health services. The focus of the centres is on the integration of health services and social services. The services are developed in close consultation with the most vulnerable populations in the neighbourhoods that we serve and each health centre has its own defined catchment area serving unique populations.

The reason why we're here today is that we work closely with those who will be affected by Bill 173, and we have a vested interest in ensuring that with the new reform system it will meet their needs. We have a perspective on community services that we believe is useful in the further development of long-term care reform.

Community health centres are unique in the Ontario health care system. We promote good health and illness prevention. We're committed to providing accessible services, especially to the higher at-risk population in our area. We empower individuals and communities to take charge of their health, therefore we're very involved in both social action and community development and they're integrated into our service delivery system.

Consumers are part of both our planning and our operations. The teams work together with clients to address the whole range of their needs, including physical, social, emotional and the financial needs of our consumers. We have many years of expertise and experience which we want to share with you in the next few minutes.

Now Karen Stotsky will tell you about our views on multiservice agencies.

Ms Karen Stotsky: We've decided to focus our presentation in our short time today on some of the characteristics that we would hope would be enshrined in multiservice organizations, since they are really a central plank of the reform strategy, and then we'll spend a few minutes talking about some of our concerns around the legislation as well.

With respect to the multiservice agencies, their importance in the legislation cannot be overstated. The purpose, as expressed in the legislation, is to address access and continuity of care, to increase the responsiveness to consumer needs and to the community at large, to streamline the accountability of the board structure and to make a significant consumer and care giver representation.

These are features that, as community health centres, we've had embodied in our organizations for quite some time. We would like to list for you some of the functions we would like to see enshrined in the MSA structures as they're developed. We've divided our comments into several different areas.

The first one has to do with the organizational structure of the MSAs. It's our hope that the organizational structure of the MSA would be done in such a way that there would be an emphasis on information sharing, collaboration and participatory decision-making. We'd like to see a fairly flat horizontal management structure, a team approach, a commitment to ongoing staff development and a commitment to defining appropriately sized catchment areas that would foster community ownership and strengthen community participation.

With respect to governance of the MSAs, we'd like to see a community-driven organization with non-profit community boards and committees; staff representation on the board to enhance the contribution of the staff; and a commitment to enable neighbourhoods to act on their own behalf.

Speaking on the point of staff representation on the board, some of the community health centres currently have staff representations on the board. Some are voting and some are not voting. What we've found is that with staff on the board it does make a difference; staff have a voice. It helps to feel ownership to the services that are provided and to the policies that are developed.

There is a stake in having the community perceive us as having a stake in the organization and, in addition, another feature is that it creates a more open environment in the organization.

With respect to dynamics of service delivery, we'd like to see a multidisciplinary approach to care and flexibility to consumer needs.

Strong links with community and colleagues is another feature that we think needs to be included, and the availability of a user-friendly appeal process that involves the consumer that's timely and appropriate.

Linked very closely to the dynamics of service delivery is the issue of consumer and community participation, and we'd like to see an organization that creates opportunities for meaningful consumer participation and that has a commitment to community development. By community development, we mean working with the community to enable them to take more control over issues that are important to them and to work with the community where they're at.

Just as an example of one of the kinds of health promotion community development initiatives that has been undertaken in our area recently, a large bureaucracy introduced the concept of a Communibus which defined a route throughout our area without very much community consultation. In the end it was quite apparent that the route that was chosen was not very accessible to seniors. One of the things we did as an organization was work with the seniors in our neighbourhood to organize them to go to a meeting, raise their concerns and make recommendations. With the involvement of seniors and seniors taking some control over the issue, there were some changes that were made.

We'd like to see a commitment of the MSAs to do some work in the area of health promotion and community development so that there is a greater identification with the community. We'd also like to ensure that the community and consumer participation is both meaningful and dynamic in that the structure is organized in such a way that this can be possible.

The other point we wanted to emphasize was the role of volunteers; not only their importance, the importance of volunteers in a neighbourhood-based agency, but also the importance of putting a coordination role in place so that volunteers can be trained, oriented and do work that is meaningful to them. David will be speaking more about the role of volunteers when we speak about our concerns.

Mr David Hole: With that intro on the role of volunteers, I just wanted to comment briefly on the Chair's recognition of my telephone reception skills at the back. It seems to me it's just a further demonstration that no matter how well organized the endeavour, the role of volunteers can never really be underestimated. I'll come back to volunteers further later on in the presentation.

One of the first points we wanted to make have to do with the issue of integration as opposed to amalgamation. It seems to us that in many of the discussion papers and other consultation things that came through the system in the development of this legislation, the notion of integration of services was very much more highly featured and evident than seems to be in Bill 173. It seems to us that most of the direction of the legislation seems to be favouring the notion of amalgamation of a whole variety of community organizations and agencies rather than facilitating integration of those agencies.

In South-East Ottawa Community Services I can't pretend that we're typical of community health centres in the province, but we're certainly not unusual in that we've placed a high emphasis on integrating programs and services. Although we're funded as a community health centre, we receive funds from the long-term care branch to administer community support programs for the elderly and, as well, we've integrated programs of visiting homemaker services from the regional municipality social services department, so we're able to provide an integrated and coordinated model of programming for the people in southeast Ottawa. Although there are many points of access to the populations in southeast Ottawa there is, none the less, a one-stop kind of service for people, particularly the elderly, requiring those kinds of things.

Similarly, we're physically located in an elderly persons' centre, an EPC, which means that people who are receiving home care programs, home support programs, and community health programs for the elderly can also very readily access cultural and recreational programs in the same facility.


In short, I think you'll find the community health centres and community resource centres in Ottawa-Carleton can provide viable models for integration and that the strength of integration means that those agencies that are contributing their resources and their staff are able to maintain their mandate and bring added strength to the organization that is integrating, whether it's a multiservice centre or some other organization.

A second concern we have relates to health promotion and wellness. Again, we were pleased to see those concepts introduced. What we're not clear from Bill 173 is just where health promotion fits and where wellness fits as concept in the range of services and programs that are proposed. In particular, it seems to us that the model most highly touted is one of case management. While we agree that there's a need for strongly coordinated assessment program no matter where people are destined in the service spectrum, it seems to us that case management and identification of needs doesn't necessarily lend itself to wellness programs.

Health promotion may well identify a need for breaking down social isolation for senior persons who are otherwise fairly isolated in their homes. A prescription of participation in an activity group or a bridge class hardly seems appropriate for a case management kind of model. We would encourage a review of the predominant case management model which we think is much more highly medically modelled by us to something that is somewhat more sympathetic to social approaches.

Building on that theme, we're concerned too about the place that social services will have under long-term care reform. It seems to me there's a genuine risk that social services professions will likely be shoehorned into more of a medical model of service delivery. The challenge here is the integration once again of health and social services and not the assimilation of social services by health professionals and health models.

A question we have is that we're not really entirely clear about the thinking behind the establishment of a fee structure for "social services" but not for "health services." We are pleased to see that health services remain universally accessible and there's no barrier imposed by a fee structure. But if the genuine intent of Bill 173 is to secure the integration of health and social services, it seems to me that this is a structural impediment to that. It seems inconsistent with one of the thrusts here.

Another concern of ours has to do with community approaches. Throughout our presentation there's been an emphasis on community and community development and community direction. One weakness of the legislation is that there's no clear definition of what the government means by community. We certainly know what we mean by it. It has to do with neighbours helping neighbours. It's very much a peer support kind of thing and people knowing one another and caring about one another. This requires a certain economy of scale and a retention of human scale.

We're concerned that, if we are genuinely going to be valuing community control of planning and management and service delivery, multiservice agencies and the other instruments for long-term care reform need to be locally based, which means they need to cover fairly small areas of population or communities of interest that are secure in their identity.

Our other concern, of course, is that this is a bill designed to marry the community services sector with the home care sector to deliver comprehensive services. The relative sizes of these two sectors suggest an inequality of power and influence. When one rolls over the other one is likely to squeak pretty loudly. I'm reminded of a Woody Allen comment that, "The lion and the lamb shall lie down together, but the lamb won't get much sleep." In this case, I'm not convinced that the community service sector is going to be getting a whole lot of sleep in this particular marriage.

In relation to the use of volunteers, to return to this theme again, aside from the value that volunteers bring to community enterprises like this -- and I'm hoping this remains a community enterprise -- it seems to me that the volunteers themselves experience an increase in their own quality of life because of what it is they're able to give back. A number of our volunteers speak of it in those terms, giving back to the community, and we want to ensure that whatever system evolves here will continue to provide a place for volunteers.

Finally, in relation to district health councils, we work very closely with the local district health council. There's considerable reference made in Bill 173 as to the continuing role. We would like to ensure that the district health council remains as much a local resource and an autonomous local resource that's in a position to continue an advisory role to the ministry. There are some concerns that some elements of this legislation may co-opt a lot of the independence and autonomy of the local district health council.

We want to ensure essentially that everything about Bill 173 ensures that control of these particular services remains at the local level, ie at the Ottawa-Carleton level. This relates too to the appeal process, and it's some concern to us that if there are consumers who are unhappy with either the range of services provided or the way in which those services are provided, apparently the appeal process takes it away from the local level to some sort of provincial appeals board and I must confess I'm a little perturbed by that. It's hard to understand how control stays local when any concerns with the local service delivery are dealt with at a provincial level. It seems to me that the level of an appeals board might do better to deal with more policy level concerns rather than service delivery concerns.

I wanted to ensure some opportunity for dialogue since that's an important part of this process and I hope there's still some time left.

Ms Evelyn Gigantes (Ottawa Centre): I'd like to thank you very much for your presentation and for the reminder that you give us as we consider this legislation about the importance of community involvement in the decision-making process, and also the importance of services which are not of the medical model in maintaining people's health and welfare in the community.

The one question I'd like to raise with you is the question of assessment. One of the earlier delegations had raised with us the notion that we should leave organizations providing service in the community currently, in particular the VON in this case, to do their own assessment. I'd like some comment from you, if I could, about the practicality of having various assessment processes involved in an integrated long-term care planning process and delivery of service process, and whether we can make any judgements about how effectively we can organize overall service delivery to the community from the existing patient placement services at the community level.

I'm very curious about what your experience is and what your thoughts are in this area.

Ms Smith: I have one response, and I know the group after us will also be talking about that. I have no problem with there being standardized assessment, but I think at different levels. For example, in our agency we might have 300 seniors this winter who call us and only want snow removal. To go and do an assessment to the same extent for someone who wants, say, respite care or bereavement support -- it would just not make sense to do the same type of assessment.

I do agree, though, that among the agencies, to standardize them would be an improvement. However, I think it should be level appropriate.

Ms Gigantes: There was one other comment coming, I think.

Ms Peggy Feltmate: I was going to say I think, as well, with assessment, that the standardizing and the training becomes really important to ensure that all the aspects are taken into account. I guess my fear would be to lose both the social aspects that are required to the strictly health and medical.

Ms Gigantes: It relates to case management too, as you raised it.


Mrs Yvonne O'Neill (Ottawa-Rideau): There's so much about your brief I'd like to comment on. I'm particularly happy that you mentioned the appeals being taken from the local level and the amalgamation versus the integration. My question: You talked a little bit about the DHC. I'd like to know if you are involved in the long-term care process here. Do you see yourself becoming an MSA? I certainly personally think that's very viable. Finally, if you could just say a little more about your very brief comment about the 20% cap, I'd like to get that on the record.

Mr Hole: I'm prepared to respond here, with some trepidation, because there isn't agreement among all community health centres on this point. With regard to MSAs, we are multiservice agencies, small M, small S, small A, and that's our modus operandi right now.

With regard to whether community health centres could and should function as sponsoring organizations for MSAs, all of our organizations are presently community directed and controlled. We're all very separate, very autonomous, and our intent is to meet the needs of the neighbourhoods that we serve. Ultimately, it would be a choice of particular community boards.

As I say, there is no universal agreement as to whether it's desirable for community health centres to take on the role of MSAs. I can tell you there's some interest in southeast Ottawa, but I don't know how typical that is of community health centres.

In relation to our involvement with long-term care planning locally at the DHC, we have some representation on the MSA working group, and we're also represented -- we actually come from two streams of service delivery, community support services as well as community health services, and we have some indirect representation on the long-term care committee, meaning that these aren't community health centre reps per se, but none the less people with whom we maintain a close liaison and ensure our voice is heard there as best we can.

Mrs O'Neill: Have you got the 20%? Can you say that?

Mr Hole: Yes, with the 20% thing, our brief suggests that we could live with that, if it has to be included, if it was administered on a global basis in the program budget rather than on a category-by-category thing. Obviously, our concern is that with any kind of restriction on the amount of purchasing of service that's available under an MSA would mean it's more likely to be an amalgamating kind of model rather than something that would facilitate integration.

My sense is that the intent is to ensure that more and more services are in the non-profit sector, and that's what's behind this cap. If that's so, then ensure that the cap relates to private sector organizations. My interest and concern would be to ensure that those non-profit organizations that have really strong roots in their local communities aren't going to be decapitated by this. They just won't be able to remain effective or be allowed to integrate their services into a structure that's designed to improve access.

The Chair: Thank you very much again. We could spend much more time on questions, but I'm afraid we're going to have to move on.

Mr Jim Wilson: Mr Chairman, while the next group is coming forward, could I just pose a question, please?

I was wondering if the parliamentary assistant had available for the committee members a response to the request for the breakdown of the funding for long-term care. It's been mentioned by the government many times that a figure of $850 million is money to be directed into long-term care, and committee members have asked for a breakdown of that. We want to know how much of that will be new user fees and how much of it is actually new money. That request is some four weeks or five weeks old, I would think.

Mr Paul Wessenger (Simcoe Centre): Yes, I understand that information is likely to be available tomorrow.


The Chair: I then call on the Community Support coalition of Ottawa-Carleton. Welcome, both, to the committee and we have a copy of your presentation. If you'd be good enough to introduce yourselves, then please go ahead.

Ms Ginette Rashleigh: My name is Ginette Rashleigh. I'm the program manager with the Gloucester Centre for Community Resources home support program, and I'm also chairperson of the community coalition. Here is my colleague Carol Halstead who is the administrator of the township of Osgoode home support.

We are presenting on behalf of the Community Support Coalition of Ottawa-Carleton. We thank this committee for the opportunity to provide feedback this morning on Bill 173 and we will offer three recommendations for your consideration.

The Community Support Coalition of Ottawa-Carleton is a federation of 19 not-for-profit agencies which are directed by volunteer boards of directors. These community-based agencies evolved from the grass-roots approach in response to a need in the community and are directly accountable to consumers and volunteers. The mechanism that addressed those needs mobilized volunteers and professional resources which responded directly to the expressed needs of seniors and their families. Some agencies are also mandated to serve disabled adults. In the early 1980s, a network of community support agencies began to meet because they shared a common vision and purpose, that of enabling individuals to live independently in their own homes, with dignity. This essential network of alliances is today's Community Support Coalition of Ottawa-Carleton.

Local community action created community support programs across Ottawa-Carleton. Some are independent agencies providing solely community support services; others provide the same or similar services through separate departments of community health or resource centres, elderly persons centres or community information centres. Some are located in the rural parts of the region; others serve urban and suburban areas. The community base, consumer focus and volunteer direction are common themes for coalition members. Diversity is our strength.

A full complement of community support services is available to Ottawa-Carleton consumers. They range, for example, from transportation to meal services to respite in the home. Essentially, community support providers have become an extension of existing family systems for both consumers and care givers. For many of those we serve, we have replaced the extended family of the past.

While broader planning issues are being addressed by others, we have chosen to focus our response to Bill 173 on those aspects which impact most directly on our clients, our volunteers and the services which we provide. We will therefore offer three recommendations for your consideration. Carol will go on to talk about the recommendations.

Ms Carol Halstead: Recommendation 1: The community support coalition recommends that the universal requirement for a plan of service in subsection 20(1) be replaced with a graduated system for intake, assessment and service. Bill 173, as currently written, requires a service plan for each client in subsection 20(1). This, for example, could create a requirement that an assessment and service plan be done for someone who wants only to attend diners' club. Within the continuum concept, no such effort or cost would be required. However, should a client's needs progress to Meals on Wheels, an intake assessment and service plan appropriate to dietary needs would then be required. This would become more comprehensive as the client's needs increased. We strongly recommend an assessment process that is appropriate to each situation.

Community support consumers directly access our agencies, without a medical referral, when they express a need for a social service. We believe that this social services approach promotes consumer choice and independence. Service delivery, frequently provided by senior volunteers, promotes the wellness model in both consumer and volunteer. Its strength has been its flexibility and responsiveness to consumer needs. The emphasis on choice has provided the least intrusive, most cost-effective service possible, and coalition members believe that this approach to community support services must be retained.

A graduated system would parallel the continuum of care and allow the consumer to be assessed only as needed for services required.

Recommendation 2: The Community Support Coalition of Ottawa-Carleton recommends that a commitment to appropriate recruitment, orientation, training, supervision and support of volunteers be made explicit in Bill 173 and that further efforts be made to safeguard volunteer participation by limiting the extent to which volunteer-delivered services are regulated.

Volunteerism is the essential component of all community support services. Volunteers provide the direct link between the community and the agency, the capacity for fund-raising and the majority of direct service.

A volunteer who provides one service may be a consumer for another service. A volunteer driver from a rural area, for example, may transport consumers locally but request a drive to downtown Ottawa for his or her own appointment. This volunteer delivers one service while receiving another. As volunteers become more familiar with our organization, they become aware of the necessity to fund-raise locally. Some individuals become a service provider, a consumer and a fund-raiser. This is an affiliation triangle that may disappear if any of the affiliation is disturbed. As a result, any loss of volunteer support can significantly reduce our organizational effectiveness, our service delivery and our financial base. Since 20% to 50% of our revenues must be raised locally, our volunteer base must be not only supported but actively nurtured. Our future depends on it.


Many volunteers who provide direct service do so in our sector precisely because of the personal approach taken: the opportunity to help people rather than clients. They identify strongly with their agency and with the act of volunteering, and are deterred by the emphasis on control and red tape. While a paid employee may need to tolerate perceived bureaucracy, a volunteer does not and will leave the organization. Volunteers' motivation is thus very different from that of paid human resources.

It has been our experience that those who volunteer have a clear personal connection with the agency where they volunteer. It is our belief that our system would be severely damaged, perhaps irreparably, if the volunteer connection is broken. Large parts of Bill 173 regulate direct service to such an extent that we fear a chilling effect on our volunteers' participation and, ultimately, on their participation in fund-raising and governance as well.

Recommendation 3: The Community Support Coalition of Ottawa-Carleton recommends the removal of the 20% limit of service by the multiservice agency in subsection 13(2). Community support services in Ottawa-Carleton are well developed. Coalition members pioneered some of our community support services in Ottawa-Carleton nearly 40 years ago, and our network has expanded so that all of the region is now served.

Agencies were created in response to expressed community needs. A great deal of effort has been expended in planning and coordination by the Council on Aging of Ottawa-Carleton, and between the agencies themselves, to ensure lack of duplication as they emerged. Clear geographic and service boundaries have been established; services are provided in French or English where appropriate and some partnerships between service providers and multicultural groups have already been developed.

There exists currently in Ottawa-Carleton a well-coordinated network of services that puts customer service first. We are the foundation of the future long-term care system in Ottawa-Carleton and we urge the government to build on that foundation.

However, it is clear that the implementation of subsection 13(2) would require existing agencies to be absorbed into a larger body and cause severe disruption in service provision. Simplified access, coordination and service delivery can be achieved without this measure. It is unnecessary in an area as well-developed as Ottawa-Carleton.

In summary, our coalition remains concerned about the overall impact of Bill 173 on the community support sector and urges closer examination of the issues. Differences between the sectors being integrated have so far only partially been taken into account by the legislation.

We remain concerned about the effect of Bill 173 on our clients. We therefore recommend that the universal requirement for a plan of service in subsection 20(1) be replaced with a graduated system for intake, assessment and service.

We remain concerned about the effect of Bill 173 on our volunteers. We therefore recommend that a commitment to appropriate recruitment, orientation, training, supervision and support of volunteers be made explicit in Bill 173 and that further efforts be made to safeguard volunteer participation by limiting the extent to which volunteer-delivered services are regulated.

We remain concerned about the effect of Bill 173 on the services we provide. We therefore recommend the removal of the 20% limit on the purchase of service by the multiservice agency in subsection 13(2).

Mme Rashleigh : Comme mentionné précédemment, la Coalition du maintien à domicile d'Ottawa-Carleton est une fédération de 19 agences à but non lucratif qui sont dirigées par un conseil d'administration bénévole. Nous avons choisi trois aspects du projet de loi 173 qui auront le plus d'impact sur nos clients et bénévoles ainsi que nos services.

La Coalition recommande qu'il n'y ait pas de plan de service d'établi au début, mais bien, qu'il soit graduel, lorsque les besoins du client progressent.

La Coalition recommande qu'il y ait un engagement de fait envers l'orientation, l'entraînement, la supervision et l'appui auprès des bénévoles et qu'il y ait un engagement formel et explicite dans la Loi 173 auprès de ceux-ci afin de sauvegarder leur participation. Le bénévolat est une partie intégrale des services de soutien à domicile.

Les services de soutien à domicile d'Ottawa-Carleton sont très développés. Nos agences ont été créées d'après des besoins exprimés par la communauté, et beaucoup de planification et de coordination entre les agences ont été faites pour assurer qu'il n'y ait pas de duplication de services. L'accès simplifié, la coordination ainsi que la livraison de services peuvent être assurés sans détruire et absorber les agences qui existent déjà.

We now invite questions.

Le Président : Merci beaucoup pour la présentation. Mr Sterling.

Mr Norman W. Sterling (Carleton): I'm particularly interested in talking about the volunteer aspect, representing areas where Carol is from in the township of Osgoode, which I guess has a population now of 13,000 or 14,000 people. If the MSAs take over the delivery of approximately 80% of the services, do you think the people of Osgoode will volunteer to help out the MSA as such, as they have with the township of Osgoode care centre? There's just a whole host of volunteer services which go on in that township. Part of living in Osgoode is giving back to the community.

Ms Halstead: There's a very strong commitment in the township of Osgoode of neighbours helping neighbours, but as the Long-Term Care Act has come before us in the last two years, I have had direct service volunteers, some of whom are board members and others who are strictly board members, who have very clearly said to me: "We will not continue to be active in this program if it is not neighbourhood-based. If we have to call Ottawa or go into there, there is no way that we will volunteer." So for many of us in the rural areas, the concern is that the clients will lose service because there are not volunteers there to provide it. That is just a rural perspective, but I'm sure my urban colleagues have a similar perspective.

Ms Rashleigh: I feel that the same thing would happen. I represent Gloucester, and certainly the volunteers have told us that they like to volunteer in their own community. They would not go to a big agency to volunteer. They certainly want to retain the local involvement.

Mr Sterling: I think one of the aspects which is most distasteful to me in this legislation is the assumption that a big overall organization is somehow going to deliver better. In my experience, in the areas that I represent, the smaller the organization and the more dispersed the organization is, one in the town of Osgoode, one in the town of Metcalfe or whatever it is, the more effective that organization is. This just totally counters how things operate in a good portion of the area that I represent.


Ms Halstead: Certainly, our coalition feels that because we are so well served in Ottawa-Carleton -- all areas have access to service; not all the same service, but not all communities require the same service -- we feel that the current system has many merits. There are always advantages to change, but to change for the sake of change can be devastating. To change the weaker links, and there are always weaker links, we see that there are possibilities there, but we also know that the volunteers who make our services happen are the crucial link, and that link, we feel, should not be tampered with.

Mr Sterling: Bottom line, are we better off or worse off with MSAs?

Mr Jim Wilson: As in the legislation.

Mr Sterling: As in the legislation.

Ms Halstead: It's a very difficult consensus question because we represent 19 not-for-profits. Certainly, we feel if it's a very narrow focus and that we're forced into amalgamation, if the little agency disappears, we would say that is a very negative aspect, but you could have an MSA, we feel, that maintains the individual agency but has a linking network, and that we see has very real positive possibilities for the clients and the volunteers.

The Chair: Again, time presses on. We thank you for coming before the committee this morning.


The Chair: I call upon the representatives from St Patrick's Home of Ottawa.

Ms Maureen Goodspeed: Good morning. My name is Maureen Goodspeed. I chair the board of directors of St Patrick's Home for the aged here in Ottawa. With me today is Lawrence Grant, our director of finance and human resources.

St Patrick's Home was founded in 1865 and is sponsored by the Grey Sisters of the Immaculate Conception. Since then, the home has responded to community needs evolving from an orphanage and an asylum for the indigent to today's fully accredited charitable, non-profit long-term care facility for the elderly. Throughout its evolution, the element of loving care has been constant at St Pat's.

We have a history and a reputation for leadership and innovation in the design and delivery of long-term care and community services to seniors. Some of our programs include:

-- The first seniors' day care program in the region.

-- A one-year pilot day program developed by the Alzheimer's society for their clients.

-- Two specialized seniors' day programs funded through a Trillium grant for a three-year period: one for seniors with physical disabilities and one for the cognitively impaired.

-- Meals on Wheels services for the surrounding community five days a week.

-- Telephone assurance programs providing daily contact for homebound seniors.

Each of these programs assist seniors to remain safely and comfortably in their own homes as long as possible.

Program quality is extremely important to St Patrick's Home. In 1979, the home was the first in the region to become accredited, and we have maintained a three-year accreditation status ever since. We're proud of our stellar reputation in the community and of our leadership in the field of long-term care and of our partnership with government and other community agencies in developing a comprehensive response to the needs of seniors in Ottawa-Carleton.

We have always supported the province in its determination to reform long-term care services and we understand the government's concern with demographic projections indicating an unprecedented increase in the population of Ontario's elderly. It is important to remember, however, that more than 90% of seniors remain in their own or in their family's homes. The provision of viable services to seniors demands a share of responsibility between care providers and governments and a clear understanding of consumer needs.

We recognize the significance of Bill 173 in attempting to address these issues. On behalf of St Patrick's Home, we thank you for this opportunity to participate in the consultation process.

I would like to discuss with you our areas of greatest concern and then conclude with specific recommendations for change. We have eight recommendations.

First of all, it's important to know that we concur with the seven stated purposes of Bill 173. However, we are very concerned that the bill, as it is presently drafted, does not provide the framework within which they can be realized. I would like to review and comment on each subsection of part I of the act.

First of all, a wide range of home-based community services must be available as alternatives to institutional care. However, Bill 173 builds a wall between community-based and facility-based services rather than an integrated health and social services system. It fails to recognize the leadership and contributions that institutions provide in maintaining the independence of seniors in their own homes, and the bill also fails to recognize that facility-based care is a necessary component in a comprehensive long-term care system. This runs directly counter to the intentions of long-term care reform.

The quality of community services and the promotion of the health and wellbeing of persons requiring such services must be assured. Bill 173 provides a rigid formula for the provision of services, which does not allow sufficient flexibility to provide the creative innovation necessary to meet the increasing and changing needs of seniors. This bill does not reflect a workable vision of independent life for seniors in the community. Rather, it is concerned with control and uniformity, which precludes independent decision-making by the consumer.

It also fails to recognize the multicultural considerations required by a diverse population. Static evaluation criteria do not recognize the diversity of the population and its range of correspondingly different needs which should be addressed by quality programming. Much of the detail in this act properly belongs in regulations, where it can be modified as required through administrative means.

As it is written now, this bill sets parameters on the services the province is willing to consider and fails to provide for the development of new, better and more cost-effective ways of managing resources for the care of the elderly.

The needs and preferences of the care receiver must be recognized. Bill 173, in its present form, makes no provision for choice or decision-making on the part of the client. Their needs will be assessed, analysed and determined through the MSA, and their only options will be to accept or decline whatever service is offered. The bill tears down the existing structure of community support services without providing any meaningful replacement, as you've just heard from the previous presenters. We are not aware of any new initiatives to expand these services in the community.

We are also concerned that the absence of user fees removes an element of control and decision from the user. It also places an unsupportable financial burden upon the province. By failing to allow for the payment of user fees, Bill 173 dramatically alters the relationship between the service user and the service provider. It creates an inconsistency in long-term care whereby seniors receiving facility-based services are expected to pay a user fee and seniors receiving community-based services are not.

As well, while the intent may have been simply to ensure that no one in need would be denied service because of inability to pay, the effect is to remove an element of decision and control from all users. The present system of user fees based on a non-intrusive means test guarantees that services are available to everyone.

We are pleased to see that the need to improve access to services has been identified in Bill 173. However, the bill describes the creation of a large bureaucracy which, far from simplifying and improving the system for clients, unnecessarily complicates service delivery and threatens the destruction of programs now available to seniors. What we really need is an agency to plan, coordinate, direct and monitor services for seniors living in their own homes to ensure that their needs are most efficiently met.

We agree that the system must be simple, accessible and fair. The level of detail in the proposed legislation is excessive, to the point of jeopardizing the effectiveness of the MSA. Bill 173, as it now reads, calls for the dismantling of a system of long-term care that has evolved over many years, a system that is built on diversity and recognizes the unique aspects of care which are essential to the individual.

The key to a successful new system is not a simple approach to meeting complex needs, but a system that meets complex needs through clear and easy access and assessment, assessment done in a way that reflects the dignity of the clients served. Assessment must include consideration for all human needs, including physical, spiritual, psychological and social needs. Care, and especially in-home services, must recognize the vulnerability of the clients served and be supportive, comprehensive and efficient. Delivery should be provided by as few individuals as possible.


The efficient management of human, financial and other resources involved in the delivery of community services is vital to the reform of long-term care. Bill 173 seems to equate efficient management of human resources and financial management with direct control. Instead, there needs to be a delegation of responsibilities whereby the MSA is restricted to management activity.

It should be noted that the costs of the present system are greatly reduced as a result of the contributions of volunteers, both as direct care providers and as charitable fund-raisers. Volunteers identify strongly with the institutions and agencies they support because they recognize the mission and values of the institution as an extension of themselves.

A ubiquitous government agency will not generate a similar passionate commitment, and the province cannot afford to replace the services provided by volunteers with paid labour. Both the quality and the quantity of care provided will deteriorate. It is contrary to good management and accounting practices to have the funding agency and the care provider be the same, but that is exactly what Bill 173 demands of the MSA.

There is a need to encourage local community involvement in planning, coordinating, integrating, managing and delivering community services, and we presently enjoy such local community involvement through the work of volunteer boards of directors of charitable institutions like St Patrick's Home, through the work of care-giving volunteers and through our fund-raisers. However, Bill 173 will remove the "community" from community services through the establishment of an MSA which is expected to be all things to all people. Bill 173 will result in the eclipse of volunteer-based community programs, will drastically alter the nature of governance and destroy our heritage of long-term care.

We have already commented that it is inappropriate for an MSA to be both funder and care provider. It is also unrealistic to project that in four years MSAs would be in a position to purchase only 20% of services from other agencies. This suggests a general erosion of services which are now available. No clear plan has been proposed whereby services presently available will be replaced.

An eighth purpose should be added to include support for families and informal care givers. The bill as it is written now fails to recognize that 90% of seniors live outside of institutions without structured programming, and this underlines the substantial contribution of family and other informal care givers.

Very briefly, this is an outline of our major concerns. We hope that the following recommendations will assist you in redrafting the bill.

(1) We recommend that distinct agencies be responsible for the purchase of service and the provision of service. The role of the MSA should be based upon a brokerage model whereby the MSA determines the need and tenders for services, assuring the best value for money.

(2) We recommend that legislation include recognition and support for family and other informal care providers, who are the primary providers of care to seniors.

(3) We recommend that the MSA budget include an allocation for pilot or demonstration projects, with the intention of developing new, innovative and cost-effective programs to meet the changing needs of an increasingly elderly population and their informal care providers.

(4) We recommend that program design and care needs assessment specifications recognize the cultural diversity of the population.

(5) We recommend that the contribution of charitable organizations and volunteers be recognized and fully incorporated into the revised long-term care system.

(6) We recommend that the new system include provision for user fees.

(7) We recommend that the phase-in period reflect the actual time required for planning and development to accomplish the objectives of the reform and that the proposed four-year implementation period be considered a guideline only.

(8) We recommend that all items dealing with control or accountability procedures be removed from legislation and placed in regulations to provide the flexibility required in the development of a comprehensive and effective long-term care system.

To be successful, the redirection of long-term care must build on and enhance the strengths of our present system, it must be sufficiently flexible to meet new challenges and it must be cost-effective. If this is to be accomplished, the experience and expertise of the present care providers must be considered a valuable resource.

As it is presently written, Bill 173 is not adequate for its purposes and is a threat to many of the organizations providing care and services to seniors. At a time when care providers and government should be working together, this bill will create an adversarial situation.

This consultation process is an important step in bringing government and care providers together, but it can be successful only if input from the front-line workers in long-term care is taken seriously. It is important to realize that the group most impacted by this legislation, the elderly and the chronically ill, are not in a strong position to make their opinions heard.

Nothing I have said today is intended to delay change. But I am very concerned that when change occurs, it be for the better, to make the long-term care system in Ontario more readily accessible and more effective for all. Bill 173 needs extensive revision to achieve this goal. I hope our recommendations and those of other care providers and our clients will assist the government in preparing appropriate legislation.

Thank you for this opportunity to explain our concerns and expectations.

Mr Gary Malkowski (York East): Thank you for your presentation. Do you have a formal mechanism in your provision of service?

Ms Goodspeed: I'm sorry?

Mr Malkowski: Do you have any formal mechanism for consumers to provide feedback regarding the service provided?

Ms Goodspeed: We've done a number of surveys and we are in constant touch with our own clients and the families of the people we work most directly with.

Mrs O'Neill: Do you have a residents' council, for instance?

Ms Goodspeed: Yes, we do.

Mr Dalton McGuinty (Ottawa South): Maureen, it's good to see you again to help acquaint some of the committee members with the history of St Patrick's Home. At a time when it's become fashionable almost to criticize some of the charitable organizations that are religiously based throughout the country, I think it's important to remember that a lot of the services, like schools, hospitals, universities and orphanages, were all originally run by religiously based institutions.

One of the constant criticisms we hear with respect to this bill is related to the negative effect it's going to have on the volunteer spirit that's extant in our communities, and I wanted to raise a particular issue here which I don't believe has been raised. We have all kinds of volunteer boards of directors, obviously, administering these kinds of services which form the subject matter of this bill. I want to get your feedback.

The bill provides that the minister will be appointing directors and program supervisors and then he or she will also be affording those directors and program supervisors immunity from liability. We won't be able to sue them. These will be people in paid positions who we will not be able to sue as long as they're acting in good faith. What about our directors who are sitting on volunteer boards of directors? Can they not now be sued?

Ms Goodspeed: Oh yes, they could be sued.

Mr McGuinty: What do you think of this immunity from liability we're giving to government appointees?

Ms Goodspeed: I think it's a very backward step. I think the directors of an institution ought to be able to be held accountable for the decisions they make and for the policies they implement, and I think to make a publicly appointed director invulnerable in a situation is a very retrograde movement.

I think a publicly appointed director is not going to have the same understanding of the mission and values of the institutions that we have now. I don't think they're going to be able to bring the same kind of intensity to their work. They're going to be spread too thin and they're not going to be able to identify as closely with the institutions they are responsible for as the people we have doing the work now. I think we stand to lose the largest and best part of our heritage in this way.


The Chair: Does the parliamentary assistant want to make a comment?

Mr Wessenger: Yes. Just to clarify, what is referred to about directors in the act are those who work for the ministry, for the government, not anything relating to any agency. Second, I'd like to make it clear that there is liability on the crown for any act of a program supervisor, so there's a clear liability of the crown for any acts of a program director. It only excuses the individual; it doesn't excuse the government from liability for their wrongful or negligent acts.

The Chair: I thank you both for coming before the committee this morning.


The Chair: I call on the representatives from Bradson Home Health Care.

Ms Allayne Evans: Good morning. We want to thank the committee for allowing us the opportunity to speak with you about the role of the private sector in Ottawa-Carleton. My name is Allayne Evans and I spoke to you once before in Toronto as a vice-president of the Ontario Home Health Care Providers' Association. I'm here to speak to you today from a more personal perspective as a vice-president of Bradson Mercantile Inc, which is a private, commercial company.

With me are Tristan Mostovac, from our Ottawa office, and Margaret Simons, from our Kanata office, two front-line workers. They've been recommended by their supervisors to come before you to answer any questions you may have about employment in the private sector.

First, I'd like to give you a brief word about Bradson. We're a wholly Canadian-owned company established in 1957 in Ottawa. We've been doing temporary staffing for 37 years. We're one of the largest privately owned suppliers of contract, temporary, technical, professional, health care and securities staff in Canada.

In 1986, after market research and analysis of the health care field, Bradson Home Health Care was created. By May 1986, we were properly insured. We had policies and procedures in place and field staff were identified, referenced and trained.

The first office opened in downtown Ottawa. We began by providing registered and certified staff to acute, chronic and nursing home institutions in the region. In April 1987, we won our first contract with the regional municipality of Ottawa-Carleton. That contract has been renewed in 1990 and 1993.

One of our objectives has been to maintain and keep the client independent in his/her own home. In 1989 we launched three Bradson seniors' programs in Nepean. The focus of each has been to provide an environment within the community where seniors could meet, socialize and provide support to each other. In 1988 we opened a satellite office in Gloucester, which is east of Ottawa, and in 1990 we opened one in Kanata, west of Ottawa, to better serve both our public and private clients in the eastern and western parts of the region. December 1991 saw the opening of another health care office, in Kemptville, to the south.

We have used our profits to expand, to grow, to be closer to both our client base and our employee base. Since 1986, we've invested in home care by opening offices and providing employment for local people. People are move comfortable, we've found, in dealing with an office that's in their neighbourhood, whether it's applying for work or whether it's requesting service. Whatever communities we work in, we contribute. It's our policy to purchase other services from that community such as advertising and equipment rental. We pay rent, we take out leases, and we pay business taxes.

We volunteer in many community agencies. My staff or I sit on a committee for the council on aging. We are members of the Registered Nurses' Association of Ontario. We're members of the Gerontological Nursing Association, the Ottawa-Carleton Industrial Training Council, the MSA working group at the district health council. We are charter members of the Canadian Home Care Association and Home Support Canada, and we also support the Ottawa-Carleton Palliative Care Association. We are as dedicated and committed to what we do as any other agency, no matter what our incorporation status.

We discovered in 1989 that the demand for trained workers far exceeded our ability to get the training at the local community college, so we set up a private vocational school, level 2, home support worker course, which is recognized by the Ministry of Education and Training. We train at our own expense at our local private vocational school.

One of the standards in this area of the province is that when we're under contract to the region, we must have 85% of our home support workers trained to level 2. The Ottawa-Carleton home care program established the standards, and all our agencies that are on contract have been audited against those standards annually for the last two years.

We've also been working for two years on developing our own customized software. All of Bradson Home Health Care staffing, billing, time card management, scheduling and criteria-matching are done on the computer. This allows us to have a high rate of efficiency with our home support workers' schedule and a low margin of error.

We provide essential services to the community and we work long hours to be cost-effective. The provincial government regulates the profits in our industry by setting the pay rate for employees and the billing rate we are allowed to charge. Any profit that is made is based on good business practices and full accountability. Governments don't bail out small business. We either make a cost recovery or we go bankrupt.

I'd like it noted that when it came to the social contract, it was decided that we were responsible enough to be considered as one of the agencies that should be brought in, and we have been told that we will be contributing for the next three years. At the time we were suffering under the not-for-profit policy of 90-10, we were also being forced to meet financial targets set by the government -- and we've done that.

The private sector can deliver the same or higher standards of care for the same amount of money or less than the MSA and at the same time we can provide choice. Why should the government insist on limiting us to 20%? Removing the private sector as a partner in the delivery of home care removes flexibility, competition and the ability to respond quickly to the changing needs in the community. I'm worried that if you reduce our involvement too much in the publicly administered system, not only will you cause serious job loss and dislocation to both clients and employees but you may, in the long run, hasten the advent of a second tier of unregulated health care delivery.

It's been a common experience to all of us that when government tries to create a mouse, it becomes an elephant.

We believe we need to step back and examine what values should be driving the change in the system. When we do that, we see that the overriding value is the need to deliver more quality care in the home by better meeting consumers' needs.

Marg Simons has asked to speak to you.

Ms Margaret Simons: Good morning. My name is Margaret Simons and I work for Bradson Home Health Care as a home support worker. I'm not used to public speaking, so I hope you will please bear with me.

There are a number of reasons that I choose to work for Bradson's. It is a well-established, solid Canadian company. It treats its employees fairly and with respect and consideration. Bradson's provides training at no cost to the employee. I took my level 2 course through Bradson's and all it cost was my time. It was offered at night also so that I could work during the day, which was important to me, and it was an excellent course.

Bradson's also offers to its employees free monthly in-service nights that cover such topics as depression in the elderly, behaviours associated with Alzheimer disease, understanding the needs of the chronically ill and the needs of their families; basically, up-to-date material that helps us as home support workers to understand our clients better and shows us ways to implement that knowledge more effectively on a day-to-day basis. This in-service also gives us a chance to interact with our peers and our supervisors.

Bradson's is a tight-knit company, and as an added incentive to attend the in-service, Bradson offers a complimentary dinner to anyone who attends. Most of the time it's just soup and buns and cheese and meat, but it's just their way of encouraging us to learn more. These nights are invaluable. They keep us up to date and focused on what we need to accomplish.


What I'm really getting at here is that even though Bradson's is a fee-for-service agency or, if you like, a profit agency, it does not cut back on its expenditures in regard to its employees. We are paid the same rates as other agencies, be they profit or non-profit, and all the agencies receive the same moneys from government funds.

The quality of care for the client is in no way compromised. We as home support workers are periodically evaluated. We are encouraged to maintain high standards of conduct, treat all our clients with respect and dignity, maintain client confidentiality and to perform our tasks as quickly and effectively as possible.

We are required to put in monthly reports on each client, noting any changes in their condition. Any problem we might have is reported directly to our coordinator. If for any reason she can't speak to us immediately, she gets back to us as soon as possible, and it's usually within a few minutes.

Bradson runs a tight ship, its priority the best possible care for the client.

We all know that demands for home care are increasing rapidly. People are living longer, hospitals and nursing homes are overcrowded and the costs are enormous. We all know this. My concern, or one of my concerns, is that the people who need the services the most will be the real losers if Bill 173 is passed. Although I am sure that the present system could be improved upon, I don't think what this bill proposes is the answer. This bill would eliminate any competition from other agencies. The government would have a monopoly on these services. I think this would result in inferior service, impersonal care and ultimately a reduction in service.

As a home support worker, I see at first hand the needs of my clients. For many seniors, we are the only person they see on a continuous basis. They get very upset if someone else has to replace their regular worker. They have suffered many losses, and they're vulnerable, afraid and often very lonely. They need well-trained home support workers they can depend on and trust. This bill cannot be passed without more study. These people who are being helped today are you and I of tomorrow.

I am a good home support worker. I show up for work every day, and by that I mean I work to the best of my ability. I work hard with my clients' best interests at heart. My client, from the time I arrive until the time I leave, gets everything I have to give. I clean, make dinner, wash clothes, bathe, toilet, and transfer them. I am conscious of any sore, bruising, swellings or any abnormalities that may be a symptom of something more serious. I am a valuable member of the home health care team, and I will, in all probability, under this bill lose my job.

I am concerned, and rightly so, that Bill 173 will cause the closure of Bradson Home Health Care and other fee-for-service agencies. These are healthy companies that are competing well with non-profit agencies. They are doing a good, efficient job. They are providing competition and employing a lot of people.

Ms Evans: We're open for any questions.

Mr Sterling: I have a question of the parliamentary assistant. I understand the private sector is now providing just under 50% of home care in the province. If they are providing it at a lesser cost than the non-profit organizations and are paying additional taxes so there's some come-back for the provincial government, why do we want to -- not "we" -- why do you want to put them out of business? If we can get a better deal, that the employees are getting paid just as much as the non-profit organization, they're getting less per hour than the non-profit so there's a smaller payout from the provincial government, and they're paying additional taxes back, why on earth would you want to put them out of business?

Mr Wessenger: I think we have to look at the aspect of the question of the service delivery concept. The concept of the MSA is to move to an integrated service delivery concept. It's not related, really, to the question of -- I think it's the fragmentation of existing services that really is the difficulty.

If I might just indicate, for instance, just a week ago I had an example in my own constituency about a problem with fragmentation of services, where there was a change in the medical condition of the patient who was receiving home care. The information was clearly communicated to the VON who was delivering the nursing services. There were two different homemaker services involved in providing homemakers to the individual, one profit and one non-profit, and there was no communication of a change in medical condition to the homemakers. When you have such a fragmented service delivery, I think you have many communication problems arising. It's a question of preference for a clearly integrated service model.

Mr Sterling: But I'm talking about the 80-20 split. That other stuff has nothing to do with the question I'm asking.

Mr Wessenger: Yes it has, because the 20% applies to non-profits just as much as it does to for-profit. There's no distinction in the question of purchased service. It's not related. It affects the non-profit agency just as much as the for-profit.

Mr Jim Wilson: Just a point of clarification, though: In the parliamentary assistant's response, he's somehow dragging the private sector into his response about this local example he had of this problem with coordinating service. Mr Wessenger, you have 96% delivery of services in your riding by the not-for-profit sector, so I assume your example more than likely is an example coming out of the current system that's in your riding. It has nothing to do with the question asked by Mr Sterling.

Mr Wessenger: I was answering the question and indicating that really the policy had to do with an integrated service delivery model. There's no question that if your concept of a service delivery is a consumer service, a purchased service, a competitive service for delivery in the community, then of course there would be the validity of the thing of, why should one be concerned about the aspect?

But if you're looking for an integrated service model, like we do in the health care system in the institutional side -- it is an integrated service delivery, the hospital model.

The Chair: For our witnesses, would you like to make a comment on that before we have to finish this section?

Ms Evans: Obviously, we agree with Mr Sterling: Why the 80-20? That was really the purpose of our being here. We just don't understand the purpose of section 13. We came before the committee to show you that we are responsible employers, that we are doing a good job. Quality of care is not an issue. We can save you a lot of money by providing this service in administration costs, so please leave us alone and get rid of the 80-20.

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


The Chair: I call on the representatives from Marianhill. Welcome to the committee.

Ms Isabel Leach: Good morning. My name is Isabel Leach, coordinator of the Dr L.U. McCluskey Centre at Marianhill. The centre is part of the Marianhill community Alzheimer system, the goal of which is to enhance the interdependence of care givers and persons with Alzheimer disease or a related dementia. The conceptual framework is enclosed in the folders you received. With me today is Eileen Sicoli, coordinator of pastoral care at Marianhill.

It is certainly a privilege to live and work in an open and bureaucratic system where opinions are sought on such critical social policy issues as Bill 173. We trust that our concerns will be taken into consideration before the next reading of the bill. Just to let you know, our presentation is outlined in yours.

Marianhill, a private, charitable home for the aged, is not only an excellent long-term care facility but it offers the elderly of our community with a continuum of care. Dr Jennifer Ingram, a noted geriatrician, in an article in Thomson newspapers said, "Anyone considering a career in gerontology should visit Marianhill." In a cost-effective and efficient manner, Marianhill has developed numerous programs integrating those in the community with the facility.

Because of the lack of specialized programs for persons with dementias, the Marianhill community Alzheimer system was developed. Our experience in the community demonstrated a need for this latest innovation. The unique Dr L.U. McCluskey Centre offers an extensive assessment process for victims, with family-focused support for the care giver. Our experience and the knowledge of other care systems that we have been sensitive to demonstrates that the proposed legislation has shortcomings.


Specifically, we are concerned about: the limited attention paid to special populations such as those with Alzheimer disease; the insufficient attention paid to the history of innovation in the private sector; the anticipated escalation in costs; the bill not being sufficiently family-focused; the need to address preventive measures such as specialized housing; and the failure to recognize the role of the health care facility in the long-term care spectrum.

In the full text of this document we deal with all six issues, but today, for the sake of brevity, we will speak to only three. Our oral presentation is outlined in the full document for you to follow.

In Canada, 5% to 10% of people over the age of 65 and 20% of those over 80 suffer from Alzheimer disease, and reports are that this figure is probably underestimated; it also does not include the related dementias which can cause similar problems for care givers. This is, and will be in the future, a significant number of people who will require assistance from a long-term care system.

Numerous attempts have been made to identify those programs and services which impact upon the life and health of people with a dementia and how they must be integrated functionally. Although extensive work has been undertaken to evolve models to service the frail elderly, for the most part they are experimental and a consensus as to the organization of the community service system has yet to emerge. Primarily, the focus has been to the physically disabled, not to the person with a dementia and their care giver. For example, many homemakers are not skilled in dealing with the special problems occurring from a dementia. Bill 173 must more adequately address this area.

In the June 1994 Gerontologist, Joshua Weiner states that by the end of this decade virtually all the parents of the baby-boom generation will be elderly; many of them will be very old and starting to use long-term care. These elderly will turn to their children for care. No longer will this be a purely academic issue; long-term care will become an intensely personal issue. The elderly of tomorrow will be better educated, have varied social and economic backgrounds, will be more technologically advanced and will have been more mobile. For many people it is tolerable for a disabled mother to live with her daughter and to spend most of her time at home. This may become less evident over time as the baby-boomers age and demand more independence. We will expect more of the system that we have helped finance for years and we will expect more say in the services we require.

We worry that this legislation is not really looking to the future; rather, it is looking only to correct past mistakes and cut costs.

Related to the demographic developments are changes in family structure -- reduced child-bearing and longer life expectancies -- resulting in more generations within families but fewer children in the nuclear families. These demographic developments, in particular cohort succession and kin availability, may constrain future developments in family forms and functions. These statistical characteristics present social policy strategists with challenges in shaping political and bureaucratic structures that can buttress family support. If ever there was a time for a new paradigm to guide long-term care policymaking, it is now.

Large monopolies, especially government bureaucracies, are not known for their innovative ideas. Healthy competition among a variety of agencies stimulates creativity in an effort to reach excellence. Marianhill is an excellent example. Marianhill is known across the province and in many parts of Canada for its varied innovations in community and institutional care. Bill 173 will stifle this kind of creativity.

Eileen will now focus on the family-focused assessments.

Ms Eileen Sicoli: Since relationships can be drawn between an elder's quality of life and a supportive family network, more attention to empower this network must become the focus of formal policy and practice initiatives. Instead of saying we will "do for you," why not say we will "assist you to do"?

Bill 173 and its resulting large bureaucratic MSAs raise two issues in this respect. The first is of control of the individual home help. If this worker is in the community to support and assist the individual client or care giver, it might be suggested that the client should have control over that worker. However, the fact that the organization can withdraw and substitute workers demonstrates that the care giver does not have control over the worker; secondly, nor does the care giver have much hope of successfully protesting at such changes. Should the person attempt to resist change and want to maintain contact with a known, liked and trusted worker or complain in any way to maintain control over his or her lifestyle, he or she is most likely to be labelled "difficult" by the organization or it will be noted as a further expression of the person's problems.

Why not empower care givers? Train them to be their own case managers. Think of the cost savings in personnel alone. Long-term care reform, as it was originally planned, with one-stop access to information and referral, would have been a good start to empowering care givers, allowing them the choice, knowing that they and not the government know best what their needs are. We believe this government has not paid sufficient attention to empowering care givers and is in fact taking most of that right away.

Studies confirm that care givers in Ontario are confronted with an arduous responsibility. Care givers are at an advanced age and often in frail physical condition. They suffer from numerous symptoms associated with the burden of care giving.

A review of informal care giving literature reports a number of critical findings that are essential to practitioners to alleviate care giver burden. I wish to mention three of them and their relevance to Bill 173.

First, the finding that care giver burden is not solely influenced by a person's level of impairment means that service providers and clinicians must look beyond the objective functional status of the person in order to adequately support care givers and enhance their effectiveness.

Second, because care givers differ dramatically in the kinds and levels of burden they experience, no single service program or even a limited set of programs will be adequate to restore the wellbeing or enhance the effectiveness of all care givers.

And third, efforts to alleviate burden by providing social support must recognize the importance of the value and meaning that the care giver attaches to this support. Simply providing additional units of support is not valued if the care giver views the meaning of support in terms other than that of providing understanding and respite.

With Bill 173, if one's needs are not met within the basket of services, will there be alternatives? How will they be determined? In working with care givers of persons with Alzheimer disease, one of the main problems in the community is that of wandering. Nowhere in the basket of services is there sufficient help for the care giver who 24 hours a day, seven days a week, must keep their eye on their loved one. The care giver is able to do all her household chores, assistance is not needed in personal support, and transportation is not an issue. Two nights a week respite might help a little, but what about the other five nights and seven days? Adult day care might help, providing the facility is able to cope with wanderers, and night care might be even better. However, there is little in this legislation that will be of any real assistance.

In Partnerships in Long-Term Care: A New Way to Plan, Manage and Deliver Services and Community Support, "Decisions on services offered will be based on need as measured by standard assessment methods." This sounds like more checkmarks. Will the above person be eligible for any service because he or she doesn't meet the criteria? If this person decides that her loved one would be better cared for and safer in a specialized Alzheimer unit, will that be an option? Are there special units available in her area, or will she be told that she doesn't qualify because she doesn't meet the criteria?

Will the care giver have access to people who are knowledgeable and skilled in a particular field, or will everyone be treated generically? Will the increased availability of home and community services deny people access to institutions if, according to the assessment, they could be looked after at home cheaper than in an institution?

If there is a waiting list for community services, how will priority be established? Will someone with medical needs take priority? Will this care giver, who is not only extremely stressed but totally exhausted, be told that she has to wait? Will the MSA provide education to the family member so they can understand the progression of the disease and not become a second victim?

The rudimentary menu of services for care givers frequently results in an overusing or misuse of service that is available. Inappropriate servicing may influence care giver burden and frustration.


Ms Leach: We believe Bill 173 will take away our freedom to meet the needs of our community as we see fit. Marianhill is progressive and I believe we are a forerunner, an example of what can be done for people in our community. We object to the introduction of MSAs as being the provider because we feel they will take away our identity and our individual initiative to provide programs.

Our values date back to our Catholic heritage in the late 1700s, but we provide professional and compassionate care to Catholics and non-Catholics alike. We do not want our mission to change from continuing Christ's healing ministry through a wide range of services to continuing the government's ministry through government-run services. It changes our philosophy, and this is not acceptable.

The Marianhill community alzheimer system, a unique, innovative program, is a prime example of empowering care givers. It is a community-directed program based in an institution, so it uses the best of two worlds. With specially trained staff, we're able to offer care givers of persons with Alzheimer disease or a related dementia an array of services, and at the same time we support the care givers in choosing service appropriate to their needs. We work closely with other community agencies by developing ways to ease communication and transfer information. If one of our services does not meet the needs of the care giver, we refer them to those that can.

What care givers like best about our system is that they gain knowledge of the disease and its process. They learn techniques to cope better with problems encountered. They know that 24 hours a day, seven days a week, they can access someone who is knowledgeable in the field and that there is somewhere they can turn in crisis.

We do not know how our system will be affected by Bill 173, but it will be unfortunate if this system, which is hailed by experts in the field as being one of the most innovative efforts to help people with Alzheimer disease, is dismantled.

Ms Sicoli: In conclusion, let me summarize our concerns.

Is this legislation truly a vision for the future? Does it take into consideration the changing demographics and future needs of the elderly population?

Will it stifle innovation and community initiatives?

Will MSAs truly be able to offer quality community care in an efficient, cost-effective manner?

Should we not be looking to empower care givers rather than taking away their right of choice and control?

What is the assessment process, and will it determine the real needs of the person and their care giver in a cost-effective manner? How will priority of service be determined?

Are the specialized housing needs of persons with a dementia to be part of the mandate of this legislation?

Where do long-term care facilities fit into the system? Will they become even less of an alternative for those seeking help?

Finally, we do support MSAs as being a coordinating body. We object to the exclusion of any reference to the needs of persons with Alzheimer disease and related dementias. We recommend you include legislation to deal with the three key areas we have expanded on today. Thank you.

Ms Gigantes: First of all, my understanding of Bill 173, and you can tell me how you see it differently, is about the use of public funds for the provision of health care services for people who have chronic health and support needs. So we're not talking here about how people choose to spend their own private moneys; we're talking about where the taxpayers' money is spent in support of the health of people with those chronic needs.

Could I ask how people pay for services at Marianhill and how that relates to what we're discussing in Bill 173? Do you do a purchase of service with some arrangement, or do people pay their own fees independently?

Ms Leach: I think it depends. All the services that we talk about, we provide, and it depends on what service it is what payment is required, if any.

Ms Gigantes: Could you give us a bit more detail?

Ms Leach: Do you mean specific examples?

Ms Gigantes: Yes, about the categories of service and how people receive them and how payment is made for those services from your base at Marianhill.

Ms Leach: For instance, adult day care?

Ms Gigantes: Yes.

Ms Leach: I shouldn't really talk about this too much because I'm not an expert in this, but I believe they pay for their meals and the rest is provided by Marianhill.

Ms Sicoli: I know our latest program that we have added is the palliative care, but that is under our chronic care beds, so they do not have to pay for that; that is totally provided. And as well the residents who come into Marianhill pay as anyone else who would go to a not-for-profit home. They pay a flat fee and then all of the programs are available to them as well.

Ms Gigantes: I'm trying to understand how it is you see services being affected by what is contemplated in Bill 173, which to my mind is at its essence a method of making sure that people's needs are being met in some system that provides priority based on assessment and need.

Ms Leach: I think we agree that everybody should be provided with services, but there are a lot of people out there doing a good job of that. According to what I see in Bill 173, it looks like the government is trying to be all things to all people, and I'm not sure that's possible. I agree with Bill 173 being a coordinating information referral so that people are aware of and can access the various agencies and various services out there. We're concerned with the provision part.

Ms Gigantes: In essence, if I could put it to you, we had an earlier submission from a group that said government should not be providing funding and providing service, but that's what every hospital does, and an MSA is going to be an independent, non-profit agency made up of people drawn from the community it serves. I don't understand this fear and loathing that seems to exist about an MSA.

Ms Sicoli: I think the fear comes from the point that we fear some of our services will be taken away and will be put under the MSA. Being a non-profit institution, we come from our own mission, our own philosophy, and these services will not be delivered in the same manner as they are being delivered right now. They will be delivered according to a government-run philosophy as such, and that personal touch that we have worked many years to be able to deliver and that our people are quite happy with could be lost.

Ms Gigantes: You have a board, though, and an MSA will have a board drawn up --

Ms Sicoli: We have a volunteer board.

Ms Gigantes: Yes, and the MSA board will be a volunteer board drawn from members of the community.

Ms Sicoli: It is my understanding, and correct me if I'm wrong, that the board will be appointed by the government.

Ms Gigantes: No, you're wrong.

Mr O'Connor: Mr McGuinty raised that as a point this morning, but it was actually wrong.

Interjection: Elected.

The Chair: I'm sorry, I'm going to have to intervene because I'm afraid we're getting --


The Chair: Excuse me. I regret that we're at the end of our time and we'll have to move along.

Mrs O'Neill: Mr Chairman, could we have the clarification that we got in writing this morning from Mr Quirt? I don't think it's fair to leave this answer the way it's sitting.

The Chair: The clarification of?

Mrs O'Neill: Of the board, the governance of the MSA.

The Chair: Parliamentary assistant.

Mr Wessenger: I'm not certain what the request is, but perhaps Mr Quirt can respond.

Mrs O'Neill: How the board is elected I think is important.


Mr Geoff Quirt: Some of the presenters have interpreted a section of the bill that talks about the minister appointing directors. That section of the bill talks about the powers that the minister delegates to civil servants like myself and about 17 other people in the long-term care division. It's government ministry functions where the minister says, "I empower this civil servant who works for me to carry out that particular function on my behalf."

The government has no intention to appoint the members of the board of directors of the multiservice agency. The government's policy is that the multiservice agency be a not-for-profit corporation and, from a policy perspective, it urges that at least one third of the members of the board of the multiservice agency be people consuming services that are delivered by the multiservice agency.

The Chair: I'll give you a chance to make the last comment on this.

Ms Leach: I was just wondering if the government has any say in the appointment of these people.

Mr Quirt: No. The government would receive a proposal from the district health council that would talk about the area that the multiservice agency would serve and would talk about how that board of directors would be developed. We expect they'll be elected in most cases from the membership, in the same way that your board of directors is probably elected in your not-for-profit charitable corporation from a membership.

Ms Sicoli: Our board of directors is not elected.

Mr Quirt: The government will not be saying, "This is the person we want on the board of the multiservice agency." The government will be establishing policy to ensure that consumers are represented, and they've also asked that representation make sure that social and health perspectives are represented. But that's the policy framework within which communities will decide themselves who are going to be members of the board of directors of the multiservice agency.

The Chair: I'm sorry; we are going to have to move on. I'm sure that as we deliberate in clause-by-clause we'll try to settle that one more clearly.


Le Président : Maintenant, j'invite les représentants du Service d'entraide communautaire pour les aînées et les aînés francophones. Merci d'être venus ce matin. Nous avons reçu deux documents. Si d'abord vous pouvez vous présenter au comité, et après, commencer votre présentation.

Mme Denise Chevrier : Je m'appelle Denise Chevrier et je suis vice-présidente du Service d'entraide communautaire.

M. Pierre Périard : Je suis Pierre Périard. Je suis le directeur général du Service d'entraide communautaire.

Mme Chevrier : Vous en avez une copie ?

Le Président : Encore une fois, il y a deux documents, dont la déclaration que vous allez faire maintenant.

Mme Chevrier : C'est ça.

Les représentants du Service d'entraide communautaire pour les aînées et aînés francophones désirent remercier les membres du comité aviseur sur le développement social, qui nous donne l'occasion d'exprimer notre point de vue sur le projet de loi 173 concernant la réforme des soins de longue durée.

La réforme des soins de longue durée provoque une restructuration radicale de la prestation des services aux aînés et aux handicapés de l'Ontario. Cette réforme vise à intégrer les services de santé et services sociaux et à faciliter l'accès aux services pour tous les consommateurs de l'Ontario. Dans le cadre de cette réforme, le projet de loi 173 énonce des directives pour la mise sur pied de nouveaux organismes dits organismes de services polyvalents, soit OSP.

Ce projet de loi vise à simplifier l'accès aux services communautaires par la mise sur pied d'un système à accès unique, à augmenter la participation des usagers à la prise de décisions et à la planification concernant la prestation des services, et à accroître la responsabilité des organismes prestataires de services. En outre, la nouvelle loi reconnaît officiellement que les conseils régionaux de santé ont le mandat de diriger la planification locale des services de soins de longue durée.

Il est important de souligner que le Service d'entraide communautaire pour les aînées et aînés francophones appuie les objets de la loi énoncés à la partie 1 du projet de loi 173. Chaque affirmation place l'individu au centre et lui accorde un rôle important dans le réseau de la santé. Veiller, améliorer, reconnaître, simplifier, promouvoir et encourager sont conformes aux principes énoncés dans le document intitulé Partenariats dans les soins de longue durée : Un nouveau moyen de planifier, d'administrer et d'offrir des services et du soutien communautaire, dans lequel les objectifs qui ont trait aux OSP veulent respecter, appuyer, intégrer, assurer, encourager et élaborer.

Le Service d'entraide communautaire appuie également la déclaration des droits de la personne qui reçoit des services communautaires. Ces droits énoncés à la partie 3 sont toujours conformes aux principes et aux objectifs de respecter et appuyer le désir de dignité, de bien-être et d'autonomie des gens, d'assurer une plus grande participation des clients et un plus grand contrôle dans la planification et la prestation des services.

Le Service d'entraide communautaire est un organisme à but non lucratif qui assure des services de soutien à domicile aux aînées et aînés francophones de 60 ans et plus de la région d'Ottawa-Carleton, et dont la mission est de favoriser leur bien-être physique, social, affectif et spirituel ; permettre aux personnes âgées francophones de demeurer le plus longtemps possible à domicile et dans un environnement qui leur est familier pour ainsi retarder le processus d'institutionnalisation ; inciter les aînées et aînés francophones à demeurer actifs dans leur communauté ; maintenir une qualité de vie le plus longtemps possible ; et assurer des services de qualité de manière efficace. Le Service d'entraide communautaire offre, depuis 1974, soit une période de 20 ans, des services bénévoles (visites amicales, télé-jase, télé-bonjour, escorte, épicerie-bus) et des services à coût minime (entretien ménager, travaux d'entretien, service de répit et transport).

Afin d'amorcer un processus de réflexion interne sur la réforme des soins de longue durée, le conseil d'administration du Service d'entraide communautaire a créé un comité ad hoc. Dans un document intitulé Pour un organisme de services polyvalents francophone Ottawa-Carleton, dont vous avez une copie, le comité a consigné notre mission, notre philosophie, nos valeurs fondamentales, les services offerts et le territoire desservi. Il a également fait une synthèse des activités des quatre dernières années et a inclu une vue d'ensemble de la population âgée francophone d'Ottawa-Carleton en relation avec l'éventail complet des services énumérés aux pages 16 et 17 dans le document intitulé Partenariats dans les soins de longue durée.

Parce que les planificateurs de la réforme des soins de longue durée s'attendent à ce que chaque organisme de services polyvalents offre un éventail complet de services, le Service d'entraide communautaire a entrepris des pourparlers et des rencontres avec les organismes francophones qui offrent actuellement des services à la population francophone. Après quelques consultations auprès de ces organismes, il nous apparaît évident qu'il serait facile de mettre sur pied un organisme de services polyvalents francophone en utilisant les organismes francophones déjà en place sur le territoire.

Les aînés francophones de la capitale nationale éprouvent beaucoup d'incertitudes et d'inquiétudes face à ce projet de loi concernant les soins de longue durée. Ils décèlent présentement aucune assurance, quant à la protection des services en français dans le projet de loi, au niveau de la prestation des services aux consommateurs. Leurs inquiétudes se traduisent par deux questions :

(1) Comment cette réforme de soins de longue durée protègera-t-elle les services en français ?

(2) Est-ce que la nouvelle loi proposée garantira la protection des services en français ?

Le Service d'entraide communautaire désire réitérer certains principes fondamentaux qui devraient guider la prestation des services en français au sein de l'organisme de services polyvalents. La communauté francophone d'Ottawa-Carleton, qui compte la plus forte concentration de francophones dans ses rangs, soit 120 000 personnes, a réussi à développer un réseau de services qui lui permet de rejoindre et de servir de façon adéquate la population âgée francophone. Bien qu'il reste des améliorations à apporter, il n'en demeure pas moins que ce réseau de services qui a mis beaucoup de temps à se bâtir a su répondre jusqu'ici aux besoins de la population âgée francophone d'Ottawa-Carleton. Il est important de développer la prestation des services en français en misant sur les acquis du réseau qui a été mis en place par la communauté francophone de la capitale nationale au cours des 20 dernières années.


Le Service d'entraide communautaire croit qu'il est important de reconnaître le principe général suivant : les aînées et aînés francophones ont le droit fondamental d'être servis dans leur langue, peu importe leur lieu de résidence à Ottawa-Carleton.

Le Service d'entraide communautaire croit également que la communauté francophone a le droit et la responsabilité d'assurer la planification communautaire, la gestion et la prestation des services qui sont destinés aux personnes âgées d'expression française d'Ottawa-Carleton.

La population francophone d'Ottawa-Carleton n'a pas du tout senti de considération envers sa langue et sa culture dans cette réforme de soins de longue durée. Il est tout à fait raisonnable et attendu qu'il y ait dans la région d'Ottawa-Carleton un organisme de services polyvalents francophone qui offrira des services en français.

Au nom de tous ses membres, ses bénévoles, ses bénéficiaires et de la population aînée francophone d'Ottawa-Carleton, le Service d'entraide communautaire pour les aînées et aînés francophones demande à la ministre de la Santé que le projet de loi 173 concernant les soins de longue durée soit amendé pour garantir l'inclusion des services en français dans la Loi sur les soins de longue durée afin de permettre la création d'un organisme de services polyvalents francophone dans la région de la capitale nationale, protégeant ainsi les droits des francophones.

Les besoins de la population aînée francophone d'Ottawa-Carleton seront mieux palliés par un OSP francophone. Le Service d'entraide communautaire préconise la nécessité d'établir des politiques claires à ce sujet. Sinon, un aîné francophone essayant d'obtenir des services d'un OSP qui n'est pas francophone sera ballotté d'un prestateur offrant des services en français à d'autres qui n'en offrent pas. Autrement, comment cette réforme se prouvera-t-elle différente de la situation connue actuellement par le consommateur francophone aîné ?

Afin de respecter la volonté exprimée par le gouvernement de fournir ces services en français, la population francophone a le droit de s'attendre à ce que la planification des services de soins de longue durée reconnaisse et remplisse l'engagement concernant la prestation des services en français. De plus, la prestation de ces services s'alliera aux facteurs de gestion de cas en français, comme l'information sur les services, l'évaluation des besoins, la détermination de l'admissibilité aux services etc. Un intervenant francophone crée un dossier en français pour un client francophone dans un OSP administré entièrement en français.

Pour conclure, nous vous remercions de l'attention que vous apporterez à ces recommandations.

Le Président : Merci pour la présentation. Monsieur McGuinty.

M. McGuinty : Merci, monsieur, madame, pour être venus devant nous autres aujourd'hui. Je suis très content que vous avez pris le temps pour venir nous présenter cette présentation de la part de notre francophonie, une partie très importante de notre population ici à Ottawa-Carleton.

Je pense que vous posez de très bonnes questions ici, en demandant ce que le projet de loi 173 va faire pour protéger les intérêts de nos aînés francophones. Les deux questions se trouvent en bas de la page 3. J'ai posé ces mêmes questions à l'adjoint parlementaire pour qu'il puisse nous donner la réponse, parce que je trouve que ce sont de très bonnes questions.

Alors, à l'adjoint parlementaire, les deux questions se trouvent en bas de la page 3. Premièrement, comment cette réforme de soins de longue durée protégera-t-elle les services en français ? Deuxièmement, est-ce que la nouvelle loi proposée garantira la protection des services en français ?

Le Président : L'adjoint parlementaire. Parliamentary assistant.

Mr Wessenger: I'm going to ask our policy person to respond to the more specific details on how this will be achieved.

Mr Quirt: In areas of the province designated under the French Language Services Act, it's the intention of the minister to list one or more multiservice agencies under the French Language Services Act, requiring that MSA to deliver services in French. It wouldn't necessarily be all multiservice agencies in a designated area, but at least one or an appropriate number will be designated under that act and they will be required to meet the conditions of the French Language Services Act in that regard.

Ms Gigantes: What would that mean in Ottawa-Carleton?

Mr Quirt: It would depend on the planning of the local long-term care subcommittee. I'm not sure how many multiservice agencies the district health council will recommend to the Minister of Health be established in Ottawa-Carleton, but clearly one or more of the MSAs that would be recommended would be designated under the French Language Services Act.

It's her intention to ensure that in every designated area of the province there are services available in French from an MSA, and she has indicated to provincial associations that have raised that issue her intention to list MSAs under that bill to ensure that all the provisions of the bill apply. She has also made it clear to district health councils that are planning for services in areas that are designated that they need to pay particular attention to planning for the needs of francophone Ontarians. No doubt DHCs need to take that into account in a number of their activities, but specifically with respect to long-term care she expects the proposals to deal with the needs of francophone community members.

Le Président : Est-ce que vous voulez ajouter quelque chose ?

M. McGuinty : Est-ce que ça vous donne du confort ?

M. Périard : Je reviens aux commentaires que nous avons faits, que si la population désire un OSP, ce qu'on appelle un organisme de services polyvalents francophones, alors, à ce moment-là il y aura absolument moyen qu'il y ait un OSP francophone dans la région. Si la population, la communauté francophone désire un OSP francophone pour répondre à ses besoins, alors, à ce moment-là ça va être une possibilité.

Le Président : Si je comprends bien ce qu'on dit, c'est que la Ministre a dit qu'on va créer un OSP francophone, au moins un, mais ça va dépendre de la planification qu'on va faire, par exemple, dans la région d'Ottawa-Carleton.

Mme Chevrier : Il existe déjà un OSP francophone dans le comté de Prescott et Russell, mais la population francophone d'Ottawa est quand même supérieure à cette population, et on trouve que la région d'Ottawa devrait être munie d'un service OSP francophone.

Le Président : Bon. Au nom des membres du comité, j'aimerais vous remercier encore une fois d'être venus ici ce matin. Merci beaucoup.

With that, members of the committee, we will break for lunch. We will reconvene at 1:30 here.

The committee recessed from 1200 to 1334.


The Chair: We will move immediately to our presenter, from the Union of Ontario Indians, Dr Alan Roy, the health director, and there may be someone else as well.

Dr Alan Roy: My name's Alan Roy. I'm the health director at the union, and to my left is deputy grand chief of the Anishinabek Nation, the band member from Saugeen First Nation.

What I'm going to do is give you a little background material, just talk to you, besides what I have in the brief, so you'll understand why we're coming in front of you today and what our credentials are in involving ourselves in this long-term care review.

From 1992 to 1994 we conducted a comprehensive consultation on long-term care needs within our communities. We published that report and we've given it to the Ontario government. They've had it for over a year. We've done extensive consultation on an aboriginal health policy for Ontario and we've been involved in drafting that policy for the past five years. That's completed now and we're in the implementation phase.

We've just drafted a framework agreement between the Ontario government and the Anishinabek Nation to implement the aboriginal health policy and essentially build seven community health centres in seven strategic areas within the union. That becomes important because that's where we think we'll locate our multiservice agencies. The long-term care facilities will be part of our aboriginal health facilities and our outreach programs to the communities.

There are 41 first nations within the Anishinabek Nation, and they're essentially the Ojibway communities around the Great Lakes. So essentially we break those down into seven strategic areas. It's going to overlap with the non-Indians' territories, but we've always anticipated, and I think the Ontario government understood, that we were expecting a parallel system that would be designed by us, implemented by us, evaluated by us and essentially staffed by our own people to meet the needs of our own clients.

In order to facilitate the implementation of Bill 173 and the long-term care within the Anishinabek Nation, we've done the following things: We've established an Anishinabek health commission with representation from each of those seven strategic areas. We have an Anishinabek training institute. We have seven sites for the aboriginal community health centres. We've done a complete costing of the long-term care programming and the multiservice agencies that we will require. We've signed a protocol that we've developed between the off-reserve and our first nations on reserve for service delivery. The multiservice agency boards will be appointed by the tribal councils in those strategic areas and they'll be accountable to the Anishinabek Nation. So, obviously, we've thought a lot about what we're doing.

We have a problem with the legislation and I'm going to ask the deputy grand chief to go through a letter that was written between the grand chief of our nation and the Chairman of this committee.

Deputy Grand Chief Vernon Roote: Thank you very much. This letter is regarding Bill 173 and the letter is addressed to you, Mr Chairman:

"The provincial reforms to the services for the elderly, frail and disabled have a major impact at the first nation level in the Anishinabek territory. The level of service, the quality, the cultural appropriateness and accessibility are issues of concern. In first nations, the only community support service offered to the frail, elderly or disabled is the homemaker and/or home support program. Both these programs have been chronically underfunded. It's been very reassuring to have the issue respected in Bill 173 when no amendments were made to the Homemakers and Nurses Services Act.

"The area that requires an amendment to the current wording is section 62.5(a) and (b): the use of the word `may' be changed to the word `will' or `shall.' The intent of section 62 is to clarify the mandate to the district health council in their geographic areas. District health councils should be directed to allow first nations to assert their jurisdictional issues. Aboriginal health and social service authorities are accountable to tribal councils and ultimately first nations. First nations will have an opportunity to formally opt into a district health council by passing a formal band council resolution. The Anishinabek proposed changes will clarify that district health councils are to back away from planning, managing and delivery of services when these functions are the responsibility of an aboriginal community or organization.

"The Anishinabek nation has developed a health commission which will be funded in part by Health Canada. Needless to say, if district health councils are occupying a field in respect to health services for the purpose of surveys delivery, planning and management, there will not only be duplication of services but room for misinterpretation of each party's role and responsibilities and create further misunderstandings between first nations and the government of Ontario.

"In addition, the aboriginal health policy initiative, that has been approved by the Ontario cabinet, vision statement speaks of self-determination in health being supported by appropriate levels of financial and human resources for aboriginal designed, developed and delivered programs and services that respect and promote community responsibility, autonomy and local control.

"In summary, the standing committee's support and advancement of amending `may' to `will' or `shall' in section 62.5(a) and (b) will provide for consistency in the provincial approach to health services at first nations."

The letter was signed by our grand council chief, who couldn't make it, and I signed for him. I'm the deputy grand chief of the Anishinabek nation.


Dr Roy: It's the essential section in the bill that we want. We want the standing committee to understand that district health councils cannot intrude into the planning and design of these. Therefore, it's going to be incumbent on the minister and the legislation to set up a situation where we'll be able to set up our own multiservice agencies, be able to appoint our own people and have those people accountable to our own structures within our area.

There is some minor stuff in the legislation that we pointed out.

The Chair: Did you wish to complete the presentation and then we'll come back to this as well?

Dr Roy: Sure.

The Chair: Okay, fine. Go ahead and finish your comments, because I know the parliamentary assistant wanted to address --

Dr Roy: I think the brief speaks for itself. They're very pointed comments.

The Chair: Then we might do that, because it might serve everyone's interests more if we can just explore the questions that were raised in the letter. I'll turn to the parliamentary assistant.

Mr Wessenger: Thank you very much for your presentation. I'm going to ask legal counsel to respond with respect to the legal reasons for the wording in the bill with respect to the "may" and "shall."

Ms Gail Czukar: It was our understanding in drafting the bill, in consultation with Carrie Hayward, the person in the Ministry of Health I'm sure you're familiar with who deals with these issues, that we needed to make it as broad and general as possible, because aboriginal health authorities or whatever they may be called are not yet in existence and aren't set up. There's no formal process for when an aboriginal health authority would take over the functions of the DHC and so on. It was left permissive so the minister could do it at the appropriate time and at the appropriate level. The intention was, of course, that as soon as there was an authority in place to do that kind of thing, the minister would tell the district health council not to exercise its authority in that area. That's the reason it's left permissive.

The Chair: Just some clarification on this: I have Mr McGuinty and Ms Gigantes, and then I'll throw it back to you.

Mr McGuinty: I'm not sure how much comfort legal counsel's response lends to your concerns, but it doesn't lend a great deal to the discomfort it presents for me.

This government has entered into a memorandum of understanding with our first nations. It's subsequently been amended and I think the best thinking of the day compels us to move step by step towards self-government. It would seem to me that this is a logical step along that path to allow our first nations people to assess their particular needs and to meet those needs in the best way they see fit.

I guess I really don't have a question, it's just a comment. What we're doing is leaving the door open for the minister in a very strict permissive way. There's no obligation, there's no deadline found within the legislation, nothing there that compels the minister to take that final step which gives you, as I say, another step along the road to self-government. If you want to comment, then please feel free to do so.

The Chair: Perhaps I'll just allow Ms Gigantes to put her thought or question and then you can respond.

Ms Gigantes: I'd like to ask legal counsel, if I could, how the "if" in subsection (5) relates to the "may," because there is an "if" which seems to establish the premises under which the minister might. The question is if the "if" is satisfied, should we be changing it to "should" instead of "might"? That certainly legally provides some qualification. I have a follow-up question.

Ms Czukar: That's right, it does. I guess the issue is whether the health --

The Chair: Excuse me, could I just ask you, because we're dealing with the clause, to read it so we at least in our minds have a sense of the "if," "might," "should," "will," "may."

Ms Czukar: Under section 62, proposed subsection 8.1(5) says:

"If health services for an aboriginal community in a district health council's geographic area are planned, managed or delivered by the aboriginal community or by an aboriginal organization, or if" -- this is not that exciting -- "resources for health services for the aboriginal community are allocated by the aboriginal community or by an aboriginal organization, the minister

"(a) may direct the district health council not to exercise one or more of its functions with respect to the aboriginal community, despite subsection (4)" which articulates the DHC's functions, "and

"(b) may direct the district health council" essentially "to cooperate with the aboriginal" health authority to plan and so on.

So the preconditions that are set in the first part that Ms Gigantes referred to are preconditions to that direction being given by the minister to the district health council not performing its functions in that area, but there are obviously a number of ways that can happen. As I said earlier, that's why it was drafted generally, because it's my understanding that there are a number of arrangements possible in different aboriginal communities in different DHC areas where in some areas you might have an actual aboriginal health authority. In other areas, it may be the aboriginal community itself and they may want to do more or less planning, more or less delivery. So it was to allow for different stages of development and different stages of readiness to take over functions of DHCs and to compel DHCs to cooperate in areas where that would be the requirement that it was left permissive.

Ms Gigantes: Again I'll ask legal counsel's help here. The tests set out in subsection (5) under the ifs are very low.

Ms Czukar: That's right.

Ms Gigantes: It says that the minister "may" if, for example, the level of involvement of the aboriginal community or aboriginal organization is merely to plan, because it's plan, manage or deliver, so you might be delivering one service or you might be planning three services. The minister still has the authority under the act then to say to the district health council, "Step aside; this community is going to organize its own pattern of service delivery."

The way I read it, and legal counsel might help, is that there's been a deliberate attempt to keep the if tests very low and say that even on a very low test of involvement by an organization or the community, the aboriginal community, the minister may go ahead and tell the related district health council to step aside here. That's my reading. I don't know if I've got that right.


The Chair: Just before asking you to respond to that, Ms Sullivan, you had a question just on that meaning as well, so can we get that on the table and then we can let our presenters respond.

Mrs Sullivan: My question is also with respect to interpretation, although of a different section, in that I'm concerned about whether in fact first nations can be designated as multiservice agencies, given that an agency such as the Red Cross, which is incorporated on a different basis, cannot be so designated and I would suspect that the same criterion would apply to first nations or to the off-reserve aboriginal groups. Similarly, if to get around that the ministry contemplates an aboriginal health council or an aboriginal health authority to become the DHC, can the DHC appoint itself as an MSA?

The Chair: We have those questions of interpretation. Do you want to comment on either or both of those, and then I'll ask the parliamentary assistant to respond, or legal counsel, as the case may be.

Dr Roy: Notwithstanding the answer we have from legal counsel, I think there are some things here that are historical in Ontario in the evolution of district health councils in the field. They tend to take over and get in there and plan, and we're saying the district health councils should not have carte blanche to move into an area and include aboriginals in their statistics, which they historically have done. There should be something that guarantees the non-involvement of district health councils until aboriginal communities invite them to be involved. That's why we suggested the wording that Deputy Grand Chief Vern Roote suggested.

The other thing is, there's nothing in the premise or the initial parts of the legislation to indicate the acceptance of a parallel structure. We've gone to a great deal of trouble to do the basic consultation and planning involved here, and I'm afraid the legislation just doesn't reflect the reality of what we prepared ourselves for. I'm wondering if down the road a minister -- it may not be the same minister as today -- would read the legislation and say, "We can only have one multiservice agency in a particular territory and there cannot be a split jurisdiction" -- or whatever -- "between the non-Indian and the aboriginal."

Mr Wessenger: I'll ask legal counsel to answer those questions she feels she can deal with, and if she wants to throw some back to me, I'm conducive.

Ms Czukar: It's my understanding that there is a consultation and a discussion process going on with various first nations' groups as to how long-term care services will be delivered in those communities and that that's a separate process and the legislation is not meant to dictate any form of service delivery with respect to them or say anything about that process. It's going to go on and it is going to produce its own results. So the provision on district health councils was put here, as I said, to try to create the opportunity for aboriginal health authorities to take over those functions as soon as possible when they were in place. The other processes that you've been engaging in are anticipated to go on and nothing will be superimposed on those until those discussions are concluded.

Dr Roy: One last comment then: We know that during the last two years many district health councils in Ontario used aboriginal statistics in their submissions to the ministry for the development of their long-term care programming, against the wishes of many of the first nations whose statistics they used. I think it may have been a reason why Ms Hayward wanted to put something into the legislation. I'm saying it doesn't go far enough, and I'm quite adamant about that.

The Chair: You've made your presentation before the committee and I think your points have been clearly made. We thank you very much and certainly will be reviewing that along with everything else as we go about our deliberations.


The Chair: I call upon the representatives from the regional municipality of Ottawa-Carleton. Welcome to the committee, regional chair. We're glad you could come to the committee today.

Mr Peter Clark: My name is Peter Clark. I'm chair of the regional municipality of Ottawa-Carleton. With me is Mr Garry Armstrong, who is the chief in charge of all the homes for the aged in the region. Garry has been a long-time member of regional staff and certainly is well known in the community in terms of the care of the aging. Thank you for the opportunity to address you. This bill is of major interest to the regional municipality of Ottawa-Carleton. It's also of major interest to all the regional chairmen across this province and the Association of Municipalities of Ontario.

We generally believe that there is a need to improve the system of long-term care. We think in this community the priorities are information access and coordination of services. We believe there is an excellent system in place in this community already, and we want to build on that. We've been working in partnership with the district health council and other planning bodies in the region to look at this bill, to talk about it, to try to come to terms with some of the principles.

We as a region are also involved in community planning of health and social services. In other words, we have a fairly broad mandate in this area as well. Right now, for your information, the region administers 92% of the $61.6 million of MSA-type services in Ottawa-Carleton. Regional home care serves over 7,000 clients daily. We operate three homes for the aged. We operate community support programs. We provide a wide range of social services above the minimum standards that the province sets.

We believe the municipal option for MSA sponsorship should be the same as every other one so that in any given community, what's right for that community can be addressed, not master planned from wherever. We believe the district health council must be able to consider all these options on an equal basis. In Ottawa-Carleton, the DHC discussion paper clearly lays out municipal sponsorship as an option for the community to consider. The region supports this approach.

Bill 173 restricts the consideration of options, so we strongly recommend the removal of subsection 11(3) so that communities can have the ability and the flexibility to consider all the options in a thoughtful, inclusive process. Why restrict it in the way it's been restricted?

Finally, I should speak to the notion of accountability. Right now, councillors are elected by the citizens and are accountable to them. Special-purpose bodies do not have the same kind of accountability. Local government is close to the constituents and understands the service needs and in a great number of cases is supplementing the broader picture. We feel we have an ability to understand diversity of community and deliver services that meet the needs of our ethnocultural communities and all other communities within this region. We already have a strong commitment to public consultation and have done considerable consultation with the public on this matter, and we do deliver services in a collaborative, community-based planning model.

I guess I'd like to sum up after Garry makes a presentation so we can sort of isolate and specify certain points, and then we'll be willing to discuss anything you wish.


Mr Garry Armstrong: I'll speak from our brief to two issues that are included in the brief, the role of volunteers and the purchase of service. From an opportunity I had as past president of the Ottawa-Carleton United Way and representative of the United Way of Ontario, I met, with a group from United Ways across the province, with the minister this past spring. Two things: One is to thank the minister for that opportunity, and perhaps to reiterate the views of not only United Way volunteers and agencies that are potentially affected -- and I realize it's potentially -- but the other volunteers and organizations that have come forward during these hearings.

I believe that, as you will see or have seen already from the presentations here in Ottawa-Carleton, we have a very strong volunteer commitment in Ottawa-Carleton, particularly evident, I think, in the district health council, the council on aging is another strong body, the social planning council and the United Way. So this is an issue of very deep concern for us and certainly for the regional municipality as well. I think whatever the outcome of the model that is developed, it certainly is an area that we share with others across the province that we have to be very careful of in terms of the development of an MSA model.

The second issue, then, would be the purchase of service, or the limit on purchase of service. I think the concern that is expressed not only by the region, by other presenters, but even by the council on aging and the district health council is the limit issue, that every community is different. We have a commitment that the region is strongly supporting to let the community decide. Our concern is that 20% is an appropriate target perhaps in some communities. What we are suggesting is that the limits contained in section 13 be removed. In fact, the removal of section 13 would allow this community, and the process is well under way, to develop a model that is not as one-stop, if you want, in the pejorative sense, not in the sense of service, that would eliminate some tremendous services that are being provided by organizations and the obvious potential impact again on volunteers.

We as a municipality, as a regional municipality, have participated with the district health council in its studies to date. The strongest issue and the number one priority in Ottawa-Carleton at this point in time remains information referral and one-stop access, and that is a priority the district health council is putting on that we are strongly supporting.

With home care, we obviously have a great concern about the issue of purchase of service. As Chair Clark has indicated, we purchase most of the services, and I think in addressing that issue of large government or bureaucracy that I know has been raised and what that means to different people, we as a municipality have not gone out with any intent to increase our staff or the services we provide directly. In fact, our approach has always been to work with organizations, such as the district health council, with provincial authorities and with local volunteers to determine what services are needed, and in most cases, in a great number of cases, we purchase them on behalf of service providers, and we feel that model has worked exceptionally well.

We are very aware of the costs that have been identified by some groups in terms of creating a new organization if that is the case. We would prefer building on what we have and our experience. For example, the region did assume the responsibilities of the board of health some years ago and are well aware of the issues of unions and negotiations etc that go along with that. On behalf of, and at the request of the province as well, we assumed responsibility for Centre d'accueil Champlain, a home for the aged in Ontario. Again, the reason I mention these is that these are not issues we pursued but were done on the basis of community consultation and in the best interest of the community, and the recommendations came from other bodies to the regional municipality of Ottawa-Carleton.

Finally, I think in terms of governing models, as chair Clark referred to, we have an extensive consultation process in place in Ottawa-Carleton and in many areas use volunteers, including the district health council. For example, for many years we have funded capital projects in hospitals only at the approval of the district health council, and similarly in many of these services that we provide we depend on volunteers and community-based organizations to assist us in determining what it is that we provide as a municipality.

So those two issues then: One is, again, supportive of all of the comments on volunteers; and secondly, the real concern about a limit of 20%, even recognizing that it's four years down the road. Let this community that this region will support determine that limit, whether we ensure they're provided or we provide them ourselves, as the section says.

Mr Clark: In closing, I guess we are requesting that the committee support local planning by removing subsections 11(3) and sections 13 and 15 from the bill so that a municipal option can be equitably assessed along with all the others. If the choice of the community is regional government, we believe we are well suited to provide MSA services, not directly but through the brokerage models that have been described by Garry. It's hard for us to believe in times of fiscal restraint that a government could consider ignoring the infrastructure, information systems and expertise that the region currently has, because it will be very expensive to replicate.

Regional council has supported examining the feasibility of administering a pilot MSA in Ottawa-Carleton, if there's community support, to assist speedy implementation. The uncertainty in the long-term care sector must be put to an end quickly. Around this table we might understand the process, but certainly among clients, staff, agencies and children of people who are in care there's a lot of uncertainty, and that's not just in Ottawa-Carleton, that's across the whole province. We need answers and we need solutions and we need them now.

In summary, we've got a system here that works well. Certainly it can be improved, and we've pointed out areas we feel are priorities, but we don't think there's any need to replace it in its entirety with a special-purpose body that wouldn't be accountable and that would eliminate volunteers in the community, and we believe that it's up to you to let this community decide.

Mr Sterling: Thank you very much for making your presentation, Mr Clark and Mr Armstrong. I might also add that Mr Armstrong is a retiring member of the Carleton Board of Education, so he not only works for a government but he also is responsible for the other side, the political side, at this time.

I'm going to make it a two-part question because I've only got one question. You say that you control 92% of a certain number of services. Is that your interpretation of all of the services that would be administered under an MSA as proposed in Bill 173?

Mr Clark: Yes.

Mr Sterling: The second part of my question is, I don't disagree with you in terms of the political accountability. I am concerned about how an MSA is elected or chosen and what its accountability is to the people. Would it not make some sense for areas which I represent, as you both know, like the township of Osgoode or the township of Rideau, where Garry resides, to have the local municipality as an MSA for some part of services, rather than the region, because in some of those municipalities, like the township of Osgoode, they relate far more closely to the local government than they do to the regional government.

Mr Clark: Well, I would agree about the relationship, but in terms of the bulk of the services, Osgoode was among the regional councils requesting that the region take over home care. It used to be that each municipality would sort of set a limit on what it expected to spend on home care and the region would deliver the service anyway. I'm not sure you gain a lot from where you're headed with that, but I think you're thinking of things like the Osgoode Care Centre, which is a fine facility. It's developed in Osgoode, serves the needs of the local area and would still operate under this thing. As far as I know, this wouldn't affect it.


In other words, the services that are part of the network of services in a region would still be there and still be operated by the operators, the way we envision it. Correct me if I'm not being accurate enough. Jump in when you feel the urge.

Mr Jim Wilson: Well, except that it is affected. It's a nursing home, the Osgoode?

Mr Clark: Yes, it is.

Mr Jim Wilson: The PCS moves under the MSA and admissions -- I assume your PCS is attached to the region right now.

Mr Armstrong: No, it's independent. Non-profit --

Mr Jim Wilson: It's independent. Because I know mine, in Simcoe county, moved to the county level. It's independent but it's essentially got the county players on it and that will move under the MSA and there's very much concern among most municipalities that they lose that also. Do you have any concerns about that?

Mr Clark: We haven't had a lot of people, but fire away.

Mr Armstrong: I can speak to the placement coordination service here locally. I served as president for two years and we're actively involved. I think the concern we have with the PCS locally is probably similar to other areas of the province. We've always had a volunteer board. We developed our system locally, with municipal involvement and with all of the institutions involved. We developed our forms that we all agreed to utilize.

We are running into some problems now that have to do with the additional responsibilities put on the local PCS in terms of the admission process. We are concerned that if this process goes on too long, in that we are underbedded in this area in the long-term care field, the admission process is going to become a major problem for us.

As an institution, however, we've always worked very closely and we've always had the same waiting lists, all amalgamated under PCS.

Ms Gigantes: I'd like to go to the question of brokerage of volunteers and the relationship to setting priorities at the local level. We're in an area in which, as I understand it, about 70% or more than 70% of the services that are provided in the community that we call long-term care services are provided by private for-profit organizations. That being the case, the extent of volunteer involvement in over 70% of the services is probably lower than one would find if, for example, the ratios were reversed and 70% were in the non-profit sector.

I'd like your comment on that and your comment too on what that structure of service provision in Ottawa-Carleton means when you come to try and assess, on a community level, what the priorities are for service. Obviously, if you're dependent currently on 70% from the private sector, then you're going to tend to assess what the priority for service is, based on what's available, and that's out of the private sector. The MSA proposal, it seems to me, offers an alternative, which is that you can on a non-profit basis build up services which the community may assess as having a higher priority than the private sector might.

Mr Armstrong: The document itself in fact recommends that the responsibility of the district health council is changed significantly in terms of making recognition of allocations of resources; in other words, what shall be provided etc, and we've worked very carefully with the DHC.

My experience with profit-making organizations in Ottawa-Carleton has been extremely positive. I refer particularly to the nursing home sector. In fact, the volunteers within that sector, since we meet them regularly in the non-profit homes, are exemplary in terms of their commitment to service, and I would suggest that it's similarly the case. The only difference would be in the makeup of boards of directors, perhaps, of non-profit as opposed to profit providers of service in the community. But I think in terms of the commitment of the volunteer, it's been strong, in my experience with the ones I've worked with, in the profit sector as well as the non-profit.

It's obviously an issue that is paramount. I have greater concerns about -- and I realize that it may be larger in some communities than others. It seems to be the fear out there that if we look at one large organization, and I know it's a non-profit board etc, the concerns are that volunteers will be lost. I think with any change, that has to be our number one priority, to ensure that we do maintain them.

Mr Clark: Just briefly, I think that the for-profit sector does stimulate as much as possible volunteerism in this community and I suggest that the other model probably would tend to destimulate volunteerism.

Ms Gigantes: Hospitals compared to nursing homes?

Mr Clark: No, we're not talking about hospitals.

Ms Gigantes: But if you look in --

Mr Clark: Community agencies.

Ms Gigantes: -- other areas of service, institutional areas of service, certainly hospitals with non-profit boards don't seem to have a problem stimulating the use of volunteer service.

Mrs O'Neill: You brought up the very fundamental question of accountability. We had a brief discussion this morning about what an MSA board would look like and how it would be elected, and it's certainly not the kind of election that the councillors in Ottawa-Carleton are going to go through in a few weeks.

My question is really a two-part question. I'm very pleased that you brought forward the idea again, which has come forward more than once today, of a pilot project, and that you volunteered for that. You talked about costing. We had the Metro council in Toronto come before us, and it has a connection directly with the United Way, as we seem to have here. They mentioned that the finance subcommittee of the long-term care committee of the DHC in Toronto had only met twice and had to fold because it had no data.

I'm wondering if you had a similar experience here with costing, that you have no data, that you can't cost this out. And then secondly, you have brought forward something I haven't seen in any other brief. You have stated on page 6, "The region is concerned that services to some clients, specifically those on social assistance and low-income earners, may be lost in this reorganization." Could you say a little bit about either of those things?

Mr Clark: I'm going to defer to our expert here in the details.

Mr Armstrong: I think perhaps in the former, in terms of the costing, the district health council and long-term care committee certainly haven't reached that stage. Perhaps that can be addressed when they make their presentation. We did cost out the one-stop shopping option that we proposed as the Ottawa-Carleton region some years ago. It was evident, even at that time, that there were going to be some significant costs involved in setting up a system of simply information referral.

As a result, that issue still has to be determined, and it's very difficult to determine the cost of an organization until you define what it is. We can certainly tell you what it costs to run the home care program and the placement coordination service; those data are there, and they're not necessarily add-on costs. I think it's when you then start building the organization that you have to determine what other costs are involved.

In terms of the question of social services and the impact on that group, I think our concern is, since we provide major services, obviously, to low-income people in Ottawa-Carleton, a very strong social services community, that we are concerned about that issue of the amalgamation of social services and health and whether or not the social services component of the low income would be in fact be hurt, certainly in the short term, as we put our priorities perhaps more on the health side.

Mr Clark: Essentially, I think he's tapped most of it. We have a social planning council, a district health council, certainly a very healthy United Way organization.

Mrs O'Neill: Twelve hundred strong this morning, Peter.

Mr Clark: All of these people are working very hard towards making sure that the most efficient and beneficial service model in this community is used, because obviously, if you're more efficient you're able, with the same resources, to apply more help, more services to the community. So it wouldn't be any mystery that that's the objective.

The Chair: I know we could go on with more questions, but I'm afraid our time is up. We thank you again for coming before the committee.

Mr Clark: You have a tough job. Thank you.



The Chair: I call on Ms Betty Margeson. Welcome to the committee.

Ms Betty Margeson: I am here as a care giver, or more accurately, at least for four years, as the daughter of a care giver. My mother and father, one or both, have been on home care since 1989. My father died in June 1993, two months short of his 81st birthday, and my widowed mother is now living with me.

My perspective this afternoon is to provide quality health care to the elderly as much as possible in a non-institutional setting. From my observations with my parents and from the work experience that I have working with senior management, working with middle management, developing policy and procedures in the department of supply and services, working on computer project teams as a documenter on application teams, I have used some of these work skills to observe what's happened as my parents have aged and, as I say, one has died.

I have three specific solutions to offer:

(1) To replace the existing personal maid service structure of home care housekeeping with (a) designated routes between houses within a neighbourhood and (b) on-the-premises housekeeping in apartment buildings;

(2) To allocate the savings to rehabilitation services to prolong their independence;

(3) To dovetail mental health time for the care giver with delivery of rehabilitation services.

I am going to skip to the specifics and come back to the benefits.

First of all, I would like to replace the personal maid service delivery system. At the moment, when you apply for home care, the client chooses the day and time of delivery of housekeeping services. The housekeeper comes on different days to people who live within the same neighbourhood, sometimes within the same block or two blocks.

In an apartment building such as the Tannenhof seniors' co-op where my parents lived, there is the same scenario, compounded by the density of population. So there are three housekeepers all in the laundry room at the same time, three housekeepers at the same neighbourhood grocery store and three housekeepers vacuuming.

The second point is that the personal maid service company, not to point out any particular company, chooses a two-and-one-half-hour minimum service period, so what's happening is that the client makes work for the housekeeper to do, especially if the visits occur more than once weekly. This is quite apt to happen as the one spouse gets much weaker and the care giver gets more and more tired. The solution has been to simply throw more housekeeping services at the care giver, so the care giver doesn't even do the dishes because, "A is coming tomorrow morning."

My recommendation is to replace this expensive one-on-one set of services with delivery routes. For example, laundry can be picked up and delivered. Grocery orders can be batched, selected, purchased and delivered to the client's kitchen counter. In fact, some grocery stores, for a minimum fee, will pick up elderly clients in a van and deliver the groceries home to the kitchen counter. Some stores will accept phone orders from regular customers and deliver the groceries and thus eliminate the need for housekeepers to shop.

Another example: A housekeeper perhaps could be assigned to an apartment building, to go from apartment to apartment to vacuum and dust weekly or once every 10 days. Nobody's place needs to be dusted every two or three days, in my opinion. For personal care services such as bathing, one person can spend a morning, yes, but with three clients; one hour each and up to one hour total billable time for walking between clients in a neighbourhood and one half-hour in an apartment building.

The benefits, as I see, from this type of thing is that the services can be more flexible in delivery. Instead of large blocks of time, the two-and-a-half-hour minimum, services can be delivered in half-hour or one-hour units. For example, clients may receive only personal care services for one hour weekly and not a two-and-one-half-hour block with a lot of unnecessary housekeeping. For example, a client may receive personal care twice daily -- morning and evening -- for a period of one half-hour to one hour.

Expenses for the housekeeping services under this system I think would be drastically reduced by 50% or more. I don't think all the housekeeping services that are being given are necessary, and overall you would see enormous savings. Even better, the client is more independent and does not make work for the housekeepers.

For those clients with special needs, other arrangements such as what I call the personal maid delivery system may be cost-effective. However, for the vast majority of clients, streamlined delivery services should be sufficient. If the client wishes but does not require personal services, then the client should pay for them, not the taxpayer.

Secondly, I would propose that the savings that would be accrued from not delivering services one on one should be allocated to rehabilitation services to prolong independence. At the moment, clients receive housekeeping services weekly or more often, and the real health care from trained professionals is often ad hoc, with long periods of no professional visits at the client's home.

I observe that the client does not always receive follow-up professional rehabilitation services after respite care in an institutional setting. For example, my father suffered from cancer and from emphysema. He was put in the Elisabeth Bruyère Health Centre for one week in December 1992. They were able to put him on his feet and get him relatively mobile, and he went home and sat. It was unfortunate that there was no follow-up.

Recommendation: Use the savings from housekeeping services for perhaps biweekly visits by a trained therapist or other professionals to exercise, socialize and encourage the client to remain as independent as possible. These visits can be part of the follow-up from planned respite care days in an institutional setting.

Benefit: The client receives more services designed to promote independence. At the moment, the least qualified person in the whole system, the housekeeper, spends the most time with the senior who is ill and with the care giver.

Dovetail the mental health time for the care giver with delivery of rehabilitation services. The real problem is care giver burnout. My father was just short of his 81st birthday; my mother was 80. There really was burnout there. On duty around the clock, the care giver deals with the emergencies, the doctors' visits, therapies and psychological crises. The key to success of the home care, instead of costly institutionalization in long-term care, is the care giver, and respite care is essential.

Planning for respite care tends to centre around away-from-home care for the home care client. This is expensive and infrequent, too infrequent to maintain the health of the care giver. It's a short-term solution to a long-term problem. Like any short-term solution, it is helpful but often not enough in itself. When the care giver burns out or the care giver declines in health, the likelihood of institutionalization for both client and care giver adds up to big expenses.

At the moment, the theory is that the care giver may leave the home while the housekeeper is on the premises. However, housekeepers have no training or authorization to administer routine medically prescribed treatments such as oxygen or pills and other medications.

In one unfortunate scenario, a plug from a Ventolin machine was knocked out of the wall. My mother was away, the housekeeper was there and my father finally struggled to get the Ventolin machine plugged into the wall and we took him to emergency at 1 in the morning. This is the kind of scenario I would like to see something done about for other people.


Recommendation: I would like to propose that you combine the biweekly visit by a trained professional with mental health time for the care giver. The care giver then may leave the home with the assurance that the client will get routine medical treatments.

Benefits: The care giver will be able to continue providing home care for longer periods of time with less likelihood of burnout. The quality of care by a refreshed care giver is higher than that of an exhausted one. The reduction in care giver burnout will promote long-term home care instead of the more costly institutionalization. Fewer care giver burnouts will mean reduced health care expense in the long term.

To summarize, I'd like to go back to the front page and tell you that I have proposed replacing the existing personal maid service with a new structure, a delivery route structure if you like. I would like to allocate these savings to rehabilitation services that would prolong independence, and I would like to dovetail mental health time for the care giver with delivery of these rehabilitation services.

The benefits: Services under this system can be more flexible in delivery. Instead of inflexible blocks of time, services can be delivered in half-hour or one-hour units. Expenses for the housekeeping services will be drastically reduced, by 50% or more. Even better, the client will be more independent and will not make work for the housekeepers.

When my mother moved in with me, she didn't think she should even wash a dish. I said: "Too bad. Here's a dishcloth, here's the dishpan, here we go." It took a while. What my mother needed was to be socialized, exercised, helped to do these sorts of things, and it has fallen upon myself essentially to do this since she's moved in with me. I do have help. I have a health problem which does not make it possible for me to help my mother bathe, so there is help coming in. There is also housekeeping help coming in because of these two-and-a-half-hour rules. The client receives more services, under the system I'm proposing, that are designed to promote independence. Fewer care giver burnouts will mean reduced health care expense in the long term.

I have no statistics to back this up. This is a personal opinion. I have not discussed these ideas with any care giving group in the community, any mental health group, any home care people. I've simply made my observations on what I've seen in my parents' home, in my own home, in the neighbourhood as I walk around. As I say, based on these personal observations and my own work experience in observing and making recommendations, this is what I present for your consideration.

Mr O'Connor: Thank you for your presentation. One of the things we have heard over and over again is the need for the consumer to be involved in the process. In the case of Alzheimer's patients, it's important that the care giver advocate on behalf of the consumer in that type of situation.

We had a presentation this morning by Marianhill, and they do provide a terrific service for Alzheimer's patients through some day care programs. That type of program of course would be exempt from the 20% rule, and it's something we have discussed in this committee room before.

What you've raised here, it seems to me, would reflect the real need of the personal care and the plan of care, so the question I'd like to ask isn't of you but of the bureaucrats, if they don't mind, through the parliamentary assistant in reflecting what you've suggested here. I think you make good, practical suggestions. It's my hope that as the MSAs evolve we're going to have people like yourself giving those good, practical suggestions to the community group that's going to have a lead role within each community of the MSAs.

Would this be possible, the suggestions as raised here, Parliamentary Assistant?

Mr Wessenger: I'm going to ask Mr Quirt to comment, but it would seem to be that this type of flexibility which you advocate is what we ought to be building into the system of our MSAs. I'll ask Mr Quirt to indicate that.

Mr Quirt: If I might just comment on the three solutions you've offered, I think you've put your finger on one of the problems in the existing system in that when the home care program contracts with a number of different organizations, normally those organizations wish a minimum amount of time that they are going to be paid for before they're willing to go out and provide a particular service. Sometimes that's two and a half hours, sometimes it's four. Some agencies are more flexible, depending on the part of the province, and sometimes there are two homemakers from two different organizations on the same block.

You're quite right that this type of coordination, we hope, would be better achieved when service providers are the people who also decide who gets served, with how much service, when. That's one of the features of the multiservice agency, empowering the people who deliver the service to decide when and how much, rather than being dependent on the person who brokers or makes the arrangements with the client and then places orders with a number of different agencies.

Your second point is a good one, about the onsite services in apartment buildings. We hope through the redirection to almost double what's spent on supportive housing programs in the province, where people aging in place in apartment buildings receive onsite support services on a 24-hour basis so that if they have an emergency in the evening, then someone can be there in a couple of minutes. It's not doctors or nurses but someone there to assist and to provide the degree of security they might otherwise have to get in a long-term care facility.

Your third point about care giver relief is a good one as well. While respite care isn't described in the bill as a particular, discrete service, we recognize that giving care givers a break is an important, legitimate reason for delivering service in the first place, whether that service is delivered by a volunteer, by a homemaker, by a nurse or a physiotherapist.

The Chair: Ms Margeson, you've brought forward a number of points which I think, as you can see, the committee has found most interesting. We thank you for taking the time and coming down here this afternoon.


The Chair: I call on the representatives from the Ottawa-Carleton Regional District Health Council. We welcome you all to the committee.

Mrs Jacqueline Neatby: My name is Jacqueline Neatby. I chair the long-term care committee of the Ottawa-Carleton Regional District Health Council. I feel privileged to be able to speak to you this afternoon on behalf of this committee and the Ottawa Carleton district health council, a council which as you know has over 20 years' experience in planning long-term care services.

I am accompanied by Mrs Avril Gunter, who chairs a working group of 33 members to implement the government's MSA policy. Mrs Gunter, two years ago, co-chaired the community consultation on long-term care, so she's well able to take this task in hand. We also have Mr Cal Martell, our able long-term care planner, who is a member of council staff.

As we have submitted a written brief, my comments will focus mostly on key issues which we would like you to consider. Before doing so, I would like to describe the context in which we are undertaking our long-term care reform.

Unlike many areas in the province, community-based services in Ottawa-Carleton absorb more than half the total provincial subsidy for long-term care services; that is, 59%. In 1991 the total provincial subsidy was $120 million. Of this, $66 million, 59%, was directed to 40 agencies which provide services which the government has earmarked to fall under the MSA. It is important to note that 94% of this $66 million goes to four agencies, the largest proportion being home care. This means that the remaining 6% goes to 36 agencies, largely voluntary community-support services agencies.


These agencies deliver an impressive array of services with small staffs and over 3,400 volunteers. They could not do so with provincial funding alone. Hence, they supplement it with municipal funding, United Way funds and voluntary fund-raising.

The strength of our voluntary sector and the existence of an impressive network of services has influenced our approach to the government's MSA strategy. As you've been told before this afternoon, we want to build on the strength of existing services, so our approach has been to work from the ground up; that is, to achieve the goals of the reform by concentrating on the functions of the MSA rather than by beginning with a predetermined form or structure.

I want to make clear that we haven't committed ourselves to any structure yet. This will happen through a community process. The 33 members of Mrs Gunter's committee represent all stakeholders, all sectors of the community, and it will be a community consultation process taking it a step at a time.

Just now we are working on the most vital function of the MSA; that is, simplified access to services. This includes a proposal for a regional telephone information and referral service. It will be submitted to the community for consultation this fall. By the fall of 1995, we expect to have recommendations dealing with the other functions of the MSA, namely assessment, coordination and structure.

We are undertaking this work with energy and commitment, because although we have a rich network of services, we need to organize them into an integrated system and we need to fill important gaps such as services to the physically disabled and services in rural areas.

We support the goals of the reform and we applaud the government for propelling this much-needed reform. However, our study of Bill 173 leads us to fear that the legal tools and mechanisms therein will subvert the goals that we are striving to attain.

Above all, we're seriously concerned about the consequences of section 13, which limits by category the ability of MSAs to purchase services from service providers. The intent of this section is to force the amalgamation of existing agencies because the government believes that the integration of case management and service delivery is the way to ensure access. There is no definitive evidence that this is the most appropriate way to achieve access.

Moreover, we believe there are significant consequences to the amalgamation of agencies. The ensuing loss of the autonomy and the identity of many of these grass-roots organizations may lead to the erosion of their community development functions as against their service delivery functions, functions currently assumed by volunteers as well. As these functions become increasingly discharged by MSA staffs, volunteer involvement will weaken, and no amount of resourcing can make up such losses. As a volunteer once said, volunteers do not grow on trees. Therefore we recommend that communities be given greater flexibility in their choice of options to achieve an integrated long-term care system, a choice greater than that provided through overreliance on agency amalgamation.

Again, section 13, in limiting the purchase of service by category instead of globally, seriously limits the capacity of a community to maintain agency partnerships which require an approach which is different from the home care model proposed throughout the act. Examples of services which require a different approach are elderly persons' centres, certain home support programs and adult day programs, which are wellness-oriented rather than needs-based. Therefore we recommend that the limitation of purchase of service be done on a global rather than a sectoral basis. In the event the government remains committed to the limitation, this would enable communities to maintain at least some of the existing agency partnerships appropriate to those they serve.

Now let us look at part VII and part VIII. These two sections which outline the duties and obligations of service providers reflect many guidelines in place for the home care programs. Again, this bill does not distinguish between an approach which is appropriate for illness and related services and one which is appropriate for wellness and health promotion. Therefore we recommend that the extension of rules governing approved agencies, part VII, and service providers, part VIII, be reconsidered because they are not appropriate for the informal, grass-roots nature of certain programs with a wellness, consumer-driven and peer support orientation.

On the subject of appeals, we were surprised by the rules governing appeals at sections 32 to 40. If the MSA is to be a community agency, it is puzzling that its clients would be given a right of appeal to a provincial body with respect to decisions about the content of service plans, the level of service and the termination of service. How will agencies be able to establish priorities if their decisions are rescinded by a provincial appeal board, especially in the face of increased demand for services -- the government's policy certainly leads to that kind of expectation -- and increasingly limited resources? Therefore we recommend that appeals to the health services board apply to provincial policy only and not to local service delivery decisions.

Now, about service plans, I would like to call attention to section 20, which requires everyone to be assessed and have a formal service plan. This seems to jeopardize the very independence of the consumer that the reform wants to promote. Again, this section applies to the case management practices of the home care program. We do not think this approach is suitable for social, recreational and home support services which focus on wellness. It is indeed hard to imagine how someone might be assessed as needing to attend a bridge club in an elderly persons' centre. This bureaucratic approach will indeed discourage persons from taking advantage of these services, thereby discouraging the initiatives consumers might take to maintain their independence.

We think that the issue of personal records is important. Therefore we strongly support the provisions of section 29 which ensure a client's access to their personal record. This will indeed relieve the frustrations that consumers have endured.

French language services: In her public statements, the Minister of Health has made a very strong commitment to the provision of services in French in designated areas, yet there is no direct reference to French language services in Bill 173. It does not suffice to say that the French Language Services Act of 1986 will be operative. This act would not legally oblige an MSA to provide services in French in a designated area. The act only obliges government ministries, agencies, boards and commissions, whose directors are all appointed, or a majority thereof, by the Lieutenant Governor In Council.

An MSA, like any other transfer payment agency or any voluntary agency, would have to apply voluntarily for designation and undertake to meet the requirements of designation. We know from experience that this is not a satisfactory way of ensuring the establishment of a range of services in French comparable to those offered in English, as would be necessary in this community, for example. We therefore recommend that Bill 173 contain a provision stating that in areas designated under the French Language Services Act, appropriate MSAs will be designated as agencies falling under the act.


District health councils: We appreciate the clarification of the role of district health councils contained in Bill 173. We notice, however, that there is no specific reference to the responsibility of district health councils for the setting of service priorities. This is an essential requirement for long-range planning and the proper allocation of funds. We therefore recommend that Bill 173 specify that the responsibilities of the district health councils include the setting of local priorities.

Social services: We are greatly concerned that the cumulative effect of Bill 173 will result in the assimilation of social services rather than their integration with health services. Our written brief describes several aspects of the bill which will have that effect. This means that social services which help maintain individual wellbeing and independence will be downgraded and eroded. We invite you to examine closely the many ways in which this bill subverts an important goal of the reform.

I would like Mrs Gunter to recapitulate the main recommendations contained in our brief, if that's all right with you, Mr Chairman.

The Chair: I always get concerned about allowing time for questions. If it's simply reiterating them -- by all means, it's your time, but I was going to try to allow each caucus to ask some questions.

Mrs Avril Gunter: We therefore recommend:

-- With reference to section 13.2, that communities be given greater flexibility in their choice of options to achieve integrated long-term care systems than is provided for through overreliance on agency amalgamation.

-- That the limitation of purchase of services be done on a global rather than a sectoral basis. This will enable communities to maintain at least some of the existing agency partnerships appropriate to those they serve.

-- That the extension of rules governing approved agencies, part VII, and service providers, part VIII, to all services be reconsidered, because they are not appropriate to the informal, grass-roots nature of certain programs with a wellness and consumer, peer support orientation.

-- That section 32 be amended to provide for appeals to the Health Service Review Board with respect to provincial policy only and not local service delivery decisions.

-- That Bill 173 include specific provisions to ensure the appropriate designation of MSAs in areas designated by the French Language Services Act.

-- That the responsibilities of district health councils specifically include the setting of local priorities.

The Chair: With the committee's indulgence, because we have before us the district health council which has been charged with the planning for long-term care, I'm going to allow each caucus a question. I would just ask if members could keep in mind the time and keep their questions sharp and short and succinct. That way we can move through quickly.

Mrs O'Neill: Thank you so much for coming. The thing that hit me as unique about your presentation was when you said "community development" and how closely related that is to the volunteers and what that really means in this community. You've brought forward the appeals process, as this community only can talk about the French-language services and the instability, and we've had that presentation.

I wanted you to go back to your last general concern. You talked about the increased flexibility, communities being given greater flexibility. Would you be able to focus on the three areas -- you want to put four, but I'm asking for three areas -- where you think flexibility would really improve this bill?

Mrs Neatby: This flexibility of course refers to the structure and the manner of coordination. I would like Mrs Gunter to address this because this is within her MSA mandate.

Mrs Gunter: You're talking about the global rather than the sectoral?

Mrs Neatby: Yes.

Mrs Gunter: The thing is that we have heard that 94% of the transfer agency money is spent by four agencies. That leaves only 6%, which is spent almost entirely in the home support area. If the 20% designation was allowed to be done on a global basis, this would enable many of the services now provided on a neighbourhood basis by many volunteers who are dedicated to their own particular areas, specialized services like respite care services and day programs to come in that 20% sector. There is no way, I think, that we could duplicate the complexity of the services we presently have if we had to offer them all through separate MSAs.

Mrs Neatby: You must remember that some of these community support services are delivered by a great variety of agencies. They're embedded in the structure of some multifunctional agencies. Just to give you an example, Glebe Centre, in our area, has 195 residential long-term care beds, it has a social recreational centre, but it has grafted on to this community support in the neighbourhood. All this enables shared resources of Glebe Centre to be used to provide that multifunctional, and it is to dismantle some of these long-established created services that I think would be not only expensive but would lead to a loss of service.

Mrs O'Neill: Partnership with the facilities.

Mrs Neatby: Yes, this is what I mean by the partnership.

Mr Jim Wilson: You make a number of very good suggestions, many of which, in fact almost all of which, I and my caucus colleagues agree with. We'll be introducing amendments to, for example, get rid of the 80-20 rule, for which there seems to be no justification from the government, amendments to get rid of a number of things. However, having been Health critic for almost four years, I can tell you that when bills leave this committee process they essentially look the same way they did when they entered this committee process, so I need some help from you.

We are very concerned with the monopolistic nature of MSAs in terms of their dual role of not only being one-stop access but also the twist that seems to have appeared along the way on the road to reform that they'll also have a monopoly in delivery of 80% of the services. Had you proposed, along the way, a different model? My question specifically is, is it necessary to amalgamate and destroy, in fact, some of these community agencies like the VON in order to achieve the objectives and principles that the bill speaks to?

Mrs Gunter: I think we need much more coordination between agencies. In the past this has been lacking, and we have been working very hard and with considerable success in this area, in getting cooperation and coordination between agencies. But though we wish to have more coordination, we do not feel this means that the agencies have to completely disappear, although they may be reformed in a slightly different way.

Mr Jim Wilson: The level of cooperation towards that goal in this region is high right now. If the government backed off for a while, would you be able to achieve that point of access, the regional phone number that was talked about, that sort of thing, without this legislation, or do you need this legislation as a gun to someone's head to get them to come to some new governance models? It's a very blunt question, but I'm a fairly blunt person.


Ms Neatby: We had been encouraged by some of the government's proposals for transitional strategies, and there seems to be a backing away from this. We had been encouraged because in our process, as I said, we start from the ground up, with the whole community there, and work out the first, say, access and then see through that process how we -- and of course we measure the costs as we go because we assume that we are not in this community. We don't assume additional funding because, for reasons of equity, and we agree with this, there are areas that are less well provided, so we'll have to make do with what we have. Hence the costs, as we go along, are significant because we don't want to increase bureaucratic structures and reduce services.

This is why our process, in terms of the interim strategies, seems to justify and encourage the way we've been approaching it and which suits us in this community. But we don't know if the government really means to back away from these interim strategies or not. The bill doesn't seem to give much encouragement there.

Mr O'Connor: One of the areas you touched on were the services that would be provided within the community, the needs the consumers have. When the needs of the consumers are assessed and plans of care developed, then they would hopefully fit somewhere within what's been described as a basket of services, though I think you touched on an important element, which is the need for the local area to be involved in the planning of the services to be provided.

I got from what you presented, though, a sense that you felt somewhat constrained by what you would need to plan and provide for. I just wondered how that might reflect what would be the needs as laid out when the assessments of the individual needs have been done through the plan for care.

Mrs Gunter: I'm not quite sure of the intent of your question. We have been looking at what we want our long-term care system to do. We have looked at the things that are working right now. We have looked at the things that need to be changed, many of which came out of the long-term care consultation process, and we are trying to change the system so that it will meet many of the needs that people expressed.

We are starting this at the beginning with the information referral part of the package because that essentially was the one that people had most problems with. We are at the same time working on service coordination between agencies, trying to standardize the intake and assessment part of the picture.

We are looking at then moving into the assessment part of the process. We await with great interest the assessment package the province is in the process of developing, which we hope will be one you can put into place in stages, so that if a person only needs a minor assessment because they are just looking at recreational services that could be done, that person in the recreational stage wouldn't have to go through a total assessment and so on. We are proceeding in stages, and we have hopes that things are going well. We will be having extensive community consultations this fall on a number of the issues.

Mr O'Connor: I'd certainly encourage the consultation. You've pointed to a lot of good things that can come about by having such an extensive consultation.

The Chair: I know we could spend quite productively the rest of the afternoon. I'm afraid that if we did we wouldn't get through all the other presenters. May I, on behalf of the committee, thank all of you for coming today.


The Chair: I call the Council on Aging for Ottawa-Carleton.

Mrs Syliva Goldblatt: It's a pleasure to be here. I'm Sylvia Goldblatt, the current president of the Council on Aging for Ottawa-Carleton. With me is Jean Shaw, a fellow volunteer, who has chaired the long-term care task force that looked at Bill 173 and produced the document that you have in front of you.

As usual, the document is far too long to present the whole thing, so what you're going to get from me is an abridged version. I hope we've cut out enough so that we leave time for you to ask questions, because your questions have been so helpful.

The Council on Aging for Ottawa-Carleton is a non-profit planning, coordinating and advocacy organization which has just launched its 19th year serving the 70,000 residents of the region of Ottawa-Carleton who are 65 years of age and over. The council is composed of seniors, professionals delivering services to seniors, care givers and others interested in seniors' issues. One of the fundamental roles of the council is to study issues and advocate on behalf of the senior consumer when appropriate.

As president of the council on aging, my comments will focus on the implications of Bill 173 from the perspective of older consumers and their care givers. I just want to throw out how pleased I was to be here for the earlier presentations, because I could see that we're all coming to you with a great many similar points. It's almost a good thing that you're going to be a little bit bored with it, but at least you're going to hear it over and over again.

It's apparent from Bill 173 that the government has continued its commitment to the development of a system which will provide services to consumers to meet their changing needs within the context of a continuum of care. It has been well documented that over 80%, actually as much as 95%, of care giving is provided by family, friends and neighbours. It will be important to continue the emphasis on consumers, care givers and volunteers to ensure that the multiservice agencies will reflect this orientation in the way it is structured and the cultural philosophy it adopts.

The council on aging also commends the government for its initiatives designed to provide safeguards for consumers, in particular the establishment of a bill of rights.

Due to the far-reaching implications of the regulations for Bill 173, the council on aging requests that there be further consultation with communities once the regulations are prepared. That will really be very important to us.

Mr Chairman and committee members, our brief will specifically deal with a number of issues. You have a list of them in front of you. I'll identify them as I go through them.

The first one we're dealing with is respite care. I just want to throw in that yesterday I spent the day in Montreal at a respite care conference, I guess really workshop, where this issue was dealt with in great detail, and it is obviously considered a very important one.


The council on aging was encouraged to see the inclusion of care giver support services and adult day programs in the mandatory services to be provided by or ensured by the MSA. However, we want to draw attention to the need for a commitment to availability of services 24 hours a day, seven days a week. As we all know, things don't stop at 5 o'clock on Friday and start again at 9 o'clock on Monday morning.

Bill 173 defines care giver support services in clause 2(1)(e) using the word "respite" on only one occasion. In addition, only care giver support services and not respite per se are identified as mandatory services in subsection 2(4). It is not clear from this terminology whether direct care giver relief programs such as in-home respite services are considered essential and will be provided. That case was made very well by the individual who spoke with you earlier.

We want to emphasize that relief for the care giver is critical for several reasons. It is key to sustaining the care recipient in the community. Without that care giver, that recipient might very well be in an institution. It can help to avoid health problems for the care givers. And it could be a deterrent to elder abuse, a subject we're all becoming increasingly sensitive to. It should be noted that homemaking services, personal support and professional services are directed towards the care recipient and that the provision of these services should be recognized as distinct from the needs of the care giver.

We're making a series of recommendations. I'm going to deal with the second one -- the first is certainly included in our recommendations but this is one that I'm going to address -- where we're recommending that respite care for the care giver be either incorporated into the care plan for the consumer receiving services from the MSA or be considered within the context of the care giver as a consumer in his or her own right. It is recommended, secondly, that in-home respite programs be provided as a mandatory service by the MSA and available for that 24 hours a day, seven days a week.

The second issue that we're addressing is consent. With the increasing emphasis on care being provided outside of institutions, inevitably more demands will be placed on care givers. In the development of service plans, if those responsible view the care recipient and the care giver as a unit requiring support, then services such as respite care will be promoted as part of the care plan. However, if the care recipient refuses to cooperate with the service plan but the care giver requests the service, it is uncertain how the care giver's request will be viewed. The council is concerned that expectations placed on care givers by the care recipient may at times be unrealistic.

We're recommending that Bill 173 include a statement concerning the rights of the care giver in addition to those of the care recipient, and secondly, that the government examine the issue of consent for services within the context of conflicting needs between the rights of the care giver and the care recipient.

The next issue I'm addressing is volunteerism. Existing services in the long-term care sector have depended greatly on volunteers. You've heard that from a great number of people today. We have somewhere around 250 volunteers working with the council on aging. With the current climate of fiscal constraint on government resources and funds, the participation of volunteers will be required even more in the years ahead.

We're recommending that Bill 173 should include a clause that every effort will be made to maintain the present level of volunteer service and to increase volunteer participation where appropriate.

Our next issue is recreation and social programs. The need to support wellness through the provision of health promotion, illness prevention, rehabilitation and social support programs has been emphasized by both consumers and provider organizations. The council on aging is concerned that the focus of Bill 173 now appears to be primarily on preventing institutionalization, with inadequate attention being paid to health promotion and illness prevention strategies. The council notes the inclusion of recreational and social programs as a recent addition to the services that will be offered by the MSA. However, it's not clear in the legislation how these programs relate to wellness and health promotion or what the impact will be on elderly persons' centres, which we've always seen as a critical service.

We're recommending that the government clarify the types of social and recreational services that will be covered by the legislation and available through the MSAs. We're also recommending that the government demonstrate the way in which Bill 173 reflects the importance of wellness programs through the provision of services by the MSA. We're further recommending that the government clarify the potential impact that this change will have on elderly persons' centres.

I'm flipping pages.

Under consumer fees, I'm just going to read our recommendation there. It's recommended that the government clarify which services will require payment by consumers and the method by which consumer payment will be calculated.

Our next issue is a limit on purchased services, and I know this one has been addressed by several other organizations. Bill 173 provides a restriction that not more than 20% of the amount budgeted for the four MSA service areas be used for the purchase of services from other service providers outside the MSA. We believe this will result in less flexibility in the design of the MSA in areas such as Ottawa-Carleton. The council is concerned that adherence to this provision may result in considerable disruption in services to the senior consumer.

We're recommending that the government provide increased flexibility in the percentage of services to be contracted out by the MSA. This percentage should be responsive to the realities in local communities and be determined through the planning process at the district health councils.

Our next issue has to do with physician involvement. I'm interested that we haven't heard about this earlier this afternoon; maybe you did this morning. The movement from a system where physicians have typically been the gatekeeper for many services to one in which they appear to be relatively excluded from the process is troubling. Well-defined relationships between physicians and the MSA need to be established in order to ensure that a true continuum of care can be realized. The council supports a model that envisions a holistic perspective in the care of the elderly.

Our recommendation is that the important role of the physician be recognized and that physicians be part of the process when the government is determining the structure and functioning of the MSA. We're further recommending that the relationship between physicians and the MSA be well defined and incorporated into the regulations for the MSA.


We want to reiterate here our next issue, the French-language services. The council on aging supports the development of services which take into account linguistic requirements. Specifically, areas which are designated under the French Language Services Act must develop services to meet the needs of francophone clients. We're recommending that the government revise Bill 173 to incorporate the stipulation that services must be provided in French in designated areas under the French Language Services Act.

Our next issues deals with governance. Here I want to simply identify our recommendations. We're recommending under governance that specific statutory recognition of volunteers, seniors and care givers be accorded in the composition of boards of directors of MSAs. We're also recommending that the requirement for approval of approved agencies and designation of MSAs be statutorily established. It's recommended that protection from liability be extended to include approved agencies, including MSAs, their directors, officers, employees and volunteers. We further recommend that any application for temporary or permanent status of an MSA include the method used to determine the board membership.

The summary and conclusion: The council on aging supports the policy direction set out in Bill 173, which provides safeguards for consumers and emphasizes the importance of consumers and their family care givers as the focus in the long-term care reform. The council does however feel that clarification is required regarding the level of support that will be provided to care givers, in particular for respite care, and how this will be determined in relation to the consumer service plan. With the policy direction of providing care increasingly in the community, adequate support for family care givers is crucial.

The council also feels that clarification is required that describes the types of social and recreational programs to be delivered through the MSA. The relationship of the MSA to elderly persons' centres should also be spelled out. The emphasis on health promotion and illness prevention must be supportive and reflected in the legislation.

The council recommends that the government revise its policy on the limit of purchased services in order to give increased flexibility to communities to design a system that best meets their needs. Through the district health council planning process, communities would then be able to establish services with the least disruption to the consumer.

The council has consistently raised concern regarding the lack of mention of physicians within the context of the long-term care reform. Relationships and linkages must be established and set out in the regulations between physicians and the MSA so that the espoused continuum of care becomes a reality.

And finally, the important role of volunteers needs to be reflected in government policy. Specific statutory recognition of volunteers, seniors and their care givers needs to be included in the boards of directors of MSAs. Furthermore, it is recommended that protection from liability be extended to include approved agencies, including MSAs, their directors, officers, employees and volunteers.

The council on aging appreciates having had the opportunity to comment on the draft legislation in Bill 173 and hopes the government will continue its commitment to community consultation. Due to the far-reaching implications of regulations for Bill 173, the council on aging recommends that the government accord communities another opportunity to provide input when the draft regulations are prepared.

The Chair: Thank you very much for a very full presentation. Every now and then the Chair has to be the heavy and look at the watch and see how we're doing with groups, so I'm afraid I'm only going to be able to allow one question at this time. It's my fault, not the committee's. Mrs Sullivan.

Mrs Sullivan: I appreciate this presentation. In your presentation you've underlined what at least two other organizations have done today and others have done on occasion, and that's to emphasize the role of the care giver.

I think the point you make about the conflict between the consent of the care giver and the care recipient is an important one, because what we see is an assessment of eligibility which may in fact be determined by whether there is a care giver in the home, whether or not the care giver feels that he or she is able to provide the care at the level that the assessment may indicate. I don't know how we're going to deal with that, but I think it's a matter that certainly has to be taken into account. As I think about it, I don't think the consent to treatment laws, when they come in, will deal with that issue. There may have to be something included in the regulations with respect to what happens when a care giver says, "No, I cannot do that."

I'm also interested in the question of physician involvement which you've raised. I think that in the assessment process we've heard a number of issues, one of them with respect to risk identification, which wouldn't require a full assessment. The other thing that we have heard is that about 90% of the cases that are in-home care do have a clinical component, and we don't see any reference to either physicians or in fact other practitioners who would deal with that clinical aspect of care. Certainly, if we're dealing with a full continuum, that has to be taken into account.

We've heard suggestions that, first of all, the family physician should be involved in the assessment process. For many that's the appropriate thing, but for others there is no family physician.

We've also heard that the MSA should be required to have a medical director who is on staff as a consultant. I just wondered if you would comment on any value that you would see in a medical director and how you think MSAs ought to be able to integrate that clinical need into the assessment process.

Mrs Goldblatt: I certainly see that as a useful option, that a clinical director, medical director, be included in the MSA. The thing that I'd also, though, be prepared to see -- the district health council has, as you know, traditionally dealt with doctors and hospitals and so on. I think they should be in a pretty good position to come forward with a constructive recommendation as to how we get this physician involvement into the MSA.

Mrs Sullivan: I guess my concern is that there's not only difficulty with the physician relationship with the MSA, but there is also a difficulty with the institution and facility relationship with the MSA, the hospital or the nursing home or whatever, if you're moving in an appropriate continuum.

Mrs Jean Shaw: If I could just say a few words to that too, I think we have to remember when we're talking of seniors that the ones who are requiring the care in the home are usually very elderly. We're talking of people in their 70s and 80s and 90s, and the supports that they have known all their life are gradually falling away as their friends and family die. So these people have very few familiar faces around them, and a trusted family physician has a great support value for elderly clients in their homes. I think, as far as the MSA is concerned, there certainly should be family physicians represented on the board itself because they have a very unique relationship with the client which is apart from anything in an institution.



The Chair: I call upon the county of Renfrew representatives to come forward. Gentlemen, welcome to the committee this afternoon.

Mr Alvin Stone: My name is Alvin Stone and I'm warden of Renfrew county. I'm pleased and I want to express our appreciation to yourself and the committee members for affording us the opportunity to present our submission on Bill 173. I believe that our brief is similar to a lot that you've heard today, and it's comforting for us to know that for the most part, Ontarians are singing from the same hymn sheet.

With me today is Michael Johnson, the chief administrative officer and treasurer of Renfrew county. Mike's available to answer any questions following the presentation of our brief. Also with me is Andrew Dickson. Andrew is a member of our welfare and homes for the aged management committee, which is a sister with the city of Pembroke. I'd ask at this time if Reeve Andrew Dickson would present our submission to the standing committee on social development.

Mr Andrew Dickson: Our delegation represents the council of the corporation of the county of Renfrew. The county of Renfrew extends from Arnprior, west of Ottawa, along the Ottawa River to Deux Rivières just east of Mattawa, with its southwesterly boundary being at Combermere, north of Bancroft. The county is the largest geographic county in the province of Ontario, comprising some 7,793 square kilometres with a population, excluding the city of Pembroke, of approximately 75,000.

The county of Renfrew does not directly deliver home care services, but we do have a long association with the delivery of those services through the Renfrew County and District Health Unit, which our organization partially funds. We appoint four county councillors to the board of health of the Renfrew County and District Health Unit. The Renfrew County and District Health Unit is the entity directly responsible for the delivery of home care services in our county and has, we believe, an excellent and enviable record of providing quality, cost-effective home care services.

Accordingly, while we have no direct involvement in those areas respecting Bill 173, An Act respecting Long-Term Care, we do have a very obvious and intense indirect interest in the future of long-term care home care services in our county.

We also, by way of introduction in this brief, note the representativeness of our organization and thus the accountability of our organization to the people of Renfrew county. In the last municipal election, November 1991, approximately 50,000 of our total population of 75,000 cast ballots. We believe that this fundamental accountability of our elected people for services delivered by municipal government, or by boards or commissions on which municipal government has elected representation, constitutes the highest form of accountability in our democratic system. We will return to this theme later on in this brief.

We also want to be on record early in this brief by noting that we support what we believe are the government's intentions with respect to those matters set out under Bill 173. We support the government, if it is their intention under improvement to home care services, to establish a system that provides more responsive services, more efficient services, more accountable services and more rationalized services. These are clearly desirable and indeed "motherhood" goals to which all of us at every level of government would subscribe.

Having stated our support for these principles, we are compelled to note that our experience in long-term care reform, as reflected in Bill 101, the Long-Term Care Statute Law Amendment Act, 1993, does not provide confidence in the viability of the government's long-term care reform planning process. While we all recognize the plight we are in, in these economic times, of reduced governmental revenue and far too great a portion of expenditure is being required to service the federal and provincial debt, the fact remains that we have moved, on the institutional side of long-term care, to fewer beds, less funding in real dollars, less resident care, more provincial rigidity, more provincial control, more provincial centralization and less capacity for local innovation.

At a time when the demographic projections of the increase of elderly are little short of awesome, with 25% of the population of our county expected to be age 65 and over within the next 25 years, we have experienced provincial government intervention in the operation of municipal homes for the aged to such an extent that fundamental questions are being asked at the municipal level with respect to the appropriateness of the delivery of long-term institutional care as a municipal responsibility.

At the municipal level, the financial uncertainty created under Bill 101 virtually prohibits any intelligent financial long-term planning. Our county, in cooperation with the city of Pembroke, operates a 180-bed long-term care institution in the town of Renfrew and a 166-bed long-term care institution in the city of Pembroke. The provisions of Bill 101 are such that we are unable to obtain any true commitment of financial partnership from the provincial government in terms of guaranteed present funding, even without recognition of inflation, beyond 1994 and no guarantee of provincial partnership when our organization is faced with costs beyond our control, as best indicated by a recent binding arbitration award under one of our collective bargaining agreements. This particular arbitration will result in an additional cost to our organization of approximately $600,000 incurred in 1994 for the years 1993 and 1994. As we sit before you today, there is absolutely no assurance from the provincial government that under the provisions of Bill 101 they will cost-share in these uncontrollable expenditures which we have incurred.

The consultation process: We recognize that the province submits that it went through an extensive consultation process prior to the tabling of Bill 173. Having been a participant in and an observer of that consultation process, we are compelled to state to this standing committee our respectful opinion that the process fell far short of its intended goals of receiving a true cross-section of input from service consumer, service provider, the tax bill payer and the general public across this province.

Certainly, from our observation of the consultation process, one could be forgiven for wondering to what extent there was an agenda for the eventual provisions of Bill 173 before the consultation process even commenced. Otherwise, where did some of those principles enshrined in Bill 173 come from?

It is our observation that some of the more problematic provisions --


The Chair: Order, committee members. It is the middle of the afternoon. I know we have all been sitting here very patiently, but we are here to listen to the delegation, so I would ask everyone if perhaps they might keep their thoughts to themselves as we go forward. Thank you.

Please go ahead.

Mr Dickson: It's our observation that some of the more problematic provisions of Bill 173 were not promoted in any credible way throughout the consultation process, flawed though that process may have been.

Surely it is essential, in these financially restricted times, that one be careful not to destroy that which has been carefully constructed over a long period of years in any impatient crusade to construct a new system. The existing home care services have evolved over a very long period of time through the efforts of a large number of highly intelligent people, highly competent organizations and highly motivated volunteers. We submit that the principle underlying any revision of home care services should be to build on the solid foundation already in place rather than to dismantle the structure presently in place in the name of some theoretical improvement. Why, in heaven's name, would one throw the baby out with the bathwater?

The accountability aspect: We turn now to the very significant issue of accountability under Bill 173, and especially with respect to the multiservice agencies proposed by Bill 173. The words "accountability," "community-driven" and "bottom up" have become buzzwords to which it is politically correct to subscribe. Unfortunately, in the application of those buzzwords, one too frequently finds a lack of reflection of reality. All too often, the implementation of those buzzwords more accurately seems to reflect either woolly headed thinking or pure wishful thinking.

The establishment of a brand-new bureaucratic structure, to be called a multiservice agency, with a board of directors to be appointed in some type of élite manner and with the buzzwords of "accountability," "community-driven" and "bottom up" to be satisfied in some form of sparsely attended annual meeting typical of so many other so-called accountable community-driven organizations is hardly a credible example of true accountability.


We respectfully submit that the only true accountability in a democracy is at the ballot box. It follows, then, that the truly accountable organizations in the province are those, such as municipal government, that are answerable on a triennial basis at the ballot box, who are responsible for the money they raise from their tax base and who are responsible for the actions of their appointees to boards and commissions that deliver publicly funded services.

Perhaps the single most troublesome aspect of the proposed establishment of multiservice agencies is that they would represent a monopoly. We are compelled, therefore, to ask a fundamental question: What makes anyone believe that this newly created monopoly will work effectively? Monopolies get bigger bureaucratically; monopolies get less responsible; monopolies get less efficient; monopolies get more autocratic; monopolies get less innovative; and finally and importantly, monopolies discourage volunteerism. Where are the monopolies that are efficient and responsive, and getting more so with the passing years? We strongly submit that they do they opposite.

The theory that efficiency, effectiveness, responsiveness and accountability will be found in a centralized agency responsible for all home care service planning and management and all long-term care service delivery stands neither the test of experience in other jurisdictions nor the test of modern management principles.

Loss of volunteerism: In an area where volunteerism forms a fundamental underlining of our social structure and culture, we are deeply troubled by the impact of the proposed multiservice agencies on volunteerism in long-term care. We note that the Ministry of Health also recognized the public concern with this aspect of multiservice agencies and has responded by producing, on a frequent basis, a propaganda sheet called Long Term Care Action Facts. The purpose of this publication from the Ministry of Health appears to be to attempt to allay fears across this province that volunteerism will be negatively affected by the creation of multiservice agencies. Obviously, this argument is falling on sceptical ears.

The second purpose of the publication appears to be to convince readers that multiservice agencies represent true accountability. We have addressed the matter of accountability earlier in this brief and will simply note that the Long Term Care Action Facts is as short on credibility with respect to the issue of accountability as it is with respect to the issue of volunteerism.

We refer you to the brief from the Catholic Health Association of Ontario. With respect to volunteerism, they said: "The passionate commitment of our staff and volunteers to the philosophies and values of these health care organizations are not the product of a `service name logo or a service location.' They are the product of our heritage." They go on to say: "How do you transplant the `heart' of an organization into a bureaucracy? It cannot be done." We hope that this committee, and through it the government, was listening to those sentiments, as expressed by that organization. We go on record as strongly supporting their position.

Approved agencies and other service providers: Section 13 of Bill 173 provides that the multiservice agency shall not spend more than 20% of the amount budgeted for community support services, homemaking services, personal support services or professional services in the agency's approved budget for the purchase of services from other service providers. This arbitrary number, previously set at 10%, totally limits local innovative approaches to the purchase and delivery of services. One is compelled to inquire, what is magic about 20% now when 10% was magic before? Surely, the guiding principle should not be some rigid mathematical percentage limitation but rather the ability of local communities to best design the coordination and delivery structure which would work most effectively in that community.

Inherent in the 20% limitation under section 13 is the bill's intent to squeeze out both existing for-profit and not-for-profit program delivery organizations. The not-so-subtle bias of the government objecting to for-profit organizations is eminently displayed in this bill. Our organization is compelled to ask, what is so fundamentally unacceptable about for-profit organizations? Why the bias? Why the flagrant determination to squeeze them out of the home care service delivery system when the track record of so many organizations is unchallengeable?

Our county, through our economic development department, spends hundreds of thousands of dollars a year attempting to promote and attract private enterprise and its job creation attributes to our county. Here on the one hand we have the county of Renfrew attempting to assist growth in its existing local industries and attempting to attract new industries to our county for job creation and economic growth purposes, while the provincial government deliberately sets out to destroy efficient and effective for-profit health care deliverers already in existence.

Equally problematic is the impact that the provisions of section 13 of Bill 173 would have on such historic and highly reputable not-for-profit volunteer organizations such as the Canadian Red Cross Society and the Victorian Order of Nurses, to name only a couple of the most obvious. It is our respectful submission that the track record of organizations such as these is such that the provisions of Bill 173, the implementation of which would inevitably result in a major squeezing of their ability to be viable, possibly to the point of their having to suspend operations in many parts of the province, is simply and utterly unacceptable.

Instead of the creation of a new and all-powerful multiservice agency as envisioned under Bill 173, we pose the question, what is wrong with choice? What is wrong with the competition that comes from providing choice? Our organization rejects the philosophy that the needs of long-term care recipients will be better served by eliminating choice from the program services menu.

Costs: We also want to go on record today as supporting those organizations that have appeared before this standing committee and made the prediction that Bill 173 will not provide better services, but what Bill 173 will do is cost more. With respect, we want to say to the standing committee that if this government persists in enacting Bill 173 in its present form, we can only hope that as an organization we have the opportunity to revisit the credibility of Bill 173 at some future meeting of this standing committee on social development, in a few years' time, to review the cost results of the enactment of the bill. We predict that the cost results will certainly not be a pretty picture.

In conclusion, the county of Renfrew notes and supports the thoughtful and well-researched positions of a number of organizations which have presented this standing committee with excellent briefs. Those briefs have raised highly significant and valid concerns with respect to Bill 173 as presently drafted. Among those organizations are the Catholic Health Association of Ontario, the Canadian Red Cross Society, the Canadian Association of Retired Persons and the Ontario Home Health Care Providers' Association. Each of these organizations, from their different perspectives and with the benefit of their individual organizational experiences, came to remarkably similar conclusions with respect to the deficiencies in Bill 173.

To summarize, it is a fundamentally flawed bill that needs not Band-Aids but rather major surgery.

As the basis for a new approach to the improvement of home care services, we concur with the specific principles as put before this committee by the Ontario Home Health Care Providers' Association:

"(1) The government should determine what services it can afford to provide and make those services available in an equitable and consistent fashion across the province.

"(2) Local communities should ensure that services are provided as efficiently and effectively as possible through managed competition among all providers.

"(3) Consumers should have much more choice in the services they receive as individuals rather than having to fit into a specific program.

"(4) The development of a client-focused information system which integrates community and facility care services must be a priority.

"(5) The government must give local communities the resources and responsibility to allocate resources at the local level. The Ministry of Health must stop trying to manage day-to-day operations of home care."

We have offered some positive suggestions on the ways the home care system can be improved to meet the needs of consumers while maintaining the essential qualities of the current system, such as competition, consumer choice and local autonomy.


We conclude by stating our final point more simply. The creation of multiservice agencies as envisioned under Bill 173 is not the answer to the improvement of home care services in the province of Ontario. Our concluding plea to the standing committee and, through you, to the government of Ontario is that we build on what we have, that we coordinate and rationalize what we have, and that we work to evolve improvements in what we have, rather than destroy what we have.

We urge that the concept of a newly created multiservice agency mandated to plan, manage and deliver home care services be set aside, that the whole issue be revisited, and that the principle be to firstly look at the rationalization of services and then at the delivery agencies, and not vice versa.

We conclude by again expressing our genuine appreciation to the standing committee on social development for the opportunity of making this submission to you from the county of Renfrew. If you have any questions, obviously, Michael or Warden Stone will be able to answer.

Mr Jim Wilson: My appreciation to the county of Renfrew. I can tell you that we've been waiting a while for groups to come forward and, in as forthright a manner, say what you've said. Many of the conclusions that you've come to, and you note some other organizations that came to similar and independent conclusions, are the same as the ones we've come to.

I really appreciate your section on buzzwords, as a politician, because I've long said in my remarks in the Legislature that we're drowning in our own political correctness. You mentioned things like "bottom up, community-driven, accountability." I often wonder about "stakeholders." I assume they mean human beings. "Reform" means less services, less of everything. "Employment equity" means quotas. We've got all kinds of things. "Consultation" means, "We've made up our minds, so let's go to the people."

It's gotten ridiculous. It comes out of 20 years of a particular party around here which has been changing the vocabulary of the people of Ontario, but their day will come up, and the good news might be that I doubt they'll be around long enough, the NDP, to actually proclaim this legislation.

I'll also tell you one other theory that I certainly have, and it's not a popular one with the government, but if you know our new labour laws in Ontario and if you take into account that the majority of the home care sector, the community support sector, right now is not unionized, if you under this legislation take all those groups, destroy them, put them under one roof, combine them with the new labour laws, you have one-stop unionization. It makes it much easier.

OPSEU in fact was before us and they complained that the bill didn't go far enough. So they're not even happy with it. But we know that that's part of the mix here too, and I think that actual efficiency in services and all the things that you mentioned on behalf of the county of Renfrew are a lesser concern to the government, and it has been the hidden agenda. I'm glad we had the opportunity to say this because you came forward in such a forthright way.

I do want to talk about costs, though, and the question is, have you got any idea now or any rough estimates or ratios or anything about what the cost might be in Renfrew? Because I assume in Renfrew you're doing things like they do in Simcoe county, and it's a fairly commonsense approach to the delivery of services right now, and in certainly my area of the province, we don't see the need to reinvent the wheel either.

In fact, in a close examination of Simcoe county, we're coming to the conclusion that a lot of these little agencies have very small administrative structures, and with a bit of cooperation we shouldn't have to go through Bill 173 and tear them apart and reinvent the wheel. But what's the situation like in Renfrew?

Mr Michael Johnson: The situation in Renfrew county is I think rather similar to that which you have described in Simcoe. Through the Renfrew County and District Health Unit for a very large number of years, a large number of different local organizations have been delivering the home care services, and the health unit then itself with their staff attempts to fill in those gaps which the other organizations are not able to meet.

The efficiency of those small organizations is a tribute to the volunteerism that we attempted to speak to in our brief, and a credit to the financial responsibility of the management of those organizations that they are able to effectively deliver home care services through the overall auspices of the Renfrew County and District Health Unit at the kind of cost that they're able to do it at.

The Chair: I regret we don't have more time, but I want to thank you for the presentation that you've brought before the committee today.

Mr Sterling: Mr Chair, just on a point of order: maybe the warden would like to tell us what's happening in Renfrew county next week.

The Chair: Fair enough. We all expect that would be something that would have the support of all members. Warden, why don't you tell us what's happening next week?

Mr Stone: Thank you, Norm, for the opportunity of course to invite everyone who's in this building to the international plowing match in Renfrew county next week, just on the east end of the city of Pembroke. I'm sure that anyone who comes along to join us next week will thoroughly enjoy themselves. I understand there's one million square feet of tents in this city for the international plowing match.

The Chair: Thank you. We'll see you at the match.


The Chair: I call on the representatives from the Ontario Hospital Association, please. I don't know whether we should ask the OHA if they're also good plowmen, but gentlemen, we welcome you to the committee.

M. Laurent Isabelle : Bonjour, Monsieur le Président, mesdames et messieurs. Permettez-moi de présenter mes collègues Michel Bilodeau, président du CHMCO, ou CCHO en anglais, the Council of Chronic Hospitals of Ontario, et Dan Drown, senior consultant of the Ontario Hospital Association division dedicated to chronic care, mental health and rehabilitation, policies and services.

Je m'appelle Laurent Isabelle. Je suis président élu ou désigné, chair-elect, de l'Association des hôpitaux de l'Ontario et j'ai la tâche plaisante de représenter l'Association des hôpitaux de l'Ontario ainsi que la CHMCO, et de vous transmettre nos commentaires ainsi que nos recommandations quant au projet de loi 173.

OHA is a voluntary organization, and suffice it perhaps to say that it is a voluntary association of 200-and-some hospitals, 17 of which are chronic care hospitals, and we are celebrating our 70th anniversary this year.

Le Président : Bonne fête.

Mr Isabelle: The association is governed by 26 trustees, male and female trustees, volunteers all, and some CEOs, all of whom have been elected to that office by their peers.

OHA, in speaking for itself and CCHO, has five major concerns, therefore five major recommendations, in order to perfect the draft Bill 173: (1) we find the approach too prescriptive; (2) we find that MSAs or multiservice agencies as proposed are a rigid, top-heavy, bureaucratic, one-stop access to care; (3) we find the thrust is adversarial because it pits institutions, hospitals, against community-based systems of care; and (4) and (5) are our concerns about district health councils, regional planning and resource allocation.

Or, dans cet ordre :

(1) The prescriptive approach: Bill 173, as did its predecessor, Bill 101, the Long Term Care Statute Law Amendment Act, in our view is micromanagement. Although government says it is seeking to promote local autonomy and advocating devolution of power, we see the structure as a top-heavy, rigid, bureaucratic one, and it's centralized control.

Forty-two areas of regulation: we see that as total control by government for long-term care services. We see that as an unnecessary, unwarranted intrusion in the autonomy of individual organizations and providers. In fact, we see that as an indictment of the volunteerism of which we in health care are so justifiably proud.

We cannot support for the consumer, indeed for the taxpayer, legislation that promotes additional layering or more government-controlled bureaucracy which widens the gap between policy-making and delivery of services. We believe the MSA model as it now reads will lead to eventual usurping of the governance and management responsibilities of community-based organizations, including hospitals. May I add that acute care hospitals with chronic care beds and the 17 chronic care hospitals are equally concerned by this draft.


The association, speaking for CCHO as well, recommends, one, that section 56 of Bill 173 be amended to allow local bodies to determine volunteer involvement and activity, local bodies to determine and to apply quality standards and operating guidelines to meet the criteria, and we add national criteria, of an accrediting body called the Canadian Council on Health Facilities Accreditation, and to allow local, individual communities to create efficient, responsive administrative structures.

(2) Multiservice agencies as one-stop access: We have supported the concept of one-stop access to long-term care services since the 1970s. We continue to support functional integration of information, referral, assessment, case management, service delivery, coordination and follow-up for consumers in need. What we cannot support is one-stop shopping. We find that it is not warranted. What is needed is more choice, high-quality services and local access to these services. Bill 173, as it now reads, potentially leads to the very opposite.

We feel there is an indictment of services provided by hospitals, services which are appropriate, which are accessible, which are timely. For example, many hospitals, acute care and chronic care, provide community support services such as outreach palliative care programs, home care services, respite care, meal programs, security checks and lifeline programs.

Many hospitals are closely affiliated with or manage long-term care facilities. Numerous local hospitals are the hub of community-based long-term care. We feel the one-stop shopping approach will jeopardize many of these excellent initiatives. It is not clear how or if these are to be integrated within MSAs or whether they will be viewed as institutionally based or community-based.

Our members believe the long-term care services already being provided are vital, they are working successfully, they're staffed by highly skilled personnel and they're supported by knowledgeable volunteers and, I might add, dedicated volunteers. These services must be recognized and funded in order to continue.

As it now stands, Bill 173 limits the number of participants, and we refer you to section 13, which limits the purchase of services outside MSAs, or it causes or forces agencies to be part of the MSA itself.

It is not clear either, in Bill 173 as it now reads, how MSAs will affect the current coordination of services for children.

We therefore recommend to amend Bill 173, and this is our second recommendation, by removing the restriction on the amount of services that can be purchased from the other service providers by MSAs.

(3) Institutional versus community-based systems of care: Bill 173 upholds the important principles of reducing inappropriate institutionalization and strengthening non-institutional care, or what Bill 173 refers to as community-based care.

En passant, j'ai encore à voir un hôpital qui se croit ne pas faire partie de sa communauté, et ça fait quand même plusieurs années que j'oeuvre dans le domaine.

Both OHA and CCHO support and have supported those basic principles. Hospitals are an integral part of their communities. They provide services which are deinstitutionalized, they shift in-service delivery to outpatient care and they provide community-based services, and these in our view are all clear illustrations of commitment to providing care close to a person's home.

Why does government continue to or appear to present institutional and community-based care as mutually exclusive rather than parallel pathways or partners of a continuum?

The compendium to Bill 173 states that institutions are often viewed as a last resort. Are they not also viewed as a point of renewal or a point of transition or a point of rehabilitation or a place where patients are assisted in their efforts to return to their home community?

We therefore strongly recommend that, three, the government abandon this very highly structured approach. Indeed, we recommend that government thrusts to reform long-term care do so by building on existing community resources, including the role hospitals play in delivering long-term care services.

In fact, our third recommendation can be interpreted as the Health minister's very own recommendation to the Metropolitan Toronto District Health Council as found in her letter of May 13, 1994, concerning interim MSAs, and I quote: "An interim or transitional strategy may be a federation of long-term care agencies agreeing to work together to provide services for a particular area." In our view, such a federation allows for the inclusion of hospitals to ensure a continuum of care.

The minister's interim model of an MSA does not require the degree of regulation called for by Bill 173. Her interim model was flexible, it endorsed local decision-making, it used the best agency to do the job and it respected existing volunteerism in all of these institutions.

(4) Local planning of services under the leadership of district health councils: In our joint paper almost a year ago, we stated:

"We feel that the district health council is currently the most effective mechanism for local planning. We fully support the DHC as the instrument through which multi-year plans should be developed, to initiate multiservice agencies and to develop local implementation strategies."

We stressed the need for data and information collection so that local planning could be done based on objective, information-based decision-making as stated in the government's Partnership Planning Framework document. OHA still holds that position. However, we find that DHCs are burdened by heavy workloads and thereby hindered in their ability to effectively plan. They are currently involved in 12 of the ministry's priority reform areas.

We had commented that DHC long-term care committees should establish appropriate membership balances of consumers, providers and other interested parties.


OHA also expressed concern with the proposal to establish long-term care funding envelopes for districts in the absence of sufficient information regarding costs, effectiveness and quality of existing programs.

Nous déclarons, à ce sujet, à l'heure actuelle les conseils régionaux de santé ne disposent pas de l'information voulue pour répartir convenablement l'enveloppe locale, qui puisait. Le projet de loi 173 incorpore les conseils régionaux de santé dans la loi pour la première fois en modifiant la Loi sur le ministère de la Santé et définit les fonctions des CRS.

L'article 62 du projet de loi indique que les CRS agissent à titre d'organismes consultatifs auprès de la Ministre en matière de besoins de soins de santé dans leurs régions géographiques respectives. Ce même article préconise que les CRS passent des recommandations sur ce qui suit : la répartition des ressources pour répondre aux besoins de la région géographique en matière de santé et les plans de création des services de soins de santé équilibrés et intégrés. On brouille ici la distinction importante qui existe entre planification et gestion en confondant l'autonomie des organismes particuliers et l'administration et la gestion de leurs responsabilités.

L'article 62 préconise aussi de donner au CRS le pouvoir d'accomplir toute autre tâche que la Ministre pourrait lui attribuer. Ce pouvoir considérable est inquiétant en soi et perpétue l'ambiguïté continuelle du rôle et du mandat des CRS. L'appendice du projet du loi indique : pour que les CRS soient capables de bien s'acquitter de leurs responsabilités de planification et de fournir des conseils fructueux à la Ministre, il faut établir clairement ces responsabilités et la délégation qu'en fait la Ministre au CRS. Le projet de loi ne fournit pas cette orientation. Le mandat qui peut comporter un pouvoir considérable et pourtant vague que propose le projet de loi 173, soulève de nouvelles inquiétudes au sujet de l'avenir de ces organismes.

L'Association des hôpitaux de l'Ontario recommande que, par conséquent, et c'est notre quatrième recommandation : l'article 62 du projet de loi soit modifié pour que l'on incorpore à la loi que les CRS, comme organes de planification et organes consultatifs auprès de la ministre de la Santé, et que tout pouvoir supplémentaire attribué aux CRS ou à tout autre organisme défini géographiquement, fassent l'objet d'un processus séparé faisant appel au débat public et à la consultation de tous les intervenants.

Finally, our concern number 5, regional planning and resource allocation: In the June 1994 final report of the minister's regional planning steering committee for southwestern Ontario, chaired by Douglas Lawson, a proposed new model for regional planning is recommended. Health Minister Ruth Grier has endorsed this proposal.

The Lawson report outlines an approach to regional planning through adding a new layer of bureaucracy. It proposes the creation of a regional health council, or RHC, for southwestern Ontario which will have a permanent staff of at least five, including an executive director. The RHC would have a similar scope of authority and responsibility as that of DHCs and, as the Lawson report states, "The authority of the RHC will evolve along similar lines to any future changes in the scope and breadth of the DHCs...."

Thus any ambiguity about DHCs resolved through Bill 173 is negated by the creation of an added higher layer of bureaucracy which lacks any legislated authority and to which DHCs will be subordinate.

As noted earlier, the Minister of Health has endorsed the proposed regional structure for southwestern Ontario and ministry officials have indicated that the implementation process is already under way. The Lawson report has been sent to DHCs in other regions for consideration in designing new regional planning structures. All this has occurred without any opportunity for public input or stakeholder consultation.

OHA not only urges that before the RHC process goes any further, it recommends there be considerably more debate and discussion in the public arena and that it be made clear in Bill 173 that any regional health care planning structures will not be created under the sections of this bill dealing with DHCs.

Finally, section 62 of Bill 173 should be amended to make it clear that no member of a DHC should receive remuneration as a council member. The same must be said about RHCs, if and when they develop.

Volunteerism in health care in Ontario, indeed in Canada, has long proven that it is competent, effective and that it's aptitude for cost containment, not forgetting fund-raising, is legendary.

Conclusion: While we support the principles of long-term care reform, we cannot support Bill 173 in its present form due to its overly prescriptive approach, its inability to achieve the concept of one-stop access without the potential dismantling of high-quality volunteer programs and the artificial separation of institutional and community-based care. In addition, the complexity of issues surrounding DHCs and the new regional health council structure being established in southwestern Ontario and possibly elsewhere should be publicly debated and discussed.

Il va sans dire, sans doute, que nous avons apprécié l'occasion de vous présenter nos recommandations et que nous vous remercions de votre attention à tous nos propos.


M. le Président : Merci pour votre présentation. On passe maintenant à Mme Gigantes.

Ms Gigantes: Mr Isabelle, thank you for your presentation. I was interested in listening to understand that of course you're presenting not just from the base of experience here in Ottawa-Carleton, which you have certainly personally, but also on behalf of hospitals, both acute and chronic hospitals, on a provincial base. It's in that context that I would like a few further comments from you, if I could, on what I sense is a kind of -- "defensive" is probably not an appropriate word, but anxious attitude that seems to me to come forward in your brief on behalf of hospitals in Ontario about their role, not only in long-term care as Bill 173 contemplates it -- and you talk about an artificial division which the government is putting forward between hospital care and community-based care, which I don't believe is there.

You're expressing an anxiety about that but also an anxiety about the role of district health councils. On the one hand you approve the planning vehicle offered by district health councils; on the other hand you say they don't have enough resources at the moment to carry forward their mandates, and I would agree with you that they are going to need increasing resources. On the other hand, when you look at the potential of development of regional district health councils, for example, the size and scope of southwestern Ontario, again that anxiety comes out: "Where do the hospitals fit in?" So overall what I'm reading from your brief is a lot of anxiety. Why are hospitals so frightened?

Mr Isabelle: Well, I'm going to ask one of my colleagues to help me with that, but, number one, it's by what we read. We find that there are contradictory statements between government intentions and what is drafted, as I've indicated in my paper. Number two, we have supported district health councils, yes, that's true, and yet we also recognize that, like a lot of other people in the province, they have to be enabled to do their job. However, we find that the legislation for district health councils is in a paper dealing with long-term care. Why not a separate legislative bill?

Now, with respect to the other comments, Madame, I'd like to refer to Dan Drown, if you accept.

Ms Gigantes: Have you ever tried to get a bill through?

Mr Isabelle: Dan, could you please address the other concern she made?

Mr Dan Drown: I think the issue of divisiveness or anxiety stems from the fact that we run into very different approaches towards management, for instance, between the two sectors of what we call long-term care, community care and hospital care. We'd like to see a greater twinning, if you will, or a pathway concept whereby we do not see a highly regulated sector adjacent to hospitals but in fact we lean on what we've learned about voluntarism, what we've learned about accreditation standards.

In effect we're not, I think, as anxious as we are perhaps frustrated by the inability to manage in a continuum fashion or create a pathway. You know, people enter and exit pathways, and in doing so, you can devise treatments which are also along the continuum basis. So I think the anxiety is more frustration in the fact that we run into very different sort of legislative mandates to accomplish the same continuum or pathway of care.

Ms Gigantes: The district health council representatives before us drew to our attention the fact that 94% of the long-term care budget that's spent on community service in the Ottawa-Carleton region goes to four agencies which are providing service in blocks and in disjointed ways, as we know it, in the community, without the kind of rationalization I'd expect you, with your interests in planning, to understand as a need within the community. If that changes, why is there a threat to the hospitals?

Mr Drown: In my mind, as long as you're dealing with enabling legislation which allows the needed flexibility, you wouldn't have a problem with bringing those things together. In fact, I think if you scratch the surface, you'll find that those community agencies may well be located in hospitals, in some instances, in terms of where the origin of the service is.

Ms Gigantes: Seventy per cent are in the private sector.

Mr Isabelle: Seventy?

Ms Gigantes: In Ottawa-Carleton, yes.

Mr Michel Bilodeau: If I may add to that, I think the level of anxiety may not be as high as you may think. There are two specific things that we say in the OHA brief. One is that we are concerned that the legislation is open-ended as regards the role of the DHC. Certainly we have no problem with the role of the DHC as a planner, but when it says that the DHC may have any other role that the minister decides to give to the DHC, that we are concerned about because we don't know what it is.

Second, we have concerns about the process that has been followed in southwestern Ontario, where basically hospitals have been put aside for the planning of the new system and are not yet involved fully in the process of regional planning. So these are our two main concerns.

The Chair: I'm sorry that I'm going to have to jump in here. I hope we've relieved some anxiety somewhere, but we have to continue. Merci pour la présentation de cet après-midi.

Mr Bilodeau: I'll stay here.

M. le Président : Monsieur Bilodeau, vous allez rester avec nous.


The Chair: The next presentation is on behalf of the Sisters of Charity of Ottawa Health Service.

Mr Michel Bilodeau: Thank you, Mr Chairman. This time I wear my other hat in my day-to-day job as president of the Sisters of Charity of Ottawa Health Service, which is commonly called the SCO Health Service.

The SCO Health Service has been created in early 1993 to bring under one board and one administration the four health care institutions owned and operated by the Sisters of Charity in Ottawa-Carleton, and that includes Saint-Vincent Hospital, a chronic care hospital and rehabilitation hospital with 516 beds; Élisabeth Bruyère Health Centre, which has 225 beds in the chronic, rehabilitation and palliative care sector; the Residence Saint-Louis, a 186-bed charitable home for the aged; and Villa Marguerite, a 71-bed not-for-profit nursing home.

In total, we provide 741 hospital beds, 257 long-term care beds, 26 detoxification centre beds, 30 spaces in day hospitals, and we serve close to 70,000 outpatients. We have a total of 2,200 employees and we have more than 1,000 volunteers who devote their time to our clientele.

I may add, which is not in your brief, that our board meetings are public, that we have direct nursing representation on our board and that we have community advisory committees that include the patients themselves and their families. We are therefore directly impacted by the long-term care reform, by the chronic care reform and by all the changes taking place in community services, including the establishment of MSAs.

I have numerous comments, but since you heard a lot of statements about Bill 173, what I'd like to do is concentrate on examples, real cases of what it will really do to some agencies and some organizations.

First of all, obviously the idea of one stop for the elderly is a good one. However, my question is, how will it work in reality? You're an elderly person. You call to one number. Now, it's not Pizza Pizza. They're not going to deliver you the service within one hour or half an hour. This receptionist or telephone operator will have either to have all the answers to all the problems, or if that's not the case, which may happen, she or he will have to refer the caller to somebody else, maybe a social worker or a case worker, and in turn, this one will have to talk to a service provider.

All of these people will have somehow to have information about the client who's calling. Just in Ottawa-Carleton there are 100,000 potential customers to be served by MSAs. Currently, several hundreds of small agencies have information about these clients, information that's in fraction in each of these agencies. If we want to have a real one-stop, we'll need to have a central file on each of these clients.

Just for the fun of it, talk to a computer company and try to centralize 100,000 charts with information that you have all over the place, and try to have significant information in there without having, first, a computer service with a lot of people in it, without having a lot of computer terminals that will have to be accessed from all the providers and all the case workers. Now, we're talking, to be realistic, millions of dollars province-wide to do that, and this is money that will be diverted from current direct services to the clients.

A lot of people talk about the 20% rule, and I'll come back to that later with a direct example. A lot of people I talked to were under the impression that it was for the private sector only. Well, this is not what the legislation says. It's for everyone, and it's a sure recipe to create a huge bureaucracy.

Let me give you a few examples, and I'll come back to bureaucracy later. Part II of the bill identifies "security checks or reassurance services" as mandatory community services provided by the MSA. We in one of our institutions offer a service called Helpline where clients have an alarm at home which is monitored 24 hours a day from one of our sites. We have staff working 24 hours a day because we operate a hospital.

Now this service, which we created ourselves in the early 1980s, at a time when nobody else wanted to create that, is supervised by a community board of something like 20 people, which includes the police, the firefighters, the ambulance dispatch centre, consumers, community workers, and we have about 30 volunteers who devote their time, going to houses, install the system and help with operation of the system. Now, is that a community service or an institutional service? I don't know and I don't care. The service is working fine; we have more than 700 clients now and people seem to be satisfied.


When, because there's funding from Comsoc, will that likely be included in the MSA? Will the efficiency improve? Will the clients be better served because the service we've been providing for 11 years now will now be under the MSA? I can't see any answer to that question in the bill or in the MSA project.

Part II also identifies "adult day programs" as mandatory service. We currently in our building rent at subsidized rates, $5 per square foot in an area that commands around $21 rent, and we pay for housekeeping. We rent space to two of such adult day programs. One is the Alzheimer day away program that's operated by VON and another one is a day centre for senior francophones.

These two services, when I talk to them, are convinced that they're becoming part of the MSA because they're funded by Comsoc in large part. Their administration costs are extremely low. They operate well. They're controlled by their clients right now. Why change them? And on the other hand, why would we rent to the MSA at subsidized rates?

I mention bureaucracy. As all these services are merged under the MSA, there will be a time, it will come very soon, when the MSA will have more than 50 employees and, with our 2,200, I know what I'm talking about. Then, as an employer, the MSA will be covered by the pay equity legislation, the health and safety legislation, the employment equity legislation. Soon employees will be unionized, and I have nothing against that, but I can assure you that salary costs will be driven up very, very fast.

To manage that you'll need a human resource department because you'll need to prepare the pay equity legislation and the employment equity plan, and these are very complex issues. When you have that, you'll need a payroll service and, in addition to your computer service that was created earlier, you'll need financial services and then you'll need a purchasing service to have all of these small agencies purchase from the same place. When the administration was done by volunteers before, it will now require professional staff to manage this place because it will be bigger.

With higher salaries and higher overhead costs, less services will be provided with the same amount of money. Is that making the system more efficient?

I can talk about mergers. I've been through a merger in the last year and a half of four organizations and we saved a lot because we merged services that were already bureaucratic. We merged large organizations that all had a lot of bureaucracy, but if you merge services that have no bureaucracy, that are managed by volunteers, you'll have to create the bureaucracy and I don't think you'll be solving the problems.

One option currently under review is to have several MSAs in a region. I've heard in Toronto, they're talking about one MSA for about 100,000 to 150,000 people. If that's the case, we'd have three or six MSAs in the Ottawa region. If that's to happen, not only the 20% ceiling becomes problematic, it just doesn't make sense. Let me give you the example of the Helpline I mentioned earlier. We have one service for 700 clients in the region. If we have five MSAs, will we duplicate and have five helplines and make them less efficient or will we have one MSA which will integrate the helpline and sell the services to the four others?

For the client of the MSA that purchase the helpline service from another MSA, what's the difference to purchase it from another MSA or purchase it from us? There's absolutely no advantage. If you create one giant MSA, yes, maybe you can think of a 20% ceiling, which I think is not good anyway, but if you have five or six or several, it just doesn't make sense any more. The Alzheimer day away program -- there's one program, two in town. If you have five MSAs, how do you split that? Who controls these Alzheimer day away programs? You'll tell me it may be part of the 20%. Well, the 20% will be blown very, very fast.

Wouldn't it be simpler to maintain these programs as they have now and have each of them contract with the MSAs? This would avoid the dismantlement of well-established programs and achieve exactly the same goal without disruption to the consumer. That's what you heard today from the district health council. That's what you heard today from the council on aging and I'm sure from a lot of other organizations. Why force a region to adopt a model it doesn't want?

In addition, because of the creation of MSAs, cultural groups which currently control their own services may well lose this control. Le centre de jour des aînés francophones, the adult day centre to which we currently rent space, has its own board made up of the members of its organization. It has several hundred members. They elect their own board. If they become part of the MSA, as they expect to be, their board will be formed mainly of English-speaking people, unless we create a French MSA only which will create other problems. But why would an organization that's been operating well and controls its own destiny with people from its own language suddenly have to have a board that is mainly made up of anglophones? How will it serve the citizens better? That's the question you should ask yourself.

In conclusion, we recommend that section 13 be amended to delete the 20% maximum for purchased service and if the government wanted absolutely to maintain a ceiling, we think this ceiling should not apply to other public health or social service agencies that already provide similar services. We agree that the MSA should play a coordination role but not an integration role.

Ms Gigantes: Mr Chair, could I just ask on a point of order: If one feels that a witness, with all due respect, has attributed to another witness something that I believe the other witness did not say, what does one do? Because I do think there has been a misunderstanding --

The Chair: One does what you are doing, so just go ahead with your point.

Ms Gigantes: -- on the part of this witness of the points that were made by the district health council and I'd be happy to give him a copy of the brief.

Mr Bilodeau: The only point I mentioned about the DHC is that they oppose a 20% ceiling. That's all I said about them.

Ms Gigantes: Well, no, your brief says something else. It says this is what the district health council wants and it says --

Mr Bilodeau: I'm referring to the 20% ceiling.

Ms Gigantes: "Wouldn't it be simpler to maintain these programs as they are now and have each MSA contract with them." That's not what they propose.

Mr Bilodeau: No. If there's a misunderstanding, I want to clarify. The only thing I want to attribute to the DHC is that they oppose the 20% ceiling, and my sentence may have not been clear. It's clear in the French text that the only thing I mentioned about them is the 20% ceiling.

Ms Gigantes: Thank you.

Mrs O'Neill: Well, Michel, I'm glad to see you again and the four organizations or facilities you're representing today -- their reputation precedes them. I'm surprised you didn't mention a little more of something that we're not talking about a lot here, and that is the relationship of the facilities to the community agencies and how you see that changing if Bill 173 goes through as is now. Facilities, if I am judging the situation correctly, have not really been significant partners in this discussion. They are significant partners in reality, but Bill 173 does not talk about facilities. All of the partnerships you've built up and so well exampled this afternoon, I feel, are somewhat in jeopardy and I wonder what you could say about that. It looks to me like less service and longer waiting lists even in things you're trying to offer at the present time.

Mr Bilodeau: I must say I'm not very much concerned by that, at least in this region. We've had, as facilities, very good relationships with district health councils. We participate, for example, in the definition of what the MSA will be. We have representation on the long-term care committees. As you know, we've operated with a placement coordination service for a long, long time and we may even avoid losing our cultural identity at the résidence although I think we'll lose it anyway in the long run because of Bill 101, but I'm not very much concerned. I think in this region at least, facilities have been involved in the planning process through the district health council. I cannot speak for other regions, but in Ottawa it's not bad.

The Chair: Thank you very much, encore une fois, d'être venu devant le comité cet après-midi.



The Chair: I call the representatives from the Ottawa West Seniors Recreation Advisory Committee. Welcome to the committee.

Mr Tom Sparling: My name is Tom Sparling.

Ms Karen Colby: Karen Colby from Central Park Lodge retirement home.

Ms Lindsay Webber: Lindsay Webber. I'm a recreation therapist in geriatric psychiatry at the Royal Ottawa hospital.

Mr Sparling: We noted in the information package that was so kindly sent to us by the clerk that brevity was an important issue. After sitting through part of the meeting, I can appreciate that and I will promise that we will be brief and to the point. I'd like to thank the committee, the support people, for their efficiency and also the committee itself for being kind enough to hear us.

This afternoon, what I propose to do is very briefly -- if you just look at page 3 of our presentation, we'll just take you through 3 pages, come back for our recommendations and conclusions and then provide time for questions and answers if the committee so chooses. Again, thank you for allowing us to be present.

I'm going to give you a little history of how we got here. The Ottawa west area has a very high concentration of seniors, those living independently and those receiving some level of support in their own homes or in public or private sector facilities. We've noted that the independent seniors are well served by municipal recreation programs, community centres, senior activity centres and the YW/YMCA. As a matter of fact, the last time I checked you sort of had to inherit a spot on the aquafit program at the YMCA. It's a very, very busy facility, and they're doing a fine job.

But who are we? If we go back to our front page here, we've got the Beacon Hill Lodge, which is a nursing home. I look after the recreation volunteer program at that facility. We have Carleton Lodge which is the home for the aged in Ottawa-Carleton. We have Central Park Lodge which is a retirement home. We have the City of Ottawa Senior Adults' section as a partner, the Dovercourt community centre which is a personal service community centre operated by a community board, the Queensway-Carleton Hospital, the Royal Ottawa hospital and West-End Villa. That's the initial group we're working with here. That's the week.

We realize that a group of seniors living in their homes, homes for the aged, nursing homes, retirement facilities and the community in general share a number of characteristics. Some of those shared characteristics may be a certain lack of mobility, perhaps a need for a wheelchair, using a walker, that type of thing, or perhaps a lack of confidence. A lot of the people we work with have lost their confidence in their abilities to cope in society.

Every time we reach out to help someone, we also take the ability away to stand on your own two feet. It's a little bit like learning to ride a bicycle; we have to find at what point one lets go of the back tire and allows the individual to have responsibility and to be successful, even if it's a very small step.

So we think that the lack of confidence, sometimes in your ability to be independent, can affect people greatly. We sometimes see the issue with the clients we work with of recreation as a foreign concept. Leisure was something that most of the people we work with did not experience. They grew up through the Great Depression, one or two world wars, and they were busy building a country. For most of them leisure was something they did not have the opportunity to be involved in. A few do have leisure and hobbies that we work with in the long-term care setting; others in the community may have developed interests after retirement. We suggest that the idea of new skills can be daunting to people who haven't had that opportunity or the education to say that it's okay, it's all right to have a hobby, it's all right to do something called play for the joy of it.

I think we're also aware that for the people we were serving, these characteristics are very human. We all have failings and fears and anxieties as we go through our daily living. We think it's important that we realize these are the same types of issues that we all face.

We felt that therefore some support and organization could be provided to these seniors who tend to be excluded from community recreation programs. We could become involved in a new type of what we call adaptive recreation programs.

What we're trying to do is bring together seniors from various locations. For example, there could be clients from the nursing home, clients from our senior apartment buildings that are funded or administered by the Ottawa-Carleton housing authority, people from retirement homes, homes for the aged, or people living independently in the community who may be clients of one of our home support agencies or who just happened to hear about a program that was going to be offered at a community centre or other service point.

We're actively seeking the people who had fallen through the cracks, and in part for the people who are working in facilities, ourselves. The issue is for us to maintain a continuum of recreation programs so that the people who do have the confidence, who do have the interest in maintaining community contacts, can be supported and encouraged in being out of facilities so in fact it is a home and not a facility, not an institution. We have people who want to reach out and maintain contact to make use of facilities the way we all would like to use facilities in the community: the library, the pool, the maintenance of service clubs etc.

We looked at these people and we said that there's no doubt there is a clientele, perhaps, here that would meet the needs of some of our people, some of the people living in communities with some support, and that together we might form the basis of some very interesting program ideas. What we sought to do was to bring together these groups of people, and in fact we've done that on two occasions, where we brought together in one case 120 people and, more recently, almost 170 persons at the Dovercourt community centre. What we found on that day was a real interest in some things that were new to these people. Weight training -- I have some photographs with us. Unfortunately, all the shots from the weight training have gone to those participants. I couldn't get them back from them because it was exciting for someone 80 years of age to realize that they could, and it was indeed possible to, look at weight training as an option, as something they might like to do.

The chair fitness programs, the water programs, the adapted program for people with special needs in the water, all can be done and provide an exciting new opportunity for these people from a number of environments who share the same characteristics, regardless of where they live.

Indeed, this fall we're going to be offering a t'ai chi program and creative writing programs. We're in partnership with the Ottawa-Carleton department of health and its Healthy Neighbourhoods program in the Lincoln Fields shopping mall, and there's a craft program under way now that has clients from the community and long-term care, and we're hoping to have residents involved in a mall-walking program. It's the teamwork and building of services and linkages between service providers that we think is important. All these programs and more we think are possible.

Assuring that there is a user-friendly environment: I think trust is a critical issue for all of us and especially people who have a sense of perhaps diminished abilities; that when they're in a situation where they can feel dependent, it's important that they know you and that there is a trust developed. I think that's a critical component of care, that people need to trust those they're working with.


This fall we're offering a number of programs that we've alluded to: the mall-walking, a creative writing program, the t'ai chi -- a number of things where we'll have clients from the community at large, people from other long-term care facilities, and opening up spaces, opening up new horizons to people.

We're at present an eight-member committee. We expect to grow between now and Christmas to perhaps 16 persons. We've had discussions with the city of Nepean and with indeed interests from Kanata as well, from the possibilities of linking up further the information, sharing that information, sharing facilities, and doing what we can to improve the quality of recreation service for people living in the community and also living in facilities.

Recreation, we believe, is a very important and cost-effective means of maintaining increasing wellness in seniors. We would ask the committee to recommend that recreation professionals such as ourselves, people in the field, other organizations such as the Activity Professionals of Ontario and an eastern Ontario group called the Health Facility Therapeutic Recreation Association, be consulted and involved as the process moves forward.

We think that another issue that needs to be addressed in the future is the issue of pay equity down the road. There is at present a difference between the level of salary between those working in different sectors, and I think that needs to be looked at. I know there are a number of things that you folks have on your agenda right now, but somewhere along the line we would appreciate some consideration of that issue.

Professionalism: We think that it's critically important that a team deal with the issues in the community, whether it's the therapist, whether it's the dietician, whether it's the medical personnel or perhaps whether it's the recreation staff person. All the skills together will, I think, provide the best possible mixture for the clients we indeed wish to serve.

The last thing is the note that in British Columbia some work has been done with regard to improvements and in the modelling for recreation professionals between the community and the long-term care setting; that there's been some work done with regard to the Therapeutic Recreation Association in British Columbia looking at improvements to education.

I think that's also a critical issue, that if we're going to have people working in the profession, the present situation at college and university may not be able to meet all the demands that we're facing. I know that at University of Ottawa, where I studied recreation, there was only one program in adapted rec, and indeed there may be a greater need for educational programs and upgrading across Ontario.

We'd also like to point that there's some reference material. I think Biomarkers is a wonderful book. There's a very interesting title called "Postponing Your Entry Into the Disability Zone." I think it's worth all of us reading, because that's a critical issue. If we can prevent people going to long-term care or needing support, then we're going to save us all an awful lot of money. I hope we get this right by the time I get there, speaking personally.

In conclusion, we'd like to make a couple of recommendations.

First of all, we'd like to recommend that recreation professionals play an active role in long-term care, be it community or facility based.

We'd like to also recommend, respectfully I might add, that the recreation professionals and the professional organizations must be consulted and involved in the development of criteria and guidelines for recreation services.

I think that the third item is, the delivery of service to long-term care clients must truly be a multidisciplinary approach to work effectively.

Item 4 is that we suggest that the multidisciplinary team should include medical, dietary, therapeutic, social service and recreation professionals.

In terms of conclusions, we have but four:

(1) We think to realize the goals of long-term care reform, the system must be integrated, as facility-based care and community support are but two sides of the same coin. Information needs to be exchanged, and I think that it's possible down the road to see people going into long-term care for a short time and then going back into the community. Indeed, that's one of the goals of the program and I think we should continue to push for that.

(2) We have shown that close cooperation -- our little experiment -- and networking will provide a better and more cost-effective service to clients whatever their location. I think that it's important to remember that efficiency and making wise use of scarce resources is why we're all here today.

(3) We believe that recreation provides a very cost-effective intervention strategy that will maintain and/or improve the wellness of many individuals. We're pleased that the district health council and the council on aging also spoke on behalf of the role of recreation in long-term care.

(4) The last thing we'd like to mention is that we also think that recreation may reduce the amount of medical interventions now required in support of the quality of life for the client. If we can prevent some medical interventions, we'll save the system a little bit of money.

The Chair: I think probably all members of the committee by the end of the week sometimes feel that they're about to enter the disability zone and we probably should have had you lead us in --

Mr Sparling: It may be an occupational hazard.

The Chair: -- some weight lifting or how to sit in our chairs in a more effective way. That being said, Mr Wilson.

Mr Jim Wilson: Thank you for your presentation. Some of the points that you make are very similar to those that were made by the council on aging earlier this afternoon. I'm just going to ask you very pointedly: Do you know how you fit in to the MSAs and the basket of services right now? Has anyone consulted with you, because we look at professional services, we have physiotherapy and occupational therapy and we've had some discussion about rehabilitation services, but none specifically about recreational and what should we be putting in there to make sure that your profession's not left out.

Mr Sparling: That's a very good question. Lindsay, anything to say?

Ms Webber: One thing that is really missing out in the community now is sort of a community recreation therapist or recreationalist, or however we've been termed. Working in the hospital, one big role of mine working with outpatients is getting them involved in community programs, but that sometimes just goes to a certain point. With OT and physio and dietary and nursing, a lot of people can be staying in the community and can be headed off before having to come into an institution or a facility for treatment. There's no such thing out there and that's, I think, something that's going to be very important, especially to keep people in their homes.

One thing with the healthy neighbourhood program, the public health nurses are trying to get people out into the community and neighbours helping neighbours, but there's no one to help these frail, lonely, isolated people to get out into the community, and where are they going to go?

Mr Jim Wilson: I was thinking you play a particularly important role in combating loneliness because, to me, I spent two evenings recently at Toronto Hospital emergency department and the prediction is after 11 o'clock at night, the physicians told me, you're going to see elderly people come in and there's nothing wrong with them medically but they're lonely, they can't sleep. Sure enough, on both nights, I think we had a total of about six, and it's enough to keep you busy because they all have to be checked and that. In chatting with them, they just had nothing to do. They're at home, they're doing what the government tells them to do, but they're going out of their minds with loneliness.

Ms Webber: For a lot of the seniors, their big social contact all week is the VON that gives them the bath, the homemaker that comes in and cleans their house, the person from Meals on Wheels that drops off their meals either once a week or once a day, and maybe the mailman, and they look forward to that.

Mr Jim Wilson: And the MPP every four years.

Ms Webber: Yes. And that's it, unless they're linked up into something.

Mr Jim Wilson: Right.


Mr Sparling: The linkage, I think, is critical because what's happened certainly in Ottawa-Carleton is that there are substantial programs for the independent elderly, for seniors, and that's wonderful because hopefully those people will never be part of the long-term care system.

I think that's a possibility, that that will occur, but one of the reasons we're here is that we had the sense that no one was speaking for recreation, that no one had been asked, and to be honest, we're getting sort of tired of it. We were getting kicked in the shins out there and we'd like to say something every now and again.

The Chair: You have, I think, brought a perspective on this that we've seen before but not to the extent that you've presented today. We want to thank the three of you for coming to committee.

Mrs O'Neill: Mr Chairman, I wonder if I can make a request we've made before in this committee. We've made a request for the draft regulations for Bill 173. I wonder, had that come up again today with these presenters? We've now had a two-week break on hearings. Is there any hope of us getting any draft of regulations around 173?

The Chair: Beyond, you mean, the regulations we received before.

Mrs O'Neill: The regulations we received, as I've examined them closely, are the regulations to Bill 101. They are not the regulations to 173. I didn't have time to examine them the day we got them, and I've been quite disappointed by that.

The Chair: Okay, the parliamentary assistant and then we must move on.

Mr Wessenger: I think it should be understood with respect to regulations under an act, they are not worked on or even prepared until the act is completed. So there are no draft regulations that exist under Bill 173.


The Chair: I call the Ontario Home Care Case Managers' Association, eastern region.

Ms Judi Burke: I'm Judi Burke and this is Susan McGurn. I want to thank you, Mr Chairman, and committee members and ladies and gentlemen. The eastern region of the Ontario Home Care Case Managers' Association --


The Chair: Order. Sorry, order. Members of the committee, hey, order. I appreciate -- order, Mr Martin -- we're at the end of a long afternoon, but I would request that we respect the presentations that are being made. We can have our arguments in the Legislature and in the corridors, but we're here to hear from the presenters.

Ms Burke: The eastern region of the Ontario Home Care Case Managers' Association includes case managers who are employed in six of the province's 38 home care programs. These programs are Kingston, Renfrew, Leeds-Grenville-Lanark, eastern Ontario, Ottawa-Carleton and Hastings-Prince Edward county.

Susan and I are pleased to present our views on Bill 173 to this committee on behalf of our members in these areas, although I understand from Susan that in Kingston, I guess it's tomorrow, Leeds-Grenville-Lanark case managers are also making another presentation.

This very important bill will not only reshape the long-term care delivery system in this province, but it will affect all of our lives in some significant way, whether we are consumers, family members, care givers or professionals working in this province's health care system. As responsible professionals with extensive experience in community-based care, we welcome reforms that will improve services to Ontario's consumers.

Our brief will have a bit of a different focus from the response by our association executive in Toronto, but we want to just repeat that we strongly endorse the Ministry of Health's long-term care reform objectives. I think you've got them all in the copy of the brief here: easier access to long-term care services; consumer participation in the planning process; a consumer bill of rights and appeal process; the integration of community services, thus addressing fragmentation and duplication in service delivery; and local planning by district health councils to accommodate the regional differences.

The purpose of this brief is to talk about case management and case managers. We haven't seen anything about case management in the bill, and that's what our concern is. I may be needing to get reading glasses, but I haven't seen anything that is listed in the bill. We prepared this response to show that case management and the skill of case managers in the home care program is an essential part of Ontario's new long-term care system, and we'd like to point out the need to include case management in Bill 173.

I've chosen to quote Carol Austin in her article "Case Management in Long-Term Care, Options and Opportunities," because she is the chairperson of the International Conference on Case Management, which will be held in Toronto next weekend. Carol, from her article "Case Management in Long-Term Care, Options and Opportunities," describes case management in this way:

"Case management is widely viewed as a mechanism for linking and coordinating segments of a service delivery system within a single agency or involving several service providers to ensure the most comprehensive program for meeting an individual client's needs for care."

Carol goes on to say:

"The principle functions of case management in long-term care are the following: (1) screening and determining eligibility; (2) assessing the need for services and related needs; (3) care planning, developing a service plan; (4) requisitioning services; (5) implementing the service plan, coordination service delivery and follow-up; (6) reassessing, monitoring and evaluating services periodically."

All of these functions are performed by case managers in the eastern Ontario region as well as throughout the province. Case managers do this not in isolation; they do it in partnership with community service providers and with community support services. In this way we can keep a balance between quality service and fiscal responsibility.

Principles of case management can be taught in a university or learned from a textbook, but good case management is learned in the field doing case management. In Ontario case management is not about managing people. It's about assuring quality community care to meet the needs of people.

The approximately 200 full- and part-time case managers employed in the eastern region have extensive job experience in hospital and community nursing and other health-related disciplines; 65% of these case managers have baccalaureate degrees, and they have all developed comprehensive assessment skills and expertise in the design of service plans. These service plans address with our clients the issues of wellness, rehabilitation, reactivation and prevention.

Susan and I have a combined community experience of over 26 years. Both of us have worked in all the specialty areas of home care, palliative care, school services, seniors case loads, hospitals. I guess I'd like to talk a little bit about our consumers here, because we don't seem to feel that the people at the ministry have a grasp of the kind of consumers that we're working with.

Today the consumers that are being serviced by the home care program have many and complex needs. Most are vulnerable and over the age of 75 and with limited personal support and cognitive impairment. Others are at home because of improved technology, and the improved technology has made it possible for them to be there. We have people that are respirator dependent, and they're able to be managed at home with support from specialized services and specialized equipment.

This particular group of people require more than just service coordination, which is discussed in the bill. Case managers with these kinds of clients assist the consumer to negotiate the system by explaining and interpreting services and interpreting the use of the services. Not everybody understands what an occupational therapist is. Not everybody understands what a nutritionist can do for them at home. Also there are many people out there who just have a great deal of difficulty accepting help from a stranger and someone coming into their own home.

We provide advice to the consumer and his family in time of crisis and we also provide them with the support and counselling. We also make available information regarding respite care and placement so that they can make wise decisions about these things. A lot of people who are considering placement after being informed about the costs and the process change their minds, especially when they realize that we can provide them with support services at home.


Another thing that we are involved in as case managers is adjusting the volume and the type of services, because needs change frequently with this group. Someone in one week may have a fall and go to hospital and require extra services, because the hospitals aren't keeping people any more. When they go into emergency, they're sent back home to manage at home with support services.

In order to make our job possible, we work in partnership, as I said, with service providers to assure that these changing needs are met. In the previous presentation they mentioned something about linking with recreation services. That's one of the things that we do with our lonely and isolated clients. We link them up with day care programs and any other recreation services available in the community.

My next statement says that every case manager in Ontario can give you examples of what good case management can accomplish. But we've decided instead to have Susan do a little visualization, because I think her visualization will give you a good idea of what case management is all about.

Ms Susan McGurn: I'm sure that over the duration of your hearings you've had lots of examples of clients who are seen by the various groups in the community, and I'm sure that you've had lots of descriptions of clients. I was recently approached, related to long-term care and to Karen Goldenberg's activities around MSA development, to put together something of what I saw happening. I guess my biggest concern -- I am an acting manager at the moment, but in normal practice I practise as a case manager, and what I was seeing was an oversimplification of the consumers, and not just the consumers, but of the service itself and the service delivery system.

We have, in health care, started describing clients as being on a continuum of health; they're either further up or further down the continuum than other people out there. That's true in one way, but it really does oversimplify the consumer we are dealing with. Because of a historical perspective in our own program in Kingston, I tried to visualize, and I'd like all of you to do this, the clients, the consumers, those people out in the public accessing the service -- and this can be yourself as well -- as a quilt. Your life experiences are all the patches that make up that quilt. Nobody's quilt is exactly the same. We come from different educational backgrounds, different work backgrounds, different monetary backgrounds, we have different family and friend supports, and that's the patchwork that makes up our life experience.

What happens when there is a crisis in our life, be that an unexpected death, a change in our physical health, a change in our mental health, a change in our finances, is that either a patch wears thin, the patch rips or the stitching comes out. It's really easy to visualize what happens to people's lives. For instance, if the stitching comes out, not only does the crisis that happened affect us, but all of those squares around the crisis are affected. That may mean that family and friends are affected, it may be that our jobs are affected, it may be that our finances are affected. By simply putting a consumer on a continuum of health, we negate a lot of that and really oversimplify the effect that the health crisis or the change in our life can have on us as individuals and as care givers of those individuals. Even recently, in the AIDS report that was forwarded to our local program, there was a documented note that in times of crisis and health stress, the last thing you wanted to be doing was trying to sort your way through the system.

What I'd like to reflect on in the context of the quilt is that there are a few things that make up a quilt. One is the backing, and the backing represents the different ministerial guidelines, programs and volunteer organizations that are out there. The other part is the patches themselves, and I don't mean the patches in a derogatory manner. Reflecting on our grandmother's quilt lying at the foot of the bed, those patches are made up of a wedding dress, an important suit, a tie, your daughter's dress for her christening. They're very important, and it's the fabric of those squares that makes up the fabric of the organizations that we're in touch with in long-term care delivery, be that VON, volunteer organizations, individual boards of health etc. We have a fabric and it's very important, because we've come from a history that's important to be maintained.

The other buzzword that goes along with long-term care is "seamless." For any of you who sew -- I don't, but I did learn this while working on this -- there's no such thing as a seamless piece of material. Seamlessness does not exist. Seamlessness comes from very close stitchwork, networking those patches together.

What I offer you is that a case manager works from a pile of those very unique patches -- not rags, but rich remembrances of our past -- and helps sort, with a client, the appropriate patches and helps to sew them into their service care. What you end up with then is a security blanket. If the ministry refuses to recognize the historical perspective and the very good things that have come out of our programs throughout the province, what we will be asked to settle for is a cheap imitation rather than an heirloom.

My comments are not included in our brief simply because it's very hard to visualize them on paper. I hope that has presented what I feel case management is, that it's the needle that helps sew in those patches and helps sort through all of the patches out there to come up with the most appropriate quilt of care that provides security to the consumer and the public.

Ms Burke: Okay, how does everybody feel? Do you like the quilt?

Just to summarize, the needs and rights and choices of consumers have always been the primary focus of the home care case manager. I'm sure this is important to the consumer, and any one of the people we work with in the community will be able to tell you that. Consumers in the current home care system have complex and changing needs. They require direction and support from an experienced professional.

I just came from a visit today with a lady and her husband, both of them not in good condition at all, and she was told on the phone while I was there that the cancer had spread to her liver. In this kind of situation, I was glad I was there at the time, because I was able to help them to decide what kind of help they needed and where they wanted to go with any of this and to give both of them a little bit of support. They had never had access to community care services in the past.

Functions of screening, assessment, service planning and coordination, which are presently being done by home care case managers, will certainly continue to be needed in the new system. I don't know who the ministry has identified to take on these tasks, but I feel that case managers who have accumulated the years of experience in performing these functions are probably the most appropriate people to carry on. Transition to an integrated system will require case managers' experience and skills to assure that consumer needs are met and quality and accountability are not compromised.

New legislation will allow for more flexibility in services and eligibility. It sounds like we're going to be able to provide any frequency of service and that eligibility criteria, because we have such a basket of services, will be opened more than they are now and there won't be so many regulations. We like that idea, because we have a lot of consumers whom we work with who probably would benefit from different kinds of services but less of each. A skilled assessor will certainly be needed to assure, again, the appropriate allocation of resources.

Finally, we want to recommend that consumers requiring long-term care continue to be assured access to a professional experienced in comprehensive assessment and service planning to assist them in making informed and appropriate choices.

We want to ask that the new system be built on the strengths of the current system and avoid the startup costs incurred when major restructuring is done.

We recommend that the expertise of the home care case managers in screening, assessment, service planning and coordination and their sense of fiscal responsibility be recognized and the need to maintain this expertise in the new delivery system be acknowledged.


We recommend that a research component be built into the new system to evaluate the system, the services and the consumer outcomes. We want to know the value of our services and how they work and whether or not we're achieving the goals that we set out to achieve with our clients.

Finally, during my 14 years as a case manager with home care, and I had seven years before that with social services, I've talked with many peers. Since I've become the membership secretary for the Ontario Home Care Case Managers' Association, I've had the opportunity to network with case managers all over the province. My experience has been that these are very committed professionals. They want to ensure that Ontario consumers receive the right service at the right time in the right place.

That came from a video. I don't know if anybody's had a chance to see it, but it's about the quick response team in Victoria. Looking at the video, I saw a lot of the kinds of things that we are already doing here in Ontario through case management.

As the members of this committee review the input from the hearings and the briefs and as you formulate your recommendations, we urge you to include case management in Bill 173 as a professional service and core function of the new MSA. This decision will ensure continued excellence and caring as well as accountability in Ontario's new community-based long-term care system.

Mr O'Connor: Thank you very much for your presentation. One thing I think that has been pointed out to us is the important need for taking into consideration what we have out there and building on all the excellent pluses that we have. Right in your beginning you said that we should use the extensive experience that's out there right now. I think that's what we want to do. When we get to the regulation point, we don't want to overlook anything that has been presented to us, but make sure that we can use that as well.

One of the things that came up this morning by one of the presentations, and I'll just maybe just ask you for a reaction to it, and we've heard it a couple of times presented to us, is that in the assessment of the needs of the consumer we don't want to focus on just the medical needs. Listening to what you've suggested here, it doesn't look like you look at only the medical needs, but I wondered if you could maybe give us some reassurance or give us some practical experiences that you do have about how we're not focusing on only a medical assessment here.

Ms McGurn: I can speak for the program that I work in. I happen to have started an orientation group this morning. Our policy and procedure manual is probably your first reassurance.

If a client is referred to the program, be it through their family physician with a medical referral or by a simple telephone call, family calling in wanting to know about services, if it's hard to get a handle on over the phone, our front-line defence is to send a case manager in to see that client. If we get in there and their need is not medically related, we don't go, "I'm sorry, our services aren't for you," and walk out the door. Right included in our policy manual is that a front-line responsibility of the case manager is to explore both the physical, emotional, social and recreational situations of that client, not just in isolation, but in the context of their family, their friends and their neighbourhood, because as we know, many of the communities we service offer different supports.

Our job if they're not eligible for service is to help them link with the appropriate services. For some consumers, that means simply providing them with the information. For other consumers it's walking with them through the corridors that take them to those services. Our job is not simply to determine eligibility of the ministry criteria for home care.

The Chair: We're caught in the time bind, but I want to thank you very much for coming before the committee and again for the quilt that you have left with us.

Mrs Sullivan: I wonder if we could ask the parliamentary assistant if the government has considered the argument of the case managers. We've indicated that we would put forward an amendment to include case management as a professional service. The government said that it was going to think about that. I wonder what its conclusion was.

The Chair: Briefly if we could, because we are well behind time.

Mr Wessenger: I certainly think the position that was put forward was that the case management function is defined in, I believe, section 20 of the bill. Therefore, that function was clearly set out in the act, and it certainly is considered a key aspect of the long-term care system.


The Chair: I call on the Canadian Red Cross Society, Ottawa branch. And to give hope to the Senior Citizens' Consumer Alliance for Long-Term Care Reform, we're almost with you.

Welcome to the committee. I again apologize. It is late in the day, but we appreciate very much that you have stayed with us and are here.

Ms Jane Levoy: I should indicate that Vera Lee Nelson, one of our senior volunteers, was to do the presentation. Vera Lee is a long-distance care giver and has had an emergency with one of her parents and has had to fly out to provide some assistance, so you're going to have to put up with me. I do ask you to bear with us. My name is Jane Levoy and I'm the manager for the homemaker service for Renfrew North.

I would like to introduce Madeleine Germain-Kennedy, who is from the Cornwall area and will be speaking after I complete my portion. I know it's been a long day, and maybe we can look on this as a benefit because you don't have to listen to the portion that Vera Lee was going to do. You have it in writing, and I really couldn't do it justice. So you get a break late in the day.

The Ottawa-Carleton branch of the Red Cross is one of the oldest branches of the society in Canada. This year it celebrates its 80th birthday, and we're proud to have provided services to our community since the early 1900s. Until 1914 we actually weren't the Canadian Red Cross, but rather provided services under the British Red Cross, and an act in Parliament then created the Canadian Red Cross. We do get acts through once in a while.

The eastern region of the Ontario division of Red Cross consists of 12 branches, and geographically the area that we provide services in is bounded by the Ottawa River and the St Lawrence River on the north and south, Algonquin Park to the west and the Quebec border on the east.

The Red Cross provides services in both official languages. The area of Prescott-Russell is one of the largest areas of French-language concentration in the province. We also provide service to the largest Polish population outside of Poland and we do provide services in Polish in that area as well. Red Cross provides services to the Algonquin first nations at Golden Lake and to the Mohawk Council at Akwesasne. Examples of services that we provide to these first nation people are homemaking and train-the-trainer components for child care and first aid, and emergency support is provided to a residence for seniors. Where possible, we recruit staff from the communities in which we provide service and therefore try very hard to reflect the language and cultural needs of these communities.

Red Cross is an integral part of all of our communities. We have a long history of compassionate, effective and efficient services throughout the world. We always respond when possible and when help is needed.

Local Red Cross support services include a variety of home support programs and homemaking services.


For the purposes of this presentation, we would like to concentrate on the statistical information for the areas that we specifically serve in this part of eastern Ontario, which include Renfrew county, Ottawa-Carleton and the five most eastern counties. These community services are provided through the efforts of over 1,300 volunteers and 600 staff, and the vast majority of these volunteers and staff are women and trained home support workers or homemakers.

Madeleine, maybe you would like to briefly describe some of the implications of the reform.

Mme Madeleine Germain-Kennedy : Merci, Jane. Monsieur le Président, distingués membres du comité, maintenant c'est à mon tour de vous adresser la parole dans la langue de Molière.

Mon nom est Madeleine Germain-Kennedy. Je dois vous dire que je suis très familière avec la Croix-Rouge de Cornwall et la région ainsi qu'avec les services qu'elle offre.

Ayant été très impliquée dans la communauté à Cornwall et les environs, à titre de bénévole, professeure, membre de divers comités hospitaliers, journaliste, reporter, commentatrice à la radio française, et j'en passe pour le moment, j'ai très souvent eu du contact avec la Croix-Rouge de Cornwall. Je parle donc en connaissance de cause. De plus, en 1985, j'ai appris que je souffrais de la sclérose en plaques, aussi connue sous SP, ou MS en anglais, multiple sclerosis. Mon médecin m'a donc référée à la Croix-Rouge de Cornwall afin d'obtenir les services d'une auxiliaire familiale.

J'ai été des plus fortunés d'avoir à mon domicile les services compétents et fiables d'une auxiliaire familiale de la Croix-Rouge alors que ma santé était des plus fébriles à ce moment-là. Quel avantage d'avoir dans son domicile une telle perle, une perle de la Croix-Rouge. Au cours des prochaines minutes, je vais vous offrir quelques commentaires sur la réforme.

La division de l'Ontario de la Société canadienne de la Croix-Rouge appuie les efforts du gouvernement dans sa réforme des soins de longue durée. Nous soutenons vivement les principes et buts décrits dans Partenariats dans les soins de longue durée : Un nouveau moyen de planifier, d'administrer et d'offrir des services et du soutien communautaire. Ces principes et objectifs ont été identifiés lors d'une consultation de grande envergure avec des participants clés, processus auquel la Croix-Rouge était fière de participer.

Cependant, quelques sections de l'ébauche du projet de loi 173, une loi concernant les soins de longue durée, ne reflètent pas les principes formulés et qui nous affectent. Nous croyons vivement que cette loi doit être une loi évolutive et non normative. Une loi évolutive pourra être adaptée dans un avenir lointain. Lorsqu'une législation contient trop de détails, elle devient rigide. La législation doit être plutôt flexible si elle veut résister aux changements rapides des soins de longue durée et si elle veut permettre aux fournisseurs de services de répondre aux besoins changeants de leur communauté. Une loi évolutive est essentielle si tous les partenaires impliqués dans les soins communautaires de longue durée sont prêts à mettre sur pied de nouvelles structures et des processus innovateurs qui déboucheront sur une véritable collaboration et une chaîne de services efficacement fournis.

De plus, nous recommandons que la législation respecte les principes et les traditions des agences bénévoles qui offrent des services communautaires de soins de longue durée. Ces agences sont bien enracinées dans leur communauté. Un grand nombre de services offerts ont été développés en réponse à des soins uniques de la communauté. Ces services ont été mis sur pied par des membres dévoués et aussi visionnaires qui ont choisi de donner de leur temps et de leur argent pour répondre aux besoins de leur communauté. Il serait donc impossible d'en évaluer le nombre d'heures.

On réfère souvent aux lettres OSP. Ces trois lettres veulent donc dire organisme de services polyvalents. La législation telle que présentement élaborée empêche la Croix-Rouge, ses régions, ses sections ou encore ses programmes de devenir un OSP ou de fournir des services comme membre d'un OSP. Malgré cela, la Croix-Rouge s'est engagée, sur la base de services développée au cours des 75 derniers ans, à subvenir aux besoins des personnes les plus vulnérables dans notre communauté.

La division de l'Ontario de la Société canadienne de la Croix-Rouge n'est pas une organisation distincte de cette dernière, mais est une partie intégrante de cette entité corporative nationale qu'est la Société canadienne de la Croix-Rouge. Celle-ci se greffe, à son tour, au Mouvement international de la Croix-Rouge et du Croissant Rouge. La Croix-Rouge a, derrière elle, une longue histoire de services mondiaux efficaces.

Et remarquez bien : il ne peut y avoir qu'une seule Société de la Croix-Rouge dans un même pays. Nous travaillons selon les règlements établis par la Société. Ces règlements décrivent les structures de commandement et les structures organisationnelles et définissent nos champs d'opérations. La Société est donc coiffée d'un seul conseil d'administration qui est le grand responsable de l'ensemble des directives et des opérations de toutes les composantes de la Société. On ne peut accepter d'entente ou de consensus qui pourrait diminuer l'autorité du conseil de la Société ou même affaiblir ses principes fondamentaux, particulièrement l'indépendance et l'unité.

La législation requiert que chaque OSP soit incorporé sous la loi des corporations de l'Ontario ou la loi des corporations coopératives de l'Ontario. Chaque OSP doit avoir son propre conseil d'administration choisi en fonction de la loi. Ces prérequis sont incompatibles avec les principes fondamentaux et la structure corporative de la Société de la Croix-Rouge.

Je vous remercie de votre attention. Maintenant, pour le mot de la fin, cette fois dans la langue de Shakespeare, de retour à Jane.

Ms Levoy: I'd like to make some specific comments on Bill 173. There are several issues that are of particular interest or concern to us that we would like to highlight in this presentation.

The Red Cross recommends that three sections of the legislation be amended. Our specific recommendations have been previously described to the standing committee. We believe that these amendments would in no way adversely affect the purposes of the act. Rather, they would enhance flexibility and allow communities to build on the existing strengths of the system.

Our first concern is that the bill describes four categories of service and specifically delineates the services that fall under each category. The basic premise underlying the breakdown appears to be the 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 practices and the emerging future trends. This program is intended to produce a worker trained to take on a role that goes beyond the current role of the homemaker. A curriculum is close to being finalized and at one point it was expected that the program would be introduced this year.

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. Many functions routinely provided by homemakers cross the boundaries between what the legislation classifies as homemaker and what's called personal support.

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


Our second concern is that the bill stipulates 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 the lack of coordination and poor access.

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 the community. Stable relationships have been developed between provider agencies, care givers and the individuals they serve. Let's learn from our experiences and work to fix the shortcomings of the existing system rather than jump into a totally new and totally unproven system.

In many communities, services are provided by several provider agencies. Each agency must retain a critical volume of service to remain economically viable. If the volume of services falls below this critical volume, the agency will not be able to stay in business. The Red Cross is very concerned that the legislation may result in waiting lists, a decline in the quality of service or limited or no choice of services. Those clients who wish to purchase services outside of the MSA system will be unable to do so if there are no alternative providers remaining in the community.

In many areas of the region it is very expensive to provide services. The entire region experiences an ongoing deficit, primarily due to the high cost of getting homemakers to the homes of those clients who live in remote areas. In some communities the Red Cross is the sole provider of services, and I know that in Renfrew county we have two areas where the Red Cross is the sole provider of service. In all of Renfrew county, for example, the population density is 11 people per square kilometre, with our largest serving centre being Pembroke, and it has a population under 13,000. One of our communities, Bissett Creek, enhances another problem. All of the people who live in that community are retired. It's difficult to hire employees in isolated communities when everyone's retired.

Given the factors we have just described, and combined with an inequitable bill rate for services, Red Cross depends on its province-wide structure to give it the flexibility to fund services in many areas where deficits are the norm, and the deficit in eastern Ontario for homemaking services likely will approach $700,000 to those members of our communities who may not get services through Red Cross if we weren't being funded from other programs within the province in Red Cross.

Our third concern is that the legislation says that MSAs have just four years to comply with all the provisions of the act. Under tight strictures of this draft legislation, communities will not have the flexibility to identify and implement the models of service delivery that suit their needs best. Red Cross is a volunteer-based organization. Our wide range of programs and services provide volunteers with diverse backgrounds and interests, with a variety of meaningful opportunities to participate in the work of the society. Our quality service comes from the partnership between volunteers and staff who are committed to our vision, the mission and our fundamental principles.

We're also concerned because we believe that the creation of an MSA will impact severely on our volunteerism. MSAs could be perceived as very impersonal agencies that many will continue to perceive as quasi-governmental. The fellowship and sense of community contribution that motivate most volunteers often depend on local agencies which have a long, well-established tradition and that provide a sense of companionship and responsiveness to local needs. We feel the legislation will have a very damaging impact on the role of the 1,300 volunteers within the eastern region of Red Cross.

We are very concerned about the enormity of the impact of this legislation if it has not been fully explained to consumers. Government speaks of expanding services to underserviced areas, yet there will be few additional resources made available. 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 legislation must permit agencies such as the Red Cross to continue to provide necessary services to the residents of the province. However, if the legislation is to be proclaimed without the amendment, the Red Cross and many similar agencies will be forced out of business. If this is to be the case, then the government has an obligation to inform the public.

Thank you very much for the opportunity to address you.

The Chair: Thank you very much. I'm sorry, because of the hour, we are not going to be able to move into questions because we do have another presenter. We have to start again at 7 o'clock and I want to make sure these folks are still going to be awake.

I could just say that we have, as you know, had presentations from a number of the Red Cross societies and, as you indicated, the specific recommendations the committee is aware of, and we thank you for those. I think I should say too, on behalf of all of those who are trying to improve their French, that we really appreciated the way in which you presented that part of the submission. I think everybody felt, "Aha, I'm really making progress." Alors, merci beaucoup.

Mme Germain-Kennedy : Ça m'a fait plaisir.

The Chair: Thank you both again for coming before the committee.


The Chair: I call on the Senior Citizens' Consumer Alliance for Long-Term Care Reform, Ottawa branch. Mr Hanmer, you've been very faithful at the back and we do welcome you and appreciate that you've taken the time to prepare the submission and come before us.

Mr Bert Hanmer: Mr Chairman, ladies and gentlemen, there's an old saw which says, "The head can absorb just as much as the seat can stand." I hope your seats can stand a little more.

My name is Bert Hanmer, a resident of Ottawa-Carleton for 43 years. Since I retired in 1980, on reaching statutory retirement age, I have worked as a senior volunteer in various programs and projects locally, provincially and nationally.

I think a word of explanation is desirable at this point. I find myself faced with a somewhat anomalous position in that I was asked to submit a supplementary brief to the main brief of the alliance before the main brief itself had been presented. It's to come up on Thursday.

Ms Gigantes: It's called an appetizer.

Mr Hanmer: That's right. I have therefore decided to put forward a number of issues which have been the subject of discussion among seniors in this community as far as MSAs are concerned. So much by way of explanation.

I have kept in touch with developments in long-term care for many years under successive Conservative, Liberal and NDP provincial governments. The formation of the Senior Citizens' Consumer Alliance for Long-Term Care Reform was a really progressive step in tackling this issue which is so important to seniors. Three major provincial groups came together in 1991 to form the alliance. Collectively, they represent approximately one million individuals. They have held lengthy public hearings, held policy conferences bringing consumers, providers and government officials together, and have compiled two substantial volumes on LTC reform that were distributed province-wide. As I indicated earlier, they'll be presenting the main brief on Thursday in Toronto.

As a senior citizen of long standing and a member of the United Senior Citizens of Ontario, I support the alliance's endorsement of the multiservice agency concept. It is an efficient and effective way of organizing community care.

I will try not to pre-empt what Mrs Jane Leitch, the alliance's chairman, may say on Thursday. I will therefore deal with comments, as I mentioned earlier, that have been raised by senior consumers in this area.

Concern and apprehension: These are testing times for senior citizens. There have been cuts in the scope of the drug program; the property tax grant has been revamped; the government of Canada introduced the clawback of old age security and amended the Income Tax Act as it affects the age credit. If we are to believe the media, extensive changes affecting eligibility to the old age security pension are in the offing. There is concern and apprehension as to what the future holds.

Change is worrisome to many people, particularly the aged sector of our population, and at the moment long-term care poses a new potential source of worry. Much of this concern arises from a lack of knowledge about the true nature of MSAs. Seniors simply do not know what it's all about. The situation is aggravated by individuals who, for reasons of their own, would prefer the status quo and who portray the proposed reform in negative terms.


It has also been suggested to me that the present is not the time to try out what is described as a radically new approach. This is nonsense. The province of Quebec has had in operation what are known as CLSCs, Centre local de services communautaires, for about 20 years. Though not identical to the proposed MSAs, they're very similar. Inquiries reveal that though there were a few teething troubles in the early days, CLSCs have been a valuable part of care in Quebec for years. The system is based on one which proved itself in Switzerland.

Initially, CLSCs did not operate on weekends, but a seven-day-a-week operation was found to be essential. This question may well be important in the planning of the MSA program. Lack of Saturday and Sunday service is a problem which currently exists. It should be remedied when MSAs are established, even though it would clearly add to the cost.

A comprehensive education and information program is essential so that seniors and others may be reassured that the proposed new service is one of proven value and not just an experimental project.

Volunteers: A great many devoted senior volunteers are involved in community support programs for their peers and for persons who are not seniors. Concern has been expressed that the introduction of MSAs would result in reduced participation by volunteers in community care programs. The seniors' consumer alliance disagrees with this view, and I concur, bearing in mind the high degree of community participation inherent in the MSA proposals. One step that might reassure volunteers that their involvement in the task of their choice will continue would be to ensure their inclusion, together with consumers, on MSA boards.

In the same vein, fund-raisers, many of whom are senior volunteers, are concerned that the establishment of MSAs may inhibit their fund-raising efforts in the future. I do not believe that this will happen. Again, a process of educating those involved will allay concerns.

Steps should also be taken in those communities where the United Way is established to ensure the fullest degree of liaison with that fund-raising organization.

Amendments to the Health Insurance Act: The seniors' consumer alliance has expressed satisfaction that the home care program, through a provision in Bill 173 to amend the Health Insurance Act, will become part of MSAs. A less satisfactory aspect of the proposed legislation is that a client of a home care program will not be automatically covered by OHIP under Bill 173. This is because eligibility criteria will be defined in the regulations. Failure to guarantee protection in the act will seriously undermine efforts to promote care in the home as against care in an institution.

Funding: One of the primary objectives of long-term care reform is the integration of a range of community services. Another is to provide assurance that local needs can best be met by a substantial element of local autonomy. The alliance believes that there should be global funding of MSAs. Without such funding, it will not be possible to achieve a truly seamless system of community services.

I might interject here that I had an experience a few years ago in the province of Manitoba, where I was spending a little time, to look into the global funding of certain large community projects providing housing, hostel care, nursing home care and a very large day centre providing home care and with an extension to the community. They had, the year before, been put on a global budget, and it was proving to be tremendously advantageous to them because if they were up here and down there, they could make the adjustments without having in every case to refer back to the original funder.

For example, if an MSA had a waiting list for some services and a lack of demand in others, the board must be able to transfer dollars from one program to another. If the draft legislation does not change, global funding may be impossible. For example, the 20% limit on the purchase of service from independent service providers would negate, in some situations, the ability of an MSA board to take full advantage of global or per capita funding.

Limits on the purchase of service: There is another aspect of the 20% limit on the purchase of service. It is that in communities such as Ottawa-Carleton, where the level of services is already high compared to some other areas, the limitation may well disrupt achieved levels of service. The inclusion of recreational and other like services could further exacerbate the problem. There would appear to be a strong case for greater flexibility in this regard.

As indicated at the outset, this presentation does not purport to refer to all important issues of concern to senior consumers. The seniors' consumer alliance brief will deal with many of these. Today's submission is intended to demonstrate that the alliance has support in this part of Ontario. We also believe that we can offer comment, for example our reference to the Quebec system, which may make a small contribution to LTC reform and result in action to reassure senior citizens as to the future.

Thank you for the opportunity to appear before you.

The Chair: I think it's appropriate that the last witness this afternoon should be someone who is a consumer and a senior. We thank you very much for the comments you've raised here which will no doubt help us when we meet with the alliance in Toronto on Thursday.

Members of the committee, we stand adjourned until 7 o'clock sharp.

The committee recessed from 1757 to 1902.


The Chair: We'll start this evening's presentations, of which we have four. The first presenters are representing the Ontario Community Support Association, area 10. Welcome to the committee. We are refreshed, and glad you could come before us. We have a copy of your submission, so if you'd just introduce yourselves, please go ahead.

Ms Janet Snyder: Good evening. I'm Janet Snyder, and with me this evening are Ann Hargest of the Visiting Homemakers Association of Ottawa-Carleton, and Nancy Wilson of Good Companions Seniors Centre in Ottawa.

We are here to represent the concerns of the 51 member agencies of area 10 of the Ontario Community Support Association. This area coincides with that of the long-term care area planning office and includes Renfrew, the regional municipality of Ottawa-Carleton, and the five counties of Prescott, Russell, Stormont, Dundas and Glengarry.

We realize that you have already heard the Ontario Community Support Association response to Bill 173 and have received its written submission. This presentation will not repeat that provincial response but will focus on area 10 concerns.

The agencies we represent deliver services to the frail elderly, persons with a disability, and those convalescing from an illness. The services provided assist individuals to live independently and maintain their health at home.

Area 10 member agencies provide services in both rural and urban settings. Services are provided by bilingual and by francophone agencies in many regions. Partnerships with several ethnic communities have been formed to assist them in providing culturally appropriate services.

Community support agencies are volunteer-driven and supported by staff. Most community support services, with the exception of homemaking, have a large number of volunteers with a small number of staff managing the programs.

The staff working in community support services come from a variety of backgrounds, thus providing a multidisciplinary approach to service delivery and management. For example, in Ottawa-Carleton, program directors include representatives from the fields of social work, nursing, recreation, teaching, dietetics and law.

The services, which were developed in response to individual community needs, differ from agency to agency. This difference is a major strength because it reflects the specific needs of each community.

Today we would like to concentrate on three particular concerns with regard to Bill 173: first, categories of service; second, volunteerism; and third, specific aspects of multiservice agencies.

Under categories of service, it is recommended that:

(1) Community support services, homemaking, personal support services and professional services be combined into a continuum of care. This approach will foster true integration of social and health services.

(2) Provision be made in the legislation to recognize the importance of the role of respite care services.

The concept of the continuum of care is fundamental to the provision of services enabling an individual, couple or family to remain at home as independently as possible despite chronic illness, disability or frailty.

The artificial distinction made separating out four types of service -- community support services, homemaking, personal support services and professional support services -- ignores, with potentially dangerous consequences, the principle of a flexible continuum of care designed to provide the least intrusive and most cost-effective service.

These distinctions indicate more status for the medical treatment end of the spectrum. The danger is in the emphasis on sickness, not health. We need integration of social and health services, not the separation of the services which are less costly yet immensely effective at keeping people at home even when frail.

The purpose of the long-term care reform as we understand it is to encourage healthy lifestyles and to extend the time where independent living at home is possible with the least cost to the community and the most choice to the consumer. Community services may no longer be available if not nurtured by the system.

The separation between homemaking and personal support services is particularly inappropriate, as it runs contrary to the recently developed personal support worker course. This course, spearheaded by the long-term care division and supported by the Ontario Community Support Association as well as the Ministry of Colleges and Universities and the Ministry of Skills Development, is designed to produce a generic worker who combines the skills of homemaking and personal care. The purpose is to have only one worker in the home who could provide the range of services needed, from light housekeeping to meal preparation to personal care such as baths and personal grooming.

Respite care: It is in respite care that the artificial nature of this distinction is most obvious. One worker, during the absence of the care giver, provides the full range of care for the individual at home, especially during periods of 12 hours or more. Services required range from preparing and serving meals to looking after the home to personal care, including feeding, bathing and dressing, as well as emotional support and reassurance, especially in the case of the cognitively impaired. There can be no distinction in the range of services required to provide for the safety and comfort of the individual, to say nothing of the peace of mind of the care giver.


The second concern is with volunteerism.

It is recommended that volunteer management in regulation 11 be expanded to require the development and implementation of a plan for the recruitment, training, scheduling, supervision, retention, recognition and expense reimbursement of volunteers.

There are two key elements to the issue of volunteerism. The first is the service the volunteers provide, and the second is the resources volunteers contribute.

The services volunteers provide: Volunteerism is an essential component in the delivery of the community-based services. If volunteers did not provide the services, either the services would not be available or costs would increase should paid staff be required to assume the role of volunteers.

Each day throughout our communities volunteers go to work willingly, with a commitment to their clients, to the services they deliver and to the agencies with which they work. The biggest snowstorm of the season doesn't stop the volunteers. Last year during a storm that closed Ottawa schools, the Meals on Wheels volunteers delivered over 500 meals to Ottawa residents. Only four clients were missed. There is no paycheque and no benefit plan to be managed. The volunteers work for many reasons, but the outcome is always the same: a stronger community.

The benefit of the services provided by the volunteers is felt by the clients, by their families and by the professionals who work with them. Volunteers also benefit from the program. Volunteer management researcher Linda Graff, in her publication Volunteer for the Health of It, published by Volunteer Ontario Publications, documents the positive impact of volunteering on the health of the individual. Community support agencies facilitate this volunteer process. The same individual may be a client in one context and then take on the role of a volunteer in another. That individual at the end of the day has a feeling of self-worth, of having contributed to the community.

The resources volunteers contribute: In addition to service delivery, volunteers serve in many other roles. They bring their professional skills and experience to the governance of the agencies and to fund-raising and public relations programs. The donation of these skills to the agencies does not show on the expenditure side of the balance sheet but has a significant impact on the revenue side. Volunteers, as individuals, are regular donors to their programs. As well, they bring to the agencies support from the corporations, community groups and service clubs with which they are associated.

Loss of volunteer support will result in loss of funds coming into the system. The impact of the loss of goodwill provided by the volunteers will be translated directly into a loss of dollars to the long-term care system. It will also result in a significant loss in direct contact with the community and a loss of new volunteers. Volunteers are an excellent source of new volunteers for the agencies.

Whatever changes are made to the system, volunteers must be retained both for the services they provide and for the resources they contribute to the system.

Our third concern relates to specific aspects of multiservice agencies.

It is recommended that (1) the limit on services purchased in subsection 13(2) be eliminated in order to allow continued structural flexibility in the individual community planning process; (2) an exception be made to subsection 12(2) to provide for the option of individual consumer control over attendant care programs, thus maximizing independence and choice.

It is essential that there be sufficient flexibility to allow each community to develop an MSA system that builds on its strengths. It is not necessary, and may not even be desirable, for all services and care providers to be assembled under one roof and for consumers to have only one point of contact in the community. A functional integration of information, referral, assessment, case management, service delivery and follow-up in multiple locations may be what is required to develop a cohesive, integrated service.

Improved coordination and access to available services are highly desirable. Close coordination will be needed if there is more than one point of contact in a community. Communication among the providers is the key.

Continuity of service delivery must be maintained for clients, for the workers and for the volunteers. Agencies must maintain a viable volume of service delivery during the transition.

There is the concern that the limit of purchase of service by service category to 20% will force the amalgamation of agencies. Again it needs to be stressed that the legislation must allow local planning and maintenance of agency identity in some way that will ensure continued volunteer support.

The act must ensure that services are planned, delivered and evaluated from an integrated social service and health 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 one that produces flexible service along a continuum of care.

Concerning attendant care, choice is critical for attendant care programs. Visiting Homemakers Association of Ottawa-Carleton administers the attendant care program for the Ottawa-Carleton region. They are aware at first hand of the need for an individual receiving services to choose who will provide the care and whether the individual wishes to direct his or her own care by direct funding.

Currently, they are conducting surveys to determine the wishes of the people receiving services through the attendant care program as to whether they wish their services to be outside an MSA or within it. It is strongly recommended that their choices be respected. This will require that flexibility be built into the access to the system.

In conclusion, we feel that these three issues, as well as those presented to you by other members of the Ontario Community Support Association, are representative of our concerns with Bill 173.

Our recommendations are that:

(1) Community support services, homemaking, personal support services and professional services be combined into a continuum of care. This approach will foster true integration of social and health services.

(2) Provision be made in the legislation to recognize the importance of the role of respite care services.

(3) Volunteer management in regulation 11 be expanded to require the development and implementation of a plan for the recruitment, training, scheduling, supervision, retention, recognition, and expense reimbursement of the volunteers.

(4) The limit on services purchased in subsection 13(2) be eliminated in order to allow continued structural flexibility in the individual community planning process.

(5) An exception be made to subsection 12(2) to provide for the option of individual consumer control over attendant care programs, thus maximizing independence and choice.

We appreciate the commitment of the provincial government to building partnerships with the community to plan and implement meaningful change, and the opportunity to express our concerns to the standing committee tonight. Thank you.

Mrs Sullivan: Thank you very much for a comprehensive brief. I think we'll all take note in particular of your recommendation with respect to attendant care programs, which have not been emphasized through the hearings to this point.

Your organizations would have participated in the consultative process with respect to long-term care reform. I'm interested in knowing if, in your view, people who appeared before the consultative committees and who participated in those hearings ever contemplated the kind of legislation that would be before us today.

Ms Snyder: It's very difficult to know what they were contemplating as they were listening to us. I know, as staff of the agencies and speaking to board members, they have been interested to watch the development and gradually understand the implications of the legislation. It certainly wasn't evident right at the outset.

Mrs Sullivan: Certainly, during those hearings and during that consultative process, the emphasis, it seems to me, was on a coordinated access, increased streamlining of the access to services to ensure that people didn't have to go through six or seven assessments but were dealt with in one way. But there was no demand or no clear cries, as far as I could tell, for a multiservice agency that was a monopoly and that put services like your own out of business. Did you see any of that? Did you see a call for the kind of approach that's being put forward in this bill?

Ms Ann Hargest: The philosophy that was put forward in the government documents indicated the importance of consumer-driven program with client choice, with service delivery being close to the people you are actually serving. This, to me, is extremely important. Certainly our agency, and I know others, felt that if these kinds of principles could be imbued in a system, we would be prepared to support it 100%. However, if we don't see that happening, perhaps the loss of identity of an agency becomes very important, because the number one thing -- client service -- is not going to be there.

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



The Chair: I call the next group. On your sheet it says the Ottawa-Carleton CUPE district council, but it's actually the Health Care Unions of Ottawa-Carleton, which represents a number of different organized labour groups. Welcome to the committee.

Ms Betty Sommers: My name is Betty Sommers and I'm the chairperson of the Health Care Unions of Ottawa-Carleton. Charlene Avon is from CUPE.

The Health Care Unions of Ottawa-Carleton represent members from the Canadian Union of Public Employees, the Ontario Public Service Employees Union, the service employees' union, allied and professional health employees' group, the Independent Canadian Transit Union and the Ontario Nurses' Association.

Through the Health Care Unions of Ottawa-Carleton, health care workers can fight for a say in how health care can be restructured locally. This group also provides support for our labour representative to the district health council and it ensures some accountability of those labour representatives to the labour community. We must organize a fight against steps to undermine the proper role of district health councils. The voice of labour will be heard.

Through the Health Care Unions of Ottawa-Carleton, health care workers can monitor the level of health services being provided in our community and we can alert the public to decisions by health care administrators which will reduce the quality of care in our community. We are the glue which is holding an ailing system together. The Health Care Unions of Ottawa-Carleton recognizes the need to restructure the delivery of long-term care in the province of Ontario. Our concerns have been formulated into the following recommendations which we make to this committee.

Governance: Who should be represented on boards of multiservice agencies and district health councils, how they get selected and disclosure requirements: We believe that the bill's provisions in this area are extremely inadequate.


(1) Section 11 of the bill should be amended to provide for a mix of appointed and elected representatives, based on the Quebec model for CLSCs and other health and social service facilities. This section should also be expanded to detail the procedures boards must follow to ensure openness and to spell out that financial and other operational documents should be readily available to the public.

(2) Section 17 of the bill prohibiting employees from being directors of agencies should be deleted.

(3) The standing committee on social development should urge the government to accept labour's position that labour should be able to nominate the labour names to district health councils through a joint Ontario Federation of Labour-Ontario Nurses' Association nominating committee. Bill 173 should be amended to provide that four labour appointees -- two labour consumers, two labour providers -- be represented on each district health council.

(4) Bill 173 should be amended to ensure that board members of multiservice agencies and district health councils be remunerated for any lost wages and expenses they incur in order to attend meetings.

Direct provision of services: Bill 173 weakens the government's earlier commitment to having multiservice agencies directly provide services.


(1) Bill 173 should limit the purchase of services to a maximum of -- we're not sure, zero, 5%, 10% of multiservice agency budgets for community support services, homemaking services, personal support services and professional services.

(2) Bill 173 should enshrine the preference for non-profit agencies and stipulate that where services are available from non-profit agencies, the MSA should provide such agencies with the opportunity to provide such service prior to purchasing them from a for-profit agency.

(3) Clauses 13(3)(b) and (c) should be deleted. These are the provisions which create exceptions to the rules governing maximum limits for the purchase of service where the purchase is in connection with short-term absences of employees due to illness, vacation or any other unplanned event, or where the service provider is a self-employed individual.

Consumer rights: While the bill provides for an appeal process for a review of agency decisions to deny persons a particular service, there is no guarantee under the bill of a person's right to necessary care.


(1) Bill 173 should enshrine the right of persons to any professional personal support, homemaking, and community support services which are necessary to enable them to live independently in their own home and in other community settings in dignity and with security.

(2) Bill 173 should clarify which agencies are responsible for providing professional personal support, homemaking, and other community support to persons who have been discharged from a hospital and who are in need of such services.

Designation of multiservice agencies: The bill's provisions contain a very strong bias against municipalities and public health units being designed as multiservice agencies. We do not agree with this approach.


(1) Delete subsection 11(3), which makes municipalities and boards of health multiservice agencies "of last resort," from Bill 173.

Employee liability and protection: Provisions of the bill hold agency employees liable if they knowingly concur with the commitment of an offence under the act without providing them with whistleblowing and other protections.


Bill 173 should be amended to provide employees with protection against refusing a direct order of their superiors to violate the act, as well as whistleblowing protection in circumstances where employees go public with information about offences under the act.

Quality management improvement: A number of provisions in the bill deal with employer quality management improvement programs, yet these programs are exempt from inspections.


(1) Subsection 52(1) of the bill, which exempts records dealing with quality management activities or quality improvement activities from the inspection provisions of the act, should be amended to delete these exemptions.

Volunteers: Bill 173 contemplates regulations requiring MSAs to develop and implement a plan for recruiting and using the services of volunteers. We do not believe that the shift to community care should involve exploiting the unpaid labour of family care givers and friends, nor do we endorse volunteers performing the services currently provided by our members.


(1) Section 20 of the bill, which provides for the development of a plan of service, should clarify that eligibility for in-home community services provided by approved agencies should be based on individual entitlement and should not be withheld or restricted on the basis that there is an unpaid care giver at home who is assumed to be able to perform those services on the person's behalf.

(2) Subsection 56(11) of the bill should be amended to clarify that any plan for the use of volunteers should be restricted to activities not usually performed by members of bargaining units of unions which represent health and social service workers.


User fees: The bill does not indicate which homemaking or community support services will be subject to user fees. There should be full public debate around which services multiservice and other agencies providing community services should be provided free of charge and which should be subject to user fees.


(1) The standing committee on social development should urge the government to make a commitment that before any regulations are made which permit the charging of user fees for homemaking or community support services, a discussion paper on the subject will be released and further public consultations should be conducted.

(2) Subsection 26(2) of the bill, which allows a contracted service provider to collect user fees from a recipient of a service, should be deleted.

Fair wages and employment security: The government has failed to adequately meet the needs and concerns of workers who will be displaced as a result of health care restructuring in general and the consolidation of services under the authority of MSAs in particular. There are no provisions in Bill 173 to ensure that MSA employees will be entitled to similar wages and working conditions, nor are there provisions to ensure that wages and benefits of community-based health care workers are comparable to the wages and benefits of other health care workers.


(1) The standing committee on social development should urge the government to ensure that multiservice and other community-based agencies should be adequately funded to provide high-quality services and pay and benefits which are comparable to the level which exists in the municipal and institutional care sectors.

(2) The standing committee on social development should urge the government to initiate a process for a province-wide employment security agreement which provides the framework for an effective and enforceable redeployment system to be administered by HSTAP to ensure that workers who are displaced by health care restructuring are placed in comparable pay and benefits in other parts of the health care system.

Mr Sterling: I'm flabbergasted at your remarks about volunteers. Number one, do you not understand that family members and community members want to help their brethren in a time of sickness or in a time of need and they don't want to be paid? Do you think we should deny them that right to help their family and friends?

Ms Sommers: I'm not saying that they should be denied, but they shouldn't be forced to be in that kind of a situation either.

Mr Sterling: Do you think they're forced?

Ms Sommers: I see it in this bill --

Mr Sterling: How are volunteers forced? How are volunteers forced to volunteer?

Ms Sommers: If there's nobody else there to do it.

Ms Charlene Avon: There are ways that they are forced into it. This is a society which is very proactive with two people working in it to keep the standard of living that's going. If you put barriers up where one person has to stay at home and take care of it, whether they want to or not -- I may well want to stay home and take care of someone.

I may well not be able to afford it. I may well have to get out and support the family. Then you're putting barriers up to those people. Then there should be other options. There are options and opportunities for people to stay home, and well be it; great. We're not saying that they shouldn't. We're saying --

Mr Sterling: But if we take the premise that we're operating at a deficit in this province of approximately $8 billion to $10 billion a year and there isn't any more money, would you rather have a volunteer providing the service or would you rather have nobody providing the service?

Ms Avon: I want to know where you're going to get the volunteers, first of all, because as a health care worker and now as a person --

Mr Sterling: No, no, no. Answer my question.

Ms Avon: I'm going to answer your question.

Mr Sterling: Where are we going to get the money?

The Chair: Order, please.

Mr Sterling: No, no. I mean, I'm asking a question.

The Chair: I know, that's fine, but just let her answer --


The Chair: Order, please. Order. Mr Sterling, order, please.


The Chair: Mr Martin, please. Order, please. The witness is trying to answer the question, and I would ask that everyone give her the time to do that.

Mr Sterling: It's ridiculous. It's a disgrace to our volunteers.

The Chair: Please go ahead.

Ms Avon: We have no disgrace to the volunteers. What we are trying to say is that -- and what I am trying to say is as a health care worker who worked in the system for 10 years before I became a staff member for CUPE, I can relate to health care and to the giving of the health care services.

What I'm saying is, there are volunteers out there, as we all well knew, with the biggest hearts and the best of intentions who have no idea of how you address or treat someone with diabetes, someone who should be eating properly. We have and I have known of cases where people have gone in and with every good intention have cut Grandma Somebody or Other's or Grandpa Somebody or Other's toenails, caused that toenail to bleed, break into the skin and set in gangrene -- done with good intentions, but still with not the knowledge that this can happen.

They have been giving diabetics food that they shouldn't have. They have given people with special diets food they shouldn't have -- good intentions. We're not saying it's wrong, that we delete all volunteers, but be realistic about it. Look at who is giving that care.

Mr O'Connor: I would suggest that you maybe take a look at a presentation made to us from York community care. It was rather astounding that -- because I do believe that your membership is actually represented by that group -- seem to be somewhat not reflective of some of the good work that's probably being provided by those staff members.

In your last recommendation you talked about HSTAP. One of the things that we have heard by presenters is what about --

The Chair: Mr O'Connor: HSTAP, can you just identify what that is, because I'm sure for a lot of people that --

Mr O'Connor: It's the training and adjustment program, but for health services.

The Chair: Thank you, just so we all understand.

Mr O'Connor: All right. What's been suggested to us is that only the unionized personnel will be able to access this type of service. What would you suggest then as the progress evolves would be put in place for some employees who may not have the benefit of a bargaining agent there to represent -- their potential for displacement. I know that we are going to require a human resources plan, but if you would react to that which has been brought to the attention of the committee.

Ms Avon: HSTAP I think is something that's very credible that the government has put forward. Basically, it is right now for the unionized workforces. What we know -- and because I represent an awful lot of nursing homes in this area under CUPE -- is that management has the same evolution. They are bringing in human resource people to help them with their troubles that they're going through too.

There's no reason why it can't be done for non-union people or middle management. It's a partnership. What we're saying is there has to be now a playing field where we're all involved, because management are being affected, non-union are being affected, union are being affected. They all affect the people who we're here for, the patient, the care receiver, who is the basic -- otherwise none of us would be working and we wouldn't have to worry about it.

I think we have to work in partnership and look at what the model is, along the same lines as we did with pay equity, if you remember. Pay equity came in for unionized workplaces, then looked at non-union workplaces and then looked at various ways -- those are the models that are out there. I say, use them.


Mr O'Connor: It's possible it would be useful if we could request maybe somebody from HSTAP to either present something to us in a written form that we can take a look at, as suggested here, or perhaps somebody come and make a presentation to us.

The Chair: Thank you both for coming before the committee this evening; we appreciate it.


The Chair: I then call on the representative from the Addiction Research Foundation. Welcome to the committee.

Ms Christine Bois: Good evening. We're pleased to be able to have the opportunity to present this brief. Let me assure you, I will be brief. This will be about 10 minutes. You've allocated me 20.

The Addiction Research Foundation is concerned about the use of psychoactive drugs by older people in Ontario. The Addiction Research Foundation is an agency of the province of Ontario. We have a mandate to conduct research into drug use and abuse, to share knowledge, develop programs and services to benefit the people of Ontario. Over the past 20 years, the Addiction Research Foundation has been active in addressing issues related to substance use among seniors.

In our comments today, we would like to show our support for the principles that Bill 173 will introduce. But we would also like to draw your attention to the importance of addressing substance use and abuse among seniors in the provision of long-term care services.

Our concern is illustrated by a quote from a book called Old and Smart by Betty Nickerson:

"You may start out taking a pill for high blood pressure and, as a result, develop a wheeze. Instead of switching blood pressure pills, you are now prescribed a new medication for asthma, which upsets your stomach and prevents you from sleeping. To treat the stomach, you are prescribed a Tagamet, which causes mental confusion. Because of jitteriness and insomnia, valium is added, yet Tagamet increases the level of valium in the blood and makes it more toxic. What started out as a blood pressure problem winds up being diagnosed as possible senile dementia."

And of course, as we know, people with senile dementia need care, perhaps in an institution.

Let us consider some of the facts about seniors and drug use. Seniors receive proportionately more prescriptions than any other age group. They are also the least able to metabolize alcohol and other drugs because of the changes that occur as people age. This places seniors at high risk: the adverse effects of medications and of the interactions between alcohol and medications. There is a high risk also for alcohol and other drug problems being mistaken for the signs of aging.

The side-effects of sleeping pills, tranquilizers and pain medication include feeling confused, poor memory, dizziness, unsteadiness or falling, headaches, nausea, constipation, irritability and feeling jittery. That, of course, sounds like the signs of aging. When these symptoms occur over a long period of time, the side-effects can lead to isolation, conflicts with family and friends, poor eating and self neglect.

Seniors 60 and over are more likely to use tranquilizers and sleeping pills than other ages. Their use is two to three times greater than younger people.

The rates of adverse effects of drugs are significant. Also significant are the consequent use, in emergency departments and the health care system in general, by seniors who have drug-related problems.

Seniors 65 and up in Ontario are the most likely age group to drink daily -- at a rate of 17.9%.

Obviously, alcohol can be used in combination with other drugs, and this produces very serious consequences.

I have mentioned that seniors who take mood-modifying medications do not metabolize drugs and alcohol as efficiently as younger people. In addition, older adults often use multiple medications for their physical problems. Even non-psychoactive medications can interact with alcohol and other psychoactive drugs.

Concern about the adverse effects of drugs has been recorded actually in the past. Three hundred years ago, the French writer Molière wrote, "Nearly all men die of their medicines, not their diseases." I would like to paraphrase that quote to read, "Nearly all men and women die of their medicines, not their diseases."

The long-term care system is changing and now, 300 years after Molière penned his criticism of drug use, it is time also to look at how we change drug use.

Both nationally and within Ontario, a number of organizations have focused on the use of medication by older adults. For example, the inappropriate use of medication by seniors was addressed in the report of the Pharmaceutical Inquiry of Ontario known as the Lowy commission. This important issue was also considered in the work of the Canadian Coalition on Medication Use and the Elderly and the Ontario drug benefits reform secretariat.

Last fall, the Ministry of Health released a substance abuse strategy called Partners in Action, and within that strategy seniors were identified as a priority population. The provincial strategy noted that a number of initiatives should lead to better pharmacotherapy among the elderly. These initiatives include building on the work of the drug reform secretariat and the potential implementation of a drug utilization review capability. Other initiatives include developing appropriate experience and training for medical and pharmacy students, and establishing linkages with the long-term care reform process.

The provincial drug strategy also named people with disabilities as a priority population. People with disabilities often do have acute care needs. Studies have shown that they are also at risk of developing problems related to drug and alcohol use. Presently the Addiction Research Foundation has a committee working to address the needs of people with disabilities.

The work of the Addiction Research Foundation is consistent with the ministry substance abuse strategy. We are planning activities, directing research and developing resources to address these priority populations: Ontario's seniors and people with disabilities.

With respect to Bill 173, the Addiction Research Foundation agrees with and supports the following principles:

(1) That consumers and their families and care givers will benefit from a long-term care system that is more accessible, better integrated and coordinated.

(2) That the act will strengthen the mandate of district health councils by giving them a legislative framework. The Addiction Research Foundation works in collaboration with district health councils at the community level. We support their work with the community and we support the coordination of planning by district health councils.

(3) That the governance of the service at the local level includes a significant number of consumers and family members. This will help to ensure that the services are responsive to people's needs.

(4) That support services will be delivered to people in their homes and in other community settings as an alternative to institutional care.

Providing service to people in their homes is consistent with our best advice on addressing problem drug use by older adults. It is consistent also with the approach of two long-standing agencies that provide services to seniors in Ontario with substance abuse problems. The Addiction Research Foundation did play a major role in the development of these effective programs. They are the community older persons alcohol program, otherwise known as COPA, based in Toronto; and lifestyle enrichment for senior adults, or LESA, here in Ottawa.

These programs have actually provided models for program development in other parts of Canada and elsewhere in the world. The Addiction Research Foundation staff, specifically a Dr Kate Graham, was involved in the evaluation of these two programs and this has fostered the international dissemination of innovative evaluation approaches.

These two programs serve as models for addressing substance abuse problems for older adults using an approach that is holistic, coordinated and community-based. They are a client-centred program that understands the context of an older person's substance use and the consequences of that use.

(5) The development of multiservice agencies will ensure the integration and coordination and access to services. In the interests of ensuring that substance use is considered in the provision of long-term care, the Addiction Research Foundation has consulted with staff of the ministry's long-term care division about the development of the assessment instrument. This instrument, which will be used by resources managers in multiservice agencies, could fully assess substance use and its impact on the health and lifestyles of Ontarians.

We would be happy to continue to provide consultation about screening questions that will identify the use and abuse of mood-modifying drugs, including alcohol, prescription and over-the-counter drugs. We would like to help ensure that the assessment tool which is developed is sensitive to drug problems.


The Addiction Research Foundation's position is that training is important. If the assessors who identify and intervene with people are sensitive to problems related to the use of alcohol and other drugs, it will go a long way towards preventing the need for institutionalization or other more complex care with its increased burden for the informal care givers.

Techniques have been developed for successfully intervening with older people once an alcohol or drug problem is identified. These techniques need to become known by the front-line workers in the long-term care process. ARF would be happy to work with the staff of the ministry's long-term care division and with the district health councils to ensure that this training is available locally as the multiservice agencies are implemented.

A training package has been developed and is available. The Addiction Research Foundation collaborated with LESA and COPA to develop a training program for care givers who work with older people. The program is called Alternatives in English, and Options in French. It consists of a training manual, a presentation for older adults, a separate presentation for care givers and a video.

In addition, within Addiction Research Foundation's planning, the training of medical and pharmacy students is being addressed. Initiatives must be developed that include components relevant to substance use by older men and women. These initiatives should improve pharmacotherapy for this age group and ensure that seniors' alcohol use is also appropriately addressed.

Education of the consumer is also important. A number of pamphlets and education materials are available, including two pamphlets being distributed by the Addiction Research Foundation across Ontario. One is called The Older Adult and Alcohol, the other The Older Adult and Sleeping Pills, Tranquilizers, Pain Medication.

In conclusion, alcohol and other drug use increases the risk of premature institutionalization for older people. Drug use can also reduce a person's quality of life and add significant financial burden to the health and social service system. It is therefore important that these issues are addressed as Ontario's long-term care system is redirected. An opportunity exists to tackle these issues with training for in-home workers and support staff, a sound curriculum for students and the development of assessments that are sensitive to drug use problems among seniors and people with disabilities.

The Addiction Research Foundation is pleased at the opportunity long-term care reform has presented in terms of working with both old and new partners to develop suitable education and training for care givers and students. As the province and the community begin to develop the intake and assessment form for multiservice agencies, we welcome the opportunity to work in concert with them.

Ms Carter: I very much appreciated your presentation, because this question of excessive drugs, particularly in relation to seniors, is one that I'm very concerned with myself. What you said about medicines isn't actually just funny. I believe about 20% of hospital admissions of seniors is due to drug-related problems.

Ms Bois: Actually, 33% of all adverse drug reactions occur in seniors and they are only 12% of the population.

Ms Carter: And of course there are some related deaths as well.

Ms Bois: Yes.

Ms Carter: So this is a very serious matter. I'm sure the ministry is very aware of this problem. It's certainly something we have in mind and obviously want to do everything we can about. You didn't mention that we do have in place now a computerized system where pharmacists can check when somebody comes in with a prescription, which will immediately tell them if there's a conflict or they're getting a double dose of the same medication or something of that nature. Could you comment on that?

Ms Bois: I did mention the drug review utilization capability. Unfortunately, I'm not fully cognizant of exactly what that computer network is doing at this point, but certainly it is a useful step in the direction of ensuring. I think pharmacists have a significant role to play in monitoring and providing education to the drug user.

Ms Carter: I think we've all been encouraging that function of pharmacists. I wonder if we could hear something about how that system is working.

Mr Jim Wilson: We just had a briefing on it last week. It's still got a few flaws.

Ms Carter: I wasn't here last week so I missed that.

Mr O'Connor: May I make a suggestion, Mr Chair? The public accounts committee had a presentation by ministry officials on that program. If you'd like, the clerk could probably get a copy of the last day of public accounts hearings where we had Ministry of Health officials there. They actually had a very good overview presentation and showed how many prescriptions that had adverse reactions to them were caught as a result of the system and the health impacts that would have been saved as a result of that, which is really quite incredible.

The Chair: We can do that. We'll get that circulated.

Ms Carter: Okay, so that is in place. Also, of course, the Drug Quality and Therapeutics Committee is very much maligned because people say we're cutting back on the drug plan, but actually I think what happens on an ongoing basis -- and I believe it always has -- is that some drugs are weeded out as not being considered effective or as being even harmful.

Ms Bois: Our position is to encourage people to consider alternatives at times for drug use that are available.

Mrs Sullivan: I think this was an important and interesting presentation to the committee and quite different than any that we've had in the past. We have certainly all, I think, been made more aware of the issues about drug abuse among seniors and misuse since the Lowy report, because it brought the issues right down to earth in a highly communicative way, and I think that was useful to us all.

My own sense is that pharmacists themselves have started to adopt a pharmaceutical care model that's more responsible than they ever have in the past, and that change is going to be at the younger level, at the newer graduates in pharmacy who are coming forward and who will, it seems to me, be trained to work in a multidisciplinary environment along with physicians. That change is not going to occur overnight.

I am, however, interested in your suggestions that the assessors who are making determinations about eligibility and needs for care of people who are entering the long-term care system should be able to identify some of the drug abuse or misuse problems which occur with applicants, particularly given the fact that there is a significant amount of concern with respect to the implementation of this bill as to how clinical expertise will be brought into the pattern. In other words, the assessor may well get a list of the over-the-counters and the prescription medications that the patient's receiving but won't be able to do anything about it, and there's doesn't seem to be a viable way that the pharmacist or the physician is then brought into the system to help devise a program to get the patient off the drugs or to work out a method of making a well person there.

I just wonder how the ARF and you see the step between the assessor and moving into a healthy environment for the patient.

Ms Bois: What you've said, the importance of ensuring that the physician and the pharmacist are working in collaboration with the assessor, is key, and I think that when we talked about training we've talked about training at kind of the institutional level -- that is, at the university -- to emphasize at that point the importance of assessing and the sharing and coordination of information. We're talking about trying to deal with it at the training level. But I think at the training level, when we're talking about the MSAs being implemented, it would be wonderful to have the physicians become involved in that training as well. We're not sure how feasible that is, but I think there's a gradual understanding that they are part of the system and will have to be working in concert with people who are working in the homes.


Mrs Sullivan: Could I just have a little addendum? When you have made your recommendations on the assessment questions, have you included over-the-counters as well as prescription medication?

Ms Bois: I would hope so. I wasn't involved in the initial consultation on that, but certainly we would encourage that, definitely, along with alcohol and over-the-counter. They're the two drugs that often are missed when we deal with the elderly. We often only think of prescription drugs.

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


Le Président : J'aimerais maintenant inviter, pour faire notre dernière présentation, le représentant du Centre de santé communautaire de l'Estrie, M. Beaulieu. Vous êtes bienvenue. Merci aussi pour le paquet que vous nous avez présenté. Nous avons aussi là-dedans une copie de votre présentation. Alors, nous sommes entre vos mains.

M. Roland Beaulieu : Mesdames et messieurs les membres du Comité permanent des affaires sociales, bonsoir. Mon nom est Roland Beaulieu. Je suis directeur général du Centre de santé communautaire de l'Estrie, Cornwall-Alexandria. Nous couvrons les trois comtés unis de Stormont, Dundas and Glengarry.

Je me dois tout d'abord de vous remercier sincèrement d'avoir bien voulu accepter de me rencontrer à une heure tardive avec un agenda aussi chargé. C'est que j'ai réalisé à la dernière minute qu'il n'y avait peu ou pas de représentation de l'est ontarien. Quand je parle de l'est ontarien, je dis bien un peu plus loin qu'Ottawa, en allant vers le Québec.

Le Président : Le vrai est.

M. Beaulieu : Le vrai est. Je n'ai pas à m'attarder non plus sur le mandat des centres de santé, leur évolution et leur place dans la communauté. Vous avez déjà rencontré les représentants des centres de santé de la région d'Ottawa qui vous ont décrit comment les centres de santé se voient comme participants dans le développement des OSP.

J'aimerais vous parler de notre région de Stormont, Dundas et Glengarry, le parent pauvre de la province. Certains parlent même du Bangladesh de l'Ontario ; ça veut dire que ce n'est pas loin de la pauvreté. Souvent oublié et méconnu du reste de la province, ce coin de province, mélange harmonisé d'anglophones et de francophones, a des besoins spécifiques en termes de soins de santé. La mise sur pied d'un centre de santé francophone pour desservir les trois comtés unis manifeste déjà les besoins spécifiques de notre communauté. Il remettait aux francophones une gamme de services dans leur langue répondant à leurs besoins.

La venue d'un accès unique au sein des soins de longue durée est attendue depuis plusieurs années. La mise en oeuvre des OSP va permettre la réalisation d'un tel projet. Il est donc très important de s'assurer que les OSP répondent aux besoins de la communauté en général et également de la communauté francophone ontarienne.

Les récipiendaires des services de soins de longue durée sont principalement des personnes âgées. Étant donné que dans les comtés de S-D-G la population de personnes âgées est plus élevée que la moyenne provinciale et que 35 % de cette population est francophone, il est important que la population âgée reçoive des services dans leur langue maternelle. Vous savez très bien que les personnes âgées de 50 ans et plus sont les personnes qui très souvent ne sont pas bilingues ; elles sont unilingues francophones ou bien unilingues anglophones. La majorité de ces personnes ne peuvent communiquer en anglais dans leur quotidien et encore moins lorsqu'il s'agit d'organiser des services de soins de longue durée pour eux ou pour un membre de leur famille.

Madame la ministre, dans son allocution le 6 juin 1994 présentée devant l'Assemblée législative, nous dit, et je cite : «Je m'engage à ce que les organisations de services polyvalents situées dans les régions désignées en vertu de la Loi sur les services en français offrent des services dans cette langue, et je ferai en sorte que les organisations de services polyvalents concernées soient désignées en vertu de cette Loi.» De plus, dans le document intitulé Partenariats dans les soins de longue durée : Un nouveau moyen de planifier, d'administrer et d'offrir des services et du soutien communautaire -- Directives d'établissement des organismes de services polyvalents, on peut y lire en page 2, «Dans les régions de la province visées par la Loi sur les services en français, on offrira des soins de longue durée en français aux Ontariens et aux Ontariennes francophones.» On retrouve également, dans les principes directeurs des OSP, l'énoncé suivant, «encourager l'équité raciale et la sensibilité culturelle». Il est donc évident que les recommandations de la Ministre sont d'offrir des services en français à la population francophone, mais dans les différents documents on ne fait pas référence à la mise en oeuvre d'un tel service. Nous pensons donc qu'en tant que centre de santé communautaire francophone, il est de notre responsabilité de vous conseiller sur la façon d'assurer des services en français aux Franco-Ontariens.

Dans le passé, dans la région des comtés de Stormont, Dundas et Glengarry, certains services se disaient francophones, mais dans la réalité la seule personne qui parlait français était la réceptionniste. Ce n'est pas ce que nous appelons des services en français. De plus, lorsque le service se dit bilingue, même si les gens font un effort véritable pour offrir des services aux francophones dans leur langue maternelle, dans la réalité, plus d'effort est mis sur les services offerts en anglais.

Pour rejoindre les francophones, il faut les connaître : connaître leurs habitudes, leurs traditions, leur culture, et qui mieux qu'un francophone pour faire ce travail ? Pour les rejoindre, il faut être un organisme francophone. L'exemple des différents organismes francophones de la région est la preuve vivante qu'il est possible de rejoindre ceux-ci, alors que certains organismes bilingues nous répètent continuellement que les francophones ne peuvent être rejoints.

Le Centre de santé communautaire dessert déjà, après deux ans et demi, plus de 900 personnes de 50 ans et plus, ce qui correspond à 32 % de notre clientèle. De ces clients, nous desservons une trentaine de personnes à domicile, personnes qui normalement devraient être en institution ou à l'hôpital. Nos médecins, infirmières, travailleurs sociaux ou psychologues se rendent à domicile pour donner du traitement ou du support aux clients et à leur famille. Cette gamme de services pourrait s'améliorer avec la venue d'un OSP francophone, et encore mieux si ce OSP se rattachait au Centre de santé. C'est pourquoi nous recommandons fortement qu'il y ait deux OSP pour couvrir Stormont, Dundas et Glengarry, soit un francophone et un anglophone.

De plus, à la lecture des différents documents sur les OSP et du document intitulé Centres de santé communautaires de l'est de l'Ontario : Une vision pour les organismes de services polyvalents en matière de soins de longue durée, produit par les CSC de l'est de l'Ontario, il apparaît évident que les centres de santé communautaires ont une structure et une philosophie similaire à celle émise pour les OSP. Si vous regardez les tableaux, vous voyez que dans les principes des OSP et les principes des CSC, on se rejoint facilement.

Dans les principes qui ont trait aux OSP et que l'on retrouve à la page 6 du document Directives d'établissement des organismes de services polyvalents, nous retrouvons : respecter et appuyer le désir de dignité, de bien-être et d'autonomie des gens. Principe des centres de santé : engagement à donner aux personnes et aux collectivités les moyens de se prendre en charge.

Principe des OSP : intégrer les services de santé et les services sociaux de longue durée. Principe des centres de santé : engagement à fournir des soins globaux, travail d'équipes multidisciplinaires et travail dans la communauté avec la communauté.

Principe des OSP : assurer une plus grande participation des clients et un plus grand contrôle dans la planification et la prestation des services. Principe des centres de santé : encourager la participation des clients dans la planification des services soit par le biais du conseil d'administration ou du développement communautaire.


Je vais faire une parenthèse ici. Les centres de santé sont administrés par un conseil d'administration dont 50 % des participants au conseil d'administration sont des clients du centre. Également, les centres de santé ont un comité, qui s'appelle comité des clients, pour faire étude des besoins réels des clients face aux programmes qui sont donnés.

Je reviens aux principes des OSP : encourager l'équité raciale et la sensibilité culturelle. Les centres de santé, dans leur engagement à offrir des services accessibles, précisent, «Les centres de santé communautaires déploient des efforts particuliers afin de satisfaire aux besoins des personnes...dont l'accès aux soins de santé requis est difficile en raison de barrières linguistiques ou culturelles.»

Principe des OSP : l'approche recommandée pour les OSP me semble une approche communautaire, et qui mieux que les CSC déjà logés dans la communauté pour rejoindre les gens de la communauté ?

En dernier lieu, un sujet qui nous inquiète beaucoup face à cette nouvelle Loi sur les soins de longue durée, c'est comment cette Loi protégera les services en français aux aînés. C'est pourquoi le Centre de santé désire demander à la commission et à la ministre de la Santé de garantir l'inclusion des services en français dans la Loi sur les soins de longue durée, protégeant ainsi les droits des francophones. De plus, le Centre de santé communautaire de l'Estrie propose que la Ministre désigne des OSP francophones pour desservir les régions désignées sous la Loi des services en français, et ceci dès la création des OSP dans les régions désignées.

Mesdames et messieurs, un grand merci pour votre attention et votre collaboration. Je demeure disponible pour répondre à vos questions.


Le Président : Merci beaucoup. Ce n'est pas une question, là.

M. McGuinty : Merci beaucoup pour votre présentation ce soir. Jusqu'à cette date-ci, est-ce que vous avez reçu les assurances que vous cherchiez de la Ministre que vous allez avoir des OSP francophones pour desservir les régions désignées sous la Loi des services en français ?

M. Beaulieu : Il n'y a pas eu de garantie comme telle dans la Loi. Madame la ministre nous a dit qu'elle ferait tout dans son pouvoir pour qu'il y ait des OSP désignés dans les régions désignées, mais il n'y a rien dans la Loi qui nous garantit ceci.

M. McGuinty : Peut-être que nous devrions donner la chance à l'adjoint parlementaire pour nous donner une garantie, disons, que nous allons avoir un OSP francophone du moins à Cornwall. Nous allons lui donner la chance de répondre à cette question-là maintenant.

Une voix : Maintenant, ce soir.

Le Président : Monsieur l'adjoint parlementaire. Un cadeau à la fin de la soirée.

Le Président : Joyeux Noël.

Mr Wessenger: I'm afraid I won't be able to -- well, I might do it privately, but I'd be afraid to try it publicly, my French. But certainly as I understand it, there's been a clear commitment. I think that where areas are designated under Bill 8, an MSA will be designated in those areas to provide the services in French. I think Mr Quirt has indicated that earlier, but I don't believe there's anything beyond that assurance, which is certainly a definite assurance. I don't know if Mr Quirt could add anything.

Mr Quirt: I think recently ministers Grier and Pouliot wrote to district health councils across the province reminding them of their obligation to plan effectively for French-language services in those designated areas, and I believe she's made it clear to district health councils that it is her intention to designate MSAs under the French Language Services Act. You're right that there isn't a specific reference to the French Language Services Act in our bill, but the French Language Services Act governs government operations. That's why there is a separate act, so that the provisions of that act don't have to be repeated in every other piece of legislation the government has ever passed.

M. Beaulieu : Merci beaucoup. Thank you very much.

Le Président : Merci beaucoup, et on va voir dans l'avenir.

M. Beaulieu : C'est qu'on parlait de Cornwall tantôt, et j'apprécie beaucoup. J'aimerais bien en avoir un à Cornwall, mais notre mandat est de couvrir les trois comtés unis de Stormont, Dundas et Glengarry. Alors, on aimerait que la population de cette région puisse être desservie dans sa langue, surtout les personnes âgées.

Le Président : Encore une fois, merci pour le document que vous nous avez donné ce soir.

M. Beaulieu : Ça me fait plaisir.

The Chair: Members of the committee, that brings to a conclusion our hearings today in Ottawa. I know some members will be going back to Toronto tonight, others tomorrow. We begin again tomorrow morning in committee room 1 at Queen's Park at 10 o'clock sharp. We have a busy day, ending, of course, going to Kingston, where we will be in hearings on Wednesday.

With that, I want to thank everyone here at the Delta Hotel in Ottawa, the ministry staff and others.

The committee adjourned at 2017.