Tuesday 16 February 1993

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

Concerned Citizens for Access and Equality

Gord Gervais, member

Sharon Lumsden, president

Mary Medcalf, Legal Assistance of Windsor

Windsor-Essex County Placement Coordination Service

Margaret-Ann Prince, director

Ontario Home Health Care Providers' Association

Fran Scott, area manager, Para-Med Health Services Ltd

Marg Goslin, branch manager, Comcare (Canada) Ltd, Windsor and Essex


Nick Carlan

Kay Kavanaugh

Victorian Order of Nurses, Chatham-Kent Ontario Branch

Lois Fallon, executive director

Windsor Western Hospital Centre

Anne Morrison, vice-president, patient services

Central Park Lodges; Ontario Long Term Residential Care Association

Jim Anderson, general manager, Central Park Lodges

Pat Sousa, director, sales marketing and management, Central Park

Lodges and president, OLTRCA

Rick Winchell, executive director, OLTRCA

Essex RNA Regional Council

Sandra Landgraff, representative

Pierina De Bellis, representative


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

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

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

Drainville, Dennis (Victoria-Haliburton ND)

Martin, Tony (Sault Ste Marie ND)

Mathyssen, Irene (Middlesex ND)

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

Owens, Stephen (Scarborough Centre ND)

*White, Drummond (Durham Centre ND)

Wilson, Gary (Kingston and The Islands/Kingston et Les Îles ND)

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

Witmer, Elizabeth (Waterloo North/-Nord PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Caplan, Elinor (Oriole L) for Mr Daigeler

Carter, Jenny (Peterborough ND) for Mrs Mathyssen

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

Lessard, Wayne (Windsor-Walkerville ND) for Mr Gary Wilson

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

Wessenger, Paul (Simcoe Centre ND) for Mr Martin

Also taking part / Autres participants et participantes:

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

Wessenger, Paul, parliamentary assistant to the Minister of Health

Clerk / Greffier: Arnott, Douglas

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

The committee met at 1420 in the Cleary International Centre, Windsor.


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

The Acting Chair (Mrs Joan M. Fawcett): I'd like to begin the hearings of the standing committee on social development this afternoon. We are here to listen to all of the submissions on Bill 101, An Act to amend certain Acts concerning Long Term Care.

I'd like to welcome everyone here this afternoon and thank you for coming. I'm very thankful that we arrived. I'm not the best flier in the world, especially in this weather, but anyway, we're here. Also, welcome to Mr Lessard, who has joined us this afternoon.


The Acting Chair: If the first presenter, Mr Gervais, would make his way forward, I understand he is representing a group. I would remind the committee and the presenter that we would like to be able to question at the end; 15 minutes has been allotted, but I think we can be a little flexible. The third presenter is coming this evening rather than at 2:45.

Interjection: At 8:15 or 8 o'clock then?

The Acting Chair: At 8 o'clock. Welcome, Mr Gervais. Would you like to begin your presentation.

Mr Gord Gervais: I'd like to say good afternoon, ladies and gentlemen. I'm a member of Concerned Citizens for Access and Equality. Concerned Citizens for Access and Equality is a group of physically disabled adults who actively advocate for freedom and access to all areas of community life.

What we have in common is that we feel we should have the same rights and privileges other people enjoy; for example, the right to live in integrated housing with the availability of attendant care services. This is a right we feel all disabled people should have. However, many disabled people are forced to live in supportive housing because the degree of support we need is either not affordable or not available.

In making this submission, we bring our own diverse backgrounds and experiences as people with physical disabilities. We are pleased to have the opportunity to contribute to the development of long-term care in Ontario.

At the outset, we would like to comment that, generally, we support the redirection of long-term care in our province. We support a philosophy which will ensure that people control their own lives. We look forward to a long-term care system which supports and contributes to the independence and integrity of each individual and recognizes the uniqueness of individual needs.

Before discussing our recommendations for a model of long-term care, it is important to emphasize that while we support the NDP government's direction, we are concerned about the government's recognition of the needs of people like ourselves. We fall somewhere in the middle with regard to personal care. We do not need placement in a nursing home; however, we require more than homemaking services. We need attendant care services, which might include some homemaking services but also includes more extensive personal care. We want to have the choice to live in the community; however, we require long-term care in order to accomplish our goals. We are concerned that the redirection of long-term care does not address our needs with regard to attendant care.

Ministry direction: In Frances Lankin's address to the Legislature on November 26, 1992, she stated that Bill 101 will assist her ministry to achieve five major policy goals. We are particularly interested in the fifth policy goal: "to make direct payments to adults with disabilities so that they can purchase and manage their own services. This goal addresses the central importance to consumers of maximizing dignity, independence and control over their own lives." We assume that you hope to achieve this goal through amendments to part IV of the Ministry of Community and Social Services Act.

Our concerns: The following represent our collective concerns with regard to the redirection of long-term care for people who are physically disabled and as a result need to live in supportive housing. You will note that our concerns are primarily related to a lack of clarity with regard to the purchase and management of attendant care services.

As previously mentioned, we require more than homemaking. However, the level of care that we require has created a barrier to accessing housing outside of supportive housing. We do not have the option of moving into integrated housing in the community, although most of us would like to have that opportunity. We cannot afford to pay an attendant care worker and we cannot afford to be on a schedule of care that does not meet our needs. For example, personal care twice a day is not enough.

How are our needs for attendant care adequately addressed in the proposed redirection of long-term care in Ontario? How will we be able to integrate fully into the community if we do not have access to attendant care services which are affordable and available to us, regardless of the degree of our disability?

Currently, our attendant care is fully subsidized. How will the proposed amendments provide us with the money to purchase our own services, given that we are provided with the opportunity to integrate into the community? For example, we had the opportunity to move into a non-profit building, but we could not afford to pay for the level of attendant care that we needed.

In our present accommodation, attendant care is available to us at all times. However, we do not control the management of our care and the services received. How will the proposed redirection provide us with the opportunity to control our attendant care and thus have increased control of our lives? Who will define the circumstances under which money for services may be made available to an individual?

Components of an effective model of attendant care: We would like to see a model of attendant care which includes the following: (1) available and affordable for people with disabilities who fall between the cracks of homemaking needs and nursing needs; (2) takes into account individual needs with regard to frequency and degree of care needed; (3) is portable; (4) based on the employer-employee relationship -- in other words, we hire our own attendant care worker and design the service; choice means control; (5) a 24-hour support-care system which could be integrated into accessible, community-based housing.

In summary, we urge the government, when finalizing the redirection of long-term care in our province, to include a review of attendant care services for people with disabilities. In addition, we are requesting clarification with regard to where the issue of attendant care needs is dealt with in the proposal for long-term care. Further, we ask that the government specifically address and distinguish attendant care as a separate and important service.

As well, we ask that the proposed changes include a statement with regard to not only "obtaining goods and services that the person requires as a result of a disability," but with regard to management of those services as well. Finally, we'd appreciate the opportunity for continued involvement in the implementation of the long-term care process as it relates to people with disabilities.

We know that this is a complex issue which involves financial considerations. At the same time, we must be given the choice to live where we want to live, regardless of our disability. We cannot do that without a commitment from the government to support our need for attendant care services, both financially and philosophically. Thank you.

The Acting Chair: Thank you very much for that. You've certainly raised a lot of questions. Now, with your permission, if we could ask you some questions?

Mr Gervais: Sure.

The Acting Chair: We'll begin today with Mr Hope.

Mr Randy R. Hope (Chatham-Kent): Thank you very much, Gord, for the presentation. As you're well aware, this is only one step of the long-term care reform.

Mr Gervais: Yes.

Mr Hope: Now we're directly funding you as an individual and letting you become the employer and establish what services you need. Some of the elements that you brought up that are -- and I'm waiting for a copy of your presentation, because I was trying to follow at the same time and take notes.

Mr Gervais: We have quite a few submissions here.


Mr Hope: Okay. It's important for us to get the viewpoints, because it's one thing just to announce what we're trying to do, but you have to put a framework, and I think what you were trying to explain to us today was to put a framework in place that would be understandable not only to the person you're dealing with, but also to yourself in making sure it's appropriate.

The other thing I wanted to bring to your attention, Gord, is that it is the minister's intention to make sure that we can expand and make sure that disability issues are brought forward in the long-term care. That expands on a number of groups that are somewhat excluded from the long-term care currently.

In March the paper will come out and I'm hoping that your group will be a part of the overall discussion that will take place once that paper is released in March, which will set the next stage. This is only one stage to straighten up a few areas, but then we'll move on and try to straighten up the other areas, and I'm hoping that your group and yourself will make a presentation to the committee.

I thank you for the comments today and I hope this is a stepping stone, and I believe I took it to be a stepping stone, but you still have a number of other concerns around supportive housing and independent living.

Mr Gervais: Yes.

Mrs Yvonne O'Neill (Ottawa-Rideau): Thank you so much, Mr Gervais, for coming. I think you bring a very different perspective, as do all presenters. We haven't heard a lot about attendant care in this particular set of hearings. Have you noticed changes in your attendant care in this last year? Are you part of the attendant care advisory committee, or could you say a little bit about that? A few people have suggested to us that attendant care should actually be written into this legislation. Maybe you would like to respond to some of those questions I have.

Mr Gervais: Right now, a lot of the funding is directed at making it possible for disabled individuals to stay in the home.

Mrs O'Neill: And some to go to work, of course.

Mr Gervais: A lot of that is being cut, I understand, too.

Mrs O'Neill: Have you personally noticed any cuts?

Mr Gervais: Personally, no, only what I've heard. What we'd like to see is to be able to get out integrated into the public and have our own support care services as well.

Mrs O'Neill: Are you saying then, Mr Gervais, that you would rather see or you're requesting that there be more of a commitment to a continuum of attendant care and that this be part of these directed fundings, that the attendant care worker would be directed by yourself?

Mr Gervais: That's right, yes.

Mrs O'Neill: Is there anything else you'd like to add about the attendant care, either of you?

Ms Sharon Lumsden: I'd just like to say what Gord said.

The Acting Chair: Excuse me. Could you identify yourself, please, just for the record?

Ms Lumsden: I'm Sharon Lumsden. I'm president of Concerned Citizens for Access and Equality. I'd like to say what Gord said. We'd like to have more charge of our attendant care. We'd like to see it implemented by the government in the long-term care. Currently, we live in a building where there are attendant care services provided, but we have no control over them.

Mrs O'Neill: The attendant care workers in the building.

Ms Lumsden: Yes. It's a 24-hour service, which is a very nice idea. We like it, but we can't manage and control our own attendant care. We don't have any hiring or firing policies. We're not allowed to have any decisions.

Mr Gervais: We don't have any input at all.

Ms Lumsden: Not any input. What we're looking for is to be able to move, have a choice to move around the city into any housing project we would like to with an attendant care as with us. It's what we call portable -- or into another integrated housing where a group of us might want to live in the integrated part of the building where we would have onsite attendant care.

Mrs O'Neill: And you don't feel you can do that at the present time?

Ms Lumsden: No.

Mrs O'Neill: Thank you for clarifying that for me.

The Acting Chair: Mr Wilson?

Mr Jim Wilson (Simcoe West): Yes.

The Acting Chair: Excuse me; sorry. There's a comment here.

Ms Mary Medcalf: I'm Mary Medcalf, Legal Assistance of Windsor. I think I'll be meeting you next week again, Randy.

I want to respond to one thing you asked, and that is that I think this group feels very strongly that attendant care needs to be more clearly identified in the legislation as a special and unique service. You had asked that earlier, and I think there's a very strong consensus in the group that this was not something that was attended to adequately in the amendments.

Mr Hope: Could I put a supplementary and ask where you would see them put this?

Ms Medcalf: I'm sorry. I didn't hear the question.

Mr Hope: I'm asking for permission to make a supplementary. It's not my turn, though.

The Acting Chair: A short one.

Mr Hope: A short supplementary.

Mr Jim Wilson: In other words, he's stealing my question.

Mr Hope: Where would we put the changes we made in the MCSS act in order to clearly define that, because we just use labels like "obtain goods and services"?

Ms Medcalf: Yes, and I think there is the issue of obtaining the goods and services, also managing the goods and services, and as this group has indicated to you, they fall between the cracks. Bill 101 deals with nursing home care, homes for the aged, homemaking services and attendant care as a very specific type of care. So this group is saying, "Look, we live in supportive housing where attendant care is onsite, we do not have the same options to move out of this housing because of the level of care that we need, which happens to be attendant care; we don't need nursing care; we don't need homemaking services; we need sort of a combination of homemaking and attendant care," which they see as something very specific.

Mr Jim Wilson: Thank you for your presentation. I think it is useful to hear these points. We've had similar testimony before the committee and we've had others also explain to us that they're worried about the wording of a couple of clauses that are contained in Bill 101.

As you know, it says the minister "may" from time to time, out of money appropriated by the Legislature, make a grant. It isn't terribly strong language, and I'm wondering, if you're meeting with Mr Hope next week, you would take the opportunity now to maybe suggest some stronger language. I think that would be appropriate, particularly for the opposition parties in bringing forward amendments, if the government doesn't do that.

I really don't have any question other than to suggest that what's very often helpful for committee members is to actually see some language come from the groups themselves. I know your lawyer's with you.

Ms Medcalf: If I could respond to that, actually, I think that in the submission the group has indicated there are some questions about who will define when somebody should be given money for attendant care or homemaking services or nursing services or whatever, so under what circumstances, what degree of disability defines how much money will be given at any given time. I think we would support, certainly, a stronger presentation.

Mr Jim Wilson: I guess my worry is that while the government pays lipservice to the commitment, it's not firmly worded in the legislation, nor do I understand that many groups are given commitments that they're going to be part of the regulatory process either. Long after we leave your good city, we don't want to leave you with false hopes.

Ms Medcalf: I'll also clarify that I'm not a lawyer; I'm a social worker.

Mr Jim Wilson: Oh, I'm sorry.

Ms Medcalf: That's okay. I thought I'd clarify that.

Mr Jim Wilson: In a legal clinic or something like that.

Ms Medcalf: That's right.

Mr Jim Wilson: It's okay. We don't have much against lawyers.

Interjection: There has been a clarification offered here.

Mr Jim Wilson: The parliamentary assistant can clarify. He's a lawyer.

Mr Paul Wessenger (Simcoe Centre): I'm actually going to ask staff to clarify the question of the eligibility. It's a grey area.

Mr Geoffrey Quirt: I'm Geoff Quirt, acting executive director of the long-term care division. As you might be aware, we're now working with representatives of the community of people with disabilities to sort out just the questions you've raised about eligibility and the definition of "disability."

Our current thinking, subject to improvement through that process, is that a similar eligibility determination would be used for people who wish to manage their own care as would be used for clients who would be accessing our new in-home services program. Through that new in-home services program, we hope to be able to deliver attendant care outreach-level services through the existing home care program, and if someone was deemed eligible under those eligibility criteria and someone was in a position to manage his own care, then he would be given the equivalent funding that he would be eligible for under the normal program, and given permission to hire his own attendant and do his own training and direct his own care.

The Acting Chair: Thank you very much for appearing before the committee. Mr Wilson, you were finished?

Mr Jim Wilson: That's fine.

The Acting Chair: Thank you for coming today, and your group that supported you. We'll keep in touch.

Mr Gervais: Thanks for your time and for taking the time to listen to us. We'll leave the submissions with you.


The Acting Chair: The next group is the Association of the Physically Handicapped Windsor-Essex County, if the representatives of that group could now come forward. I might take the time to point out that the ministry staff have now joined us and I thank them for being at the table.

Possibly I should mention that I am the acting chair today. The Chair who is normally in this seat, Charles Beer, had a very important meeting he had to attend, so I am in the chair today.

Mrs Elinor Caplan (Oriole): And a very fine Chair.

The Acting Chair: Thank you. Is there anyone present from the association of the physically handicapped?


The Acting Chair: It's my understanding that the Victorian Order of Nurses is present at this time and maybe, because we have a fairly tight schedule, we would ask that they come forward, if that would be all right.

Welcome to the committee. Perhaps you would identify yourself, please, for the record.

Mrs Margaret-Ann Prince: My name is Margaret-Ann Prince and I am the director of the Windsor/Essex County Placement Coordination Service. The Windsor/Essex County PCS is administered by the Victorian Order of Nurses, and as director of PCS, I welcome the opportunity to respond personally to the amendments in legislation known as Bill 101. The Ontario PCS association has also responded to the bill.

The amendments will streamline and amalgamate the current system for long-term care facility admissions. The intent to make long-term care equitable to all is positive, especially for those residents who have been considered as less desirable and denied access to the system. This would include the behavioural and management cases.

Bill 101 will also enable adults with physical disabilities to purchase and manage their own services, a move which will support their dignity and independence.

To ensure that the consumer is best served, there must be a centralized, independent and objective coordination service available which has the responsibility and the authority to assist consumers to obtain the most suitable placement or service according to their needs. This will also have to be a program with flexibility.

Our PCS program affirms a commitment to maintaining and improving upon our collaborative working arrangements with the management of long-term care facilities. We continue to recognize the rights of the client to choose, particularly when it pertains to specific religious, ethnic or cultural preferences.

Clients should not be admitted to facilities without considering all aspects of the placement and discussing with the facility representative any applicants whose needs may not be considered by the facility as appropriate for a current bed vacancy. They too should be able to appeal any decision that seems to contradict those rights before an admission occurs.

Eligibility criteria must be precise in order to be consistently applied throughout the province. Regulations authorizing admission to a long-term care facility must be equally precise. The immunity clause for placement coordination will offer little protection if such regulations are ambiguous.

Regulations regarding screening for infectious diseases such as tuberculosis, salmonella, hepatitis and HIV should be standardized. Regulations must specify what testing is required, when it is to be done, and who assumes the costs. Presently, in our area, the screening requests are not standardized.

Clarification is also needed regarding who can give consent on behalf of the consumer for application or admission into a facility, and under what circumstances. Regulations should specify how and under whose authority information can be transmitted between long-term care facilities and placement coordinators.

PCS recognizes that an appeal procedure to review a determination of ineligibility is essential to maintain our accountability. The presence of the placement coordinator at the appeal board, as well as the powers assigned to the board, are supported.

It is recommended that notice be given not only to the applicant but also to his care giver or next of kin.

I would like to share some other concerns as to Bill 101 affecting programs in Windsor-Essex county.

We support having all admissions to long-term care facilities via a placement coordinator. I trust that the existing PCS will be designated as the placement coordinator. The statement in the documents is ambiguous, as it does not refer to the placement coordination service but rather to the coordinator, who will be appointed by the minister.

Although we have been able to refer to three respite beds in our area -- two in the city and one in the county -- it is essential that all facilities be mandated to accommodate short-stay admissions. If equal access is to be maintained, short-stay respite beds must not be used as a way of securing an indirect admission to a long-term care facility. I would hope for a different method of funding than what is presently in use in order to enable clients of limited financial means to have access to these beds.

Downsizing of some acute-care beds in our area is inevitable. Many heavier-care patients occupy these beds at present. Nursing homes will only receive these clients when the funding for level of care is in place. In order to transfer these clients locally, some facilities will have to update their physical accommodation. Also, staff will require in-service education in order to acquire the skills for the specific treatments required for this client group. If the funding dollars are not flowed in a timely way, none of these changes will occur and there will be a tremendous backlog of frail elderly still in hospital with no appropriate place to go. Planning and education should begin before any additional acute-care beds are downsized.

In reference to the appeal mechanism, it is not specified as to whether anyone else can initiate an appeal on behalf of the client and who would comprise the membership of the appeal board.

If quality assurance plans are to be monitored, this implies provincial standards that would address a wide variety of expectations. Those standards could and should be the first step towards accreditation.

Because Windsor-Essex has several facilities that house both retirement home and nursing home clients, it is a concern that the bill has no guidelines for internal transfers within a facility to a special care unit or from a retirement section into a nursing home bed. There is the possibility of preferential consideration being given to in-house residents, to the detriment of community or hospital clients. This process needs to be addressed.


Presently, the amendments to legislation confirm the essential function provided by the placement coordination services. It is expected that where population warrants, there will continue to be programs known as placement coordination services.

With the authority given to the placement coordinator, there will be reliable and accurate statistics on bed usage and bed requirements throughout the province, as well as standardization of the care requirements of consumers admitted to long-term care.

To conclude, with the foregoing questions addressed, Bill 101 ensures that consumers and their families will have a simplified, objective and equitable process to access long-term care. My colleagues and I look forward to its implementation.

At this point I would be pleased to receive any questions.

The Acting Chair: Thank you very much, and I thank you for your concise brief to allow for questions. We'll begin the questioning with Ms O'Neill.

Mrs O'Neill: Thank you very much, Ms Prince. I'd like to begin the questions by asking the parliamentary assistant and/or ministry officials whether we got a reading on this placement coordinator service, because that question came up in Thunder Bay yesterday. We asked for an interpretation whether the present and existing coordinator services that appear in many forms across the province are going to be grandfathered or considered as the placement coordinator. Have we got any answer to that yet?

Mr Wessenger: Yes, the answer is that it will be designated as a placement coordinating service under the act. Then of course it will be extended to other areas of the province.

Mrs O'Neill: I'm glad to have that on the record, because I think a lot of people are very interested in that. They have built systems over the years and many confidences have been placed.

You have brought forward two things which I think are important and you've highlighted them. You seem to have a fear about the capital needs that would flow from this Bill 101. You also seem to be expressing some concern about professional development. Do you feel that the bill is not clear enough on these issues? Would you like to say a little bit more about how you think the bill should reinforce those, as you see, necessary needs that are going to arise out of its implementation?

Mrs Prince: I think the bill has given a very strong degree of authority to the placement coordinator to help with the placement coordination of these persons. From our standpoint, what we're seeing is that if the funding isn't on schedule -- and there have been so many delays -- and people have to start planning now to meet the time when the funding supposedly will be brought into the system, people are waiting in active care beds and won't be able to access the system, even though we supposedly have authority to coordinate that, because the care givers in the facilities will perhaps not have been updated at that point in time, because they're going to be getting a different calibre of client who needs a much more extensive type of treatment. It's not just going to be the frail elderly who are going there to be maintained.

Mrs O'Neill: Do you think there'll be a need for provincial support for that kind of professional development?

Mrs Prince: Yes.

Mrs O'Neill: Did you want to say a little more about the capital needs that you see arising?

Mrs Prince: In reference to?

Mrs O'Neill: You mentioned that you felt that there would be many structural changes that would be needed.

Mrs Prince: Yes, the other entity being that some of our long-term care facilities are not going to be able to physically accommodate the people who are being referred to them. Because of their age and the manner in which they were built years ago, they're not going to be able to take certain people who, say, need a suction machine, or there isn't going to be the physical space. That's just a question. It's a concern and something we're dealing with all the time.

Mrs O'Neill: Thank you for placing those with us.

Mr Jim Wilson: Thank you very much for your presentation. I would suggest that you get in writing, from the parliamentary assistant or better still the minister, the fact that your existing PCS system will be incorporated into what's envisioned in Bill 101, because if that were the case, why wouldn't the government simply write that into legislation? That's something we'll be pursuing.

Mr Drummond White (Durham Centre): She has it on Hansard.

Mr Jim Wilson: If Hansard, in other areas like advocacy and consent to treatment, is of any help. You can't bring Hansard to the bank. We've proven that in past legislation that this government's passed. We will pursue that.

In your statement here you said, "I hope for a different method of funding than what is presently in use, in order to enable clients of limited financial means to have access to these beds." Could you expand on that.

Mrs Prince: Recently, there has been a charge initiated per day for perhaps a week or a two-week stay. Previously, these costs were covered under a health card, an OHIP card. Now with the cost, we find that people who really do need the services provided are cancelling their commitment, due to the cost.

Another factor is that the Ministry of Health has never been able to fund respite care beds, and the clients themselves cannot afford to pick up the tab of the copayment plus the ministry's payment to utilize a bed in the nursing home. When we have vacant nursing home beds on an ongoing basis, we think that perhaps that's an avenue that could be addressed.

Mr Jim Wilson: For the record, can you tell us what those user fees or copayments are?

Mrs Prince: Approximately $40 a day.

Mr Jim Wilson: Which is an awful lot of money.

Mrs Prince: It is, and we're talking about the average family that has been maintaining this client at home generally for a very long period.

Mr Jim Wilson: Secondly, if I may, you go on in point 3 on page 3 to point out the need for some capital improvement or that there may be a need for capital improvement in order to update the physical accommodation. Can you give the committee an overview, in your opinion, of how much work has to be done in the Windsor-Essex area?

Mrs Prince: I couldn't speak for that sector, I'm sorry.

Mr Jim Wilson: Okay, but you're aware that there's certainly a need there?

Mrs Prince: Yes.

Mr Jim Wilson: There certainly is a need; there's a backlog of literally hundreds of nursing homes that will have to be brought up to standard. I want to ask you one general question, if you don't mind. I know locally there's been a lot of discussion about hospitals closing and the possible closure and amalgamation of hospitals. In my area of the province, which is more over towards the Collingwood and Wasaga Beach area, I find that a lot of seniors are quite scared about long-term care reform. Perhaps it's because it hasn't been explained as well as it might have been, or perhaps it's because it's being done in such a piecemeal fashion that we don't have the whole picture. Is there worry among seniors in the area that there won't be the hospital beds and that we're not seeing the shift of resources into community-based care?

Mrs Prince: I think they have a genuine concern in terms of the cutback, the downsizing on beds. First of all, they don't understand why the system has to be like that. They have difficulty not being able to access when they think they should be in a hospital bed and really they can be maintained at home in the community.

Mr Jim Wilson: There's still very much the mentality out there and people still very much prefer institutional care or feel they should be in institutional care.

Mrs Prince: I think we have to really gear up our public education in terms of getting seniors educated now about all of these major changes. Another concern we have, and it may have been discussed in other centres you visited, is the fact that once the homes for the aged do not admit level 1 residential care, where do all these people go? Some of them have been on a waiting list already for seven or eight months, sometimes longer.

Mr Jim Wilson: Exactly.

Mrs Prince: Then D-Day is going to come, when they're told, "You can't access the system." It would be enlightening for us to have some idea of when that announcement is going to be made, when they will not be admitting this level, because then, in fairness to those families, they could be directed to another source of facility support.

Mr Jim Wilson: Actually, I very much appreciate you saying that.

The Acting Chair: Thank you. We have to move on.

Mr Jim Wilson: I just want to make a point on that, Chair.

The Acting Chair: Thirty seconds?

Mr Jim Wilson: Thirty seconds; I'm aware, and I think some committee members are aware of that, but what you've just told us has not been debated at this committee. In fact, some may find it new news that there is a group of seniors there which is going to be left out in the cold if we don't do something about it in the very near future.

The Acting Chair: Mr White and then Mr Wessenger.

Mr White: I want to thank you for your presentation. Our first presentation was from the Victorian Order of Nurses in Durham, which is Oshawa, where I come from. They did an excellent job and so did you.

Mrs Prince: Thank you.


Mr White: There are a number of things that I particularly appreciated about your presentation. First of all, it's very articulate; you have a lot of very specific points that you make.

Obviously, when we go to other communities where there aren't placement coordination services, people look at the legislation and say: "What is this? Some sort of a terrible central control from downtown Moscow or something that's going to be inflicted on our community?" But as in Thunder Bay, where we just came from, and here, I think that with the kind of professionalism your organization shows, that coordination will be of a great benefit to Windsor, especially as it's backed up by law.

I want to pick up on one detail, and that is around the family support clause. I'm a social worker, a family therapist by trade, so I'm kind of interested in this. I also have a mom who's kind of elderly.

Mrs Prince: We all do.

Mr White: You talked here at the bottom of page 2 about the issue of clarification being needed regarding who and under what circumstances a person is given consent to make decisions or to represent a consumer, and at the top of page 3, "that notice should be given not only to the applicant but also to his care giver or next of kin."

I would think that in a lot of these situations it's very difficult to determine, because you have an elderly person who's sometimes okay, sometimes not and probably performs best when he has someone directly there supporting him. How do you include that in your decision-making and in your consultation with that consumer, with that senior?

Mrs Prince: I guess I was referring to the document in terms of, if someone who was ineligible for admission to a particular facility, that the care giver or the next of kin had to be not only just a support for the person who isn't going to be able to be admitted to a particular facility, but it should not just leave the client independently.

Mr White: So just telling that individual consumer would be a way of avoiding dealing with the issue. It would be that sometimes you have someone who's a little on the infirm side, who may not realize the ramifications of this issue, may need the support of a daughter, son or friend or whoever to be there, and that should be addressed.

Mrs Prince: Their own support system.

Mr White: Yes. Could you give us some suggestions, perhaps in writing later, about how that could be dealt with to ensure that that individual's, that consumer's rights aren't abused?

Mrs Prince: Yes, I will.

Mr White: Thank you.

The Acting Chair: The parliamentary assistant, Mr Wessenger.

Mr Wessenger: Thank you very much for your presentation. I'm going to try to deal with some of your issues, and then one of them I'm going to refer to staff, because I think it would be useful to have some information that probably has not yet been presented to the committee by staff.

First of all, with respect to your concern with respect to screening for infectious diseases, the ministry is working on standards for that and they will be incorporated in regulations at a later date, so they will be standardized.

With respect to the matter of the internal transfers, of course in future, with the placement coordinating services, all those persons will have to go through your organization in order to be placed. So I think you will have control in determining the matter --

Mrs Prince: That will take care of itself down the road.

Mr Wessenger: -- of eligibility and the question of priorities.

Placement coordination services will be extended across the province. But in the interim, until they're all in place, of course there'll be a need to have placement coordinators appointed initially, and probably initially some of the facilities themselves will do their own placement until the placement coordination services are in existence in that particular area.

The last item I'm going to turn over to ministry staff, and that's the question of respite care. I understand that respite care will be mandated, but there were other questions you raised, so I'll have that clarified.

Mr Quirt: Mrs Prince, you quite rightly pointed out that one of the problems in this system currently is that nursing homes are at a financial disadvantage if they wish to be in the respite care business, because we don't fund nursing homes directly; we ensure the clients who go in there. If a bed is left empty, that's lost revenue to the nursing home.

Under the new system, we'll be contracting with each facility, whether it's a home for the aged run by a charitable group, a municipality or a private nursing home, and we will establish a minimum occupancy expectation for each facility. By establishing an occupancy expectation that's lower than 100%, we will in effect allow beds to be left open for respite purposes in each facility.

If one particular facility seems to have a greater demand than another for respite services, its occupancy expectation would be again further lowered so more beds would be available to meet the needs of clients who might come in on an emergency basis or come in for planned respite while care givers have a vacation.

In addition, I'd point out that it's our intention to have a user fee for respite care that's lower than the normal accommodation fee, in recognition of the lifestyle costs a care giver or a spouse may have in the community.

Mrs Prince: That's great news. We welcome that.

The Acting Chair: We're very grateful.

Mr Jim Wilson: Chair, before moving on to the next witness, I could just ask staff a question.

The Acting Chair: All right.

Thank you very much for appearing today. Some of the things you brought up haven't been brought before this committee before and we appreciate that.

I will ask once again whether the association of the physically handicapped is here. If not, then we'll move to Para-Med Health Services. Is there a representative from that group? Thank you. If you would make your way forward.

Mr Jim Wilson: Chair, could I just ask a question following up what Mr Quirt just told the committee? I'd just like to ask a question of clarification on that.

The Acting Chair: Yes.

Mr Jim Wilson: Mr Quirt, I was just wondering, what's the incentive for the nursing home, for example, if you're going to have a lower occupation expectancy but you're going to pay them at the 100% level? The incentive there to ensure that they do provide some respite care services is the user fee, or is there another incentive? My fear would be the obvious question. They might just leave the beds empty.

Mr Quirt: I don't think an incentive is particularly necessary, because most nursing home operators would wish to respond to the community need as they saw it for respite care in their community. Right now there's a disincentive for them to leave beds empty for that purpose. We feel by removing that disincentive and allowing operators of facilities, whether private sector nursing homes or municipal homes or charitable homes, to respond to a community need, they'll be quite willing and able to do that. There will be no disincentive to the facility with respect to a reduced consumer payment for that respite service either.

Mr Jim Wilson: Well, that's one way of putting it, there'll be no disincentive, but if you're running a pretty slim --

The Acting Chair: Mr Wilson, I think possibly we could discuss this at the very end and move on to the next presenters and not keep them waiting.

Mr Jim Wilson: Sure, but it was new information to the committee.

The Acting Chair: I realize that, and that's why I suggested that possibly we could explore it further at the end when the presentations have been finished.


The Acting Chair: Welcome to the committee. You could identify yourselves, please, for the record.

Mrs Fran Scott: Thank you, Madam Chairperson. Thank you for agreeing to hear our presentation. I am Fran Scott, area manager with Para-Med Health Services for Windsor and Essex county. I would like to also introduce Margaret Goslin, who is branch manager for Comcare, Windsor and Essex county.

We are members of the Ontario Home Health Care Providers' Association, and I would like to give you a brief profile of our industry. Our members in this community operate through three offices of two member agencies. Close to half of publicly funded homemaking services are provided by our members. As well, publicly funded services on the average make up about half of our members' business, although it is much higher in several of our agencies, with some totally dependent on publicly funded home care.

Our agencies are Canadian-owned. We provide service at the same cost as the not-for-profit agencies. We employ approximately, for my particular agency, 300 health and support service workers in this community. Almost all of them are women. Many of them are visible minorities, and more than half of them work part-time in order to take advantage of flexible schedules to fit their families' needs. As well, most of management are women, and many entrepreneurial women are owners.

We have closely followed the government long-term care redirection. The central thrust in the redirection is to help people stay in their own homes longer through expanded community-based health care, rather than being cared for in a health care facility. We strongly support such a direction. Our experience has shown us how people benefit from care at home for as long as possible.


Now that we have the first piece of legislation dealing with long-term care redirection in front of us, that thrust is confirmed in the draft legislation. Bill 101 would control entry to long-term care facilities by giving authority to placement coordinators to determine who gets into which long-term care facility. Consumers will be required to prove that they cannot get enough care or the right care in the community before they can be placed in a facility.

Controlling access to facility care is based on the premise that there will be more care in the community, but there are as yet no plans or funding in place to expand community-based care to the extent that will be necessary to make home care available as a true alternative to facility care.

We think the committee should take note that the Minister of Health has considered virtually eliminating commercial agencies from the provision of publicly funded home care. We were very surprised to learn that this was even being considered, because it is totally contradictory for the government to declare its aim to expand community-based care, where obviously home care plays a major role, while at the same time planning to severely limit the involvement of half the providers of home care services.

If the government wanted to enforce a not-for-profit preference by directing all new business to not-for-profit agencies, no legislation or regulations would be needed to force our members out of publicly funded home care. It could be done simply by not giving us any more business. This could force many of our member companies into failure and into bankruptcy.

Other impacts which would result from closing off opportunities for new publicly funded home care to the commercial agencies include, first of all, dislocation and loss of jobs at a time of high unemployment -- job loss for those who can least afford it in fact.

Second is a loss of choice for consumers.

Third is a two-tier system of in-home health care, as in the past. For example, clients themselves or third-party payers like insurance companies could contract with commercial agencies to provide service to the same client served in other parts of the day by not-for-profit agencies. The clients end up with multiple workers, and the government's goal of minimal intrusion into clients' lives and homes is aborted.

Fourth is increased cost to the taxpayers, since the deficits of the not-for-profit agencies have historically been covered by the provincial government.

Fifth, the elimination of benchmarks in performance in the home care sector could well result in lower efficiency. On that last point, it may interest you to know that the commercial agencies' share of the market increased in recent years because we are flexible, responsive and efficient and have been able to meet service demands which the not-for-profit agencies could not; for example, providing service 24 hours a day, seven days a week, to ensure clients received care when they required it.

In many areas we have lived with the not-for-profit preference all along. It has in fact meant that our agencies received the second call. If the home care directors cannot obtain the service they need from the first call to the not-for-profit agency, they call us second. We can continue to live with this practice, but we can't continue to operate if we receive no calls at all.

The association believes that delivery of home care can be improved. We believe there should be more management of quality of the service and we favour standards for in-home care. We are working with our not-for-profit colleagues on developing proposals for province-wide standards which can be applied to all home care providers. We are also involved in other joint projects to improve in-home care. We are participating, along with other providers and unions, in the resource group on reimbursement convened by the government. We are also participating in the government project on the training of workers for our industry and for long-term care facilities.

With regard to standards, there is another section of Bill 101 on which we wish to comment. An amendment would allow the Ministry of Community and Social Services to provide payments directly to disabled persons who wished to self-manage their funding and attendant services. We recognize the change is aimed at assisting adults with disabilities to realize their ambition to live as independently as possible and we applaud that ambition. Nevertheless, the disabled person self-managing his or her own care should receive care which meets provincial standards and the province should know that its money is being used effectively. Workers who provide that care should be protected against loss of benefits like workers' compensation, unemployment insurance and Canada pension. Workers should continue to receive ongoing professional training, as they would if working for a not-for-profit or a commercial agency.

Clients like ventilator-dependent quadriplegics should know their care givers have the most up-to-date training possible. We urge the committee to recommend that the framework for self-managed care includes safeguards for both clients and workers.

The Ontario Home Health Care Providers' Association believes in a balanced home care system with a mix of both commercial agencies and not-for-profit agencies. We have consulted as many people as possible involved in policy development to try to understand why the government would want to limit our participation in publicly funded home care. Clients, particularly home care programs, have publicly expressed their support and desire for a pluralistic system. They have provided evidence to the Minister of Health of why a future long-term care system will require a balance.

We urge the committee to look at Bill 101 in the total context of long-term care redirection. If the thrust towards more community care is a good one, and we believe it is, then it is counterproductive and contradictory to remove key providers of community care just at a time when more, not less, home care is needed.

The not-for-profit agencies in the past have been unable to meet rapidly expanding need by themselves. The cost to the government of a system without the benchmarks that a pluralistic system brings would be high. The system would become more bureaucratic and less flexible and all of these factors would not be in the interests of the Ontario public. Thank you. We'd be pleased to answer any of your questions.

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

Mr Jim Wilson: Thank you very much for your presentation. I just want to begin by saying that I think your fears that the private sector may be driven out of the business of providing community-based health care services to individuals are well-founded if one looks at the day care sector, where the government has spent almost $200 million driving the private sector out of day care, not creating one new space or one new subsidy, but simply getting rid of Mr and Mrs Smith's day care down the street and putting up a so-called not-for-profit day care next door.

So your fears are very well founded, even though I'm glad I have first crack at questioning here because, as you go around the table, the government will tell you that's crazy, they did the same thing in the day care sector and it turned out to be absolutely untrue.


You point out that the eligibility criteria, as contained in the draft manual that's accompanying this legislation -- my reading of that would be the same as yours, that it's fairly strict in that the onus is on the potential resident, or the consumer, to prove that he or she has no other option. Do you want to just comment on that because it's something that hasn't been dealt with at any length in this committee.

Mrs Scott: In my perspective from reading the document, I understand that the consumer will be required to go through a financial assessment to be placed in a facility. We're not objecting to that, but how that is going to be handled is our concern and whether or not the consumer will be given an option to stay in their home or to go into a facility. I believe that is our primary concern: Will they be given the choice?

Mr Jim Wilson: The government has closed -- this is important because the government has closed 5,300 hospital beds since coming to office. Theoretically they're saving a lot of money on the institutional side.

Mrs Scott: Correct.

Mr Jim Wilson: Have you seen evidence locally that that money is being shifted into the vast improvement in community-based services that are going to be required to meet even the minimum standards of Bill 101? In other areas of the province we've had testimony -- we all read the papers from all different regions of the province -- we've seen both for-profit and not-for-profit providers laid off in the community setting. So my worry, I think, is something you've tapped into, and that is, if the government is going to drive the private sector out and is not flowing additional dollars it's saving on this so-called deinstitutionalization dividend, then we may very well end up with a piece of legislation that is very difficult to put into place.

Those are all my questions and comments.

Ms Jenny Carter (Peterborough): There are just three points I'd like to raise. One is, I don't think anybody's been driven out here. I know the minister has said there's a preference for not-for-profit, but we are looking at a system which is going to expand probably quite rapidly and it seems to me there's going to be room for everybody for quite some time to come and then I think there will be special niches too. I don't think anybody's going to be driven out of business, certainly in the short run.

One thing I'd really like to comment on. You were talking about the disabled who are going to be funded to have their attendants directly and that the training of those people should be laid out. We have heard from potential employers of that kind, from disabled people hoping to be able to do that, and they do not want those people to be trained because they say they have been living with their own disability, whatever it is, for a long time, they know exactly how to manage whatever it is and they want to train that person themselves. I just wondered what your comment on that might be.

Mrs Scott: I agree that certain circumstances require the family member perhaps to include their training package with the health care employee. I believe the training is accessible through the community colleges for these private employees if they choose to go that route, although I believe also that there is concern that people will accept positions in a private manner who are not adequately trained.

Ms Carter: But what I'm saying is that these people see the help they need as being an everyday thing rather than health care, although it's a little more than most of us would require, and that they want to train that person themselves in the very specific way they themselves wish things to be done, rather than having somebody who's trained, whether it's in a community college or wherever else.

Also, you were talking about 24-hour access. It's my impression that the Victorian Order of Nurses and maybe other providers do, in fact, give that.

Mrs Scott: Yes, in many areas they do, and certainly in Essex county they do. Also, the other not-for-profit agency, the Red Cross, does provide 24-hour care seven days a week. We're not suggesting that in all areas this does not take place. I made reference that we were able to grow, because in the past they did not, at one point, provide 24-hour care seven days a week.

Ms Carter: We have to have that, I suppose.

Mr Wayne Lessard (Windsor-Walkerville): Mrs Scott and Mrs Goslin, I know we've met with respect to this issue in the past, and you know my position. I feel there's some room for the commercial sector in providing health care and I've expressed that opinion to the former minister, Ms Lankin.

Mr Wilson indicated in his questioning about the reallocation of resources. He alleged there are lots of beds all over the province which the provincial government's responsible for closing and that none of the savings are being reallocated, and he never gave you a chance to respond to that. I wonder whether you've seen some changes in the Windsor community resulting from the planning for the long-term care hospital replacement and following up on the reforms that we're proposing here, because it's my impression that Windsor has really been doing a lot of planning and has been in the forefront in the province as far as gearing up to these changes. I wonder if you can respond to that.

Mrs Marg Goslin: I do agree with what you're saying. The Windsor community and the Essex county community have actually been very fortunate in the programs that have been brought on board recently. We've had the quick response program, the early obstetrical discharge program, the integrated homemaking program, newly brought into Windsor and this has alleviated the situation considerably.

The one thing to keep in mind is that the number of hours that are able to be accessed are very limited. If you look at two hours a day, sometimes two hours a day are not enough to necessarily keep you in your home. That aspect is difficult, when there is the hours limit there, and I do realize there does need to be some limitation.

The Acting Chair: There was some clarification, Mr Wessenger?

Mr Wessenger: Yes. I'd like to thank you for your presentation. Just to clarify, long-term care is not a deinstitutionalized program at all. In fact, if you look at the additional moneys going into long-term care, you'll find over $200 million is going in to enhance care in the institutional side and the other $441 million is going into the community side. One of the examples of that, of course, under the proposal -- you mentioned the two-hour limitation period. I understand under the new program, those hours will be added to. I think that is definitely an enhancement of the community care.

Mrs O'Neill: I have one short question. Some communities have noticed a change in the uptake of services such as yours by the municipal authorities, by the local councils. Have you noticed any change in this area or do you know of any in southwestern Ontario where there seem to be fewer requests from the municipal level for your services?

Mrs Scott: No.

Mrs O'Neill: Okay. That was my only question. Thanks.

Mrs Caplan: Are you members of the umbrella organization of private sector small business providers of home care services in the province?

Mrs Goslin: The Ontario Home Health Care Providers' Association, yes.

Mrs Caplan: Are you aware of or have you been informed of a meeting that was held between the leadership of your organization, a policy adviser from the Ministry of Health and a policy adviser from the Premier's office recently?

Mrs Scott: We were aware that they were attempting to have a meeting with the representatives.

Mrs Caplan: I know how difficult it was for that meeting to be finally set up, but I'm aware that the meeting was held recently. Notwithstanding Mr Lessard's assurances, I believe -- and I wondering whether you've been told -- that directly your organization was informed there was no room for private small business in the delivery of health and social services and that this was the ideology and policy of the NDP government. Are you aware of that?

Mrs Scott: No, I wasn't aware of that.

Mrs Goslin: I wasn't aware of that either.


Mrs Caplan: If you hear that from your organization and would like to inform the committee, it would be helpful because the committee should hear that if that's the statement that was made to your organization. I was told that it was. We know there have been a number of anti-small-business initiatives taken by this government. I'm very aware of your concerns.


Mrs Caplan: The move on private sector child care is just one example.

Mr Hope: Elinor, let's put on the record exactly what the Liberals were trying to do with child care.

Mrs Caplan: Oh, good.

Mr Hope: Let's put it exactly on the record.

Mrs Caplan: I'm just putting the facts on the table, Mr Hope.

The Acting Chair: Order, please.

Mr Hope: Put facts on the table; don't put fearmongering.

Mrs Caplan: The facts on the table are that it is the policy of your government --

Mr Jim Wilson: The people in this area deserve to be told the truth.

Mrs Caplan: Exactly.

The Acting Chair: Ms Caplan has the floor at the moment.

Mrs Caplan: Thank you, Madam Chair. These happen to be the facts. You've come here today to express concerns about the viability of your industry, which today is providing 41% of service in the province of Ontario in all of home care provision, and responding to a need. I think you explained very well the preference policy that has been in place for quite some time. I'm pleased that you did because the parliamentary assistant had some misconceptions about that.

Let me ask you, how were your staff? How have they been treated in the past around government initiatives formerly to improve wages and enhancements and rates and so forth compared to the non-profit service or the public service deliverers?

Mrs Goslin: It's been exactly the same; no difference.

Mrs Caplan: So the preference was in a purchasing policy?

Mrs Goslin: Yes.

Mrs Caplan: In the past it had not been in how you were treated according to government policy?

Mrs Goslin: No.

Mrs Caplan: Could you explain that for the parliamentary assistant and particularly Mr Hope? He didn't seem to understand that yesterday.

Mr Hope: I can understand quite clearly. I don't need you to ask the question.

Mrs Caplan: Let them explain.

Mr Jim Wilson: You guys never ask these questions.

The Acting Chair: Let the presenters respond, please.

Mrs Caplan: It's important to understand how the system works if you're looking at making significant reforms, Mr Hope, and it's important for the parliamentary assistant to hear this as well, since he was obviously misguided yesterday or not informed when he made certain statements that are on the record. We have experts here who can tell us how the system works in Windsor. I think we should give them the courtesy of listening to them.

The Acting Chair: I think that's an excellent suggestion. Could you respond, please.

Mrs Goslin: The example I can give you is that I've been with Comcare for over six years now, and the billing rate that Red Cross has received for the last six years has always been exactly the same as the billing rate that the commercial agencies have received. When the homemaker rate reform went into effect, we had the same policies we all had to abide by, which of course the commercial agencies did.

Mrs Caplan: Thank you very much for that explanation. The reason you're here today is that this is your opportunity, in the discussions of Bill 101 and as we look at overall reforms, to raise your concerns. This is the appropriate forum to do that.

We've been hearing a concern raised about this legislation that it will limit choice and flexibility. The concern on choice, I think, goes far beyond the services that your agency provides, but the flexibility of this legislation is one that's reflected. The reason your industry has grown in the way it has, has been because you've been flexible enough to respond to changing needs. Do you see this legislation or the government's policy in discriminating against private sector providers as ultimately limiting choice or being inflexible, and if so, how?

Mrs Goslin: Yes, we definitely do view it as a very inflexible system, because certainly if the consumer is going to want to purchase service, he's very limited as to what agencies, especially in Windsor at the present time -- it really is singular -- could be accessed. If there is a problem from the consumer's point of view with purchasing service or if there's a problem with someone in management, then the consumer really has no choice because it would be a monopoly at the present time in Windsor if the commercial agencies did not function.

Mrs Caplan: Last question: If the government forces you out of business by not treating you the same as you have been treated in the past or not permitting your agencies to be called upon for government-funded services, what would happen to all of those people who purchase your services now, because they have no other place to purchase those services? I'm talking about the people who want more than the basic care the system provides.

Mrs Goslin: In the Windsor area, they'd have no choice but they'd all have to go to the not-for-profit agency, and at the present time we do not feel that the not-for-profit agency could give all the service to the Windsor and Essex community. So instead of having enhanced service, we would have far less service as a result of that, and we would end up with a lot of very unhappy elderly individuals, in our community anyway.

Mrs Caplan: What I've heard you say is that the government policy we understand is being proposed would result in Windsor as being an absolute cut in services, not only for services funded by the government but also for individuals who choose a greater level of service.

Mrs Goslin: That's correct.

Mrs Scott: It could also result in a two-tiered system whereby, as I explained, a person is receiving publicly funded home care for a portion of the hours per day and then, in order to enhance those services, needs to go to a commercial agency to provide the additional services. That would result in multiple care givers going into the homes to provide services, which is something that I believe we want to get away from.

I've had a perfect example just this week whereby I could explain to the committee that the government direction in the Department of Veterans Affairs program has changed its mandate and has allocated private funding to individual consumers to use for home care as they choose.

Mrs Caplan: Greater choice.

Mrs Scott: Yes. It has resulted in a situation with my agency whereby we are providing two hours of publicly funded home care through the government home care program to a client, and this person happens to be a veteran, so those services have been enhanced by two additional hours of services. In order for him to receive those two additional hours -- it didn't happen in this scenario, because we chose to allow our employee to go in those two additional hours, but in many circumstances they may be required to employ a separate private person for those two additional hours for Veterans Affairs Canada,, because it is the consumer's choice to hire the employee that he chooses.

Mrs Caplan: So in this case, because of the flexibility of your service, you were able to accommodate that client's need.

Mrs Scott: That's correct. I don't believe it's something we would want to do on a regular basis, because the employee, who is considered our employee, for instance, for two hours of that day is fully covered under our liability insurance under Canada pension and under workers' comp, and for the additional two hours has no coverage whatsoever and no supervision.

Mrs Caplan: Good points.

The Acting Chair: You certainly have provided us with a little spirited exchange and I thank you very much for coming today and providing the information.



The Acting Chair: Our next presenter is Nick Carlan, if he would come forward, please. Welcome to the committee.

Mr Nick Carlan: Thank you, Madam Chairman and members of the committee. My name is Nick Carlan and I'm retired. I consider myself a senior activist, whatever that means, but the last time I was active was when Elinor Caplan was in town and we had that little parade at the --

Mrs Caplan: I remember it well.

Mr Carlan: -- Liberal convention at the Heartbeat.

Mrs Caplan: I remember it well.

Mr Carlan: There's no more Heartbeat; they're all dead.

Just to talk in philosophical terms, I really enjoyed the previous speakers' very high-tech points of view they made, but I'd just like to talk as an ordinary person. By the way, my wife edited this speech, so if it doesn't come out right, you can blame her, and she lives at 11830 Riverside Drive.

Mr Jim Wilson: I think Mr Crosbie tried something like that earlier in the week.

Mr Carlan: That's not nice, is it, a sexist thing? I think there could be some physical fallout, eh?


Mr Carlan: I just hope that the health care system will serve all of us as ordinary citizens. Just because we reach the age of 65 or become disabled, we become categorized. I feel that growing old, and becoming disabled and dying young is part of living and I think we should all be treated equally, although different types of health care are needed. Hopefully, the ministry and the provincial government will accept us in the mainstream of living regardless of the fact that we're over 65. We're no different than the younger people in this country. Health care should be a matter of right and not a special privilege, regardless of the various cares we need.

We're very, very happy that the chronic care facility will now be built at the Windsor Western Hospital Centre after, it was reported in the Windsor Star, about 25 years in the making. We're very, very happy with that, because many seniors were housed in an old school, if you know, on Riverside Drive, by the Ford Motor coal pile, and it was surely not a place for seniors to have their last days. We're very happy about that and, myself, I feel the government has fulfilled that commitment, and there's more to come.

My main point here today is that I feel that there's a new direction and that long-term planning -- long-term care and long-term planning -- is needed, but I think we have to be on top of it. I think the planning has to be constant and daily, and I believe we have to believe in our researchers, in our consultants and in our scientists so that, as our population grows and the changes come about, for instance in the area of AIDS, we should be prepared for that.

We should take health out of the political system. We shouldn't have political debates on health. This we should give to the scientists. The scientists should say to the ministry, "This is what we need and this is what you better put in place," and Mr Laughren here would tell them to get the money. This is very simply put. I don't think health care should be based on, say, politicians coming to town and patting the old people on the head and saying, "Don't worry, we're going to take care of you." I think we've got to take health care out of that sort of political arena and make it a very serious and sober effort.

Many people I've talked to have expressed the opinion that they feel like they're in the third row. We have the politicians and we have the doctors and the nurses, and then the consumer. We're in the back row trying to see what you fellows are doing, you know, what you're all about, and we don't seem to have the ear. I feel that there should be an avenue where we can talk about these things and you will listen and something will be done about it. We shouldn't maybe have to demonstrate down Riverside Drive any more.

That, I feel, is a very, very important point, that you people give us a chance to talk about what we need. If there's a shortcoming, it's one thing, but then if there are some improvements, we can suggest that you listen and you listen sincerely.

Again, I'm just reiterating that long-term health must be established by today's health planning. I agree, and I believe everyone agrees, that health care should not be abused. It's a real concern of the medical people to realize that the high cost of providing medical services -- that day may be coming to an end. It just seems to me that that part of the budget is excessive. There are new demands on the health care system: AIDS and Alzheimer's disease. Hopefully, the curtailment of smoking will help us in curing, say, cancer.

With all these things put together, there are two questions that I put to you: Is health a privilege or is health a right? I think it's both. Thank you very much.

The Acting Chair: Thank you very much. It's good of you to come as a private citizen. We're interested in what everyone has to say. Would you be willing to answer some questions, if the committee has any?

Mr Carlan: Anything Elinor has to say.

The Acting Chair: Mr Lessard, we'll start with you, please.

Mr Lessard: Thank you very much, Mr Carlan. I'm glad to see that your wife had an opportunity to edit your remarks, because you certainly included a lot of material in there and covered a lot of ground. I'm glad that she kept you concise and to the point.

Just to emphasize, some of the changes that have been taking place in the delivery of health care and home care even in the last decade I think were exhibited in your reference to the chronic care hospital. As you know, we refer to it as the long-term care hospital now, not as the chronic care hospital. You said a few things about the history of that facility which are connected to the reforms that we're referring to here in this committee today. For the benefit of the committee members who may not be familiar with that, why don't you give some of the background from your perspective as to that facility?

Mr Carlan: The old facility, Riverview? The seniors were housed in the Riverview Hospital. It was formerly a school. I believe it would probably be 100 years old, with pipes hanging out. The service people are beautiful there.

Mr Lessard: That's something that has been in the planning for quite a number of years.

Mr Carlan: We have to take the people with us and leave that old building there, because you wouldn't describe it as a dump, but it was really pretty old, you know.

Mr Lessard: So I guess you're happy to see that the new facility is finally going to be built.

Mr Carlan: Yes, I am very happy for my friends.

Mrs O'Neill: Mr Carlan, you seem to have had some experience with long-term care.

Mr Carlan: Well, I'm probably a potential customer.

Mrs O'Neill: Have you had a chance to examine the bill that we're working on, Bill 101?

Mr Carlan: Yes. To tell you the truth, it's very complicated for myself.

Mrs O'Neill: Are there things that you would like to highlight for us that you feel could be simplified? Certainly I think most of the residents or people who will be affected are seniors, and we're all progressing towards that. I think it's important that seniors understand this bill. Could you say a little bit about what you think could be simplified or the guarantees? You were rather broad in suggesting -- and I think your statement about health being a privilege and a right is one that we should remember, because in this country, that's very true.


Mr Carlan: You see, when I come here to speak, probably it's a very selfish thing on my part, because I had to wait five months for my heart surgery. I just didn't feel that the ministry or the health department was doing right by me. It finally came through, but I didn't think that was necessary.

I'm not sure about the infighting in hospitals, but Windsor is a great town and we love it. We have 600,000 people in this area. We know that 600 have heart attacks and 300 are going to need heart care. They were doing nothing about that. It's time we moved on that one in particular.

Mrs O'Neill: Thank you for your input today. I think it's been helpful.

Mr Jim Wilson: I too appreciate your words of wisdom and the courage you have in coming forward and sharing your views with the committee. You talk about -- I gather some frustration in your voice -- how many seniors feel like they're in the third row behind politicians and the health care providers and the medical profession.

I sense that too in my own area of the province. People are very worried about the direction of long-term care, because we don't know the whole picture and exactly what the system is going to look like a few years down the road. This bill, as the government reminds us from time to time, is simply one piece in the puzzle.

But one important part of this piece in the puzzle is the government's commitment to transfer money to the nursing home and homes for the aged sector. It's to the tune of about $208 million and it's supposed to be new money. But $150 million of that $208 million is to be made up through increased user fees for individuals. I find most people have an opinion on user fees one way or the other. I was just wondering if you want to take the opportunity to tell the committee how you feel about this.

Mr Carlan: Are you talking about fees while you're in an institution or at home?

Mr Jim Wilson: Yes, while you're in the institution. There are increases in the accommodation. Seniors will be asked to pay for a portion of their accommodation costs, a little more than some of them are paying now.

Mr Carlan: I know my neighbour is benefiting from home care. The lady comes twice a week. She cooks for him. The VON comes in once a week and then Meals on Wheels comes twice a week. I know he pays for the two meals. All the rest, I take it, is paid through some fund.

Mr Jim Wilson: Are you aware that seniors now pay for a portion of their stay in nursing homes, for example, or homes for the aged?

Mr Carlan: Do I agree with that? If I had the money and if I wanted to be there --

Mr Jim Wilson: You wouldn't mind.

Mr Carlan: -- I wouldn't mind paying whatever I could.

Mr Jim Wilson: I appreciate it. Thank you.

The Acting Chair: Thank you very much. I appreciate your coming. Our next presenter is Kay Kavanaugh.

Mr Carlan: She's not here.

The Acting Chair: She's not here yet.

Mr Carlan: Oh yes, she is.

The Acting Chair: While we're waiting for her to get herself assembled before the committee, maybe we could go back, if Mr Wilson wanted to pursue some of the questions that he was adamant to have answered.

Mr Jim Wilson: I was just trying from my own education curve to ascertain exactly how this works, because just from what I heard the impression I got was that if I were a nursing home and at a pretty slim profit margin and respite care did come at some -- I may want to respond to the needs of that community as I believe owners of nursing homes, homes for the aged etc do. I use the word "incentives" -- and I gather it's the wrong word -- but why wouldn't I just leave those respite care beds empty rather than incur any cost if I'm in a tight profit situation or no-profit situation?

Mr Quirt: That's a good question. If in fact you came to the officials in our division and said that you wanted to be in the respite care business and we reduced your occupancy expectation and then in effect you weren't interested in delivering respite care and left the beds open, our compliance adviser would visit, find out that you haven't delivered any respite care and raise your occupancy expectation probably higher than it was in the first place.

Mr Jim Wilson: That's what I want to hear. You say you remove any disincentives. To me, that's kind of an incentive to provide that care when your intention was to provide that care. I understand the government is fully expecting you to live in that intention. Does that intention form part of the service agreement between the government and the home?

Mr Quirt: That's correct. It would be.

Mr Jim Wilson: And you would spell out its expected occupancy?

Mr Quirt: That's correct. After our staff and the officials from the nursing home or the home for the aged discussed what the demand was for respite care in that area and agreed upon a level of respite care, we'd hope the facility would provide it.

The Acting Chair: Thank you very much.


The Acting Chair: Would Kay Kavanaugh be ready to come forward at this time?

Mr Hope: Madam Chair, while she comes forward, I think it's important for the committee to know something about Mrs Kavanaugh. Mrs Kavanaugh is a Canada 125 medal recipient, the Charles Brooks award recipient in Windsor, and also she's received a provincial Volunteer of the Year award.

The Acting Chair: Well, our congratulations to you.

Mr Jim Wilson: We should be giving you our seats.

Mrs Kay Kavanaugh: No, not really. I've got enough on my plate now.

The Acting Chair: It's a privilege to have you here at the committee. Welcome, and thank you again for letting us in on that. Perhaps you would like to go ahead with your presentation at this time.

Mrs Kavanaugh: Yes, I will. I'd like to thank you for the invitation to come before you. This long-term care is a concern of mine as I'm also president of a retirees group. I feel very deeply about the conditions that people are going to be subject to, so I hope this presentation helps you to deliver and bring the kind of service we want here in Windsor.

Long-term care: Why change? The shift in demographics must be taken very seriously, because elderly people are high users of health care and support services. The present patterns of providing care are inappropriate and unattainable given our aging society. We must change the way elderly people are served by setting up the infrastructure of community services.

Adults with physical disabilities: There are currently 25,000 to 40,000 persons with physical disabilities and only 10% of them currently receive publicly funded services. However, family members provide the bulk of the care and the estimate is that 50% of adults with physical disabilities will outlive their family care givers.

This group values control and independence, which presents a challenge to government, workers and agencies to make them more responsive to their unique needs.

The most pressing reason for reforming Ontario's long-term care system is to prepare for our aging population. We will experience an aging population growth by the year 2010 of approximately 68% in people 65 years of age and over.

The present patterns of providing care are inappropriate and unattainable given our aging society. We must conscientiously change the way we serve our elderly people by building up the infrastructure of community services as opposed to the enormous pressure to build costly beds.

Current problems are reliance on costly institutions and fragmentation of services and planning, uneven distribution of resources and training of workers to match changing consumer needs and standards. We also have changing consumer attitudes.

People are often in institutions because of lack of community services and support or simply because no one has taken the time to explore alternatives. The cost is simply prohibitive.

There are many examples of fragmented service: long-term care, health and social services currently delivered separately with poor coordination between them. There is no coherent provincial and regional planning. There now are multiple long-term programs, each with different access points, eligibility, fund-raising policies, and some even provide the same service as homemaking. Stacking of services from different programs and service agencies is often required and then this complicates service coordination unduly.

Some valuable programs and services are simply not available in many areas of this province. I would like to recommend the need for consumer autonomy and choice and the "one door to many services" approach.


There is inequity province-wide in the availability of in-home services. Vast areas of the province do not have access to the expanded personal care and homemaking services made available with the introduction of this program. Not having an integrated homemaking program results in inappropriate use of more expensive services, such as nursing, and results in greater responsibility for family care givers. This means people who really need these services go without or enter long-term care facilities as the only option.

When describing community support services, it is important to highlight that over 10,000 volunteers are employed in supporting elderly people in their communities. Supportive housing is a critical service to expand throughout the province, as it is for many consumers the only alternative to living in an institution or being totally dependent on family care givers.

In the many areas not having placement coordination services, you will find inappropriate use of the limited number of long-term care beds, people who could have remained at home if they had assistance in exploring community alternatives. You will likely find disheartened consumers who face the task of finding the most appropriate facility.

One of the overriding problems we face is the money we spend to keep elderly people for extended periods of time in acute care hospital beds, and the overdependence on institutional services is a problem we face in redirecting the long-term service system. We need to correct this picture by allocating a greater proportion of new resources to building up community services and reallocating the money to long-term care.

It is important that residents be asked to contribute to their accommodation costs only. By that I mean for room and board and that assets will no longer be considered in the calculation of residents' fees. No one should be refused care because of an inability to pay. Those who have a limited ability to pay should pay at an affordable, reduced rate.

There should be direct payments to adults with disabilities so that they can purchase and manage their own services. This addresses the central importance to consumers of maximizing dignity, independence and control over their own limits.

I also ask that the Ontario government remain committed to the $647-million investment in long-term care. I also believe that services should be fully accessible, fully funded and provided by qualified health care professionals in public and non-profit settings.

I believe there are compelling reasons for the district health council to engage in a cautious reform of the health care system so that the services our community has had a legitimate right to expect are enhanced, not eroded or eliminated altogether.

I am concerned that the motivation behind the shift of health resources in the community sector is so that underpaid, inadequately trained home care workers would provide services at a lower cost than in the institutional sector, without challenging the real factors driving up the cost of health care: physicians and certain administrators in hospitals. Unless the district health council ensures otherwise, the ones who will pay for these cost savings are the consumers, who will receive lower-quality services, and the staff of these community agencies, who will be paid much lower than their counterparts in the institutional sector.

Crucial questions, such as what additional services could be provided by the hospitals, are not fully considered. For example, several hospitals in Ontario provide home care services and a wide array of outpatient services which would also be delivered in the Windsor area. One way to ensure quality home care services is to provide them out of hospitals. There are several hospitals-in-the-home programs, such as the one at Parry Sound, which should be examined before attempting to move home care services to community agencies, some of which may be commercial operations.

Why expand the fragmented network of community agencies currently providing home care services when hospitals have a proven record and already employ a large pool of qualified health care workers? I believe hospital board members must be held accountable to the community for their decisions. Presently, the governance of hospitals is medically driven and administratively manager-driven. What we desperately need is a sincere working partnership between all major players within our health care systems.

The question of how religious affiliation should impact on hospital governance structures, as well as the inclusion of district care givers on hospital boards, must be addressed as soon as possible.

I expect the Ministry of Health to prevent job losses by requiring hospitals to implement redeployment strategies, job retraining and realistic plans for early retirement.

It is crucial to take steps to avoid the possibility of patients falling through the cracks, as they did when psychiatric patients were deinstitutionalized in the early 1970s.

I believe that in order to prevent deterioration of the health care system, these recommendations should be implemented to protect health care workers, patients and the community at large:

(1) That before any layoffs are considered, the steering committee will ensure that every effort is used to eliminate all financial, non-human waste in the system;

(2) That any pressure by hospital administrators to coerce employees into concessions be stopped immediately;

(3) That for-profit health care, as seen in private labs, and all contracted services, such as Versa Services, Angus Co, Health Care Consultants etc, be eliminated;

(4) That an examination of the fee-for-service system be conducted to assist the impact of this payment method for doctors on local and provincial health care budgets;

(5) That recommendations of the provincial steering committee reviewing the Public Hospitals Act to centralize power and authority in the hands of the hospital and CEOs at the expense of the board of directors, clinical staff and other hospital staff be rejected;

(6) That all hospital budgets, salaries etc be disclosed fully to the public;

(7) That user fees not be introduced, but rather that accessible and affordable health care be emphasized;

(8) That the district health council's steering committee, in conjunction with the health council and the ministry, make health care institutions more accountable to the community they serve by advocating one elected board of directors for Essex county;

(9) That the district health council demand a moratorium on all major capital expenditures, such as purchasing equipment or repairs, or any other major expenditures by the area hospitals, as these may be intended to influence the current reconfiguration process.

An open, collaborative process must be maintained to enhance and serve the best health care system in the world.

I have serious reservations about many elements of the proposed health care reform, in particular the explicit anti-institutional bias. Many institutions have already started to downplay inpatient care in favour of outpatient services. Several hospitals in Ontario have also developed innovative home care programs.

Our community has made an enormous investment in the institutional sector, and it would be wrong to diminish its role in a restructured health care system. It makes more sense to transform institutions by making them more responsive to residents and front-line workers and to the communities they serve. Rather than limiting their parameters, hospitals should be expanding the range of services they provide. Services would improve through better coordination and programs could be offered along a full continuum of care. This would be more cost-effective and would also prevent the massive dislocation of trained health care workers implicit in the change process.

I think that it is incumbent on district health committees to proceed cautiously down the path of reform, and the health care workers and consumers must not shoulder the burden of these changes.

These are my thoughts. Thank you very much.

The Acting Chair: Thank you very much. One can certainly see why you have received your various awards. We begin the questioning with Mrs O'Neill.

Mrs O'Neill: Thank you, Mrs Kavanaugh. You have brought forward some very strong points towards the end of your brief, and I'm very pleased you presented them in point form. I think several of those either have already been brought forward by others or are in the works in other pieces of legislation. But it's true, many of these decisions have not been made, and I think they need to be highlighted in the whole backdrop of health care reform.


I'd like you, if you could, to talk to your ninth point on page 6. I find it somewhat conflicting in that the bill we're studying, as far as we can see, is going to talk to people being classified according to their needs and placed in facilities according to their needs. Others have brought to us that this is going to involve capital expenditures. Certainly, if hospitals and acute care hospitals that don't seem to be economical and do not always meet the needs of some of the residents are going to be moved, other facilities will have to have capital expenditures.

I find it confusing that in a time when there seems to be a demand for better health care -- equipment is certainly part of that -- you are suggesting what I interpret as a freeze. Would you like to say a little more about that so I won't misunderstand if that's not what you mean?

Mrs Kavanaugh: You are talking about 9?

Mrs O'Neill: Yes, I am.

Mrs Kavanaugh: In doing my research, it has been brought to my attention that certain hospitals have taken a look at doing certain expenditures that would maybe enhance their hospital so that it wouldn't be one of the ones that's closed. That was my concern, that these things not happen at this moment. They probably need to happen, but not at this moment. I think it puts a different picture on each hospital if certain equipment and certain procedures or whatever are implemented, because I don't think that's what health care wants to look at. Let's go ahead with the plan and then let's implement what needs to be implemented, not do purchasing and whatever just to enhance your chances of staying open.

Mrs O'Neill: You are suggesting then that the district health council have a very high profile in the planning process.

Mrs Kavanaugh: Absolutely.

Mrs O'Neill: And you would see them prioritizing the community needs through that process.

Mrs Kavanaugh: Absolutely.

Mrs O'Neill: Okay, that's clarified it quite considerably for me. Thank you very much.

Mr Jim Wilson: Thank you, Mrs Kavanaugh, for an excellent presentation. You raised a myriad of points and I think all of them are well taken by members of this committee. As Mrs O'Neill mentioned, we've heard some of them before, but I think you have a tremendous emphasis and a worry which is commendable on behalf of hospital workers for instance who have been laid off and do appear to be taking the brunt of the bed closures on their own shoulders.

Along that line, though with a different twist, in point 3, at the bottom of page 5, you talk about Versa Services, Angus Co and Health Care Consultants, that these contracted services be eliminated. I know what Versa does. What does Angus Co do for the hospital sector?

Mrs Kavanaugh: It's a supplier of hospital needs, things that have to go into a hospital to make it run.

Mr Jim Wilson: Implements.

Mrs Kavanaugh: Implements, I guess you'd call them, or instruments or whatever.

Mr Jim Wilson: Has there been a particular problem with these companies in this area?

Mrs Kavanaugh: In my research, they're saying that it shouldn't take place. When you're going to do a whole new system, there are capable people and capable companies that maybe do these jobs better than those I'm naming. I talk to many hospital people and this is what they tell me.

Mr Jim Wilson: You mention elsewhere in your brief that you believe there is a role for the private sector and that you're just singling out companies on this particular page that may have had a bad record or that local people don't feel very happy with.

Mrs Kavanaugh: That's right. Local people don't feel very happy with Versa Services. When I talk to some of the people whom I know, they're not satisfied with some of the meals that are produced at some of the hospitals. They feel the hospital could do a better job itself, maybe even more economically, because at Versa there is a profit margin there that has to be considered, and they seem to think that's the way it should go.

Mr Jim Wilson: I want to tackle that for a moment, because I see a lot of that in the local papers when I read about the Windsor area. Have you ever seen a study in your entire lifetime that shows the private sector can provide these services mentioned by these companies cheaper than government?

Mrs Kavanaugh: No, I haven't actually seen one, and I couldn't find any in the research.

Mr Jim Wilson: Would you be surprised if I told you that none exists?

Mrs Kavanaugh: No wonder I couldn't find it.

Mr Jim Wilson: That's true.

The last question is, the figure the Ontario Nurses' Association uses is that 2,800 nurses have been laid off. That's their numbers. The government and the opposition dicker over the numbers a bit. But do you think enough's being done for those laid-off workers?

Mrs Kavanaugh: Enough is not being done at this time, but I think with the change, if we are going to keep more people in their homes, then we're going to need more nursing in the homes. People need to be bathed and people need to have their medication regulated. There's a number of things that I think trained nurses will be able to do, so I think there could probably be some retraining along the Victorian Order of Nurses kind of training for these people to be picked up again and be part of the new health look. I think then the people who are going to receive that service are going to receive a higher quality of service than they would otherwise.

Mr Jim Wilson: Those people bring a wealth of experience.

Mrs Kavanaugh: They bring a wealth of experience, that's right, and to be a nurse, you're a certain kind of person, I think.

Mr Jim Wilson: Agreed.

Mrs Kavanaugh: I think there's a certain kind of loving care there that nurses bring to their patients, and I think these people should not be discarded and have to retrain to go into something that's really not --

Mr Jim Wilson: Not their chosen profession.

Mrs Kavanaugh: Yes, their chosen profession. I also feel that not only am I concerned about those people, but I'm also concerned about the people who are going to need that kind of care. If the nurses are not there, if they've gone on to something else, what do we do about that? Are people who are going to need that care going to get what they really need?

Mr Jim Wilson: I think the government's trying to help people who are laid off in the hospital sector to be retrained and put in the community sector.

Mrs Kavanaugh: That would be wonderful.

Mr Jim Wilson: The jury's out how effective that will be, but I think, to give the government some credit, there has been some money set aside for retraining. Unfortunately, our concern is that there may be an agenda, as you heard us talk about earlier, to drive some of the private sector out to create a space for the hospitalized workers, and I would sort of say that two wrongs don't make a right is kind of my way of looking at that.

Mrs Kavanaugh: That's right.

Mr Wessenger: I'd like to thank you very much for your presentation. You certainly seem to have covered a great number of the points in the whole health care field and in particular with respect to long-term care and I certainly appreciate that.

Just one little comment I'd like to make: When you highlight the growth in the aging population we're going to have by the year 2010, I'd just like to add a figure that probably makes it even more challenging, and that is that by the year 2010 there'll be a 161% growth in people 80 years and over. I think that really shows the extent of the challenge.

Also, I was particularly interested in your comments about the need for much more coordination in the long-term care area. I don't know whether you're familiar with the proposals with respect to creating community multiservice agencies.

Mrs Kavanaugh: No, I haven't seen too much on that.

Mr Wessenger: That is one of the proposals that is out there with respect to attempting the coordination of all these programs.

Mrs Kavanaugh: That makes me feel good.

Mr Hope: Thank you, Mrs Kavanaugh. As usual, you're right on the nose with a lot of your stuff. You've done your research.

As I was indicating about the 125 medal you received, the Charles Brooks award you received and also the provincial Volunteer of the Year award -- I forgot one -- it's the Woman of the Year from the Women's Incentive Centre that you received also.

Mrs Kavanaugh: Yes.

Mr Hope: I wanted to make sure that is also on the record and appropriately shown.

Mrs Kavanaugh: Thank you.


Mr Hope: One of the areas I want to touch on might create some communication back and forth across this table, but you know the unemployment rate that's currently existing in the city of Windsor, and around the casino. I live in Chatham, so we're all feeling the same effect. Most of it is an effect of the free trade agreement, and the North American free trade agreement coming on. A lot of younger people are leaving this community and going elsewhere for employment opportunity.

The numbers you have presented on your first page of your presentation, the percentage of age 65, is that the current effect that is happening with our young people leaving our communities, where the son or the daughter is no longer living in that community, so the dependency of family is leaving also, when you were looking at your calculation?

Mrs Kavanaugh: That isn't one of the things I found, but it's certainly a point. What I found was that the baby-boomers, as we hear all the time, are now going through the system and they will in these years. The effects of them going through the system is what we're talking about. Eventually, there will be a downsizing of people 65 and over, but right at this present time and up to that time, there will be a growing number of people just on their very own.

But the problem of care givers in the home -- and since I'm Woman of the Year I need to say this -- I think that if we allow it, women are again going to be the brunt of everything. They have to keep house, they have to have another job, they have to be a care giver. How much can they take? I think you're probably going to see a backlash and some women are going to say: "It's my family. I know it's my family. But I have a responsibility to my young family. I have to get my children into college. I have to work so that my children can enjoy the advantages that you and I had." I don't think it's so much the transient population as it is just a social impossibility for women to take that on.

Mr Hope: Okay. One of the areas I want to touch on is that you talked about streamlining and bringing people together, and I know you're involved in the Windsor area. Your name is well known to a lot of us who live in the area. But what I want to say is, how do we tear down the walls that are currently existing in those different organizations? With less provincial money, everybody's trying to fight for a little bit more. How do we then bring those groups together to say, "Look, things have to change; it's not the way it used to be; provincial revenues are down"? How do we get people to the table to do that?

Mrs Kavanaugh: I think first of all you would invite them to the table, then you lay your cards on the table and you explain to them: "This is the way it is and this is the way we're proposing to change it. If you are affected, we're sorry, but this is the way it is."

I think you just cannot go in through the back door, pussyfoot or whatever. Changes need to be made, things need to be done and there's a direct way to do them. I figure that when you do things the direct way, then people understand 100% that they have to change too.

The old ways have worked fairly well for us when there was a lot of money around and when we didn't have the number of elderly people we're now seeing. But these kinds of things have gone by the wayside, so I think we all have to be made to understand that we have to make changes. I think we're all reticent to make changes. You all say: "Why? This is working good." But it isn't really "working good" and I think they have to be told.

Mr Hope: I look forward to hearing your viewpoints come March when we release the other document on long-term care, because I know you, along with Nick and others who live in the Windsor community, will be putting their nose to the book. I look forward to listening to you.

Mrs Kavanaugh: Great. Thank you.

The Acting Chair: Thank you very much, Mrs Kavanaugh. It was good to have you here. Good wishes on all of your continued work.

Mrs Kavanaugh: I have to apologize for the typing. I am not a typist.

The Acting Chair: It was just fine. Thank you.


The Acting Chair: Next we have the Victorian Order of Nurses, Chatham division. Welcome. Come forward and take your seat, identify yourself and present your submission.

Mrs Lois Fallon: I'm Lois Fallon, the executive director of the VON in Chatham-Kent.

VON Chatham-Kent appreciates the opportunity to respond to the proposed legislative amendments known as Bill 101. Although many aspects of this bill more directly affect facilities such as nursing homes, charitable homes for the aged and municipal homes, the bill also affects programs and clients of VON Chatham-Kent, Ontario.

I do not intend to repeat information concerning VON that I understand you have heard provincially about the organization. I will restrict my comments to the impact as seen on our local branch.

VON Chatham-Kent administers three services: the visiting nursing service with several programs, placement coordination service, and a palliative care volunteer service.

The greatest impact of Bill 101 will be on the placement coordination service, or PCS, with a lesser possible impact on the visiting nursing service. The present role of PCS service and staff will change to embrace the responsibilities to determine eligibility for admission and to authorize admissions to facilities.

Support is given to the legislation that allows for an appeal process regarding ineligibility for admission; the access to information regarding services and consumer care plans; procedures for making complaints; a short stay accommodation requirement; and direct funding grants for persons with disabilities to assist in obtaining goods and services required as a result of that disability.

We do have some concerns about the legislation and they include: Although sections of the legislation are common and standardized, there are still separate but very similar acts. Chronic care facilities or beds are not addressed. Residents' councils are not required in all of the long-term care facilities. No opportunity for choice by the consumer or the substitute decision-maker is noted. The consumer could have a choice of service location, either in a facility or in the community setting. Likewise, if facility services are the choice, there is a need to have choice of which facility to enter, rather than this decision being made solely by the placement coordinator.

No consideration of alternative or new funding methods is apparent. How do these changes impact on long-term care policy changes? Can funding become more flexible within the new framework, even between facilities and in-home services? There is a need to develop precise eligibility criteria for the levels of care that are consistently applied by all placement coordinators. Consistent procedures for authorization for admission need to be applied by all placement coordinators.

The eligibility criteria and authorization procedures must be readily available to the public. It is not definite that the placement coordination is provided by an independent and objective program. The conditions on the grant for goods and services for the disabled person need to be developed, readily available and consistently applied.

I thank you for this opportunity to comment on these concerns of our VON branch and look forward to working towards realistic solutions.

Mr Jim Wilson: Thank you, Ms Fallon, for your presentation. It was short and to the point, which we certainly appreciate. I want to talk about the points you raised about either no consumer choice or, I guess, properly worded, certainly very limited consumer choice. I gather you're referring here to placement in a preferred facility. Do you want to just expand on your reading of the bill?

Mrs Fallon: The reading of the bill to me does not really state that there would be a consumer choice. It just sort of said that the placement coordinator will determine the eligibility and determine the facility. As I see placement working now, they do work very closely with the consumer to find out, after the level-of-care requirement is decided, which facility that person would really like to go to and that person would be directed that way first, if at all possible.

If it is an emergency situation and that facility does not have an open bed or room, then they would be able to go to a facility that did have an open bed or a room, but that would not necessarily mean the very first move that was made, and I didn't see that or read that in the legislation. It may happen, but I don't see it in the legislation.


Mr Jim Wilson: I think we've been given some assurance as a committee that there is to be some more flexibility in terms of how the placement coordinator and whom the placement coordinator consults when going about those decisions. But I would agree with you that the wording in the legislation is pretty stringent and doesn't appear that flexible, and we're going to try and work with the government to change that wording if we can.

I wanted to know what you thought about, as has been mentioned by other presenters in other areas of the province, a facility's right to perhaps not accept what the facility might deem an inappropriate placement. Do you think there's room in this bill for a facility to have a say in a decision made by a placement coordinator?

Mrs Fallon: I did not read that in the bill as it was stated. No, I didn't.

Mr Jim Wilson: It doesn't exist. Do you think it should exist?

Mrs Fallon: Yes, I think it should exist. I think it's still very inappropriate to have someone who is very confused in the same room as someone who is not confused. If they can't do that with changes within the facility, I think there still can be some instances where it would be inappropriate for someone to be placed in that bed at that particular time.

Mr Jim Wilson: Thank you. I appreciate those comments.

Thirdly, it's been suggested to the committee that perhaps the powers of the placement coordinator are too numerous and clearly heavy-handed. It was suggested to us by some presenters that -- I want to ask you this as a member of the VON -- perhaps the same person determining eligibility should not also be determining everything else in terms of placement in which facility and where, that there may be an inherent conflict of interest. Do you see any of that? Have you given any thought to conflict of interest?

Mrs Fallon: That was one of the reasons I felt that it should be at least an independent outside program that administered, that the PCS coordinator was a member of, so that there shouldn't be that conflict of interest. I won't guarantee that every single person, being a human being, wouldn't react one way or the other.

Mr Jim Wilson: So we should separate who determines eligibility?

Mrs Fallon: No, I don't necessarily feel that. I think that -- and how the coordinator actually determines that eligibility. Do they go out and make the interview or do they accept someone else's word? That's not even thought of, from what I could read, in the legislation. They just had some kind of reason to make up their mind whether they were eligible or not. That's why clear criteria for that have to me made.

Mr Jim Wilson: And should be spelled out, where possible.

Mrs Fallon: And everybody should use the same criteria in the same way, so that someone in Timmins doesn't interpret it differently than they do in Chatham. It should be done exactly the same way with both areas.

Mr Wessenger: Thank you very much for your presentation. I'd just like to assure you that yes, consumer choice is very relevant in this policy. We may even have amendments on that -- who knows? -- clarifying. I just want to indicate that the procedure is that the consumer should make the choice of which facility he or she wants to apply to.

Secondly, I just thought I'd indicate to you what the legislation says with respect to the refusal of a facility to take. It says:

"An approved corporation maintaining and operating an approved charitable home for the aged shall admit a person who meets the requirements of subsection (5), unless a ground for refusal of admission described by the regulations exists."

The ground for refusal of admission will be that basically, in general terms, the facility is not able to service that particular type of client.

I would like to ask you a question, however, with respect to your comments, saying that there's a need to develop precise eligibility criteria for the levels of care that are consistently applied by all placement coordinators, and also consistent procedures for authorization for admission need to be applied by all placement coordinators.

The reason I asked you to comment on that and clarify is that we've had some facilities that have come here and asked for more flexibility in these criteria. I'd like you to comment on why you feel you need more consistency rather than more flexibility.

Mrs Fallon: I probably am commenting on it as if I were a person who was doing the job of placement coordination; also the fact that if the procedure to go through if I didn't like where I was placed is not clearly spelled out, there are going to be many questions by the consumer. "Why did I not go to X nursing home instead of X chronic care bed?" and so on and so forth.

If those criteria are very clear and very straightforward on what are the admission requirements to go to this level of care, you meet those requirements or you don't meet those requirements. "I want to go to a certain nursing home." "You do not meet the requirements to go to a nursing home, and here they are: (1), (2), (3), (4), (5), (6), (7)."

If they're not clear, I think there will be a lot more people who say: "That's where I want to go anyway, because that's around the corner from where I live. I have somebody who works in that facility in my family." There are many different reasons why they want to choose one. But it's the level of care that's required rather than the choice between three nursing homes or three homes for the aged, or rest homes, or whatever other level of care; that was my concern.

Mr Wessenger: Fine. Thank you very much.

The Acting Chair: Mr Hope.

Mr Hope: You know Jackie. She always keeps me informed of everything, about what's going on in the health care profession, on the contrary to what some of the opposition may say. I don't know much about health care, but I know I have a constituency assistant who's had 25 years plus and is a volunteer -- I don't know if she currently still is, but I know she was a volunteer in the VON in providing services. One of the important things that I see is the 200 dedicated volunteers that we have in a population density and a geographic size that we are: 200 volunteers.

One of the things that I would like for you to get on the record -- hopefully we share the same concern -- is about the geography, that our placement coordination in Kent county stay alone and somebody doesn't bring us in line with the Windsor area. I'm sure you would have some concern there, if we were to be lumped in with somebody else in the Kent county areas.

Mrs Fallon: At the present time the geographic area is definitely the county lines. Yes, we would hope that it would stay that way, because it's a large enough area for the number of people to cover anyway, and if you don't have people who are close by who understand what's happening, who can know all the different facilities in that particular area, I think it would be more difficult to take in two counties.

The one concern I do have, and it happens a lot of times, is the people who live on the county lines, whether it be the county line between Lambton and Kent, Essex and Kent or Elgin and Kent. There are always a certain number of people who prefer to go just the other side because that's the direction they always go, and I think that's going to happen in every county. The larger area that you cover is not necessarily going to change that concern about which service they can go to.

From my understanding, even if I lived on the county line and wanted to go to the home for the aged in Petrolia rather than the one in Kent county, I probably could do that if I went through the right placement coordinator. I see no reason why they couldn't share that kind of information if the right procedures are in place.

Mr Hope: I also noticed in your presentation -- and I thought maybe you'd like to get it on the record -- about the needs of rural Ontario versus the larger areas. I wondering if you could share your viewpoints with us about the need of funding and the difference from large-density areas to large geographic, low-density areas.

Mrs Fallon: I think that especially rural areas have very definite choices and likes of where they would like to stay -- their friendships, their family -- much more so than I have found even in, say, the difference between living in the city of Chatham and the county of Kent. There is a difference in reaction on their loyalties to where they want to be and what choices they can have. They are very definite about what they like and what they don't like, what they want and what they don't want.

I think rural people as well tend to look after themselves or each other within the community. Because there are fewer people to worry about and you've known the same people for years and you've gone to the same church and belonged to all the same clubs, you tend to look after each other for a longer time, until it becomes very heavy care. I think that really does make a difference. There are also usually more family and friends close by than when living in an urban centre.


The Acting Chair: Mr Wessenger, you had a clarification.

Mr Wessenger: Yes, I would like to have staff clarify with respect to the role of the placement coordinating agency geographically. I think it would be helpful.

Mr Quirt: With respect to the process of a placement coordinator determining someone eligible for admission to a long-term care facility, that can happen anywhere in the province and any placement coordinator can determine you eligible. It would be the responsibility of that placement coordinator to make sure the client was considered for admission to the facility of the client's choice regardless of where that was.

For example, if a long-term care client in Kingston were to become aware that there was a German-Lutheran home in the region of Niagara, that person could be determined eligible for admission to a long-term care facility in Kingston and would receive every consideration for a spot in the German-Lutheran home. If his need for admission was higher than someone from next door to that facility, the person from Kingston would get in first.

The objective is to make sure that all people eligible for long-term care facilities are considered equally for admission to the facility of their choice and that people's admission be prioritized based on their need.

The Acting Chair: Thank you very much. Now, Mrs Caplan or Mrs O'Neill first, whichever you decide between you.

Mrs O'Neill: Mrs Fallon, I'm very pleased that you talked about the accountability aspects in your brief, however brief it is. We had three seniors before us yesterday who spoke with a great deal of passion about their desire to be independent, to be able to make choices and to know the options available to them. I think you are sensitive to that, even though you haven't said it as explicitly. I'm very happy you brought that forward. I'm misunderstanding, I think, your statement that, "Residents' councils are not...." What does that mean?

Mrs Fallon: In the legislation -- and I don't have my legislation right at the moment -- in only one of the sections of the act does it say residents' councils are required. It doesn't say in all of the rest homes, homes for the aged and the nursing homes parts of that act's changes.

Mrs O'Neill: I thought that's what you meant. If you read it here, you could say that you were saying they're not required. I guess it's just a misinterpretation I was making. These people were members of a residents' council and they were making their point very explicitly, and you're making the same point, that there should be a right for a residents' council in each facility. Could you say a little bit more about your statement that there was "no consideration of alternative or new funding methods"? Could you say a little bit more about that for us?

Mrs Fallon: I think I'm bringing up the ideas that we're hearing about the long-term care changes.

Mrs O'Neill: That would be helpful.

Mrs Fallon: None of us really know what is going to happen anyway. Really, in this legislation nothing has been shown that alternative funding methods, other than direct payment to the facility, have been considered. What those methods are could be wide and varied. Could there be more partnerships between facilities for specialty things? Could there be partnerships between community organizations and facilities? There are many ramifications of that.

Mrs O'Neill: Are you also thinking about the role of municipalities?

Mrs Fallon: That's part of it, yes. There are many things, but actually I was thinking about more direct funding for a bed in a facility being filled or not. Could some of that be used to get expertise on s part-time basis on a short-term basis from outside of that facility rather than hiring someone internally totally?

Mrs O'Neill: I hope those things will be looked at. Our fear is that most of them will be in regulations only, and I'm glad you're bringing forward your concerns so that the regulations, hopefully, will be based on some of those.

The Acting Chair: Mrs O'Neill, ministry staff wonder if you would like some of that clarified.

Mrs O'Neill: If it's possible, let's go for it.

Mr Hope: Oh, carefree today, aren't we?

Mrs O'Neill: I'm always that way, Randy. You know.

Mr Quirt: Ms Fallon, you're right that there's no description of the funding formula per se in the bill. There is a full description of the funding arrangements available, if you're interested, and certainly there's a program manual that talks about that in detail. We'd be happy to provide your organization with a copy of that.

You asked a question specifically about whether facilities could use funding for quality-of-life programs, for example, physiotherapists or occupational therapists or social workers in a partnership way, and that's entirely possible. The nursing home or home for the aged would be given a fixed amount for quality-of-life programs per client per year, and it could use that in whatever collaborative way it wished. That would be noted in their service agreement.

To give you a concrete example, I was advised the other day that a home for the aged in Brockville and a nursing home across the road have already spoken about hiring a social worker and sharing the cost from the funding provided in the quality-of-life program component of their budgets.

Mrs O'Neill: At least we know we've got one problem cleared up.

Mrs Caplan: I think you've addressed your concerns extremely well about the opportunity for choice of the results of how the policy is implemented, and we've had some very good information presented by the ministry that I think will be very helpful for the committee as well.

There are two concerns that you have not addressed during the question time. One is your concern that residents' councils are not required in all long-term care facilities. We know that they are presently required in nursing homes under the Nursing Homes Act. Why do you think they have not been included, and would you recommend that they should be included in all designated long-term care facilities?

Mrs Fallon: It's my opinion that they should be included. I do not know why they were not. Whether it was just one of those things or if there's a real reason why they were not, I have no idea, but I see them as being very positive steps.

Mrs Caplan: My question's to the parliamentary assistant. As a matter of policy, why was it the position of your government not to require residents' councils in all long-term care facilities?

Mr Wessenger: The answer I'll give to that one is I think that some very good points have been made indicating that they ought to be included in all facilities, and certainly that will be looked at very carefully, and hopefully we can have the appropriate action taken to ensure that it's done.

Mrs Caplan: What he just said is they're going to bring forward an amendment to do that.

Mr Jim Wilson: Maybe.

Mrs Caplan: We think. I think that's important to have on the record and I think it's good to have that clarified.

The second question I have for you relates to your concern about chronic care facilities, as they are now called. We know that some of the chronic care facilities in the province are already changing their names to long-term care facilities, and that hasn't been defined anywhere, but that's a cause for concern. We've got a chronic care role study which has been under way for two and a half years. We understand that it will be available in March.

At the same time, we also have the long-term care policy framework, which has been promised repeatedly over the last year. It was supposed to be available last January. We've also been given a commitment from the parliamentary assistant to make his best effort that both of them will be available in March.

What I'd like from you today is your opinion -- we've asked this of others before the committee -- of whether it's called a chronic care facility, a chronic care hospital or a long-term care facility and whether you believe that those which are a part of the chronic care role study today should be included in level-of-care funding regardless of what their role is or whether they should be included in this legislation.

Mrs Fallon: I think they should be included in the legislation. I realize that because many of them are already in a hospital setting as such, it would be very difficult to write up legislation for one part of a hospital, but I feel a lot of the suggestions that have been given for the other levels of care, the nursing homes and homes for the aged, really could apply to the chronic care setting.

Mrs Caplan: Thank you.

The Acting Chair: Thank you very much for appearing. We hope a lot of these questions will be answered as soon as possible and certainly we can look forward to that.

If I could ask the committee to just remain briefly, we have an update from our research officer and then we will resume. I would like to thank all of those who have appeared before and those who have just stayed to listen to what is going on. We will resume the hearings at 6:30. This evening we will have four presenters. The one group who could not appear this afternoon -- is it Reliacare? Is that how you say it? -- Reliacare will be with us around 8 o'clock, we hope. Thank you.

Ms Alison Drummond: You should all have at your places -- I handed it out this afternoon -- the summary of the first week of hearings. There are a couple of things I just want to note about that.

Usually we have a page with a caveat, which didn't get in so I'm putting it on Hansard. It's not a verbatim transcript of anything; always refer to Hansard or the submission itself, if you need that. It's just a general idea of what's been going on in the hearings.

The second thing is, it's not quite the usual format where it addresses specific clauses of the bill. Further along in that process of writing out the summary we will be bringing in the specific clauses of the bill as much as we can. Thanks.

The Acting Chair: Thank you very much. The committee stands adjourned until 6:30 this evening.

The committee recessed at 1652.


The committee resumed at 1836.

The Acting Chair: Good evening, everyone. Once again, the standing committee on social development is now in session for the hearings on Bill 101, An Act to amend certain Acts concerning Long Term Care. We have with us ministry staff, who are, as always, helpful, and also translation services.


The Acting Chair: If the presenter is ready, we will have Anne Morrison from Windsor Western Hospital Centre.

Ms Anne Morrison: I want to thank everyone for the opportunity to present our points today. Windsor Western Hospital Centre is a 550-bed, multisite health care organization, and we have an 83-year history of providing high-quality care that's specialized and general, medical and health services to residents in Essex county.

Currently, we provide both inpatient and outpatient services in medicine, surgery, rehabilitation, psychiatry, mental health and chronic care, and it's with respect to chronic care and long-term care that I make my presentation today.

Our chronic care program is provided currently on two sites. Riverview Hospital on Riverview Drive East in Windsor has 150 approved beds and offers supportive clinical services on both an inpatient and an outpatient basis. Riverview Hospital has been providing care for the chronically ill in Essex county since 1938. The hospital merged with the IODE Memorial Hospital to form Windsor Western Hospital Centre in 1972. The impetus for this merger was to plan the replacement of Riverview Hospital. Our Prince Road site operates 76 approved chronic care beds for appropriately assessed residents.

Our current program is dedicated to the provision of care by a qualified multidisciplinary team which includes family practitioners, consultant medical staff, nurses, physiotherapists, occupational therapists, speech-language pathologists, social workers, psychologists, chiropodists, dentists, dietitians, pharmacists, chaplains, recreational therapists, volunteers and others.

We focus on the individual resident in order to provide a quality of lifestyle that recognizes the dignity and unique value of the individual and fosters self-direction. Care planning, discharge planning and follow-up services involve the residents, their families and outside agencies where appropriate.

Our role in long-term care is changing. We have been involved in planning the replacement of Riverview Hospital since 1972. At least three distinct approvals have been received to construct a new chronic care facility since 1972. Prior to our existing plans, the most recent approval was to construct a 270-bed -- there's an error in the document -- facility in two stages on our Prince Road site in 1990. Phase 1, which provided building support systems, was completed in 1991.

In late 1990, as a result of the new directions in long-term care reform, Windsor Western was requested to replan phase II, the residential component of the facility in two phases. One was a new 225-bed long-term care facility and the second was a 45-bed geriatric assessment and rehabilitation unit in renovated space resulting from plan downsizing of acute care beds in Windsor. The new facility was planned to operate under the new long-term care reform policies and standards. Approval to proceed with construction on this new 225-bed long-term care facility was received in December 1992 and we are now progressing with construction.

Windsor Western is in the unique position of currently being a major provider of chronic care in the Windsor-Essex region. When our new facility opens in the fall of 1994 we will be a long-term care facility operating under the changes proposed in Bill 101 and related legislation. For this reason we're pleased to have the opportunity to make this presentation today.

As a current provider of chronic care and a member of the provincial long-term care system, Windsor Western shares many of the government's goals with respect to long-term care reform and has a strong commitment to the four principles outlined in the discussion paper Redirection of Long-Term Care and Support Services in Ontario, namely, the primacy of the individual and the right to dignity, security and self-determination; promotion of racial equality and respect for cultural diversity; importance of family and community; and equitable access to appropriate services.

Further, we believe that there is a need to bridge service gaps in the existing system in order to ensure a coordinated continuum of long-term care in Ontario. A well-developed continuum of services will ensure that the appropriate types and levels of service will be available to consumers when they need them and that clear distinction in provider roles and standards of care will minimize service overlap and facilitate equitable access to care.

We understand that Bill 101 is the first piece of planned legislation to govern long-term care reform and that it was developed to meet five specific policy goals: achieve equitable and needs-based funding for long-term care facilities in the province; strengthen accountability of long-term care organizations in relation to management and service provision; implement a consistent facility resident payment policy; establish a single point of access to facility services; and be able to make payments directly to adults with disabilities to self-manage their own support services.

However, we have some concerns regarding certain elements of the proposed changes. Our first area of concern is related to the equitable and needs-based funding objective and how it's incorporated in the proposed legislation. The proposed changes will clearly equalize the level of payment for long-term care. That's not in dispute. However, we are concerned that increased equality in funding levels has been achieved by a decrease in the average level of funding and consequently the level of service that will be provided. We understand that the level of funding being considered is in the range of $80 to $85 per resident day.

In the absence of results of the provincial-wide assessment of level of care needs of the long-term care system for residents using the Alberta classification tool, it is difficult to assess whether this level of funding will meet the needs of the resident population targeted. Our current chronic care population was assessed as requiring the highest level of care under the Alberta classification system in the preliminary sampling review over 18 months ago. We don't expect to serve a significantly different population in our new facility. Our staff are challenged to meet current standards of care at existing funding and staffing levels. Our current per-diem nursing costs alone exceed the proposed new daily revenue level by approximately $15 to $20 a day. The result of this funding change will be a deprofessionalization of the system.

With the expansion of community-based services aimed at assisting individuals to stay in the community for as long as is possible and prudent, we have seen a progressive increase in the level of care required by new admissions to our long-term care facilities. The provincial commitment to further expand community-based services is supported. However, the outcome of this service development will be a concurrent increase in the level of care required by individuals assessed for long-term care placement. This pattern was experienced in Alberta in the 1980s, and we will experience the same in Ontario in the 1990s.

The proposed level of funding and the scope of services it is to cover raises concerns about whether the proposed changes will in fact ensure needs-based funding.

Our second area of issue is some of the proposals dealing with strengthening of accountability. To ensure appropriate accountability for the management of resources and the provision of quality of care is an important objective.

However, the proposed service contracts and expansion of the inspection system that has been used in the nursing home system will not guarantee quality of service. The use of compliance management, peer review through accreditation and continuous quality improvement programs have had more success in improving standards and quality of service in the health care industry than step-by-step manuals.

Most provincial nursing homes and homes for the aged have successfully met the progressively upgraded standards and criteria established by the Canadian Council on Health Facilities Accreditation. Further, the province's recently passed Advocacy Act provides the opportunity for residents and/or their families or advocates to generate a review of care if concerns are raised. We believe this approach will be more effective than government inspections.

The concept of service contracts and care plans will clearly state the limits of service delivery requirements. Government discussions to date have created tremendous expectations for expanded and improved service delivery in long-term care. However, the proposed per diem of $80 to $85 for long-term care facilities will not support these promises. Further, this legislation does not appear to offer any flexibility for facilities to manage their case load, should the resources required to meet the care plan and service contract not be available.

The issue of governance is unclear in the proposed legislation. The chronic hospital system in which Windsor Western currently works is governed by local voluntary boards which act to ensure that facilities operate within industry standards and are responsive to local service needs. The proposed legislation appears to strengthen accountability to a centralized government agency, which we believe is in conflict with recommended regionalization of services and enhanced local autonomy.

The third area of concern that we have relates to issues around the establishment of single point of access to facility services. The establishment of a single organization to facilitate access to long-term care facilities has the potential to significantly improve resource allocation and appropriate access to services and should prevent unnecessary or early admission to long-term care institutions. This model was successfully implemented in Alberta using the placement coordinator as the gatekeeper to the system.

However, as currently stated, Bill 101 appears to provide limited choice for the consumers assessed for a level of care. This may weaken the system's ability to meet the ethnic, religious and geographic preferences of individuals. In addition, facilities appear to have limited ability to manage their case mix severity in order to ensure that they can meet their service contract and safely provide the level and quality of services contracted. It is very important that the appeal mechanism be timely and responsive.

In conclusion, Windsor Western recognizes and supports the conceptual framework of long-term care reform and agrees with the objectives Bill 101 was established to meet.

However, we do remain concerned about the impact of the proposed changes on the ability of long-term care facilities to manage resources and ensure the projected level and quality of service expected within the proposed funding levels. Sufficient operational flexibility must be available to allow long-term care facility managers to manage local service delivery responsively and responsibly.

We urge the minister to reconsider the operational issues of concern we have identified and thank you all for the opportunity to present our concerns here today.


The Acting Chair: Thank you very much for being here, and now, with your permission, we have some questions for you.

Ms Morrison: Certainly.

Mr White: Thank you very much for your presentation. You bring up a number of interesting points and a number of concerns, obviously, some of which have been shared by other people. I just wanted to ask a couple of questions in regard to the placement coordination service locally. That's been in place for a few years, has it?

Ms Morrison: Yes.

Mr White: Have you found that to be an onerous body? Have they not taken into consideration the clients' concerns and wishes and ethnic backgrounds?

Ms Morrison: I can't make a comment that that's been a negative process to date. What we do find currently is that many individuals sit on several waiting lists right now. There is not a consolidated waiting list for placement in the community. It's an issue that we're grappling with currently through a planning committee on long-term care in the region.

What is of concern to people is some of the wording in the legislation that appears to limit choice. So while there's a lot of support for the concept and strengthening the current system, there is concern about some of the wording that appears to limit choice, both on the part of the consumer and of the facility which may have the vacancy that's been identified for that consumer.

Mr White: What I'm asking about is the present system, which would remain pretty well intact. For those areas where there already is placement coordination, the system would be essentially unchanged under the legislation --

Ms Morrison: No, that's not true.

Mr White: -- and I'm wondering if you have had problems with the present placement coordination service.

Ms Morrison: We're interpreting the wording in Bill 101 as placing more restrictions on choice than the current system, as it's operating now, provides. There is central coordination of placement, but there is a fair degree of latitude for preferences on specific facilities in the county. It's the nature of the wording that has raised concern. It appears more restrictive.

Mr White: The present system would stay in place, but if the wording needed to be changed, I'm sure that counsel would look at that. Thank you.

Ms Carter: Thank you for your general appreciation of what the act is trying to do. I just wondered if you could clarify what you're saying about funding. You say that the proposed per diem of $80 to $85 won't support the promises. Now, as we all know, the amount of funding will depend on the levels of care being given, on the weighting of how severe the actual people in that facility are. Will that not solve the problem, so that if you get more people in the higher levels of care, you will get more funding to meet that?

Ms Morrison: The levels-of-care funding, as the system works in Alberta and as I understand is proposed for Ontario, operates on an average, so while there are interfacility differences in funding based on the assessment of the level-of-care mix that an individual facility has for that year, it is really a redistribution of existing funding among existing services. So it is not related necessarily to need; it is related to redistributing existing dollars targeted for that sector.

Ms Carter: Except that there are additional dollars going into the system, so there is going to be more money on average available than there is at the moment.

Ms Morrison: For certain facilities. Other facilities -- and that's part of the evening out of the funding through the system.

Ms Carter: Okay. I'd also like to thank you for being, I think, the first person to mention in your presentation that the Advocacy Act is relevant here and is going to provide a vehicle for consumers to have their say. I appreciate that.

Mrs Caplan: Thank you for an excellent presentation. The questions I have really relate to a number of issues that have been raised by a number of presenters. If I could go through them with you -- and I would invite the parliamentary assistant or Mr Quirt to jump in in case I haven't explained it quite as I understand it. First, on the issue of your funding concern, I think it is a legitimate and valid concern, particularly since the chronic role study has not been complete and we don't know for certain how chronic hospitals are going to be treated.

The first question is: Do you think chronic hospitals should be included? Let me change the phraseology. Do you think chronic hospitals or long-term care facilities, if that's what they end up being called, should be included in Bill 101?

Ms Morrison: We believe the role of chronic hospitals does need to be confirmed. The role of chronic hospitals with respect to providing specialized services to specialized populations and providing more active treatment for a sector of the population that can benefit from that is still a valid role in the continuum of care.

Whether the funding mechanism that is designated to cover the long-term care sector will be appropriate for the chronic hospital sector remains to be seen. We still are without the results of the assessment and so we're not sure of where everyone fits. Chronic hospitals may be better served by programmatic funding.

Mrs Caplan: What we heard earlier today -- and this is where I would like confirmation if I'm correct or incorrect -- is that the ministry envisions supplemental quality-of-life program funding to be available as an enhancement over and above the per diem allotted to the level-of-care funding under the Alberta classification system.

Mr Wessenger: Yes, I will have the staff confirm that.

Mrs Caplan: Yes, that's what I heard this afternoon. I just wanted that confirmed.

Mr Quirt: That's correct. The funding formula would provide funding for three distinct different cost centres: funding that would vary in accordance with residents' care requirements for nursing and personal care, funding for quality-of-life programs that would be provided separately and would have to be spent on those services and, thirdly, funding on accommodation.

I would point out, however, that in the case of facilities that currently operate with costs above the amount of funding to which they'd be entitled under the new system, the province's position is that we would in effect red-circle those facilities and continue to provide the level of funding they're currently receiving from residents in the province. I suspect that would be the case with the new Windsor Western Hospital Centre.

Ms Morrison: Yes, it has been.

Mr Quirt: That's also the case with four other chronic care facilities that through either a local planning process, as was the case here in Windsor, or through a decision by the board of directors have decided to redevelop as long-term care facilities.

Mrs Caplan: I think that clarification is important because it then allows for you, in the absence of the chronic care role study and the policies that flow from that, to advise this committee whether, on behalf of the hospital, you feel that not only Windsor Western but all long-term care facilities should be a part of this legislation.

Ms Morrison: I think if the areas of the legislation we're concerned about were addressed, then they could be considered under the legislation.

Mrs Caplan: What I hear you say, and correct me if I'm wrong, is that if your concerns are not addressed, then conversely you don't think it should be included.

Ms Morrison: That's correct.


Mrs Caplan: Okay, I wanted to be clear on that. The second point that you made had to do with choice -- and we've heard a lot about that issue -- consumer choice as well as the ability of the institution to participate in the selection of individuals appropriate to that institution. What we heard from Mr Quirt today was that an institution would be able to refuse admission to a patient whom it did not believe would be appropriately cared for in that institution. Is that correct, Mr Quirt?

Mr Quirt: Yes, they would be able to refuse admission on grounds that would be specified and protected in regulation. That's what the bill reads at this point. The regulations would prescribe the reasons that a long-term care facility could refuse admission of a prospective resident. The regulation would talk about, in general terms, the inability of that facility to appropriately care for the resident. It may be a structural issue or it may be that the resident requires a particular therapy or service the facility's not equipped to provide. We would hope that placement coordinators, as we've heard earlier from placement coordination submissions, would not refer a client requiring that type of service in the first place.

Mrs Caplan: Would you be more comfortable, Ms Morrison, if that policy intent was included in the legislation as opposed to being left to regulation?

Ms Morrison: Yes, our concern is not that unlimited choice be made available. That's part and parcel of the review process and having criteria for admission for specific levels of care. Our concern was the flexibility that would be allowed to make individual choices that may run counter to existing criteria on an issue-by-issue basis.

Mrs Caplan: What I've heard you say is that you'd be pleased to see an amendment in this legislation that would enhance individual consumer choice and would clarify the choice permitted to the institution when the placement might not be appropriate from the institution's point of view.

Ms Morrison: That's correct.

Mrs Caplan: Okay, that was the second point. Do I have time for another question?

The Acting Chair: One more.

Mrs Caplan: The last question I have is really the one relating to inspection. You're aware that the ministry changed its procedure from a prosecutorial approach to a compliance/continuous improvement approach. You've had some experience with that?

Ms Morrison: Yes.

Mrs Caplan: On page 4 you make the point that: "The use of compliance management, peer review through accreditation and continuous quality improvement programs has had more success in improving standards and quality of service in the health care industry than step-by-step manuals.... This approach will be more effective than the `government inspections.'" The concern I have is that, as you know, the NDP in opposition opposed that change. To me, this bill reflects that ideology. I think it's very important that, if you and others believe in a quality improvement approach, it would be helpful if you could actually make suggestions on the kind of amendment or wording that could be incorporated in the legislation that would ensure accountability as well as allowing for a more progressive quality improvement approach to ensuring and raising standards of quality of care.

Ms Morrison: The one point we were concerned about is that there is a very precise statement about having a quality assurance program. We don't take issue with quality assurance programs per se. Quality assurance has become a bread-and-butter issue in the industry, but the industry has evolved and a more common approach now is one that builds on the quality assurance and moves into continuous quality improvement and effective risk management.

Mrs Caplan: If you weren't able to make the recommendation, what I'm hearing you say is that you would prefer an amendment to this legislation that (1) required accreditation and (2) required a total quality management program within the institution to be accountable through the accreditation process.

Ms Morrison: Yes.

The Acting Chair: I believe we have a clarification.

Mr Wessenger: Yes, I'd just like to confirm, because it has been confirmed before, that we also share your concern about the use of the words "quality assurance plan." More appropriate language is being looked at because certainly the intent, without getting into current language, is to have a quality management approach.

Mr Jim Wilson: Thank you, Ms Morrison, for your presentation. If I may say, Chair, to the parliamentary assistant, Mr Wessenger, that's a bit of good news you've given us, that the government's willing to move and maybe change the language in the act to "continuous quality improvement" rather than "quality assurance." It's nice to know that these hearings are having some effect, and we're only halfway through them.

Mrs Caplan: We got two today.

Mr Jim Wilson: It's been a banner day. Ms Morrison, when you mentioned your comments surrounding the funding issue, you were well aware that your new long-term care facility is to be red-circled. You mentioned in your oral presentation that the shortfall in the per diem could be $15 to $20 a day.

Ms Morrison: No, I would like to correct that.

Mr Jim Wilson: Sure.

Ms Morrison: The $15- or $20-a-day shortfall is in relation to what our nursing budget alone is.

Mr Jim Wilson: Yes, I realize that.

Ms Morrison: Our per diem is significantly larger than that.

Mr Jim Wilson: Than $15 to $20 a day, yes. Your per diem is $80 to $85; that's what you're expecting.

Ms Morrison: No, that is the range that we have heard is being considered for this sector. As a chronic care hospital, our current per diem is over $200 a day. That allows us to provide a broader range of services. Our concern is that at our existing nursing staff level, which we find quite challenging and which our residents complain about, the cost for nursing expenses per day currently is $100. On top of that, we have other issues. That does not address the issues of hotel services, of other program services and other associated expenses.

Mr Jim Wilson: Taking into account the other funding opportunities that Mr Quirt talked about just a few minutes ago, and given your comments that the whole discussion around long-term care has perhaps raised expectations in the community, what's the discussion been at your board tables in terms of your future ability to deliver the level and quality of care that you're delivering now? Do you expect to see a decrease if the funding isn't straightened out?

Ms Morrison: As I've stated, we're concerned. We have a level of funding that we have been assured will be red-circled, but I don't think I have to outline in significant detail the level of salaries and benefits and the impact of such expenses as WCB. Effectively, if we had a nursing staff member go off on a benefit issue with WCB and we were obliged to pay the full cost, that would translate into the expenses for four FTEs in a year. The going rate is about $200,000 for a case. If the individual is not able to come back to work, that translates on average to about four FTEs in the department of nursing. That's with a mixed staffing level.

Our concern is not so much the red-circling now, but the impact of progressive expenses in labour contracts, WCB fees and other rising costs. We may be slower at reaching this level of funding or its comparator a few years down the road because of the red-circling, but we're here today because we know we've now been streamlined into the system, and that is our future, whatever the impact of annual increases between now and wherever we catch up.


Mr Jim Wilson: You make the point quite clearly in your presentation that it's levels-of-care funding but not necessarily levels-of-care funding, and that there's a pool of money that you're given that's capped, essentially, and yet you're expected to meet government standards. You expect you'll be able to do that, but you're saying that something like a WCB case, just one, could throw your budgeting right off.

Ms Morrison: That's correct.

Mr Jim Wilson: I think it's fair for committee members to take note of that. Just in terms of the --

The Acting Chair: Last question.

Mr Jim Wilson: Yes, thank you. I note Mrs Caplan had a few of them, and I thought they were all good, Elinor.

The Acting Chair: We could say this is your fourth, sir.

Mr Jim Wilson: I'll make it very quick. As Mrs Carter pointed out, you're one of the few -- I guess probably the only presenter today -- to mention the Advocacy Act. What I read between the lines in your comments there is that perhaps it's overkill to impose an expanded inspection system plus the advocates. I sat through, as did other members here, the advocacy hearings and introduced a number of amendments to that legislation, and certainly we were assured by the government that in fact advocates essentially were acting like inspectors and would ensure that any problems in the system were brought to the attention of people who could do something about it. Do you just want to briefly comment on that?

Ms Morrison: Yes. We support the Advocacy Act and we think that if there are benefits to be achieved it will take some adjustment in certain sectors, but our concern is that with the Advocacy Act and the strengthening of the inspection system there will be a bit of overkill in review.

The Acting Chair: Mr Wessenger, a quick question.

Mr Wessenger: Yes, just a quick question: I'd like to know, are there any patients in your chronic care facility now who will not be able to be included in your new long-term care facility? Secondly, what will the new building do with respect to the change of environment for the patients in the facility?

Ms Morrison: With respect to your first question, we believe there are a number of residents in our existing facility who may not move to the new facility. We are currently working in committee in the community to define admission criteria for our new facility. One of the issues we had in planning this new facility under long-term care reform and our timing was that we were planning ahead of formalized policy, and so we were doing so with negotiations with the planning bodies within the ministry and effectively we weren't really definitively clear about the population we were serving. That challenged us to plan in such a way that the facility could effectively handle a very wide range of individuals and individual needs.

We have a couple of specific populations. One unit in particular is a 30-bed cognitively impaired unit for a population we do not take care of now. That's the ambulant, cognitively impaired, difficult-to-handle senior. So that is a population, that's 30 beds of the 225, that we're not taking care of now but somebody is taking care of them somewhere in the system.

With respect to the improvements the facilities will offer, we're very proud of the building. We think the building will provide a level of living environment and opportunity for more independent living than we can clearly offer through out units either at Prince Road or Riverview. The largest contrast of course is with Riverview, which was originally constructed to be a residential school and is probably an historic monument in the long-term care system in this province. I haven't met anybody who hasn't gone through at least two of the cycles of planning the replacement of Riverview. We were becoming an institution of our own on that point alone.

Our concern with the building I guess, if we have any, is that we were planning on a model and some requirements, and it's going to make it very challenging to work, down the road, on these funding parameters. We're not a small facility that has four people in a room and the tight space per resident that involves and the differences in overhead expenses. Our facility was planned and approved and is proceeding with construction with a design that has, on average, 1,000 square feet per resident, and we have no on-site kitchen for production, no on-site laundry for laundry production. It was basically planned on a purchase service arrangement.

Further, the room configuration was planned with the guidelines of 80% single rooms and 20% double. Now, having taken several of our residents through, the reaction of residents is that they're moving into a very nice hotel and we're proud of that. They like that and they can't believe that long-term care facilities are going to be this nice. But there is a cost associated with that.

We have a lot of facilities. We have excellent rehabilitation service areas. We have recreational facilities internally and externally. The cognitively impaired unit has a protected, secured garden that is designed specifically for this population. We have planned for a unit designated for the young disabled because we, in the city, chronically have somewhere between 35 and 45 young disabled individuals who because of the configuration of housing and resources in the community, are forced to live in institutional living. But we believe they need a different environment than living in units with the frail and very confused elderly. That's another population. They have service needs that someone who has been in a home for the aged or a nursing home doesn't have and we will be dealing with those.

I think some of the challenges in the funding will be finding some middle road between maintaining a level of funding that's economically reasonable for the care provided for the population in a long-term care system that can deal with that. Then we have other issues that are going to take specialized programmatic funding that will require a topup system. It was positive to hear that there was a potential for that. We would welcome any discussion on how we can best fit in that.

Mr Wessenger: Thank you very much. I really appreciate your letting me know about what just sounds a marvellous facility.

Ms Morrison: You're welcome to come and visit any time. We have some mock-up rooms we are pleased to show.

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

Mrs O'Neill: Madam Chair, I have a question that I would like to pursue with ministry staff that Ms Caplan touched on.

The Acting Chair: Possibly while the next group, Central Park Lodges, is coming forward you could put that on the record.

Mrs O'Neill: I've had a lot of correspondence on the fears of red-circling and it's now coming forward in these discussions. I wonder if we could have, either in writing or verbally, just how that plan is going to work. Are there going to be a number of years that are going to be allocated around red-circling or could it go on for a long time? How is the amount going to be determined that a facility will be classified as being eligible for red-circling?

I think it's something we should, if we have the information, try to clarify because, as I say, I've got between 5 and 10 letters on this item on my desk right now.

The Acting Chair: Would you like to take it under consideration?

Mr Quirt: I can describe it briefly now and follow up with a briefing note on that topic, if you'd like.

Mrs O'Neill: I think that would be very helpful if you could that.


Mr Quirt: The policy on red-circling is a simple one in that the province has made a commitment that no long-term care facility will get less support from a combination of the resident income and the provincial subsidy than it currently has. So, for example, a municipal home for the aged that now operates with costs above what it'll be eligible for under the new system will continue to get the same level of support from the province and residents, and that translates to the municipality being able to continue with its existing level of operational expenditure with the same municipal contribution.

The same is true, as I mentioned earlier, of those facilities that are now in the process of converting from a chronic care hospital to a long-term care facility, and we estimate that roughly 10% of the long-term care facilities in the province will be red-circled. Obviously the facilities that are red-circled are those that are the most highly funded 10% of facilities in the province. We will not know precisely how many are red-circled until we know the precise amount of funding available through the estimates process and match that to the case mix index of each facility.

No decision has been made on an economic adjustment policy for those red-circled facilities. One would be made once the scope of the situation was known; in other words, once we knew how many facilities would be red-circled, what percentage of the facilities were in that category and what costs were associated -- how far out of line they were with the rest of the long-term care facilities in the province. We'll provide a note that describes that policy for you.

Mrs O'Neill: Thank you very much.


The Acting Chair: Thank you for your patience. I understand, as the clerk has pointed out, that you represent Central Park Lodges and the Ontario Long Term Residential Care Association.

Mr Jim Anderson: Yes.

The Acting Chair: Would you kindly introduce yourselves, and then you may begin.

Mr Anderson: Madam Chair and committee members, my name is Jim Anderson. I'm general manager of Central Park Lodges in Windsor. I have with me Pat Sousa, who is director of sales marketing and management contracts for Central Park Lodges and is also president of the Ontario Long Term Residential Care Association, and Rick Winchell, who is the executive director of the Ontario Long Term Residential Care Association.

The Acting Chair: Thank you for coming. Welcome.

Mr Anderson: My throat isn't that great, so if it's all right with the committee, I'll start off and pass it off to Mrs Sousa and she can finish up.

The Acting Chair: Certainly.

Mr Anderson: Central Park Lodges has been providing quality residential care services to thousands of seniors across Canada since 1961, and here in Windsor since 1972. Our company has also played a key role in shaping the standards of our provincial sector's professional organization, the Ontario Long Term Residential Care Association. Together, Central Park Lodges and the association are committed to service excellence and ensuring that Ontario's consumers have retirement living options that are second to none.

The association has represented privately operated retirement homes since 1976. The over 600 facilities in the residential care sector in Ontario play a major role in the long-term care system. More than 30,000 seniors, disabled and post-psychiatric residents, whose average age is 83, live as independently as possible in these facilities; 20% receive general welfare assistance.

People tend to move into a residential care setting when daily support becomes a necessity or because they prefer the sense of belonging and social energy that only a professionally staffed congregate setting can provide. Essentially, residential care helps people maintain their independence while offering a wide range of choice in location, amenities, services, size, type of unit and price.

Basic services can include socialization or interaction programs; 24-hour security and professional care support; assistance with bathing, eating, dressing and medication; personal care programs; community outreach activities such as pastoral and transportation; meals, housekeeping and laundry.

Residential care helps people maintain dignity, respect, equality, security and a sense of belonging, autonomy and choice. It fills the service gap between home care and extended care. As the government moves to redirect long-term care, the need for residential care service will increase because of several factors:

(1) Consumers are demanding more choice.

(2) There are increasing restraints on public funding of all care programs.

(3) There is a planned decrease in the number of extended and hospital beds for the elderly and disabled.

(4) The size of the elderly population will be increasing substantially and steadily.

Residential care is an important part of the community. Our sector is helping to alleviate the pressure on the publicly funded system at a time when government will have to try to deliver more services with less money.

As an important link in the continuum of long-term care, Central Park Lodges and the association are concerned about Bill 101. It is the first piece of long-term care redirection and as such it describes how the government intends to legislate publicly funded long-term care institutions.

From our perspective as experienced providers of residential care services, Central Park Lodges is troubled by several aspects of Bill 101. The bill leaves too many issues to regulators and provides too much power to government and its inspectors. It holds facilities accountable for providing for all residents' needs without ensuring that appropriate funding will be provided to make this possible. Most important, the bill restricts choice by limiting people's ability to make informed decisions. Specifically:

Consumer choice is restricted: Consumer choice is not given priority, and an applicant's ability to appeal a coordinator's decision is limited. Facilities are not given an opportunity to match potential residents' needs with the facility's mission, services and programs.

The bill is deficient in its recognition of the province's cultural diversity, most notably in the francophone community.

The bill sets out a new placement function, but the details as to how the placement coordinator will function are missing. In the best interests of consumer choice, we also remain concerned that a singular placement system may restrict information involving care and accommodation options provided by private sector operators.

We are concerned about Bill 101's attempt to move the publicly funded sector away from an insured service to a contractual agreement model with no accountability to maintain equitable, consistent services to meet residents' needs.

Bill 101 may downgrade the publicly funded system through overregulation and underfunding, making it inferior to a privately operated system which offers choice and flexibility.

The bill seems to set out a more adversarial direction to inspections in the publicly funded system than currently carried out. Facilities in this sector have successfully operated with a different approach to patient care, using accreditation and quality management practices to monitor and improve, where necessary, patient care and services.

Mrs Pat Sousa: Central Park Lodges and the Ontario Long Term Residential Care Association strongly believe the best interests of Ontario's older consumers will be best served by a long-term care system that considers the following:

-- That the placement coordinator serve to help people make informed decisions about all the choices they have in long-term care; this should include a sensitivity to the cultural diversity of the province.

-- That applicants have a timely and efficient appeal mechanism with respect to placement.

-- That existing resources be used for placement coordination and that no level of bureaucracy is created for this purpose.


-- That the government be held accountable to maintain equitable and consistent services in publicly funded long-term care facilities in Ontario.

-- That the legislation not require facilities to provide all services as defined in the care plan unless the government assumes responsibility for funding these services.

-- That sanctions should only be implemented as a last resort; facilities must have the right to appeal the sanctions.

-- That the powers of inspectors not be increased and that the use of the existing compliance management program be continued.

Over the past two years, the residential care sector has been part of a broad examination by the Commission of Inquiry into Unregulated Residential Accommodation, the Lightman commission, which has been attempting to define the role of the sector.

The Lightman commission has recommended that residential care be regulated under accommodation-related legislation, which effectively impairs the sector's ability to deliver care. Both Central Park Lodges and the Ontario Long Term Residential Care Association believe that the commission recommendations would have vast and very negative implications for the residents of retirement homes and their families.

We acknowledge that there have been problems in some rest and retirement homes and that there is a need for province-wide standards and a formal system of disputes resolution to address residents' concerns. Since 1985, the Ontario Long Term Residential Care Association has lobbied for consistent provincial standards.

Our approach to meeting this need is the most practical, efficient and least expensive way to deal with some of the problems that have arisen in Ontario's rest and retirement homes. This approach would not create any additional cost to the resident or to either of the two levels of government.

Specifically, we are urging the government to enact provincial legislation and incorporate mandatory standards enforced by the municipalities. These standards would set out the terms for obtaining a licence to build and operate a rest or retirement home. They would also apply to all residential care settings across both public and private facilities that offer residential care units.


Mr Anderson: Central Park Lodges share the Ontario Long Term Residential Care Association's belief that the residential care sector is an integral element of the long-term care continuum, but its participation is challenged by the Lightman commission's recommendations. Additionally, we believe that there are some problems with Bill 101. These issues combine to restrict consumer choice in long-term care.

We have presented recommendations that, we're confident, will help protect consumer choice, and the important issue of choice will only be optimized by considering an alternative and more practical approach to regulating the residential care sector. Thank you.

The Acting Chair: Thank you very much. Mrs O'Neill.

Mrs O'Neill: It's nice to see you again. I'm very pleased that you mentioned the francophone community. We have not heard a lot about the francophone community or indeed from the francophone community in this set of hearings. I hope that may change when we go up to my home in Ottawa next week.

I'd like you to say a little bit more about the issue that I think is coming to the fore via people like yourselves and indeed in some of the municipalities. On page 2 you're talking about the accountability issue. I'd like you to say a little bit more about how you feel that is either going to be in jeopardy -- or if you even want to use the word "deteriorate" -- under this bill.

Mr Rick Winchell: Specifically, our concern is that under the contractual agreement approach, people are clearly more accountable, as opposed to the publicly funded approach.

Mrs O'Neill: Can you say a little bit about how that happens in your environment?

Mr Winchell: We have an interesting situation in our own environment in that we are privately operated, so we are not accountable, as you probably already know, except on a municipal level. There are many municipalities that have existing bylaws. In Windsor, Hamilton and Ottawa there are contractual agreements. That is the rationale behind the birth of our association, whereby as a volunteer organization we have been pushing very hard for standards. I can go back as far as the days when the Conservatives had a majority government in this province.

Mrs O'Neill: That's a long time ago.

Mr Winchell: That's a long time ago.

Mr Jim Wilson: But boy, were they good days.

Mr Winchell: I can tell you that through each government we have been very strong in trying to push for provincial standards for residential care, and unfortunately it has fallen on deaf ears. Where we're becoming extremely concerned is that we're now being looked upon, as a result of the Lightman commission, as being accommodation providers only and not being recognized as an integral part of the long-term care continuum. As you well know, there's a huge gap between home care and extended care, as we'll call it, right now.

Mr Anderson: We have a good level of residents, as Wayne is there quite often and he knows. We went over some of this, and their biggest concern is who this person is going to be -- and the families we talked to are concerned -- who's going to be telling them where they're going, and if they don't want to go there, what are going to be their options, or how is it going to be judged? There are so many things left out for them.

Our residents are very independent-minded to start with. They came all through life and they're still paying their own way and they want to know if this is in some way going to be steering them where they don't want to go or where it's not appropriate. We have mixed cultures and maybe the slot will say they should go here, but this facility has a better base of Italian-speaking people or they're more comfortable with the peer group here. They're concerned about who's placing this and what criteria they are going to use.

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

Mr Anderson: Yes, we do.

Mr Winchell: I can also add that the most accountability we have -- as you may or may not know, across the residential care sector in Ontario the average occupancy is less than 80% -- is to our consumers. They have the ability to walk across the street. That's exactly what will happen if we aren't providing quality services.

Mrs O'Neill: Thank you very much. I'm sorry that you feel that somehow is in some kind of jeopardy with Bill 101, but I tend to agree with you. In any case, your facility is worth visiting. I'm very happy I had that opportunity.

Mr Jim Wilson: Thank you for your presentation. As the Health critic for the Ontario PC party, I admit we weren't perfect, and standards were long overdue, but subsequent governments haven't done anything on that front either. I want to ask you a general question in light of the Lightman commission report and Bill 101. Generally, what do you feel is the future of your sector, rest and retirement homes? Because this bill may be a signal that you'll be swept up in its contents at some point in the future.

Mr Winchell: I would like to say that with regard to all the legislation and all the regulations a couple of points have to be made. First of all, you can't stop the tide of aging. We believe the phenomenon is getting to the point that all the promises and commitments -- for example, with regard to community-based services we see already and we know that existing community-based services are strained right across the province. It's one thing to talk about delivering a comprehensive model; it's quite another to deliver it.

Let me tell you straight up front that we have no tolerance for somebody who's not providing a quality service. That's why we consistently have been pushing for provincial standards as opposed to municipal bylaws. But I believe that this province, with the aging phenomenon and the funding realities, cannot continue to ignore the contribution of residential care. I believe we have a healthy future because again, ultimately, if people have the ability to pay, they will come and make that choice.

Mr Jim Wilson: I want to say two things on that, though. First, there are a lot of people who are in the nursing home business right now who fear that this government may have a bias against them in terms of private sector involvement in the delivery of health care services to our elderly. Second, if I look at rest and retirement homes in my own part of the province, I do get complaints the odd time from constituents who feel that in fact some of the residents in those homes are in need of almost chronic care services. Because maybe there aren't other services in the community, the rest and retirement home sector is having to increase the level of care it's making available to its residents, to some points where I've had consumers come to me and say, "You can't tell the difference between the rest home in town and the nursing home in town." Given those two phenomena, I ask you again, what do you think the future is of your sector?

Mr Winchell: Okay, I'd like to answer your first question, which was with respect to the current government's attitude of private sector involvement in health deliveries. In fact, it's a stated preference of the long-term redirection that there be preference given to not-for-profit providers. My question from day one, and the association's question all along, has been, where is there a correlation between ownership and quality? I brought it up at the seniors alliance at the Old Mill last summer, if this government could please consider at least putting the ideology aside and putting it to the test. A good example of that is the Hyde report, which was done in 1983 in Alberta, where they bit the bullet and said, "Let's cut to the chase and find out if in fact not-for-profit means superior quality." The end result was no; there's no correlation between quality and management. I also managed to get the Minister of Health of that day to admit that there are just as many bad products on the not-for-profit side as there are on the profit side. That's the way I'd respond to your first question.


Mr Anderson: In speaking about Windsor, which I'm familiar with, anybody who's familiar with Central Park Lodges in Windsor knows we work with everyone in Central Park Lodges. We're an outreach type of facility. We support Windsor Western through fund-raisers, we're community-organized and we support publicly funded facilities like Riverview, which is down the street from us. We make available our facilities for them to come in at any time, and they let us use their parking lot when we have parties.

I don't have a problem in Windsor and I'm sitting in probably the heaviest-regulated-bylaw city for residential care. I have no problem with the drive for some sort of regulation across the province. The major problem my residents have, and have indicated through petitions and other means, is that as they're paying their way, they don't want to have that interfere with their choice of who is going to take care of them, who's going to feed them and how they want to be done that way.

I think the bylaws in Windsor are a classic example of not enough yet but something that has worked quite well in this city, at least as far as I'm concerned. I can't admit nursing home people or I will be fined. When my people reach nursing home stage, they have to be papered. If they have funds available to hire extra-duty nurses, that's their choice to spend the funds on that.

I do not argue with the fact that we only take care of people to a certain level, but it's not either the public or private nursing homes' fault if the system is backlogged through chronic care, into nursing homes and back on our laps. I've got people who can't get into nursing homes and fortunately most of them have the money to pay for that extra care. It's not that I'm sitting there wanting to run a nursing home, but what am I going to do? Throw these people out on the street?

Mr Jim Wilson: You can't throw them out on the street.

Mrs Sousa: I've been in this business for 15 years and I've seen a definite change in trends. In 1977 our average age was 72 and the people walked in. Now, our average age is 85 because they're getting services in the community. Some of them have been actually ghettoed in their homes with those community services, longer than they should have been. When they come into the facilities, they are much more in need of care. Also, the residents have come through the consumer age. They're smarter people. They want a choice. If they don't want to move to a nursing home, they want to be able to have the choice, if they can, of buying the services from the community in the facility, or from the facility and staying in the lifestyle that they've been accustomed to for maybe four or five years.

Mr Jim Wilson: Well, I appreciate it. I think that's a --

Mr Winchell: Can I just answer your second question, though, about the future? One of the concerns and one of the primary reasons we want to address this committee today is because the power of the -- I don't know whether they're going to be coordinators, area managers; call them whatever you want. All I know is that the concern from an information standpoint is that if there is a bias for a not-for-profit system, then will the consumer in fact be given the kind of information at the front end to make an informed choice? So far, I haven't heard one shred of evidence that there will be a broad menu of resources available where people can make an informed choice.

Right now, by the way, and this has been something that is frustrating for us as a small association, the average consumer doesn't know the difference between a nursing home, a retirement home and a home for the aged. To follow up on what Mr Wilson was saying earlier, if you call right now to complain about a retirement home and you call seniors' issues, invariably it's referred to us. We've been working very closely with seniors' affairs before and now seniors' issues in trying to resolve consumer complaints. I can tell you, I deal with them personally on a regular basis. Invariably, it's a complaint about something that has nothing to do with a retirement home; it's a home for the aged, it's a nursing home. People are very confused, which brings us back to our major concern: Is there going to be a concerted effort by this province to inform the consumer about the various products?

Mr Jim Wilson: A very good point.

Mr Wessenger: Could you tell me how many residents there would be in these registered retirement homes in Ontario?

Mr Winchell: Approximately 30,000.

Mr Wessenger: That compares with, shall we say, approximately 60,000 in the nursing homes and homes for the aged.

Mr Winchell: I'm not including in that number, however, the residential care beds in homes for the aged. It might be as high as 36,000 when you include those. Mr Quirt might have a better handle on that.

Mr Wessenger: You indicated that you would prefer to be regulated by legislation?

Mr Winchell: No, I said that our association would like to see consistently enforced province-wide standards.

Mr Wessenger: Wouldn't that be regulation, if the province passed a special act setting out standards for the retirement homes and rest homes? That would be regulation, in effect.

Mr Winchell: I would like to see the province set the standards and the municipalities enforce those standards.

Mr Hope: They'll get mad at us if they do that.

Mr Wessenger: What do you see wrong with the consumer protection model for residents of your homes? For instance, you could have such things as a requirement that registered retirement homes have residents' councils. You could have a bill of rights set in.

Mrs Sousa: We have those now.

Mr Winchell: We absolutely support and endorse all those suggestions. We can't live with the idea of suddenly a single-person commission coming along and looking at everything from a boardinghome to Central Park Lodges and everything in between and deciding that we're not care providers. I can tell you right now that if you go across this province and talk to referral agencies, care coordinators, social workers -- and I'm talking about from the not-for-profit side -- they recognize the valuable contribution of quality residential care. The problem that I have, and I speak on behalf of the association, is that Dr Lightman has very conveniently used the term "rest home" to roll in everything from a basement boardinghome to a 24-hour, all-inclusive, fully professionally staffed residential care facility.

Mr Anderson: We've had a bill of rights in Central Park Lodges for years. It's right up on the board and it spells things right out. It's very similar to what's proposed. I wouldn't mind those going right across to everybody.

Mr Winchell: Actually, I brought copies of our commitment to resident quality.

Mr Wessenger: Could I just follow up again. I actually am quite familiar in my own community with two very good facilities in the retirement homes area. I'm somewhat familiar with the residents in those facilities as well. You have a placement coordinating agency here. Are people referred to you who are not appropriate for a nursing home? Does that happen too?

Mr Anderson: Yes. We work mostly with Margaret-Ann Prince and the VON primarily, but we take respite care, recuperative care and vacation care. Recuperative can come directly from the hospitals. All the hospitals refer to us. They have a list of people in the residential care sector, and they look at where they think they would be appropriate.

We're lucky here that the people we know in placement coordination, like the VON, know all of us very well, and they've been here a long time. So when they place someone with us, it's usually a good fit. The odd time, we've gone back to her and said, "She might be better over -- " if she's, say, Italian-speaking; she might be more comfortable. That's why I wanted to speak here. You're coming to a community that works well with its placement coordination services.

Mr Wessenger: Do you have any idea of the number of your residents who would be receiving some level of care now from community services?

Mr Anderson: From the VON?

Mr Wessenger: Yes, the VON.

Mr Anderson: Probably, on a daily basis, there are about four or five.

Mr Winchell: About 1%?

Mr Anderson: Yes, about 1% of VON coming into the facility.

Mr Wessenger: So it very low level at the moment.

Mr Anderson: And also therapy; there are always four or five on therapy. They come down from Riverview to do their therapy, rather than us, to have them --

Mrs Sousa: And they'll do palliative care too.

Mr Anderson: And they took mobile diagnostics away from us, but that's a whole new argument. We used to be able to have X-rays in our facilities. Now our residents have to pay for an ambulance to go out in the cold, come back -- they didn't find it -- and go back again. But anyway, Mr Cooke's office and Mr Lessard's got a nice letter from my care coordinator. We're hoping to have it reviewed.

Mr Wessenger: Okay, thank you.


Ms Carter: I'm concerned with your problem with the Lightman report. My understanding is that Lightman is recommending that normal landlord and tenant requirements should apply to people in rest homes. I would suspect that is, say, more at the sort of lower end of the scale than at a facility like yours, but I was just wondering what your objection to that might be. It seems to me that this is a way of giving people in these homes -- even, as I say, at the sort of lower scale -- the kinds of rights that we all take for granted.

Mrs Sousa: I think the main objection that we have to Lightman's report is that under the Landlord and Tenant Act, we would have to give our residents 24 hours' notice to access their rooms. For instance, most of the residents who move into our facilities move in there because they have a need. They wouldn't leave their home if they didn't have that. So their safety is in jeopardy by being under the Landlord and Tenant Act.

There are also several recommendations in there that just don't make sense. For instance, I think it's recommendation 100 that states that as long as you're 16 years of age or older and can read and write, you can give medications. Now, that is very --

Ms Carter: So maybe it would need to be a tailored version of the Landlord and Tenant Act, but it does seems to me that there are rights in there that maybe should be specific.

Mr Anderson: It's the wrong act, essentially.

Mrs Sousa: There's nothing wrong with some of his recommendations at all, but as Jim says, it is the wrong act.

Mr Anderson: I think it's the wrong vehicle they're using to get to the right --

Mr Winchell: We're taking a housing act and applying it to a care setting. Our objection is that we are care providers. Dr Lightman has only seen us as accommodation providers. If you look at the implications -- we've left copies -- of the application of the Landlord and Tenant Act specifically, it is not something that we as care providers could live with. More importantly, it's not something our residents want to live with.

Mrs Sousa: We have had meetings with our resident families and talked to them about this. They are very angry to think that this would be done to them, because they feel their choices are taken away from them if they have to go under the Landlord and Tenant Act and with some of the recommendations that are coming out.

Mr Anderson: The majority of our residents are very with it. I think they're taking some isolated incidents and, like you said, some other types of boarding homes and trying to apply to all of us, which are the vast majority of them. I want my residents to have protection and believe they have protection, and they know they have protection. I know there are some settings where they don't, but the Landlord and Tenant Act is like taking a sledgehammer to a flea. We can maybe look at the areas of problems and mould something that will fit it.

Mr Winchell: Dr Lightman has said from day one that he focused his attention on the minority, small trouble spots.

Ms Carter: Well, that's my impression.

Mr Winchell: As a result, he has taken a housing act and applied it to -- we have to remember that the whole reason for Dr Lightman's appointment was after the longest-running inquest into a boarding home, not a retirement home. There's a significant difference, as you well know, Mrs Carter.

Ms Carter: But then I wonder, if the kinds of standards that you're suggesting were brought in, whether it might rule out some of those homes, which would mean that there would be a shortage of accommodation at the lower end of the market.

Mrs Caplan: If I could, I think the point you're making is that those standards would allow for a differentiation of the type of facility or home, and differentiate between rest home and retirement home and allow you even to define what these different beings are.

Mr White: These are very articulate witnesses, Mrs Caplan. Let them speak for themselves.

The Acting Chair: Order.

Mrs Caplan: Does that not --

Mr Winchell: Absolutely. We're talking about --

The Acting Chair: Perhaps we could wrap this section up, because I do have two more questioners here and we have a group waiting. I'd really appreciate it if we could.

Mr Winchell: Okay. I'd only say that a boarding home provides no care, as opposed to residential care, which is 24-hour professionally staffed.

Mr Anderson: Different levels.

Mr White: First of all, if I could just clarify the issue about not-for-profit and for-profit residential facilities, the minister made it very clear that while there may be a preference for not-for-profit services -- that is, community services, VON, Red Cross etc -- in this particular situation in regard to nursing homes and homes for the aged, which this act deals with, there is "no attempt to destabilize or disadvantage the existing private sector involvement that presently exists." In fact, the nursing home association came before our committee and spoke very highly of the act, because it actually brings them up in terms of a level playing field.

Mr Winchell: Absolutely.

Mr White: This is a tremendous benefit, really, to the for-profit sector.

Mr Winchell: Not all nursing homes are for-profit, though.

Mr White: No, but the majority of nursing homes are for-profit.

Mr Winchell: For the nursing home sector, it brings it to a level playing field with the funding for homes for the aged. That's really what we're talking about.

Mr White: Yes. The issue, though, I think, that you bring up is very, very good. Central Park Lodges are exceptional facilities in the rest or retirement sphere. There's a continuum, of course. Some of them are not. My friend Mr Lessard speaks very highly of your facility. He runs by it every day.

Mr Anderson: He eats in it regularly.

Mr Lessard: That's why I have to run by it.

Mr White: I'm wondering: You've talked about your efforts to get legislation, to get regulation so that other facilities could be at least comparable to yours, so that you would know that you're in the same kettle as something which is not noxious to you. But you've been frustrated, time and again.

Mr Anderson: We'll go back. Rick went back to the Conservatives. I'll go back to the Liberals. We started lobbying them. I have to point out that I think Dr Lightman was appointed by the Liberals, wasn't he?

Mr Winchell: No, he wasn't; he was appointed by Elaine Ziemba.

Mr Anderson: I think it's crossed all boards. I think it's time that everybody came together on the one issue. I don't think one party or the other can -- I think everybody, if there is blame to be laid, including us, has maybe a share.

Mr Winchell: I would just add that we had several years ago, just actually as the Liberals passed the torch over to the NDP, developed a model standard which we have taken to both governments. Copies of it are available here for the committee. That's the type of approach we're talking about that will keep everybody --

Mr White: I think you know this is not the forum for that particular bill, but I hope you press on with it.

Mr Lessard: I want to thank you very much for your presentation. I have the letter from your residents with respect to their comments on the Lightman report. When I was at Central Park Lodge on Sunday, I picked up the residents' perspective on regulation of the retirement homes. I read that when I knew that you were going to be attending here today and tried to figure out how you were going to tie the Lightman report into the long-term care health reform. I want to thank you for being able to clarify that in my mind and, I hope, for the rest of the committee members.

The Acting Chair: Thank you very much. I really appreciate your coming. You certainly got a little bit of lively discussion and your concerns are well taken.



The Acting Chair: Next is the Essex county RNAs association. We certainly appreciate your patience in waiting quietly back there. Kindly identify yourselves and then begin your presentation.

Mrs Sandra Landgraff: My name's Sandra Landgraff and my colleague is Pierina De Bellis. We're from the Essex RNA Regional Council. Pierina will be helping me to do this submission.

The Essex RNA Regional Council is grateful for the opportunity to express its views about the government's plan for redirecting long-term care services in this province.

As many of you will already know, registered nursing assistants, RNAs, are the second-largest health profession in Ontario after registered nurses. Some 35,000 RNAs are currently registered in the province.

While we work in a variety of settings, RNAs have to be seen as a key health profession in the provision of long-term nursing care, both in the community and in institutions. As our population ages, we expect to see the role of RNAs in long-term care expand when more individuals will require the kind of nursing care RNAs are trained to provide.

We agree that consumers must have access to services which affirm the role of the individual, that greater emphasis must be placed on health promotion and disease prevention, that the social and economic determinants of health must be examined and that services should be delivered in familiar surroundings and integrated with family and community life. We also believe that services should be fully accessible, fully funded and provided by qualified health care professionals in public and non-profit settings.

It is clear that reduced federal funding has prompted the provincial government to find ways to contain mounting health care costs. RNAs believe there are compelling reasons for the government to engage in a cautious reform of the health care system, so that the services the public has had a legitimate right to expect are enhanced, not eroded or eliminated altogether.

We hope that RNAs and other health care providers will be represented on local planning agencies responsible for long-term care. We believe firsthand knowledge of the system will be helpful in making sure that plans for the future are grounded in reality.

In our view, these governments and the senior bureaucrats in the Ministry of Health and the Ministry of Community and Social Services have wanted to shift resources to the community sector so that underpaid, inadequately trained home care workers would provide services at a lower cost than in the institutional sector, without challenging the real factors driving up the costs of health care: physicians and the large number of highly paid administrators in institutions.

Unless the government ensures otherwise, the ones who will pay for the cost savings are the consumers who will receive lower-quality services and the staff of these community agencies who will be paid much lower than their counterparts in the institutional sector. As it stands, the government's plan will place additional responsibilities on to the families and friends of elderly people and people with disabilities. For a variety of reasons, persons needing services and their families may not request home care services but may prefer some other setting such as a long-term care facility. It is doubtful that individuals' preferences will be protected in the proposed long-term care system.

Unless there are systemic safeguards, we believe that the government's plan will lead to a reduction in the quality of care. Many nursing and personal care services provided by training professionals are not duties which most family members are able to perform in addition to their work outside the home and other demands on their time, such as child care. Families that are ill-equipped to take care of their aging parents may take their anger out on them for these additional responsibilities. As a result, we are concerned that there may be an increase in elder abuse.

The government's plan also appears to be contingent on increasing the use of volunteers. If this is the case, we are deeply concerned that the standard of care will be seriously compromised. Long-term care services must be delivered by people who are trained to provide them, either in a facility or in the home. Unfortunately, many institutions and community agencies take advantage of the goodwill of volunteers to use them as a source of free labour. Instead of viewing volunteers as people who can provide extra personal contact and enriched services, many of our employers see them as a way to cut wage bills by substituting them for paid employees.

For example, since some facilities are short-staffed and the existing staff are usually overworked, administrators have attempted to justify using more volunteers on patient care grounds. Ontarians who need health care services should not be forced to depend on volunteers.

To guarantee quality care, the government must ensure that care providers are properly trained and qualified. Volunteers have a role to play in providing auxiliary services, but should not be used as a pool of free labour in place of experienced and skilled health care workers.

In the government's consultation paper, the issue of support for family care givers is addressed as follows: "One of the key directions in long-term care services for the future is improved support for family care givers." The regional council believes that rather than offering support, the government will be placing greater expectations on women to provide care for family members. The planned changes will likely draw more women into "the sandwich generation," where they will be responsible both for raising their children and caring for the frail elderly.

In today's economic and social reality, the majority of women participate in the labour force. For them to fully take part in society, women cannot be expected to "fill in all the cracks." Yet more than ever they are forced to patch together services needed for their family members, such as child care and home support services. The government says its service coordination agencies will improve the coordination of these services, but we fear SCAs will be biased in favour of care provided by family members rather than outside support.

RNAs are concerned about the apparent exclusion of children with long-term illnesses or disabilities in the scope of long-term review. In many parts of the province, there are very few options appropriate for children with special needs, particularly for multihandicapped youth. There are long waiting lists for spaces in group homes and in long-term facilities in most communities. As a result, parents must travel for hours in order to visit their children.

Ms Pierina De Bellis: We are concerned that the government has accepted the argument that quality services can be delivered cheaper and better by community agencies or private operators. However, Ontario's previous experience with the deinstitutionalization of ex-psychiatric patients in the 1970s was judged largely to be a failure. The motivation for deinstitutionalization was to reduce institutional care costs, although the government promised that community services would develop in tandem to help former patients reintegrate into community life.

There are real dangers that long-term care reform may result in a similar faulty system. If patients are not admitted to or are removed from institutions, the burden of providing this care will be shifted to family and friends, who will not be able to cope with the additional demands placed on them. Our concern is that in an effort to deal with federal funding cuts for health care and the size of the provincial deficit, the government is cutting institutional care budgets before putting the necessary systems in place so that people can be cared for adequately at the community level on a 24-hour basis.

Therefore, we believe a logical option would be in the expanding role of hospital and non-profit homes in the provision of community-based health care. One way to ensure quality home care services is to provide them out of an existing long-term care facility. For example, there is a pilot project at a municipal home for the aged where some employees are charged with providing home care. It enables qualified staff to go to seniors' homes and provide the necessary services such as nursing, dietary etc. This allows seniors to remain at home months or years longer than they might have otherwise. If they become too ill, either temporarily or permanently, to care for themselves, they can then be moved to the home for the aged. This provides a continuum of care and ensures that the services provided are monitored so that their high quality is maintained.

An expansion in community-based care will mean that patients in long-term care facilities will require increasingly heavy levels of care. The government's proposed funding formula recognizes that nursing care for heavy-care patients is greater than for those needing lighter levels of care. However, some accommodation and programming costs under the proposed formula will be fixed. How will the funding formula recognize that these costs also vary according to the levels of care?

For example, persons requiring heavy levels of care usually have special food needs that are more expensive to provide than those on a regular diet. Other accommodation costs such as housekeeping and laundry, as well as programming costs, are higher for heavy-care patients. These additional costs and staffing needs must be recognized in the government's funding scheme.

We strongly oppose the involvement of the private sector in health care delivery. Our fear is that long-term care reform will expand the market for these companies which will result in a greater inability to develop, monitor and enforce standards of care.


The rapid expansion of the private sector into home care causes us great concern. In 1978-79 the hours provided to Ontario patients were 82% non-profit and 18% commercial. In 1988 the ratio was shifted to 62% non-profit, 38% commercial. At a recent health care conference, it was stated by a member of the Ministry of Health that the ratio is now close to 50-50. Obviously the increase in the commercial sector has been at the expense of the not-for-profit sector, with the private sector growing at an increasing rate during the last 13 years.

The reality is that RNAs already provide much of the nursing care currently available within the long-term care system, both in the community and in institutions. We see the potential for our role to expand in the future as our population ages and as services become more accessible throughout the province.

RNAs need to be working at their full potential in accordance with their skills and training and the systems need to acknowledge that RNAs have the skills necessary to assess and re-evaluate patient needs. They are also competent to provide coordinating services. Unless we design the system so that it takes advantage of the most cost-effective service provider in accordance with their skills and training, the overall cost of our redesigned system will be needlessly high.

The regional council has concerns about the current direction of government's thinking with respect to human resource training and long-term care. For example, the government's report says that new provincial training guidelines will be developed for health care aides so that they will be equipped to work in facilities in the community. We believe that the different settings imply expectations which really require quite different types of training. That's why, for example, there was a specific program developed on guidelines for training RNAs to work in the community.

We believe that before designing an appropriate training program, planners and educators must first decide what functions these workers are going to be asked to perform. We see the work of health care aides as primarily focused on providing assistance with personal care: grooming, dressing, eating and toileting etc.

When it comes to providing long-term within institutions it seems very likely that the average person receiving inpatient care in the future will have more complex needs than is presently the case. This suggests that there will be a need to increase the nursing staff component in long-term facilities. Once again, the most cost-effective provider of nursing care is the RNA and we must ensure that sufficient RNAs are available to staff these positions.

In conclusion, we remind the government that the changes being contemplated will have enormous impact on our medicare system. We believe that it is incumbent on the government to proceed cautiously down the path of reform and that health care workers and consumers must not shoulder the burden of these changes.

The Acting Chair: Thank you very much. Mr Wilson.

Mr Jim Wilson: Thank you very much for your presentation. There are just a few points in there, not surprisingly, I probably don't agree with, but I do agree that health care workers are taking a disproportionate share of the burden and difficulties as the government moves from hospital-based care to community-based care.

I did want to ask you if you specifically have recommendations, particularly when you talk about the direction in which the government is moving and the direction in which, to be fair, previous governments were moving. It is placing greater expectations on women to provide care for family members. I see that in my own community and I see that in my own family, and I could go on at great length with a story about my grandmother recently.

But at the end of the day you find out that even in the best of families there's a real hesitation there to do what might have to be done. If grandma's going to stay in her home longer or in someone else's home, it can boil down in some families that someone has to quit their job and stay home with her, and in the best of families you'll find a great resistance. So the tendency is to ensure that grandmother goes into a nursing home, and I've seen that in my own family, for a number of very good reasons. That is the practicality of it all, the fact that there are two wage earners in most families now, and there have to be to keep up with the taxes.

Do you want to just sort of give us a feel for what you think we can do in the context of this legislation to alleviate that? Long-term care reform is a reality and the direction the government is going in is a reality. We have an opportunity now, with one piece of that reality, to maybe help alleviate those concerns of family members.

Mrs Landgraff: That's why I believe it's vital that they do have people come in from hospitals, institutions, whatever, to help with the care. You say that the problem right now may boil down to someone having to quit his job while he can hardly afford to keep the family he has on the wages of two wage earners. How do you propose they're ever going to be able manage on one wage?

Another concern is that I know there was mention of paying a family to look after a mother or a father, whatever the case may be. The problem with that is that it's fine if everyone gets along, but I'm sure everyone's aware that there are two members in a marriage. One may not be as pleased with having a parent in the home, and that just causes more problems. The children end up feeling that they're being neglected because the time is being spent with the grandparent.

I also have grave concern because there's no mention that it's 24-hour availability for care. We just came back from a conference and there was grave concern there because a lot of people said they work shifts. What happens at 4 o'clock when you're going to work if there's no service available? I think there has to be something set up.

The way it is right now, if you have all the agencies, you have fragmented care, because you have all these different groups. The problem with that is that because they are outside agencies the government may be paying a good buck to get their services, but unfortunately the person going in to do the service is not getting the good buck. They're getting a quarter of the money that agency is getting. To me, after a while, the people doing the service don't really have their heart in it. It's a job; they go and do it.

Mr Jim Wilson: Is that the main problem you have with the involvement of the private sector in the delivery of home care service?

Mrs Landgraff: Very much so.

Mr Jim Wilson: Inferior wages?

Mrs Landgraff: Inferior wages, but also whether they're well trained.

Mr Jim Wilson: Do RNAs not work in the private sector?

Mrs Landgraff: Some do, yes, but our concern is because the shift they seem to want -- bring in the health care aide. I don't understand the government's theory on that one. There's legislation going through that people who do not have a certificate of competency cannot have hands-on care of the patient. Actually if they're in the home, you have to be able to know what you're looking for. If they're just going in to bathe a person, whatever, they may not know what problem to look for.

We have problems right now. We've heard from people who work for public health about people who decide they want to stay in their home. They tell us what the condition in the home is. We're saying, "Why aren't these people put into a nursing home, whatever, if they can't look after themselves?" They're told: "That's their choice. They want to stay in the home. We know we're going to go in one day and find them dead, but that's the way things are and there's nothing we can do about it." We've heard that from RNAs who are working with public health and VON in other areas of the province.

Mr Hope: I've been sitting here trying to figure out -- I notice the opposition stayed away from an issue. But if you were saying you're in support of the private sector out there providing health care services, they would be jumping on the bandwagon and saying NDP and everything else.

I'm sitting here trying to phrase a question of how I'm going to ask you. You're saying, "Get the private sector out of the health care system." I noticed you used the words "strongly opposed to the involvement of the private sector." I'm trying to think what a Liberal or a Tory would ask in a question.

Mrs O'Neill: Why don't you ask your own question, Randy?

Mr Hope: Aren't these people taxpayers in the province of Ontario and have the right to be there when the services are not? Aren't you being, how would you say, selective in what government funding goes for? Don't these people pay taxes? Why do you want them out of this sector?

Mrs Landgraff: The problem is that if it's outside of an institution, whatever, how are you going to safeguard the standards of what's going on in that community as well? I have a problem with everything becoming deinstitutionalized, because to be perfectly honest, I feel government, and it doesn't matter what government it is, has discovered that health care is too expensive, and there are more and more elderly and they want it out in the community so that the time can come -- because it has been shown that this is not necessarily going to be a cheaper way of going, and we don't have funds for what we have now.


If we don't have funds for what we have now and we put it out in the community, it's going to cost even more. Then all of a sudden whatever government happens to be in power at the time is going to say, "We can't afford this any more," and it will become totally private and people will have to pay and the whole accessibility will go down the drain.

I've had a major concern about that ever since this whole thing was mentioned. I think it's a good idea if people can stay in the home, but I don't like the business that everything wants to go out to the public sector and then it's expensive so we can't afford it, "Let's cut it," or you're going to have to pay so much to have the service.

Mr Hope: Pretend I'm sitting over on that side trying to come up with these questions, because I notice they're standing away from this, okay?

Mrs Landgraff: It doesn't matter what side it is; I feel any government --

Mr Hope: I support what you're saying, but the thing is, I'm trying to bring some clarification. The only reason you would want probably private out of there is so they can have these big union wages because non-profit and the government -- so you can have big union wages and you can run deficits.

Ms De Bellis: That is totally berserk. No, that is not the intention there. We do not want health care to be a bargain, and that's what it's going to be. It's whoever can get the most money.

We're the patient advocates. These poor people are out there and they're just being shipped from hospital and they're being told, "Well, you know, we can take care of you in the home or we can put you in the hospital." If they can stay in the home, fine, but there have to be the services and they have to be able to afford it.

They have to have qualified people to come in. You don't want someone to come in and look at you or to change your catheter or whatever who doesn't even know what he's doing. You want qualified people. You don't want them working for a company that says: "You go out there. You've got 20 minutes or 15 minutes to do the turn. Keep going." That's what health care is today. It's an assembly line.

Mr Hope: I'm going to move to a little bit more around the issue of -- I know St Clair College here in Windsor administers the health care aide program that goes on in the city of Chatham, which is my riding. I wonder, when you talk about education, is that the type of education? You know, they have it through the KITAC program, the Kent Industrial Training Association Council, where RNAs and RNs go in and teach the program? Is that the type of education system, accreditation system that you're looking for for people to do services in our community?

Ms De Bellis: Yes. You want them to have a proper program. You don't want them having people come off the street and give them two weeks, or sometimes they get six hours' training, and say: "Adios. Here's your workload. Go to it." You don't want that. You wouldn't want that type of person taking care of your mother or your father or yourself.

That's where you have to base yourself when you're contemplating the reform. Would you want this being done to your mother or to your loved one? No, you wouldn't. You need people who are trained, who know what they're doing.

Mr Larry O'Connor (Durham-York): I wanted to get into a little bit of the fray that my colleague had. Of course, I wanted to look at it from a different point of view. First of all, with your conclusion that we should slow down with the reform, I guess that's one thing that kind of struck me funny, because I know that when I first got elected as an MPP, people kept saying, "Where's the long-term care reform?" and then, of course, it was a long time coming. So we are moving and it's slow.

I guess when we all come to committee we always come with a little bit of a bias from our own ridings. I represent a rural riding, and continuing along the thoughts of the non-profit and the private, in the small, rural towns quite often, in trying to deliver non-profit health care within the community, trying to get maybe people who could be members of the board who would help facilitate taking care of the needs so that we can make sure there's accountability and so that one part of regional government, for example -- they seem to focus in on one area and maybe quite often forget about the rural areas that are part of a large regional government.

Could you help with some recommendations that would help in trying to take a look at that deficiency? Because that deficiency is what has led to the growth within the private sector coming into the small rural communities because they've seen a need. You've recognized right in your brief that we expect far too much of the women within our communities. We expect them to do child rearing, we expect them to take care of aged parents and grandparents and we put too much stress on them now. How can we ease that burden and make sure we provide quality care? I ask for a recommendation because it's a difficult and complex situation. As my colleagues across the floor recognize that there's a need for a private sector, I guess that's quite often --

The Acting Chair: That's a fairly lengthy preamble.

Mr Hope: Just like Elinor.

Mr O'Connor: When you take a look at rural areas, then you've got a problem, so --

Mr Jim Wilson: I was kind of enjoying it.

Mrs Caplan: He didn't ask a question.

The Acting Chair: Oh, he asked about six, and I'm not sure which one he wants answered.

Mr O'Connor: The focus would be on recommendations of how we could possibly increase a non-profit sector within a rural community where you don't have the possibility of increasing --

Mr Jim Wilson: They are not only asking the questions; they are answering them.

The Acting Chair: Do you have anything further or do I move on to the next?

Ms De Bellis: Just that we agree with that. There's a major problem with the women because they're the ones who are going to get the brunt of it. In the small rural areas, yes, there is a problem. We have with the community of Essex, even Leamington -- they're small communities and the private sector sees there's a need and is just going right in. They're coming into the hospitals. We have agencies that are literally coming in and wanting to take services out of the hospital. They'll come in and they'll do it for you. So they're not only doing it outside; they're trying to get into a hospital. We're going through a reconfiguration process in this city and these guys are coming in. They're coming from the States. They're just coming in and saying: "There's a need there and we can provide it. We're just going to go right in."

Mr Hope: Because it's cheaper.

Ms De Bellis: It is. That's the sad part, but you have to look at the care. Are they providing the care? What's happening?

Mrs O'Neill: I am very happy that you mentioned on page 3 the exclusion of the children with long-term illnesses and disabilities because I do think that issue has to be attended to and has to be attended to very soon. We have a crisis in many communities.

I have a couple of things I'd like you to clarify and then I have a comment. On page 2 you say, "It is doubtful that individual preference will be protected in the proposed long-term care system." Would you tell me why you feel that way? I can't find any reason within your brief that backs that up, although we've had it said by several people. Could you give us your own interpretation of that?

Mrs Landgraff: My feeling is that if someone, a family member, feels his parents should be admitted into a nursing home, an institution, whatever, whatever panel is set up for this whole reform is going to block it. Because it will be expensive, they'll say, "No, I don't feel that's necessary; they can stay in the home," and just try to add another service in to keep them quiet. That's one of my great concerns. As well, I'm concerned for the feeling of the elderly, but I also have, as I said, a great concern that someone is going to be allowed to stay in the home on his own when it is unsafe. Who is going to make that decision of whether a person really cannot manage on his own?


Mrs O'Neill: Okay. I have another clarification, but I have to comment immediately that I think you're underscoring several people here. First of all, the elderly people, in my mind, have the ability in many cases to be making their own decisions, to be respected and indeed to take risks.

I've just been through that. My father died on January 6. He was in the hospital for three days before he died. I had only non-profit people working with my father and myself, and I don't think there were any real doubts in either his mind or my mind that the care was second to none.

I get very offended, and I am in some of these hearings, when we talk about "putting" people or doing this. I feel you people work in this area and you've got sensitivities, and I don't deny that, but I really do feel that in many cases -- you made the statement that, "Well, we go in and find the person dead." That could have happened to my father. That was his wish. He had all his faculties of thinking and I wanted him to have his wish, and I'm not sorry and a geriatric specialist told me after he died that I had made the right decision and I feel she was right. That's personal, but I had to get it on to the record.

In any case, if I may go back, you say also in your brief, "The government says its service coordination agencies will improve the coordination of these services, but we fear SCAs will be biased in favour of care provided by family members." Is that the same comment you want to make to the previous question I asked? Is it the same point?

Ms De Bellis: What's happening now is that we're even looking at the hospital, with the quick response, which is a success. You have to evaluate. You were fortunate with your father. He could stay home; you had the support systems. A lot of communities don't have that. We don't have the VON that's 24-hour care. We don't have the homemaker who's available. We don't have the relief for family. It's not there. The family perhaps could try to manage but there aren't the support systems out there.

What's happening now in the hospital is that some of these elderlies are coming in, and they're not given a choice. It's like, "Okay, you're going back home and this is what you're going to have," and off they go, because they realize, "Well, the doctor said it's okay, and the nurse, and, you know, it's all right." But in actuality, in reality, this person should be assessed as possibly having to stay in hospital. Maybe he needs a rest home.

We're not saying we don't want them in the home. There are some who are fine in the home, if the resources are there. The problem is, we want them to have a choice. We don't want them to go in and hear, "Well, we're shifting into community, so off you go," because that's what's happening now, and it's a fear. It's a grave, grave concern, because a lot of the RNAs who are working out there -- both RNs and RNAs and health care aides -- are fearful that they're going to find more people going into the home with broken hips, possibly dead, because they're not assessed. It's not because you don't want to assess them, but there's a time factor and, once again, you're in there for 10, 15 minutes and off you go. It's a major concern.

Mrs O'Neill: All right. I think you have your attitude towards that and I have mine. My colleague has a question.

Mrs Caplan: You mentioned a number of things I'd like to just make sure that we understand, that the committee understands your point of view. On your last page, you restate that you believe the most cost-effective provider of service is the one that should be providing the service. What that means to me, on behalf of the taxpayers, is that you agree that there should be value for money and that wherever possible you should use the most cost-effective service.

You also use the term "evaluate," and I guess the question I would ask you is that I'm assuming that you have determined through that evaluation, whether it's outcome review or standard-setting or some process of accreditation or something like total quality management, who can provide the most cost-effective service. That's something you seem comfortable with, to be able to make a statement about wanting to see that you get value for money by having the most cost-effective provider provide the service. Is that an accurate statement of what you believe?

Mrs Landgraff: That's right.

Mrs Caplan: So could I take it the next step and say, from a public policy point of view, if government's looking at the policy of long-term care, then in the question of who should provide the service, if that's what we're asking, we should ask, who can provide the best-quality service at the best price? Is that a reasonable statement of your point of view?

Mrs Landgraff: Yes, but our concern is that the government isn't necessarily going to be concerned about the best quality; it's going to be the cheapest.

Mrs Caplan: All right, but in your notion of the fact that RNAs provide cost-effective service, if you were comfortable that you had built in that accountability, that evaluation, that accreditation, that outcome review, if that were built in and this legislation built in the requirement to have that kind of evaluation, would you then be satisfied with the statement that it is important that we provide the best-quality service at the best price on behalf of the taxpayers of the province?

Mrs Landgraff: Yes, I think it's important.

Mrs Caplan: Then what difference does it make whether it is the commercial sector or the not-for-profit sector if they both have to meet that test? Wouldn't the healthy competition around who can provide the best-quality service at the best price -- provided you have the test of evaluation and accountability, why would you care who manages it as long as they meet that test?

Ms De Bellis: I think the past really says it all because you can have the accountability, the public out there. The bottom line is the price -- "I'm going to do it better." There's a major concern because in the past the quality of care was not there. That trust has been broken, so you have to rebuild that. That's a major concern for us.

Mrs Caplan: In fact, the studies in health care prove the opposite. Service provided by both the private sector and the public sector is subject to the same standard and outcome review as far as quality of care is concerned. In fact, both have been leaders in the whole total quality of management area. It is more, in my view, a question of making sure that you enshrine that concept to ensure that the taxpayers are getting value for money and that the very best-quality service is being provided at the best price regardless of who manages or what label is on the door, whether it is commercial or public.

Ms De Bellis: Obviously that's your opinion and that's ours. As I said, there have been major concerns.

Mrs Caplan: I understand.

Mrs O'Neill: You shouldn't paint with a wide brush in that --

Mr Hope: Well, you do.

The Acting Chair: Order, please.

Mr Hope: We'll just get the roller out and roll it.

The Acting Chair: Looking at the hour, I think everyone is --

Mrs O'Neill: -- everywhere and anywhere. I'm very offended that health care workers would do that to other health care workers. I'm sorry, because I've had some very different experiences, very different.

Ms De Bellis: Once again, that's your opinion.

Mrs O'Neill: That's my experience.

The Acting Chair: I think that's the idea of hearings, to get all opinions. I thank you for coming before the committee tonight. I thank you also for waiting because you did have an extra-long wait. Thank you very much.

There will be a short subcommittee meeting, if I could have the representatives, please.

Mr O'Connor: Is ReliaCare coming?

The Acting Chair: No, they are not coming. We'll stand adjourned until 9 o'clock tomorrow morning at this very place. I thank everyone for their attendance.

The committee adjourned at 2039.